'Moral distress'-time to abandon a flawed nursing construct?

Moral distress has been characterised in the nursing literature as a major problem affecting nurses in all healthcare systems. It has been portrayed as threatening the integrity of nurses and ultimately the quality of patient care. However, nursing discourse on moral distress is not without controversy. The notion itself is conceptually flawed and suffers from both theoretical and practical difficulties. Nursing research investigating moral distress is also problematic on account of being methodologically weak and disparate. Moreover, the ultimate purpose and significance of the research is unclear. In light of these considerations, it is contended that the notion of moral distress ought to be abandoned and that concerted attention be given to advancing inquiries that are more conducive to improving the quality and safety of moral decision-making, moral conduct and moral outcomes in nursing and healthcare domains.

Family presence during management of acute deterioration: clinician attitudes, beliefs and perceptions of current practices

BACKGROUND: The nature of acute clinical deterioration has changed over the last three decades with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite this change, research related to family presence continues to focus on care during resuscitation rather than during acute deterioration. AIM: To explore healthcare clinician attitudes, beliefs and perceptions of current practices surrounding family presence during episodes of acute deterioration in adult Emergency Department patients. METHODS: Clinicians (n=156) from a single study site in Melbourne, Australia completed a 17-item survey. RESULTS: Participants disagreed that family members would interrupt (59.0%) or interfere (61.5%) with patient care if present during episodes of patient deterioration. Most (77.6%) participants stated that they included family during episodes of patient deterioration. Females, nurses and Australians/New Zealanders had a more positive attitude towards including family during episodes of patient deterioration when compared to males, doctors and clinicians of other ethnicities. Nurses with post-graduate qualifications and those with more years of experience had a more positive attitude towards including family during episodes of patient deterioration than nurses without post-graduation qualification and with less years of experience. CONCLUSIONS: Clinicians had predominantly positive attitudes towards including family during episodes of patient deterioration and perceived it to be a common day-to-day practice. Gender, profession, country of birth, education level and years of experience all impacted on clinician attitudes, beliefs and perceptions of family presence during acute deterioration.

The acceptance of nursing information systems: an analysis using UTAUT

Nurses are the largest group of health-care professionals in hospitals providing 24-h care to patients. Hence, nurses are pivotal in coordinating and communicating patient care information in the complex network of health-care professionals, services, and other care processes. Further, surveillance and timely interventions by nurses impact quality of care, reduce errors, and decrease health-care costs. Information communication technologies (ICTs) provide the capabilities to support many aspects of nursing care. However, within the context of acute nursing care, there is a lack of integrated technology solutions to support the complex interactions associated with nursing activities and thereby the delivery of high-quality and safe care. Generally, to date, the literature reports low levels of acceptance of ICT solutions by nurses. To address this, the following discussion serves to examine nurses’ acceptance of an integrated point-of-care solution for acute nursing contexts. The ICT was specifically designed to be sensitive to nurses’ needs with the expectation that this will lead to high levels of user acceptance. An evaluation of the acceptability of the proposed solution is presented using unified theory of acceptance and use of technology (UTAUT). Through the UTAUT lens, initial reactions of the participating nurses were examined. The findings provided us with feedback to redesign the solution to better fit with the dynamics and complexity of nursing care. The study has implications for theory, including using UTAUT in health-care contexts, and for practice, including recommendations for the design and development of ICT solutions suitable for nursing contexts.

An evaluation of an action research nursing documentation project

AIMS AND OBJECTIVES: The aim of this study is to describe healthcare professionals' experiences and perceptions of an intervention implemented in an action research project conducted to improve nursing documentation practices in four municipalities in Norway.

BACKGROUND: Documentation of individualized patient care is a continuing concern in healthcare services and could impacts the quality and safety of healthcare. Use of electronic systems has made some aspects of documentation more comprehensive, but creation of an individualized care plan remains a pressing issue.

DESIGN: A qualitative descriptive design was used.

METHODS: An action research project was conducted between 2010 and 2012 to improve the content and quality of nursing documentation in community healthcare services in four municipalities. One year after the project was completed four focus group interviews were conducted with healthcare professionals, one for each involved municipality. Two unit managers were interviewed individually. Qualitative content analysis was used.

RESULTS: Three themes emerged: healthcare professionals perceived competing interest; they experienced that they had to manage complexity and changes; and they highlighted a clear and visible leader as important for success.

CONCLUSIONS: Quality improvement activities are essential. Healthcare professionals experience a complicated situation when electronic health record systems do not support workflow. Further research is recommended to focus on the functionality and user interface of EHR systems, and on the role of leadership when implementing changes in clinical practice. This article is protected by copyright. All rights reserved.

An analysis of clinical handover miscommunication using a language and social psychology approach

Clinical handover is a key communication event in patient care and a major contributing factor in adverse events in hospitals. Current research on handover emphasizes communication skills training. We investigate the intergroup context and systemic factors of the hospital environment that also affect handover. We explore the responses of 707 health professionals about handover practice. We invoke Coupland and colleagues’ integrative model of “miscommunication” to interpret these. Results support the model. Responses reflect a lack of communication competency, intergroup group relations, and the hidden ideology of the health care system. Health professionals in hospitals are often unaware of the socio-structural element in health care and so cannot bring about cultural change. We suggest that clinicians work with communication and interdisciplinary scholars to bring about system improvement.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional "waitlist and triage" model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction.

METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial.

DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.

L’étendue effective de pratique des infirmières oeuvrant en santé mentale et le niveau de formation

L’importance du rôle de l’infirmière dans le système de santé autant au niveau de l’accessibilité que la qualité et la sécurité des soins et services donnés à la population est reconnue. Pour être en mesure d’exercer pleinement ce rôle, les infirmières doivent être en mesure d’exercer à leur pleine étendue de pratique. Les infirmières œuvrant dans le domaine de la santé mentale n’y font pas exception. Or, les recherches démontrent que les infirmières ne parviennent pas à mettre en oeuvre l’ensemble des activités pour lesquelles elles détiennent la formation et l’expérience. Cette recherche vise à mesurer l’étendue de pratique effective des infirmières oeuvrant en santé mentale ainsi qu’à identifier l’influence du niveau de formation sur cette étendue de pratique. Cette étude prend appui sur le SCOP model de Déry et al. (2015) qui mentionne que certaines caractéristiques de l’environnement et individuelles, telles que le niveau de formation, peuvent influencer l’étendue effective de la pratique des infirmières. Le déploiement de cette étendue de pratique a le potentiel d’influencer à son tour la satisfaction professionnelle des infirmières (Déry et al., 2013), la qualité des soins aux patients ainsi que d’autres variables organisationnelles telles que l’accessibilité, les durées moyennes de séjours et les coûts. Un devis corrélationnel descriptif a été retenu pour cette étude. Un questionnaire de type Likert a été complété par les infirmières (n=80) d’un Institut universitaire en santé mentale du Québec. Des analyses de la variance ont été utilisées pour comparer les moyennes d’étendue de pratique selon les ni-veaux de formation. Les résultats démontrent un déploiement sous-optimal de l’étendue de la pratique des infirmières (4,24/6; E.T.= 0,63). Cette étendue de pratique est tout de même supérieure à l’étendue de pratique des infirmières d’autres milieux qui a été mesurée à l’aide du questionnaire de l’étendue de la pratique infirmière (QÉPI). Les analyses effectuées concernant l’influence du niveau de formation sur l’étendue de pratique n’ont révélées aucune différence significative entre les niveaux de formation F (3, 77) = 0,707, p = 0,551. Le niveau de formation des infirmières, la présence d’un biais de représentation, le manque de puissance statistique et certaines caractéristiques de l’emploi peuvent expliquer ces résultats. Les résultats de cette étude semblent constituer une recherche empirique initiale puisqu'il s’agit à ce jour de l’unique recherche à avoir mesuré l’étendue de pratique des infirmières œuvrant en santé mentale à l’aide du QÉPI et à avoir tenté de connaître l’influence que pouvait avoir le niveau de formation sur l’étendue de leur pratique.

Test of a Smock System on CPR Primary Emergency Measures and Medical Errors During Simulated Emergencies

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on:1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.

L’étendue effective de pratique des infirmières oeuvrant en santé mentale et le niveau de formation

L’importance du rôle de l’infirmière dans le système de santé autant au niveau de l’accessibilité que la qualité et la sécurité des soins et services donnés à la population est reconnue. Pour être en mesure d’exercer pleinement ce rôle, les infirmières doivent être en mesure d’exercer à leur pleine étendue de pratique. Les infirmières œuvrant dans le domaine de la santé mentale n’y font pas exception. Or, les recherches démontrent que les infirmières ne parviennent pas à mettre en oeuvre l’ensemble des activités pour lesquelles elles détiennent la formation et l’expérience. Cette recherche vise à mesurer l’étendue de pratique effective des infirmières oeuvrant en santé mentale ainsi qu’à identifier l’influence du niveau de formation sur cette étendue de pratique. Cette étude prend appui sur le SCOP model de Déry et al. (2015) qui mentionne que certaines caractéristiques de l’environnement et individuelles, telles que le niveau de formation, peuvent influencer l’étendue effective de la pratique des infirmières. Le déploiement de cette étendue de pratique a le potentiel d’influencer à son tour la satisfaction professionnelle des infirmières (Déry et al., 2013), la qualité des soins aux patients ainsi que d’autres variables organisationnelles telles que l’accessibilité, les durées moyennes de séjours et les coûts. Un devis corrélationnel descriptif a été retenu pour cette étude. Un questionnaire de type Likert a été complété par les infirmières (n=80) d’un Institut universitaire en santé mentale du Québec. Des analyses de la variance ont été utilisées pour comparer les moyennes d’étendue de pratique selon les ni-veaux de formation. Les résultats démontrent un déploiement sous-optimal de l’étendue de la pratique des infirmières (4,24/6; E.T.= 0,63). Cette étendue de pratique est tout de même supérieure à l’étendue de pratique des infirmières d’autres milieux qui a été mesurée à l’aide du questionnaire de l’étendue de la pratique infirmière (QÉPI). Les analyses effectuées concernant l’influence du niveau de formation sur l’étendue de pratique n’ont révélées aucune différence significative entre les niveaux de formation F (3, 77) = 0,707, p = 0,551. Le niveau de formation des infirmières, la présence d’un biais de représentation, le manque de puissance statistique et certaines caractéristiques de l’emploi peuvent expliquer ces résultats. Les résultats de cette étude semblent constituer une recherche empirique initiale puisqu'il s’agit à ce jour de l’unique recherche à avoir mesuré l’étendue de pratique des infirmières œuvrant en santé mentale à l’aide du QÉPI et à avoir tenté de connaître l’influence que pouvait avoir le niveau de formation sur l’étendue de leur pratique.

Preferência do local de cuidados dos doentes em fim de vida: revisão sistemática da literatura

PROBLEMÁTICA: Com o aumento da população e comummente com o aumento de doenças crónicas, leva a um crescimento de doentes que necessitam de cuidados paliativos. A intervenção em cuidados paliativos visa o alívio do sofrimento e melhorar a qualidade de vida do doente e sua família, respeitando as suas preferências e desejos. Os profissionais de saúde necessitam de formação em Cuidados Paliativos, respeitando as expetativas dos doentes e permitir que a pessoa seja cuidada no seu local preferido de cuidados e não recorrer consecutivamente a urgências e internamentos de agudos. OBJETIVOS: Demonstrar a importância da identificação da preferência do local de cuidados dos doentes em fim-de-vida, compreender a importância do planeamento de cuidados e Diretivas antecipadas de vontade (DAV), relacionar a escolha do local de cuidados com o local de morte, identificar os fatores que influenciam e condicionam a escolha do local de cuidados dos doentes em fim-de-vida e por fim, perceber a organização e qualidade dos serviços. DESENHO: Revisão sistemática da literatura que inclui estudos de natureza qualitativa. METODOLOGIA: Foram incluídos oito estudos, publicados entre 1 de Janeiro de 2016 e 31 de Agosto 2016, pesquisados em bases de dados de referência e com acesso ao texto integral. RESULTADOS: Este estudo demonstra a importância das preferências dos doentes e serem registadas, a importância das Diretivas Antecipadas de Vontade, bem como o planeamento do cuidado de forma antecipada. É fundamental ter em conta os fatores que influenciam e condicionam a escolha do local de cuidados. CONCLUSÃO: Deve dar-se importância às preferências do local de cuidado dos doentes em fim-de-vida. Os doentes em fim-de-vida na sua globalidade preferem ser cuidados e morrerem em casa. As equipas multidisciplinares desenvolvem um papel preponderante no cuidado aos doentes em fim-de-vida. Quando os cuidados prestados são de alta qualidade, permite ao doente ser cuidado e morrer no seu local preferido.

Äldre invandrares från före detta Jugoslaviens förväntningar i mötet med sjuksköterskor i Sverige : -En kvalitativ intervjustudie

Dagens samhälle blir allt mer mångkulturellt. Det ställer högre krav på både omvårdnaden och sjuksköterskan. Sjuksköterskans eventuella brist på kompetens om kulturskillnader kan skapa kulturkrockar, missförstånd och felaktig omvårdnad. Syftet med studien var att undersöka vilka förväntningar äldre invandrare från förre detta Jugoslavien har i möten med sjuksköterskan i Sverige samt hur sjuksköterskans kompetens kan skiljas från undersköterskor, sjukgymnaster och arbetsterapeuter. Metod: Studien är kvalitativ med en induktiv ansats och baseras på sex intervjuer med äldre invandrare som ursprungligen kom från fd. Jugoslavien. Personlig kontakt togs med informanterna om deltagande i undersökningen genom serbiska/bosniska/kroatiska/makedoniska. Författaren informerade om studien och att de som ville delta kontaktade författaren. Insamlat material analyserades systematiskt med innehållsanalys. Resultat: Det som framkom att de äldre invandrarna förväntade sig i mötet med sjuksköterskan presenteras i följande fem kategorier; Att få bekräftelse för uttalade behov; Empatisk kontakt; Kommunikation och dialog i mötet; Respekt för sina värderingar och syn på hälsa och Trygghet. Slutsatsen: omvårdnad av äldre patienter med en annan kulturell bakgrund kräver båda kulturell kompetens och professionellt förhållningssätt. Sjuksköterskan behöver kunna identifiera patientens vårdbehov och i detta fallet även övergå de språkliga barriärer och nå patienten och förstå deras behov.

PPM-HDA: privacy-preserving and multifunctional health data aggregation with fault tolerance

Wireless body area networks (WBANs), as a promising health-care system, can provide tremendous benefits for timely and continuous patient care and remote health monitoring. Owing to the restriction of communication, computation and power in WBANs, cloud-assisted WBANs, which offer more reliable, intelligent, and timely health-care services for mobile users and patients, are receiving increasing attention. However, how to aggregate the health data multifunctionally and efficiently is still an open issue to the cloud server (CS). In this paper, we propose a privacy-preserving and multifunctional health data aggregation (PPM-HDA) mechanism with fault tolerance for cloud-assisted WBANs. With PPM-HDA, the CS can compute multiple statistical functions of users' health data in a privacy-preserving way to offer various services. In particular, we first propose a multifunctional health data additive aggregation scheme (MHDA⁺) to support additive aggregate functions, such as average and variance. Then, we put forward MHDA^⊕ as an extension of MHDA⁺ to support nonadditive aggregations, such as min/max, median, percentile, and histogram. The PPM-HDA can resist differential attacks, which most existing data aggregation schemes suffer from. The security analysis shows that the PPM-HDA can protect users' privacy against many threats. Performance evaluations illustrate that the computational overhead of MHDA⁺ is significantly reduced with the assistance of CSs. Our MHDA^⊕ scheme is more efficient than previously reported min/max aggregation schemes in terms of communication overhead when the applications require large plaintext space and highly accurate data.

Iowa Physician Orders for Scope of Treatment (IPOST) Work Plan, April 21, 2014

To promote community care coordination and advanced care planning. Seamless communication and execution of individual patient care choices across the healthcare continuum.

The impact of ethics education in medical laboratory science.

Teachers and students were asked what ethics education is offered in their program. The survey of the teachers regarding ethics education revealed some differences between english and french schools. It was found that franch schools favoured ethics courses taught by philosophers while english schools favoured ethics courses taught by health care providers. Furthermore, case studies were reported to be used more often in english schools and more often in assignments. However, regarless of the differences, 87 % of teachers agreed that ethics training is a high priority and most teachers thought that ethics training in their programs was adequate. At same time, students were asked to answer some questions that involved ethical dilemmas wherein some moral decisions would have to be made. Their responses revealed their level of moral development, based on Kohlberg's theory of moral development. The impact of ethics courses in the curriculum on moral development was correlated taking into account what ethics education students actually received with what year-of-study they were in (1st year, end of program or two years post graduation). Students were presented scenarios about falsifying records, communication, student dishonesty and preanalytical impact on patient care. These are authentic issues that technologists face on a daily basis. In reply to multiple-choice questions, respondents chose, in order of personal preference, the three best answers out of six offered to complete a statement regarding ethics. Statistical analysis was performed using SPSS (Statistical Package for Social Studies), employing crosstabulations and Oneway Anova. Factors including respondents age range, mother tongue, gendre, and years of schooling were considered.

Impacto de la implementación de un modelo de gestión integral de atención de la enfermedad y cuidado coordinado en la población en diálisis en Colombia

La atención hospitalaria en el costo global de la atención de los pacientes en diálisis es muy importante. Este estudio se realizó con el fin de evaluar resultados posteriores a la implementación de un modelo de gestión de la enfermedad y cuidado coordinado en una red de diálisis en Colombia, evaluando los cambios específicos en las tasas de hospitalización de una cohorte de pacientes renales con dos años de seguimiento. El modelo se enfoca básicamente en mejorar la atención de los pacientes en diálisis protocolizando en el manejo de comorbilidades (diabetes, riesgo cardiovascular, patologías infecciosas) y en el cuidado coordinado entre el tratamiento ambulatorio y hospitalario de los pacientes en diálisis asegurando la continuidad en el proceso de atención de los pacientes. El Estudio observacional analítico de cohortes compuesto por 2 fases una primera cohorte histórica retrospectiva y una segunda con dos cohortes prospectivas, incluyó pacientes mayores de 18 años, con más de 90 días en diálisis, con al menos tres meses de intervención con el modelo de gestión de enfermedad en la red Renal Therapy Services (RTS®). En conclusión, la realización de este estudio, se pudo asociar a la reducción en la atención hospitalaria de pacientes en diálisis y a una menor mortalidad, modelos como este y otras soluciones para mejorar los desenlaces en salud en los pacientes en diálisis deben seguir siendo implementados para aliviar la carga de la enfermedad y reducir los costos de la atención en salud de esta población.