A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH).

BACKGROUND: Post-partum haemorrhage (PPH) is an obstetric emergency that requires effective teamwork under complex conditions. We explored healthcare team performance for women who suffered a PPH, focusing on relationships and culture as critical influences on teamwork behaviours and outcomes. METHODS: In collaboration with clinical teams, we implemented structural, process and relational interventions to improve teamwork in PPH cases. We were guided by the conceptual framework of Relational Coordination and used a mixed methods approach to data collection and analysis. We employed translational simulation as a central, but not singular, technique for enabling exploration and improvement. Key themes were identified from surveys, focus groups, simulation sessions, interviews, and personal communications over a 12-month period. RESULTS: Four overarching themes were identified: 1) Teamwork, clear roles and identified leadership are critical. 2) Relational factors powerfully underpin teamwork behaviours-shared goals, shared knowledge, and mutual respect. 3) Conflict and poor relationships can and should be actively explored and addressed to improve performance. 4) Simulation supports improved team performance through multifaceted mechanisms. One year after the project commenced, significant progress had been made in relationships and systems. Clinical outcomes have improved; despite unprecedented increase in labour ward activity, there has not been any increase in large PPHs. CONCLUSIONS: Teamwork, relationships, and the context of care can be actively shaped in partnership with clinicians to support high performance in maternity care. We present our multifaceted approach as a guide for leaders and clinicians in maternity teams, and as an exemplar for others enacting quality improvement in healthcare.

A Synthesis of Coping Experiences After Infant Death.

The purpose of this article was to synthesize qualitative research data that examine parental coping strategies following infant death. This qualitative synthesis found that parents who effectively cope with the death of their infant would continue the bond with the deceased child, have differences in the way they manage their emotions about the loss, and have intergenerational support in the form of family being present, acknowledging the death, performing immediate tasks, and providing helpful information. Nurses should be vigilant to ensure parents receive "memories" of their infant after an in-hospital death. Knowledge of the coping process can assist nurses and clinicians to better care and support parents following an infant death and, in turn, facilitate the healing process.

Bathing With 2% Chlorhexidine Gluconate: Evidence and Costs Associated With Central Line-Associated Bloodstream Infections.

In a coordinated national effort reported by the Agency for Healthcare Research and Quality, the use of 2% chlorhexidine gluconate (CHG) has reduced the central line-associated bloodstream infection (CLABSI) rate by 40%. Conversely, a recent randomized clinical trial determined that chlorhexidine bathing did not reduce the CLABSI rate. The objectives of this study were to conduct meta-analysis and clarify the effectiveness of 2% CHG bathing by nurses on CLABSIs in adult intensive care unit patients and to determine the contributing costs attributable to CLABSIs and 2% CHG bathing. Eligible studies that included the outcome of bloodstream infection rate for central lines were considered. A rigorous systematic review protocol and software tools available from the Joanna Briggs Institute via OvidSP were used. Agency for Healthcare Research and Quality tools assisted with identifiable CHG bathing costs. Four studies were included in the meta-analysis for the outcome of primary bloodstream infections, and 2 studies narratively supported the meta-analysis. A relative risk of 0.46 with 95% confidence interval (0.34-0.63) was determined. This significant effect is seen in an overall z-score of 4.84 (P < .0001). This meta-analysis supports that 2% CHG reduces CLABSIs. The estimated cost increase of 2% CHG-impregnated cloths is $4.10 versus nonmedicated bathing cloths. The cost associated with a single CLABSI is 10 times more than the cost of using 2% CHG-impregnated cloths. Nursing provides significant influence for the prevention of CLABSIs in critical care via evidence-based best practices.

Implementation of an evidence-based seizure algorithm in intellectual disability nursing: A pilot study.

Based on the results of the Surrogate Decision-Making Self Efficacy Scale (Lopez, 2009a), this study sought to determine whether nurses working in the field of intellectual disability (ID) experience increased confidence when they implemented the American Association of Neuroscience Nurses (AANN) Seizure Algorithm during telephone triage. The results of the study indicated using the AANN Seizure Algorithm increased self-confidence for many of the nurses in guiding care decisions during telephone triage. The treatment effect was statistically significant -3.169(p < 0.01) for a small sample of study participants. This increase in confidence is clinically essential for two reasons. Many individuals with ID and epilepsy reside within community-based settings. ID nurses provide seizure guidance to this population living in community-based settings via telephone triage. Evidenced-based training tools provide a valuable mechanism by guiding nurses via best practices. Nurses may need to be formally trained for seizure management due to high epilepsy rates in this population.

Advanced Practice Nursing Simulation for Neonatal Skill Competency: A Pilot Study for Successful Continuing Education.

BACKGROUND: Skill readiness remains a challenge for all health care professionals who are involved in direct patient care. Researchers suggest that skill retention may decrease within 6 months of an educational session. The purpose of this study was to explore competency retention for high-risk, low-frequency procedures, specifically, managing a difficult airway and placing a laryngeal mask airway, using a web-based content refresher. METHOD: The pilot study was conducted in two sessions. Session one established clinical skill competency. Six months later, the advanced practice RNs were randomized into two groups. Group 1 reviewed didactic content and participated in a complex airway management simulation. Group 2 participated only in a complex airway management simulation. RESULTS: This study showed a positive trend in maintaining competency for a low-frequency procedure for which complex airway management was given, using web-based content review. It is feasible to maintain competency for low-frequency procedures using web-based content refreshers. CONCLUSION: This pilot study benefited advanced practice nurses by providing them with the potential to maintain competency in this high-risk, low-frequency procedure. Continuing education is an important consideration for health care organizations.

Improving the adoption of evidence-based practice through RN-to-BSN education.

BACKGROUND: Although enrollment in RN-to-BSN degree completion programs has grown profoundly, a dearth of literature exists regarding the impact of RN-to-BSN education and the adoption of evidence-based practice (EBP). This study examined the elements of RN-to-BSN education that improve the awareness and adoption for EBP. METHOD: A mixed methods meta-synthesis was conducted using qualitative, textual-narrative, and descriptive research studies. Data from six articles were analyzed, using standardized critical appraisal instruments. RESULTS: Two findings were identified. First, EBP skills for RN-to-BSN students are influenced by exposure to educational partnerships, contextual teaching and learning, and practice experiences. Second, barriers to adoption exist for RN-to-BSN students, which limit advances in nursing practice. CONCLUSION: A variety of contextual teaching and learning strategies can provide empowerment for RN-to-BSN students to adopt EBP in their practice. Forming partnerships in creating EBP experiences may set the stage for RN-to-BSN leadership opportunities in today's health care system.

Kenya and distance education: a model to advance graduate nursing.

Africa is faced with a myriad of challenges, such as HIV/AIDS, malaria, tuberculosis, and a variety of political and historical complications that have affected the educational system for advanced nursing practice. In Kenya, the current situation in the higher education sector does not give nurses an opportunity to pursue graduate education after they have acquired the basic diploma in nursing due to limited government support and the type of education system existing in the country today. Although distance education has been available in Kenya for professionals such as teachers, in public universities, this kind of opportunity is unreachable for nurses who are working and need to further their education. Nurses desire to have access to advanced practice education to equip them with the relevant knowledge to cope and address the complex health issues arising in the management and care of patients. A collaborative model is presented as a potential solution for this need. Four major constituents are identified including hospitals and agencies, communities of interest, Kenyan universities and international education partners. Each has a part to play including contributions to information, communication of opinion and expertise, money and support, infrastructure and in-kind resources. Distance education is cost-effective and will help in building capacity at various levels of nursing including leadership in clinical practice, teaching, administration and research.

Podcasting as an instructional supplement to online learning: a pilot study.

There is increasing interest in the use of mobile technologies for nursing educational purposes in academic settings, but few evaluative studies exist. Understanding the best use of podcasting during distance learning is basic for instructional design. This pilot study compared online reading to a supplementary podcast to determine graduate nursing students' preferences and usage. Results indicated that students did not download the podcast to a mobile device but multitasked while listening. The podcast and the readings were equally supported as important by nursing students. Podcasting in distance-accessible courses may engage students by providing a human voice and thus a better virtual connection. Podcasting is only one method of knowledge acquisition; distance learning courses should consider providing multiple learner-centered delivery methods, given the variety of learning styles.

Podcasting as an instructional supplement to online learning: a pilot study.

There is increasing interest in the use of mobile technologies for nursing educational purposes in academic settings, but few evaluative studies exist. Understanding the best use of podcasting during distance learning is basic for instructional design. This pilot study compared online reading to a supplementary podcast to determine graduate nursing students' preferences and usage. Results indicated that students did not download the podcast to a mobile device but multitasked while listening. The podcast and the readings were equally supported as important by nursing students. Podcasting in distance-accessible courses may engage students by providing a human voice and thus a better virtual connection. Podcasting is only one method of knowledge acquisition; distance learning courses should consider providing multiple learner-centered delivery methods, given the variety of learning styles.

A database for nurse practitioner clinical education.

This article presents the utility and lessons learned regarding subscription to a database service for tracking nurse practitioner clinical education at the Indiana University School of Nursing. Initiatives and activities, such as the one described in this article, support the implementation of the Technology Informatics Guiding Educational Reform strategic agenda related to the transformation of nursing education through evidence and informatics. Descriptive reports of clinical database management are useful to conceptualize the evaluation of teaching and learning experiences as well as document the significance to students, faculty, future employers, and administration. The use of a database system for documentation of clinical experiences allows the student to practice and master informatics capabilities. Through data analysis, faculty can coordinate and assess students in the clinical environment and tailor learning experiences based on aggregated sets of patient encounters. Examination of the nature of patient encounters and clinical activities experienced permits an evidenced informed approach to student progress, curriculum development, and formative and summative evaluations.

Mentoring Nurse Faculty: Outcomes of a Three-Year Clinical Track Faculty Initiative.

Clinical track faculty often lack mentoring opportunities needed to develop their scholarship which may hinder their academic promotion. The Clinical Track Faculty Mentoring Initiative was designed to foster scholarship development and academic promotion of clinical assistant professors. Fifteen clinical assistant professors in two cohorts and their mentors participated in the Initiative. Each Cohort lasted two years with one overlapping year. Participating clinical assistant professors were required to attend five check-in meetings, a summer writing workshop, school and university promotion information sessions, and mentor-protégé meetings. Program outcomes were assessed quarterly and they included knowledge of promotion processes, mentorship quality, scholarship productivity, and academic promotion. Scores on knowledge of promotion processes and perceived mentorship quality among participating clinical assistant professors were significantly increased. Participating clinical assistant professors published, on average, 3.33 papers and delivered 6.4 presentations in two years. The Initiative demonstrated an effective mentoring program that incorporated a multimethod approach with clear program goals, strong systems support, and high mentorship quality.

Sudden infant death and sleep practices in the Black community.

PURPOSE: A Black infant dies every 13 hours in the state of Indiana. The overall infant mortality rate in 2013 was 7.2 deaths per 1000 live births, but for Black infants, the rate was 15.3 deaths per 1000 live births. For over 20 years, placing an infant to sleep on his back has decreased the death rate from sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS), but many Black families continue to advocate bed sharing, prone sleeping, and inappropriate bedding/sleep surfaces, predisposing an infant to a significantly higher risk for SUID/SIDS. Therefore, the purpose of this study is to understand why Black women are less likely than White women to follow safe sleep recommendations for their infants. DESIGN: A rigorous search of the literature was performed by searching the Web of Science, OVID, CINAHL, PsychINFO, and PubMed using the search terms: infant or child, death, loss, SIDS, SUID, qualitative, African American, Black, culture, safe sleep, experiences, and United States. A total of 217 articles were obtained. After review of inclusion and exclusion criteria and critical appraisal, only seven articles remained for the research study. METHODS: The meta-synthesis of these seven original qualitative studies was performed using the Qualitative Assessment and Review Instrument from the Joanna Briggs Institute to assist with data management. Data were extracted and representative quotations were categorized. Categories were arranged into like themes. Themes were then synthesized with meta-aggregation. RESULTS: A total of 17 subthemes were identified and were formulated into three primary themes: convenience, safety, and culture. The final synthesized theme was that Black mothers are motivated by their beliefs. PRACTICE IMPLICATIONS: Black mothers tend to believe that SUIDS/SIDS is a random occurrence and is not preventable, so they see a little reason to make their infant sleep in a cold, hard crib, when they could sleep in a warm, comfortable bed with them. Nurses should work with Black mothers to understand their cultural beliefs while educating them about safe sleep practices.

Mentoring Nontenured Track Nursing Faculty: A Systematic Review.

The purpose of this systematic review was to evaluate the effectiveness of mentoring strategies for nursing faculty progression and productivity in the nontenure track at institutions of higher education. Sixty articles were included in the review. Findings revealed that nontenure track nursing faculty require planned programs and mentoring strategies unique to their role and abilities. Schools of nursing can improve on faculty progression, scholarship, and career growth by providing structured mentoring activity.

Illustrations of Unexpected Infant Sleep Deaths.

Case illustrations from central Indiana provide the narrative for infant suffocations because of unsafe sleep environments. Accidental strangulation or suffocation in bed is caused by co-bedding, blankets and pillows in cribs, or wedging and entrapment. Knowledge of the evidence-based risks associated with case data may assist further in the prevention of unexpected infant sleep deaths and may better inform best practice for death scene investigation including forensic nurses.

When Baby Stops Breathing: Analysis of Mothers' Interviews.

Sudden unexplained infant death is responsible for 14% of Indiana's infant mortality. The purpose of this qualitative research study was to describe mothers' experiences when death of an infant occurred suddenly and unexpectedly. Field deputies or social workers interviewed mothers from central Indiana during the child-death team investigations. The Thematic Analysis Program from the Joanna Briggs Institute was used to analyze interview data. Sixteen de-identified interview cases were extracted, and a meta-aggregate method was conducted. The three synthesized themes were Extreme Emotional Shock, We Feel Like We're to Blame, and Working Toward Moving On. Understanding these phenomena from mothers' experience may assist in eliminating risks associated with infant deaths and inform nursing practice and policy.

Infant Co-Bedding: Practices and Teaching Strategies.

PURPOSE: Studies show that co-bedding is a common cause of death in babies. The purpose of this study is to identify teaching strategies that can be used to increase safe sleep practices. DESIGN AND METHODS: A rigorous systematic literature search identified articles that expressed ways in which to provide co-bedding teaching or provided recommended approaches to educating mothers and families about co-bedding risks. NOTARI software, from OVID Tools, was used to appraise articles, extract data, and thematically organize the findings, resulting in meta-aggregation. RESULTS: Two major findings were synthesized from four categories. First, co-bedding occurred despite knowing risks and having received teaching. Second, families should receive co-bedding messages tailored to their specific circumstances and risks. PRACTICE IMPLICATIONS: Findings showed that the lack of dialogue in co-bedding teaching often deters caregivers and families from seeking further education or consultation. Nurses need to ensure that safe sleep practices are taught and that the material provided pertains to the caregiver's specific cultural and familial situation.

Clinical education and clinical evaluation of respiratory therapy students.

Different blends of knowledge, decision making, problem solving,professional behaviors, values, and technical skills are necessary in the changing health care environments in which respiratory therapists practice. Frequently, novice students are expected to perform quickly and efficiently,and it may be forgotten that students are still learning and mastering the foundation pieces of practice. Clinical educators take on the responsibility of student development in addition to overseeing patient care. Normally,these volunteer instructors are role models for respiratory therapy students. The characteristic of initiative when demonstrated by a beginning student is attractive to the clinical instructor, promotes sharing of experiences, and may evolve into a mentor-protege relationship. Some clinical instructors may be underprepared to teach and are uncomfortable with student evaluation. Respiratory therapy facilities in conjunction with academic institutions may consider sponsoring ongoing programs for clinical teachers. Teaching and learning in the clinical environment is more than demonstration of skills and knowledge. Furthermore, it can be debated whether the memorization of facts or of the steps of a skill is more valuable than competency in problem solving, clinical reasoning, or information retrieval. New knowledge is built within a context and is further integrated when grounded by experience. Development of "prediction in practice" or the anticipation of the next necessary actions may be worth integrating into the instructional toolbox. Intuition has been defined as an "understanding without a rationale". This definition separates intuition from rational decision making and presents intuition as a type of innate ability. Reflection when guided by clinical instructors can help deepen critical thinking, as will Socratic questioning on a regular basis. Most clinical staff can agree on the performance of an incompetent student, but discrimination of the levels of competence is more challenging. Observations allow the assessor to obtain the data necessary to evaluate performance, followed by assessment, which denotes a judgment made on the basis of an observation of events. Performance assessment should have stability and consistency, measure what is intended to be measured, and truly determine competence. In contrast, reflective analysis has been shown to be successful for clinical evaluation, thus departing from strict competency and product-based assessment. Students yearn to become clinically knowledgeable, and their enthusiasm should be fostered. An interest in clinical practice is the primary reason individuals enroll in respiratory therapy education programs. Educators,managers, and staff should assure that students experience an appropriate, rich, and diverse clinical curriculum that with practice develops clinical judgment, reasoning, and reflection on practice.

Reliability of and correlation between the respiratory therapist written registry and clinical simulation self-assessment examinations.

STUDY OBJECTIVES: The purpose of this study was to determine the reliability of two respiratory therapy self-assessment examinations: the written registry examination (WR), and the clinical simulation examination (CSE). We then used reliability coefficients to test the true correlation between the WR and CSE by employing the Spearman-Brown formula to attenuate for unreliability. DESIGN: This was a nonexperimental correlational study. SETTING: The study was conducted at respiratory therapy education programs located in four states. PARTICIPANTS: Sixty advanced-level respiratory therapy students enrolled in the final semester of their programs. MEASUREMENTS AND RESULTS: Fifty-eight students completed the WR, and 56 students completed the CSE. The reliability coefficient for the WR was 0.79. The reliability coefficient for the CSE when taken as a whole was 0.76. However, the CSE is separated into two sections, information gathering and decision making, which are scored separately. Cronbach alpha computed for the information-gathering section was 0.72, while the alpha coefficient for the decision-making section was only 0.64. The correlation between the WR and CSE was 0.86 after attenuation for reliability. CONCLUSIONS: The estimate of the reliability for the CSE is less than that for the WR, and the two examinations are strongly correlated. This leads us to question whether the CSE adds to the validity or reliability in the testing of respiratory therapists.

Clinical utility of measures of breathlessness.

BACKGROUND: The clinical utility of measures of dyspnea has been debated in the health care community. Although breathlessness can be evaluated with various instruments, the most effective dyspnea measurement tool for patients with chronic lung disease or for measuring treatment effectiveness remains uncertain. Understanding the evidence for the validity and reliability of these instruments may provide a basis for appropriate clinical application. OBJECTIVE: Evaluate instruments designed to measure breathlessness, either as single-symptom or multidimensional instruments, based on psychometrics foundations such as validity, reliability, and discriminative and evaluative properties. Classification of each dyspnea measurement instrument will recommend clinical application in terms of exercise, benchmarking patients, activities of daily living, patient outcomes, clinical trials, and responsiveness to treatment. METHODS: Eleven dyspnea measurement instruments were selected. Each instrument was assessed as discriminative or evaluative and then analyzed as to its psychometric properties and purpose of design. RESULTS: Descriptive data from all studies were described according to their primary patient application (ie, chronic obstructive pulmonary disease, asthma, or other patient populations). The Borg Scale and the Visual Analogue Scale are applicable to exertion and thus can be applied to any cardiopulmonary patient to determine dyspnea. All other measures were determined appropriate for chronic obstructive pulmonary disease, whereas the Shortness of Breath Questionnaire can be applied to cystic fibrosis and lung transplant patients. The most appropriate utility for all instruments was measuring the effects on activities of daily living and for benchmarking patient progress. Instruments that quantify function and health-related quality of life have great utility for documenting outcomes but may be limited as to documenting treatment responsiveness in terms of clinically important changes. CONCLUSIONS: The dyspnea measurement instruments we studied meet important standards of validity and reliability. Discriminative measures have limited clinical utility and, when used for populations or conditions for which they are not designed or validated, the data collected may not be clinically relevant. Evaluative measures have greater clinical utility and can be applied for outcome purposes. Measures should be applied to the populations and conditions for which they were designed. The relationship between clinical therapies and the measurement of dyspnea as an outcome can develop as respiratory therapists become more comfortable with implementing dyspnea measurement instruments and use the data to improve patient treatment. Dyspnea evaluation should be considered for all clinical practice guidelines and care pathways.

Diabetes barriers and self-care management: the patient perspective.

For those individuals diagnosed with diabetes, the challenge is how to cope and manage the many aspects of their lives. The aim of this qualitative synthesis was to evaluate research studies for findings and then synthesize patients' experiences within the context of diabetes self-care while facing daily barriers. A total of 95 findings from 21 studies were categorized via like themes. These themes were further analyzed and aggregated to represent an interpretive meta-synthesis via a rigorous methodological protocol as described by Pearson, Robertson-Malt, and Rittinmeyer and the Joanna Briggs Institute. Meta-synthesized findings suggest that patients "avoid and hinder self-management" as well as "desire self-care and living life." Clinicians can improve interactions and potentiate understanding when the therapeutic approach is about the person living with diabetes as opposed to clinical control.