Gerontological nursing: professional priority or eternal Cinderella?

Over thirty years ago geriatric nursing, as it was then called, was at the forefront of nursing research in the United Kingdom. Concurrent with the emergence of geriatric medicine as a distinct speciality, the pioneering study of Doreen Norton and colleagues (Norton et al. 1962) served to highlight both the deficits that existed in the hospital care of older people and the enormous potential of nursing to improve the situation, particularly for the ‘irremediable’ patient (Norton 1965). Caring for those who could not be cured but required on-going support was seen to constitute ‘true nursing’ and was identified as an area of practice in which nurses should excel (Norton 1965, Wells 1980). Such potential went largely unrealised, however, as nursing focused on acute, hospital-based care (Nolan 1994). As a consequence, those working in continuing care struggled to find value in their work and patients were subjected to ‘aimless residual care’ (Evers 1991), a situation exacerbated by the continued application of the biomedical model (Reed and Watson 1994). Despite claims that nurses working with older people have ‘special skills’ (Royal College of Nursing 1993), the nature of such skills has therefore never fully been explicated. Indeed, Armstrong-Esther et al. (1994) asked what nurses currently contribute to the well-being of elderly people and, following their study, suggested that nurses must take the initiative and expand their role if ‘we are going to avoid simply warehousing the elderly until they die’. The need to act is particularly pressing at present as the spectre of ‘bed-blockers’ emerges once more and there is growing professional concern that older people may soon be denied the right to receive care from a qualified nurse (Nursing Times 1996)

Barriers to Timely Activation of Rapid Response Teams

Timely activation of the rapid response team (RRT) depends on the nurse\u27s willingness and ability to make a rapid decision. The practice-focused questions for this DNP project sought to identify barriers that contribute to delays in activating the RRT when needed in medical-surgical patients. The self-efficacy theory was the guiding theory and was used to examine self-confidence and performance along with Donabedian\u27s health care model. Qualitative data were obtained through focus groups and identified 2 prominent thematic barriers among nurses with less than 3 years\u27 experience: a lack of self-confidence and the of lack of knowledge and experience. Results of a chart review included 34 charts to determine if the RRT were called appropriately and were inconclusive. Finally, an 11 item survey with 9 demographic questions showed a statistically significant difference on the summed survey score between nurses with less than 3 years of experience and more tenured nurses, indicating a lack of perceived support, self-confidence, and knowledge among the nurses with less than 3 years of experience (Pearson chi square = 7.403 with 2 df and p = .025). Results were presented to leaders at the site and the recommendations resulting from these observations include the use of high-fidelity simulation education. Nurse educators and senior leadership from the medical surgical units agreed to accept the recommendations and proceed with developing an educational solution to address the barriers. Building knowledge, skills and self-confidence in nurses reduces the barriers to effective use of the RRT, and results in better outcomes for hospitalized medical-surgical patients, a positive social change

Development and validation of a questionnaire on nurses' knowledge and recognition of early signs of clinical deterioration

Introduction: There is evidence-based concern that nurses on general wards do not recognise signs of physiological and clinical deterioration and delay calling for more skilled assistance for review of a patient showing signs of deterioration. Aim: The development and validation of a questionnaire to assess factors influencing general ward nurses’ ability to recognise and respond to patient deterioration; nurses’ knowledge of physiological and clinical parameters associated with patient deterioration; and nurses’ self-reported clinical reasoning ability. Methodology: A mixed methods sequential 4-phase study design was employed: 1) an indepth literature review to identify and develop content domains and item statements for a prototype questionnaire; 2) determining the index of content validity (CVI) (n=5 expert registered professional nurses) of all item statements; 3) conducting cognitive interviews (n=3 expert registered professional nurses) to explore face validity and the quality of the revised prototype questionnaire; and 4) assessing stability of the final validated questionnaire through test-retest reliability testing (n=30 nurses: Registered Professional Nurses with four years of training, Enrolled Nurses with two years of training, Enrolled Nursing Auxiliaries with one year of training) two weeks apart. Results: The CVI exceeded the pre-set proportion of ≥70% agreement for 56/65 (86.2%) item statements scoring 3 (relevant only needing minor editing) or 4 (extremely relevant); removal of 3/65 (4.6%) items from the prototype questionnaire. Cognitive interviews then resulted in amendment of 30/78 (38.5%) item statements; removal of 2/78 (2.6%) from the revised prototype questionnaire. The weighted kappa statistic for level of agreement beyond chance for nurse respondents’ test-retest data was fair (0.21-0.4) for 18/47 (38.3%) items, moderate (0.41-0.6) for 12/47 (25.5%) items and substantial (0.61-0.8) for 13/47 (27.7%) items. Registered Professional Nurses’ responses between time 1 and time 2 were more consistent than for Enrolled Nurses and Nursing Auxiliaries. Conclusion and recommendations: The researcher-developed questionnaire was validated by registered professional nurses, but there is concern about its stability, tested on three categories of nurses. The questionnaire should be reassessed for content and face validity using a sample inclusive of all categories for nurses who take and interpret patients’ vital signs in an attempt to improve the reliability of the questionnaire

Development of a professional practice competency for undergraduate nursing students at a private catholic university in Western Australia: A mixed-method study

This research investigating professional student nursing practice occurred at a private Catholic university in Western Australia. The objects of this university articulate the provision of education in the context of Catholic faith and values. The objects are further expressed through the university’s 10 graduate attributes, which every student should have achieved by graduation. These attributes aim to foster and grow the qualities of ethical practice, interpersonal skills, professionalism, specialist knowledge and skills to support local and global communities. Suggested university strategies for attaining these attributes include undertaking high-quality work-integrated learning and building strong and mutually beneficial relationships with industry partners to successfully meet the future workforce needs of industry and society. However, it has been acknowledged by the School of Nursing and Midwifery that assessment of these attributes in the Bachelor of Nursing clinical practice program is vague and nonspecific. Additionally, it has been recognised by the school that the assessment of nursing professionalism as a standalone construct, which holds many common characteristics to the graduate attributes, is not present in the current student clinical placement assessment tool. Attainment of these graduate attributes and professionalism in nursing practice can only be ensured through appropriate assessment that guides student practice and learning. Nursing professionalism relates to the knowledge, skills, conduct, behaviour and attitudes of registered nurses when undertaking their role. The Nursing and Midwifery Board of Australia requires a registered nurse to practice all duties in a competent, safe, ethical and professional manner, adhering to the Registered Nurse Standards for Practice, Code of Conduct for Nurses and International Council of Nurses’ Code of Ethics. Difficulties related to the assessment of professionalism have been anecdotally described as resulting from the disparity between the meaning of the term ‘professionalism’ to nurses and how it is applied, assessed and measured in clinical practice. Professionalism is a well-recognised term in the nursing profession, with the literature describing many commonly accepted qualities and attributes of this. However, the perception of professionalism in clinical practice is varied, subjective and contextually based. Unprofessional conduct in the clinical setting is diametrically opposed to professionalism, and can be time consuming to manage and obstructive to patient-centred healthcare goals. In acknowledgement of these gaps in the school student assessment process, this study developed a professional practice competency to measure and assess this essential construct of nursing practice for Bachelor of Nursing students from a private Catholic university in Western Australia. It implemented an exploratory sequential mixedmethods approach with a two-phase design. Phase 1 used a Delphi panel to obtain consensus and face validity of criteria to measure nursing professionalism and the university graduate attributes. Phase 2 employed a table of specifications methodology, with clinical facilitators providing content validity for professional practice competency. It is envisaged that the developed professional practice competency, consisting of 33 statements, will assist undergraduate nursing students to gain valuable and timely insight into their own professional role and the university and clinical expectations, and subsequently allow adjustment and achievement of professional practice competency in a real-time context

Emergency nurses’ experiences of the implementation of early goal-directed fluid resuscitation therapy in the management of sepsis

Background: Severe sepsis is a life-threatening condition caused by the body’s overwhelming immune response to an infection. It can lead to organ failure and death if immediate treatment, such as intravenous (IV) fluids and antibiotics, are not commenced within the first hour. While a large number of studies have analysed the administration of first-dose antibiotics, the time-critical initiation of IV fluids has not always been given its deserved priority. To date, studies have not explored factors that inhibit timely IV fluid administration and the experience of emergency nurses relating to initiating early goal-directed fluid resuscitation (EGDFR). Purpose: To explore the experiences of emergency nurses related to initiating EGDFR in the care of patients with sepsis Methods: A qualitative exploratory approach, encompassing face-to-face semi-structured interviews, was used for data collection. Ten registered nurses were interviewed, who were currently practicing in emergency settings across New South Wales (NSW). Braun and Clarke’s (2006) thematic analysis framework guided the data analysis. Findings: Three themes and associated subthemes were identified. The three themes are (i) Nurses’ perceptions and experiences regarding IV fluid administration in sepsis, (ii) Challenges related to initiating IV fluid, and (iii) Strategies to improve compliance with EGDFR. Participants described various factors they found that inhibited timely initiation of IV fluids, including busyness of the department, delayed diagnosis of sepsis, complex patient presentations and limited scope of nurses’ practice to initiate IV fluids. Conclusion: It is anticipated that the outcomes of this research will provide an impetus for re-evaluating current protocol guidelines to provide a positive impact on the scope of emergency nurse practice for initiating EGDFR

The work of registered nurses and care assistants with older people in nursing homes: Can the outcomes be distinguished?

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.The need for Registered Nurses (RNs) in the long-term care of older people is being questioned, particularly in the context of nursing shortages, while suggestions for 'professionalising' Care Assistant (CA) roles are emerging. Despite ongoing debates about the importance of their work, research has so far been unable to provide an evidence-base for the outcomes of the work of either RNs or CAs in UK care homes. Using a multi-method interpretive approach, adopting a structure-process-outcome framework and grounded in the philosophical hermeneutics of Hans-Georg Gadamer, this qualitative research sought to illuminate the distinct contributions made by RNs and CAs to outcomes for older people in care homes. RNs and CAs from around the UK contributed 'significant' examples of their work for Phase 1 of the study and Phase 2 comprised researcher fieldwork (observation, interviews and documentary analysis) in three care homes around England. Participants included RNs, CAs, older residents, relatives, home managers and professionals working in the homes. The findings offer a rich and detailed analysis of the realities of the work, much of which takes place 'behind closed doors' and has been described to a limited extent in the literature. They suggest that the CAs' daily support helps residents to function and to feel valued, and that close, reciprocal, family-type relationships develop. The health knowledge and clinical expertise of good RNs is critical in determining residents' health outcomes, particularly in the long-term, and RNs' 24-hour 'perceptual presence' can make life or death differences in acute or emergency situations. RNs also influence the environment, atmosphere and quality of care in the home. In the context of the literature, the findings offer new insights into the role and contribution of RNs and CAs, the outcomes of their work and the priorities of residents. The study produced new models of RN and CA roles in care homes, encompassing dimensions not previously acknowledged in the literature or their job descriptions, and a new framework within which the outcomes of care for older people could be evaluated. The research offers a positive image of work with older people in independent sector care homes

Nurse Escorts’ Perceptions of Their Ability to Manage Patient Clinical Deterioration During Nurse-Led Inter-Hospital Ambulance Transfer in the Wheatbelt Region of Western Australia: A Mixed Methods Study

The Western Australia (WA) Country Health Service (WACHS) requires a ward or emergency department registered nurse (RN) to assume the responsibility of conducting inter-hospital nurse-led patient ambulance transfers. In WACHS, these nurses are usually generalist nurses with no specialised training. WACHS has various escalation policies, guidelines and support systems for nurses when they are located within the hospital and wards. However, despite these escalation protocols being clear in this setting, their relevance and practicality during patient transport is uncertain. This research explores how well equipped WACHS RNs in the Wheatbelt region of WA are in managing clinical deterioration of patients during inter-hospital nurse-led ambulance transfers. The WACHS Wheatbelt has identified ‘failure to recognise the need to escalate clinical care’ as a clinical risk in the in-hospital setting. The risk outlines knowledge and skills deficits, lack of access to specialist advice, failure to recognise observations that fall into the parameters that require intervention, and failure by nurses to follow clinical deterioration policy as causes that result in treatment delay, increased morbidity and mortality, delay in transfer, and increased length of stay. It should be appreciated that during road transfer there are additional factors that will increase the risk of failure to adequately detect and manage acute clinical deterioration. This study aims to • explore nurses’ perceptions about caring for a patient during road ambulance transfer, acknowledgement of clinical deterioration, and its occurrence on patients being transferred, and how well equipped the nurse escort is in detecting and managing acute deterioration; and • seek to support future policy formulation and decision-making with regard to nurses training, induction and ongoing education on inter-hospital transfer. This study employed a mixed methods descriptive design using quantitative and qualitative data obtained in two phases. In Phase One using an online survey, the study explored the self-reported skills level of the RNs, the support available during transport, their perceptions of their role and abilities during transport, and their confidence and knowledge to enact policies that govern their practice away from the hospital setting. In Phase Two, the nursing leaders and policy makers were interviewed on an individual face-to-face basis, where they were requested to clarify, elaborate or comment on the quantitative and qualitative data from Phase One. Phase One respondents acknowleged that nursing a patient in an ambulance had associated risks that require advanced clinical skills and confidence that would not normally be as critical when working within a hospital and with a team. Ambulance transfer logistics and inherent challenges require a trained patient escort. Respondents highlighted different practices, use of different guiding tools, and processes that were not uniformly applied within the region. This variation was evidenced in the different documentation kept by nurses during transfer, different interpretation of available policies, escalation processes for deterioration, and general attitude towards conducting these transfers. Inter-hospital patient transfers were viewed as complicated with associated risks, most of which were expected and cannot be completely eliminated. However, there was an acknowledgement that some of the factors that negatively affect these transfers could be eliminated by clearer guidelines and support for the transferring nurse. During Phase Two, a significant finding highlighted how the patient was in most instances safe, but the likely lack of support for the nurses due to ambiguity with inadequate backup was reaffirmed. Phase Two also confirmed that if strategies were to be put in place to guide, support and prioritise not only patient safety but also nurses’ welfare, then the model of using RNs to conduct inter-hospital nurse-led patient transfers would need to be sustainable and can be improved. This was important to note as it is unlikely that the RN will remain the most likely staff member to continue to meet the ever-growing demand to transfer patients intra-regionally and to metropolitan areas by road ambulance. There was a general appreciation that inter-hospital transfers are complex and that the WA rural health setting is unique and challenging. The generalist RN was viewed as having vital transferrable skills to adequately care for patients being transferred. These RNs were reported to be skilful and resilient in a setting where there is limited support for their personal wellbeing or professional development. The policies relating to inter-hospital patient transfers were assessed as unfamiliar, irrelevant or impractical, leading to disparities between what the policy stipulates and the realities of practice. This study will be critical in supporting health service discussions about policy formation and decision-making with regard to nurses’ training, induction, ongoing education and support in the ever-growing nurses’ responsibility of transferring patients between hospitals

‘Teleswallowing’: a case study of remote swallowing assessment

Purpose: Telemedicine has enabled speech and language therapists (SLTs) to remotely assess swallowing difficulties (dysphagia) experienced by nursing home residents. The new technique, “teleswallowing”, was designed by the Speech and Language Therapy Service at Blackpool Teaching Hospitals NHS Foundation Trust. It allows prompt assessment, avoiding potential risks of aspiration pneumonia, malnutrition, poor rehabilitation, increased hospital stays and reduced quality of life (Hinchey et al., 2005; Langmore et al., 1998). The purpose of this paper is to report on a second pilot of teleswallowing and the concomitant adoption study. Design/methodology/approach: The adoption study employed qualitative methods, including consultations with senior managers, semi-structured interviews with nursing home matrons/managers and nurses, two focus groups and semi-structured interviews with SLTs. The project clinical lead kept an activity log, which was used to estimate resource savings. Findings: Over a three-month period, six SLTs and 17 patients in five nursing homes participated in teleswallowing assessments. Teleswallowing benefited both patients and participating nursing homes. Better use of therapist time and cost savings were demonstrated and evidence showed that the service could be successfully scaled up. Despite this, a number of barriers to service transformation were identified. Originality/value: This is the first implementation of teleswallowing in the UK, but it has been used in Australia (Ward et al., 2012). The approach to engaging stakeholders to understand and address barriers to adoption is novel. The value lies in the lessons learned for future innovations

Simulation Use in Pre-Licensure Nursing Programs: Assuring Excellence in New Nurse Competence and Confidence

Purpose: This program evaluation project aims were to review the current state of simulation experiences in pre-licensure undergraduate nursing programs in Washington State and determine policy recommendations related to the future use of simulation experiences in clinical nursing education. The evaluation compared student outcomes of NCLEX pass rates associated with clinical simulation versus traditional clinical nursing experiences. Programs were evaluated for compliance with INACSL Simulation Standards of Best Practice. Conceptual Framework: The NLN/Jeffries Theory provided the framework for an analysis of program evaluation data regarding using the INASCL Simulation Standards of Best Practice. Design/Method: The study design was a descriptive mixed method using a compilation of survey questions from the National Council State Boards of Nursing (NCSBN) Survey of Simulation Use in Pre-licensure Nursing Program Changes and Advancements and the Program Assessment Survey for Simulation (PASS). Ten completed surveys provided data for qualitative and quantitative analysis. Results: Variation exists between nursing programs related to clinical hours per course. All programs offer a variety of simulation experiences as part of their pedagogy. Variation was also noted in program use of simulation activities substituted for traditional clinical hours, with 1:1 ratio being used when hours were substituted. All programs were aware of the INACSL Standards and were in varying stages of full implementation of those best practices. All programs met and most programs exceeded the minimum passing standard for NCLEX. Conclusions: The simulation experience of the past year of Covid 19 supports the role of simulation in substitution for traditional clinical hours at both 1:1 and 2:1 ratio