Planned change or emergent change implementation approach and nurses' professional clinical autonomy.

BACKGROUND: Nurses' clinical autonomy is considered important for patients' outcome and influenced by the implementation approach of innovations. Emergent change approach with participation in the implementation process is thought to increase clinical autonomy. Planned change approach without this participation is thought not to increase clinical autonomy. Evidence of these effects on clinical autonomy is however limited. AIMS AND OBJECTIVES: To examine the changes in clinical autonomy and in personal norms and values for a planned change and emergent change implementation of an innovation, e.g. intensive insulin therapy. DESIGN: Prospective comparative study with two geographically separated nurses' teams on one intensive care unit (ICU), randomly assigned to the experimental conditions. METHODS: Data were collected from March 2008 to January 2009. Pre-existing differences in perception of team and innovation characteristics were excluded using instruments based on the innovation contingency model. The Nursing Activity Scale was used to measure clinical autonomy. The Personal Values and Norms instrument was used to assess orientation towards nursing activities and the Team Learning Processes instrument to assess learning as a team. RESULTS: Pre-implementation the measurements did not differ. Post-implementation, clinical autonomy was increased in the emergent change team and decreased in the planned change team. The Personal Values and Norms instrument showed in the emergent change team a decreased hierarchic score and increased developmental and rational scores. In the planned change team the hierarchical and group scores were increased. Learning as a team did not differ between the teams. CONCLUSIONS: In both teams there was a change in clinical autonomy and orientation towards nursing activities, in line with the experimental conditions. Emergent change implementation resulted in more clinical autonomy than planned change implementation. RELEVANCE TO CLINICAL PRACTICE: If an innovation requires the nurses to make their own clinical decisions, an emergent change implementation should help to establish this clinical autonomy.

Intensive insulin therapy implementation by means of planned versus emergent change approach.

BACKGROUND: Nurses' participation in decisions about new care procedures and protocols is potentially of benefit for patient outcomes. Whether nurses' participation in decisions is allowed in the implementation of innovations depends on the implementation approach used for the introduction. A planned change implementation approach does not allow it, an emergent change implementation approach does. AIM: To compare a planned change and an emergent change implementation approach to introduce an intensive insulin therapy to an intensive care unit (ICU). DESIGN: A prospective comparative study in an ICU in the Netherlands of two teams of nurses using either implementation approach. METHODS: Pre-introduction of the comparability of the two teams was assessed. The nurse compliance to the protocol was assessed as being nurses' behaviour according to the protocol and leading to acceptable glucose values. The effectiveness of the implementation was assessed by measuring the percentage of patients' glucose values within the target range, the occurrence of hypoglycaemic events and the time to glucose value normalization. Data were collected from December 2007 till January 2009. RESULTS: In the emergent change approach team there was better nurse compliance measurements than in the planned change approach team (83.5% vs 66,8% conform protocol), a better percentage of glucose values in the target range (53,5% vs 52.8%) and a shorter time to glucose value normalization. CONCLUSION: The implementation approach allowing nurse participation was associated with better nurse compliance and patient outcome measurements. The implementation approach did not conflict with introducing an evidence-based innovation. It was also associated with more effective adaptation of the protocol to changing circumstances. RELEVANCE FOR CLINICAL PRACTICE: When a new treatment requires adaptability to changing circumstances to be most effective, nurses' participation in decisions about the implementation of the treatment should be considered.

Psychometric properties of the Dutch version of the American Nursing Activity Scale in an intensive care unit.

AIM: To report the development and psychometric testing of the Dutch version of the Nursing Activity Scale in a Dutch intensive care unit nursing population. BACKGROUND: The Nursing Activity Scale developed by Schutzenhofer measures professional clinical autonomy, by inquiring about the nurses' intention to exercise their own clinical decisions. This autonomy is increasingly relevant due to the ongoing professionalization, nurses increasingly have to make their own clinical decisions. DESIGN: Instrument development. METHOD: The study was conducted from November 2007-February 2008 and consisted of the following steps: translation, expert panel content validation, reliability testing and further content validation, test-retest stability examination, additional internal consistency, and validity assessment. RESULTS: After the first reliability testing two items seen to describe a situation not applicable to intensive care unit nursing in the Netherlands were deleted from the questionnaire. In the test-retest stability assessment the intra class correlation coefficient was 0·76. The Cronbach's alpha of the final questionnaire was 0·82. The alphas of the subsamples with higher scores were significantly different from those with lower scores, supporting the validity of the weighing of the items. CONCLUSION.: The Dutch version of the nursing activity scale consists of 28 items and provides the opportunity to measure professional clinical autonomy for Dutch intensive care nurses using a well-established method.

Effects of cell-saving devices and filters on transfusion in cardiac surgery: a multicenter randomized study.

BACKGROUND: Cell-saving devices (CS) are frequently used in cardiac surgery to reduce transfusion requirements, but convincing evidence from randomized clinical trials is missing. Filtration of salvaged blood in combination with the CS is widely used to improve the quality of retransfused blood, but there are no data to justify this approach. METHODS: To determine the contribution of CS and filters on transfusion requirements, we performed a multicenter factorial randomized clinical trial in two academic and four nonacademic hospitals. Patients undergoing elective coronary, valve, or combined surgical procedures were included. The primary end point was the number of allogeneic blood products transfused in each group during hospital admission. RESULTS: From 738 included patients, 716 patients completed the study (CS+filter, 175; CS, 189; filter, 175; neither CS nor filter, 177). There was no significant effect of CS or filter on the total number of blood products (fraction [95% confidence interval]: CS, 0.96 [0.79, 1.18]; filter, 1.17 [0.96, 1.43]). Use of a CS significantly reduced red blood cell transfusions within 24 hours (0.75 [0.61,0.92]), but not during hospital stay (0.86 [0.71, 1.05]). Use of a CS was significantly associated with increased transfusions of fresh frozen plasma (1.39 [1.04, 1.86]), but not with platelets (1.25 [0.93, 1.68]). Use of a CS significantly reduced the percentage of patients who received any transfusion (odds ratio [95% confidence interval]: 0.67 [0.49, 0.91]), whereas filters did not (0.92 [0.68, 1.25]). CONCLUSIONS: Use of a CS, with or without a filter, does not reduce the total number of allogeneic blood products, but reduces the percentage of patients who need blood products during cardiac surgery.

Pilot study on the influence of liver blood flow and cardiac output on the clearance of propofol in critically ill patients.

OBJECTIVE: To investigate the effect of cardiac output and liver blood flow on propofol concentrations in critically ill patients in the intensive care unit. METHODS: Five medical/surgical critically ill patients were enrolled in this preliminary study. Liver blood flow was measured using sorbitol. The cardiac output was measured by bolus thermodilution. NONMEM ver. V was applied for propofol pharmacokinetic analysis. RESULTS: The clearance of propofol was positively influenced by the liver blood flow (P < 0.005), whereas no significant correlation between cardiac output and propofol clearance was found. A correlation between liver blood flow and cardiac output or cardiac index could not be assumed in this patient group. CONCLUSIONS: Liver blood flow is a more predictive indicator than cardiac output for propofol clearance in critically ill patients when the techniques of hepatic sorbitol clearance and bolus thermodilution, respectively, are used. Further study is needed to determine the role played by liver blood flow and cardiac output on the pharmacokinetics of highly extracted drugs in order to reduce the observed high interindividual variabilities in response in critically ill patients.