Registered nurses' own experience of using a nurse-initiated pain protocol based on their working experience.

AIMS AND OBJECTIVES: To explore registered nurses' (RNs) own experience of using the nurse-initiated pain protocol (NIPP) in the emergency department (ED) based on their working experience. BACKGROUND: Pain is known to be one of the most common symptoms among adult patients seeking care at the ED. Several strategies aiming to improve pain management have been developed. Despite some improvements in pain management using NIPP, a large number of patients continue to have inadequate pain treatment when cared for in EDs. DESIGN AND METHOD: A cross-sectional study design based on a questionnaire was used. The variable working experience was based on a theory that experience will make a change in RNs' knowledge. Descriptive statistics and Pearson's chi-square tests were used for analysing quantative data. Qualitative data were analysed by summative content analysis. RESULTS: Seventy RNs answered the questionnaire (response rate 42%) and 61% considered the NIPP adequate to relieve patients' acute pain at the ED. No significant difference was found on how the RNs used the NIPP. However, qualitative data showed that more experienced RNs adapt the NIPP according to the patients' needs in a higher extent. CONCLUSION: A majority of the RNs consider the NIPP to be adequate to relieve patients' acute pain in the ED. An increase in working experience showed an impact on how the NIPP was used, with an increase in pain management that is personalised depending on individual patients' needs. The RNs used several alternatives to both dosage and type of medication when the ED becomes crowded. RELEVANCE TO CLINICAL PRACTICE: Registered nurses' working experience should be considered when planning nursing schedules to be better able to meet patients' needs. Guidelines should be developed and evaluated by both healthcare professionals and patients.

Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden.

BACKGROUND: Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Other studies have analyzed the individual and system contributory factor leading to a medication error. Nurses have a key role in medication administration, and there are contradictory reports on the nurses' work experience in relation to the risk and type for medication errors. METHODS: All medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. In order to test for possible differences between nurses' work experience and associations within and between the errors and contributory factors, Fisher's exact test was used, and Cohen's kappa (k) was performed to estimate the magnitude and direction of the associations. RESULTS: There were a total of 613 medication errors in the 585 cases, the most common being "Wrong dose" (41 %), "Wrong patient" (13 %) and "Omission of drug" (12 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found; the most common being "Negligence, forgetfulness or lack of attentiveness" (68 %), "Proper protocol not followed" (25 %), "Lack of knowledge" (13 %) and "Practice beyond scope" (12 %). In 78 % of the cases, an average of 1.7 system contributory factors was found; the most common being "Role overload" (36 %), "Unclear communication or orders" (30 %) and "Lack of adequate access to guidelines or unclear organisational routines" (30 %). The errors "Wrong patient due to mix-up of patients" and "Wrong route" and the contributory factors "Lack of knowledge" and "Negligence, forgetfulness or lack of attentiveness" were more common in less experienced nurses. The experienced nurses were more prone to "Practice beyond scope of practice" and to make errors in spite of "Lack of adequate access to guidelines or unclear organisational routines". CONCLUSIONS: Medication errors regarded as malpractice in Sweden were of the same character as medication errors worldwide. A complex interplay between individual and system factors often contributed to the errors.

Custodian for elderly with memory impairment in Sweden - a study of 260 physicians' statements to the court.

BACKGROUND: In the modern world with new family structures, international migration and increased life expectancy, there is a growing need for legal ways of assisting elderly with impaired mental capacity to decide about their life and assets. There are few studies about the physician's role when a court appoints proxies for vulnerable elderly. Many doctors do not know how to assess mental capacity, and most lawyers and judges know little about medicine. METHODS: Applications for a custodian sent to the Stockholm Chief Guardian' Office in Sweden were used. Physician's statements to the court for elderly with memory impairment were selected and 260 statements were scrutinized with regard to formal quality, the narrative content and the physician who wrote it. RESULTS: The quality of the statements varied from one sentence to excellent. Most statements were written by senior family practitioners or geriatricians. Seventeen % of the statements were handwritten and had more formal shortcomings than machine/computer written statements.The majority of patients needed massive help with daily life and economy. Median age was 84 years of age. MMSE score was given in 20% of the cases and varied from 6-27.A diagnosis of dementia was established in 57%. At the time of application, at least 48% were in a hospital or nursing home and at least 27% were in their private home. Only 5% were living with a spouse or a child. In 53% of the cases, the doctor knew the patient, but in 40% of the cases, the identity of the patient was not confirmed. The physician found that 54% were unable to understand the idea of getting a custodian, but out of those very vulnerable elderly, 20% had signed consent and 57% were considered able to be heard in court. CONCLUSIONS: There is a large variation in the quality of physicians' statements to the court concerning the mental capacity of elderly patients with cognitive impairment. Many statements have serious short-comings, and the system is not safe. There is a strong need for guide-lines, and additional training for all professionals involved.

Micturition problems after bladder distension during hospitalization in Sweden: "I'm not ill, just damaged for the rest of my life".

BACKGROUND: Urinary retention is a common complication following hospital care, which can result in overdistension of the bladder and, at worst, chronic bladder damage and persistent micturition difficulties. OBJECTIVES: The purpose of this study was to explore patients' experiences of micturition problems after bladder distension and their effects on the patients' everyday lives. METHODS: The Swedish Patient Insurance LÖF was used to identify patients from January 2007 to June 2010 who have reported micturition problems after hospital care and have had their injuries classified as avoidable bladder damage due to overdistension. Narrative interviews were conducted with 20 volunteers and analyzed by qualitative content analysis. RESULTS: The micturition problems affected everyday life through constraints (dependence on disposables and access to toilets, clothing restrictions, limitations on social life and career), suffering (pain, infections, impaired sex life, leakage), and concerns for the future (fear of worsening symptoms and fear of losing control with age). Aspects related to having been harmed by the healthcare system were the harm could have been avoided (lack of knowledge, insufficient routines, mistrust), obstacles to overcome when reporting an injury (difficulties in obtaining knowledge about the possibility of reporting an injury, ambivalence toward reporting their healthcare providers), and a wish to improve care (raise awareness, prevent harm to others). DISCUSSION: Bladder distension is a healthcare-related injury that can cause suffering and practical, emotional, and psychosocial problems with a great impact on the life of the person affected and anxiety for the future. The healthcare system must, therefore, raise awareness and improve preventive routines.

Translation and validation of the wound-specific quality of life instrument Cardiff Wound Impact Schedule in a Swedish population.

PURPOSE: To translate and validate the wound-specific health-related quality of life instrument, the Cardiff Wound Impact Schedule (CWIS) in a Swedish population. METHODS: The instrument was first translated into Swedish, using the Standard Linguistic Validation Process. The Swedish version of the CWIS was then tested for its psychometric properties in a Swedish context. A total of 117 patients with acute and hard-to-heal wounds were included. The patients were asked to fill in the Swedish version of the CWIS and the generic instrument SF-36 at baseline and after 1 week. Patients with acute wounds were also asked to fill in both instruments after 6 weeks. RESULTS: Face validity and content validity were assessed by patients and an expert group, and judged as good. Criterion validity was calculated with correlation between CWIS and SF-36, reaching moderate to high values. Reliability of the three domains of the CWIS measured with internal consistency and test-retest stability was acceptable to excellent. Internal responsiveness was assessed with standardised response mean and showed moderate to high sensitivity. CONCLUSIONS: This study concludes that the Swedish version of CWIS is a valid and reliable tool for measuring health-related quality of life in patients with acute and hard-to-heal wounds.

Preoperative ultrasound monitoring can reduce postoperative bladder distension: a randomized study.

OBJECTIVE: The aim of this study was to explore whether close preoperative ultrasound monitoring starting in the emergency room (ER) could prevent postoperative bladder distension among acute orthopaedic patients. MATERIAL AND METHODS: A randomized controlled trial was conducted at a 650-bed level-2 centre in Sweden. Inclusion criteria were admittance via ER to an orthopaedic ward for acute surgery. Bladder volumes were measured with a portable ultrasound scanner (Bladderscan BVI 3000). In the intervention group, all patients were scanned in the ER and then regularly at the ward at predefined times until surgery. In the control group, no regular scanning was performed before surgery. During surgery, the same procedure was performed for both groups: bladder scanning immediately after arrival to the recovery room and continuous postoperative scanning until voiding. The primary outcome was postoperative bladder distension, defined as a bladder volume ≥500 ml. Secondary outcomes were postoperative urinary tract infection and hospital length of stay. RESULTS: A total of 281 patients completed the study, 141 in the intervention group and 140 in the control group. Postoperative bladder distension was significantly higher in the control group (27.1% vs 17.0%; p = 0.045, 95% confidence interval 4.9-19.8) in the intention-to-treat, per-protocol and as-treated analyses. No statistical difference was found between the intervention group and the control group regarding the secondary outcomes. CONCLUSIONS: Frequent bladder monitoring starting in the ER can reduce postoperative bladder distension among acute orthopaedic patients. A preoperative bladder monitoring protocol should be implemented early in the ER for all patients admitted for acute orthopaedic procedures.

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UNLABELLED:  The aim of this retrospective study was to identify risk factors related to unsuccessful treatment and complications with negative pressure wound therapy (NPWT). METHODS: A consecutive series of patients treated with NPWT for wounds of various etiologies (n = 87) from 2005-2007 at a general hospital in a large city (Stockholm, Sweden) were assessed for risk for unsuccessful treatment and complications associated with NPWT. RESULTS: Twenty-nine percent of the patients treated with NPWT had unsuccessful treatment results. The strongest risk factors associated with unsuccessful treatment were pressure ulcers (OR 4.6) or a positive culture for Staphylococci (OR 3.4). The complication rate was 21%, of which 14 patients had to terminate treatment. A positive culture for either Staphylococci or Pseudomonas was strongly associated (P = 0.001) with risk of complications during NPWT treatment. Patients with insufficient peripheral circulation in the extremities had a risk of both unsuccessful treatment and complications. CONCLUSION: The findings of the present study stress the importance of evaluating bacterial cultures and adequate antibiotic therapy when infection is suspected. The status of the patient's peripheral macrocirculation in the lower extremities seems to have a significant impact on the risk of unsuccessful treatment or complications. Therefore, is it of great importance to evaluate peripheral circulation status before initializing NPWT. .

Medication reviews with computerised expert support: evaluation of a method to improve the quality of drug utilisation in the elderly.

PURPOSE: This paper aims to examine whether a computerised system for medication reviews can support physicians' decisions and improve the quality of drug treatment in the elderly. DESIGN/METHODOLOGY/APPROACH: This is a descriptive intervention study. The study included 275 patients living in community settings and nursing homes in Stockholm, Sweden. Patient data were analysed using computer software and scrutinised by a clinical pharmacologist. Pharmaco-therapeutic advice was sent to the physician responsible for each patient. The main outcome measures were initiation and discontinuation of drugs, changes of doses and rates of identified drug-related problems. FINDINGS: Expert opinions were given by the clinical pharmacologist, for 275 patients, mean age 85 years; 70 per cent female. An average of 3.3 remarks was given concerning unsuitable drugs, unclear indication, dosing when the kidney function was decreased, drug-drug interactions and quality indicators. On average 1.5 drug-related problems (DRP) per patient were attended to by the responsible physician at each unit. The most common action taken was withdrawal of a drug (n = 208). On average the drug use decreased from 10.4 to 9.5 drugs per patient, and several quality indicators were met. The drug costs decreased, and resulted in a more cost-effective drug therapy. ORIGINALITY/VALUE: The paper develops and tests a method for intervention in the care of elderly patients. The method is based on a computerised expert support system for medication reviews at a distance and on education of the staff. A safer drug therapy with improved quality and cost-effectiveness is thus provided.

Nurse-led medication reviews and the quality of drug treatment of elderly hospitalized patients.

PURPOSE: To evaluate if nurses after receiving training in clinical pharmacology can improve the quality of the drug therapy in elderly hospitalized patients. METHODS: Nurses were given a 1-day training in clinical pharmacology to identify drug-related problems (DRPs).All patients admitted to the ward aged 65 or more were studied. Patients at the same ward before the intervention were considered as control group. Outcome variables were re-hospitalized 3 months from discharge, drug-related readmissions, the proportion of inappropriate drug use (IDU), and DRPs found by the nurses. RESULTS: Of 460 patients (250 intervention group and 210 in the control group) 38 and 36%, respectively, had at least one re-admission to hospital (p=0.86) and 24% of the patients died. Eighteen and 17% (43/37), respectively, used one or more inappropriate drug (p 0.90). The nurses found 86 clinically significant DRPs not detected by the usual care. A substantial part of the DRPs detected by the nurses were revealed with assistance of Symptoms Assessment Form (SYM). There were no statistical difference in the number of drug-related re-admissions between the groups, 14/16, respectively, (p=0.40). CONCLUSIONS: Nurses are able to detect a high proportion of clinically relevant DRPs not detected by the usual care and thereby increase the quality of the drug treatment in elderly hospitalized patients. Our study showed no effect on re-hospitalization or IDU. By using a SYM nurses can find DRPs that computer-based decision support systems miss.

Psychometric properties of the virtual patient version of the Lasater Clinical Judgment Rubric.

A number of studies attest to the effectiveness of virtual patients in fostering and assessing students' development of clinical reasoning. An objective assessment of students' clinical reasoning is, however, challenging. This study focused on determining the psychometric properties of the virtual patient version of the Lasater Clinical Judgment Rubric, a rubric that is aimed at assessing nursing students' clinical reasoning processes when encountering virtual patients. A nonexperimental design was used in which data from 125 students' reflections on solving two different virtual patient scenarios were included in the analysis. First, a deductive content analysis was conducted using the categories of the rubric as a lens. After that, each student's performance was quantified according to the different levels of the rubric. Exploratory factor analysis and test of normality and reliability, including the Kaiser-Meyer-Olkin test, Bartlett's test, the Shapiro-Wilk test, and Cronbach's alpha were used in the analysis. The result suggested three factors: "Understanding the patient", "Care planning" and "Reflecting" that explained 81.8% of the variance. Cronbach's alpha was 0.931. The result showed the rubric to be a valid assessment instrument for assessing nursing students' clinical reasoning when encountering virtual patients.

A clinical evaluation of the Janus Web Application, a software screening tool for drug-drug interactions.

PURPOSE: To evaluate the clinical relevance of the Janus Web Application (JWA) in screening for potential drug-drug interactions (DDIs). METHODS: One hundred and fifty patients taking two drugs or more were studied. Potential DDIs were identified by the JWA. Interviewing the patient and looking into his/her medical records provided complementing information. A clinical pharmacologist judged which potential DDIs were clinically relevant. Potentially relevant DDIs identified by the JWA were then correlated with clinically relevant DDIs. RESULTS: A total of 150 significant potential DDIs were found. Sixteen percent (24/150) were judged to be clinically relevant. CONCLUSIONS: A very small proportion of DDIs was considered clinically relevant in the specific clinical context. To optimise the software's user-friendliness, the following points need to be considered: the possibility of eliminating trivial potential DDIs, individualising drug alerts, and providing written information, accessible via a hyperlink.

A Rubric to Assess Students' Clinical Reasoning When Encountering Virtual Patients.

BACKGROUND: Training with virtual patients has been proposed as a suitable learning activity to improve clinical reasoning skills for nursing students. However, published instruments with the capacity to assess students' reasoning process in the encounter with virtual patients are lacking. METHOD: Deductive and abductive analyses were used to adapt the Lasater Clinical Judgment Rubric (LCJR) to assess nursing students' clinical reasoning skills in the encounter with virtual patients. The new rubric's ability to capture nursing students' clinical reasoning processes was tested using deductive analysis and statistical analysis. RESULTS: A grading rubric for virtual patients, the vpLCJR, was developed. Cronbach's alpha showed .892, indicating good internal consistency. CONCLUSION: The rubric vpLCJR, which deconstructs aspects of clinical reasoning for both students and faculty members, can be used to clarify expectations, assess students' clinical reasoning process, and provide feedback for learning when nursing students encounter virtual patients. [J Nurs Educ. 2018;57(7):408-415.].

Drug use and perceived health in recently hospitalized older people.

Older patients often have multiple diseases, resulting in treatment with many drugs. This may increase the risk for drug-related problems. This study aimed to analyse the congruence between the patient's self-reported drug use and the medical record, and the relationship to perceived health among older patients recently discharged from hospital. A total of 200 patients over 65 years of age who were admitted to a medical ward and were treated with at least one drug participated in an interview study one week after discharge from the hospital. The patients provided information on their current drug therapy. This information was compared to the prescriptions documented in the medical record. Thirty per cent of the study population reported a drug use which was in congruence with the medical record, 28% used less drugs than prescribed, and 42% more. Statistical analysis showed a high probability of non-congruence with prescriptions among patients who reported poor health.

Patients' experience of advanced wound treatment-a qualitative study.

INTRODUCTION: Each patient experiences wound treatment differently, and it is important to enhance the knowledge of the impact of the treatment to be able to individualize patient care. METHODS: This descriptive qualitative study aims to describe the experience of patients with wounds treated with advanced moist wound therapy (AMWT) and negative pressure wound therapy (NPWT). Data were collected from 15 diaries written by patients during their treatment, and analyzed with content analysis. RESULTS: The results identified an overall theme of "threat to normality," and 3 subcategories including "impact on daily life," "manageability," and "powerlessness." CONCLUSION: While there were many similarities in the descriptions of the patients in the 2 groups, there also were unique features for each treatment group. For patients treated with AMWT, the main concern was pain. For patients treated with NPWT, the main concern was the optimal functioning of the machine. Patients undergoing wound treatment have different focuses, concerns, and needs related to treatment modality. It is important for health care personnel to carry this in mind to be able to individualize patient care. .

Developing an assessment tool for intended learning outcomes in clinical practice for nursing students.

This report describes the development of a new criterion based reference tool to assess nursing knowledge and competence in clinical practice. Nursing education has changed from educating a profession, based on tested experience, to being based on a scientific approach and research based knowledge. Assessment should be capable of measuring whether intended learning outcomes have been reached or not, and if the aims of a course have been fulfilled in order to ensure safe and competent nursing care. The intended learning outcomes from a first year course syllabus were integrated and formed into a three-graded criterion-referenced assessment tool, Assessment of Clinical Education, (AClEd). The AClEd is to be seen as a template, and may be tailor-made in accordance to the objectives, level and criteria of a specific course. The tool showed validity in assessing nursing skills not only the nursing student's ability to perform a task but also, most importantly, the quality of nursing care.

Negative pressure wound therapy - a descriptive study.

 To address a persistent lack of evidence regarding the clinical outcomes of negative pressure wound therapy (NPWT) and identify which patient groups are most likely to benefit from NPWT, a retrospective, descriptive study was conducted to describe outcomes of this treatment modality when used in clinical practice. Charts from a consecutive series of 87 patients (median age 68 years, range 16 - 92 years) who received NPWT during a period of 24 months were abstracted to a statistical software file. Patient demographics, history, and comorbidity variables as well as treatment outcomes were obtained from the computerized in- and outpatient record system. Treatment outcomes were grouped as successful (goal of care was met) or not successful (goal of care was not met). Successful treatment was noted for a total of 62 patients (71%) with a median treatment time of 17 days. The proportion of patients with a successful outcome was significantly higher in patients with infectious, postoperative, and traumatic wounds than in patients with wounds related to peripheral vascular disease or pressure ulcers (P = 0.001). Treatment complications were observed in 18 patients (21%); five were related to infection. Quality-of-life concerns were noted as a reason for stopping treatment in four patients and equipment problems were recorded for two patients receiving NPWT in the home. This study confirms previous re- search that NPWT may be an effective and safe treatment method for acute wounds but further studies are needed to evaluate treatment efficacy and effectiveness in patients with peripheral vascular disease or pressure-induced wounds. Results also suggest that research protocols should include patient quality-of-life outcomes.

Perioperative bladder distension: a prospective study.

OBJECTIVE: Postoperative urinary retention and bladder distension are frequent complications of surgery. The aim of this study was to determine the incidence of perioperative bladder distension in a surgical setting and to identify predisposing factors among patients undergoing common general and orthopaedic procedures. MATERIAL AND METHODS: This was a prospective observational study of 147 adult patients admitted to orthopaedic and surgical departments. Bladder volumes were measured with an ultrasound scanner on three occasions: after emptying the bladder before being transported to the operating theatre, and then immediately before and after surgery. RESULTS: Thirty-three patients (22%) developed bladder distension (>500 ml), eight preoperatively and 25 postoperatively. A total of 21 patients (14%) had a bladder volume >300 ml immediately before surgery. Orthopaedic patients were more likely to develop preoperative bladder distension than surgical patients and had significantly higher postvoid residual volumes. In the binary logistic regression analysis age, gender and time of anaesthesia could not predict bladder distension. Patients undergoing orthopaedic surgical procedures, however, were prone to bladder distension (odds ratio 6.87, 95% confidence interval 1.76 to 26.79, p=0.006). CONCLUSIONS: This study shows that orthopaedic surgical patients are more prone to bladder distension perioperatively. The conventional method of encouraging patients to void at the ward before being transported to the operating theatre does not necessarily mean an empty bladder at the start of the operation.

Nurses are increasingly involved in pharmacovigilance in Sweden.

INTRODUCTION: In Sweden, voluntary adverse drug reaction (ADR) reporting started over 40 years ago to detect rare, serious, unexpected adverse, mainly type B, reactions. During the period 1965-2004, 92,000 reports were assessed. Since certain nurses are licensed to prescribe a limited number of drugs, nurses also form part of the reporting team. AIM: To analyse the ADR reporting by nurses in Sweden. METHODS: All reports by nurses and other health-care personnel entered into the Swedish ADRs database SWEDIS (Swedish Drug Information System) were retrieved for the 10-year period 1995-2004 (Swedish population: 9 million). The intention was to analyse the nurses' reports from a quantitative and qualitative point of view. RESULTS: The total number of ADR reports has gradually increased during the past 10 years from 3000 to over 4000 in 2004 (465 per million inhabitants), an increase by 28%. All ADR reports originate from health care personnel. The nurses' contribution to the ADR reporting increased from 2-3% in the mid-90s to 12% in 2004. The most common drugs involved in the nurses' reporting were various kinds of vaccines. Skin reactions dominated among the nurses' ADR reports. The ADRs reported by nurses were, as a consequence of many vaccine reports, compared to all reports, not so often classified as serious, but were on the other hand more often assessed with a causal relationship. CONCLUSIONS: Nurses, in their position as drug administrators who record signs and symptoms of the patients, play an increasingly important role for detection of suspected ADRs and are now contributing to a significant amount of the ADR reporting in Sweden.

Adherence to drug treatment in association with how the patient perceives care and information on drugs.

AIM: This study was to explore concordance with drugs prescribed and the patient's self-reported drug consumption, in relation to the older patient's perceived care and information given. BACKGROUND: Lack of adherence to prescriptions may lead to therapeutic failure with risks for relapse, unnecessary suffering and increased costs. DESIGN: A cross-sectional study with structured interviews of 200 patients who had recently been treated in a medical ward. METHODS: Patients' medical records were studied to obtain information on their current use of drugs. The data were analyzed by logistic regression, adherence being the dependent response variable. RESULTS: The mean age of the study group was 79 years. The number of drugs reported in the medical chart ranged from one to 17 with a mean of 6.9. The patients reported a drug consumption ranging from 0 to 24 with a mean of 7.3. When comparing the interview results with the information in the medical charts, 30% of the patients showed adherence. An association was found between adherence and self-reported health status. Patients in the non-adherent group reported a higher consumption of drugs. Patients felt that the opportunity to ask questions of either the responsible physicians or of the nurses was influential in decreasing risk. CONCLUSION: In this study, the patient's total drug consumption was considered. The study showed a large discrepancy between the drugs stated in the medical chart and patient's self-reported drug consumption. The study failed to show that perceived information or educational level had an impact on the results but implicate that the quality of information influences adherence. RELEVANCE TO CLINICAL PRACTICE: It is of importance to recognize patients at risk for non-adherence. Decreased health status and many drugs are the main risk factors for patients being non-adherent, and should be recognized as such.