Acute care teaching in the undergraduate nursing curriculum

AIM: To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards.
BACKGROUND: Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum.
PRACTICE DEVELOPMENT INITIATIVE: An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module.
CONCLUSIONS: Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care.
RELEVANCE TO CLINICAL PRACTICE: The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.

Using Workload Measurement Tools in Diverse Care Contexts: the Experience of Staff in Mental Health and Learning Disability Inpatient Settings

Introduction The critical challenge of determining the correct level and skill-mix of nursing staff required to deliver safe and effective healthcare has become an international concern. It is recommended that evidence-based staffing decisions are central to the development of future workforce plans. Workforce planning in mental health and learning disability nursing is largely under-researched with few tools available to aid the development of evidence-based staffing levels in these environments. Aim It was the aim of this study to explore the experience of staff using the Safer Nursing Care Tool (SNCT) and the Mental Health and Learning Disability Workload Tool (MHLDWT) in mental health and learning disability environments. Method Following a 4-week trial period of both tools a survey was distributed via Qualtrics on-line survey software to staff members who used the tools during this time. Results The results of the survey revealed that the tools were considered a useful resource to aid staffing decisions; however specific criticisms were highlighted regarding their suitability to psychiatric intensive care units (PICU) and learning disability wards. Discussion This study highlights that further development of workload measurement tools is required to support the implementation of effective workforce planning strategies within mental health and learning disability services. Implications for Practice With increasing fiscal pressures the need to provide cost-effective care is paramount within NHS services. Evidence-based workforce planning is therefore necessary to ensure that appropriate levels of staff are determined. This is of particular importance within mental health and learning disability services due to the reduction in the number of available beds and an increasing focus on purposeful admission and discharge.

Exploring the effects of change on nursing practice in acute ambulatory care settings : a qualitative study

As a result of the current changes taking place in the delivery of acute care services, the emergence of acute ambulatory care (AAC) settings is expanding. According to a literature review, the volume, acuity, and complexity of patient care in these settings is increasing while the time the patients spend under the care of nurses is decreasing. Two forces, hospital downsizing and advancing technology, are identified as the major contributors to the shift in acute care delivery. The effects that these changes are having on the clinical nursing practice of registered nurses working in AAC settings are not known. Given that AAC settings are rapidly expanding, it can be anticipated that the delivery of nursing care will continue to be compressed into a shorter time frame. Therefore, the following qualitative research question was formulated: What are the problems and issues related to clinical nursing practice in acute ambulatory settings? The purpose of this study was to explore the problems and issues associated with change and clinical nursing practice including the educational needs of nurses working in MC settings. Specific objectives of the study included the following: (a) to explore the problems and issues related to nursing practice in select AAC settings; (b) to explore the similarities and differences in perspectives related to role expectation between nurse managers, nurse educators, and staff nurses; and (c) to develop a conceptual framework that will guide the construction of an instrument needed for further research. This study used semistructured individual interviews and focus group sessions to collect data from the three categories of registered nurses. More specifically, data were collected from one nurse manager, two charge nurses, two nurse educators and fifteen staff nurses, working in three different MC settings of a major teaching hospital. Collected data were separately analyzed by the researcher and an external rater following grounded theory methodology. By using open and axial coding, the problems and issues identified by nurses were grouped into several major and minor themes. In final analysis, by using selective coding, the four core themes (intensification, moderation, frustration, and adaptation) were extracted. Each core theme was presented and discussed in relation to hospital downsizing and advancing technology. The relationships among the four core themes were discussed and depicted in a model termed the "Impact and Consequence Model on Nursing Practice in MC Settings." Implications for further research are discussed and research hypotheses, based on the research findings, are presented.

O Cuidador de Enfermagem e o Cuidar em Uma Unidade de Terapia Intensiva; The Nursing Caregiver and the Caring in Intensive Care Units

There are several aggressive factors in Intensive Care Units (ICU), which reach not only patients, but the nursing caregivers, since they participate in complex procedures and death of patients. Nursing caregivers may have difficulties on their daily work routine that can influence the way of care. The goal of this study was to identify the aspects of nursing caregivers working in adult ICU. It is a describe-exploratory study with qualitative approach, developed among 21 ICU adult nursing caregivers of a school hospital in Paraná. The data were collected in May and July, 2009 by recorded and transcribed semi-structured interviews. Four categories for analysis were identified: the aspects of ICU assistance, the meaning of healthcare for the nursing caregivers, the understanding of healthcare positive aspects and disclosing the difficulties of caring. The results revealed that caring is related to some factors such as mixed feelings, the mental and physical damage caused by stress; the understanding of total caring, scientific-technique procedures, family engagement in the assistance and humanization. The positive aspects are related to the welfare due to satisfaction in the work done and recognition of work. The difficulties involved death situations, psychological and biological damages, establishing links with patients and the uncaring toward the nursing caregivers.

Qualidade de vida do cuidador de enfermagem e sua relação com o cuidar; Quality of life of the nursing caregiver and its relationship with care

Objective:To identify aspects that affect the quality of life of nursing caregivers and their relationship with care in an Intensive Care Unit for Adults (A-ICU). Methods:This was a descriptive study with qualitative approach, taking as subjects 21 professionals who constitute the nursing staff of the A-ICU of a school hospital in Maringá-PR. Unstructured interview was used as a strategy to collect data, conducted between May and June 2009. Data analysis was based on the method of content analysis. The categories identified were: overlooking improvement in quality of life related to the resources in an A-ICU; the quality of life influencing the form of care; interpersonal relationships into the health team reflecting on the quality of life and care. Results:The analysis of caregivers’ speech and the results of the observation showed that there is correlation between the aspects they consider influential in their quality of life and the way of caring for patients in an A-ICU.Conclusion: The findings indicate that, among the influential aspects, the stressful factors overlap the enhancing ones. From this perspective, dealing with caregiver’s suffering might be the starting point for the improvement in quality of care in an A-ICU.

Challenges of measuring and linking patient outcomes to nursing interventions in acute care settings

Measuring and linking patient outcomes to nursing intervention is an important task that has professional, financial and political ramifications. The importance and complexity of measuring patient outcomes accurately should not be overlooked, as there are a number of emergent factors that influence this process. These include the turbulent context of practise, variations in care due to the large number of health professionals, individual patient characteristics impacting on outcomes, determining appropriate nursing outcome measures, nursing's lack of autonomy within the system and difficulties experienced while trying to link patient outcomes to nursing interventions. So that the results reflect reality, it is important for researchers in the field to take note and consider these factors when measuring patient outcomes. The present article aimed to examine and discuss a number of these factors as they relate to the evaluation of patient care.

Nursing handover : it's time for a change

Nursing handover is a common part of nursing practice that is fundamental to safe patient care. Despite this, the literature provides little direction on the best way to conduct handover. This project aimed to examine nurses' perceptions of handover and to determine the strengths and limitations of the handover process. A staff survey was distributed to nurses in all inpatient wards at a metropolitan tertiary hospital. A total of 176 nurses responded to the staff survey. The findings revealed conflicting opinions about the effectiveness of the handover process; although a number of nurses were positive about current handover practice, indicating they were provided with sufficient information about patients and given opportunity to clarify patient care information, other nurses identified aspects of handover that could be improved. These included: the subjectivity of handover information, the time taken to conduct handover, repetition of information that could be found in the patients' care plans, and handing over of information by a nurse who has not cared for the patient. Some attention needs to given to addressing the perceived weaknesses associated with the handover process.

An evaluation of a national program to implement the cornell scale for depression in dementia into routine practice in aged care facilities

Background: Screening tools have been recommended for use in aged care to improve the detection and treatment of depression. This study aimed to evaluate the impact of a program for the routine implementation of the Cornell Scale for Depression in Dementia in Australian facilities, to determine whether use of the instrument by nurses led to further monitoring of depressive symptoms, medical referral, and changes in treatments prescribed for depression.
Methods: A file review was completed for 412 participants out of a total of 867 older people (47.5%) who resided in ten aged care facilities. The review examined Cornell Scale assessment data, medication charts, medical history, nursing progress notes, and resident care plans. Nursing staff who administered the Cornell Scale to each participant were also interviewed, and ten facilitymanagers took part in an interview to determine barriers to the effective implementation of the instrument.
Results: The Cornell Scale had been administered to 46.8% of the sample in the previous 12 months, with 25% of these participants scoring 9–13 and 27% scoring 14 and above. Less than one third of the residents with high scores were monitored by the staff following the assessment. Only 18% of residents with high scores were referred for further assessment of depression, while 10% received a treatment change.
Conclusions: The absence of a protocol for responding to high Cornell Scale scores limited the potential of this program to result in widespread improved treatment of depressed older people. The use of the Cornell Scale by aged care nurses with limited training raised concern.

Providing quality mental health nursing in primary health care settings in Kenya : A discussion paper.

Kenya, a country of 38 million people in East Africa has about 75 Psychiatrists and 500 Psychiatric Nurses, the majority work in the private sector and mainly in urban areas. Mental illness is common in Kenya, however, specialist services are sparse and primary care struggles to cope, and this has been worsened by general health programs which have been slow to appreciate the significance of mental health. The World Health Organisation recommends that provision of good quality mental health care does not only involve increasing the number of health workers but changing the skill mix and developing new competencies among existing workers. Successful implementation of mental, neurological and substance abuse disorder services in Kenya will depend on nurses, who constitute majority of the workforce located in provinces, districts and community clinics.

This discussion paper will address s key workforce issues affecting the up-scaling of mental health services, and the delivery of quality mental health nursing care in primary health care settings in Kenya. Strategies to develop skills and competencies of new and existing personnel will be discussed.

Mind the gap! : A discussion on the disparity between low and high income countries in the provision of mental health care and the implications for capacity building in Kenya’s nursing workforce.

About fourteen per cent of the global burden of disease has been attributed to mental, neurological and substance use disorders. A number of initiatives have been launched in recent years to respond to this, the World Health Organisation (WHO) introduced the Mental Health Gap Action Programme (mhGAP) to address the widening gap between what is needed to provide adequate mental health services and what is currently available, especially in low and middle income countries where the gap is widest.
This discussion paper will focus on mental health nursing in Kenya, a country in East Africa with a population of 42 million people. Mental illness is common in Kenya with up to twenty five per cent prevalence rates, yet mental health services are sparse at the tertiary and primary care level and mental health remains a low budget and policy priority for the government. The aim of this paper is to raise participants’ awareness of the challenges of delivering mental health nursing care in low-income countries such as Kenya, and to explore possible solutions to the problem.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care out-reach service on acute health care utilisation

Background: Over the last decade, high demand for acute health care services by long-term residents of residential care facilities (RCF) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include: comprehensive care planning, management of intercurrent illness and rapid access to acute care substitution services.Objective: To evaluate whether the RECIPE service decreased acute health care utilisation.Design: A retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment.Setting: A 300 bed metropolitan teaching hospital in Australia and 73 RCF within its catchment.Subjects: There were 1327 patients enrolled in the service with a median age 84 years, 61% were female. Methods: Data was collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative dataset. Primary outcomes change in admission rates, length of stay and beddays per quarter.Results: In the two years prior to enrolment the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (p=0.046). Prior to enrolment the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (p=0.003). Conclusions:This study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

In-reach nursing services improve older patient outcomes and access to emergency care

Aims: To identify the impact of in-reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care. Methods: Retrospective cohort study compared clinical outcomes of 2278 presentations from 2009 with 2051 presentations from 2011 before and after the implementation of in-reach services. Results: Median emergency department length of stay decreased by 24 minutes (7.0 vs 6.6 hours, P<0.001) and admission rates decreased by 23% (68 vs 45%, P<0.001). The proportion of people with repeat emergency department visits within six months decreased by 12% (27 vs 15%). The proportion of admitted patients who were discharged with an end of life palliative care plan increased by 13% (8 vs 21%, P=0.007). Conclusions: There was a significant reduction in the median length of stay, fewer hospital admissions and fewer repeat visits for people from residential aged care following implementation of in-reach services.

Nurses' perceptions of using an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury: A qualitative study.

Evidence to guide initial emergency nursing care of patients with severe traumatic brain injury (TBI) in Thailand is currently not available in a useable form. A care bundle was used to summarise an evidence-based approach to the initial emergency nursing management of patients with severe TBI and was implemented in one Thai emergency department. The aim of this study was to describe Thai emergency nurses' perceptions of care bundle use. A descriptive qualitative study was used to describe emergency nurses' perceptions of care bundle use during the implementation phase (Phase-One) and then post-implementation (Phase-Two). Ten emergency nurses participated in Phase-One, while 12 nurses participated in Phase-Two. In Phase-One, there were five important factors identified in relation to use of the care bundle including quality of care, competing priorities, inadequate equipment, agitated patients, and teamwork. In Phase Two, participants perceived that using the care bundle helped them to improve quality of care, increased nurses' knowledge, skills, and confidence. Care bundles are one strategy to increase integration of research evidence into clinical practice and facilitate healthcare providers to deliver optimal patient care in busy environments with limited resources.

Using an evidence-based care bundle to improve initial emergency nursing management of patients with severe traumatic brain injury

AIMS AND OBJECTIVES: To test the feasibility of an evidence-based care bundle in a Thai emergency department. The specific objective of this study was to examine the impact of the implementation of the care bundle on the initial emergency nursing management of patients with severe traumatic brain injury. BACKGROUND: A care bundle approach is one strategy used to improve the consistency, quality and safety of emergency care for different patients groups, however, has not been tested in patients with severe traumatic brain injury. DESIGN: A pretest/post-test design was used. The study intervention was an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury. METHODS: Nonparticipant observations were conducted between October 2012-June 2013 at an emergency department of a 640 bed regional hospital in Southern Thailand. The initial emergency nursing care was observed in 45 patients with severe traumatic brain injury: 20 patients in the pretest period and 25 patients in the post-test period. RESULTS: There were significant improvements in clinical care of patients with severe traumatic brain injury after implementation of the care bundle: (1) use of end-tidal carbon dioxide monitoring, (2) frequency of respiratory rate assessment, (3) frequency of pulse rate and blood pressure assessment, and (4) patient positioning. CONCLUSION: This study demonstrated that implementation of an evidence-based care bundle improved specific elements of emergency nurses' clinical management of patients with severe traumatic brain injury. RELEVANCE TO CLINICAL PRACTICE: The study suggests that a care bundle approach can be used as a strategy to improve emergency nursing care of patients with severe traumatic brain injury.