From educator to facilitator: Healthcare professionals' experiences of, and views about, delivering a type 1 diabetes structured education programme (DAFNEplus ) informed by behavioural science.

AIMS: The DAFNEplus programme incorporates behaviour change techniques into a modified educational intervention and was developed to help address the glycaemic drift observed amongst graduates of standard DAFNE programmes. As the programme's success will be contingent on staff buy-in, we explored healthcare professionals' experiences of, and views about, delivering DAFNEplus during a clinical trial to help inform decision making about rollout post-trial. METHODS: We interviewed n = 18 nurses and dieticians who delivered DAFNEplus during the trial. Data were analysed thematically. RESULTS: While many shared initial reservations, all described how their experiences of DAFNEplus programme delivery had had a positive, transformative impact upon their perceptions and working practices. This transformation was enabled by initial training and supervision sessions, the confidence gained from using scripts to support novel programme content delivery, and experiences of delivering the programme and observing DAFNEplus principles being well received by, and having a positive impact on, attendees. Due to these positive experiences, interviewees described a strongly felt ethical mandate to use some DAFNEplus techniques and curriculum content in routine clinical care. While being supportive of a national rollout, they anticipated a variety of attitudinal and logistical (e.g. workload) challenges. CONCLUSIONS: This study provides a vital dimension to the evaluation of the DAFNEplus programme. Interviewees found the intervention to be acceptable and expressed high levels of buy-in. As well as offering potential endorsement for a national rollout, our findings offer insights which could help inform development and rollout of future behaviour change interventions to support diabetes self-management.

Relational Quality Between the RN and Nursing Assistant: Essential for Teamwork and Communication.

OBJECTIVE: Nurse (RN) and nursing assistant (NA) relational quality was examined along with associations between relational quality and evaluations of teamwork and communication. BACKGROUND: RN and NA teams constitute the primary nursing care delivery method, and the quality of their relationship affects system capacity for improving patient outcomes; adverse events are linked to communication and teamwork breakdowns. METHODS: RN (N = 889) and NA (263) relational quality was examined using a cross-sectional secondary analysis from system assessment with the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. RESULTS: RN and NA perceived relational quality indicated significant differences in teamwork and safety grade ratings, with both groups reporting perceived teamwork as high when patient safety grade was low. CONCLUSIONS: This study supports the benefits of improving the RN-NA teamwork-communication relationship. An enhanced RN-NA relational quality can be used by nurse leaders to optimize patient care delivery outcomes.

Manager's influence on the registered nurse and nursing assistant relational quality and patient safety culture.

AIMS: The purpose of this study is to describe the perceptions of relational quality of the registered nurse and nursing assistant and examine how their view of the manager's influence impacts overall patient safety culture of a unit. BACKGROUND: The primary delivery of nursing care within acute care systems uses teams of registered nurses and nursing assistants. METHODS: A cross-sectional secondary analysis of data collected in the spring of 2018 using the Agency for Healthcare and Quality Hospital Survey of Patient Safety Culture and a seven-item questionnaire measuring relational quality was conducted. The sample included 1,152 responses. RESULTS: The manager influenced overall perceptions of safety regardless of the relational quality between the registered nurse and nursing assistant. CONCLUSIONS: This study found manager behaviours that promote patient safety and also influence overall perceptions of patient safety culture regardless of the relational quality between the registered nurse and nursing assistant. IMPLICATIONS FOR NURSING MANAGEMENT: Positive registered nurse and nursing assistant relational quality amplifies perceptions of patient safety culture, yet it is the manager's behaviours regarding safety that make the stronger contribution in building a culture of safety.

Getting work done: a grounded theory study of resident physician value of nursing communication.

Poor communication between nurses and physicians results in patient injury and increased healthcare costs. While multiple attempts have been made to improve communication between the two professions, evidence confirms little progress has been made. Previous research focused on standardizing communication processes and protocols between nurses and physicians rather than examining the relational component of these human interactions. The purpose of this study was to explore physician valuing of nursing communication in the context of patient care. Interviews were conducted with 15 internal medicine resident physicians. A constructivist grounded theory approach was used to develop the substantive theory of Getting Work Done. Getting Work Done incorporated three major categories: discerning the team, shifting communication, and accessing nurse knowledge and abilities. Hierarchical behaviors and language, and nurse collusion in both, characterized nurse-physician communication and situated the nurse outside the decision-making team. Complex work environments further devalued nurse-physician communication. Interprofessional education and practice must advance the unique and essential role of all health care professionals such that mutual valuing replaces hierarchical actions with collaborative systems for determining the most effective approaches to patient care.

Interventions to promote teamwork, delegation and communication among registered nurses and nursing assistants: An integrative review.

AIMS: To understand the strategies to influence patient outcomes by synthesizing existing evidence on effective interventions for teamwork, delegation and communication between registered nurses and nursing assistants. BACKGROUND: Three-quarters of deaths in hospitals are related to breakdowns in teamwork and communication. Acute care systems utilize teams of registered nurses and nursing assistants for primary delivery of nursing care. Research has been conducted to improve the partnership between the dyad. Literature reviews are needed to synthesize the effectiveness of delegation and communication interventions between registered nurses and nursing assistants on patient outcomes. METHODS: The authors applied Whittemore and Knafl's integrative review methodology to conduct an integrative review of the literature. Databases searched included Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed along with reference searches. Included articles were intervention studies related to teamwork, delegation or communication between registered nurses and nursing assistants, and published from 2000 to 2019. Methodological quality was assessed utilizing the Mixed Methods Appraisal Tool. The Systems Engineering Initiative for Patient Safety model 2.0 was applied as a guiding framework to analyse the findings. RESULTS: Seven articles met the inclusion criteria. The interventions in these articles focused on building a foundation of trust and respect through simulation, education and mindful communication. Four of the seven articles measured patient outcomes including patient falls, hospital-acquired pressure injuries and patient satisfaction. Three articles reported decreased patient falls, two articles reported increased patient satisfaction, while one article reported a reduction in pressure injury. Five of the studies reported improved teamwork and/or communication, and two studies reported improved job satisfaction. CONCLUSIONS: There has been limited research on the impact of the registered nurse-nursing assistant relationship on patient safety and care outcomes. The existing research demonstrates a need for interventions to foster a dynamic and effective relationship between registered nurses and nursing assistants. There is a need for more interventional studies linking improved teamwork, delegation and communication between the registered nurse and nursing assistant to patient outcomes such as falls and hospital-acquired pressure injury. IMPLICATIONS FOR NURSING MANAGEMENT: Several interventions exist to improve teamwork and communication between the registered nurse-nursing assistant dyad. Leaders need to assess their own culture and develop interventions to build and maintain high-functioning teams. Future research is necessary to develop interventions aimed at improving delegation from registered nurses to nursing assistants for applicable activities.

Leveraging the Power of Board Leadership in Professional Nursing Organizations.

Nurses who aspire to lead a professional nursing organization can significantly influence the future of the nursing profession. This article describes 4 essential responsibilities required in a board leadership position as identified by a group of nurse leaders who have each served as the board president of a national or international professional nursing organization.

Changing New Graduate Nurse Profiles and Retention Recommendations for Nurse Leaders.

OBJECTIVE: This study compares and contrasts new graduate nurse attributes and perceptions using findings from a 2010 study and a recent analysis of new graduate nurses participating in the same residency program. BACKGROUND: As millennials saturate the healthcare work environment, their unique views and needs will influence the evolution of new graduate nurse residencies. METHODS: This study used previously reported data on new graduate nurses between 1999 and 2009 and compared it with a secondary analysis of data collected on new graduate nurses between 2011 and 2016. RESULTS: This study provides evidence that millennial new graduate nurses' levels of commitment and satisfaction do not moderate turnover intentions in the 1st 2 years of practice as they did in the previous group of new graduate nurses. CONCLUSIONS: Job embeddedness, a construct that measures the likelihood of whether a person is going to stay, may be a better measurement among new graduate nurses than commitment or satisfaction because millennials, a generation that is predominant in current new graduate nurses, are more engaged than loyal.

Valuing breastfeeding: a qualitative study of women's experiences of a financial incentive scheme for breastfeeding.

BACKGROUND: A cluster randomised controlled trial of a financial incentive for breastfeeding conducted in areas with low breastfeeding rates in the UK reported a statistically significant increase in breastfeeding at 6-8 weeks. In this paper we report an analysis of interviews with women eligible for the scheme, exploring their experiences and perceptions of the scheme and its impact on breastfeeding to support the interpretation of the results of the trial. METHODS: Semi-structured interviews were carried out with 35 women eligible for the scheme during the feasibility and trial stages. All interviews were recorded and verbatim transcripts analysed using a Framework Analysis approach. RESULTS: Women reported that their decisions about infant feeding were influenced by the behaviours and beliefs of their family and friends, socio-cultural norms and by health and practical considerations. They were generally positive about the scheme, and felt valued for the effort involved in breastfeeding. The vouchers were frequently described as a reward, a bonus and something to look forward to, and helping women keep going with their breastfeeding. They were often perceived as compensation for the difficulties women encountered during breastfeeding. The scheme was not thought to make a difference to mothers who were strongly against breastfeeding. However, women did believe the scheme would help normalise breastfeeding, influence those who were undecided and help women to keep going with breastfeeding and reach key milestones e.g. 6 weeks or 3 months. CONCLUSIONS: The scheme was acceptable to women, who perceived it as rewarding and valuing them for breastfeeding. Women reported that the scheme could raise awareness of breastfeeding and encourage its normalisation. This provides a possible mechanism of action to explain the results of the trial. TRIAL REGISTRATION: The trial is registered with the ISRCTN registry, number 44898617 , https://www.isrctn.com.

Factors Facilitating Publication by Clinical Nurses in a Magnet® Hospital.

OBJECTIVE: This study examined the cognitive, behavioral, and environmental factors that facilitate publication by clinical nurses in Magnet® hospitals. BACKGROUND: The culture promoted by the Magnet Recognition Program® promotes nurses practicing in those settings to use, generate, and disseminate best practices. Successful and promising models of care and nursing practice are rarely disseminated beyond the organization where they are practiced. The questions persist: what barriers to writing for publication exist for clinical nurses, and how do we overcome them to advance emergent evidence? METHODS: A focused ethnographic, multiple-case study design examined 5 well-published nurses with high levels of dissemination occurring outside the Magnet organization where they were employed. RESULTS: Nurses in this study most often credited cognitive and behavioral factors for promoting publication. Although the organization encouraged peer-reviewed publication, there were limited environmental efforts to support efforts to publish in peer-reviewed journals by clinical nurses. CONCLUSIONS: The results of this case study call for more research on the multifaceted factors that promote publication by clinical nurses in the practice environment. Publication of research in peer-reviewed journals was supported by environmental influences of time to write, collaborative writing opportunities, and supportive and accurate guidance from editors.

Pregnancy and associated events in women receiving enzyme replacement therapy for late-onset glycogen storage disease type II (Pompe disease).

AIM: Glycogen storage disease type II (GSD II or Pompe disease; OMIM; 232 300) is a rare autosomal recessive lysosomal storage disorder resulting from deficiency of α-glucosidase and accumulation of glycogen in muscle. Clinical symptoms include weakness of skeletal and respiratory muscles and, in infants, cardiomyopathy. Patients with GSD II receive infusions of recombinant α-glucosidase (enzyme replacement therapy; ERT), which slow the progression of the disease. ERT is given to male and female patients of all ages but as yet little is documented on the effects of continuing ERT during pregnancy. The aim of this case series was therefore to ascertain the pregnancy outcomes of women with GSD II on ERT and to describe adverse events associated with pregnancy, delivery and therapy. METHODS: The medical records of eight women attending the Royal Free Hospital Lysosomal Storage Disorders Unit were reviewed. Four of the eight women had seven pregnancies over a period of 8 years. RESULTS: In this series GSD II was associated with interventional deliveries but normal neonates. Cessation of ERT in early pregnancy resulted in deterioration of maternal symptoms and emergence of allergic reactions on restarting ERT. CONCLUSION: Individualized care plans are required to ensure the best neonatal and maternal outcomes. Consideration should be given to the potential benefits to mother and fetus of continuing ERT during pregnancy.

Nursing Administration Research Priorities: Findings From a Delphi Study.

OBJECTIVE: The aim of this study is to determine the priorities for nursing administration research (NAR) in the United States. BACKGROUND: Previously known as the Council of Graduate Educators in Administrative Nursing, CGEAN provides an avenue for researchers and educators focused on NAR to partner, dialogue, obtain funding resources, and present their findings at a biennial International Nursing Administration Research Conference (INARC). In late 2013, with a goal of building consensus, CGEAN convened an INARC postconference to initiate the process of establishing critical NAR priorities for the future. METHODS: Data from a 3-staged Delphi study were used to identify relevant research topics and determine administrative research priorities. RESULTS: Eight final categories of NAR were determined. CONCLUSIONS: This study found economic valuing of nursing and designing effective future healthcare delivery systems to be high priorities for NAR.

Application of CGEAN's Research Priorities: PhD, DNP Scholarship.

The Accountable Care Act of 2010 is stimulating rapid transformations of healthcare systems. The shift from a focus on providing healthcare in a closed system to improving the health of communities demands rapid innovation by nurse leaders. Nurse leaders prepared at the doctorate of nursing practice level and PhD-prepared nursing health services researchers are needed to develop and evaluate best practices as they emerge. This column expands on the findings from CGEAN's Delphi study.

Revising the Scope and Standards for Nurse Administrators.

In the fall of 2013, the American Nurses Association began the process of redesigning the scope and standards for the nurse administrator. This article provides a synthesis of the top 10 changes in the new Scope and Standards for Nurse Administrators that are being reviewed for approval. These changes reflect the continuing evolution of practice for nurses serving as leaders across the United States.

Encouraging breastfeeding: financial incentives.

The NOSH (Nourishing Start for Health) three-phase research study is testing whether offering financial incentives for breastfeeding improves six-eight-week breastfeeding rates in low-rate areas. This article describes phase one development work, which aimed to explore views about practical aspects of the design of the scheme. Interviews and focus groups were held with women (n = 38) and healthcare providers (n = 53). Overall both preferred shopping vouchers over cash payments, with a total amount of £200-250 being considered a reasonable amount. There was concern that seeking proof of breastfeeding might impact negatively on women and the relationship with their healthcare providers. The most acceptable method to all was that women sign a statement that their baby was receiving breast milk: this was co-signed by a healthcare professional to confirm that they had discussed breastfeeding. These findings have informed the design of the financial incentive scheme being tested in the feasibility phase of the NOSH study.

Healthcare providers' views on the acceptability of financial incentives for breastfeeding: a qualitative study.

BACKGROUND: Despite a gradual increase in breastfeeding rates, overall in the UK there are wide variations, with a trend towards breastfeeding rates at 6-8 weeks remaining below 40% in less affluent areas. While financial incentives have been used with varying success to encourage positive health related behaviour change, there is little research on their use in encouraging breastfeeding. In this paper, we report on healthcare providers' views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle. This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster randomised controlled trial. METHODS: Fifty-three healthcare providers were interviewed about their views on financial incentives for breastfeeding. Participants were purposively sampled to include a wide range of experience and roles associated with supporting mothers with infant feeding. Semi-structured individual and group interviews were conducted. Data were analysed thematically drawing on the principles of Framework Analysis. RESULTS: The key theme emerging from healthcare providers' views on the acceptability of financial incentives for breastfeeding was their possible impact on 'facilitating or impeding relationships'. Within this theme several additional aspects were discussed: the mother's relationship with her healthcare provider and services, with her baby and her family, and with the wider community. In addition, a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women. CONCLUSION: Healthcare providers believe that financial incentives could have both positive and negative impacts on a mother's relationship with her family, baby and healthcare provider. When designing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted, while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low.

Nursing administration research: an evolving science.

The nature and focus of nursing administrative research have evolved over time. Recently, the research agenda has primarily reflected the national health policy agenda. Although nursing research has traditionally been dominated by clinical interests, nursing administrative research has historically addressed the interface of reimbursement, quality, and care delivery systems. This article traces the evolution of nursing administrative research to answer questions relevant to scope, practice, and policy and suggests future directions.

The prognostic ability of early Braden Q Scores in critically ill children.

BACKGROUND: Pressure ulcer (PU) risk assessment tools are an important component of good nursing care; however, it is essential that these tools offer a good sensitivity and specificity, in addition to clinical utility in the population being assessed. OBJECTIVES: The aim of this study was to examine how the lowest Braden Q score recorded in the first 24 h of paediatric intensive care unit admission related to the risk of PU development in an English PICU (paediatric intensive care unit). METHODS: A retrospective cohort study was undertaken over 12 months in a single PICU in the North West of England. 891 critically ill children with a Braden Q score were evaluated. The lowest Braden Q score within the first 24 h of PICU admission was matched to reported PU development and grade. RESULTS: The Braden Q score was found to perform well in children aged 3 weeks to 8 years without congenital heart disease (CHD), which is the population it was validated on. At a cut off score of ≤16 it yielded a sensitivity of 100% specificity of 73.1%, positive predictive value (PPV) 2.56 and a negative predictive value (NPV) of 100 and an area under the curve (AUC) of 0.87(0.75-0.98). When used in other age groups and when it included children with CHD, it performed less well with lower AUC and wider confidence intervals, but it performed moderately well in the group of term to 14 years with a sensitivity of 75% specificity of 72.6%, PPV 1.5 and a NPV of 99.8 and AUC of 0.74 (0.49-0.98). CONCLUSION: Our results in a heterogeneous UK PICU population found the Braden Q score performed well in the specific population it was validated for (PICU children aged 3 weeks to 8 years without CHD), however, it performed moderately well in the more heterogonous PICU population of term to 14 years including children with CHD.

Long-term benefits and adverse effects of intermittent versus daily glucocorticoids in boys with Duchenne muscular dystrophy.

OBJECTIVE: To assess the current use of glucocorticoids (GCs) in Duchenne muscular dystrophy in the UK, and compare the benefits and the adverse events of daily versus intermittent prednisolone regimens. DESIGN: A prospective longitudinal observational study across 17 neuromuscular centres in the UK of 360 boys aged 3-15 years with confirmed Duchenne muscular dystrophy who were treated with daily or intermittent (10 days on/10 days off) prednisolone for a mean duration of treatment of 4 years. RESULTS: The median loss of ambulation was 12 years in intermittent and 14.5 years in daily treatment; the HR for intermittent treatment was 1.57 (95% CI 0.87 to 2.82). A fitted multilevel model comparing the intermittent and daily regiments for the NorthStar Ambulatory Assessment demonstrated a divergence after 7 years of age, with boys on an intermittent regimen declining faster (p<0.001). Moderate to severe side effects were more commonly reported and observed in the daily regimen, including Cushingoid features, adverse behavioural events and hypertension. Body mass index mean z score was higher in the daily regimen (1.99, 95% CI 1.79 to 2.19) than in the intermittent regimen (1.51, 95% CI 1.27 to 1.75). Height restriction was more severe in the daily regimen (mean z score -1.77, 95% CI -1.79 to -2.19) than in the intermittent regimen (mean z score -0.70, 95% CI -0.90 to -0.49). CONCLUSIONS: Our study provides a framework for providing information to patients with Duchenne muscular dystrophy and their families when introducing GC therapy. The study also highlights the importance of collecting longitudinal natural history data on patients treated according to standardised protocols, and clearly identifies the benefits and the side-effect profile of two treatment regimens, which will help with informed choices and implementation of targeted surveillance.

Detecting meaningful change using the North Star Ambulatory Assessment in Duchenne muscular dystrophy.

AIM: Clinician-reported outcome instruments such as the North Star Ambulatory Assessment (NSAA) need to be able to detect clinically important change to be suitable for clinical trials. However, in Duchenne muscular dystrophy (DMD), identifying changes in function is not straightforward. In this study, we use Rasch-transformed data to examine the responsiveness and minimal important difference (MID) of the NSAA in males with DMD receiving different corticosteroid regimes. METHOD: NSAA data were examined from 198 males (mean age at assessment was 8 y 6 mo [SD 2 y 6 mo] range 4 y-18 y; 805 assessments). Responsiveness was assessed using mean score changes (using Rasch-transformed data) between adjacent pairs of age groups, pairwise squared t-values from paired samples t-tests, and an effect size calculation. The MID was assessed using the effect size calculation and 0.5 standard deviation (SD) of mean score differences. RESULTS: Our findings revealed a difference in change scores over time between the two corticosteroid regimes. Mean NSAA person estimates were higher in the daily prednisolone group. The mean MID (0.5 SD) was 8.8 and 6.9 for the daily group and intermittent group respectively. INTERPRETATION: This study, based on Rasch-transformed NSAA data, provides an initial basis for the interpretation of clinical change in DMD over time and between corticosteroid regimes. Our proposed MIDs can be mapped back to differences in specific item content across the range of the NSAA.

Increasing the intensity of nursing leadership: graduate preparation for nurse leaders.

The numbers of nurses holding formal leadership and management positions without baccalaureate preparation are disheartening. The 2008 National Sample Survey reported that approximately one-half of nurses in manager and above positions hold less than a bachelor's degree. The formal preparation of nurse leaders is critical for continued progress in advancing patient safety and quality as well as promoting innovative models of care delivery. Helping nurses in leadership positions, especially where the expectation does not already exist to have such educational preparation, is a challenge that the profession must address.