Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units.

BACKGROUND: Patient falls remain a common adverse event in acute care facilities. Findings from research into structured nursing rounds interventions (SNRIs) indicate promise as a fall prevention practice. Translating, adapting, and sustaining SNRI in real world clinical practices is an important next step. AIM: The purpose of this study was to evaluate the feasibility of adapting and translating a SNRI to reduce the risk and incidence of patient falls on two orthopedic inpatient units. It was hypothesized that SNRI would reduce fall rates up to 1-year postintervention and that patient risk factors and documented SNRI activities would predict falls. METHODS: Using a repeated measures design, fall rates and risk assessment data were collected at baseline, during the 12-week SNRI implementation, and 1-year following implementation. The adapted SNRI included hourly prescribed rounding activities documented on a study specific form. Medical records of patient falls were reviewed for each period. Focus groups were conducted with nurses' postintervention. RESULTS: Observed (probability) fall rates were 1.8%, 0.8%, and 1.1% for the three periods, respectively. Numbers of falls per 1,000 hospital days (incidence) were 4.5, 1.6, and 3.2 for the three periods. Mean fall risk assessment scores were 2.7 ± 1.1, 2.7 ± 1.1, and 2.5 ± 1.1 for the three periods. Fall rates declined during SNRI (borderline trend), yet 1-year follow-up rates drifted back toward baseline. SNRI dosage and fall risk scores did not predict fall rates. Patients who fell during the three periods were not at greatest risk. Nurses interpreted SNRI as an imposition and the documentation a burden. CONCLUSIONS: Findings illuminate the multiple challenges in translational research. SNRI appeared to reduce fall rates initially, but fidelity to the SNRI implementation and documentation was variable and fall reduction gains appeared lost 1 year later. Nurses expressed the importance of balancing intervention fidelity and individualizing patient interventions.

Using high-fidelity simulation to develop nurse-physician teams.

BACKGROUND: This study was undertaken to determine whether interdisciplinary high-fidelity simulation training improves group cohesion in nurse-physician teams. In addition, perceptions of collaboration and satisfaction with patient care decisions were measured in nurse-physician participants. METHODS: Clinical scenarios relevant to the general surgical urology inpatient unit were conducted in an interdisciplinary high-fidelity simulation center. Participants included physicians and staff nurses. RESULTS: Participants reported a positive shift in group cohesion over time. In addition, the results suggested a positive shift in perceptions of collaboration and satisfaction with patient care decisions over time. The youngest participants (Millennial Generation, born in the 1980s and 1990s) showed the most significant growth in response to the training. CONCLUSION: This study provides evidence of benefits of high-fidelity simulation that extend beyond the training. Simulation training may be a strategy to build and strengthen relationships across nurse-physician teams. In addition, this type of training may positively affect collaboration and satisfaction with patient care decisions. When data were analyzed by generational grouping, the most significant growth occurred in the Millennial Generation participants. These influences need to be explored further.

The "millennials": first year in practice.

Each year, thousands of novice nurses join the workforce. The overwhelming majority begin their careers in an acute care facility. Most of what we know about novice nurses comes from studies conducted over the last several decades. These studies have focused heavily on issues such as novice/expert differences on the performance of tasks. While they illuminate differences in judgment and decision-making skills, they provide little information on the reality of the novices' clinical practice. What is missing in the literature is an insider's look from the perspective of the millennial-born (1980-1999) novice nurse. Millennial novice nurses have both educators and experienced nurses searching for communication and learning strategies to engage the newest members of the nursing profession, yet the perceptions of millennial novice nurses have not yet been identified. This is a qualitative interpretive longitudinal study that utilized phenomenology as the philosophical and context method to illuminate the perceptions of millennial novice nurses. Audio-taped interviews were conducted at 3 months, 6 months, and 1 year. Findings have implications for both nurse educators and nurses in acute care facilities, especially those orienting the newest generation of novice nurses.

Evidence-based training for enhancing psychiatric nurses' child behavior management skills.

Management of behavior problems in an inpatient child and adolescent psychiatric unit is largely the responsibility of nurses, yet few evidence-based programs exist that prepare nurses for this role. A pilot study examined the effects of a 3-day standardized parent/teacher training program adapted for inpatient child and adolescent psychiatric unit nurses. Findings indicated that the standardized parent/teacher training program resulted in significant increases in self-reported use of child praise/incentives and working with parents, with accompanying desired changes in observed nurse behaviors during nurse-child play sessions. Participants rated the program positively and highlighted gains of greater empathy and fewer judgments of parents. Findings support evidence-based training programs for nursing staff and suggest further research.

'They leave at least believing they had a part in the discussion': understanding decision aid use and patient-clinician decision-making through qualitative research.

OBJECTIVE: This study explores how patient decision aids (DAs) for antihyperglycemic agents and statins, designed for use during clinical consultations, are embedded into practice, examining how patients and clinicians understand and experience DAs in primary care visits. METHODS: We conducted semistructured in-depth interviews with patients (n=22) and primary care clinicians (n=19), and videorecorded consultations (n=44). Two researchers coded all transcripts. Inductive analyses guided by grounded theory led to the identification of themes. Video and interview data were compared and organized by themes. RESULTS: DAs used during consultations became flexible artifacts, incorporated into existing decision making roles for clinicians (experts, authority figures, persuaders, advisors) and patients (drivers of healthcare, learners, partners). DAs were applied to different decision making steps (deliberation, bargaining, convincing, case assessment), and introduced into an existing knowledge context (participants' literacy regarding shared decision-making (SDM) and DAs). CONCLUSION: DAs' flexible use during consultations effectively provided space for discussion, even when SDM was not achieved. DAs can be used within any decision-making model. PRACTICE IMPLICATIONS: Clinician training in DA use and SDM practice may be needed to facilitate DA implementation and promote more ideal-type forms of sharing in decision making.

Perspective: medical education research and the institutional review board: reexamining the process.

Medical school and residency training curricula across the country have undergone extensive revisions and, much like clinical quality improvement (QI) initiatives, require assessments of new programs. Because sharing knowledge is a hallmark of academic medicine, program evaluation may come under the purview of the institutional review board (IRB); however, the distinction between QI and research is often unclear. And yet a medical education (ME) inquiry can be designed according to either paradigm. The purpose of this article is to bring IRBs and ME researchers closer to a shared understanding of key concepts underlying human participation in research and QI activities, and to consensus on the application of these concepts. The current QI discourse provides a useful framework for making this distinction; the authors identify key theoretical principles and practical considerations derived from this work that are relevant to ME and training, such as the application of the regulatory definition of human subject research to ME inquiries. For ME inquiries defined as human subject research, and therefore subject to IRB review, this article explores the application of the human research regulations to ME research. It concludes with practical suggestions for institutions, IRBs, and ME researchers, which range from formal procedures for making the QI versus research distinction, to instruction in study design and development and the human subject regulatory implications. The intent is to promote a discussion that will result in greater consensus and a more consistent application of the regulatory framework.