Assessment of an established dialysis nurse practitioner model of care using mixed methods research

AIMS AND OBJECTIVES: To assess a dialysis nurse practitioner (NP) model of care by examining satisfaction, quality of life (QOL) and clinical outcomes of haemodialysis patients and explore experiences of dialysis nurses.

DESIGN: Mixed methods.

METHODS: Database analyses of dialysis indices amongst a sample (n = 45) of haemodialysis patients; a survey (n = 27) examining patient experience, satisfaction and QOL; and in-depth interviews with a sample (n = 10) of nurses.

RESULTS: Nurses commended the NP role, with five themes emerging: "managing and co-ordinating", "streamlining and alleviating", "developing capability", "supporting innovation and quality" and "connecting rurally". Patients' average age was 66 years and 71% were male. Patients' satisfaction with the care they received was rated 3.5/4 or higher across seven parameters and the average QOL score was 7.9/10.

CONCLUSION: The NP model of care is effective in enhancing patient care within a collaborative framework. The challenge is to sustain, and enhance the model, through mentorship programs for potential candidates.

Recognising and responding to 'cutting corners' when providing nursing care: a qualitative study

AIMS AND OBJECTIVES: The aim of this study is to report on a key finding of a larger study investigating the 'gaps' in patient care that registered nurses encounter during the course of their practice. A key finding of this larger study was that 'cutting corners' was a gap discerned by nurses. BACKGROUND: 'Cutting corners' has been characterised as a 'violation' and threat to patient safety, although there is a paucity of research on this issue. DESIGN: Naturalistic inquiry using a qualitative exploratory descriptive approach. METHODS: Data were collected from a purposeful sample of 71 registered nurses from emergency department, critical care, perioperative, rehabilitation and transitional care and neurosciences settings in Australia and analysed using content and thematic analysis strategies. RESULTS: Cutting corners was a common practice that encompassed (1) the partial or complete omission of patient care, (2) delays in providing care and (3) the failure to do things correctly. Corners were cut in patient assessment, essential nursing care, the care of central venous catheters and medication administration. The practice of cutting corners was perceived as contributing to preventable adverse events. CONCLUSIONS: The study found that cutting corners created gaps that contributed to unfinished nursing care and preventable adverse events. The findings of the study raise the possibility that cutting corners is a salient but underinvestigated characteristic of nursing practice. Further research and inquiry are needed to deepen understanding of cutting corners and its impact on patient safety. RELEVANCE TO CLINICAL PRACTICE: Identifying the nature and implications of cutting corners when providing nursing care is an important contributing factor to improving patient safety and quality care.

Challenging the handover : recommendations for research and practice

Communicating nursing care during the patient's total hospital stay is a difficult task to achieve within the context of high patient turnover, a lack of overlap time between shifts, and time constraints. Clear and accurate communication is pivotal to delivering high quality care and should be the gold standard in any clinical setting. Handover is a commonly used communication medium that requires review and critique. This study was conducted in five acute care settings at a major teaching hospital. Using a grounded theory approach, it explored the use of three types of handover techniques (verbal in the office, tape-recorded, and bedside handovers). Data were obtained from semi-structured interviews with nurses and participant field observations. Textual data were managed using NUD-IST. Transcripts were critically reviewed and major themes identified from the three types of handovers that illustrated their strengths and weaknesses. The findings of this study revealed that handover is more than just a forum for communicating patient care. It is also used as a place where nurses can debrief, clarify information and update knowledge. Overall, each type of handover had particular strengths and limitations; however, no one type of handover was appraised as being more effective. Achieving the multiple goals of handover presents researchers and clinicians with a challenging task. It is necessary to explore more creative ways of conducting the handover of patient care, so that an important aspect of nursing practice does not get classified as just another ritual.

Who, when and where? Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice

Patients who suffer an adverse event (AE) are more likely to die or suffer permanent disability. Many AEs are preventable. Nurses have long played a pivotal role in the prevention of AEs. Much of the literature to date pertains to the role of nurses in the prevention of AEs such as falls, pressure areas and deep vein thrombosis. Prominent risk factors for AEs are the presence of physiological abnormality, failure to recognize or correct physiological abnormality, advanced patient age and location of patient room. Ongoing physiological assessment of patients is a nursing responsibility and the assessment findings of nurses underpin many patient care decisions. The early recognition and correction of physiological abnormality can improve patient outcomes by reducing the incidence of AEs, making nurses' ability to identify, interpret and act on physiological abnormality a fundamental factor in AE prediction and prevention. This paper will examine the role of nurses in AE prevention, using cardiac arrest as an example, from the perspective of physiological safety; that is, accurate physiological assessment and the early correction of physiological abnormality.

Tensions and constraints for nurses in hospital-in-home programmes

Economic necessity constrains health-care expenditure and waiting lists for hospital treatments remain high. As a result, more care is delivered via alternative means, such as same-day surgery initiatives and home-care programmes. Acute care delivered in the home to patients who would otherwise require hospitalization is becoming an increasingly acceptable means of treatment. These Hospital-in-the-Home programmes offer increased comfort while delivering comparable outcomes to many patient groups. The purpose of this paper is to generate discussion concerning the tensions that exist for nurses who practice in the home under the auspices of acute-care institutions. Data drawn from field work that formed part of a critical ethnography is used to generate the discussion. The larger research project explored the constructions of the role of the nurse in four Hospital-in-the-Home programmes in Victoria, Australia. It will be argued that there is significant pressure exerted upon nurses to support the imperative to reduce bed days in acute hospitals by transferring people to their home. At times, this agenda clashes with the nurses’ professional commitment to provide holistic patient care yet the dilemmas are largely unacknowledged and/or unrecognized by the nurses despite the tension they generate.

`Don`t call me sweetie!` patients differ from nurses in their perceptions of caring

Effective nursing care relies on congruent nurse-patient perception of needs. This study used Q methodology to compare nurses' and patients' perceptions of important nursing care behaviour. Q methodology applies statistical analysis to qualitative data through a technique of comparative rating using a forced choice format. The Care Q Sort, comprising fifty statements of nursing behaviour, was administered to nurses and patients from medical wards. Participants ranked the nursing behaviours from most to least important. Analysis was completed on 74 rankings. There was agreement for many behaviours but bimodal distributions for nurses' scores for some statements which may be attributable to different professional levels. An additional open comments section provided an experiential dimension to the research results. The findings will inform nursing practice and patient care planning.

Complementary therapies and diabetes

There is increasing recognition that people with diabetes use a range of complementary therapies (CT), for a number of conditions, but do not always inform their conventional health practitioners about their use. Controlling blood glucose levels in people with diabetes is important to reduce the consequent metabolic abnormalities and symptoms and the incidence of long-term complications. Conventional medical and nursing practitioners often incorrectly assume that they are used to control blood glucose levels, e.g. using herbal medicines to increase insulin production or reduce insulin resistance. CT can be beneficial for people with diabetes. They can also lead to adverse events. This paper describes the outcome of monitoring complementary therapy use in our diabetic outpatient services in 2001, the results of a focus group (n=10) to explore issues identified in the monitoring process and a survey undertaken with a convenience sample of diabetes educators (n=40).

Twenty percent of patients used CT and there were three adverse events in the monitoring phase. Eight of the 10 focus group participants used CT and 16 of the diabetes educators used CT in patient care. Only one had a complementary therapy qualification.

Observation of pain assessment and management- the complexities of clinical practice

• Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions.

• This observational study sought to investigate nurse–patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings.

• Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions.

• Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients.

• These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.

Medication management by graduate nurses: before, during and following medication administration

The purpose of the present study was to explore graduate nurses' perceptions of their medication management activities in the acute care context. A qualitative research design with a semistructured interview schedule was used to elicit information from participants. The sampling population consisted of graduate nurses involved in direct patient care in medical and surgical wards of a Melbourne metropolitan teaching hospital, completing a graduate nurse program. Twelve graduate nurses participated in the interviews. Two major themes emerged: (i) monitoring medications and (ii) interventions for patient care. The findings indicate that graduate nurses are required to address several facets of the medication management role in their daily practice. It is pertinent to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals. Through collegial support, graduate nurses should also be encouraged to critically examine the different possibilities when making clinical judgments about monitoring patient medications.

Students perceptions of learning outcomes from group-based, problem-based teaching and learning activities

Objective: A study aimed at exploring the variation in perceptions of learning outcomes reported by undergraduate nursing students enrolled in a problem-based learning subject in a pre-registration Bachelor of Nursing course (BN).
Method: Students were asked to respond to four open-ended questions which focussed on their learning outcomes in the different teaching/learning modalities of the subject. Data were analysed in two phases using a modified phenomenographic analysis. In the first phase a set of categories of description were developed from the student responses to questions related to the learning modalities. In the second phase the individual responses were classified in terms of the categories. Finally, correlations between the learning modalities were identified. In this paper the approach to analysis, the process of category identification and the correlations between the learning modalities will be described and the implications for further research and teaching will be discussed.
Results: The findings indicated that there were two distinct groups of student responses. Inward focussed students who described outcomes in terms of their own learning and students whose focus was outward i.e. describing learning in terms of patient care and how learning relates to that care. Another important result shows the relationship between the learning modalities and outcomes. From the students' perspective, the most sophisticated outcomes of the lectures and laboratories were ideas and skills to be used and applied in clinical settings. Whereas, the group-based activities in which clinical problems were presented to the students in the form of Situation Improvement Packages (SIPS) focussed their attention on the clinical setting which constituted a preparation for the realities of clinical practice.
Conclusion: The findings from this study indicate that students perceive their learning in the group based teaching/learning modality (SIPS) as effective in focussing them on the reality of their role in the clinical practice environment while lectures and laboratories provided the skills and knowledge required for this setting.

Health professionals' attitudes toward caring for people with hepatitis C

An estimated 170 million people worldwide have hepatitis C, which is a significant cause of morbidity and mortality. Therefore, health professionals (HPs) are likely to care for people with hepatitis C at some stage in their careers. However, little is known about HPs' attitudes towards treating people with hepatitis C. An analytical, cross-sectional survey was conducted to explore the inter-relationship among HPs' hepatitis C knowledge and attitudes towards treating people with hepatitis C and their self-reported clinical behaviour: Self-administered questionnaires were distributed to 3675 complementary therapists, dentists, medical practitioners, nurses, pharmacists, undergraduate medical and nursing students and people with hepatitis C in Victoria, Australia. Forty-six per cent responded (n = 1510). Only HP (complementary therapists, dentists, medical practitioners, nurses and pharmacists) data is presented (n = 1347).

Most HPs demonstrated adequate hepatitis C knowledge, but some displayed intolerant attitudes toward people with hepatitis C. Their self-reported compliance with infection control practices indicated that they frequently treated people with hepatitis C differently from other patients by using additional infection control precautions while treating patients with hepatitis C. In addition, fear of contagion and disapproval of injecting drug use emerged as barriers to their willingness to treat people with hepatitis C.

The results suggest that focusing education strategies on changing HPs' attitudes toward people with hepatitis C, injecting drug users, and infection control guidelines rather than concentrating solely on medical information might ultimately improve patient care.

Stigmatization of patients with AIDS : understanding the interrelationships between Thai nurses' attitudes towards HIV/AIDS, drug use and commercial sex

There is currently a scarcity of research on the nature of HIV/AIDS stigma within the Thai health context. This is problematic given the negative role of stigma in hindering the provision of patient care and treatment. This study used a mixed-method approach to investigate the interrelationships between the stigma of HIV/AIDS and the stigmas relating to its various modes of disease transmission including injection drug use (IDU). Twenty interviews were conducted with trainees and qualified nurses from a Bangkok college. Participants were presented with vignettes describing a hypothetical person varying in disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU,  commercial sex (CS), blood transfusion, no co-characteristic). Using a Q-sort task, participants arranged the vignettes along a bipolar scale according to their willingness to interact with the persons, and were asked to explain their decisions. Univariate and multivariate regression analyses showed that IDU, AIDS, and CS were all individually stigmatizing. Strong interactions were found between the stigmas of HIV/AIDS, IDU, and CS. Interview data also showed clear biases toward patients according to their IDU and CS habits. The findings  suggest that addressing these co-stigmas could be vital to the success of efforts aimed at reducing the disease stigma of HIV/AIDS.

Stroke : the increasing complexity of carer needs

In Australia, more than 346,000 individuals who experience a stroke return to living in their homes with varying degrees of disability. They rely on emotional and physical support from informal carers, typically family members. Informal carers have an indispensable role in patient care poststroke, and the ability of carers to manage this role effectively is crucial for stroke survivors to be able to return home. The aim of this study was to examine the impact of the caring role on carers of stroke survivors, particularly the services provided and the levels of depression and well-being experienced. The study used a longitudinal design incorporating survey methods. Stroke survivors were assessed for functional ability, quality of life, and depression using three assessment tools: the Stroke Impact Scale, World Health Organization Quality of Life-BREF scale, and Zung Self-Rating Depression Scale. A total of 26 people were surveyed: 13 stroke survivors and their 13 carers. Carer knowledge of stroke support services was also explored. Information was collected by using survey methods and structured interviews at 3 weeks and at 3 months postdischarge. The main finding was that depression scores for carers and stroke survivors were below Australian norms at both assessment time points. The major concern identified by carers was poor follow-up procedures for initiating rehabilitation in the home. This study highlighted that a lack of appropriate discharge planning, in conjunction with early discharge of stroke survivors, can have an impact on the rehabilitation process and place increased and unrealistic demands on carers.

Development of a collaborative model to improve school health promotion in the Netherlands

In recent decades, school health promotion programs have been developing into whole-school health approaches. This has been accompanied by a greater understanding among health promoters of the core-business of schools, namely education, and how health promotion objectives can be integrated into this task. Evidence of the positive impact of school health promotion on health risk behavior of students is increasing. This article focuses on the processes and initial results of developing a collaborative model tailored for whole-school health in the Netherlands, named schoolBeat. The Dutch situation is characterized by fragmentation, a variety of health and welfare groups supporting schools, and a lack of sound integrated youth policies. A literature review, observations, and stakeholder consultation provided a clear picture of the current situation in school health promotion, and factors limiting a comprehensive and needs-based approach to school health. This revealed that a health promotion team within a school is fundamental to an effective approach to tailored school health promotion. A respected member of school staff should chair this team. To strengthen the link with the school care team, the school care coordinator should be a member of both teams. To provide coordinated support to all schools in a region, participating organizations decided to share advisory tasks. These tasks are included in the regular health promotion work of their staff. This means working with one advisor representing all school-health organizations per school, and using a comprehensive overview of possible support and projects promoting health. Empowering schools in needs assessments and comprehensive school health promotion is an important element of the developed approach. This article concludes with an examination of emerging issues in evaluating collaborative school health support during the first 18 months of development, and implementation and future perspectives regarding sustainable collaboration and quality improvement.

Decision-making models used by `graduate nurses` managing patients` medications

Background. Nurses in a graduate programme in Australia are those who are in the first year of clinical practice following completion of a 3-year undergraduate nursing degree. When working in an acute care setting, they need to make complex and ever-changing decisions about patients' medications in a clinical environment affected by multifaceted, contextual issues. It is important that comprehensive information about graduate nurses' decision-making processes and the contextual influences affecting these processes are obtained in order to prepare them to meet patients' needs.
Aim. The purpose of this paper is to report a study that sought to answer the following questions: What are the barriers that impede graduate nurses' clinical judgement in their medication management activities? How do contextual issues impact on graduate nurses' medication management activities? The decision-making models considered were: hypothetico-deductive reasoning, pattern recognition and intuition.
Methods. Twelve graduate nurses who were involved in direct patient care in medical and surgical wards of a metropolitan teaching hospital located in Melbourne, Australia participated in the study. Participant observations were conducted with the graduate nurses during a 2-hour period during the times when medications were being administered to patients. Graduate nurses were also interviewed to elicit further information about how they made decisions about patients' medications.
Results. The most common model used was hypothetico-deductive reasoning, followed by pattern recognition and then intuition. The study showed that graduate nurses had a good understanding of how physical assessment affected whether medications should be administered or not. When negotiating treatment options, graduate nurses readily consulted with more experienced nursing colleagues and doctors.
Study limitations. It is possible that graduate nurses demonstrated a raised awareness of managing patients' medications as a consequence of being observed.
Conclusions. The complexity of the clinical practice setting means that graduate nurses need to adapt rapidly to make sound and appropriate decisions about patient care.