Redesigning Work With a Lightweight Approach to Coordination Technology.

Coordination of information and resources is central to efficient ward management. Tools to aid coordination include standardized procedures and paper lists and, more recently, electronic tools such as whiteboards and mobile solutions. This study reports on the experiences and effects of designing and implementing collaboration technology, and how the use of light-weight technology has enabled redesign of traditional work processes. The process followed the principles for user-centered development and is evaluated through observations and informal interviews of users and stakeholders. In addition to the expected changes in work processes, we found that short redesign cycles with heavy user involvement afforded by this technology enabled implementation of new ways of structuring and combining information that were not foreseen. This turned the collaboration technology into a tool that also guided prioritization between tasks and contributed to the effects seen in use of resources, user satisfaction, and quality of treatment.

Towards a measure of accountability in nursing: A three-stage validation study.

AIMS: The aim of this study was to develop and psychometrically evaluate a three-dimensional questionnaire suitable for evaluating personal and organizational accountability in nurses. BACKGROUND: Accountability is defined as a three-dimensional value, directing professionals to take responsibility for their decisions and actions, to be willing to explain them (transparency), and to be judged according to society's accepted values (answerability). Despite the relatively clear definition, measurement of accountability lags well behind. Existing self-report questionnaires do not fully capture the complexity of the concept nor do they capture the different sources of accountability (e.g., personal accountability, organizational accountability). DESIGN: A three-stage measure development. METHODS: Data were collected during 2015-2016. In Phase 1, an initial database of items (N = 74) was developed, based on literature review and qualitative study, establishing face and content validity. In Phase 2, the face, content, construct, and criterion-related validity of the initial questionnaires (19 items for personal and organizational accountability questionnaire) were established with a sample of 229 nurses. In Phase 3, the final questionnaires (19 items each) were validated with a new sample of 329 nurses and established construct validity. RESULTS: The final version of the instruments comprised 19 items, suitable for assessing personal and organizational accountability. The questionnaire referred to the dimensions of responsibility, transparency, and answerability. The findings established the instrument's content, construct, and criterion-related validity as well as good internal reliability. CONCLUSION: The questionnaire portrays accountability in nursing, by capturing nurses' subjective perceptions of accountability dimensions (responsibility, transparency, answerability), as demonstrated by personal and organizational values.

Beyond BFHI: The Spatz 10-Step and Breastfeeding Resource Nurse Model to Improve Human Milk and Breastfeeding Outcomes.

A report released by the World Health Organization states that worldwide less than 10% of birth occur in hospitals certified through the Baby-Friendly Hospital Initiative. Furthermore, the Baby-Friendly Hospital Initiative's primary focus is on breastfeeding for healthy, mother-infant dyads. This article provides alternative models for implementing evidence-based care during maternal-infant separation so that mothers can achieve their personal breastfeeding goals. These include the Spatz 10-step model for human milk and breastfeeding in vulnerable infants and the Breastfeeding Resource Nurse model. Clinical outcome data are provided to demonstrate the effectiveness of the models as well as a road map of strategies to implement the models and measure outcomes.

Single Therapeutic Project and Nursing Process from an interdisciplinary care perspective. / Projeto Terapêutico Singular e Processo de Enfermagem em uma perspectiva de cuidado interdisciplinar.

OBJECTIVE: To analyze the single therapeutic project and the nursing process regarding its specificities and intersection points from the interdisciplinary care perspective. METHODIntegrative review of the literature from articles available in the Lilacs, SciELO, MEDLINE and PubMed databases, published in Portuguese, English and Spanish from 2005 to 2015. RESULTS: It was identified 23 articles. From these, 17 on the nursing process, six on the single therapeutic project and one about multiprofessional residency. From the analysis, their specificities and intersection points that describe the alignment and similarities between them were identified in the primary and mental health cares. CONCLUSIONS: The single therapeutic project and the nursing process are aligned in health practices in primary and mental health cares. The multiprofessional residency allows this alignment among them, and the nurse contributes to the interdisciplinary care with the nursing process.

Nursing Care Systematization in a basic health unit: perception of the nursing team.

OBJECTIVE: To conduct a situational diagnosis of the Nursing Care Systematization (NCS) in a Basic Health Unit from the perception of the nursing team. METHOD: This was a quantitative, descriptive-exploratory study, conducted in a Basic Health Unit in the interior of São Paulo state, Brazil. A structured questionnaire containing Likert scale was used for data collection, previously validated by specialists. RESULTS: The questionnaire was applied to 21 nursing professionals. It was verified that implementation of NCS and the nursing process is still incipient in the Basic Health Units. Regarding its use in all nursing actions: 19% of respondents believe that it is never used, 38% thought that it is rarely implemented, and 29% responded sometimes. The main difficulties identified were related to the lack of institutional structure, highlighting a lack of capacity by the institution (81%). The team has a reasonable understanding about the subject, but pointed out that professional education does not prepare them for performing NCS in primary care. CONCLUSION: Institutional interest in NCS is necessary to enable implementation. The study can contribute to the effective implementation in this unit and point out guidelines for its implementation in other similar contexts.

[From an institution's management to the caregivers in the field: driving a change of practices]. / Du management institutionnel au terrain : impulser une dynamique pour changer les pratiques.

The managerial project of the nursing directorate set up by an adult general psychiatric unit aims first and foremost to change practices in the field. This approach firstly involves structuring the institution's management. The project's main areas of focus are then rolled out through actions prioritising the bold, innovative dimensions of caregiving. This project highlights the skills of many nurses who demonstrate high levels of creativity in their nursing practices and management of patients.

Fostering development of nursing practices to support integrated care when implementing integrated care pathways: what levers to use?

BACKGROUND: Care integration has been the focus of recent health system reforms. Given their functions at all levels of the care continuum, nurses have a substantial and primordial role to play in such integration processes. The aim of this study was to identify levers and strategies that organizations can use to support the development of a nursing practice aligned with the requirements of care integration in a health and social services centre (HSSC) in Quebec. METHODS: The research design was a cross-sectional descriptive qualitative study based on a single case study with nested levels of analysis. The case was a public, multi-disciplinary HSSC in a semi-urban region of Quebec. Semi-structured interviews with 37 persons (nurses, professionals, managers, administrators) allowed for data saturation and ensured theoretical representation by covering four care pathways constituting different care integration contexts. Analysis involved four steps: preparing a predetermined list of codes based on the reference framework developed by Minkman (2011); coding transcript content; developing general and summary matrices to group observations for each care pathway; and creating a general model showing the overall results for the four pathways. RESULTS: The organization's capacity for response with regard to developing an integrated system of services resulted in two types of complementary interventions. The first involved investing in key resources and renewing organizational structures; the second involved deploying a series of organizational and clinical-administrative processes. In resource terms, integration efforts resulted in setting up new strategic services, re-arranging physical infrastructures, and deploying new technological resources. Organizational and clinical-administrative processes to promote integration involved renewing governance, improving the flow of care pathways, fostering continuous quality improvement, developing new roles, promoting clinician collaboration, and strengthening care providers' capacities. However, progress in these areas was offset by persistent constraints. CONCLUSIONS: The results highlight key levers organizations can use to foster the implementation and institutionalization of integrative nursing practices. They show that progress in this area requires a combination of strategies using multiple complementary levers. They also suggest that such progress calls for rethinking not only the deployment of certain organizational resources and structures, but also a series of organizational and clinical processes.

Using incident reports to inform the prevention of medication administration errors.

AIMS AND OBJECTIVES: To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. BACKGROUND: Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. DESIGN AND METHODS: This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. RESULTS: Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. CONCLUSIONS: Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. RELEVANCE TO CLINICAL PRACTICE: Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health professionals to manage daily medications should be prioritised.

Newly graduated nurses' use of knowledge sources in clinical decision-making: an ethnographic study.

AIMS AND OBJECTIVES: To explore which knowledge sources newly graduated nurses' use in clinical decision-making and why and how they are used. BACKGROUND: In spite of an increased educational focus on skills and competencies within evidence-based practice, newly graduated nurses' ability to use components within evidence-based practice with a conscious and reflective use of research evidence has been described as being poor. To understand why, it is relevant to explore which other knowledge sources are used. This may shed light on why research evidence is sparsely used and ultimately inform approaches to strengthen the knowledgebase used in clinical decision-making. DESIGN AND METHODS: Ethnographic study using participant-observation and individual semistructured interviews of nine Danish newly graduated nurses in medical and surgical hospital settings. RESULTS: Newly graduates use of knowledge sources was described within three main structures: 'other', 'oneself' and 'gut feeling'. Educational preparation, transition into clinical practice and the culture of the setting influenced the knowledge sources used. The sources ranged from overt easily articulated knowledge sources to covert sources that were difficult to articulate. The limited articulation of certain sources inhibited the critical reflection on the reasoning behind decisions. Reflection is a prerequisite for an evidence-based practice where decisions should be transparent in order to consider if other evidentiary sources could be used. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Although there is a complexity and variety to knowledge sources used, there is an imbalance with the experienced nurse playing a key role, functioning both as predominant source and a role model as to which sources are valued and used in clinical decision-making. If newly graduates are to be supported in an articulate and reflective use of a variety of sources, they have to be allocated to experienced nurses who model a reflective, articulate and balanced use of knowledge sources.

The role of locally-designed organizational artifacts in supporting nurses' work: an ethnographic study on the wards

INTRODUCTION: This paper aims to describe how nurses' planning and coordination work is performed through the use of locally designed tools (i.e., diaries, planners, reminders, and organizers). These tools are investigated as the materialization of organizational work, thus offering a complementary perspective on nursing practice to that proposed by the professional mandate and supported by official artifacts in use. METHOD: Ethnographic study. RESULTS: By analyzing locally designed artifacts, the rationale that enables nurses to make the flow of activities work is highlighted and explained. Evidence is provided by a description of how nurses' tacit knowledge is reified and embedded into objects produced by the nurses themselves. Implications for the design of digital systems supporting nursing practice are discussed. CONCLUSION: The analysis of these artifacts has allowed an understanding of practices used by the nurses to manage the workflow in the wards.

Infection Risk Reduction in the Intensive Care Nursery: A Review of Patient Care Practices That Impact the Infection Risk in Global Care of the Hospitalized Neonates.

Neonates are at high risk for developing an infection during their hospital stay in the neonatal intensive care unit. Increased risk occurs because of immaturity of the neonate's immune system, lower gestational age, severity of illness, surgical procedures, and instrumentation with life support devices such as vascular catheters. Neonates become colonized with bacteria prior to or at delivery and also during their hospital stay. They can then become infected with those bacteria if there is a breakdown in the primary defenses such as tissue injury due to skin breakdown, nasal erosion, or trauma to the respiratory tract. Neonates are also at high risk for bacterial translocation due to the altered permeability of the intestinal mucosa, loss of commensal flora, and bacterial overgrowth. The unit-based neonatal care team must implement global care delivery and safety practices, utilize published care guidelines, know and apply evidence-based practices from collaborative quality improvement efforts and other sources, and use auditing and monitoring practices that can identify risks and lead to better practice options to prevent infections. This article presents several aspects of global neonatal care delivery, including vascular access, which may reduce the risk of systemic infection during the hospitalization.

From Caterpillars to Butterflies: Engaging Nurse Leaders in Evidence-Based Practice Reform.

Evidence-based practice (EBP) occurs when the integration of best evidence is brought to the bedside to ground patient care decisions. Barriers to EBP have lingered for years and held unabated. The experiences of an academic medical center offer fresh perspectives in devolving the accountability for EBP where care is provided and received by patients. More specifically, the initiative is a focused engagement of nurse leaders in administrative positions for energizing bedside nurses to reform the enculturation of EBP. The goal is not to control but to explore approaches of handling the barriers with a complexity mindset amidst uncertainties. Nurses' collective engagement is envisioned to spark or refine creative ideas that will steer and account for EBP outcomes. The flight of the butterfly is used as a metaphor; hence, the title for the Monarch Moments Initiative.

A Family-Focused Delirium Educational Initiative With Practice and Research Implications.

Delirium is burdensome and psychologically distressing for formal and informal caregivers, yet family caregivers often have very little understanding or knowledge about delirium. As part of a large multisite intervention study, the Early Nurse Detection of Delirium Superimposed on Dementia (END-DSD), the authors identified a need for family educational materials. This educational initiative's purpose was to develop a delirium admission brochure for family members to aid in the prevention and earlier identification of delirium during hospitalization. A brochure was developed using an iterative approach with an expert panel. Following three iterations, a final brochure was approved. The authors found that an iterative expert consensus approach can be used to develop a brochure for families. Major content areas were helping families understand the difference between delirium and dementia, signs and symptoms of delirium, causes of delirium, and strategies family members can use to prevent delirium. A caregiver-focused educational brochure is one intervention to use in targeting older adults hospitalized with delirium.

[Support of the nursing process through electronic nursing documentation systems (UEPD) ­ Initial validation of an instrument]. / Unterstützung des Pflegeprozesses durch die elektronische Pflegeprozessdokumentation (UEPD). Erste Validierung eines Messinstruments.

BACKGROUND: Electronic nursing documentation systems, with standardized nursing terminology, are IT-based systems for recording the nursing processes. These systems have the potential to improve the documentation of the nursing process and to support nurses in care delivery. AIM: This article describes the development and initial validation of an instrument (known by its German acronym UEPD) to measure the subjectively-perceived benefits of an electronic nursing documentation system in care delivery. METHOD: The validity of the UEPD was examined by means of an evaluation study carried out in an acute care hospital (n = 94 nurses) in German-speaking Switzerland. Construct validity was analyzed by principal components analysis. RESULTS: Initial references of validity of the UEPD could be verified. The analysis showed a stable four factor model (FS = 0.89) scoring in 25 items. All factors loaded ≥ 0.50 and the scales demonstrated high internal consistency (Cronbach's α = 0.73 ­ 0.90). Principal component analysis revealed four dimensions of support: establishing nursing diagnosis and goals; recording a case history/an assessment and documenting the nursing process; implementation and evaluation as well as information exchange. CONCLUSIONS: Further testing with larger control samples and with different electronic documentation systems are needed. Another potential direction would be to employ the UEPD in a comparison of various electronic documentation systems.

Providing a navigable route for acute medicine nurses to advance their practice: a framework of ascending levels of practice.

This article conveys concerns raised by delegates at the International SAM Conference (Manchester, 2015) regarding how to advance nursing practice in acute medicine. It endeavors to capture the essence of 'how to advance practice' and 'how to integrate advanced practice' within the workforce structures of an acute medicine unit (AMU). It addresses the production of tacit knowledge and the recognition and integration of this to developing the nursing workforce. The current context of NHS efficiencies and recruitment issues emphasize the value of retaining tacit knowledge. Uniquely, this article offers an early conceptual framework through which levels of advancement and potential transition points to advance nursing practice in acute medicine are articulated. Determining how to advance requires identification of prior accomplishments such as, tacit knowledge, experiential learning, CPD, specialist courses and management experience. This requires nurses to make judicious decisions to advance their practice and the distinction between 'amassing experience' and 'career progression'. It aims to stimulate thinking around the practicalities of advancement, the value of tacit knowledge and potential realization through the framework trajectory.

Intuitive Decision Making as the Culmination of Continuing Education: A Theoretical Framework.

The ability to make sound clinical decisions is the cornerstone of excellent nursing care and the goal of continuing nurse educators. Research has revealed that expert nurses make fewer errors in decision making; it also has shown differences in the decision-making process of expert nurses, compared with novice nurses. Specifically, expert nurses report a greater use of intuitive decision making. Accordingly, an important goal for continuing nurse educators is the development of intuitive decision making by nurses. This article proposes a pattern-based, constructivist educational framework that synthesizes Benner's novice to expert (NTE) theory, Damascio's somatic marker hypothesis (SMH), and Hammond's cognitive continuum theory (CCT). This framework provides a foundation for continuing education that fosters the development of intuitive decision making in nurses. Although this framework needs further empirical validation, it is theoretically sound and applicable to all areas of nursing, and its implementation could help reduce errors in decision making by nurses, thus improving patient outcomes.

Innovations in prenatal genetic testing beyond the fetal karyotype.

Current trends in prenatal genetic testing will affect nursing practice, education, research, and policy making. Although fetal genetic testing has been the traditional focus, new technologies open the possibility of acquiring genomic information for both parents and offspring, revealing windows onto individuals' lifelong health. Noninvasive prenatal testing of cell-free fetal DNA also has become a reality. Some of the recent advances in detecting cytogenetic and heritable molecular variants in pregnancy are overviewed. Exemplars of prenatal tests are presented and related ethical, legal, and social implications are considered. Educating clinicians with updated genomic knowledge has been outpaced by new technologies and direct-to-consumer marketing of prenatal tests. Implications for nursing are discussed.

Inseparability between public health, planetary health and the nursing process: premise for sustainable development.

The aim is to conduct theoretical reflection on the inseparability among public health, planetary health and the nursing process in light of complexity thinking, with the aim of contributing to healthy and sustainable development. Study with a theoretical-reflexive approach that accessed bibliographical sources from contemporary authors who defend the inseparability between public health and planetary health and, at the same time, provide theoretical-systemic support to the nursing process, under an inductive critical bias. The nursing process is conceived as a complex phenomenon, which comprises interdependent dynamics, dialogical approaches, critical-reflective perception and prospective leadership. Theoretical reflection on the nursing process and sustainable development raises an expanded, contextualized and interdependent look at the role of nursing professionals in different health contexts, in order not to compromise well-being and environmental health.