What factors influence nurses’ assessment practices? Development of the Barriers to Nurses’ use of Physical Assessment Scale

Aim To develop and psychometrically test the Barriers to Nurses’ use of Physical Assessment Scale. Background There is growing evidence of failure to recognise hospitalised patients at risk of clinical deterioration, in part due to inadequate physical assessment by nurses. Yet, little is known about the barriers to nurses’ use of physical assessment in the acute hospital setting and no validated scales have been published. Design Instrument development study. Method Scale development was based on a comprehensive literature review, focus groups, expert review and psychometric evaluation. The scale was administered to 434 acute care registered nurses working at a large Australian teaching hospital between June and July 2013. Psychometric analysis included factor analysis, model fit statistics and reliability testing. Results The final scale was reduced to 38 items representing seven factors, together accounting for 57.7% of the variance: (1) reliance on others and technology, (2) lack of time and interruptions, (3) ward culture, (4) lack of confidence, (5) lack of nursing role models, (6) lack of influence on patient care, and; (7) specialty area. Internal reliability ranged from .70 to .86. Conclusion Findings provide initial evidence for the validity and reliability of the Barriers to Nurses’ use of Physical Assessment Scale and point to the importance of understanding the organisational determinants of nurses’ assessment practices. The new scale has potential clinical and research applications to support nursing assessment in acute care settings.

A prospective cohort study examining the preferred learning styles of acute care registered nurses

Objectives This paper reports on the preferred learning styles of Registered Nurses practicing in acute care environments and relationships between gender, age, post-graduate experience and the identified preferred learning styles. Methods A prospective cohort study design was used. Participants completed a demographic questionnaire and the Felder-Silverman Index of Learning Styles (ILS) questionnaire to determine preferred learning styles. Results Most of the Registered Nurse participants were balanced across the Active-Reflective (n = 77, 54%), and Sequential-Global (n = 96, 68%) scales. Across the other scales, sensing (n = 97, 68%) and visual (n = 76, 53%) were the most common preferred learning style. There were only a small proportion who had a preferred learning style of reflective (n = 21, 15%), intuitive (n = 5, 4%), verbal (n = 11, 8%) or global learning (n = 15, 11%). Results indicated that gender, age and years since undergraduate education were not related to the identified preferred learning styles. Conclusions The identification of Registered Nurses’ learning style provides information that nurse educators and others can use to make informed choices about modification, development and strengthening of professional hospital-based educational programs. The use of the Index of Learning Styles questionnaire and its ability to identify ‘balanced’ learning style preferences may potentially yield additional preferred learning style information for other health-related disciplines.

The ACORN Standards : our aide memoire to professional practice

The Oxford English Dictionary defines a standard as “a required or agreed level of quality or attainment” or “principles of conduct informed by notions of honour and decency”. What does this mean for perioperative nurses? Standards provide minimum requirements for best practice and are regarded as generally accepted principles of patient care and perioperative management. In health care, standards provide a common language and set of expectations that enable health care professionals, systems and organisations to work together for best patient outcomes...

School-based youth health nurses and adolescent decision-making concerning reproductive and sexual health advice : how can the law guide healthcare practitioners in this context?

This paper outlines some of the issues faced by School-Based Youth Health Nurses working in Queensland, in relation to the legal principles surrounding the provision of reproductive and sexual health advice. The paper outlines a number of specific issues faced by nurses working within this setting and considers the legal principles underpinning the issues concerning consent and confidentiality. The discussion in this paper demonstrates how the legal principles – which are often viewed as complex and uncertain by nurses working within this field – may be used as a guide to underpin good practice and compliance with the law. Although this paper is considered in the context of nurses working within Queensland, the principles and factors outlined are relevant to healthcare practitioners working within all Australian jurisdictions.

An exploratory study of staff nurses' knowledge of delirium in the medical ICU: An Asian perspective

Aim The aim of this study was to establish intensive care unit nurses’ knowledge of delirium within an acute tertiary hospital within South East Asia. Background Delirium is a common, life threatening and often preventable cause of morbidity and mortality among older patients. Undetected and untreated delirium is a catalyst to increased mortality, morbidity, functional decline and results in increased requirement for nursing care, healthcare expense and hospital length of stay. However, despite effective assessment tools to identify delirium in the acute setting, there still remains an inability of ICU nurses’ to accurately identify delirium in the critically ill patient especially that of hypoactive delirium. Method A purposive sample of 53 staff nurses from a 13-bedded medical intensive care unit within an acute tertiary teaching hospital in South East Asia were asked to participate. A 40 item 5-point Likert scale questionnaire was employed to determine the participants’ knowledge of the signs and symptoms; the risk factors and negative outcomes of delirium. Results The overall positively answered mean score was 27 (67.3%) out of a possible 40 questions. Mean scores for knowledge of signs and symptoms, risk factors and negative outcomes were 9.52 (63.5%, n = 15), 11.43 (63.5%, n = 17) and 6.0 (75%, n = 8), respectively. Conclusion Whilst the results of this study are similar to others taken from a western perspective, it appeared that the ICU nurses in this study demonstrated limited knowledge of the signs and symptoms, risk factors and negative outcomes of delirium in the critically patient. The implications for practice of this are important given the outcomes of untreated delirium.

Advanced arterial blood gas analysis in septic shock : a Singaporean nursing case review.

Introduction The admission to the Intensive Care Unit with a diagnosis of sepsis and/or septic shock is not uncommon. The aim of this article is to present a nursing case review of a patient admitted to the intensive care unit with a diagnosis of septic shock and the use of bedside acid–base formulae to inform clinical decision making. Method We chose to use a case review. This method is useful in reporting unusual or rare cases and is typically seen more in medicine than in nursing. Discussion The gentleman in question was a self-presentation with a short history of fever and worsening shortness of breath. His condition worsened where he required admission to the intensive care unit. The use of ‘advanced’ acid–base interpretation to guide his nursing care provided a platform from which to advance a deeper understanding of the intricacies the critically ill patient often presents. Conclusion The use of case review is enlightening in understanding the disease process and the decision-making that accompanies this. The lessons learnt are applicable to a wider nursing audience because understanding acid–base physiology is beneficial in supporting and advancing critical care nursing practice.

Mixed venous oxygen saturation monitoring revisited : thoughts for critical care nursing practice

Background Less invasive methods of determining cardiac output are now readily available. Using indicator dilution technique, for example has made it easier to continuously measure cardiac output because it uses the existing intra-arterial line. Therefore gone is the need for a pulmonary artery floatation catheter and with it the ability to measure left atrial and left ventricular work indices as well the ability to monitor and measure a mixed venous saturation (SvO2). Purpose The aim of this paper is to put forward the notion that SvO2 provides valuable information about oxygen consumption and venous reserve; important measures in the critically ill to ensure oxygen supply meets cellular demand. In an attempt to portray this, a simplified example of the septic patient is offered to highlight the changing pathophysiological sequelae of the inflammatory process and its importance for monitoring SvO2. Relevance to clinical practice SvO2 monitoring, it could be argued, provides the gold standard for assessing arterial and venous oxygen indices in the critically ill. For the bedside ICU nurse the plethora of information inherent in SvO2 monitoring could provide them with important data that will assist in averting potential problems with oxygen delivery and consumption. However, it has been suggested that central venous saturation (ScvO2) might be an attractive alternative to SvO2 because of its less invasiveness and ease of obtaining a sample for analysis. There are problems with this approach and these are to do with where the catheter tip is sited and the nature of the venous admixture at this site. Studies have shown that ScvO2 is less accurate than SvO2 and should not be used as a sole guiding variable for decision-making. These studies have demonstrated that there is an unacceptably wide range in variance between ScvO2 and SvO2 and this is dependent on the presenting disease, in some cases SvO2 will be significantly lower than ScvO2. Conclusion Whilst newer technologies have been developed to continuously measure cardiac output, SvO2 monitoring is still an important adjunct to clinical decision-making in the ICU. Given the information that it provides, seeking alternatives such as ScvO2 or blood samples obtained from femorally placed central venous lines, can unnecessarily lead to inappropriate treatment being given or withheld. Instead when using ScvO2, trending of this variable should provide clinical determinates that are useable for the bedside ICU nurse, remembering that in most conditions SvO2 will be approximately 16% lower.

The consultative process used in outreach : a narrative account

Aim The aim of this paper was to provide a narrative account of the communication skills used in an effective outreach consultation utilizing Neighbour’s consultative model. Other consultation models were considered; however, because of their overly comprehensive approach or emphasis on behaviour modification, these were deemed inappropriate. Background The nursing profession has endured significant changes of late and as a result is developing more autonomous roles in both the community and the acute health care settings. In the past, the term consultancy was used within the medical context; nowadays, there are advance nurse practitioners for whom consultancy is an integral part of their role. Although every nursing interaction is in essence a consultation, the fact that nurses are taking up on new advanced roles highlights the necessity for nurses to develop their consultation skills even further. Therefore, it makes sense to explore what aspects of that consultancy role needs special consideration in order to ensure that positive outcomes are achieved. Conclusions This paper has used a narrative account to uncover those salient skills needed to enhance the therapeutic relationship with a patient requiring the services of outreach. Furthermore, the application of a recognized consultation model was used to elucidate the underpinning knowledge of systematic history taking and assessment as well as demonstrating the communication skills and strategies needed to increase the patient’s participation and empowerment throughout the consultation. Relevance to clinical practice Effective communication skills encompassed in a consultative model are integral to the success in safeguarding the well-being of patients requiring advanced levels of care. Prejudging or pre-empting information being conveyed can be detrimental to patient safety and may prolong or complicate treatment plans.

From expert to tasks, expert nursing practice redefined?

Aim The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

The pathophysiology of emphysema : considerations for critical care nursing practice

Emphysema is caused by exposure to cigarette smoking as well as alpha1-antitrypsin deficiency. It has been estimated to cost the National Health Service (NHS) in excess of £800 million per year in related health care costs. The challenges for Critical Care nurses are those associated with dynamic hyperinflation, Auto-PEEP, malnutrition and the weaning from invasive and non-invasive mechanical ventilation. In this paper we consider the impact of the pathophysiology of emphysema, its effects on other body systems as well as the impact acute exacerbations have when patients are admitted to the Intensive Care Unit.

Challenges of recruiting hospice patients with advanced cancer to research : reflections on a delirium screening study

Introduction Delirium research in palliative care, particularly in the dying phase, is possible but is frequently met with ethical and methodological challenges. This paper describes the challenges faced in a previous delirium screening study. Methods Within 72 hours of admission to an acute inpatient specialist palliative care unit one hundred consecutive patients over 18 years of age with advanced cancer were invited to be screened for delirium using validated screening tools. Results Of the 100 consecutive admissions 49 patients were unable to participate including seven who did not meet the inclusion criteria and nine (six families and three patients) who withheld consent. The remaining 33 patients were more unwell and closer to death than those who were recruited. Reasons for non- participation included being too unwell (ten), unresponsive (nine), died (two) or discharged (three) before recruitment and exceeding the 72hour time limit (nine). Conclusion Gate keeping and physical condition of patients were the main obstacles to recruitment and is consistent with barriers faced in previous studies involving palliative care and dying patients. While it is possible and necessary to conduct studies in palliative care, including the terminal phase, as reflective practitioners we must maintain the balance between the demands for evidence-based practice and our compassion and respect for our most vulnerable of patients.

Mentoring : improving transition to practice

Nurse graduates indicate the transition from student of nursing to registered nurse (RN) is a difficult conversion. This impending change of role and accompanying higher expectations placed upon newly graduating RNs causes concern for students as their Bachelor of Nursing program nears completion. A career mentor scheme is suggested as a way to better prepare final year students for this transition. Evaluations indicate the positive impact the scheme has made on both mentors and mentees as it has enhanced their career development.

Critical care nurses' perceptions of their educational needs

A survey of nurses working in critical care units in 89 Queensland hospitals was conducted to investigate their perceptions of critical care nurses' educational needs. Two thirds of the 62 respondents were from rural units and one third were from metropolitan units. Most respondents, irrespective of geographic location, wanted critical care education to be located in hospitals and to be accredited as a graduate diploma course. Rural and metropolitan nurses had similar educational needs and many worked for hospitals that were not offering adequate orientation or inservice critical care education. The findings that nursing staff turnover was a problem in metropolitan units and that the rural workforce was more stable have implications for the development of educational programs.

Distinguishing between task and contextual performance for nurses : development of a job performance scale

Aim. This paper is a report of a development and validation of a new job performance scale based on an established job performance model. Background. Previous measures of nursing quality are atheoretical and fail to incorporate the complete range of behaviours performed. Thus, an up-to-date measure of job performance is required for assessing nursing quality. Methods. Test construction involved systematic generation of test items using focus groups, a literature review, and an expert review of test items. A pilot study was conducted to determine the multidimensional nature of the taxonomy and its psychometric properties. All data were collected in 2005. Findings. The final version of the nursing performance taxonomy included 41 behaviours across eight dimensions of job performance. Results from preliminary psychometric investigations suggest that the nursing performance scale has good internal consistency, good convergent validity and good criterion validity. Conclusion. The findings give preliminary support for a new job performance scale as a reliable and valid tool for assessing nursing quality. However, further research using a larger sample and nurses from a broader geographical region is required to cross-validate the measure. This scale may be used to guide hospital managers regarding the quality of nursing care within units and to guide future research in the area.

Predicting emotional exhaustion among haemodialysis nurses : a structural equation model using Kanter’s structural empowerment theory

Aim To test an explanatory model of the relationships between the nursing work environment, job satisfaction, job stress and emotional exhaustion for haemodialysis nurses, drawing on Kanter's theory of organizational empowerment. Background Understanding the organizational predictors of burnout (emotional exhaustion) in haemodialysis nurses is critical for staff retention and improving nurse and patient outcomes. Previous research has demonstrated high levels of emotional exhaustion among haemodialysis nurses, yet the relationships between nurses' work environment, job satisfaction, stress and emotional exhaustion in this population are poorly understood. Design A cross-sectional online survey. Methods 417 nurses working in haemodialysis units completed an online survey between October 2011–April 2012 using validated measures of the work environment, job satisfaction, job stress and emotional exhaustion. Results Overall, the structural equation model demonstrated adequate fit and we found partial support for the hypothesized relationships. Nurses' work environment had a direct positive effect on job satisfaction, explaining 88% of the variance. Greater job satisfaction, in turn, predicted lower job stress, explaining 82% of the variance. Job satisfaction also had an indirect effect on emotional exhaustion by mitigating job stress. However, job satisfaction did not have a direct effect on emotional exhaustion. Conclusion The work environment of haemodialysis nurses is pivotal to the development of job satisfaction. Nurses' job satisfaction also predicts their level of job stress and emotional exhaustion. Our findings suggest staff retention can be improved by creating empowering work environments that promote job satisfaction among haemodialysis nurses.