Untenable Expectations: Nurses' Work in the Context of Medication Administration, Error, and the Organization.

We explored nurses' work in the context of medication administration, errors, and the organization. Secondary analysis of ethnographic data included 92 hours of non-participant observation, and 37 unstructured interviews with nurses, administrators, and pharmacists. Think-aloud observations and analysis of institutional documents supplemented these data. Findings revealed the nature of nurses' work was characterized by chasing a standard of care, prioritizing practice, and renegotiating routines. The rich description identified characteristics of nurses' work as cyclical, chaotic and complex shattering studies that explained nurses' work as linear. A new theoretical model was developed, illustrating the inseparability of nurses' work from contextual contingencies and enhancing our understanding of the cascading components of work that result in days that spin out of the nurses' control. These results deepen our understanding why present efforts targeting the reduction of medication errors may be ineffective and places administration accountable for the context in which medication errors occur.

Developing the Resilience Framework for Nursing and Healthcare.

Despite four decades of resilience research, resilience remains a poor fit for practice as a scientific construct. Using the literature, we explored the concepts attributed to the development of resilience, identifying those that mitigate symptoms of distress caused by adversity and facilitate coping in seven classes of illness: transplants, cancer, mental illness, episodic illness, chronic and painful illness, unexpected events, and illness within a dyadic relationship. We identified protective, compensatory, and challenge-related coping-concept strategies that healthcare workers and patients use during the adversity experience. Healthcare-worker assessment and selection of appropriate coping concepts enable the individual to control their distress, resulting in attainment of equanimity and the state of resilience, permitting the resilient individual to work toward recovery, recalibration, and readjustment. We inductively developed and linked these conceptual components into a dynamic framework, The Resilience Framework for Nursing and Healthcare, making it widely applicable for healthcare across a variety of patients.

Nurse-Delivered Telephone Intervention to Reduce Oral Mucositis and Prevent Dehydration.

PROBLEM STATEMENT: This study evaluates the feasibility of a nurse-delivered telephone intervention to reduce oral mucositis severity and prevent dehydration in patients with lung or head and neck cancer undergoing chemotherapy and radiation therapy. DESIGN: This study used a two-phase, qualitatively driven, mixed-methods descriptive design. DATA SOURCES: 11 participants were recruited from an academic cancer center in southern Florida. Participants received symptom management education followed by twice-weekly tailored nurse coaching telephone calls. ANALYSIS: Questionnaires measuring symptom severity, health-related quality of life, perceived self-efficacy, and symptom self-management were administered at four data points. Data on unscheduled medical visits were collected. Guided interviews were conducted four weeks post-treatment and analyzed qualitatively using content analysis. FINDINGS: Participants found the intervention to be acceptable. Oral mucositis symptom severity was minimized, and dehydration was avoided. The intervention enabled symptom self-management and improved perceived self-efficacy. IMPLICATIONS FOR PRACTICE: Emotional support provided by the nurse was crucial, exemplifying improvement over an automated system.

Anemia Management in Rural Haitian Children: A Mixed Methods Study.

INTRODUCTION: We examined factors influencing anemia outcomes in rural children following implementation of a prevention program. METHOD: Mixed methods study of children, parents, and clinicians utilized statistical modeling and content/ethnographic analysis. Retrospective chart abstraction evaluated treatments administered and measured hemoglobin in children aged 6 to 59 months (n = 161). Prospective interviews/questionnaires examined parent (n = 51) and clinician (n = 19) perceptions. RESULTS: Anemia prevalence decreased by 21.2%. Predictors of increased hemoglobin were clinic visit number and age at first visit. Once anemia improved, children were likely to remain improved (P = .65). Despite favorable program perceptions, stakeholders emphasized ecological barriers, including social disadvantage and local practices. DISCUSSION: Socioeconomic factors prevented guideline concordant behaviors. Persistent attention to intrapersonal, interpersonal, and community social determinants is a sine qua non for successfully managing the epidemic. The first step to provide culturally congruent care is to explicitly acknowledge that guideline-concordant behaviors are often complex.

Theoretical Coalescence: A Method to Develop Qualitative Theory: The Example of Enduring.

BACKGROUND: Qualitative research is frequently context bound, lacks generalizability, and is limited in scope. OBJECTIVES: The purpose of this article was to describe a method, theoretical coalescence, that provides a strategy for analyzing complex, high-level concepts and for developing generalizable theory. Theoretical coalescence is a method of theoretical expansion, inductive inquiry, of theory development, that uses data (rather than themes, categories, and published extracts of data) as the primary source for analysis. Here, using the development of the lay concept of enduring as an example, I explore the scientific development of the concept in multiple settings over many projects and link it within the Praxis Theory of Suffering. METHODS: As comprehension emerges when conducting theoretical coalescence, it is essential that raw data from various different situations be available for reinterpretation/reanalysis and comparison to identify the essential features of the concept. The concept is then reconstructed, with additional inquiry that builds description, and evidence is conducted and conceptualized to create a more expansive concept and theory. RESULTS: By utilizing apparently diverse data sets from different contexts that are linked by certain characteristics, the essential features of the concept emerge. Such inquiry is divergent and less bound by context yet purposeful, logical, and with significant pragmatic implications for practice in nursing and beyond our discipline. CONCLUSION: Theoretical coalescence is a means by which qualitative inquiry is broadened to make an impact, to accommodate new theoretical shifts and concepts, and to make qualitative research applied and accessible in new ways.

The Paradox of Safety in Medication Management.

The reduction of medication errors is largely dependent upon the structure of the medication management system and the role of the pharmacist in the acute care setting. The significance of this claim became evident in an ethnographic study of nurses' work in which data were generated from extensive observations, formal interviews, and document reviews. Each step of medication management-from ordering to administering-was microanalyzed, and spaces and places for error emerged. Results revealed medication errors defined by proximity to the patient. Pharmacists became a surprising "stop-gap" between the physicians and patients in the recognition and interception of medication errors occurring far removed from the bedside and did not formally support the reporting of these errors. Understanding the complexity of this process and the roles of involved personnel reminds us that there is presently no fool-proof plan for the reduction of medication errors and implies a culture of safety remains elusive.

Preserving Self: Theorizing the Social and Psychological Processes of Living With Parkinson Disease.

The purpose of this constructivist grounded theory article is to identify, explore, and theorize the social and psychological processes used by people with Parkinson disease. Analytic procedures generated the five-stage theory of Preserving self of people with Parkinson disease: (a) making sense of symptoms, (b) defining turning points, (c) experiencing identity dilemmas, (d) reconnecting the self, and (e) envisioning a future. Reminders of former selves and capabilities were painful; participants desperately sought normalcy. Participants developed creative methods for maintaining independence but frequently overestimated their abilities and took risks. Participants were 15 men and 10 women (ages 40-95), most of whom lived with their families. Disease status was ascertained through medication logs and two scales: Hoehn and Yahr staging and Activities of Daily Living. Data included 62 in-depth interviews, nonparticipant observation, and participant photos, videos, and related documents. Recommendations were derived from the theory to support processes of Preserving Self as interventions designed to reduce the loss of self and to enhance Preserving self. These recommendations included developing relationships, teaching expected and unexpected feelings and behaviors, and involvement with sensory integrating activities.

Psychosocial Response to New-Onset Diabetes as a Long-Term Effect of Allogeneic Hematopoietic Stem Cell Transplantation.

Currently, little information is available to guide health care practitioners on how to facilitate positive outcomes in individuals who develop new-onset diabetes after allogeneic hematopoietic stem cell transplantation (allo HSCT) for treatment of hematological cancers. Results from this constructivist grounded theory study provide a theoretical framework explaining the psychosocial process of change that middle-age and older adults experience when developing new-onset diabetes in this context. Two predominant factors influenced this change: treatment burden and perception of diabetes. Key findings were that participants with ongoing complications, primarily graft-versus-host disease, experienced a high degree of treatment-related burden and unclear perceptions of diabetes when compared with those with no or few post-allo-HSCT complications. These factors limited their capacity to positively respond to and self-manage their condition. Implications for practice are to thoroughly consider these two factors when developing patient-centered interventions for middle-age and older adults with new-onset diabetes after allo HSCT.

Eliciting the Functional Processes of Apologizing for Errors in Health Care: Developing an Explanatory Model of Apology.

The purpose of this article was to analyze the concept development of apology in the context of errors in health care, the administrative response, policy and format/process of the subsequent apology. Using pragmatic utility and a systematic review of the literature, 29 articles and one book provided attributes involved in apologizing. Analytic questions were developed to guide the data synthesis and types of apologies used in different circumstances identified. The antecedents of apologizing, and the attributes and outcomes were identified. A model was constructed illustrating the components of a complete apology, other types of apologies, and ramifications/outcomes of each. Clinical implications of developing formal policies for correcting medical errors through apologies are recommended. Defining the essential elements of apology is the first step in establishing a just culture in health care. Respect for patient-centered care reduces the retaliate consequences following an error, and may even restore the physician patient relationship.

The Changing Nature of Guilt in Family Caregivers: Living Through Care Transitions of Parents at the End of Life.

Older adults cared for at home by family members at the end of life are at risk for care transitions to residential and institutional care settings. These transitions are emotionally distressing and fraught with suffering for both families and the older adult. A theoretical model titled "The Changing Nature of Guilt in Family Caregivers: Living Through Care Transitions of Parents at the End of Life" was developed using the method of grounded theory. When a dying parent cannot remain at home to die, family members experience guilt throughout the transition process. Findings indicated that guilt surrounding transfers escalated during the initial stages of the transfer but was mitigated by achieving what family members deemed as a "good" death when relatives were receiving hospice care. The findings of this interpretative approach provide new insights into family-focused perspectives in care transfers of the dying.

Application of mixed-methods research in clinical practice

Nursing is a discipline that traditionally considers the whole person and, following this mandate, nursing research is also considered to have a holistic perspective. Yet research methods demanded that the researcher focus on some part of the person­to quantitatively measure some biological, psychological, or social aspect of the persons, or to qualitatively describe an experience within the context of the family, work or illness. Mixed-methods design overcomes this imitations, and expands the scope of the research considerably, for now nurses can do both. We can both measure and describe the experience in the same project.

Using qualitative methods to access the pain experience.

Qualitative methods provide us with techniques to access the pain experience of patients in ways that provide explanation for apparent contradictions and idiosyncrasies that are difficult to access. In this article, I review three such strategies and the application of qualitative research to practice: (1) the analysis of the ways participants speak about agonizing pain using narrative inquiry, (2) comparisons of childbirth pain in two cultural groups using ethnography and (3) present a qualitative theory, the Praxis Theory of Suffering. This theory provides a theoretical explanation for behaviours that presently confound the understanding of distress using the Distress Thermometer. An alternative approach, 'reading' patients' behavioural manifestations of distress, is recommended.

Effects of bed height on the biomechanics of hospital bed entry and egress.

BACKGROUND: Although a significant proportion of patient falls in hospitals occur in the vicinity of the hospital bed, little is known about the contribution of bed height to fall risk. OBJECTIVE: To compare lower extremity joint torques and angles during hospital bed entry and egress at two bed heights. METHODS: Twelve adults (age > 55) were purposively selected and had variety of strength and mobility limitations. Biomechanical data for this pilot study were collected with three digital video cameras and processed to obtain estimates for joint torques and included angles. RESULTS: At the low bed height, hip torque for bed entry was significantly higher, and hip, knee, and ankle flexion angles were significantly smaller. The absence of significant differences in knee and ankle torques were the result of a compensation strategy that shifts the center of mass forward by flexing the torso during low bed ingress. Torque data from the egress motion were similar, however 50% of participants were unable to rise from the low bed without assistance. CONCLUSIONS: Healthcare providers should be aware that low bed heights pose safety risks to the population for which they were designed-elderly persons at high risk for falling.

Critical Analysis of Strategies for Determining Rigor in Qualitative Inquiry.

Criteria for determining the trustworthiness of qualitative research were introduced by Guba and Lincoln in the 1980s when they replaced terminology for achieving rigor, reliability, validity, and generalizability with dependability, credibility, and transferability. Strategies for achieving trustworthiness were also introduced. This landmark contribution to qualitative research remains in use today, with only minor modifications in format. Despite the significance of this contribution over the past four decades, the strategies recommended to achieve trustworthiness have not been critically examined. Recommendations for where, why, and how to use these strategies have not been developed, and how well they achieve their intended goal has not been examined. We do not know, for example, what impact these strategies have on the completed research. In this article, I critique these strategies. I recommend that qualitative researchers return to the terminology of social sciences, using rigor, reliability, validity, and generalizability. I then make recommendations for the appropriate use of the strategies recommended to achieve rigor: prolonged engagement, persistent observation, and thick, rich description; inter-rater reliability, negative case analysis; peer review or debriefing; clarifying researcher bias; member checking; external audits; and triangulation.