Optimizing nurses' enacted scope of practice to its full potential as an integrated strategy for the continuous improvement of clinical performance: A multicentre descriptive analysis.

AIM: This study aims at better understanding the relationships between nurses' enacted scope of practice, work environment and work satisfaction, missed care, and organizational indicators of performance. BACKGROUND: The enacted scope of practice model describes the determinants and consequences of the actual enactment of the nursing scope of practice. METHOD: A correlational design was used to investigate nurses' enacted scope of practice in five Canadian healthcare centres. RESULTS: Suboptimal enacted scope of practice were found in the current sample. Significant positive correlations were found between the total enacted scope of practice score, use of qualification, control over tasks, decisional latitude and psychological demand as well as role ambiguity. Moreover, a higher enacted scope of practice was correlated with lower organizational indicators of short-term absenteeism. CONCLUSION: Results suggest an insufficient deployment of nurses' enacted scope of practice, likely caused by some job characteristics, leading to lower work satisfaction and negative patients and organizational outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Optimizing nurses' enacted scope of practice would be a significant integrated strategy for improving organizational performance, patient care and nurses' satisfaction and well-being. Nurses and frontline managers must be involved in the decision-making process necessary to improve nurses' enacted scope of practice.

Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial.

BACKGROUND: Many children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses. AIMS: The aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both. MATERIALS AND METHOD: A within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05. RESULTS: Results showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported. CONCLUSION: VR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.

Implementation of an intersectoral outreach and community nursing care intervention with refugees in Quebec: A protocol study.

AIM: To establish and assess an intersectoral local network focused on the roles of registered nurses and primary healthcare nurse practitioners to ensure the continuity of care and service pathways for refugees in Quebec. DESIGN: Developmental evaluation with a mixed methodology. METHODS: The qualitative component will include: (1) a document review; (2) observations of participants during meetings of different governance structures; (3) semi-structured interviews with key actors (n = 40; 20/neighbourhood interventions); and (4) focus groups with end users of the services (refugees) (n = 4; 6 to 8 participants per group). The quantitative component will be based on: (1) a data sheet on health and social interventions for refugees users filled in by registered nurses, primary healthcare nurse practitioners and physicians and (2) data analysis of the clinical-administrative database since 2012. This study received funding in June 2019 and Research Ethics Committee approval was granted in July 2020. DISCUSSION: In Quebec, refugee vulnerability is exacerbated by the lack of integration of existing resources and the lack of access to care and continuity of services. To address these issues, an integrated local network for refugees must be developed. Additionally, we will explore the role of registered nurses and their collaboration with primary healthcare nurse practitioners. IMPACT: This study will provide recommendations on how to optimize the scopes of practice of registered nurses and primary healthcare nurse practitioners, adapt care and services and develop a local intersectoral network to better meet the complex needs of refugees. It will evaluate the use and the appreciation of new services for targeted populations (neighbourhoods and refugees) and aim to improve the accessibility, continuity and user experience of all health services for those populations.

Scope of Nursing Practice in a Tertiary Pediatric Setting: Associations With Nurse and Job Characteristics and Job Satisfaction.

PURPOSE: While professional nursing, like other health professions, has a recognized educational base and a legal scope of practice that is remarkably consistent across societies, there are important variations even within the same institution or organization in the extent to which professional nurses engage in the full range of activities for which they are qualified. There has been limited study of enacted (actual) scope of nursing practice (ESOP) or of its impacts on nurse job outcomes, such as job satisfaction. The aim of this study is to measure ESOP, as well as its predictors and impact on job satisfaction, in a specialty university-affiliated tertiary referral center in one of the few remaining jurisdictions outside the United States that continue to educate registered nurses at multiple educational levels. METHODS: This was a correlational cross-sectional design using structural equation modeling. Self-administered questionnaires were completed by 301 registered nurses holding permanent positions in specific clinical areas for 6 months or longer in a pediatric hospital in the province of Quebec, Canada. FINDINGS: ESOP or actual scope of practice was low-on average, nurses applied the range of skills within their theoretical scopes of practice only occasionally or "less than frequently" in their daily work (3.21 out of a possible 6 points). ESOP was strongly related to decision latitude (ß = 0.319; p  = .012), role ambiguity (ß = 0.297; p  = .011), and role overload (ß  =  0.201; p  = .012). The personal characteristics that exerted the greatest direct influence on ESOP were education level (ß  =  0.128; p  = .015) and growth need strength (ß  =  0.151; p  = .008). Results also showed that ESOP exerts a direct positive influence on nurses' job satisfaction (ß  =  0.118; p  = .006). Structural equation modeling analyses revealed a good fit of the data to the hypothesized conceptual model (χ²/df ratio index =  1.68, root mean square error of approximation  =  0.049, confirmatory fit index  =  0.985). CONCLUSIONS: Specific aspects of nurses' jobs are closely related to ESOP. ESOP is limited by certain job and personal characteristics and appears to affect nurses' job satisfaction. CLINICAL RELEVANCE: Results suggest that ESOP might be improved by adjusting nursing job characteristics and practice environments and that expanding ESOP increases nurse job satisfaction and may improve other health system outcomes as well.

Which priority indicators to use to evaluate nursing care performance? A discussion paper.

AIMS: A discussion of an optimal set of indicators that can be used on a priority basis to assess the performance of nursing care. BACKGROUND: Recent advances in conceptualization of nursing care performance, exemplified by the Nursing Care Performance Framework, have revealed a broad universe of potentially nursing-sensitive indicators. Organizations now face the challenge of selecting, from this universe, a realistic subset of indicators that can form a balanced and common scorecard. DESIGN: Discussion paper drawing on a systematic assessment of selected performance indicators. DATA SOURCES: Previous works, based on systematic reviews of the literature published between 1990 - 2014, have contributed to the development of the Nursing Care Performance Framework. These works confirmed a robust set of indicators that capture the universe of content currently supported by the scientific literature and cover all major areas of nursing care performance. Building on these previous works, this study consisted in gathering the specific evidence supporting 25 selected indicators, focusing on systematic syntheses, meta-analyses and integrative reviews. IMPLICATIONS FOR NURSING: This study has identified a set of 12 indicators that have sufficient breadth and depth to capture the whole spectrum of nursing care and that could be implemented on a priority basis. CONCLUSIONS: This study sets the stage for new initiatives aiming at filling current gaps in operationalization of nursing care performance. The next milestone is to set up the infrastructure required to collect data on these indicators and make effective use of them.

Education and Role Title as Predictors of Enacted (Actual) Scope of Practice in Generalist Nurses in a Pediatric Academic Health Sciences Center.

OBJECTIVE: The aim of this study is to document the enacted (actual) scope of practice (SOP) of nurses in pediatric settings in relation to education level and position. BACKGROUND: Baccalaureate-prepared staff nurses routinely carry out only a fraction of the activities essential for quality of care and patient safety they have been educated for. A direct care nurse clinician role exists for nurses with bachelor's degrees in Quebec, Canada. METHOD: Survey of 301 nurses in a pediatric university hospital in Quebec was conducted. RESULTS: Enacted (actual) SOP for baccalaureate-educated nurses was significantly broader than that of nurses with junior college diplomas and nurse clinicians (baccalaureate-educated) carried out complex activities more frequently. CONCLUSION: The creation of job titling and role descriptions that reflect the upper range of nursing competencies could be an important tool for promoting broadened SOP for baccalaureate nurses.

[Supporting preceptor skills development with a forum discussion]. / Soutenir le développement des compétences de préceptrices a l'aide d'un forum de discussion.

The success of nursing students in clinical settings is significantly influenced by the nurse's preparation level of the preceptor's role. It is therefore essential to create and make available training activities that prepares and support the development of these skills in clinical settings. Among the significant benefits to participate in preceptorship training activities, the satisfaction of feeling better prepared and to share experiences with colleagues is well recognized. Thus, the online environment allows the creation of programs that encourage exchanges and discussions in addition to promote a social learning space. This article presents the implementation of an online training activity to support the development of preceptors skills in clinical settings with nursing students. The results of this clinical experience revealed several constraints to the involvement of nurses in this activity and enhanced the importance of an organizational partnership between the institution and the clinical environment to overcome these constraints.

Multicentre implementation of a nursing competency framework at a provincial scale: A qualitative description of facilitators and barriers.

RATIONALE: Nurses are responsible for engaging in continuing professional development throughout their careers. This implies that they use tools such as competency frameworks to assess their level of development, identify their learning needs, and plan actions to achieve their learning goals. Although multiple competency frameworks and guidelines for their development have been proposed, the literature on their implementation in clinical settings is sparser. If the complexity of practice creates a need for context-sensitive competency frameworks, their implementation may also be subject to various facilitators and barriers. AIMS AND OBJECTIVES: To document the facilitators and barriers to implementing a nursing competency framework on a provincial scale. METHODS: This multicentre study was part of a provincial project to implement a nursing competency framework in Quebec, Canada, using a three-step process based on evidence from implementation science. Nurses' participation consisted in the self-assessment of their competencies using the framework. For this qualitative descriptive study, 58 stakeholders from 12 organizations involved in the first wave of implementation participated in group interviews to discuss their experience with the implementation process and their perceptions of facilitators and barriers. Data were subjected to thematic analysis. RESULTS: Analysis of the data yielded five themes: finding the 'right unit' despite an unfavourable context; taking and protecting time for self-assessment; creating value around competency assessment; bringing the project as close to the nurses as possible; making the framework accessible. CONCLUSION: This study was one of the first to document the large-scale, multi-site implementation of a nursing competency framework in clinical settings. This project represented a unique challenge because it involved two crucial changes: adopting a competency-based approach focused on educational outcomes and accountability to the public and valorizing a learning culture where nurses become active stakeholders in their continuing professional development.

Measuring actual scope of nursing practice: a new tool for nurse leaders.

OBJECTIVE: : This project describes the development and testing of the actual scope of nursing practice questionnaire. BACKGROUND: : Underutilization of the skill sets of registered nurses (RNs) is a widespread concern. Cost-effective, safe, and efficient care requires support by management to facilitate the implementation of nursing practice at the full scope. METHODS: : Literature review, expert consultation, and face validity testing were used in item development. The instrument was tested with 285 nurses in 22 medical units in 11 hospitals in Canada. RESULTS: : The 26-item, 6-dimension questionnaire demonstrated validity and reliability. The responses suggest that nurses practice at less than their optimal scope, with key dimensions of professional practice being implemented infrequently. CONCLUSIONS: : This instrument can help nurse leaders increase the effective use of RN time in carrying out the full scope of their professional practice.

Adaptation and validation of a nursing competencies framework for clinical practice on a continuum of care from childhood to adulthood: A Delphi study.

BACKGROUND: Too few of nursing competencies framework exceed applicability to a given environment, are validated by a research process or used to guide continuing development of nursing competencies. OBJECTIVES: The study objectives were: 1) to adapt and validate a nursing competencies framework from the continuum of care from childhood to adulthood and 2) to explore implementation strategies. DESIGN: A collaborative approach including nurses from different practice perspectives. A modified Delphi method supported the adaptation and the validation of a nursing competencies framework. SETTING: This study was conducted in a pediatric and an adult care university hospitals in Montreal. PARTICIPANTS: Forty-two nurses were recruited from both university hospitals. METHODS: A modified Delphi study was conducted. An online questionnaire, containing dichotomous and open-ended questions, was used to collect data on the nursing competencies framework and the suggested implementation strategies for its use. Consensus percentage was calculated, and thematic analysis was used to analyze nurses' comments and implementation strategies suggested. RESULTS: The nursing competencies framework (NCF), adapted and validated in this study, includes seven competencies and four development stages, from advanced beginner to clinical expert nurses. After three rounds, the nursing competencies framework describes the professional role from the continuum of care from childhood to adulthood, and proposes a self-assessment tool that promotes professional development and continuing education of nurses. Moreover, four strategies for implementing the framework in the clinical setting obtained a consensus of 70% or more. CONCLUSIONS: A nursing competencies framework was validated by a rigorous research process and adapted to diverse contexts of care. The results revealed a common vision of the nursing practice for patients and their families on the life course from childhood to adulthood. This innovative framework carries the potential to be a relevant and unique reference tool. The nursing competencies framework can provide guidance for the development of nurses' competencies in clinical setting. Additionally, it is a relevant reference that should be use for knowing the scope and the standards of the professional practice in nursing education.

Projector-based virtual reality dome environment for procedural pain and anxiety in young children with burn injuries: a pilot study.

BACKGROUND: Virtual reality (VR) is a non-pharmacological method to distract from pain during painful procedures. However, it was never tested in young children with burn injuries undergoing wound care. AIM: We aimed to assess the feasibility and acceptability of the study process and the use of VR for procedural pain management. METHODS: From June 2016 to January 2017, we recruited children from 2 months to 10 years of age with burn injuries requiring a hydrotherapy session in a pediatric university teaching hospital in Montreal. Each child received the projector-based VR intervention in addition to the standard pharmacological treatment. Data on intervention and study feasibility and acceptability in addition to measures on pain (Face, Legs, Activity, Cry, Consolability scale), baseline (Modified Smith Scale) and procedural (Procedure Behavior Check List) anxiety, comfort (OCCEB-BECCO [behavioral observational scale of comfort level for child burn victims]), and sedation (Ramsay Sedation Scale) were collected before, during, and after the procedure. Data analyses included descriptive and non-parametric inferential statistics. RESULTS: We recruited 15 children with a mean age of 2.2±2.1 years and a mean total body surface area of 5% (±4). Mean pain score during the procedure was low (2.9/10, ±3), as was the discomfort level (2.9/10, ±2.8). Most children were cooperative, oriented, and calm. Assessing anxiety was not feasible with our sample of participants. The prototype did not interfere with the procedure and was considered useful for procedural pain management by most health care professionals. CONCLUSION: The projector-based VR is a feasible and acceptable intervention for procedural pain management in young children with burn injuries. A larger trial with a control group is required to assess its efficacy.

Influences on and outcomes of enacted scope of nursing practice: a new model.

Enacted scope of practice is a major issue for nursing administrators, given the potentially negative effect on accessibility, continuity, safety and quality of care, job satisfaction, and organizational costs of nurses working at reduced scope. Optimal deployment of nurses to a fuller enacted scope of nursing practice holds much promise for addressing all of these larger challenges. In this sense, new model of the Enacted Scope of Nursing Practice presented in this article provides a number of directions for interventions that could improve health system functioning.