Nurses' critical event risk assessments : a judgement analysis

Aims. To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event.

Background. Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours.

Methods. A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

Results. Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (Ra) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

Conclusion. Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

Relevance to clinical practice. Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

Grounded theory of nursing's contribution to inpatient rehabilitation

There is growing awareness of the benefits of rehabilitation both in Australia and overseas. While the provision of rehabilitation services is not new, recognition of this type of health service as an integral part of health care has been linked to changes in the provision of acute care services, advances in medical technology, improvements in the management of trauma and an ageing population. Despite this, little attention has been paid to nursing's contribution to patient rehabilitation in Australia. The aim of this grounded theory study, therefore, was to collect and analyse nurses' reports of their contributions to patient rehabilitation and to describe and analyse contextual factors influencing that contribution. Data were collected during interviews with registered and enrolled nurses working in five inpatient rehabilitation units in New South Wales and during observation of the nurses' everyday practice. A total of 53 nurses participated in the study, 35 registered nurses and 18 enrolled nurses. Grounded theory, informed by the theoretical perspective of symbolic interactionism, was used to guide data analysis, the ongoing collection of data and the generation of a substantive theory. The findings revealed six major categories. One was an everyday problem labelled incongruence between nurses' and patients' understandings and expectations of rehabilitation. Another category, labelled coaching patients to self-care, described how nurses independently negotiated the everyday problem of incongruence. The remaining four categories captured conditions in the inpatient context which influenced how nurses could contribute to patient rehabilitation. Two categories, labelled segregation: divided and dividing work practices between nursing and allied health and role ambiguity, were powerful in shaping nursing's contribution as they acted individually and synergistically to constrain nursing's contribution to patient rehabilitation. The other two categories, labelled distancing to manage systemic constraints and grasping the nettle to realise nursing's potential, represent the mutually exclusive strategies nurses used in response to segregation and role ambiguity. From exploration of the relationship between the six categories, the core category and an interactive grounded theory called opting in and opting out emerged. In turn, this grounded theory reveals nursing's contribution to inpatient rehabilitation as well as contextual conditions constraining that contribution. The significance of these findings is made manifest through their contribution to the advancement of nursing knowledge and through implications for nursing practice and education, rehabilitation service delivery and research.

Women clinical nurses' constructions of collegiality : an ethnomethodological study

This research is about a shared journey of being together. It involved thirteen women nurses (including myself) in a process approach to working with data collected through audio transcriptions of conversations during group get-togethers, field notes and journalling over twelve months. The project was conducted in a large acute care metropolitan hospital where the ward staff interests lie in a practice history of the medical specialty of gynaecology and women's health. Prior to commencement ethical approval was gained from both the University and hospital ethics committees. Accessing the group was complicated by the political climate of the hospital, possibly exaggerated further by the health politics across the state of Victoria, at a time of major upheaval characterised by regionalism, rationalisation and debt servicing. In order to ascertain women clinical nurses' constructions of collegiality I adopted an ethnomethodological approach informed by a critical feminist lens to enable the participants to engage in a process of openly ideological inquiry, in critiquing and transforming practice. I felt the choice of methodology had to be consistent with my own ideological position to enable me to be myself (as much as I could) during the project. I wanted to work with women to illuminate the ways in which dominant ideologies had come to be apprehended, inscribed, embodied and/or resisted in the everyday intersubjective realities of participants. The research itself became a site of resistance as the group became aware of how and in what ways their lives had become distorted, while at the same time it collaboratively transformed their individual and collective practice understandings, enabling them to see the self and other anew. Set against the background of dominant discourses on collegiality, women's understandings of collegiality have remained a submerged discourse. Revealed in this work are complex inter-relationships that might be described by some as collegial!, but for others relations amongst these women depict alternative meanings in a rich picture of the fabric of ward life. The participants understand these relations through a connectedness that has empathy as its starting point. In keeping with my commitment to engage with these women I endeavoured to remain faithful to the dialogical approach to this inquiry. Moreover I have brought the voices of the women to the foreground, peeling away the rhizomatic interconnections in and between understandings. What this has meant in terms of the thesis is that the work has become artificially distanced for the purposes of academic requirements. Nevertheless it speaks to the understandings the participants have of their relationships; of the various locations of the visible and invisible voices; of the many landscapes and images, genealogies, subjectivities and multiple selves that inform the selves with(in) others and being-in-relation. Throughout the journey meanings are revealed, revisited and reconstructed. Many nuances comprise the subtexts illuminating the depths of various moral locations underpinning the ways these women engage with one another in practice. The process of the research weaves through multiple positions, conveying the centrality of shared goals, multiple identities, resistances and differences which contribute to a holding environment, a location in which women value one another in their being-in-relation and in which they stand separately yet together.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

Nurses’ utilisation of complementary therapies : a pilot study exploring scope of practice

The increasing use of complementary therapies (CTs) by the public requires nurses to be fully informed about the use and safety of these modalities. In addition, nurses need to be aware of what constitutes complementary therapy practice, its overlap with nursing practice and how to respond appropriately to patients' requests for access to and information about CTs. A pilot study that aimed to describe nurses' knowledge about, and the use of CTs was conducted in four hospitals in southeast Queensland, Australia. One hundred and twenty-nine nurses (65% response rate) of varying levels of qualification and expertise completed a questionnaire. Over 80% of the participants indicated that they engaged in some form of complementary therapy (CT) activity. The entire sample worked in acute care hospitals but 5% engaged in CTs while employed in a second job. These nurses worked in either individual private practice or a multidisciplinary clinic setting. Only 2% of the sample had formal qualifications in a specific CT. Many nurses seemed unsure about what should be defined as a CT. The most common CTs engaged in by nurses were massage, music therapy and relaxation techniques but some nurses also participated in acupuncture, acupressure, hypnotherapy and osteopathy. Some nurses were confused about the difference between CT and usual nursing care. In addition, there were knowledge deficits relating to institutional policies and professional standards. Our findings suggest that nurses require more education about the scope of CT and how it differs from nursing practice. Nurses also require access to clear policies about the safe use of CTs in specific practice settings and about appropriate referral of clients to complementary therapists with accredited qualifications.

Medication administration via enteral tubes : a survey of nurses' practices

Aim: This article is a report of a study examining the practices of acute care nurses when administering medication via enteral tubes. Background. Administering medication via enteral tubes is predominantly a nursing responsibility across countries. It is important to establish what nurses actually do when giving enteral medication to inform policy and continuing education development.

Method: In 2007, a survey was conducted using a random sample of acute care nurses at two large metropolitan hospitals in Melbourne, Australia. There were 181 Registered Nurses who participated in the study; 92 (50Æ8%) practised in intensive care units, 52 (28Æ7%) in surgical areas, 30 (16Æ6%) in medical areas and 7 (3Æ9%) were from combined medical–surgical areas. The questionnaire was developed by the researchers and a pilot study was conducted in August 2006 to test reliability, face validity and user-friendliness of the tool.

Results: Nurses reported using a range of methods to verify enteral tube position prior to administering enteral medication; some were unreliable methods. A majority reported administering enteric-coated and slow or extended release forms of medication, and giving solid forms of medication when liquid form was available. Nearly all (96%) reported flushing a tube after giving medication, 28% before, and 12% always flushed between each medication.

Conclusion: Enteral medication administration practices are inconsistent. Some nurses are using unsafe practices and may therefore compromise patient care.

Effectiveness of pain management in hospital in the home programs

Objectives: The objective of the study was to examine patients’ experiences of pain in Hospital in the Home (HITH) programs and
identify the issues related to providing optimal pain management for acute care patients in the home environment.
Methods: A descriptive survey of patients’ experience of pain and pain management in 3 HITH programs in metropolitan Melbourne,
Australia (n=359). Data were collected by telephone interview using a modified version of The American Pain Society’s Patient Outcome Questionnaire. Patients were interviewed 48 to 72 hours after admission to the HITH program. Consecutive, adult, acute care patients were invited to participate in the study. Patients who had previously participated or had communication difficulties unable to be overcome with the assistance of an interpreter were excluded.
Results: Sixty-nine percent of patients interviewed experienced pain at home and 86% of these patients had experienced pain in the 24 hours before the interview. Over half (56%) of the patients had experienced moderate-to-severe worst pain in the previous 24 hours and 33% reported moderate-to-severe pain as their average pain experience. Two hundred thirty-two (93.2%) of the 250 patients who experienced pain had pain in hospital before being transferred to HITH. Of these patients, 52.2% (n=132) were prescribed analgesics to take home with them; the remaining 118 patients experiencing pain were not prescribed analgesics and either sourced analgesics once home (n=81, 68.1%) or did not take any analgesics (n=38, 31.9%).
Discussion: Treatment of pain at home was suboptimal with patients experiencing moderate-to-severe pain and discomfort during the treatment phase of their illness. Lack of appropriate discharge planning strategies meant that patients went home without adequate analgesia and use of non prescribed pain medication was common. The number of patients transferred home without analgesics indicates a worrying under recognition of the need for analgesia in this care context and poses a risk to patient safety that is no less significant because patients are at home.

Economic evaluation of adult rehabilitation: a systematic review and meta-analysis of randomized controlled trials in a variety of settings

Objectives:
To report if there is a difference in costs from a societal perspective between adults receiving rehabilitation in an inpatient rehabilitation setting versus an alternative setting. If there are cost differences, to report whether opting for the least expensive program setting adversely affects patient outcomes.

Data Sources:
Electronic databases from the earliest possible date until May 2011. All languages were included.

Study Selection
Multiple reviewers identified randomized controlled trials with a full economic evaluation that compared adult inpatient rehabilitation with an alternative. There were 29 included trials with 6746 participants.

Data Extraction
Multiple observers extracted data independently. Trial appraisal included a risk of bias assessment and a checklist to report the strength of the economic evaluation.

Data Synthesis:
Results were synthesized using standardized mean differences (SMDs) and meta-analyses for the primary outcome of cost. The Grading of Recommendations Assessment, Development, and Evaluation was applied to assess for risk of bias across studies for meta-analyses. There was high-quality evidence that cost was significantly reduced for rehabilitation in the home versus inpatient rehabilitation in a meta-analysis of 732 patients poststroke (pooled SMD [δ]=−.28; 95% confidence interval [CI], −.47 to −.09), without compromise to patient outcomes. Results of individual trials in other patient groups (orthopedic, rheumatoid arthritis, and geriatric) receiving rehabilitation in the home or community were generally consistent with the meta-analysis. There was moderate quality evidence that cost was significantly reduced for inpatient rehabilitation (stroke unit) versus general acute care in a meta-analysis of 463 patients poststroke (δ=.31; 95% CI, .15–.48), with improvement to patient outcomes. These results were not replicated in 2 individual trials with a geriatric and a mixed cohort, where costs did not differ between general acute care and inpatient rehabilitation. Three of the 4 individual trials, inclusive of a stroke or orthopedic population, reported less cost for an intensive inpatient rehabilitation program compared with usual inpatient rehabilitation. Sensitivity analysis included a health service perspective and varied inflation rates with no change to the significant findings of the meta-analyses.

Conclusions:
Based on this systematic review and meta-analyses, a single rehabilitation service may not provide health economic benefits for all patient groups and situations. For some patients, inpatient rehabilitation may be the most cost-effective method of providing rehabilitation; yet, for other patients, rehabilitation in the home or community may be the most cost-effective model of care. To achieve cost-effective outcomes, the ideal combination of rehabilitation services and patient inclusion criteria, as well as further data for nonstroke populations, warrants further research.

Estimating the intensity of ward admission and its effect on emergency department access block

Emergency department access block is an urgent problem faced by many public hospitals today. When access block occurs, patients in need of acute care cannot access inpatient wards within an optimal time frame. A widely held belief is that access block is the end product of a long causal chain, which involves poor discharge planning, insufficient bed capacity, and inadequate admission intensity to the wards. This paper studies the last link of the causal chain-the effect of admission intensity on access block, using data from a metropolitan hospital in Australia. We applied several modern statistical methods to analyze the data. First, we modeled the admission events as a nonhomogeneous Poisson process and estimated time-varying admission intensity with penalized regression splines. Next, we established a functional linear model to investigate the effect of the time-varying admission intensity on emergency department access block. Finally, we used functional principal component analysis to explore the variation in the daily time-varying admission intensities. The analyses suggest that improving admission practice during off-peak hours may have most impact on reducing the number of ED access blocks.

Measuring hospital falls prevention safety climate

The prevention of falls is a key safety priority for hospitals. There are no tools that examine the safety climate from a falls prevention perspective. The aim of this study was to measure the falls prevention safety climate at an Australian metropolitan hospital. The Victorian Safety Climate Survey (SCS) was used to examine the general safety climate, with four items replicated and modified to examine the falls prevention climate. Data (n = 458) for the six SCS domains compared favourably with statewide data. The falls prevention items were correlated with the original items from which they were derived but responses regarding falls prevention tended to be less positive than patient safety more broadly. Priorities for improvement identified using a falls safety climate survey can inform the development of falls prevention strategies and form the basis of a more comprehensive tool to explore the falls prevention safety climate.

The effects of physical environments in medical wards on medication communication processes affecting patient safety

Physical environments of clinical settings play an important role in health communication processes. Effective medication management requires seamless communication among health professionals of different disciplines. This paper explores how physical environments affect communication processes for managing medications and patient safety in acute care hospital settings. Findings highlighted the impact of environmental interruptions on communication processes about medications. In response to frequent interruptions and limited space within working environments, nurses, doctors and pharmacists developed adaptive practices in the local clinical context. Communication difficulties were associated with the ward physical layout, the controlled drug key and the medication retrieving device. Health professionals should be provided with opportunities to discuss the effects of ward environments on medication communication processes and how this impacts medication safety. Hospital administrators and architects need to consider health professionals' views and experiences when designing hospital spaces.

Effectiveness of an electronic inpatient medication record in reducing medication errors in Singapore

This study examined the effectiveness of an inpatient electronic medication record system in reducing medication errors in Singaporean hospitals. This pre- and post-intervention study involving a control group was undertaken in two Singaporean acute care hospitals. In one hospital the inpatient electronic medication record system was implemented while in another hospital the paper-based medication record system was used. The mean incidence difference in medication errors of 0.06 between pre-intervention (0.72 per 1000 patient days) and post-intervention (0.78 per 1000 patient days) for the two hospitals was not statistically significant (95%, CI: [0.26, 0.20]). The mean incidence differences in medication errors relating to prescription, dispensing, and administration were also not statistically different. Common system failures involved a lack of medication knowledge by health professionals and a lack of a systematic approach in identifying correct dosages. There was no difference in the incidence of medication errors following the introduction of the electronic medication record system. More work is needed on how this system can reduce medication error rates and improve medication safety. © 2013 Wiley Publishing Asia Pty Ltd.

The cost-benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial.

Little is known about the cost-benefit of soft silicone foam dressings in pressure ulcer (PU) prevention among critically ill patients in the emergency department (ED) and intensive care unit (ICU). A randomised controlled trial to assess the efficacy of soft silicone foam dressings in preventing sacral and heel PUs was undertaken among 440 critically ill patients in an acute care hospital. Participants were randomly allocated either to an intervention group with prophylactic dressings applied to the sacrum and heels in the ED and changed every 3 days in the ICU or to a control group with standard PU prevention care provided during their ED and ICU stay. The results showed a significant reduction of PU incidence rates in the intervention group (P = 0·001). The intervention cost was estimated to be AU$36·61 per person based on an intention-to-treat analysis, but this was offset by lower downstream costs associated with PU treatment (AU$1103·52). Therefore, the average net cost of the intervention was lower than that of the control (AU$70·82 versus AU$144·56). We conclude that the use of soft silicone multilayered foam dressings to prevent sacral and heel PUs among critically ill patients results in cost savings in the acute care hospital.

Nurses' knowledge and attitudes regarding pain in Saudi Arabia

Unrelieved pain is a worldwide health care problem that can lead to unnecessary complications and increased health care expenditure. The aim of this study was to examine nurses' knowledge and attitudes toward pain in Saudi Arabia. A descriptive design was employed using the Nurses' Knowledge and Attitudes Survey regarding pain. The study took place in a tertiary teaching hospital in Saudi Arabia. All nurses employed in the hospital were eligible to participate. A total of 775 questionnaires were distributed to nurses working in acute care, intensive care, and nursing education and administration settings. In all, 593 respondents completed the questionnaires, representing a response rate of 76.5%. Data were analyzed using descriptive and inferential statistics. Most participants were from overseas (97.5%), speaking 23 different languages; 36.5% of nurses held a bachelors of science degree in nursing or the equivalent. The mean score of correctly answered items in was 16.9 (95% confidence interval, 16.6-17.31) out of a total possible score of 40. Nurses demonstrated some misconceived attitudes such as not giving the required dose of morphine to a smiling patient despite the patient being in pain. It is of concern that the findings identified problems of inadequate knowledge and inappropriate attitudes regarding pain assessment and management in Saudi Arabia. Considering these problems, the development of pain programs and policies affecting national and international nurses is highly imperative.

Cancer patients' perceptions of the barriers and facilitators to patient participation in symptom management during an episode of admission

BACKGROUND:: Symptoms by definition are subjective, and patients' role in their assessment and management will impact on patient outcomes; thus, symptom management is an area of acute care practice where facilitation of patient participation is vital if quality outcomes are to be achieved. OBJECTIVE:: This study originated from a large multimethod research program exploring patient participation in symptom management in an acute oncology setting. The purpose of this article is to explore patients' perceptions of the barriers and facilitators to participating in their symptom management during an episode of admission to an acute oncology ward and the relationships between these perceptions and patients' preference for participation. METHODS:: One hundred seventy-one cancer inpatients consented and completed an interview-administered questionnaire. Patients' preference for participation was measured using the Control Preference Scale. Responses to open-ended survey questions were evaluated using content analysis. RESULTS:: Ten categories were identified in the analyses of patient perceptions of the barriers and facilitators to participating in care decisions relating to their symptoms. Patients, irrespective of their Control Preference, reported multiple barriers and facilitators to participating in their symptom management. CONCLUSIONS:: Patients overall perceived information as the most critical component of participation. Irrespective of patients' preference for participation, there were similarities in the barriers and facilitators to the operationalization of participation in the acute care setting reported. IMPLICATIONS FOR PRACTICE:: Understanding patient perceptions of barriers and facilitators of participating in symptom management has provided important insights into person and system factors in the acute care sector impacting quality patient symptom outcomes.