Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit.

BACKGROUND: Proning intubated intensive care unit patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the intensive care unit. LOCAL PROBLEM: Nursing units previously designated for medical/surgical populations had to adjust quickly to provide evidence-based care for COVID-19 patients attempting self-proning. METHODS: Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale. INTERVENTIONS: A new self-proning nursing protocol was implemented outside the intensive care unit. RESULTS: Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol. CONCLUSIONS: Implementation of a new nursing protocol is possible with strong unit-based support, even during a pandemic.

Strengthening nursing surveillance in general wards: A practice development approach.

AIMS AND OBJECTIVES: To explore the context and culture of nursing surveillance on an acute care ward. BACKGROUND: Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety. DESIGN: Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project. METHODS: Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July-August 2017. This study adhered to the COREQ guidelines. RESULTS: We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk. CONCLUSION: Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature. RELEVANCE TO CLINICAL PRACTICE: Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice-based research that empowers frontline nurses and teams to develop person-centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety.

An Evaluation of Simulation Debriefings on Student Nurses' Perceptions of Clinical Reasoning and Learning Transfer: A Mixed Methods Study.

To aim of this study was to explore undergraduate nursing student (n = 256) perceptions of clinical reasoning ability and learning transfer after participating in either a standard post simulation debriefing or a debriefing based on transfer of learning principles. BACKGROUND: It is assumed that students will transfer what they have learned from simulation to real world practice, however, some students are unable to identify the relevance of simulated learning experiences if scenarios are dissimilar to clinical placement settings. The nature and extent what is able to be transferred from simulated to real settings is unclear, particularly in relation to complex processes such as clinical reasoning. Transfer of learning to a new situation involves deliberate cognitive effort, including reflection and mindful abstraction of central attributes of a problem. As reflection is a key element in learning transfer, the debriefing element of simulation was seen to be a platform for this study. METHOD: A convergent parallel mixed methods design used a pre-test, post-test survey and focus group interviews. RESULTS: No statistically significant difference in post-test clinical reasoning scores between groups was found. There was a statistically significant improvement in 12 out of 15 criteria among the control group and in 8 of the criteria among the intervention group. Qualitative findings provided some evidence that learning had transferred to clinical settings. Evidence of "near" transfer was more evident than "far" transfer. CONCLUSION: Positive findings included that all students perceived they had transferred the skills of patient assessment and effective communication during episodes of patient care. The concept of a "framework" being verbalized by many of the intervention group during practice is a promising finding and may be a useful direction for further research focusing on the instructional demonstration of explicitly promoting a level of abstraction of problems and prompting participants to search for conceptual connections. This may indicate retained idea or concepts from the debriefing which may be useful in future practice.

Clinical Reasoning: A State of the Science Report.

Clinical reasoning is the cognitive process that nurses use to gather and incorporate information into a larger bank of personal knowledge. This incorporated information guides therapeutic actions, and helps determine client care. Since the process guides therapeutic actions regarding client care, failure to use the process effectively leads to poor clinical decision-making, inappropriate actions, or inaction. Because of the criticality of this process, this paper presents an analysis of the literature that reveals the current state of the science of clinical reasoning, identifies gaps in knowledge, and elucidates areas for future research. A systematic review of the databases the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Educational Resources Information Center (ERIC), PsychInfo, the Education Full Text (H.W. Wilson), and PubMed revealed 873 articles on the topic of clinical reasoning. Quality appraisal narrowed the field to 27 pieces of literature. Appendix A gives the State of the Science Coding Sheet used to identify the selections used in this research. Appendix B contains a summary of this literature. Although analysis of this literature shows that three theories exist on how to utilize most effectively the clinical reasoning process presently; a clear consistent definition is lacking. Additional research should focus on closing gaps that exist in defining the process, understanding the process, establishing linkages to non-clinical reasoning processes, and developing measures to both develop and accurately measure clinical reasoning.

Newly graduated nurses' use of knowledge sources in clinical decision-making: an ethnographic study.

AIMS AND OBJECTIVES: To explore which knowledge sources newly graduated nurses' use in clinical decision-making and why and how they are used. BACKGROUND: In spite of an increased educational focus on skills and competencies within evidence-based practice, newly graduated nurses' ability to use components within evidence-based practice with a conscious and reflective use of research evidence has been described as being poor. To understand why, it is relevant to explore which other knowledge sources are used. This may shed light on why research evidence is sparsely used and ultimately inform approaches to strengthen the knowledgebase used in clinical decision-making. DESIGN AND METHODS: Ethnographic study using participant-observation and individual semistructured interviews of nine Danish newly graduated nurses in medical and surgical hospital settings. RESULTS: Newly graduates use of knowledge sources was described within three main structures: 'other', 'oneself' and 'gut feeling'. Educational preparation, transition into clinical practice and the culture of the setting influenced the knowledge sources used. The sources ranged from overt easily articulated knowledge sources to covert sources that were difficult to articulate. The limited articulation of certain sources inhibited the critical reflection on the reasoning behind decisions. Reflection is a prerequisite for an evidence-based practice where decisions should be transparent in order to consider if other evidentiary sources could be used. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Although there is a complexity and variety to knowledge sources used, there is an imbalance with the experienced nurse playing a key role, functioning both as predominant source and a role model as to which sources are valued and used in clinical decision-making. If newly graduates are to be supported in an articulate and reflective use of a variety of sources, they have to be allocated to experienced nurses who model a reflective, articulate and balanced use of knowledge sources.

Improving Patient Safety through the Use of Nursing Surveillance.

Surveillance and monitoring each represent a distinct process in patient care. Monitoring involves observation, measurement, and recording of physiological parameters, while surveillance is a systematic, goal-directed process based on early detection of signs of change, interpretation of the clinical implications of such changes, and initiation of rapid, appropriate interventions. Through use of an illustrative clinical example based on Early Warning System scoring and rapid response teams, this article seeks to distinguish between nurse monitoring and surveillance to demonstrate the impact of surveillance on improving both care processes and patient care. Using a clinical example, differences between surveillance and monitoring as a trigger for deployment of the rapid response team were reviewed. The use of surveillance versus monitoring resulted in a mean reduction in rapid response team deployment time of 291 minutes. The median hospital length of stay for patients whose clinical care included using surveillance to initiate the deployment of the rapid response team was reduced by 4 days. Monitoring relies on observation and assessment while nursing surveillance incorporates monitoring with recognition and interpretation of the clinical implications of changes to guide decisions about subsequent actions. The clinical example described here supports that the use of an automated surveillance system versus monitoring had a measurable impact on clinical care.

Institutionalizing Clinical Reasoning: A Grounded Theory of the Clinical Reasoning Processes RNs Use to Recognize Delirium.

Delirium is a common disorder among hospitalized older adults often leading to prolonged hospitalization, increased health care costs, and sometimes death. The goal of the current study was to construct a grounded theory that explains the clinical reasoning processes that RNs use to recognize delirium in older adults in acute care settings. Seventeen participants in three hospitals were interviewed. The core category that emerged from the data was institutionalizing clinical reasoning. Findings from the current study can be a starting point for RNs to bring self-awareness to variables that influence their reasoning processes.

Nurse-led clinic: effective and efficient delivery of assessment and review of patients with hepatitis B and C.

BACKGROUND: Hepatology and gastroenterology services are increasingly utilising the skills and experience of nurse practitioners and nurse specialists to help meet the increasing demand for healthcare. A new nurse-led assessment clinic has been established in the liver clinic at Geelong Hospital to utilise the expertise of nurses to assess and triage new patients and streamline their pathway through the healthcare system. AIM: The aim of this study is to assess quantitatively the first 2 years of operation of the nurse assessment clinic at Geelong Hospital, and to assess advantages and disadvantages of the nurse-led clinic. METHODS: Data were extracted retrospectively from clinical records of new patients at the liver clinic. Quarterly 1-month periods were recorded over 2 years. Patients were categorised according to the path through which they saw a physician, including missed and rescheduled appointments. The number of appointments, the waiting time from referral to appointments and the number of 'did-not-attend' occasions were analysed before and after the institution of the nurse-led assessment clinic. The Mann-Whitney rank sum test of ordinal data was used to generate median wait times. RESULTS: There was shown to be a statistically significant longer waiting time for physician appointment if seen by the nurse first. The difference in waiting time was 10 days. However, there was also a reduction in the number of missed appointments at the subsequent physician clinic. Other advantages have also been identified, including effective triage of patients and organisation of appropriate investigations from the initial nurse assessment.

Use of an electronic patient-reported outcome measurement system to improve distress management in oncology.

OBJECTIVE: Management of patient distress is a critical task in cancer nursing and cancer practice. Here we describe two examples of how an electronic patient-reported outcome (ePRO) measurement system implemented into routine oncology care can practically aid clinical and research tasks related to distress management. METHODS: Tablet personal computers were used to routinely complete a standardized ePRO review of systems surveys at point of care during every encounter in the Duke Oncology outpatient clinics. Two cases of use implementation are explored: (1) triaging distressed patients for optimal care, and (2) psychosocial program evaluation research. RESULTS: Between 2009 and 2011, the ePRO system was used to collect information during 17,338 Duke Oncology patient encounters. The system was used to monitor patients for psychosocial distress employing an electronic clinical decision support algorithm, with 1,952 (11.3%) referrals generated for supportive services. The system was utilized to examine the efficacy of a psychosocial care intervention documenting statistically significant improvements in distress, despair, fatigue, and quality of life (QOL) in 50 breast cancer patients. SIGNIFICANCE OF RESULTS: ePRO solutions can guide best practice management of cancer patient distress. Nurses play a key role in implementation and utilization.

[The role of family carers of people with dementia in the assessment of need on the example of the CarenapD study]. / Die Rolle pflegender Angehöriger von Menschen mit Demenz in der Bedarfsbestimmung am Beispiel der CarenapD-Studie.

Need driven dementia care at home requires the use of needs assessments like CarenapD. The CarenapD Manual states that the person with dementia (PwD) and caregivers (CA) should be included in the assessment process. In a pre-post study CarenapD has been applied in PwD (n = 55) and CA (n = 49) by professional staff (n = 15), CA were much more involved than PwD. Needs in PwD in T0 and T1 showed frequently functional needs(50 %), no need were frequently found in dementia-specific needs (42 %) and frequently unmet need was present in social needs (35 %). Burden-related needs in CA were reduced from T0 to T1 in daily difficulties (-14 %), support (-20 %) and breaks from caring (-9 %).This secondary analysis compares the need results of PwD and CA to discuss the unequal involvement of clients. In this secondary analysis needs data of PwD and CA is included. Need in PwD at T0 and T1 showed frequently met functional need (50 %), frequently no need in dementia specific needs (42 %) and high unmet need in social needs (35 %). Burden in CA could be reduced from T0 to T1 in Daily Difficulties (-14 %), Support (-20 %) and Breaks from Caring (9 %). Compared to the literature it is remarkable that a high rate in no need was found in dementia specific needs. Needs of CA show congruent results, it seems to have come to relief of burden in CA. Lack of knowledge and shame in CA as well as the continuous presence of both clients within the assessment process may have caused that dementia-specific needs were not enough addressed. PwD and CA should be actively involved in the assessment process and should contribute their individual point of view, as stated in the CarenapD Manual.

[CLIC and mental healthcare]. / Clic et santé mentale.

The Gagny local centre for information and coordination in gerontology (CLIC) became officially accredited in December 2004. Located within the town hall, it consists of an adviser in social and family economics who acts as the centre's manager, coordinator and assessor, as well as an assessment nurse.

Pressure ulcers and prevention among acute care hospitals in the United States.

BACKGROUND: Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities. METHODS: Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers. RESULTS: The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status. CONCLUSIONS: Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.

ABCDEs of ICU: Early mobility.

The intensive care unit (ICU) provides a critical level of care to medically unstable patients. Patients need intensive monitoring and treatment that may require emergency interventions. The vulnerability and complexity of the ICU unintentionally creates an environment that limits and poorly defines the intervention of early mobility in the unstable critically ill patients. The short- and long-term effects of immobility and bed rest increase acute complications, the length of stay in the ICU and hospital, and mortality and morbidity rates. According to current research, instituting early mobility programs can improve patient outcomes. Current research has demonstrated the safety and feasibility of the initiation of early mobility programs in the critically ill. The benefits to patients enhance recovery of functional exercise capacity, weaning outcomes, self-perceived functional status, and muscle force and strength. Consequently, patient's length of stay in the ICU and in hospital decreases and improves health outcomes. The scope of practice for nurses and other health care providers should guide by evidenced-based research to reduce complications and enhance patient outcomes. Further research is necessary to establish and institute policies and protocols on early mobility programs in the ICU to direct patient care. The role of the clinical nurse specialist can contribute by conducting evidence-based research, educating health care providers and patients, and implementing protocols. The hope is to change the culture of the ICU for the better.

ABCDEs of ICU: Awakening.

UNLABELLED: Critically ill patients in the intensive care unit (ICU) who require mechanical ventilation often require continuous sedation infusions. These 2 interventions are associated with adverse outcomes such as increased duration of mechanical ventilation, increased length of stay in both the ICU and the hospital, and significant physiological and psychological complications. Daily sedation interruption (DSI) can reduce these adverse effects thereby improving long-term outcomes after critical illness. CONCLUSION: DSI is safe, practical, cost-effective, and results in positive outcomes for patients; however, there are barriers to implementing and incorporating DSI into daily practice. Further research is required to provide additional evidence and promote more widespread utilization.

ABCDEs of ICU: Choice of sedative.

When the clinical picture of a patient in the intensive care unit necessitates placement of an artificial airway supported by mechanical ventilation, a regimen of sedation and analgesia is initiated with the goal of providing anxiolysis and pain control to facilitate ventilation and therapeutic and diagnostic intervention. However, some of the most commonly used sedative agents, such as benzodiazepines, may have profound long-term effects on patients' health, including neuropsychological functioning. With more patients now surviving intensive care, more patients are suffering from these negative health consequences. A review of recent research on the subject suggests that more novel, non-benzodiazepine agents such as dexmedetomidine, fluorinated ether gases, and remifentanil function effectively as sedative agents in intubated patients in the intensive care unit, and are less likely to lead to delirium, agitation, aggression, psychosis, and other complications; in addition, use of these alternatives is associated with shorter times to awakening, extubation, and ICU discharge, as well as shorter overall length of stay and decreased cost of care.

The implementation of PEARS training: supporting nurses in non-critical care settings to improve patient outcomes.

Children's Hospital Boston's Life Support Program began offering the newly developed American Heart Association Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) course for nurses working in non-critical care settings in December of 2007. The goal was to provide an appropriate alternative to pediatric advanced life support (PALS) training for clinical staff caring for the general pediatric population. To date, more than 900 nurses have completed the course with feedback from the participants being extremely positive. Even more impressive is a more appropriate use of the hospital's emergency medical response system promoting early intervention and the significant reduction in cardiac arrests on inpatient units. During a 12-month period, nurses involved in activations of the response system were asked to rate their ability to assess, categorize, decide and act after each event. The overwhelming majority agreed they were able to apply the PEARS systematic approach of assessment and early intervention to the situation. This article describes the planning and implementation of PEARS training for non-critical care nursing staff and provides data that demonstrates improved patient outcomes. Supporting activities and strategies promoting early recognition and interventions contributing to the successful reduction of cardiac arrests on inpatient units are also discussed.

Changing nursing practice: letting go of the nursing history on admission.

In this project, 2 performance improvement (PI) methodologies were used to evaluate the process of nursing admission and history collection. Nurses have a responsibility to methodically assess bedside care, ensuring that practice changes do not merely add on to an often inefficient workload but add value. This article illustrates the use of PI to modify the initial nursing inpatient admission assessment process.

Time changes for scheduled nursing assessments: impact on clinical decisions and patient discharge.

Using a shared governance model, a clinical nursing practice change was implemented to increase collaborative decision making among health care providers at morning rounds. The goal of this project was to improve nursing workflow at the beginning of the shift and improve patient flow by discharging patients earlier. By changing the time of morning vital signs and nursing assessments from 0800 to 0600, staff reported increased collaboration among the multidisciplinary team and improved nursing workflow.

Taking a patient history: the role of the nurse.

History taking is a key component of patient assessment, enabling the delivery of high-quality care. Understanding the complexity and processes involved in history taking allows nurses to gain a better understanding of patients' problems. Care priorities can be identified and the most appropriate interventions commenced to optimise patient outcomes.