Starting Out: qualitative perspectives of new graduate nurses and nurse leaders on transition to practice.

AIM: To describe new graduate nurses' transition experiences in Canadian healthcare settings by exploring the perspectives of new graduate nurses and nurse leaders in unit level roles. BACKGROUND: Supporting successful transition to practice is key to retaining new graduate nurses in the workforce and meeting future demand for healthcare services. METHOD: A descriptive qualitative study using inductive content analysis of focus group and interview data from 42 new graduate nurses and 28 nurse leaders from seven Canadian provinces. RESULTS: New graduate nurses and nurse leaders identified similar factors that facilitate the transition to practice including formal orientation programmes, unit cultures that encourage constructive feedback and supportive mentors. Impediments including unanticipated changes to orientation length, inadequate staffing, uncivil unit cultures and heavy workloads. CONCLUSIONS: The results show that new graduate nurses need access to transition support and resources and that nurse leaders often face organisational constraints in being able to support new graduate nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations should ensure that nurse leaders have the resources they need to support the positive transition of new graduate nurses including adequate staffing and realistic workloads for both experienced and new nurses. Nurse leaders should work to create unit cultures that foster learning by encouraging new graduate nurses to ask questions and seek feedback without fear of criticism or incivility.

Orai3 Surface Accumulation and Calcium Entry Evoked by Vascular Endothelial Growth Factor.

OBJECTIVE: Vascular endothelial growth factor (VEGF) acts, in part, by triggering calcium ion (Ca(2+)) entry. Here, we sought understanding of a Synta66-resistant Ca(2+) entry pathway activated by VEGF. APPROACH AND RESULTS: Measurement of intracellular Ca(2+) in human umbilical vein endothelial cells detected a Synta66-resistant component of VEGF-activated Ca(2+) entry that occurred within 2 minutes after VEGF exposure. Knockdown of the channel-forming protein Orai3 suppressed this Ca(2+) entry. Similar effects occurred in 3 further types of human endothelial cell. Orai3 knockdown was inhibitory for VEGF-dependent endothelial tube formation in Matrigel in vitro and in vivo in the mouse. Unexpectedly, immunofluorescence and biotinylation experiments showed that Orai3 was not at the surface membrane unless VEGF was applied, after which it accumulated in the membrane within 2 minutes. The signaling pathway coupling VEGF to the effect on Orai3 involved activation of phospholipase Cγ1, Ca(2+) release, cytosolic group IV phospholipase A2α, arachidonic acid production, and, in part, microsomal glutathione S-transferase 2, an enzyme which catalyses the formation of leukotriene C4 from arachidonic acid. Shear stress reduced microsomal glutathione S-transferase 2 expression while inducing expression of leukotriene C4 synthase, suggesting reciprocal regulation of leukotriene C4-synthesizing enzymes and greater role of microsomal glutathione S-transferase 2 in low shear stress. CONCLUSIONS: VEGF signaling via arachidonic acid and arachidonic acid metabolism causes Orai3 to accumulate at the cell surface to mediate Ca(2+) entry and downstream endothelial cell remodeling.

Nursing unit leaders' influence on the long-term sustainability of evidence-based practice improvements.

AIM: To describe how actions of nursing unit leaders influenced the long-term sustainability of a best practice guidelines (BPG) program on inpatient units. BACKGROUND: Several factors influence the initial implementation of evidence-based practice improvements in nursing, with leadership recognized as essential. However, there is limited knowledge about enduring change, including how frontline nursing leaders influence the sustainability of practice improvements over the long term. METHODS: A qualitative descriptive case study included 39 in-depth interviews, observations, and document reviews. Four embedded nursing unit subcases had differing levels of program sustainability at 7 years (average) following implementation. RESULTS: Higher levels of BPG sustainability occurred on units where formal leadership teams used an integrated set of strategies and activities. Two key strategies were maintaining priorities and reinforcing expectations. The coordinated use of six activities (e.g., discussing, evaluating, integrating) promoted the continuation of BPG practices among staff. These leadership processes, fostering exchange and learning, contributed to sustainability-promoting environments characterized by teamwork and accountability. CONCLUSIONS: Unit leaders are required to strategically orchestrate several overlapping and synergistic efforts to achieve long-term sustainability of BPG-based practice improvements. IMPLICATIONS: As part of managing overall unit performance, unit leaders may influence practice improvement sustainability by aligning vision, strategies, and activities.

An organizational perspective on the long-term sustainability of a nursing best practice guidelines program: a case study.

BACKGROUND: Many healthcare innovations are not sustained over the long term, wasting costly implementation efforts and often desperately-needed initial improvements. Although there have been advances in knowledge about innovation implementation, there has been considerably less attention focused on understanding what happens following the early stages of change. Research is needed to determine how to improve the 'staying power' of healthcare innovations. As almost no empirical knowledge exists about innovation sustainability in nursing, the purpose of our study was to understand how a nursing best practice guidelines (BPG) program was sustained over a long-term period in an acute healthcare centre. METHODS: We conducted a qualitative descriptive case study to examine the program's sustainability at the nursing department level of the organization. The organization was a large, urban, multi-site acute care centre in Canada. The patient safety-oriented BPG program, initiated in 2004, consisted of an organization-wide implementation of three BPGs: falls prevention, pressure ulcer prevention, and pain management. Data were collected eight years following program initiation through 14 key informant interviews, document reviews, and observations. We developed a framework for the sustainability of healthcare innovations to guide data collection and content analysis. RESULTS: Program sustainability entailed a combination of three essential characteristics: benefits, institutionalization, and development. A constellation of 11 factors most influenced the long-term sustainability of the program. These factors were innovation-, context-, leadership-, and process-related. Three key interactions between factors influencing program sustainability and characteristics of program sustainability accounted for how the program had been sustained. These interactions were between: leadership commitment and benefits; complementarity of leadership actions and both institutionalization and development; and a reflection-and-course-correction strategy and development. CONCLUSIONS: Study findings indicate that the successful initial implementation of an organizational program does not automatically lead to longer-term program sustainability. The persistent, complementary, and aligned actions of committed leaders, in a variety of roles across a health centre department, seem necessary. Organizational leaders should consider a broad conceptualization of sustainability that extends beyond program institutionalization and/or program benefits. The development of an organizational program may be necessary for its long-term survival.

The sustainability of healthcare innovations: a concept analysis.

AIM: To report on an analysis of the concept of the sustainability of healthcare innovations. BACKGROUND: While there have been significant empirical, theoretical and practical contributions made towards the development and implementation of healthcare innovations, there has been less attention paid to their sustainability. Yet many desired healthcare innovations are not sustained over the long term. There is a need to increase clarity around the concept of innovation sustainability to guide the advancement of knowledge on this topic. DESIGN: Concept analysis. DATA SOURCES: We included literature reviews, theoretical and empirical articles, books and grey literature obtained through database searching (ABI/INFORM, Academic Search Complete, Business Source Complete, CINAHL, Embase, MEDLINE and Web of Science) from 1996-May 2014, reference harvesting and citation searching. METHODS: We examined sources according to terms and definitions, characteristics, preconditions, outcomes and boundaries to evaluate the maturity of the concept. RESULTS: This concept is partially mature. Healthcare innovation sustainability remains a multi-dimensional, multi-factorial notion that is used inconsistently or ambiguously and takes on different meanings at different times in different contexts. We propose a broad conceptualization that consists of three characteristics: benefits, routinization or institutionalization, and development. We also suggest that sustained innovations are influenced by a variety of preconditions or factors, which are innovation-, context-, leadership- and process-related. CONCLUSION: Further conceptual development is essential to continue advancing our understanding of the sustainability of healthcare innovations, especially in nursing where this topic remains largely unexplored.

Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP.

BACKGROUND: Making evidence-based practice (EBP) a reality throughout an organization is a challenging goal in healthcare services. Leadership has been recognized as a critical element in that process. However, little is known about the exact role and function of various levels of leadership in the successful institutionalization of EBP within an organization. AIMS: To uncover what leaders at different levels and in different roles actually do, and what actions they take to develop, enhance, and sustain EBP as the norm. METHODS: Qualitative data from a case study regarding institutionalization of EBP in two contrasting cases (Role Model and Beginner hospitals) were systematically analyzed. Data were obtained from multiple interviews of leaders, both formal and informal, and from staff nurse focus groups. A deductive coding schema, based on concepts of functional leadership, was developed for this in-depth analysis. RESULTS: Participants' descriptions reflected a hierarchical array of strategic, functional, and cross-cutting behaviors. Within these macrolevel "themes," 10 behavioral midlevel themes were identified; for example, Intervening and Role modeling. Each theme is distinctive, yet various themes and their subthemes were interrelated and synergistic. These behaviors and their interrelationships were conceptualized in the framework "Leadership Behaviors Supportive of EBP Institutionalization" (L-EBP). Leaders at multiple levels in the Role Model case, both formal and informal, engaged in most of these behaviors. LINKING EVIDENCE TO ACTION: Supportive leadership behaviors required for organizational institutionalization of EBP reflect a complex set of interactive, multifaceted EBP-focused actions carried out by leaders from the chief nursing officer to staff nurses. A related framework such as L-EBP may provide concrete guidance needed to underpin the often-noted but abstract finding that leaders should "support" EBP.

The effect of transforming care at the bedside initiative on healthcare teams' work environments.

BACKGROUND: Different initiatives have been implemented in healthcare organizations to improve efficiency, such as transforming care at the bedside (TCAB). However, there are important gaps in understanding the effect of TCAB on healthcare teams' work environments. AIM: The specific aim of the study is to describe findings regarding the TCAB initiative effects on healthcare teams' work environments. METHODS: A pretest and posttest study design was used for this study. The TCAB initiative was implemented in fall 2010 in a university health center in Montreal, Canada. The sample consisted of healthcare workers from four different care units. RESULTS: Statistically significant improvement was observed with the communicating specific information subscale from the measure of processes of care variable, and a significant difference was found between the support from colleagues variable, which was higher at baseline than postprogram. The differences for psychological demand, decisional latitude, and effort-reward were not significant. CONCLUSIONS: TCAB is an intervention that allows healthcare teams to implement change to improve patients' and families' outcomes. Ongoing energy should focus on how to improve communication among all members of the team and ensure their support.

Advanced practice nursing, health care teams, and perceptions of team effectiveness.

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness.

AIM: This article describes a new conceptual framework for acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness. BACKGROUND: Acute care nurse practitioners contribute positively to patient care by enacting an expanded scope of practise. Researchers have found both positive and negative reactions to the introduction of acute care nurse practitioners in healthcare teams. The process of role enactment, shifting role boundaries, and perceptions of team effectiveness has been studied disparately. A framework linking team structures and processes to desirable outcomes is needed. DATA SOURCES: Literature was obtained by searching CINAHL, PsycInfo, MedLine, PubMed, British Nursing Index, Cochrane Library, JSTOR Archive, Web of Science, and Google Scholar from 1985-2010. A descriptive multiple-case study was completed from March 2009-May 2009. DISCUSSION: A new conceptual framework describing how role enactment and boundary work affect perceptions of team effectiveness was developed by combining theoretical and empirical sources. The framework proposes proximal indicators used by team members to assess their team's performance. IMPLICATIONS FOR NURSING: The framework identifies the inter-related dimensions and concepts that different stakeholders need to consider when introducing nurse practitioners in healthcare teams. Further study is needed to identify team-level outcomes that reflect the contributions of all providers to quality patient care, and explore the patients' and families' perceptions of team effectiveness following the introduction of acute care nurse practitioners. CONCLUSION: The new framework can guide decision-making and research related to the structures, processes, and outcomes of nurse practitioner roles in healthcare teams.

Part 2: Nurses' career aspirations to management roles: qualitative findings from a national study of Canadian nurses.

AIM: Our aim was to investigate direct-care nurses' interests in formal management roles and factors that facilitate their decision-making. BACKGROUND: Based on a projected shortage of nurses by 2022, the profession could be short of 4200 nurse managers in Canada within the next decade. However, no data are currently available that identify nurses' interests in assuming manager roles. METHODS: Using focus group methodology, we conducted 18 focus groups with 125 staff nurses and managers in four regions across Canada. RESULTS: Major themes and subthemes influencing nurses' decisions to pursue management roles included personal demographic (education, age, clinical experience and life circumstances), personal disposition (leadership skills, intrinsic rewards and professional commitment) and situation (leadership development opportunities, manager role perceptions and presence of mentors). Although nurses see management roles as positive opportunities, they did not perceive the rewards to be great enough to outweigh their concerns. CONCLUSIONS: Findings suggested that organizations need to provide support, leadership development and succession opportunities and to redesign manager roles for optimum success. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders need to ensure that they convey positive images of manager roles and actively identify and support staff nurses with leadership potential.

Part 1: The influence of personal and situational predictors on nurses' aspirations to management roles: preliminary findings of a national survey of Canadian nurses.

AIM: To examine the influence of personal and situational factors on direct-care nurses' interests in pursuing nursing management roles. BACKGROUND: Nursing managers are ageing and nurses do not appear to be interested in nursing management roles, raising concerns about a nursing leadership shortage in the next decade. Little research has focused on factors influencing nurses' career aspirations to nursing management roles. METHODS: A national survey of nurses from nine Canadian provinces was conducted (n = 1241). Multiple regression was used to test a model of personal and situational predictors of nurses' career aspirations to management roles. RESULTS: Twenty-four per cent of nurses expressed interest in pursuing nursing management roles. Personal and situational factors explained 60.2% of nurses' aspirations to management roles. Age, educational preparation, feasibility of further education, leadership self-efficacy, career motivation, and opportunity to motivate others were the strongest predictors of aspirations for management roles. CONCLUSIONS: Personal factors were more strongly associated with career aspirations than situational factors. There is a steady decline in interest in management roles with increasing age. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leadership training to develop leadership self-efficacy (particularly for younger nurses) and organizational support for pursuing advanced education may encourage nurses to pursue nursing management roles.

Boundary work and the introduction of acute care nurse practitioners in healthcare teams.

AIM: This article is a report of a study of boundary work following the introduction of an acute care nurse practitioner role in healthcare teams. BACKGROUND: Acute care nurse practitioners enacting their roles in healthcare teams have faced a number of challenges including a mix of positive and negative views of the acute care nurse practitioner role from healthcare team members and acute care nurse practitioner roles crossing the boundaries between the medical and nursing professions. Understanding the process by which the boundaries between professions changed following the introduction of an acute care nurse practitioner role was important since this could affect scope of practice and the team's ability to give patient care. METHODS: The study was conducted in two university-affiliated teaching hospitals in Canada. A descriptive multiple case study design was used. Data were collected from March to May 2009. RESULTS: Participants (N = 59) described boundary work as a process that included: (1) creating space; (2) loss of a valued function; (3) trust; (4) interpersonal dynamics; and (5) time. The development of trust among team members was essential. The co-location of team members working on common projects, and medical and nursing leadership facilitated boundary work. CONCLUSION: The micro-level processes of boundary work in healthcare teams have important implications for the development of full scope of practice for acute care nurse practitioners, effective inter-professional teamwork and the integration of new roles in healthcare systems. Future research needs to be undertaken in different contexts, and with patients and families.

Patient and nurse staffing characteristics associated with high sitter use costs.

AIM: This paper is a report of a study of the relationships between patient health conditions, nurse staffing characteristics and high sitter use costs. BACKGROUND: Increasing recourse to patient sitters is a major cost concern to hospitals. To reduce these expenses, we need to understand better the factors associated with high sitter use costs. METHODS: From a cohort of 43,212 medical/surgical patients admitted to an academic health centre in Montreal (Canada) in 2007 and 2008, all 1151 patients who received a sitter were selected. We applied multivariate logistic regression, using the Generalized Estimating Equation framework, to estimate the relationships between patient health conditions, nurse staffing characteristics and being in the upper two quintiles of sitter costs, vs. the lower three. RESULTS: The median sitter cost per patient, in Canadian dollars, was $772·35 (IQR = $1737·84); and $2397·00 (IQR = $3085·03) among the patients with high sitter use costs. In multivariate analyses, dementia, delirium and other cognitive impairments (OR = 1·49; 95% CI = 1·01-2·22) and schizophrenia and other psychoses (OR = 2·42; 95% CI = 1·08-5·76) increased the likelihood of high sitter use costs. In addition, every additional worked hour per patient per day by Registered Nurses (OR =0·33; 95% CI = 0·27-0·39) and by patient care assistants (OR = 0·11; 95% CI = 0·08-0·15) reduced the likelihood of high sitter use costs. Conclusion. Circumstances of understaffing and patients having psycho-geriatric conditions are associated with high sitter use costs. Improving staffing and providing additional resources to support the care of psycho-geriatric patients may lower these expenses.

Registered nurses' job demands in relation to sitter use: nested case-control study.

BACKGROUND: Increases in overtime and absenteeism among registered nurses (RNs), in conjunction with a workforce having less experience, have resulted in high RN job demands. At the same time, there has been an increase in hospitals' use of patient sitters (i.e., unskilled attendants), but it is not known if these two changes are correlated. OBJECTIVE: The aim of this study was to determine if indicators of RN job demands, specifically overtime, absenteeism, and experience, are related to greater sitter use. METHOD: A nested case-control study design was used. All patients who were assigned a sitter (cases) were selected from a cohort of 43,212 medical and surgical patients who had been admitted to an academic health center in Montreal (Canada) in 2007 and 2008. For each case (n = 1,179), up to four controls (n = 4,167) were selected randomly among patients who did not receive a sitter. Multivariate logistic regression, within a generalized estimating equation framework, was used to assess the association between RN job demand indicators and sitter use, while controlling for other risk factors for sitter use. RESULTS: Compared with controls, patients who were assigned sitters had been subject to high rates of RN overtime and absenteeism and lower RN cumulative experience in the period prior to sitter use. Each additional hour of RN overtime increased the likelihood of sitter use by 108% (odds ratio = 2.08, 95% confidence interval = 1.32-3.29). Every 5 years of collective RN experience reduced the odds of sitter use by 23% (odds ratio = 0.77, 95% confidence interval = 0.66-0.89). Absenteeism was not associated with sitter use. DISCUSSION: High RN overtime and collective inexperience are associated with greater sitter use. A possible explanation is that sitters are used to palliate failures to meet high job demands. Further research is required to assess the impact of sitter use on patient outcomes.

Intervention patterns of pivot nurses in oncology.

The Pivot Nurse in Oncology (PNO) is a health care professional dedicated to providing patients with cancer and their families with continuing and consistent supportive care throughout the care trajectory. The purpose of this paper is to describe the variation and frequency of nursing interventions delivered by 12 PNOs at our health centre. An administrative analysis over a three-year period revealed a total of 43,906 interventions that were grouped into 10 categories. This analysis provided a description of the intervention frequency and these interventions were further collapsed into the four role functions of the PNO. Coordination/continuity of care and the assessment of needs and symptoms were identified as the dominant practice domains of the PNO in the professional cancer navigator role.

Advanced practice nursing, health care teams, and perceptions of team effectiveness.

This article summarizes the results of an extensive review of the organizational and health care literature of advanced practice nursing (APN) roles, health care teams, and perceptions of team effectiveness. Teams have a long history in health care. Managers play an important role in mobilizing resources, guiding expectations of APN roles in teams and within organizations, and facilitating team process. Researchers have identified a number of advantages to the addition of APN roles in health care teams. The process within health care teams are dynamic and responsive to their surrounding environment. It appears that teams and perceptions of team effectiveness need to be understood in the broader context in which the teams are situated. Key team process are identified for team members to perceive their team as effective. The concepts of teamwork, perceptions of team effectiveness, and the introduction of APN roles in teams have been studied disparately. An exploration of the links between these concepts may further our understanding the health care team's perceptions of team effectiveness when APN roles are introduced. Such knowledge could contribute to the effective deployment of APN roles in health care teams and improve the delivery of health care services to patients and families.

Vascular access-related bloodstream infections in First Nations, community and teaching Canadian dialysis units, and other centre-level predictors.

BACKGROUND/AIMS: Vascular access-related bloodstream infection (BSI) is frequent among patients undergoing hemodialysis increasing their morbidity and mortality, but its occurrence across various dialysis centre types is not known. The aims of this study were to describe the incidence rates and assess the variability in BSI risk between dialysis centre types and other centre-level variables. METHODS: We conducted a retrospective cohort study of 621 patients initiating hemodialysis in 7 Canadian dialysis centres. Cox regression models, where access type was continuously updated, were used to identify predictors of BSI occurrence. RESULTS: During follow-up of the cohort (median age 68.1 years, 41.7% female, and 76.7% initiating with a central venous catheter, CVC), 73 patients had a BSI (rate: 0.21/1000 person-days). The BSI risk was not different in First Nation units (adjusted relative risk: 0.47, 95% confidence interval: 0.06-3.72) and teaching hospitals (1.33, 0.70-2.54) compared to community hospitals. No other centre-related variables were associated with the risk of BSI. CONCLUSION: We did not find differences in the BSI risk among dialysis unit types, or any other centre-related variables. The rates of BSI in our population were lower than those observed in other settings, but the high proportion of patients using CVCs is concerning.

Individual nurse and organizational context considerations for better Knowledge Use in Pain Care.

Nurses are involved in many of the painful procedures performed on hospitalized children. In collaboration with physicians, nurses have an exceptional responsibility to have knowledge to manage the pain; however, the evidence indicates this is not being done. Issues may be twofold: (a) opportunities to improve knowledge of better pain care practices and/or (b) ability to use knowledge. Empirical evidence is available that if used by health care providers can reduce pain in hospitalized children. Theory-guided interventions are necessary to focus resources designated for learning and knowledge translation initiatives in the area of pain care. This article presents the Knowledge Use in Pain Care (KUPC) conceptual model that blends concepts from the fields of knowledge utilization and work life context, which are believed to influence the translation of knowledge to practice. The four main components in the KUPC model include those related to the organization, the individual nurse, the individual patient, and the sociopolitical context. The KUPC model was conceptualized to account for the complex circumstances surrounding nurse's knowledge uptake and use in the context of pain care. The model provides a framework for health care administrators, clinical leaders, and researchers to consider as they decide how to intervene to increase knowledge use to reduce painful experiences of children in the hospital.