The development and initial validation of a clinical tool for patients' preferences on patient participation--The 4Ps.

AIMS: To report on the development and initial testing of a clinical tool, The Patient Preferences for Patient Participation tool (The 4Ps), which will allow patients to depict, prioritize, and evaluate their participation in health care. BACKGROUND: While patient participation is vital for high quality health care, a common definition incorporating all stakeholders' experience is pending. In order to support participation in health care, a tool for determining patients' preferences on participation is proposed, including opportunities to evaluate participation while considering patient preferences. METHODS: Exploratory mixed methods studies informed the development of the tool, and descriptive design guided its initial testing. The 4Ps tool was tested with 21 Swedish researcher experts (REs) and patient experts (PEs) with experience of patient participation. Individual Think Aloud interviews were employed to capture experiences of content, response process, and acceptability. RESULTS: 'The 4Ps' included three sections for the patient to depict, prioritize, and evaluate participation using 12 items corresponding to 'Having Dialogue', 'Sharing Knowledge', 'Planning', and 'Managing Self-care'. The REs and PEs considered 'The 4Ps' comprehensible, and that all items corresponded to the concept of patient participation. The tool was perceived to facilitate patient participation whilst requiring amendments to content and layout. CONCLUSIONS: A tool like The 4Ps provides opportunities for patients to depict participation, and thus supports communication and collaboration. Further patient evaluation is needed to understand the conditions for patient participation. While The 4Ps is promising, revision and testing in clinical practice is required.

Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record.

AIM: To describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records. DESIGN AND SETTING: A cross-sectional descriptive study performed in 29 wards at a university hospital in Iceland. The study included skin assessment of patients and retrospective audits of records of patients identified with pressure ulcers. PARTICIPANTS: A sample of 219 patients was inspected for signs of pressure ulcers on 1 day in 2008. Records of patients identified with pressure ulcers were audited (n = 45) retrospectively. RESULTS: The prevalence of pressure ulcers was 21%. Information in patient records lacked accuracy, completeness and comprehensiveness. Only 60% of the identified pressure ulcers were documented in the patient records. The lack of accuracy was most prevalent for stage I pressure ulcers. CONCLUSIONS: The purpose of documentation to record, communicate and support the flow of information in the patient record was not met. The patient records lacked accuracy, completeness and comprehensiveness, which can jeopardise patient safety, continuity and quality of care. The information on pressure ulcers in patient records was found not to be a reliable source for the evaluation of quality in health care. To improve accuracy, completeness and comprehensiveness of data in the patient record, a systematic risk assessment for pressure ulcers and assessment and treatment of existing pressure ulcers based on evidence-based guidelines need to be implemented and recorded in clinical practice. Health information technology, including the electronic health record with decision support, has shown promising results to facilitate and improve documentation of pressure ulcers.

Accuracy and continuity in discharge information for patients with eating difficulties after stroke.

AIMS: To describe the accuracy and continuity of discharge information for patients with eating difficulties after stroke. BACKGROUND: Eating difficulties are prevalent and serious problems in patients with stroke. Screening for eating difficulties can predict undernutrition and subsequent care needs. For optimal care, information transferred between care settings has to be comprehensive and accurate. DESIGN: Prospective, descriptive. METHODS: The study investigated a sample of 15 triads, each including one patient with stroke along with his patient record and discharge summary and two nursing staff in the municipal care to whom the patient was discharged. Data were collected by observations of patients' eating, record audits and interviews with nurses. Data were analysed using content analysis and descriptive statistics. RESULTS: Accuracy of recorded information on patients' eating difficulties and informational continuity were poor, as was accuracy in the transferred information according to nursing staff's perceptions. All patients were at risk of undernutrition and in too poor a state to receive rehabilitation. Nevertheless, patients' eating difficulties were described in a vague and unspecific language in the patient records. Co-ordinated care planning and management continuity related to eating difficulties were largely lacking in the documentation. Despite their important role in caring for patients with eating difficulties, little information on eating difficulties seemed to reach licensed practical nurses in the municipalities. CONCLUSIONS: Comprehensiveness in the documentation of eating difficulties and accuracy of transferred information were poor based on record audits and as perceived by the municipal nursing staff. Although all patients were at risk of undernutrition, had multiple eating difficulties and were in too poor a state for rehabilitation, explicit care plans for nutritional problems were lacking. RELEVANCE TO CLINICAL PRACTICE: Lack of accuracy and continuity in discharge information on eating difficulties may increase risk of undernutrition and related complications for patients in continuous stroke care. Therefore, the discharge process must be based on comprehensive and accurate documentation.

Registered nurses' thinking strategies on malnutrition and pressure ulcers in nursing homes: a scenario-based think-aloud study.

AIM: The aim of this study was to explore the thinking strategies and clinical reasoning processes registered nurses use during simulated care planning for malnutrition and pressure ulcers in nursing home care. BACKGROUND: Clinical reasoning is an essential component of nursing practice. Registered nurses' thinking strategies and clinical reasoning have received limited attention in nursing science. Further research is needed to understand registered nurses' clinical reasoning, especially for prevention of malnutrition and pressure ulcers as they are important quality indicators of resident care in nursing homes. DESIGN: A qualitative explorative design was used with a think-aloud interview technique. METHODS: The transcribed verbalisations were analysed with qualitative deductive content analysis. Data were collected during six months in 2007-2008 from 30 registered nurses at nine nursing homes in Norway. RESULTS: The registered nurses used a variety of thinking strategies, but there were differences in the frequency of use of the different strategies. The three most commonly used thinking strategies were 'making choices', 'forming relationships' and 'drawing conclusions'. None of the nurses performed a structured risk assessment of malnutrition or pressure ulcers. Registered nurses started with assessing data from the scenarios, but after a short and elementary assessment they moved directly to planning. CONCLUSION: Many different thinking strategies were used in registered nurses' clinical reasoning for prevention of malnutrition and pressure ulcers. The thinking strategy 'making choices' was most commonly used and registered nurses' main focus in their reasoning was on planning nursing interventions. RELEVANCE TO CLINICAL PRACTICE: This study showed that most of the registered nurses go directly to planning when reasoning clinically about residents in nursing homes. A lack of systematic risk assessments was identified. The insight gained from this study can be used to recommend improvements in tools designed for nursing homes to support the registered nurses.

Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records.

The nursing process and standardized nursing terminologies are essential elements to structure nursing documentation in daily nursing information management. The aim of this study was to describe sustainability and whether and how standardized nursing terminologies, in handwritten versus preprinted versus computerized nursing care plans, changed the content and completeness of documented nursing care. Three audits of patient records were performed: a pretest (n = 291) before a yearlong implementation of standardized nursing terminologies in nursing care plans followed by two posttests: (1) 3 weeks after implementation of nursing terminologies (n = 299) and (2) 22 months after implementation of nursing terminologies and 8 months after implementation of a computerized system (n = 281) in a university hospital. Content and completeness of documented nursing care improved after implementation of standardized nursing terminologies. Documentation of nursing care plans, signs and symptoms, related factors, and nursing interventions increased, whereas mean number of nursing diagnoses per patient did not change between audits. Computerized nursing care plans had the biggest impact, with more variety of nursing diagnoses and increased documentation of signs and symptoms, related factors, and nursing interventions. The use of standardized nursing terminologies improved nursing content in the nursing care plans. Moreover, computerized nursing care plans, in comparison with handwritten and preprinted care plans, increased documentation completeness.

Multidisciplinary recording and continuity of care for stroke patients with eating difficulties.

Eating difficulties after stroke are common and can, in addition to being a risk for serious medical complications, impair functional capability, social life and self-image. Stroke unit care entails systematic multidisciplinary teamwork and continuity of care. The purpose of this study was to describe (i) multidisciplinary stroke care as represented in patient records for patients with eating difficulties, and (ii) the written information that was transferred from hospital to elderly care. Data from 59 patient records were analysed with descriptive statistics and by categorization of phrases. Signs of multidisciplinary collaboration to manage eating problems were scarce in the records. While two notes from physiotherapists were found, nurses contributed with 78% of all notes (n = 358). Screening of swallowing and body weight was documented for most patients, whereas data on nutritional status and eating were largely lacking. The majority of notes represented patients' handling of food in the mouth, swallowing and lack of energy. Care plans were unstructured and few contained steps for managing eating. Discharge summaries held poor information on care related to eating difficulties. The language of all professionals was mostly unspecific. However, notes from speech-language therapists were comprehensive and entailed information on follow-up and patient participation.

Clinical decision support systems to prevent and treat pressure ulcers and under-nutrition in nursing homes.

Clinical decision support systems (CDSSs) are believed to have the potential to improve care and change the behavior of health personnel. The project has focused on developing a CDSS to support prevention of pressure ulcer and undernutrition that is completely integrated in the electronic health record in nursing homes. Nursing staff have been involved in all phases in the development of the CDSS, which at present is ready to be implemented and systematically evaluated.

Nursing informatics in Sweden - the agenda for the future.

With the purpose of getting an overview of the current research and development in information systems and terminology for nursing practice and outline strategies for the future, an initiative for a workshop was taken at the national level in Sweden by the Section for Nursing Informatics, the Society of Nursing and the Association of Health Professionals in 2007. For the workshop around 30 nurses were invited, representing clinical practice, education, and research. The workshop resulted in recommendations for future strategies to support the development of nursing informatics in Sweden.

Considering patient non-participation in health care.

OBJECTIVE: The aim of this study was to depict patient non-participation as described by a diverse group with recent experiences of being patients. BACKGROUND: Patient participation is regarded as a primary condition for optimal quality of care, suggesting that non-participation should be avoided. A common understanding of the concept of patient non-participation is needed. A discrepancy in definitions of patient non-participation has been found in health-care interactions, health-care classifications and health-care research, and little is known of what patient non-participation represents to patients. STUDY DESIGN: A survey consisting of closed-ended and open-ended questions was administered to persons that had recently been patients to gather respondents' descriptions of what they considered as patient non-participation. Qualitative content analysis was used to analyse free-text descriptions, and descriptive statistics were used for the close-ended alternatives. FINDINGS: Lacking information (e.g. not being provided with appropriate information) and lacking recognition (e.g. not being listened to and/or lacking recognition as an individual with individual needs and concerns) were significant aspects of patient non-participation. Furthermore, non-participation encompassed facing organization-centred, as opposed to patient-centred, health care as well as feeling insecure in health care interactions. CONCLUSION: The findings provide input for a better understanding of what patients experience as non-participation. Organising for the caregivers to be able to thoroughly listen to the patients' illness narratives would easily reduce the risk of patient's experiencing what is described as non-participation and would provide a sound base for patient learning needs.

Clinical decision-making: predictors of patient participation in nursing care.

AIM: To investigate predictors of patients' preferences for participation in clinical decision-making in inpatient nursing care. BACKGROUND: Patient participation in decision-making in nursing care is regarded as a prerequisite for good clinical practice regarding the person's autonomy and integrity. DESIGN: A cross-sectional survey of 428 persons, newly discharged from inpatient care. METHODS: The survey was conducted using the Control Preference Scale. Multiple logistic regression analysis was used for testing the association of patient characteristics with preferences for participation. RESULTS: Patients, in general, preferred adopting a passive role. However, predictors for adopting an active participatory role were the patient's gender (odds ratio = 1.8), education (odds ratio = 2.2), living condition (odds ratio = 1.8) and occupational status (odds ratio = 2.0). A probability of 53% was estimated, which female senior citizens with at least a high school degree and who lived alone would prefer an active role in clinical decision-making. At the same time, a working cohabiting male with less than a high school degree had a probability of 8% for active participation in clinical decision making in nursing care. CONCLUSIONS: Patient preferences for participation differed considerably and are best elicited by assessment of the individual patient. Relevance to clinical practice. The nurses have a professional responsibility to act in such a way that patients can participate and make decisions according to their own values from an informed position. Access to knowledge of patients'basic assumptions and preferences for participation is of great value for nurses in the care process. There is a need for nurses to use structured methods and tools for eliciting individual patient preferences regarding participation in clinical decision-making.

Nutritional status and patient characteristics for hospitalised older patients with chronic obstructive pulmonary disease.

AIM: The aim of the study was to describe and compare nutritional status and social and medical characteristics among older patients with chronic obstructive pulmonary disease admitted to an acute care hospital ward for respiratory medicine. BACKGROUND: Chronic obstructive pulmonary disease is a condition associated with risk of developing malnutrition. A body mass index <20 is predictive of hospitalisation for acute exacerbations of chronic obstructive pulmonary disease. Knowledge about patient characteristics is crucial for the identification of malnourished patients and the development of nursing care for these patients. DESIGN: Quantitative descriptive study. METHODS: Thirty-three hospitalised women and 17 men with a mean age of 75.7 years (SD 6.9) were consecutively included. A very severe case of chronic obstructive pulmonary disease was indicated in 28 out of 39 patients who underwent a lung function test. Data were collected with measurement of nutritional status using Mini Nutritional Assessment, anthropometry and lung function. RESULTS: Nearly half of the patients (48%) were identified as malnourished, an equal part as at risk for malnutrition and two patients as well nourished. The mean Mini Nutritional Assessment score of 17.2 (SD 3.99) for all patients was near the Mini Nutritional Assessment cut-off score (i.e. 17) for malnutrition. Patients identified as malnourished had a mean body mass index of 18.9 and those at risk for malnutrition had a mean of 23.4. It was more common for those identified as malnourished to live singly, to not live in own property and to be dependent on daily community service. Seven patients identified as malnourished died during the data collection period. CONCLUSIONS: This study provides important knowledge about further risks of impaired nutritional status among older patients with chronic obstructive pulmonary disease. RELEVANCE TO CLINICAL PRACTICE: This knowledge can provide registered nurses with the necessary knowledge to make them aware of certain patients needing particular kinds of attention.

Methodological issues in interviews involving people with communication impairments after acquired brain damage.

Qualitative research has made a significant contribution to the body of knowledge related to how people experience living with various chronic diseases and disabilities; however, the voices of certain vulnerable populations, particularly those with impairments that affect their ability to communicate, are commonly absent. In recent years, a few researchers have attempted to explore the most effective ways to ensure that the voices of people with communication impairments from acquired brain damages can be captured in qualitative research interviews; yet several methodological issues related to including this population in qualitative research remained unexamined. In this article, the authors draw on insights derived from their research on the experiences of adult survivors of stroke and traumatic brain injury to describe methodological issues related to sampling, informed consent, and fatigue in participant and researcher while also making some recommendations for conducting qualitative interviews with these populations.

What if nurses get what they have always sought: totally personalized care? Trends affecting nursing informatics.

We may be moving towards an era where nurses may get what they say they have always wanted--totally personalized care. This paper examines four major trends, i.e. the increasing importance of the genome, the informed patient, the rise of the patient-payer, and the 'instant gratification generation'. Each individually, and in combination, will have potential impacts on the future of health and nursing. The implications of these issues, and others are explored, as well as nursing's readiness to deal with the implications of truly and totally personalized care.

Emergency department triage: is there a link between nurses' personal characteristics and accuracy in triage decisions?

INTRODUCTION: A common task of registered nurses is to perform emergency department triage, often using an especially designed triage scale in their assessment. However, little information is available about the factors that promote the quality of these decisions. This study investigated personal characteristics of registered nurses and the accuracy in their acuity ratings of patient scenarios. METHODS: Using the Canadian Triage and Acuity Scale (CTAS), 423 registered nurses from 48 (62%) Swedish emergency departments individually triaged 18 patient scenarios. RESULTS: The registered nurses' percentage of accurate acuity ratings was 58%, with a range from 22% to 89% accurate acuity ratings per registered nurse. In total, 60.3% of the registered nurses accurately triaged the scenarios in 50-69% of the cases. No relationship was found between personal characteristics of the registered nurses and their ability to triage. DISCUSSION: The lack of a relationship between personal characteristics of registered nurses and their ability to triage suggests that there might be intrapersonal characteristics, particularly the decision-making strategies used which can partly explain this dispersion. Future research that focuses on decision-making is likely to contribute in identifying and describing essential nursing characteristics for successful emergency department triage.

Patient participation in decision making in nursing.

Patient participation in decision making concerning nursing needs is an important aspect of high quality care, of interest for both planning and implementing care. However, patients' perspective on participation in clinical decision making has not been studied extensively and the literature is inconclusive of what roles patients prefer to adopt. The aim was to investigate associations between patient demographics and preferences for participation in clinical decision making and to compare patients and RNs perceptions of the patients' preferences for participation. A cross sectional study including 80 nurse-patient dyads was adopted. The Control Preference scale was used to collect data. The findings showed that younger and more educated patients preferred to be more active in some aspects of decision making than older and less educated patients did. Further, in comparison with RNs inference of patient preferences for participation, patients preferred to be more passive in decision making in relation to nursing needs in general, as well as for physical and psychosocial needs. Differences in perceptions between patients and RNs concerning patient participation could hamper high quality care and need to be addressed.

Recording of nursing assessment and interventions for stroke patients with eating difficulties.

A standardised language is a necessary condition for successful development and implementation of electronic patient records. In the present study a record audit was performed at a Swedish stroke unit. The aims were to analyse how the nursing process on eating difficulties after stroke was represented in nursing documentation and to describe the information that was transferred to the next care provider at discharge. Data were analysed using descriptive statistics and content analysis. Results show that care planning and nursing interventions were not visible in patient records. Furthermore, the language proved vague and expressed in a "non-professional" manner.

The use of qualitative data analysis software (QDAS) to manage and support the analysis of think aloud (TA) data.

This methodological paper describes how qualitative data analysis software (QDAS) is being used to manage and support a three-step protocol analysis (PA) of think aloud (TA) data in a study examining emergency nurses' reasoning during triage. The authors believe that QDAS program QRS NVivo will greatly facilitate the PA and will allow them to identify and describe the information that triage nurses concentrate on during triage, and how they structure this information to make a triage decision. These findings could assist in designing and creating decision support systems to guide nurses' triaging. Additionally, details about how to use QRS NVivo for PA of TA data may assist and guide future informatics research using similar methodology are presented here. This innovative use of QDAS holds great promise for future nursing informatics research.

Mapping VIPS concepts for nursing interventions to the ISO reference terminology model for nursing actions: A collaborative Scandinavian analysis.

The aims of this study were to analyze the coherence between the concepts for nursing interventions in the Swedish VIPS model for nursing recording and the ISO Reference Terminology Model for Nursing Actions and to identify areas in the two models for further development. Seven Scandinavian experts analyzed the VIPS model's concepts for nursing interventions using prototypical examples of nursing actions, involving 233 units of analyses, and collaborated in mapping the two models. All nursing interventions in the VIPS model comprise actions and targets, but a few lack explicit expressions of means. In most cases, the recipient of care is implicit. Expressions for the aim of an action are absent from the ISO model. By this mapping we identified areas for future development of the VIPS model and the experience from nursing terminology work in Scandinavia can contribute to the international standardization efforts.

Growth data of underprivileged children living in rural areas of Chin State, Burma/Myanmar, compared to the WHO reference growth standards: an observational study.

OBJECTIVES: To explore growth data (height-for-age, weight-for-age and BMI-for-age) of children living in poor socioeconomic conditions in rural areas of Chin State, Burma/Myanmar; and to compare these data with the growth and development z-score (GDZ) values for school-aged children and adolescents, provided by the WHO. SETTING: A support and educational programme, run by the Swedish association Chin Development and Research Society (CDRS), was carried out among underprivileged school-aged children, unable to attend school without economic and practical support, living in villages and remote areas in Chin State. PARTICIPANTS: Community leaders who were well familiar with the citizens in the community identified children in need of this support. Other community members could also suggest or apply for this. The sample includes all participating children in the CDRS programme at the time of the data collection in six townships. The children were placed in host families, close to a suitable school. Two samples with a total of 639 children from 144 villages and remote areas were obtained:1. Children in the CDRS Chin Programme (CCP) (2007-2010) comprised 558 children: 50% girls and boys.2. Children in the Chin Society (CCS) (2010) comprised 81 children: 44% girls and 56% boys. PRIMARY OUTCOME MEASURES: Growth data. RESULTS: All growth data from both groups deviated significantly from the WHO standard references (p ≤ 0.001). The prevalence of stunting (height-for-age ≤-2SD) was 52% among girls and 68% among boys. High levels of wasting (weight-for-age ≤-2SD) were found among girls 29% and boys 36% aged 5-10 years. In addition, severe thinness (BMI-for-age ≤-2SD) was found among girls 31% and boys 44%, all results to be compared to the expected 2.27%. CONCLUSIONS: Many more than expected-according to the WHO reference values-in CCP and CCS suffered from stunting, wasting and thinness.

Experiences of parenting a child with medical complexity in need of acute hospital care.

Parents of children with medical complexity have described being responsible for providing advanced care for the child. When the child is acutely ill, they must rely on the health-care services during short or long periods of hospitalization. The purpose of this study was to describe parental experiences of caring for their child with medical complexity during hospitalization for acute deterioration, specifically focussing on parental needs and their experiences of the attitudes of staff. Data were gathered through individual interviews and analyzed using qualitative content analysis. The care period can be interpreted as a balancing act between acting as a caregiver and being in need of care. The parents needed skilled staff who could relieve them of medical responsibility, but they wanted to be involved in the care and in the decisions taken. They needed support, including relief, in order to meet their own needs and to be able to take care of their children. It was important that the child was treated with respect in order for the parent to trust the staff. An approach where staff view parents and children as a single unit, as recipients of care, would probably make the situation easier for these parents and children.