Surgical nurses' perceptions and experiences of a medications and oral restrictions policy change: A focus group study.

AIMS AND OBJECTIVES: To explore the perceptions and experiences of surgical nurses before and after introducing the Medications and Oral Restrictions Policy (the Policy). BACKGROUND: The Policy was developed following extensive consultation, and evidence-based strategies were considered for its implementation. However, it is possible uptake did not meet expectations. DESIGN: Focus group interviews. METHODS: Three focus groups were conducted in November 2015 around 'what worked, what didn't and why, before and after hospital-wide implementation of the Policy.' Data were coded and analysed using an inductive-deductive thematic analysis approach. The COREQ checklist guided reporting. RESULTS: The three groups consisted of 16, 14 and six surgical nurses. Before the Policy, there was confusion, lack of clarity and guidance, and lack of experience and confidence in managing medications when patients had oral restrictions. After the Policy rollout, there was a sense of 'knowing what to do' because of improved clarity and decision support; but there were also problems with: not everyone knowing about the policy, particularly due to staff movement and turnover; and, individual interpretation of the policy including use of its signs outside of context, and decision-making processes. CONCLUSION: Exploration of nurses' perceptions of a medication-related policy change found that while the Policy provided clarity and decision support for some, it made little difference for others. Limited reach of the policy was an issue despite an effort to address this at the outset, as well as variations in interpretation of the policy and subsequent decision-making. RELEVANCE TO CLINICAL PRACTICE: How individuals interpret information and their understanding of the context behind the policy or guideline may affect implementation and should be considered alongside other barriers when implementing medication-related initiatives. Furthermore, implementation strategies that are independent of ongoing resources and/or key champions to sustain should be prioritised for all initiatives.

Improving communication of the daily care plan in a teaching hospital intensive care unit.

BACKGROUND: Patients admitted to intensive care units have complex care needs. Accordingly, communication and handover of the medical care plan is very important. OBJECTIVE: To assess changes in ICU nurses' understanding of the medical daily care plan after development and implementation of a pro forma to improve documentation and communication of the plan. DESIGN, SETTING AND PARTICIPANTS: The study was conducted between February and November 2012 in a mixed medical-surgical, 18-bed, closed ICU in a teaching hospital. Baseline and post-intervention surveys assessed ICU bedside nurses' self-reported understanding of elements of the daily care plan. INTERVENTION: After receiving input from bedside nurses and medical staff, we developed the daily care plan as a single-page pro forma for handwritten documentation of a clinical problems list, plan and interventions list, daily chest x-ray results, a modified FAST-HUG checklist, and discharge planning during the evening consultant ward round. The finalised pro forma was introduced on 25 July 2012. RESULTS: Introduction of the pro forma daily care plan was associated with marked and statistically significant improvements in nurses' self-reported understanding of a list of the patient's clinical problems, the management plan after the ward round, issues for discharge for the following day (all P < 0.001) and, to a lesser extent, the physiological targets and aims (P = 0.003) and interpretation of the daily chest x-ray (P < 0.001). In the post-intervention survey, only 4/118 free-text comments (3.4%) suggested that documentation of the plan was doctor-dependent, compared with 28/198 (14.1%) at baseline (P = 0.002). CONCLUSIONS: Introduction of a single-page, handwritten, structured daily care plan produced marked improvements in ICU nurses' self-reported understanding of elements of the medical plan, and may have reduced practice variation in medical plan documentation. The effects of this intervention on patient outcomes remain untested.