Documentation of diabetes care in home nursing service in a Swedish municipality: a cross-sectional study on nurses' documentation.

OBJECTIVES: To assess what was documented by Registered Nurses regarding diabetes care in a Swedish municipality's home nursing service; to what extent diabetes-related nursing actions were planned for, performed and evaluated according to the goals of metabolic control, treatment and prevention of complications. DESIGN: Cross-sectional study. SUBJECTS: Registered Nurses' documentation of patients with diabetes mellitus (n=172). MAIN OUTCOME MEASURES: Number of recorded different nursing actions planned, performed and evaluated. RESULT: The overall standard of records was insufficient. Evaluation of blood glucose levels and metabolic control was documented in 61% of the records; weight was documented in 4% of the records. Blood pressure was recorded in 10%. Ongoing foot ulcers were documented in 21%. Patient education or actions to prevent foot ulcers was not recorded. Tablet and insulin administration were well recorded. The nursing process was not followed. STUDY LIMITATION: Updated medicine lists were missing in many files, this might have resulted in an underestimation of the number of included records. CONCLUSION: The Registered Nurses are responsible for a vulnerable patient group suffering from multi-organ disease unable to maintain their own diabetes self-care. Insufficient documentation may lead to impaired quality of care. We suggest that improved documentation routines include a structure of planning, performing and evaluation of metabolic control (blood glucose measurements, Hba1c, weight and nutrition status), complications (regular blood pressure measurements, protective foot care) and education of health care assistants in assisted diabetes self-care.

"This is nursing": nursing roles as mediated by precepting nurses during clinical practice.

In nursing education, it has been argued that professional socialization is facilitated by clinical experiences where students work together with precepting nurses. However, few studies found have focused on how nurses think and act as preceptors, hence providing a base for professional socialization to occur. Therefore; this study aimed to describe how preceptors mediated nursing as a profession to undergraduate nursing students during clinical practice. This was an ethnographic study guided by symbolic interactionism. A purposeful sampling of 13 precepting nurses was observed during the field work period. In addition, 16 staff nurses, purposively selected, and experienced in precepting, participated in focus group interviews. All text from field notes and interviews were read as a whole and analyzed following the ethnographic approach. Findings illustrated how nursing was mediated as the medical-technical, the administrative, and the caring role. Preceptors aimed for professionalism in their students by teaching the students to reflect on what they can do independently as nurses. Preceptors strived to verbalise their practical knowledge to make theory explicit and contextualize to student nurses. This knowledge can guide implementation of preceptor programmes focusing on the meaning and implications of professionalism.

Time to precept: supportive and limiting conditions for precepting nurses.

AIM: This paper is a report of a study describing conditions for precepting in a Swedish clinical context from the perspective of precepting nurses. BACKGROUND: Clinical practice is a complex part of nursing education, and registered nurses who are acting as preceptors for nursing students face a number of challenges that need to be addressed during the precepting process. METHOD: An ethnographic approach guided by symbolic interactionism was used. Data were collected by participant observation and focus group interviews over a ten-month period in 2006-2007. Participants were selected by purposive sampling of 13 staff nurses who were preceptors during the field work period. In addition, 16 staff nurses, experienced in precepting, were purposively selected for four focus groups. FINDINGS: Precepting was found to be a complex function for nurses, influenced by conditions that could be both supportive and limiting in nature. Three themes described these conditions: organization, comprising clinical responsibilities and routines; collaboration, focusing on professional relations and interactions; and the personal perspective, comprising preceptors' experiences, need for feed back and notions of benefits. Time as a limiting condition reappeared through all categories. CONCLUSION: It is important to raise the issue of time and its impact on the precepting process. Precepting needs to be further discussed in terms of an integrated nursing competence prioritized by all stakeholders involved in clinical practice. Therefore; efforts should be made to plan nurses' clinical work so that allocated time for precepting can be facilitated.

Pedagogical strategies used in clinical medical education: an observational study.

BACKGROUND: Clinical teaching is a complex learning situation influenced by the learning content, the setting and the participants' actions and interactions. Few empirical studies have been conducted in order to explore how clinical supervision is carried out in authentic situations. In this study we explore how clinical teaching is carried out in a clinical environment with medical students. METHODS: Following an ethnographic approach looking for meaning patterns, similarities and differences in how clinical teachers manage clinical teaching; non-participant observations and informal interviews were conducted during a four month period 2004-2005. The setting was at a teaching hospital in Sweden. The participants were clinical teachers and their 4th year medical students taking a course in surgery. The observations were guided by the aim of the study. Observational notes and notes from informal interviews were transcribed after each observation and all data material was analysed qualitatively. RESULTS: Seven pedagogical strategies were found to be applied, namely: 1) Questions and answers, 2) Lecturing, 3) Piloting, 4) Prompting, 5) Supplementing, 6) Demonstrating, and 7) Intervening. CONCLUSIONS: This study contributes to previous research in describing a repertoire of pedagogical strategies used in clinical education. The findings showed that three superordinate qualitatively different ways of teaching could be identified that fit Ramsden's model. Each of these pedagogical strategies encompass different focus in teaching; either a focus on the teacher's knowledge and behaviour or the student's behaviour and understanding. We suggest that an increased awareness of the strategies in use will increase clinical teachers' teaching skills and the consequences they will have on the students' ability to learn. The pedagogical strategies need to be considered and scrutinized in further research in order to verify their impact on students' learning.

Nurses' clinical reasoning concerning management of peripheral venous cannulae.

AIM: The aim was to describe nurses' clinical reasoning regarding peripheral venous cannulae management by focusing on the clinical information and circumstances considered during the decision-making process. BACKGROUND: On every shift nurses make several decisions, among others concerning the management of peripheral venous cannulae. Thrombophlebitis is a common complication associated with its use, although more severe complications can arise. There are clinical practice guidelines within the area, but they are not always adhered to. Previous studies have examined decisions related to the management of peripheral venous cannulae, but did not include observations in a naturalistic setting. DESIGN: A qualitative study combining observations and interviews. METHODS: Participant observation facilitated open interviews about the clinical reasoning behind decision-making in observed situations, as well as semi-structured interviews regarding clinical reasoning about the general management of peripheral venous cannulae. Transcribed interview texts were analysed with content analysis. RESULTS: Three main categories describe clinical information and circumstances: the individual patient situation, the nurse's work situation and experience of peripheral venous cannulae management. The overall theme of the interview texts was that the clinical reasoning was a balancing act between minimising patient discomfort and preventing complications from the peripheral venous cannulae. CONCLUSIONS: At all times the patients' well-being was considered, but the ways the nurses approached this differed depending on how they considered clinical information in the individual patient situation, circumstances in their own work situation and their experience of peripheral venous cannulae management. RELEVANCE TO CLINICAL PRACTICE: Knowledge of the clinical information and circumstances considered in naturalistic settings, is valuable when implementing and adjusting clinical practice guidelines to local settings. This knowledge is also useful in nursing education as student nurses' and nurses' ability to balance between preventing complications and avoiding discomfort is important for enhancing patient care.

Obtaining a foundation for nursing care at the time of patient admission: a grounded theory study.

The nursing process can be viewed as a problem-solving model, but we do not know whether use of the whole process including care plans with interventions based on nursing diagnoses improves nurses' ability to carry out assessments. Therefore, the aim of this study was to illuminate and describe the assessment and decision-making process performed by nurses who formulated individual care plans including nursing diagnosis, goals and interventions or who used standardized care plans when a patient was admitted to their ward for care, and those who did not. Data collection and analysis were carried out by means of Grounded theory. Nurses were observed while assessing patients, after which they were interviewed. The main concern of all nurses was to obtain a foundation for nursing care based on four strategies; building pre-understanding, creating a caring environment, collecting information on symptoms and signs and performing an analysis from different perspectives. It appeared that the most important aspect for nurses who did not employ care plans was the medical reason for the patient's admission. The nurses who employed care plans discussed their decisions in terms of nursing problems, needs and risks. The results indicate that nurses who formulated care plans were more aware of their professional role.

Professional approaches in clinical judgements among senior and junior doctors: implications for medical education.

BACKGROUND: Clinical experience has traditionally been highly valued in medical education and clinical healthcare. On account of its multi-faceted nature, clinical experience is mostly difficult to articulate, and is mainly expressed in clinical situations as professional approaches. Due to retirement, hospitals in Scandinavia will soon face a substantial decrease in the number of senior specialist doctors, and it has been discussed whether healthcare will suffer an immense loss of experienced-based knowledge when this senior group leaves the organization. Both senior specialists and junior colleagues are often involved in clinical education, but the way in which these two groups vary in professional approaches and contributions to clinical education has not been so well described. Cognitive psychology has contributed to the understanding of how experience may influence professional approaches, but such studies have not included the effect of differences in position and responsibilities that junior and senior doctors hold in clinical healthcare. In the light of the discussion above, it is essential to describe the professional approaches of senior doctors in relation to those of their junior colleagues. This study therefore aims to describe and compare the professional approaches of junior and senior doctors when making clinical judgements. METHODS: Critical incident technique was used in interviews with nine senior doctors and nine junior doctors in internal medicine. The interviews were subjected to qualitative content analysis. RESULT: Senior and junior doctors expressed a variety of professional approaches in clinical judgement as follows: use of theoretical knowledge, use of prior experience of cases and courses of events, use of ethical and moral values, meeting and communicating with the patient, focusing on available information, relying on their own ability, getting support and guidance from others and being directed by the organization. CONCLUSION: The most prominent varieties of professional approaches were seen in use of knowledge and work-related experience. Senior doctors know how the organization has worked in the past and have acquired techniques with respect to long-term decisions and their consequences. Junior doctors, on the other hand, have developed techniques and expertise for making decisions based on a restricted amount of information, in relation to patients' wellbeing as well as organizational opportunities and constraints. This study contributes to medical education by elucidating the variation in professional approaches among junior and senior doctors, which can be used as a basis for discussion about clinical judgement, in both pre-clinical and clinical education. Further research is required to explain how these professional approaches are expressed and used in clinical education.

The importance of awareness of nursing students' denotative images of nursing.

The aim of this article is to describe the images that recent nursing students in Eurocentric culture have of nursing and discuss how these images can be used to highlight nurses' authority and autonomy in comparison with the medical profession. The empirical material consists of short narratives from 168 nursing students. Three themes emerged from the categories of answers: The Nurse as an Idealistic Helper, The Nurse as a Realistic Developer, and The Nurse as a Young Seeker. The essence of nursing could be traced in these themes even if a solid ground of nursing shows itself in changing forms. According to this study and previous research, nursing can be considered as a mummified occupation in its essence, given that the old values and stereotypes largely remain. The main motives for becoming a nurse are altruism, a desire for autonomy, and flexibility. To strengthen the profession, both teachers and clinical supervisors should use the students' images of nursing as a starting point in nursing education and develop them in different contexts.

Registered nurses' adherence to clinical guidelines regarding peripheral venous catheters: a structured observational study.

BACKGROUND: Peripheral catheterization is a common procedure, which affects numerous patients in health care today. Having peripheral venous catheters in situ might lead to complications such as thrombophlebitis and sepsis, and clinical guidelines have been developed to assist nurses in their decision-making. Several reasons are given for clinicians not always adhering to clinical guidelines, although such adherence might lead to fewer complications. AIMS: This paper aims to describe registered nurses' adherence to national and local guidelines on peripheral venous catheters by focusing on time in situ, site, size, and documentation at the dressing. An additional aim is to describe the thrombophlebitis frequency associated with peripheral venous catheters in situ. METHODS: Structured observational study of patients with peripheral venous catheters in situ, conducted from December 2004 to June 2005. Data of 343 peripheral venous catheters were analyzed. RESULTS: Nurses partly adhered to national and local guidelines concerning size and site. Guideline adherence concerning documentation at the dressing was low. The results showed that non-adherence pertaining to time in situ varied between 5% and 26.3%. Differences between adherence to national or local guidelines were shown for size, site, and documentation at the dressing. Mild thrombophlebitis (Grades 1 and 2) was observed in 7.0%. CONCLUSIONS: Nurses partly adhered to clinical guidelines. Differences in guideline adherence were observed for wards with local or national guidelines, as well as for wards with different specialities. In accordance with clinical guidelines, the nurses seemed to replace or remove peripheral venous catheters before any severe complications arose. IMPLICATIONS FOR PRACTICE, RESEARCH, AND MANAGEMENT: Adherence to clinical guidelines has an impact for preventing patient complications and thus it is essential that nurses are aware of their existence. Feedback and discussions of guideline adherence or of complication rates might influence nurses' clinical decision-making.