Implementation of a paediatric early warning system as a complex health technology intervention.

The national implementation groups of early warning systems in the UK and Ireland have identified a need to understand implementation, adoption and maintenance of these complex interventions. The literature on how to implement, scale, spread and sustain these systems is sparse. We describe a successful adoption and maintenance over 10 years of a paediatric early warning system as a sociotechnical intervention using the Nonadoption, Abandonment, Challenges to the Scale-Up, Spread, and Sustainability Framework for Health and Care Technologies. The requirement for iterative processes within environment, culture, policy, human action and the wider system context may explain the possible reasons for improved outcomes in small-scale implementation and meta-analyses that are not reported in multicentre randomised control trials of early warning systems.

Do nurse navigators bring about fewer patient hospitalisations?

PURPOSE: Nurse navigators (NNs) coordinate patient care, improve care quality and potentially reduce healthcare resource use. The purpose of this paper is to undertake an evaluation of hospitalisation outcomes in a new NN programme in Queensland, Australia. DESIGN/METHODOLOGY/APPROACH: A matched case-control study was performed. Patients under the care of the NNs were randomly selected ( n=100) and were matched to historical ( n=300) and concurrent ( n=300) comparison groups. The key outcomes of interest were the number and types of hospitalisations, length of hospital stay and number of intensive care unit days. Generalised linear and two-part models were used to determine significant differences in resources across groups. FINDINGS: The control and NN groups were well matched on socio-economic characteristics, however, groups differed by major disease type and number/type of comorbidities. NN patients had high healthcare needs with 53 per cent having two comorbidities. In adjusted analyses, compared with the control groups, NN patients showed higher proportions of preventable hospitalisations over 12 months, similar days in intensive care and a smaller proportion had overnight stays in hospital. However, the NN patients had significantly more hospitalisations (mean: 6.0 for NN cases, 3.4 for historical group and 3.2 for concurrent group); and emergency visits. RESEARCH LIMITATIONS/IMPLICATIONS: As many factors will affect hospitalisation rates beyond whether patients receive NN care, further research and longer follow-up is required. ORIGINALITY/VALUE: A matched case-control study provides a reasonable but insufficient design to compare the NN and non-NN exposed patient outcomes.

Evaluation frameworks in health services: An integrative review of use, attributes and elements.

AIMS AND OBJECTIVE: To synthesise the evidence on the use of evaluation frameworks by nurses and midwives in research designed to improve healthcare services and practice. A secondary aim was to identify the attributes and elements of evaluation frameworks. BACKGROUND: Evaluation is an integral component of any initiative to improve outcomes or change clinical practice. Yet often an evaluation may not yield the information required to sustain or integrate an initiative into practice. Evaluation frameworks can support effective evaluations, but there is a lack of consensus regarding elements and attributes of frameworks that support use. METHODS: We undertook an integrative review to synthesise the use of evaluation frameworks in practice guided by the Preferred Reporting Items for Systematic review and Meta-Analysis flow diagram and checklist 2009 (Supporting Information File 4). The protocol was registered with PROSPERO (CRD42018087033). A broad range of electronic databases were systematically searched using keywords. FINDINGS: Twenty-five papers were included from a diverse range of clinical areas and across high-, middle- and low-income nations. Twenty of the research projects had used nine existing frameworks, and five had developed an evaluation specific to an initiative. Frameworks supported the processes of evaluation and made them more meaningful by simplifying a complex process (providing structure and guidance for the evaluation processes); identifying and including stakeholders; explaining reasons for outcomes; generating transferable lessons; and identifying the mechanisms driving or inhibiting change. CONCLUSION: Nurses and midwives reported that frameworks were useful in undertaking evaluations. Each framework had positive attributes and missing or confusing elements. When undertaking an evaluation, it is pertinent to review the elements and attributes of a framework to ensure it includes evaluation measures that are relevant to specific projects. RELEVANCE TO CLINICAL PRACTICE: Nurses are actively involved in evaluation of clinical practice. This review identifies important elements to consider when choosing a framework for evaluation.

The value of a learning needs analysis to establish educational priorities in a new clinical workforce.

A learning needs analysis was undertaken in a newly formed workforce. The goal of the learning needs analysis was to establish both the skill set and educational needs in the nursing workforce prior to moving to a new purpose built facility. The results would then enable nurse educators to develop, plan and deliver appropriate educational strategies. Staff (73%) completed an online survey; the results were collated and analysed. The results of the learning needs analysis suggested an experienced workforce that had great capacity to care for children across a wide spectrum of acute clinical needs. Interestingly the results of the learning needs analysis conflicted with the clinical reality. To investigate possible reasons for this difference we conducted a focus group session with nurse educators. The focus group findings highlighted the significance of change and how that impacted on the clinical capacity of experienced staff. We concluded that the results of the learning needs analysis were representative however they needed careful interpretation in the context of substantial change.

Developing an intervention to equip nurses for acute life threatening events (ALTEs) in hospital: a phenomenological approach to healthcare research.

OBJECTIVES: To understand staff's experiences of acute life threatening events (ALTEs) in a pediatric hospital setting. These data will inform an intervention to equip nurses with clinical and emotional skills for dealing with ALTEs. METHOD: A mixed design was used in the broader research program; this paper focuses on phenomenon-focused interviews analyzed using interpretative phenomenological analysis (IPA). RESULTS: Emerging themes included staff's relationships with patients and the impact of personhood on their ability to perform competently in an emergency. More experienced nurses described "automatic" competence generated through increased exposure to ALTEs and were able to recognize "fumbling and shaking" as a normal stress response. Designating a role was significant to staff experience of effectiveness. Key to nurses' learning experience was reflection and identifying experiences as "teachable moments." Findings were considered alongside existing theories of self-efficacy, reflective thought, and advocacy inquiry to create an experiential learning intervention involving a series of clinical and role-related scenarios. CONCLUSION: The phenomenological work facilitated an in-depth reading of experience. It accentuated the importance of exposure to ALTEs giving nurses experiential knowledge to prepare them for the impact of these events. Challenges included bracketing the personhood of child patients, shifting focus to clinical tasks during the pressured demands of managing an ALTE, normalizing the physiological stress response, and the need for a forum and structure for reflection and learning. An intervention will be designed to provide experiential learning and encourage nurses to realize and benefit from their embodied knowledge.