Measuring Scope of Practice Enactment among Primary Care Registered Nurses in Ontario

Background: Primary care is the sector of health care in which patients first establish contact with the health system, are provided person-focused care over time for all new or common needs, and receive coordinated integrated health services provided elsewhere by other members of the health care team. Registered Nurses (RNs) in Canada provide care within this sector in varying roles. The extent to which RNs enact their full scope of practice in primary care settings in Canada is not known. The Actual Scope of Practice questionnaire (ASCOP) is a 26 item Likert scale questionnaire developed by researchers in Canada and validated in the acute care setting to measure the extent to which RNs apply the knowledge, skills and competencies of the professional full scope of practice. Similar to the acute care setting, there is a need to measure scope of practice enactment in the primary care setting. Objectives: The overall aim of this thesis was to measure scope of practice enactment in the primary care setting. Two research objectives were addressed: (1) to revise and adapt the ASCOP questionnaire for use in the primary care setting, and (2) to determine internal consistency, construct validity, and sensitivity of the modified instrument, the ASCOP-PC. Methods: To address the first objective, a narrative literature review and synthesis and an expert panel review was conducted. To address the second objective a cross-sectional survey of 178 RNs working in primary care organizations in Ontario was conducted Results: The ASCOP, with few modifications, addressed key attributes of nursing scope of practice in the primary care setting. The ASCOP-PC yielded acceptable alpha coefficients ranging from 0.66 to 0.91 and explained variances from 44.2 to 62.6. Total mean score of 5.16 suggests that RNs within these models of care almost always engage in activities reflected in the ASCOP-PC. Interpretation: Findings from this study support the use of a the modified ASCOP questionnaire as a reliable and valid measure of scope of practice enactment among primary care nurses in the primary care setting.

An Assessment of How Nurse Practitioners Create Access to Primary Care in Canadian Residential Long-Term Care Settings

The aim of this paper is to explore the role and activities of nurse practitioners (NPs) working in long-term care (LTC) to understand concepts of access to primary care for residents. Utilizing the "FIT" framework developed by Penchanksy and Thomas, we used a directed content analysis method to analyze data from a pan-Canadian study of NPs in LTC. Individual and focus group interviews were conducted at four sites in western, central and eastern regions of Canada with 143 participants, including NPs, RNs, regulated and unregulated nursing staff, allied health professionals, physicians, administrators and directors and residents and family members. Participants emphasized how the availability and accessibility of the NP had an impact on access to primary and urgent care for residents. Understanding more about how NPs affect access in Canadian LTC will be valuable for nursing practice and healthcare planning and policy and may assist other countries in planning for the introduction of NPs in LTC settings to increase access to primary care.

Caring for Children Dying from Cancer at Home: a Qualitative Study of the Experience of Primary Care Practitioners

Background. The rarity of childhood cancers makes providing palliative care in the community an unusual event for primary care practitioners. Providing this care requires effective interprofessional collaboration with the team that forms to provide the care often working together for the first and only time. Objective. To explore the experiences of primary care practitioners following their involvement in the palliative care of a child with cancer at home. Methods. The study design was a community-based qualitative study. The study location was the West Midlands region. Purposeful sample of GPs and community nurses involved in providing palliative care to 12 children. One-to-one in-depth interviews with 47 primary care professionals (10 GPs and 37 community nurses) and 5 facilitated case discussions were undertaken. Field notes were documented and grounded theory data analysis undertaken: chronological comparative data analysis identifying generated themes. Results. GPs had minimal input into the preceding care of children undergoing treatment for cancer but sought to re-establish their role at the child’s transition to palliative care. GPs felt they had a role to play and could add value to this phase of care, highlighted their continuing role with the child’s family and acknowledged that they had gained from the experience of contributing. However, lack of specialist knowledge and uncertainty about their role within the team made this more challenging. In contrast, community nurses were routinely involved in both active treatment and palliation care phases. There was little evidence of collaboration between the specialist and primary care professionals involved. There was considerable variation in out of hours provision across cases. Conclusions. Engaging primary care practitioners needs to be more actively anticipated and negotiated at the transition to palliation. Variation in out of hours care is another cause for concern. Enhancing inter-professional collaboration and planning during both active and palliative care phases may help. Keywords. Cancer, family medicine, palliative care, paediatric.

Exploring Forensic Nursing Ethics and Practice: Roles, Loyalties and Photodocumentation Practices

Thesis (Ph.D.)--University of Washington, 2016-08

Knowledge and awareness of type 1 diabetes among primary school initial teacher trainees

Prevalence of colonizing bacteria and their association with primary bacteremias in hemodialysis of a university hospital

to be from 2.5 to 5.5 cases per 1,000 catheter-day. the clinical impact is relevant and increases the cost of the HD Unit. Methods: The present study is the irst of 2 phases. It was conducted from January to December of 2012, and included all patients and nurses who were in the HD Unit. The prevalence of Gramnegative bacilli (GNB) and methicillin-resistant Staphylococcus aureus (MrSA) colonizing the nasal passages and the skin is described. Also, phenotypic association was sought by genus, species and sensitivities between colonizing bacterial strains and blood cultures with GNB and MRSA. Results: the study included 70 patients and 10 nurses. the prevalence of nasal colonization in patients by GNB was 9% and 6% in the pericatheter, and no nursing GNB colonization was discovered. The prevalence of MRSA nasal colonization was 19% and 6% in the pericatheter for patients and in the nurses the nasal colonization was 50% and 10% in the hands. We identiied 29 cases of primary bacteremia. The primary bacteremia rate is 1.5 per 1,000 catheter-day or 0.4 episodes per patient per year. Conclusion: We demonstrated a high prevalence of MrSA colonization in patients and nurses in the HD Unit. No relationship was found between primary bacteremia by GNB and patients and nurses’ bacteria colonization by the phenotypic comparison.

Primary health care nurse perception and men’s expectation of the role of the primary health care nurse in providing men’s health services in the primary care setting in Victoria

 This study adds significantly to the current paucity of knowledge around men's health in Australian primary care and in particular stresses the need for men's health care education to be more reliable and systematic foundation for men's sexual health, mental health and health promotion.

End of life clinician-family communication in ICU: a retrospective observational study - implications for nursing

Objective: The objective of this study was to identify practice issues that influence end of life communication and care of patients and families in the intensive care unit (ICU).

Design: This study used a retrospective observational approach utilising a medical record review. Setting: An Australian metropolitan mixed medical/surgical ICU. Subjects: There are two parts to this study. The first part related to all of the patients who died in the ICU in one calendar year, a total of 97. The second part of this study related to a random selection of 25% of these patients, a total of 24.

Results: This study showed that death in the ICU was often anticipated, and that whilst communication between family and medical personnel was evident in the medical record, the involvement or occurrence of communication between the nurse and the family was not recorded, and that nurses were included in only 25% of formal family meetings.

Conclusion: Whilst this study confirmed that death is often predicted for critically ill patients, and opportunities for communication with the family or next of kin assists to achieve consensus on end of life decisions, the involvement of nurses, as primary care-givers is not well represented in the medical record, thus undermining the importance of the nurses role in direct patient care that extends to the family in the ICU.

Measuring nursing competencies in the operating theatre: instrument development and psychometric analysis using Item Response Theory

BACKGROUND: Concern about the process of identifying underlying competencies that contribute to effective nursing performance has been debated with a lack of consensus surrounding an approved measurement instrument for assessing clinical performance. Although a number of methodologies are noted in the development of competency-based assessment measures, these studies are not without criticism. RESEARCH AIM: The primary aim of the study was to develop and validate a Performance Based Scoring Rubric, which included both analytical and holistic scales. The aim included examining the validity and reliability of the rubric, which was designed to measure clinical competencies in the operating theatre. RESEARCH METHOD: The fieldwork observations of 32 nurse educators and preceptors assessing the performance of 95 instrument nurses in the operating theatre were used in the calibration of the rubric. The Rasch model, a particular model among Item Response Models, was used in the calibration of each item in the rubric in an attempt at improving the measurement properties of the scale. This is done by establishing the 'fit' of the data to the conditions demanded by the Rasch model. RESULTS: Acceptable reliability estimates, specifically a high Cronbach's alpha reliability coefficient (0.940), as well as empirical support for construct and criterion validity for the rubric were achieved. Calibration of the Performance Based Scoring Rubric using Rasch model revealed that the fit statistics for most items were acceptable. CONCLUSION: The use of the Rasch model offers a number of features in developing and refining healthcare competency-based assessments, improving confidence in measuring clinical performance. The Rasch model was shown to be useful in developing and validating a competency-based assessment for measuring the competence of the instrument nurse in the operating theatre with implications for use in other areas of nursing practice.

The adoption of roles by primary care providers during implementation of the new chronic disease guidelines in urban Mongolia: a qualitative study

(1) BACKGROUND: In 2011, new chronic disease guidelines were introduced across Mongolia. No formal advice was provided regarding role delineation. This study aimed to analyse the roles that different primary care providers adopted, and the variations in these, in the implementation of the guidelines in urban Mongolia;

(2) METHODS: Ten group interviews with nurses and ten individual interviews each with practice doctors and practice directors were conducted. Data was analysed using a thematic approach based on the identified themes relevant to role delineation;

(3) RESULTS: There was some variability and flexibility in role delineation. Factors involving teamwork, task rotation and practice flexibility facilitated well the guideline implementation. However, factors including expectations and decision making, nursing shortage, and training gaps adversely influenced in the roles and responsibilities. Some role confusion and dissatisfaction was identified, often associated with a lack of training or staff turnover;

(4) CONCLUSIONS: Findings suggest that adequate ongoing training is required to maximize the range of roles particular provider types, especially primary care nurses, are competent to perform. Ensuring that role delineation is specified in guidelines could remove confusion and enhance implementation of such guidelines.

Key milestones in the operationalisation of professional nursing ethics in Australia: a brief historical overview

Objective To provide a brief historical overview of the achievement of key milestones in the development of mechanisms for operationalising professional nursing ethics in Australia; examples of such milestones include: the publication of the first Australian text on nursing ethics (1989), the provision of the first Australian national distance education course on nursing ethics for registered nurses (1990), the adoption of the first code of ethics for Australian nurses (1993), and the commissioning of the first regular column on nursing ethics by the Australian Nurses Journal (2008).

Setting Australian nursing ethics.

Primary argument An historical perspective on the achievement of key milestones in the development of mechanisms for operationalising professional nursing ethics in Australia has been poorly documented. As a consequence an authentic ‘Australian voice’ is missing in global discourses on the history and development of nursing ethics as a field of inquiry. Compared with other countries, the achievement of key milestones pertinent to the operationalisation of nursing ethics in Australia has been relatively slow. Even so, over the past three decades an Australian perspective on nursing ethics has gained a notable voice in the international arena with Australian nursing scholars now making a significant contribution to the field.

Conclusion Nursing ethics in Australia remains a ‘work in progress’. Although significant achievements have been made in the last three decades, the ongoing development of mechanisms for advancing nursing ethics in Australia would benefit from the development and implementation of a strategic agenda of collaborative, internationally comparative, cross disciplinary scholarship, research and critique.

Evaluation of the impact of nursing clinics in the rheumatology services

Nursing clinics in rheumatology (NCRs) are organisational care models that provide care centred within the scope of a nurse’s abilities. To analyse the impact of NCR in the rheumatology services, national multicenter observational prospective cohort studied 1-year follow-up, comparing patients attending rheumatology services with and without NCR. NCR was defined by the presence of: (1) office itself; (2) at least one dedicated nurse; and (3) its own appointment schedule. Variables included were (baseline, 6 and 12 months): (a) test to evaluate clinical activity of the disease, research and training, infrastructure of unit and resources of NCR and (b) tests to evaluate socio-demographics, work productivity (WPAI), use of services and treatments and quality of life. A total of 393 rheumatoid arthritis and ankylosing spondylitis patients were included: 181 NCR and 212 not NCR, corresponding to 39 units, 21 with NCR and 18 without NCR (age 53 + 11.8 vs 56 + 13.5 years). Statistically significant differences were found in patients attended in sites without NCR, at some of the visits (baseline, 6 or 12 months), for the following parameters: higher CRP level (5.9 mg/l ± 8.3 vs 4.8 mg/l ± 7.8; p < 0.005), global disease evaluation by the patient (3.6 ± 2.3 vs 3.1 ± 2.4), physician (2.9 ± 2.1 vs 2.3 ± 2.1; p < 0.05), use of primary care consultations (2.7 ± 5.4 vs 1.4 ± 2.3; p < 0.001) and worse work productivity. The presence of NCR in the rheumatology services contributes to improve some clinical outcomes, a lower frequency of primary care consultations and better work productivity of patients with rheumatic diseases.

Nephrology nursing publications : topics and research methods

Four peer-reviewed nephrology nursing society journal publications from 2010 to 2015 were analysed. Journal articles (n=638) were categorised into type, treatment cohort, specific topic and research methods. Primary research (40%) were the most frequent types of publications, followed by systematic reviews (25%) and case studies (16%). Publication patient cohorts were dominated by haemodialysis (41%), followed by chronic kidney disease (15%), kidney transplantation (14%), peritoneal dialysis (12%) and end-of-life care (9%). The most frequent specific topics were vascular access (56 publications), nutrition (35), patient self-management (31), medications (26) and patient quality of life (24). The case study was the most popular method of publishing clinical experience, while cross-sectional survey was the most published research method, followed by qualitative research approaches. There were a low number of publications addressing cost and new therapies.