A pre-post interventional study to reduce time spent on clinical documentation by nurses and midwives.

AIM: To evaluate the impact of a co-designed intervention to reduce time spent on clinical documentation and increase time for direct patient care. DESIGN: A pre- and post-test interventional study with multi-method evaluation, reported according to the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs guidelines. METHODS: An intervention to decrease the burden of documentation was co-designed and implemented. Pre- and post-intervention data were collected via time and motion studies and the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey. Documentation audits were conducted to assess intervention fidelity. RESULTS: Twenty-six shifts were observed (13 pre-intervention, 13 post-intervention). Although the coronavirus pandemic contributed to decreases in staffing levels by 38% (from 118 to 73 staff), the number of task episodes completed increased post-intervention, across all shift patterns. Documentation took less time to complete post-intervention when assessing time per episode. A mean increase of 201 episodes was observed on morning shifts, 78 on evening shifts and 309 on night shifts. There were small increases for time spent on direct patient care compared to pre-intervention but there was less time per episode. Results from the BurDoNsaM survey indicated that participants felt documentation took less time post-intervention. Documentation audits found completion improved as staff gained familiarity, but deteriorated when staffing levels were reduced. CONCLUSION: The intervention was able to reduce time spent completing documentation, increasing the time available for direct patient care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Completing clinical documentation is part of the daily work of nurses and midwives. Clinical documentation needs to accurately capture key information in a concise and streamlined manner to avoid unnecessary burdens and release time for direct patient care. IMPACT: This study tested a co-designed intervention to address the burden of clinical documentation for nurses and midwives, The intervention reduced time spent on clinical documentation and increased time for direct patient care, This study could be replicated to reduce the burden of clinical documentation in other settings and benefit clinicians and patients by releasing more time for direct patient care. REPORTING METHOD: The study is reported using the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs (TREND) guidelines. PATIENT OR PUBLIC CONTRIBUTION: The research project and intervention evaluated in this study were co-designed through a clinician-researcher collaboration. A research team that consisted of clinically based nurses and midwives and nurse scientists was formed to address the burden of clinical documentation. As the end-users of clinical documentation, the clinically based nurse and midwife co-investigators were involved in the design, conduct, interpretation of the data, and preparation of the manuscript.

Co-design of an intervention to reduce the burden of clinical documentation: A clinician-researcher collaboration.

AIM: To co-design an intervention to reduce the burden of clinical documentation for nurses and midwives. METHODS: A clinician-researcher collaboration used an action research approach to co-design an intervention to reduce clinical documentation. The study consisted of three phases: 1) Analysis of pre-intervention data, 2) Evaluation of existing documentation, 3) Intervention co-design and implementation. RESULTS: A total of 116 documents were reviewed using a three-stage evaluation process, identifying 28 documents that could be discontinued and 33 documents to be modified for the intervention. This resulted in an average of 7 documents for women who had a vaginal birth (decreased from 13), 9 documents for women who had a caesarean (decreased from 18), and 7 documents for newborns (previously 7-10). The minimum number of documents for a mother and baby reduced from 20 pre-intervention to 14 post-intervention. CONCLUSION: The collaboration successfully co-designed and implemented an intervention to address the burden of clinical documentation that can be replicated in other healthcare settings.

A point prevalence study of palliative care need and referral rates in adult inpatients.

AIM AND OBJECTIVES: To gain an understanding of palliative care need and service utilisation in adult inpatients. The objectives were to 1) Determine the size and characteristics of the population of adult inpatients who were appropriate for palliative care referral, 2) Establish what percentage of patients, who were appropriate for a palliative care referral, had been referred to and/or were receiving palliative care. BACKGROUND: Internationally there is evidence of high levels of unmet palliative care need. Early access to palliative care is associated with improved outcomes including improved quality of life and reduced healthcare costs. DESIGN: An observational point prevalence study was reported using the STROBE guidelines. METHODS: Data were collected directly from inpatient medical records at a 578-bed tertiary private-not-for-profit hospital by three Registered Nurses on 3 June 2021. Palliative care need was assessed using the prognostic criteria for the 12 conditions outlined in the Gold Standards Framework. RESULTS: A total of 270 inpatients met study inclusion criteria. At a hospital population level, 29% (n = 78) of adult inpatients could have benefitted from palliative care. Of the 78 patients assessed as meeting criteria for palliative care, 29% (n = 23) were currently receiving palliative care with a majority of patients 71% (n = 55) not receiving palliative care. CONCLUSIONS: This study prospectively collected data and included all 12 conditions outlined in the Gold Standards Framework and found a high level of palliative care need. There was evidence of a high level of unmet palliative care need across conditions and treating specialities. RELEVANCE TO CLINICAL PRACTICE: Estimates of palliative care need can be used to improve access to palliative care and assess operational requirements, including the staffing levels required to meet the level of palliative care need for adult inpatients.

Aboriginal perspectives on recognising clinical deterioration in their child and communicating concerns to clinicians.

AIMS AND OBJECTIVES: To explore the perspectives of family members of Aboriginal children about a) their involvement in recognising clinical deterioration in a hospital setting and b) the effectiveness of a poster designed to promote family involvement. BACKGROUND: To assist in the early recognition and response to clinical deterioration for hospitalised children, many escalation of care processes now include family involvement. Little is currently known about the perspectives of Australian Aboriginal families in recognising deterioration in their child and raising the alarm, or if current escalation of care systems meet the needs of Aboriginal families. DESIGN: Qualitative pragmatist approach using semi-structured interviews. METHODS: Seven interviews were conducted with five mothers and two grandmothers of Aboriginal children who were inpatients at a children's hospital. Thematic analysis was undertaken. FINDINGS: Two themes were identified: Theme one was: Family role in recognising and responding to clinical deterioration, with two subthemes of knowing when to worry and communicating concerns. Participants reported that some families needed more knowledge to recognise clinical deterioration. Communication barriers between families and clinicians were identified. Theme two was: Effective visual communication with three subthemes of linguistic clarity, visual appeal and content. CONCLUSIONS: Additional strategies are needed to promote effective communication between clinicians and families of Aboriginal children in hospital. Posters were considered effective, particularly if including a cultural connection, images and simplified language. PRACTICE IMPLICATIONS: These insights provide important information for health professionals and health service managers to be aware that additional communication strategies are required to support Aboriginal family involvement in recognising clinical deterioration and escalation of care.

Nurse resilience for clinical practice: An integrative review.

AIM: To evaluate and synthesize research that has investigated nurse resilience, to develop an understanding of what nurses' feel affects their resilience, their experiences and how resilience can impact individual nurses, patients and employers. DESIGN: Integrative review. DATA SOURCES: CINAHL, MEDLINE and PsycINFO, searched from the date each database was available to July 2019. REVIEW METHODS: Primary research studies explicitly investigating resilience in any type of licensed nurse were eligible for inclusion. Studies were critically appraised for methodological quality using the Joanna Briggs Institute Quality Appraisal Framework. Data from each study were abstracted, coded and themes were identified according to the review aims and key findings of each study. RESULTS: Twenty-seven studies met the inclusion criteria. Eight sub-themes and three main themes were identified: The Resilient Nurse, Nurses' Experiences of Resilience and Employment Conditions and Nurse Resilience. CONCLUSION: Nurse resilience is a complex and dynamic process, and high levels of resilience are associated with reduced psychological harm and increased well-being. Attempts to determine the characteristics of the resilient nurse have been inconclusive and research has predominately focussed on individual factors which could affect resilience, with minimal research exploring external factors which affect nurse resilience including work environment and conditions. Nursing work was characterized by adversity and nurses described the development and use of strategies to maintain their resilience. IMPACT: This review found that individual factors have received most attention in research investigating nurse resilience. Findings suggest that nurse resilience protects against negative psychological outcomes and nurses independently develop and use strategies to manage adversity. Factors in the workplace which affect resilience are under-researched, and addressing this gap could assist with the development of comprehensive interventions and policies to build and maintain nurse resilience.

Is nursing and midwifery clinical documentation a burden? An empirical study of perception versus reality.

AIMS AND OBJECTIVES: To measure time spent on clinical documentation and nurses and midwives' perceptions of this aspect of their role. BACKGROUND: Nurses and midwives rely on accurate documentation when planning care. However, documenting and communicating care can be onerous, time-consuming and at times duplicated or redundant. While documentation provides a record and means of communicating care, it should not detract from the delivery of care. DESIGN: An observational time and motion study and survey design reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. METHODS: The study was conducted with Western Australian nurses and midwives working in a private not-for-profit hospital from July-October 2019. An observational study was undertaken to measure the practice of documentation on each shift. Participants' perceptions of clinical documentation were measured using a self-report survey. RESULTS: A total of 120 hr of observation were undertaken. Total observed time spent on documentation was 28.1% on morning shifts, 22.7% on afternoon shifts and 20.9% on night duty. The mean self-reported time for clinical documentation was 50.4% on morning shifts, 40.7% on afternoon shifts and 37.9% on night duty. Issues with duplication and unnecessary paperwork were identified. CONCLUSIONS: Although participants tended to overestimate time spent on documentation, it still consumed a significant proportion of time. Frustrations with paperwork may amplify nurses' negative perceptions of documentation. Clinical documentation needs to be reviewed, revised and reduced to release time back to direct patient care and reduce clinician dissatisfaction. RELEVANCE TO CLINICAL PRACTICE: Clinical documentation is required in all areas of clinical practice and forms an important legal record. Understanding the demands of clinical documentation can assist in reviewing and improving documentation to release time back to direct patient care.

The impact of organisational values on nurse resilience: A mixed-methods study.

AIM: To investigate the impact of organisational values on nurse resilience. BACKGROUND: Nurses encounter significant occupational adversity, which can result in negative psychological consequences. Investigating the role of resilience as a protective factor focuses on what enables some nurses to positively adapt in challenging work environments. Comparatively, little attention has been paid to organisational factors and nurse resilience. METHOD: A two-phase mixed-methods design comprising a cross-sectional survey and focus groups. RESULTS: Three hundred and ninety-four nurses responded to the survey with 25 participating in four follow-up focus groups. Significant associations were found between resilience levels and agreement with organisational values (p = .022) and agreement about the importance of values (p = .018). Three themes relating to organisational values were identified: pressures and challenges; supports and strategies; and impact of organisational values. CONCLUSIONS: Organisational values may positively impact resilience if nurses concur with those values and believe they are shared by their employer. IMPLICATIONS FOR NURSING MANAGEMENT: To promote nurse resilience, organisations and nurse leaders should consider developing, implementing and operating with a set of employee-adopted values, which need to be demonstrably upheld across the organisation.

Development and content validation of the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey.

AIM: To develop a validated tool to measure nursing and midwifery documentation burden. BACKGROUND: While an important record of care, documentation can be burdensome for nurses and midwives and may remove them from direct patient care, resulting in decreased job satisfaction, associated with decreased patient satisfaction. The amount of documentation is increasing at a time where staff rationalisation results in decreasing numbers of clinicians at the bedside. No instrument is available to measure staff perceptions of the burden of clinical documentation. DESIGN: Survey development, followed by rwo rounds of content validation (April and May 2019). METHODS: Based on the literature a 28 item survey, with items in 6 subscales, representing key areas of documentation burden was developed. Item (I-CVI), subscale (S-CVI/Ave by subscale) and overall content validity indexes (S-CVI/Ave) were calculated following two review rounds by an expert panel of clinical and academic nurses and midwives. RESULTS: Level of agreement for the first iteration of the survey was low, with many items failing to reach the critical I-CVI threshold of 0.78. No subscale reached a S-CVI/Ave above 0.8 and the overall scale only achieved a S-CVI/Ave score of 0.67. Thirteen items were removed, seven were edited and five new items added, based on the expert panel feedback, substantially improving the content validity. All individual items achieved an I-CVI ≥0.78, the S-CVI/Ave was above 0.85 for all subscales and the total S-CVI/Ave was 0.94. CONCLUSION: The Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey can be considered as content valid, according to the content validity analysis by an expert panel. IMPACT: The BurDoNsaM survey may be used by nurse leaders and researchers to measure the burden of documentation, providing the opportunity to review practice and implement strategies to decrease documentation burden, potentially improving patient satisfaction with the care received.

Neonatal Admission and Its Relationship to Maternal Pain: Pain Scores and Analgesia.

The aim of this study was to determine whether postnatal women whose babies required neonatal intensive care unit (NICU) admission self-reported lower pain scores and required less analgesia than women whose babies remained with them. A prospective matched audit comparing pain scores and analgesia requirements where every woman with a baby admitted to the NICU was matched to 2 women whose babies remained on the ward was undertaken. Matches were based on age, number of previous births, type of birth, episiotomy, and epidural or spinal analgesia use. Data were collected on pain scores and analgesia administered in the first 72 hours postbirth. A total of 150 women were recruited and matched from November 2015 to May 2017. No statistically significant differences were found between the 2 groups for opiate analgesia use (P = .91) or pain scores (P = .89). Regardless of NICU admission, significantly higher pain scores were reported in participants who had episiotomies (P = .03). Birth via cesarean birth resulted in significantly higher pain scores (P < .01) and greater opiate administration (P < .01). This study found no statistically significant difference between pain scores or analgesia use of mothers whose babies required NICU admission and mothers whose babies remained with them.

Exploring work-related stressors experienced by mental health nurses: A qualitative descriptive study.

INTRODUCTION: The challenging work environments mental health nurses (MHNs) encounter can negatively impact their mental health, psychological well-being and physical health. While these impacts have been investigated in quantitative research, little is known about work-related stress from the perspective of MHNs. AIM: To explore the stresses faced by nurses working in mental health settings and to gain an understanding of the underlying workplace context. METHOD: A descriptive qualitative study with data collected via semi-structured individual telephone interviews conducted with n = 21 Western Australian MHNs. Data were analysed using reflexive thematic analysis. RESULTS: A total of 85 codes were generated that led to the identification of 13 subthemes and 4 main themes: (1) mental health nursing context, (2) work environment stressors, (3) factors that alleviate stress and (4) the impact of workplace stress. DISCUSSION: Many of the stressors MHNs were exposed to are modifiable, such as understaffing and poor skill mix. Modifiable stressors increased risk for MHNs, impeded patient care and exacerbated inherent stressors such as patient acuity and complexity. IMPLICATIONS FOR PRACTICE: This study collected data that provide rich descriptions of the experiences of MHNs and identify modifiable work-related stressors that could be alleviated through effective leadership and management.

Defining the influence of external factors on nurse resilience.

In the context of pressures faced by the nursing profession including increasing patient acuity and global nursing shortages, the importance of nurse resilience has gained attention in research and practice. Resilience is viewed as a protective factor that enables individuals to avoid psychological harm and continue in their work. There is limited evidence on the impact of external factors such as work conditions on nurse resilience. This study aimed to explore how external factors influence nurse resilience and to incorporate this knowledge into an updated definition of nurse resilience. As part of a two-phase mixed methods study, focus groups were conducted to obtain qualitative data to explore nurse's perceptions of resilience and factors they felt affected their resilience. Data analysis identified three main themes derived from 10 subthemes: Perceptions of Resilience, Pressures and Challenges, and Support and Strategies contributed to understanding how external factors can affect nurse resilience. A range of factors emerged including the impact of workplace conditions, organizational philosophy, the performance of managers, and the teams nurses work within, which were not reflected in an earlier definition of nurse resilience derived through a concept analysis. These factors were incorporated in an updated definition of nurse resilience. Understanding resilience in the nursing profession and the external factors that affect it is critical to the development of effective research, policies, interventions, and work environments to protect nurse well-being, promote nurse retention, and ensure the provision of quality patient care.

Nurse resilience: A concept analysis.

Nurse resilience is attracting increasing attention in research and practice. Possession of a high level of resilience is cited as being crucial for nurses to succeed professionally and manage workplace stressors. There is no agreed definition of nurse resilience. A concept analysis was undertaken to examine nurse resilience using a priori selected analysis framework. This concept analysis aims to systematically analyse resilience as it relates to nurses and establish a working definition of nurse resilience. Sixty-nine papers met the search criteria for inclusion. Key attributes of nurse resilience were social support, self-efficacy, work-life balance/self-care, humour, optimism, and being realistic. Resilience enables nurses to positively adapt to stressors and adversity. It is a complex and dynamic process which varies over time and context and embodies both individual attributes and external resources. Sustaining nurse resilience requires action and engagement from both individuals and organizations.

An intervention to improve patient understanding and use of preoperative chlorhexidine washes.

BACKGROUND: Despite a lack of consensus around which type of preoperative wash is most effect in preventing surgical site infection, their use in clinical practice remains common. Chlorhexidine gluconate (CHG) is widely used however a previous study indicated issues with patient understanding and use of CHG. In response an intervention was developed which aimed to improve patient understanding and compliance with CHG. METHODS: A patient information sheet and a standardised script to guide preadmission phone calls were developed to improve the delivery of information to patients at the study hospital. These interventions were implemented for four months with adult surgical inpatients. A cross-sectional survey was then conducted to assess the effectiveness of the intervention. RESULTS: A 75% (n = 226) response rate was attained. The majority of participants (86%, n = 189) used CHG prior to their surgical procedure and of these 71% (n = 129) used CHG the recommended two times. The quality of information received from the preadmissions nurses was rated more highly than information delivered by other hospital staff. Openended questions revealed key issues including lack of information, time and access issues, and inconsistencies in CHG use. CONCLUSION: The value of standardised calls and information sheets was evident in participants who reported receiving these measures. A moderate increase was seen from the original study in the number of participants who used CHG washes the recommended two times. However, issues remained with inconsistent information across the hospital. Clinicians need to draw on high quality, contemporary research to inform clinical practice.

Ultrasound-guided femoral nerve blocks are not superior to ultrasound-guided fascia iliaca blocks for fractured neck of femur.

OBJECTIVE: To determine if an ultrasound-guided femoral nerve block (FNB) is superior to an ultrasound-guided fascia iliaca compartment block (FICB) in providing pain relief to patients with a neck of femur or proximal femoral fracture. METHODS: A double-blind randomised controlled trial was conducted. All participants received two blocks, one active and one placebo. An active FICB was administered to 52 participants and 48 participants received an active FNB. RESULTS: Analysis was completed on data collected from 100 participants. Most patients were elderly and the majority were female. Both FICB and FNB achieved clinically significant mean reductions in pain scores (2.62 for FICB and 2.3 for FNB). There was no significant difference in reduction in pain scores between the two cohorts, P = 0.408. CONCLUSIONS: Ultrasound-guided FNB is not superior to ultrasound-guided FICB, with both facilitating an equivalent analgesia effect in patients with a neck of femur or proximal femur fracture.

Improving the Clinical Skills and Knowledge of Midwives and Nurses Caring for Late Preterm Neonates.

BACKGROUND: Due to changes in funding, late pre-term neonates are no longer admitted to neonatal units unless diagnosed with a specific medical condition. Consequently, neonates born at a gestational age of 35 weeks and 0 days to 36 weeks and 6 days are cared for on postnatal wards. Compared with full-term infants, late preterm neonates are at increased risk of hypothermia, hypoglycemia, hyperbilirubinemia, feeding difficulties, respiratory complications, and mortality. METHOD: An educational intervention focusing on the care of the late preterm neonate was developed, and quantitative data were collected pre- and post-intervention to assess the effect on knowledge, skills, and attitudes. RESULTS: Of the midwives and nurses who participated, 65% (n = 13) strongly agreed and 35% (n = 7) agreed their knowledge and confidence had increased. The mean score increased from a range of 20 to 25 pre-intervention to 22 to 25 post-intervention. CONCLUSION: The intervention increased the self-reported confidence and self-reported competence of participants, who also felt more supported caring for late preterm neonates. [J Contin Educ Nurs. 2019;50(12):551-556.].

Journal Clubs: Engaging Clinical Nurses and Midwives in Research.

It is essential that nurses and midwives can understand and critically evaluate research to ensure the delivery of high-quality evidence-based care. Journal clubs are an educational method that helps to develop research capacity and assist with bridging the gap between research and clinical practice. To maintain competence and remain current with the latest evidence, a commitment to continuing professional education is required. This article describes how a successful journal club led to clinical nurses identifying a gap in their own practice, which resulted in a research project being conducted by the members of the journal club. J Contin Educ Nurs. 2018;49(3):141-144.