Clinical decision-making processes among graduate nurses, specialist nurses and nurse practitioners A collaborative international study.

AIM: To explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. BACKGROUND: Clinical decision-making in an emergency department environment is a complex process often occurring in times of crisis. It is an important aspect contributing to the quality of care. However, empirical research is limited regarding the decision-making process in different nursing roles. METHODS: In accordance with the consolidated criteria for reporting qualitative research, a qualitative and observational study was conducted to explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. Six Registered Nurses, six Nurse Specialists and six Nurse Practitioners were observed. A total of 40 hours of observation was made at each setting according to a structured observation guideline, followed by clarifying questions. The data material was analysed by means of a qualitative manifest and latent content analysis. RESULTS: Three themes arose: acting in accordance with routines, previous experience and intuition; considering patient experience; and facilitating new alternatives based on critical thinking. The Registered Nurses mainly used the first approach, the Nurse Specialists used the first and the second approaches, and the Nurse Practitioners used all three approaches. CONCLUSIONS: The results highlight the differences in decision-making processes between these groups. Nurse Practitioners were the only group that facilitated and evaluated new alternatives using their clinical autonomy, such as stepping up and making independent and collaborative decision-making. IMPLICATION: The results can be used in countries developing advanced practice nursing education and defining their scope of practice to inform stakeholders.

An international comparison of student nurse practitioner diagnostic reasoning skills.

BACKGROUND: Nurse practitioners (NPs) play a pivotal role in health care provision. Diagnostic reasoning is an important core skill of advanced practice. PURPOSE: The purpose of this study was to compare diagnostic reasoning skills of NP students. It also identified the variability in clinical teaching components of a sample of international NP curricula. METHODS: An international group of NP students completed an online survey using a validated diagnostic reasoning scale during the first year of their NP program. Program faculty surveyed provided data on core curricula. RESULTS: The NP students' ( n = 152) mean diagnostic thinking inventory (DTI) score was 142, flexibility in thinking subscale score mean of 73 with a knowledge structure in memory of 69. The programs surveyed required bioscience courses. Most programs provided opportunities for students to practice diagnostic thinking using individual precepted clinical hours (range 500-950) and objective structured clinical examinations. CONCLUSION: The lower scores of this group of NP students were similar to other NP students and first-year medical residents. Higher mean scores in the DTI reflect expertise and are developed over time. Courses providing a foundation of biomedical knowledge were identified in each program, with opportunities for the NP students to practice diagnostic thinking using objective structured clinical examinations and clinical practice hours. IMPLICATIONS: The use of the diagnostic reasoning inventory is a useful tool for evaluating student NP's diagnostic reasoning during their NP program. Nurse practitioner programs should consider the provision of dedicated clinical hours, including supervised clinical practice experiences and objective structured clinical examinations to improve diagnostic reasoning.

Psychometric testing of the facilitative student-patient relationship scale within six EUROPEAN countries.

AIM: The aim of the study was to test the psychometric properties of the Facilitative Student-Patient Relationship (FSPR) Scale in clinical practicum in hospital settings within six European countries. DESIGN: A multi-country, cross-sectional survey design was applied. METHODS: A convenience sample of graduating nursing students (N = 1,796) completed the FSPR Scale. Psychometric testing was carried out through explorative factor analysis and confirmatory factor analysis. Internal consistency was assessed using Cronbach's alpha. RESULTS: Both validity and reliability of the scale were confirmed. The explorative factor analysis yielded a two-factor construct explaining 47.7% of the total variance, identifying two sub-scales: caring relationship and learning relationship. Confirmatory factor analysis confirmed the two-factor structure. The Cronbach alpha coefficients (0.8-0.9) indicated acceptable reliability of the scale.

An exploration of the levels of clinical autonomy of advanced nurse practitioners: A narrative literature review.

AIMS AND OBJECTIVES: The aims of the review are to synthesise current evidence about advanced nurse practitioner clinical autonomy and consider how this may inform clinical practice and research. BACKGROUND: Clinical autonomy is one of the cornerstones of advanced nursing practice globally, yet there is limited synthesis of clinical autonomy in the literature. DESIGN: This is a narrative literature review. DATA SOURCES: The databases Cumulative Index to Nursing and Allied Health Literature, EBSCO host, Cochrane Library, CINAHL and MEDLINE were searched for publications between 2005 and 2020 inclusive. REVIEW METHODS: A systematic approach was used to analyse the literature reviewed. Two reviewers undertook quality appraisal. RESULTS: Nineteen articles were selected. Four major themes emerged: (1) 'ANP Stepping Up'-moving into and accepting advanced nursing practice roles and clinical responsibilities; (2) 'ANP Living It'-ANPs' ability to act independently including an understanding of task mastery and self-determination; (3) 'ANP Bounce-back ability'-depicted in challenges that threaten their ability to practice clinically autonomously; (4) 'ANP Setting in Motion'-indirect care activities and service-level improvements. CONCLUSION: A clearer understanding of advanced nurse practitioner clinical autonomy could help develop more in-depth knowledge. Research of advanced nurse practitioners' clinical autonomy would improve full utilisation in clinical practice.

The level of competence of graduating nursing students in 10 European countries-Comparison between countries.

AIM: To analyse graduating nursing students' self-assessed competence level in Europe at graduation, at the beginning of nursing career. DESIGN: An international cross-sectional evaluative design. METHODS: Data were collected in February 2018-July 2019 from graduating nursing students in 10 European countries. Competence was assessed with a validated instrument, the Nurse Competence Scale (NCS). The sample comprised 3,490 students (response rate 45%), and data were analysed statistically. RESULTS: In all countries, graduating nursing students assessed their competence as good (range 50.0-69.1; VAS 0-100), albeit with statistically significant differences between countries. The assessments were highest in Iceland and lowest in Lithuania. Older students, those with working experience in health care, satisfied with their current degree programme, with excellent or good study achievements, graduating to 1st study choice and having a nursing career plan for future assessed their competence higher.

Conducting research through cross national collaboration.

AIM: To explore the collaborative nature of an international research project with other advanced practice nurse researchers and critically analyse the process. BACKGROUND: Research within the nursing community is recognized internationally as important to ensure that nurses participate in cutting-edge health care and promote evidence-based practices, yet there is little detail found in literature on how a successful collaborative relationship is initiated and conducted in advanced practice research. DESIGN: Discussion paper: The purpose of this paper is to discuss the process of collaboration on a research study among advanced practice nurses from four countries who are members of an international organization. IMPLICATIONS FOR NURSING: The collaborative process in international nursing research can be challenging and rewarding. It is important to remember that there is a relationship between the complexity of the study and the time required to complete it. Keys to success include following established guidelines. CONCLUSION: This project was a valuable experience in developing collaborative relationships as well as creating partnerships for future research to build on the knowledge gained. The authors' linkages to universities facilitated their participation in the research and completion of the ethical review processes. The use of social media and university resources was indispensable.

The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis.

BACKGROUND: Nurses are pivotal in the provision of high quality care in acute hospitals. However, the optimal dosing of the number of nurses caring for patients remains elusive. In light of this, an updated review of the evidence on the effect of nurse staffing levels on patient outcomes is required. AIM: To undertake a systematic review and meta-analysis examining the association between nurse staffing levels and nurse-sensitive patient outcomes in acute specialist units. METHODS: Nine electronic databases were searched for English articles published between 2006 and 2017. The primary outcomes were nurse-sensitive patient outcomes. RESULTS: Of 3429 unique articles identified, 35 met the inclusion criteria. All were cross-sectional and the majority utilised large administrative databases. Higher staffing levels were associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and a greater number of patients receiving percutaneous coronary intervention within 90 minutes. A meta-analysis involving 175,755 patients, from six studies, admitted to the intensive care unit and/or cardiac/cardiothoracic units showed that a higher nurse staffing level decreased the risk of inhospital mortality by 14% (0.86, 95% confidence interval 0.79-0.94). However, the meta-analysis also showed high heterogeneity (I2=86%). CONCLUSION: Nurse-to-patient ratios influence many patient outcomes, most markedly inhospital mortality. More studies need to be conducted on the association of nurse-to-patient ratios with nurse-sensitive patient outcomes to offset the paucity and weaknesses of research in this area. This would provide further evidence for recommendations of optimal nurse-to-patient ratios in acute specialist units.

Postoperative hyperglycaemia of diabetic patients undergoing cardiac surgery - a clinical audit.

BACKGROUND: Previous studies have shown that hyperglycaemia is associated with postoperative complications in cardiac surgical patients. Conversely, well-controlled glucose levels are said to reduce major infectious complications in diabetic patients. AIM/OBJECTIVES: The purpose of this clinical audit was to evaluate the blood glucose levels of diabetic patients undergoing cardiac surgery and to determine the effectiveness of postoperative glycaemic control. METHODS: A group of 150 patients from a large Irish cardiac surgery centre was selected by convenience sampling. An audit tool was designed to capture the patients' blood glucose levels, treatment regimes and postoperative complications. FINDINGS: The findings showed major variations between 'high', 'good' and 'borderline' blood glucose levels in the pre- and postoperative phase. Although blood glucose testing practices seemed inconsistent, mean levels measured 'borderline'. Furthermore, the treatment regimes varied greatly and suggest a lack of consensus regarding the management of postoperative hyperglycaemia. A total of 52% (n = 78) patients developed 114 complications with a level of 21.4% (n = 32) postoperative wound infections. CONCLUSION: The findings from this audit highlight the importance of regular blood glucose testing to enable early detection of hyperglycaemia and timely initiation of appropriate treatments regimes for diabetic patients undergoing cardiac surgery. Findings also show that hyperglycaemia derangement may make a difference in the recovery phase. While patients will benefit from lesser wound infections, hospitals might save costs involved with treating postoperative complications. RELEVANCE TO PRACTICE: More consistent blood glucose testing might be achieved through the use of evidence-based protocols. However, the education of staff is as important as it develops knowledge on the complex metabolic interactions of diabetic patients undergoing cardiac surgery. While this means investing in staff education and policy development, costs for daily care and expensive treatments for complications will be saved as patient recovery will be speedier and less eventful.

The need for nurses to have in service education to provide the best care for clients with chest drains.

Chest drains are a widespread intervention for patients admitted to acute respiratory or cardiothoracic surgery care areas. These are either inserted intraoperatively or as part of the conservative management of a respiratory illness or thoracic injury. Anecdotally there appears to be a lack of consensus among nurses on the major principles of chest drain management. Many decisions tend to be based on personal factors rather than sound clinical evidence. This inconsistency of treatment regimes, together with the lack of evidence-based nursing care, creates a general uncertainty regarding the care of patients with chest drains. This study aimed to identify the nurses' levels of knowledge with regard to chest drain management and identify and to ascertain how nurses keep informed about the developments related to the care of patients with chest drains. The data were collected using survey method. The results of the study revealed deficits in knowledge in a selected group of nurses and a paucity of resources. Nurse managers are encouraged to identify educational needs in this area, improve resources and the delivery of in service and web-based education and to encourage nurses to reflect upon their own knowledge deficits through portfolio use and ongoing professional development.

Nurses' knowledge of chest drain care: an exploratory descriptive survey.

Chest drains are a common feature of patients admitted to acute respiratory or cardio-thoracic surgery care areas. Chest drains are either inserted intraoperatively or as part of the conservative management of a respiratory illness or thoracic injury. Anecdotally, there appears to be a lack of consensus among nurses on the major principles of chest drain management. Many decisions tend to be based on personal factors rather than sound clinical evidence. This inconsistency of treatment regimes, together with the lack of evidence-based nursing care, creates a general uncertainty regarding the care of patients with chest drains. This study aimed to identify the nurses' levels of knowledge with regard to chest drain management. The research objective of this study was to describe the nurses' levels of knowledge regarding the care of the patient with chest drains. The data were collected using survey method. The results of the study revealed deficits in knowledge in a select group of nurses. Several service-led options exist with regard to improving knowledge in this area, such as service study days as well as ward-based tutorials. However, in an era of increasing accountability together with the impetus for each nurse to provide evidence-based care, it is crucial for individual nurse responsibility in the pursuit of knowledge in this area. Nurses must be supported by local practice development and through personal portfolio use to identify gaps in knowledge and seek appropriate training and resources.