Nurses' perceptions of reasons for missed nursing care in hospitals: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to identify and synthesize the best available evidence on nurses' perceptions of the reasons for missed nursing care in hospitals. INTRODUCTION: Missed nursing care in hospitals is a complex and global problem affecting patients, nurses, and the health care system. An in-depth understanding of reasons for missed nursing care is essential to prevent it from happening in hospitals. Nurses' perceptions of reasons for missed nursing care in hospitals are related to the care environment, such as staff levels; nurses' workload; levels of experience and competencies; incomplete communication; and poor teamwork. As such, the reasons are multifaceted, and there is a need to synthesize qualitative evidence on nurses' perceptions of the reasons for missed nursing care in hospitals. INCLUSION CRITERIA: The phenomenon of interest is nurses' perceptions of reasons for missed nursing care. This systematic review will consider qualitative studies that include the perceptions of nurses working in hospital settings. METHODS: Following an initial search in PubMed, a full search strategy will be conducted in CINAHL (EBSCOhost), PubMed, Embase, Scopus, Google Scholar, and GreyNet International. The JBI approach will inform study selection, critical appraisal, data extraction, and meta-aggregation. Confidence in the findings will be assessed in accordance with the ConQual approach. REVIEW REGISTRATION: PROSPERO CRD42023438198.

Newly graduated nurses' commitment to the nursing profession and their workplace during their first year of employment: A focused ethnography.

BACKGROUND: The commitment of nurses to their profession and workplace is closely linked to the delivery of high-quality patient care. Existing literature highlights the positive impact of commitment on care quality and patient outcomes. Conversely, a lack of commitment can lead to nurse burnout and disengagement. However, it remains unclear whether and how cultural beliefs and practices influence newly graduated nurses' commitment to the nursing profession and their workplace. AIM: To explore the cultural beliefs and practices influencing newly graduated nurses' commitment to the profession and commitment to their workplace during their first year of employment. DESIGN: A focused ethnographic study. METHODS: Data consisted of field notes from 94 h of participant observations and 10 semi-structured interviews with newly graduated nurses working in acute care settings in Denmark. Data were analysed using ethnographic content analysis. Data were collected between March and June 2022. RESULTS: The findings reveal a major theme, termed 'A State of Transience among Newly Graduated Nurses', consisting of two themes: 'Newly Graduated Nurses' Pursuit of Professional Development and Supportive Work Environments' and 'A Lack of Formal Agreements or Conditions to Meet Expectations for Professional Development.' CONCLUSION: Hospitals and nurse managers need to support newly graduated nurses in their first employment after registration by providing a range of clinical experiences through job rotation opportunities within the same organization, deliver on promises for onboarding support and foster a culture of trust. These strategies will help maintain the motivation, commitment and ability of newly graduated nurses to deliver high-quality patient care, thereby reducing the likelihood of turnover. RELEVANCE FOR CLINICAL PRACTICE: A trusting and supportive work environment is fostered by providing diverse clinical experiences and consistent support for newly graduated nurses. To address potential high turnover associated with job rotation, hospitals need to rethink how retention is defined and measured, moving beyond hospital unit-level models and measures. REPORTING METHOD: This study reports to the SRQR guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Nurses' and Physicians' Ideas on Initiatives for Effective Use of the Early Warning Score: A Participatory Study.

Ineffective use of the early warning score (EWS) can compromise recognition and response to patients' deteriorating condition. This study explores nurses' and physicians' ideas on initiatives for supporting the effective use of the EWS in a hospital setting. Participatory workshops were conducted, and data were analyzed using content analysis. Ideas generated for integrating new functions into the EWS protocol to facilitate effective use are described. Also recommended was that all users receive training and an update on how to use the EWS score to support acceptance and confidence using the protocol and thereby increase adherence to the EWS. Further research is needed on the efficiency of incorporating nurses' clinical judgment in the EWS protocol within different specialties and the effect on adherence to the tool.

Bedside nurses' perspective on the Fundamentals of Care framework and its application in clinical practice: A multi-site focus group interview study.

BACKGROUND: A changing nursing workforce and an increase in demands for care together with more complex care, raise arguments that leading and guiding nursing practice is more challenging than ever. Therefore, nurses need to have a shared agenda and a common language to show the importance of nursing care and the consequences of not addressing this in an appropriate way. In response to this the Fundamentals of Care framework was developed to also contribute to the delivery of person-centred care in an integrated way. However, to gain acceptance and applicability we need to ensure the framework's relevance to clinical practice from bedside nurses' perspectives. OBJECTIVE: To describe bedside nurses' perspectives on the Fundamentals of Care framework and how it can be applied in clinical practice. DESIGN: A descriptive qualitative design informed by the Fundamentals of Care framework. SETTING(S): The study was undertaken at seven hospitals in Sweden, Denmark and the Netherlands during 2019. PARTICIPANTS: A total sample of 53 registered nurses working at the bedside participated. Participants had a wide variety of clinical experience and represented a range of different nursing practice areas. METHODS: Twelve focus group interviews were used to collect data and analysed with a deductive content analysis approach. RESULTS: Bedside nurses perceived that the Fundamentals of Care framework was adequate, easy to understand and recognised as representative for the core of nursing care. The definition for fundamental care covered many aspects of nursing care, but was also perceived as too general and too idealistic in relation to the registered nurses' work. The participants recognised the elements within the framework, but appeared not to be using this to articulate their practice. Three main categories emerged for implications for clinical practice; guiding reflection on one's work; ensuring person-centred fundamental care and reinforcing nursing leadership. CONCLUSIONS: The Fundamentals of Care framework is perceived by bedside nurses as a modern framework describing the core of nursing. The framework was recognised as having clinical relevance and provides bedside nurses with a common language to articulate the complexity of nursing practice. This knowledge is crucial for bedside nurses both in clinical practice and in leadership roles to be able to speak up for the need to integrate all dimensions of care to achieve person-centred fundamental care. Various activities for reflection, person-centred care and leadership to apply the framework in clinical practice were presented, together with minor suggestions for development of the framework. TWEETABLE ABSTRACT: Bedside nurses recognise their clinical practice within the Fundamentals of Care framework, showing the core of modern nursing.

New graduate nurses' delivery of patient care: A focused ethnography.

AIM: To explore factors influencing newly graduated nurses' delivery of direct care in acute care hospital settings. DESIGN: Qualitative study using focused ethnography. METHODS: During the period from March to June 2022, a total of ten newly graduated nurses were purposively sampled, and data were collected through 96 h of participant observation as well as ten semi-structured interviews. This research took place in a large hospital located in Denmark. Data were analysed using LeCompte and Schensul's ethnographic content analysis. RESULTS: Three main structures were developed from the data: 'Contrasting Intentions and Actions for care delivery', 'Organizational Constraints Block Interpersonal Aspects of Nursing Care' and 'Newly Graduated Nurses' Suppressed Need for Support Constitutes Delay in Care Actions'. CONCLUSION: Newly graduated nurses were committed to delivering high-quality care but were aware they sometimes provided compromised care. The paradox between a commitment to care and compromised care delivery was borne out of tensions between newly graduated nurses' professional beliefs and nursing values, a desire to integrate patients' needs and preferences, and organizational constraints on everyday practices where newly graduated nurses often worked alone without the support of a more experienced nurse. Critical reflection on cultural, social and political forces that influence direct care delivery might support newly graduated nurses to deliver direct patient care more intentionally. RELEVANCE TO CLINICAL PRACTICE: Establishment of onboarding programs and other support activities for newly graduated nurses to cope with contrasting intentions and actions that must address organizational constraints is essential. These development programs should include how critical reflection competency is supported to address value inconsistencies and emotional distress to ensure high-quality patient care. REPORTING METHOD: The reporting adhered to the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: 'No Patient or Public Contribution'.

Establishing and leading a cross-institutional partnership to integrate fundamentals of care into clinical practice, nursing education and research.

AIM: The aim was to describe and discuss the process of establishing and leading a cross-institutional partnership to regain focus on and reconceptualize fundamental nursing care in clinical practice, nursing education and research in one region in Denmark. DESIGN: A discursive paper. The case study method is used as an adapted frame for describing and discussing the establishment and strategic decisions of a cross-institutional partnership. DATA SOURCES: This discursive paper draws on the authors' experiences with establishing a cross-institutional partnership and related literature. IMPLICATIONS FOR NURSING: The paper addresses the challenges surrounding fundamental care. Establishing cross-institutional partnerships can contribute to a reconceptualization of fundamental care and initiate discussions on what nursing care is and requires. The paper provides an example of how a cross-institutional partnership can be established and describes and discusses the opportunities and challenges in doing so. CONCLUSION: A key step in the process of establishing a partnership is to actively involve key stakeholders and stimulate their commitment to investing time and resources in the partnership. This requires commitment, clear strategic direction and leadership. Another key step is engaging and informing executive management leaders, and continuously nurture their interest. IMPACT: The paper aims to inform clinicians, educators, nursing leaders, researchers and policy makers on how to organize a formal partnership structured around a strategic research, development and implementation programme where the focal point of the collaboration is improving nursing care by integrating the conceptual FoC framework. NO PATIENT OR PUBLIC CONTRIBUTION: Patients, service users, caregivers or members of the public were not involved in this study as it is a discursive paper based on the authors' experiences and relevant literature.

Umbrella review: Newly graduated nurses' experiences of providing direct care in hospital settings.

AIM: To summarize existing research syntheses reporting newly graduated registered nurses' experiences of providing direct care in hospital settings. DESIGN: Umbrella review. DATA SOURCES: An extensive search of all relevant databases was conducted for research syntheses. Initial key terms included "new* nurse", "nursing care" and "hospital setting" in combination with index terms to find relevant literature. METHODS: Critical appraisal, data extraction and summary were performed independently by two reviewers according to the Joanna Briggs Institute guidelines for undertaking umbrella reviews. RESULTS: Nine research syntheses published between 2010 and 2019 and representing 173 studies were included following critical appraisal. The evidence was summarized in narrative form with supporting tables. Twenty-six sub-branches and seven main-branches were organized in a coding tree showing the structure of three overlapping themes: "Feeling a lack of competency", "Sense of emotional distress" and "In need of support". CONCLUSIONS: Evidence demonstrates that newly graduated registered nurses' experiences of a lack of competency, emotional distress and need for support emerged as essential requirements for the provision of competent and safe direct care for the patient. IMPACT: Newly graduated registered nurses face multiple challenges in the transition from student nurse to practicing nurse. Unmet expectations of being a newly graduated nurse might lead to low levels of job satisfaction, high attrition rates or missed nursing care. Nurse educators, leaders and policy makers should be mindful that newly graduated registered nurses' perceptions of professional and personal identity and degree of support influences newly graduated registered nurses' direct care provision.

Clinical supervisors' perceptions and use of the fundamentals of care framework in supervision of nursing students.

AIM: To explore clinical supervisors' perceptions and use of the Fundamentals of Care framework in supervising nursing students in clinical placement in hospital settings. DESIGN: A qualitative study using focus group interviews. Reported in accordance with Consolidated Criteria for Reporting Qualitative Research. METHODS: Twelve clinical nurse supervisors working in medical, surgical or psychiatric wards in hospitals in Denmark participated in four focus groups conducted from September to November 2020. Data were analysed using thematic analysis. RESULTS: Clinical supervisor's perceptions and use of the framework are described in three themes: structuring students' clinical learning, supporting tool for learning what nursing care is and developing own supervision practice. CONCLUSION: Supervisors perceive the Fundamentals of Care framework positively and use it as a supporting tool to structure and facilitate students' reflection on what nursing is and requires. They perceive that having a shared framework across school and clinical setting contributes to a safe and positive learning environment. Furthermore, using the framework develops their own practice as clinical supervisors.

Nurses' Clinical Decision-Making in a Changed COVID-19 Work Environment: A Focus Group Study.

This study aims to explore how a changed COVID-19 work environment influences nurses' clinical decision-making. Data were collected via three focus groups totaling 14 nurses working in COVID-19 pandemic wards at a Danish university hospital. The factors influencing decision-making are described in three themes; navigating in a COVID-19 dominated context, recognizing the importance of collegial fellowship, and the complexities of feeling competent. A strong joint commitment among the nurses to manage critical situations fostered a culture of knowledge-sharing and drawing on colleagues' competencies in clinical decision-making. It is important for nurse leaders to consider multiple factors when preparing nurses not only to work in changing work environments, but also when nurses are asked to work in environments and specialties that deviate from their usual routines.

Nursing care during COVID-19 at non-COVID-19 hospital units: A qualitative study.

The maintenance of physical distance, the absence of relatives and the relocation of registered nurses to COVID-19 units presumably affects nursing care at non-COVID-19 units. Using a qualitative design, this study explored registered nurses' experiences of how COVID-19 influenced nursing care in non-COVID-19 units at a Danish university hospital during the first wave of the virus. The study is reported using the COREQ checklist. The analysis offered two findings: (1) the challenge of an increased workload for registered nurses remaining in non-COVID-19 units and (2) the difficulty of navigating the contradictory needs for both closeness to and distance from patients. The study concluded that several factors challenged nursing care in non-COVID-19 units during the COVID-19 pandemic. These may have decreased the amount of contact between patients and registered nurses, which may have contributed to a task-oriented approach to nursing care, leading to missed nursing care.

Newly graduated nurses' socialisation resulting in limiting inquiry and one-sided use of knowledge sources-An ethnographic study.

AIM: To explore how the socialisation into the clinical setting and interaction between newly graduated nurses and experienced nurses influences the new graduates' use of knowledge sources. BACKGROUND: Newly graduated nurses' use of knowledge sources in decision-making has been subject to an increased interest in relation to evidence-based practice. Despite interventions to strengthen nurses' competencies required for making reflective clinical decisions within an evidence-based practice, studies highlight that new graduates only draw on knowledge from research, patients and other components within evidence-based practice to a limited extent. Research exploring new graduates' use of knowledge sources calls attention to the experienced nurses' decisive role as a valued knowledge source. The new graduates' process of socialisation and their interaction with the experienced nurse raises further questions. METHODS: Ethnography using participant-observation and individual semi-structured interviews of nine newly graduated nurses from a University Hospital in Denmark. Data were collected in 2014. The study adheres to COREQ. RESULTS: Two main structures were found: "Striving for acknowledgment" and "Unintentionally suppressed inquiry." CONCLUSIONS: New graduates are socialised into limiting their inquiry on clinical practice and unintentionally being restricted to using the experienced nurse as predominant knowledge source. Depending on how the experienced nurse responds to the role as predominant knowledge source, they could either limit or nurture the new graduates' inquiry into practice and thus the variety of knowledge sources used in clinical decision-making. Limited inquiry into the complexity of nursing practice indirectly excludes the use of a variety of knowledge sources, which are fundamental to an evidence-based practice. RELEVANCE: If clinical practice wishes to benefit from the newly graduated nurses' inquiring approach and skills within evidence-based practice, clinical practice will have to greet the nurses with a supportive culture where questioning practice is seen as a strength rather than a sign of insecurity and incompetence.

Exploring nursing students' use of the Fundamentals of Care framework in case-based work.

AIMS AND OBJECTIVES: To explore how nursing students perceive and use the conceptual Fundamentals of Care framework in case-based work in nursing education and furthermore to describe influencing factors on perceptions and use of the framework. BACKGROUND: The Fundamentals of Care framework has been integrated in core courses in two Schools of Nursing in Region North Denmark in response to studies reporting that nursing students and newly graduated nurses lack the knowledge, skills and competencies to meet the challenges of delivering fundamental care in clinical practice. An integration of the framework in case-based work in nursing education has not previously been studied. DESIGN AND METHODS: The study design was focused ethnography. Data were collected using participant observations, focus group interviews and individual interviews. Four groups of four to five nursing students participating in case-based work sessions and three faculty members from two Schools of Nursing were included. The study adhered to COREQ. RESULTS: The results show an uncertainty among the students about how to understand and use the conceptual framework in case-based work. The uncertainties derive from diversities in faculty members' perceptions and curricular planning among others. However, the framework appears to support the students' learning about what nursing is and requires. CONCLUSIONS: The study indicates that integrating Fundamentals of Care framework in case-based work may be one way of teaching nursing students the complexities of integrated fundamental nursing care. However, there is a need to consider how to support students in articulating Fundamentals of Care, and to draw attention to the influence of role models and curricular planning. RELEVANCE TO EDUCATIONAL PRACTICE: The study provides knowledge relevant when customising future educational interventions regarding the integration of Fundamentals of Care in nursing education and may provide valuable knowledge of evaluation strategies.

Integrating the fundamentals of care framework in baccalaureate nursing education: An example from a nursing school in Denmark.

AIMS AND OBJECTIVES: To describe and discuss the process of integrating the Fundamentals of Care framework in a baccalaureate nursing education at a School of Nursing in Denmark. BACKGROUND: Nursing education plays an essential role in educating nurses to work within healthcare systems in which a demanding workload on nurses results in fundamental nursing care being left undone. Newly graduated nurses often lack knowledge and skills to meet the challenges of delivering fundamental care in clinical practice. To develop nursing students' understanding of fundamental nursing, the conceptual Fundamentals of Care framework has been integrated in nursing education at a School of Nursing in Denmark. DESIGN AND METHODS: Discursive paper using an adjusted descriptive case study design for describing and discussing the process of integrating the conceptual Fundamentals of Care Framework in nursing education. RESULTS: The process of integrating the Fundamentals of Care framework is illuminated through a description of the context, in which the process occurs including the faculty members, lectures, case-based work and simulation laboratory in nursing education. Based on this description, opportunities such as supporting a holistic approach to an evidence-based integrative patient care and challenges such as scepticism among the faculty are discussed. CONCLUSION: It is suggested how integration of Fundamentals of Care Framework in lectures, case-based work and simulation laboratory can make fundamental nursing care more explicit in nursing education, support critical thinking and underline the relevance of evidence-based practice. The process relies on a supportive context, a well-informed and engaged faculty, and continuous reflections on how the conceptual framework can be integrated. RELEVANCE TO CLINICAL PRACTICE: Integrating the Fundamentals of Care framework can support nursing students' critical thinking and reflection on what fundamental nursing care is and requires and eventually educate nurses in providing evidence-based fundamental nursing care.

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.

Newly graduated nurses' use of knowledge sources: a meta-ethnography.

AIM: To advance evidence on newly graduated nurses' use of knowledge sources. BACKGROUND: Clinical decisions need to be evidence-based and understanding the knowledge sources that newly graduated nurses use will inform both education and practice. Qualitative studies on newly graduated nurses' use of knowledge sources are increasing though generated from scattered healthcare contexts. Therefore, a metasynthesis of qualitative research on what knowledge sources new graduates use in decision-making was conducted. DESIGN: Meta-ethnography. DATA SOURCES: Nineteen reports, representing 17 studies, published from 2000-2014 were identified from iterative searches in relevant databases from May 2013-May 2014. REVIEW METHODS: Included reports were appraised for quality and Noblit and Hare's meta-ethnography guided the interpretation and synthesis of data. RESULTS: Newly graduated nurses' use of knowledge sources during their first 2-year postgraduation were interpreted in the main theme 'self and others as knowledge sources,' with two subthemes 'doing and following' and 'knowing and doing,' each with several elucidating categories. The metasynthesis revealed a line of argument among the report findings underscoring progression in knowledge use and perception of competence and confidence among newly graduated nurses. CONCLUSION: The transition phase, feeling of confidence and ability to use critical thinking and reflection, has a great impact on knowledge sources incorporated in clinical decisions. The synthesis accentuates that for use of newly graduated nurses' qualifications and skills in evidence-based practice, clinical practice needs to provide a supportive environment which nurtures critical thinking and questions and articulates use of multiple knowledge sources.