Memories of nursing in Singapore - an oral history approach.

Background: Documentation of the voices of nurses provided valuable insight and a greater understanding of the nursing experience in Singapore. Aim: To record nurses' experiences of journey of nursing profession in the acute care setting in Singapore from the early days of formalisation of nursing education to today's practice as a profession with various specialisation and career tracks. Method: An oral history research approach was adopted, with purposive and snowball sampling to recruit nurses (both current and retired) who had trained in Singapore from 1956 which marked the beginning of the founding of the School of Nursing to current. Interviews were conducted with an interview guide. Thematic analysis was utilised to analyse the audio-recorded data. Results: The 54 participants with a range of 10-54 years of nursing experience were interviewed and they completed their nursing training between 1952 and 2006. Four themes were generated: essence of nursing, inevitable changes across nursing profession, resilience and future outlook in nursing. Conclusions: Understanding the experiences of these nurses generated an in-depth understanding of the personal, social and historical events that were at play in fostering today's nursing practice. With the evolution of the roles in nursing, compassion in current practice needs to be re-evaluated. Continuous learning is essential to meet the needs of the changing healthcare landscape.

Predicting suicide and suicide attempts in adults in acute hospitals: A systematic review of diagnostic accuracy evaluating risk scales.

BACKGROUND: Prediction of suicide and suicide attempts is an aspirational goal for clinicians and policy makers. This requires scrutiny of various diagnostic accuracy measurements. OBJECTIVE: To evaluate the diagnostic accuracy of suicide risk scales in inpatient and emergency departments, and combined settings within hospitals, and consider the best scale in predicting suicide and suicide attempts in adults. DESIGN: Systematic review of diagnostic accuracy. SETTINGS: Inpatient and emergency rooms of acute hospitals. METHODS: The searched databases included PubMed, Embase, ProQuest, MEDLINE, Web of Science, CINAHL, Cochrane, PsycINFO and Scopus. Grey literature databases (ProQuest Dissertations and Theses, Google Scholar and OpenSIGLE) and reference lists of all included studies were also searched. Eligibility criteria included prospective cohort studies of suicide or attempted suicide in adults. A narrative synthesis was done for true positives, true negatives, false positives and false negatives, and they were calculated for sensitivity, specificity, likelihood ratios, predictive values and diagnostic odds ratios. RESULTS: The included 33 studies differed in the methodological characteristics and scales used. The sensitivity of scales, specificity, positive predictive value, and diagnostic odds ratios ranged from 17 to 100%, 11-93%, 0.43-40.9%, and 0.77-18.5, respectively. CONCLUSION: The choice of scale for predicting suicide attempts in adults in hospitals depends on many factors. None of the scales evaluated produced accurate diagnostic measurements. The Manchester Self-Harm Rule and Suicide Crisis Syndrome should be used in the emergency department and inpatient setting, respectively, while the Suicide Intent Scale should be used in combined settings.

Effectiveness of continuous glucose monitoring in maintaining glycaemic control among people with type 1 diabetes mellitus: a systematic review of randomised controlled trials and meta-analysis.

AIMS/HYPOTHESIS: The aim of this work was to assess the effectiveness of continuous glucose monitoring (CGM) vs self-monitoring of blood glucose (SMBG) in maintaining glycaemic control among people with type 1 diabetes mellitus. METHODS: Cochrane Library, PubMed, Embase, CINAHL, Scopus, trial registries and grey literature were searched from 9 June 2011 until 22 December 2020 for RCTs comparing CGM intervention against SMBG control among the non-pregnant individuals with type 1 diabetes mellitus of all ages and both sexes on multiple daily injections or continuous subcutaneous insulin infusion with HbA1c levels, severe hypoglycaemia and diabetic ketoacidosis (DKA) as outcomes. Studies also included any individual or caregiver-led CGM systems. Studies involving GlucoWatch were excluded. Risk of bias was appraised with Cochrane risk of bias tool. Meta-analysis and meta-regression were performed using Review Manager software and R software, respectively. Heterogeneity was evaluated using χ2 and I2 statistics. Overall effects and certainty of evidence were evaluated using Z statistic and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) software. RESULTS: Twenty-two studies, involving 2188 individuals with type 1 diabetes, were identified. Most studies had low risk of bias. Meta-analysis of 21 studies involving 2149 individuals revealed that CGM significantly decreased HbA1c levels compared with SMBG (mean difference -2.46 mmol/mol [-0.23%] [95% CI -3.83, -1.08], Z = 3.50, p=0.0005), with larger effects experienced among higher baseline HbA1c >64 mmol/mol (>8%) individuals (mean difference -4.67 mmol/mol [-0.43%] [95% CI -6.04, -3.30], Z = 6.69, p<0.00001). However, CGM had no influence on the number of severe hypoglycaemia (p=0.13) and DKA events (p=0.88). Certainty of evidence was moderate. CONCLUSIONS/INTERPRETATION: CGM is superior to SMBG in improving glycaemic control among individuals with type 1 diabetes in the community, especially in those with uncontrolled glycaemia. Individuals with type 1 diabetes with HbA1c >64 mmol/mol (>8%) are most likely to benefit from CGM. Current findings could not confer a concrete conclusion on the effectiveness of CGM on DKA outcome as DKA incidences were rare. Current evidence is also limited to outpatient settings. Future research should evaluate the accuracy of CGM and the effectiveness of CGM across different age groups and insulin regimens as these remain unclear in this paper. PROSPERO REGISTRATION: Registration no. CRD42020207042. FUNDING: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The development and psychometric evaluation of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients scale.

BACKGROUND: Validated measures of ward nurses' safety cultures in relation to escalations of care in deteriorating patients are lacking. OBJECTIVES: This study aimed to develop and evaluate the psychometric properties of the Clinicians' Attitudes towards Responding and Escalating care of Deteriorating patients (CARED) scale for use among ward nurses. METHODS: The study was conducted in two phases: scale development and psychometric evaluation. The scale items were developed based on a systematic literature review, informant interviews, and expert reviews (n = 15). The reliability and validity of the scale were examined by administering the scale to 617 registered nurses with retest evaluations (n = 60). The factor structure of the CARED scale was examined in a split-half analysis with exploratory and confirmatory factor analyses. The internal consistency, test-retest reliability, convergent validity, and known-group validity of the scale were also analysed. RESULTS: A high overall content validity index of 0.95 was obtained from the validations of 15 international experts from seven countries. A three-factor solution was identified from the final 22 items: 'beliefs about rapid response system', 'fears about escalating care', and 'perceived confidence in responding to deteriorating patients'. The internal consistency reliability of the scale was supported with a good Cronbach's alpha value of 0.86 and a Spearman-Brown split-half coefficient of 0.87. An excellent test-retest reliability was demonstrated, with an intraclass correlation coefficient of 0.92. The convergent validity of the scale was supported with an existing validated scale. The CARED scale also demonstrated abilities to discriminate differences among the sample characteristics. CONCLUSIONS: The final 22-item CARED scale was tested to be a reliable and valid scale in the Singaporean setting. The scale may be used in other settings to review hospitals' rapid response systems and to identify strategies to support ward nurses in the process of escalating care in deteriorating ward patients.

Nurses' experiences on the road during transition into community care: An exploratory descriptive qualitative study in Singapore.

Healthcare systems are evolving to meet the demands of an ageing population whereby the provision of health care services in the community has increased to alleviate the burden faced by acute care health facilities. As the result, the number of community nurses are expected to increase in order to meet the demand. Several studies have identified the unique challenges faced by the growing responsibilities of community nurses. However, fewer studies focused on the experiences of nurses transitioning to become community nurses as they rise to meet the unique challenges of working in the community. This study aimed to explore the experiences of nurses' transitions into community care while gaining insight into the transition process. The study adopted the exploratory qualitative approach. Data collection was performed through semi-structured interviews with 14 community nurses in Singapore. Interview sessions were digitally recorded and transcribed into verbatim, and the thematic analysis approach was used for data analysis. Three major themes and nine subthemes were developed from the data of 14 interviews. The three major themes are: 'Changes in Dynamics in a Nurse-Patient Relationship', 'To Live Up to Expectations', and 'Negotiating the Landscape in the Community'. New community nurses are experiencing stress and struggling to adapt with performing nursing care in uncontrolled environments. Additionally, higher expectations have been set on them even when they are still in transition. It is important to provide support for nurses, including in-service talks, courses and formal orientation programs. The study findings highlighted the importance of adequately preparing new community nurses and provided insights on developing a customised formal orientation program. This study also contributed to the limited body of knowledge with respect to nurses' transition experiences into community care.

Nurses' perception and experiences towards medical device-related pressure injuries: A qualitative study.

AIMS AND OBJECTIVES: This study aims to explore nurses' perceptions and experiences regarding pressure injuries caused by medical devices and to understand the perceived challenges and barriers nurses face in preventing medical device-related pressure injuries. BACKGROUND: Nurses have a responsibility to prevent pressure injuries and play a major role in their prevention. As there has been a lack of research on medical device-related pressure injuries, not much is known about nurses' perceptions and experiences. This therefore hinders the establishment of effective and efficient interventions in nurses' education and in the practical environment. DESIGN: A descriptive qualitative design was adopted, and the COREQ checklist was employed to report on the current study. METHODS: The study was conducted at an acute care hospital in Singapore. Purposive sampling was used, and a total of 21 enrolled and registered nurses who had recent experiences with medical device-related pressure injuries were recruited between August and December 2018. Face-to-face interviews were conducted using a semi-structured interview guide. A thematic analysis was performed to analyse the qualitative data. RESULTS: Five themes emerged regarding pressure injuries: (1) preventable yet unavoidable, (2) everyone's responsibility, (3) harmonising theory with practice reality, (4) pre-existing conditions may limit injury prevention and management; and (5) nurses expressed a need for experiential training. CONCLUSIONS: The study's findings could be used to develop improvements in nursing practice and policy at acute care hospitals, as well as to improve awareness of medical device-related pressure injuries among healthcare professionals. Moreover, the findings can also inform future research studies to develop effective evidence-based practices and improve patient outcomes. RELEVANCE TO THE CLINICAL PRACTICE: This study reveals the unique challenges and dilemmas that nurses face and will help to inform healthcare institutions and management in developing programmes and improving protocols to reduce the incidence rate of pressure injuries caused by medical device.

A call for better doctor-nurse collaboration: A qualitative study of the experiences of junior doctors and nurses in escalating care for deteriorating ward patients.

BACKGROUND: Despite the widespread implementation of medical emergency teams (METs) in hospitals to provide immediate interventions to deteriorating ward patients, little is known about how junior doctors and nurses escalate care for deteriorating ward patients in hospitals with established MET services. OBJECTIVES: The objective of this research study was to explore the experiences of junior doctors and nurses in escalating care for clinically deteriorating patients in general wards. METHODS: Twenty-four individual interviews were conducted with 10 junior doctors and 14 registered nurses of a 1000-bed acute general hospital with the most established MET service in Singapore. Interviews were transcribed verbatim and analysed using an interpretive thematic analysis approach. FINDINGS: Three salient themes emerged from thematic analysis: (1) MET activations versus the primary team doctors' reviews, (2) challenges in obtaining medical reviews, and (3) unspoken rules of the escalation of care. Participants' decisions to call the MET or to escalate to the primary team doctors not only depended on the severity of a patient's deterioration and their perceptions of the primary team doctors' capacity to manage the patient but also were largely influenced by sociocultural factors that were shaped by the hierarchy of medical professions. Key challenges faced by nurses in obtaining medical reviews from junior doctors for patients with early deterioration included presenting "convincing" evidence of patient deterioration and "packaging" information about patient deterioration. CONCLUSIONS: The decision to call a MET or the primary team doctors is a complex judgement that is greatly influenced by the dynamics of perceived hierarchy between the medicine and nursing professions and within the medicine profession. Educational and organisational changes that enhance doctor-nurse interprofessional and intraprofessional collaboration among all levels of doctors may improve the process of the escalation of care for deteriorating patients and thus improve patient safety for hospitalised patients.

Adherence to diet and medication and the associated factors among patient with chronic heart failure in a multi-ethnic society.

OBJECTIVE: To investigate diet adherence, medication adherence and self-care behaviour among patients with chronic heart failure (CHF) in a multi-ethnic society and identify the significant factors associated with their diet and medication adherence. METHODS: A cross-sectional descriptive correlational study was conducted with a convenience sample of 107 patients with CHF recruited from two cardiology wards of a public tertiary hospital in Singapore. Study variables were measured using the Dietary Sodium Restriction Questionnaire, the Medication Adherence Rating Scale-5 items and the European Heart Failure Self-care Behaviour Scale-12 items. RESULTS: Our sample reported positive attitudes towards diet adherence, poor self-care behaviour, and good medication adherence. The multiple linear regression results indicated that lower income, Chinese ethnicity, diabetic complications, current smoking, lower New York Heart Association classification I and II, and poorer self-care behaviour predicted poorer diet adherence. In addition, absence of hypertension, having non-myocardial infarction as a cause of CHF, and moderately diminished ejection fraction were identified as significant predictors of poorer medication adherence. CONCLUSION: The findings from this study have established the need to improve current education and rehabilitation programmes for patients with CHF by addressing those factors significantly influencing their adherence to diet and medication.

Risk of skin tears and its predictors among hospitalized older adults in Singapore.

AIM: To identify the characteristics that may be predictive of development of risk of skin tears among hospitalized older adults in Singapore. BACKGROUND: Skin tears are wounds that are partial or full-thickness separation of skin layers, which are common in older adults. Skin tears can result from shearing, friction, and/or blunt force. Skin tears have correlated with prolonged hospitalization, raised health-care costs and poorer quality of life. METHODS: This cross-sectional descriptive correlational study recruited a convenience sample of 140 patients aged 65 years or above from a Singapore acute hospital. A modified International Skin Tear Advisory Panel (ISTAP) Skin Tear Risk Assessment Pathway was used for data collection; this is a validated instrument to assess patients for risks of skin tears in clinical settings. RESULTS: The results of the multiple linear regression analysis indicated that increasing age, being underweight, caregiver-dependence and dementia predicted higher levels of risk of skin tears among hospitalized older adults in Singapore. These factors accounted for 33.6% of the variance. CONCLUSION: This study can aid health-care professionals assess patients' risk of skin tears and implement appropriate interventions to minimize risks of skin tears.

Seeing the whole picture in enrolled and registered nurses' experiences in recognizing clinical deterioration in general ward patients: A qualitative study.

BACKGROUND: The implementation of early warning scoring systems and medical emergency teams that aim to reduce failure to rescue in general wards is only effective if frontline nurses can recognize and act on clinical deterioration in a timely manner. While much of the research to date has primarily focused on registered nurses as recognizers of clinical deterioration, little research has sought to explore the role of enrolled nurses in recognizing clinical deterioration and to provide a big picture of how enrolled and registered nurses recognize clinical deterioration in general ward patients. OBJECTIVES: To conduct an exploration of the experiences of enrolled and registered nurses in recognizing clinically deteriorating patients in general wards. DESIGN: A qualitative, descriptive design. SETTING: General wards at a 1,000-bed acute general hospital in Singapore. PARTICIPANTS: A purposive sample of 22 enrolled and registered nurses who had at least 6 months of nursing experience and who were working in the general wards. METHODS: Individual semi-structured interviews were conducted between October 2016 and February 2017. Interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS: Four salient themes emerged from the data analysis. The first, 'Having a sense of knowing', illustrates how knowing a patient and past experiences facilitated the early recognition of clinical deterioration before the patient turned haemodynamically unstable. The second, 'Patient assessment practices', depicts the physical assessment skills that nurses used to detect clinical deterioration. The third, 'Delegation of routine patient care and assessment to enrolled nurses', demonstrates that nursing activities were delegated to enrolled nurses with lesser directional and supervisory aspects that "delegation" implies, which can potentially compromise patient safety. The fourth, 'Missing the big picture', identifies overwhelming workload and fixation on specific parameters of a patient as reasons for both enrolled and registered nurses missing the big picture of the patient's deterioration. CONCLUSIONS: This study provides a snapshot of the recognition of clinical deterioration among enrolled and registered nurses in general wards. Our findings illuminate the need to support the roles of enrolled and registered nurses, with an emphasis on patient assessment and strengthening collaborative practices among nurses, to improve early recognition and timely treatment of clinically deteriorating ward patients.

Perceptions of preceptorship among newly graduated nurses and preceptors: A descriptive qualitative study.

Preceptorship is important to newly graduated nurses as they transit from being a student to a practitioner, but it can be stressful for the preceptors. With the current problem of nurse shortage, perceptions about preceptorship need to be explored. The objective of the study is to explore the perceptions, experiences, and needs of nursing preceptors and their preceptees on preceptorship, using a descriptive qualitative design. Audio-recorded semi-structured interviews were conducted from August 2016 to November 2016 in an acute tertiary hospital in Singapore. Ten preceptor-preceptee pairs were interviewed. Thematic analysis was used to analyze the interview transcripts. Four themes emerged from the thematic analysis: (1) social role of the preceptor, (2) letting go of preceptees, (3) communication and the use of technology, and (4) involvement of nursing managers. This study reported about contextual influence on the perceptions of preceptorship, showing both positive and negative aspects of preceptorship. Future multi-centered and longitudinal studies are needed to explore preceptors' and preceptees' perceptions of preceptorship so that intervention programmes can be developed to support them.