Defining Expertise in Cancer Nursing Practice.

BACKGROUND: Thirty-five years ago, Benner defined an expert nurse as one who applies deep knowledge and experience across different contexts and clinical situations. Since that time, there has been little exploration of expertise in cancer nursing. OBJECTIVES: To explore and describe characteristics of expert cancer nurses and to consider whether Benner's typology of an expert nurse remains relevant in today's complex oncology settings. METHODS: An exploratory, descriptive study using audio-recorded focus group methodology was undertaken. Audio-recordings were transcribed, and an inductive thematic analysis approach applied to the data. Nurses also documented key characteristics of expert practice on Post-it notes to illustrate dominant characteristics. RESULTS: Twenty-four registered nurses from a comprehensive cancer center in Australia took part in 1 of 3 focus groups. Seven key themes were identified: knowledge, leadership, adaptability, communication, motivation, patient-centered care, organization, and culture. Key word cloud characteristics included knowledge, compassion, motivation, experience, and communication. CONCLUSIONS: Many of the expert characteristics identified in this study reflect traits common to other nursing specialty groups. Of particular relevance to cancer nurses was "adaptability," reflecting the complexity of contemporary cancer care and reaffirming Benner's definition of an expert nurse as one who can fluidly connect knowledge and experience to unfamiliar practice contexts. IMPLICATIONS FOR PRACTICE: Understanding characteristics of expert cancer nurses may help inform and support professional practice advancement and guide future research about select characteristics of expert cancer nurses to patient- and system-level outcomes.

Maternity connect: Evaluation of an education program for rural midwives and nurses.

BACKGROUND: Rural and regional health services often find it difficult to maintain their maternity service and skills of their maternity workforce and enable women to give birth close to home. The Maternity Connect Program is a professional development initiative aimed at supporting and upskilling rural and regional maternity workforces to meet their maternity population care needs. AIM: To evaluate the Maternity Connect Program from the perspectives and experiences of participating midwives/nurses and health services. METHODS: A retrospective audit of data routinely collected as part of the Maternity Connect Program: initial needs assessments (baseline survey), and one month and six months post-placement surveys completed by participants, placement health services and base health services. The main outcome measures were: participants' (midwives and health services) level of satisfaction with the Program; and changes in midwives'/nurses' perceived level of confidence in performing key midwifery skills after participating in the program. RESULTS: Respondents (n = 97 midwives/nurses; n = 23 base health services; n = 4 placement health services) were satisfied with the program and there was an increase in midwives/nurses' confidence when providing specific aspects of maternity care (birthing, neonatal and postnatal). Midwives/nurses report transferring skills learnt back to their base health service. CONCLUSION: The Maternity Connect Program appears to be a successful educational model for maintaining and increasing clinician confidence in rural and regional areas.

Achieving Hepatitis C Elimination By Using Person-Centered, Nurse-Led Models of Care: A Discussion of Four International Case Studies.

Nurse-led models of care are an important strategy in the management of patients with chronic disease because of the person-centered approach that allows the needs of the individual to be prioritized and addressed in accessible settings. Hepatitis C is caused by a blood-borne virus that can cause liver disease and liver cancer; it predominantly affects marginalized populations, including people who inject drugs. Since 2013, all oral, direct-acting antiviral regimens have been available to cure hepatitis C. Nurses are well placed to be involved in the delivery of hepatitis C testing and treatment because of their extensive reach within marginalized communities and holistic approach to patient care. Four case studies of nurse-led models of care operating in Australia, Canada, the United Kingdom, and the United States are presented to illustrate the important role nurses have in delivering accessible, person-centered hepatitis C testing and treatment. Each case study demonstrates the success of overcoming barriers to hepatitis C testing and treatment such as geographic isolation, incarceration, social marginalization, and inflexible healthcare systems. Achieving the global target to eliminate hepatitis C by 2030 will require the nursing profession to embrace its role as the first point of contact to the healthcare system for many members of marginalized communities potentially at risk of hepatitis C. Nurses are well placed to reduce barriers and facilitate access to healthcare by scaling up activities focused on hepatitis C testing and treatment.

Evaluation of the impact of a nurse-led program of systematic screening of comorbidities in patients with axial spondyloarthritis: The results of the COMEDSPA prospective, controlled, one year randomized trial.

OBJECTIVE: To evaluate the impact of a nurse-led program of systematic screening for the management (detection/prevention) of comorbidities. METHODS: Prospective, randomized, controlled, open, 12-month trial (NCT02374749). PARTICIPANTS: consecutive patients with axial Spondyloarthritis (axSpA) (according to the rheumatologist) THE PROGRAM: A nurse collected data on comorbidities during a specific outpatient visit. In the event of non-agreement with recommendations, the patient was informed and a specific recommendation was given to the patient (orally and in a with a detailed written report). Patients were seen after one year in a nurse-led visit. TREATMENT ALLOCATION: random allocation (i.e. either this program or an educational program not presented here and considered here as the control group). MAIN OUTCOME: change after one year of a weighted comorbidity management score (0 to 100 where 0= optimal management). RESULTS: 502 patients were included (252 and 250 in the active and control groups, respectively): age: 47±12 years, male gender: 63%, disease duration: 14±11y. After one year, no differences were observed in a weighted comorbidity management score. However, the number of patients in agreement with recommendations was significantly higher in the active group for vaccinations (flu vaccination: 28.6% vs. 9.9%, p<0.01; pneumococcal vaccination:40.0% vs. 21.1%,p=0.04), for cancer screening (skin cancer screening: 36.3% vs. 17.2%, p=0.04) and for osteoporosis (bone densitometry performed: 22.6% vs. 8.7%, p<0.01; Vitamin D supplementation initiation: 51.9% vs. 9.4%, p<0.01). CONCLUSIONS AND RELEVANCE: This study suggests the short-term benefit of a single-visit nurse-led program for systematic screening of comorbidities for its management in agreement with recommendations, even in this young population of patients with axSpA.

A New Perspective on Spiritual Care: Collaborative Chaplaincy and Nursing Practice.

Spirituality is a key focus and ethical obligation of nursing practice, but many nurses express uncertainty or discomfort with this aspect of their role. The purpose of this article is to explore the domains of religion, spirituality, and culture as commonly conceptualized by chaplains, as a framework for nurses to provide spiritual care interventions to patients in acute care hospitals. Using anecdotes and illustrations from palliative care practice, this article discusses the enhanced benefits to patients and families when spiritual needs are addressed, with specialty-level chaplain interventions, primary spiritual interventions provided uniquely by nurses, or interventions that require the cooperation of both professions. Lessons learned from the inpatient palliative care team experience can also apply to chaplaincy and nursing care for patients in settings beyond the acute care hospital and in disciplines beyond palliative care.

Low-Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors.

INTRODUCTION: Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals. METHODS: Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis. RESULTS: We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group. DISCUSSION: Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey.

INTRODUCTION: Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians. METHODS: This study was a secondary analysis of data from the population-based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife-attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates. RESULTS: Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making. DISCUSSION: Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

Medical Abortion in Midwifery Scope of Practice: A Qualitative Exploration of the Attitudes of Registered Midwives in British Columbia.

INTRODUCTION: Across Canada and internationally, access to abortion remains challenging, particularly for those living in rural and remote communities. International research and policy call for the training of advanced practice clinicians, including midwives, to provide abortion services to fill the ever-increasing access gap. Research in other jurisdictions has examined the attitudes of midwives toward this potential expansion of scope of practice, but such studies have not been undertaken in British Columbia. This qualitative research study explored the attitudes of registered midwives toward expanding their scope of practice to include the provision of medication abortion in British Columbia. METHODS: In-depth qualitative interviews with British Columbia registered midwives were conducted and analyzed using thematic analysis. RESULTS: Fifteen interviews were conducted. Analysis of the interviews identified 5 primary themes: the incorporation of medication abortion into the midwifery scope of practice to increase access, the congruence of the midwifery model of care and provision of medication abortion, the role of registered midwives as guardians of reproductive rights, the need for a paradigm shift in how the profession is viewed, and the practicalities of potential scope expansion. DISCUSSION: This study shows some British Columbia registered midwives are interested in including medication abortion in their scope of practice. Midwives have the potential to bridge some of the health care delivery gaps in areas underserved by abortion providers and communities where medication abortion is not available. Further research is needed to more fully understand the perspectives of registered midwives in British Columbia as a whole.

Nurse-led integration of palliative care for chronic obstructive pulmonary disease: An integrative literature review.

AIMS AND OBJECTIVES: To uncover what is known about nurse-led models or interventions that have integrated palliative care into the care of patients with chronic obstructive pulmonary disease. BACKGROUND: Chronic obstructive pulmonary disease is a highly symptomatic, incurable disease characterised by chronic symptoms that without appropriate palliation can lead to unnecessary suffering for patients and their caregivers. While palliative care practices can relieve suffering and improve quality of life, most palliative models of care remain cancer-focused. New models, including nurse-led care that integrates palliative care for patients with chronic obstructive pulmonary disease, could address patient suffering and therefore need to be explored. METHOD: A mixed-studies integrative review was undertaken. Seven databases were searched for articles published between 2008-2018. The PRISMA framework was applied to the search, and six studies met the review eligibility criteria. Content analysis of the articles was undertaken, and data were compared, looking for different nurse-led models and outcomes related to palliative care in chronic obstructive pulmonary disease. RESULTS: Nurse-led, integrated palliative care models for patients with chronic obstructive pulmonary disease are rare and just four of the six articles found in this review had published results. Advance care planning was found to be the most common focus for nurse-led interventions in chronic obstructive pulmonary disease, and in all cases, results demonstrated an improvement in end-of-life discussions and completion of advance care directives. Of the reviewed articles, none used a qualitative framework to explore nurse-led models that integrated palliative care in chronic obstructive pulmonary disease. CONCLUSION: While nurse-led advance care planning was one type of palliative care practice associated with positive patient outcomes, there is a need for deeper exploration of nurse-led models that holistically address the bio-psycho-social-spiritual needs of patients with chronic obstructive pulmonary disease, and their caregivers. RELEVANCE TO CLINICAL PRACTICE: Integrating nurse-led supportive care clinics into chronic obstructive pulmonary disease services could be a way forward to address the unmet bio-psycho-social-spiritual needs of patients with chronic obstructive pulmonary disease, and their caregivers.

Relative effectiveness and cost-effectiveness of the midwifery-led care in Nova Scotia, Canada: A retrospective, cohort study.

OBJECTIVES: To compare neonatal and maternal outcomes, and the relative risk of interventions between mothers attended to by midwives, general practitioners, and obstetricians, and to assess the cost-effectiveness of the employee-model of midwifery-led care in Nova Scotia, Canada, when compared with general practitioners. DESIGN, SETTING, AND PARTICIPANTS: The study was a retrospective cohort study involving routinely collected clinical and administrative data from all low-risk births from January 1st, 2013 to December 31st, 2017. There were 24,662 observations. MEASUREMENTS: Descriptive statistics were used to summarise the mother's socio-demographic characteristics. We used a nearest-neighbour matching estimator in assessing differences in outcomes, and generalized linear models in the estimation of the risks of interventions, adjusting for potential confounders. An analytic decision tree served as the vehicle for the cost-effectiveness analysis, assessed using the net monetary benefit approach. All health care resources utilized were measured and valued. Neonatal intensive care admissions avoided was the measure of outcome. We performed probabilistic sensitivity and subgroup analyses. FINDINGS: Mothers attended to by midwives spent less time at the hospital during birth admissions, were less likely to have interventions, instrumental births, and more likely to have exclusive breastfeeding at discharge from birth admission. There were no differences in Apgar scores and neonatal intensive care unit admissions. The employee-model of midwifery-led care was found to be cost-effective. KEY CONCLUSIONS: The midwifery program is both effective and cost-effective for low-risk pregnancies IMPLICATIONS FOR PRACTICE: Increasing the number of midwives will increase access and represents value for money.

Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop.

BACKGROUND:: Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion. OBJECTIVE:: Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center. DESIGN:: Two-session, nurse-led ACP workshops for patients and their family caregivers. SETTING/PARTICIPANTS:: The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers. MEASUREMENTS:: Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews. RESULTS:: Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important. CONCLUSIONS:: The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.

Spirituality and Interprofessional Healthcare Education: An Exploratory Study.

Undergraduate and graduate programs for healthcare professions are inconsistent in curricular offerings and incorporation of spiritual training. This study reviewed perceptions and opinions about spiritual care held by students at an American university. Data were collected using the Spirituality and Spiritual Care Rating Scale and one open-ended question. Findings indicated that many students were comfortable incorporating spirituality into practice, and they desired additional training. As to how students would apply spirituality to their practice, themes of facilitating connection, holistic care, spiritual interventions, and benefits of spirituality were identified.

Building God's Kingdom Through Strengths-Based Teaching.

Teaching nursing students using a strengths-based instructional framework provides an encouraging and positive learning environment. The authors advocate learning one's own strengths and gifts through the Strengthsfinder tool, then applying that self-understanding to teach in a way that instills confidence in students.

Using patient-reported outcome measures to deliver enhanced supportive care to people with lung cancer: feasibility and acceptability of a nurse-led consultation model.

PURPOSE: Developing new supportive/palliative care services for lung cancer should encompass effective ways to promptly identify and address patients' healthcare needs. We examined whether an in-clinic, nurse-led consultation model, which was driven by use of a patient-reported outcomes (PRO) measure, was feasible and acceptable in the identification of unmet needs in patients with lung cancer. METHODS: A two-part, repeated-measures, mixed-methods study was conducted. Part 1 employed literature reviews and stakeholder focus group interviews to inform selection of a population-appropriate needs assessment PRO measure. In Part 2, lung cancer nurse specialists (CNS) conducted three consecutive monthly consultations with patients. Recruitment/retention data, PRO data, and exit interview data were analysed. RESULTS: The Sheffield Profile for Assessment and Referral to Care was the PRO measure selected based on Part 1 data. Twenty patients (response rate: 26%) participated in Part 2; 13 (65%) participated in all three consultations/assessments. The PRO measure helped patients to structure their thinking and prompted them to discuss previously underreported and/or sensitive issues, including such topics as family concerns, or death and dying. Lung CNS highlighted how PRO-measures-driven consultations differed from previous ones, in that their scope was broadened to allow nurses to offer personalised care. Small-to-moderate reductions in all domains of need were noted over time. CONCLUSIONS: Nurse-led PRO-measures-driven consultations are acceptable and conditionally feasible to holistically identify and effectively manage patient needs in modern lung cancer care. PRO data should be systematically collected and audited to assist in the provision of supportive care to people with lung cancer.

Midwifery Management of Pregnant Women Who Are Obese.

INTRODUCTION: Obesity is associated with increased risks for adverse health outcomes during and after pregnancy in both the woman with obesity and her infant. This study was designed to investigate midwifery management of pregnant women with obesity. METHODS: Certified midwives and certified nurse-midwives who were members of the American College of Nurse-Midwives were sent a survey. The survey instrument was divided into 4 sections: demographic characteristics; practice guidelines and protocols; the role of the 2015 Levels of Maternal Care guidelines for referral, including transfer to a higher level of care; and factors that influence management of pregnant women with obesity. Descriptive statistics were used to analyze data. RESULTS: In a sample of 546 midwives, 87% of respondents reported observing an increase in perinatal complications associated with obesity. Midwives reported increasing discomfort with the care of pregnant women with obesity as body mass index (BMI) increased. For pregnant women with extreme obesity, the respondents reported less frequent use of physiologic birth guidelines only and increased use of interventions, referral to physician care, and transfer to a higher level of care. Approximately half (270, 49.5%) reported having a guideline that addressed the care of women with obesity. Of these, 145 midwives (53.7%) reported that extreme obesity was the BMI threshold for identifying an increased or high risk for perinatal complications. Sixty percent (339) of midwives who participated requested guidance for management of laboring women who are obese. DISCUSSION: This study provides a greater understanding of midwifery management practices when caring for women with obesity and opportunities to improve care. The results suggest that midwifery management alters with increased BMI, specifically in the care of women with extreme obesity. Suggestions for future study include research on management of pregnant women with obesity and extreme obesity with outcome data examining management strategies that provide safe, satisfying care.

Accommodating Indigenous Nurse-Initiated and Managed Antiretroviral Therapy (NIMART) Reporting in a Developing Country Context.

Financial reporting represents a critical tool in eliminating HIV across Papua New Guinea (PNG). Using the tenets of the theory of indigenous alternative reporting, this paper considers how the PNG Nursing Council may accommodate nurse-initiated and managed antiretroviral therapy (NIMART) reporting. Textual analysis of indigenous reporting expectations placed on the PNG Nursing Council are examined in a NIMART context to examine levels of reporting compliance exercised by council administrators from year-end reports (1980 to 2016) to accommodate NIMART reporting. The study revealed that the 2014 annual report of the PNG Nursing Council generated a 40% NIMART compliance rate, offering encouraging signs of financial reporting that could make room for NIMART reporting. The study suggested that local mechanisms could be used to meet local indigenous reporting expectations in order to adopt NIMART reporting. The study also has far-reaching implications for other developing country nursing councils wanting to develop NIMART reporting.

[Nurse style of central vein! Our experience in the peripherally inserted central venous catheter]. / "Centrális véna ­ novér módra?" Perifériáról bevezetett centrális vénás kanülökkel szerzett tapasztalataink.

What is PICC line insertion? The PICC is a soft, flexible catheter which is made of polyurethane or silicone, and is inserted via an upper or lower extremity peripheral vein into superior or inferior vena cava. The origin of PICC line dates back to the early 1950s. Since the introduction of the PICC catheter, this method of venous catheterization has gone through many changes as regards the technique of insertion or the type of catheter used. Despite the routine use of PICC line worldwide, little progress has been made in its use in Hungary. In this short review we will briefly summarise the use of PICC line, its indications, advantages, disadvantages, and on complementary devices which are necessary during the procedure. We discuss our experience in insertion of PICC line at Pécs University, where the procedure is solely done by a certified registered nurse. We hope that with continuous progression of nurse competency, this procedure will be implemented at a higher scale in Hungary. Orv Hetil. 2017; 158(22): 856-863.