Improving the governance of patient safety in emergency care: a systematic review of interventions

OBJECTIVES: To systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.DESIGN: A systematic review of the literature.METHODS: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews and PsychInfo were searched for studies published between January 1990 and July 2014. We included studies evaluating interventions relevant for higher management to oversee and manage patient safety, in prehospital emergency medical service (EMS) organisations and hospital-based emergency departments (EDs). Two reviewers independently selected candidate studies, extracted data and assessed study quality. Studies were categorised according to study quality, setting, sample, intervention characteristics and findings.RESULTS: Of the 18 included studies, 13 (72%) were non-experimental. Nine studies (50%) reported data on the reliability and/or validity of the intervention. Eight studies (44%) reported on the feasibility of the intervention. Only 4 studies (22%) reported statistically significant effects. The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively.CONCLUSIONS: Characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in EMS organisations and EDs. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base

Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers

Objective To evaluate whether risk assessment scales can be used to identify patients who are likely to get pressure ulcers.Design Prospective cohort study.Setting Two large hospitals in the Netherlands.Participants 1229 patients admitted to the surgical, internal, neurological, or geriatric wards between January 1999 and June 2000.Main outcome measure Occurrence of a pressure ulcer of grade 2 or worse while in hospital.Results 135 patients developed pressure ulcers during four weeks after admission. The weekly incidence of patients with pressure ulcers was 6.2% (95% confidence interval 5.2% to 7.2%). The area under the receiver operating characteristic curve was 0.56 (0.51 to 0.61) for the Norton scale, 0.55 (0.49 to 0.60) for the Braden scale, and 0.61 (0.56 to 0.66) for the Waterlow scale; the areas for the subpopulation, excluding patients who received preventive measures without developing pressure ulcers and excluding surgical patients, were 0.71 (0.65 to 0.77), 0.71 (0.64 to 0.78), and 0.68 (0.61 to 0.74), respectively. In this subpopulation, using the recommended cut­off points, the positive predictive value was 7.0% for the Norton, 7.8% for the Braden, and 5.3% for the Waterlow scale.Conclusion Although risk assessment scales predict the occurrence of pressure ulcers to some extent, routine use of these scales leads to inefficient use of preventive measures. An accurate risk assessment scale based on prospectively gathered data should be developed

Patient perceptions and understanding of pressure ulcer risk in the community: Empirical Research Qualitative

Aims To explore patient perceptions and understanding of their pressure ulcer risk and how information is communicated between a nurse and patient in the home setting. Design A pragmatic qualitative research design including community-dwelling patients, who were deemed at risk of developing a pressure ulcer. Methods Observation of routine interactions between nurse and patient regarding their pressure ulcer risk and semi-structured interviews with 15 community patients following the nursing interaction. Results Four key overarching themes emerged from the data analysis that were related to patient perceptions and understanding of pressure ulcer risk. These included Pressure Ulcer Awareness, Importance of Repositioning, Healthy Eating and Risk Interpretation. Conclusion Patient perception and understanding of pressure ulcer risk is different from the scientific, professional view. Patient risk perception was based on heuristics and wider personal factors and social influences. Impact The study provides important new insights into clinical practice in relation to how pressure ulcer advice and information are provided and interpreted in the community setting. Reporting Method Adhered to the Standards for Reporting Qualitative Research (SRQR) Patient or Public Contribution A small selection of patients within the NHS Trust in which the research was conducted contributed to the design of the study, in particular some of the interview questions and timing

Development of an e-supported illness management and recovery programme for consumers with severe mental illness using intervention mapping, and design of an early cluster randomized controlled trial

Background: E-mental health is a promising medium to keep mental health affordable and accessible. For consumers with severe mental illness the evidence of the effectiveness of e-health is limited. A number of difficulties and barriers have to be addressed concerning e-health for consumers with severe mental illness. One possible solution might be to blend e-health with face-to-face delivery of a recovery-oriented treatment, like the Illness Management & Recovery (IMR) programme. This paper describes the development of an e-health application for the IMR programme and the design of an early clustered randomized controlled trial. Method/Design: We developed the e-IMR intervention according to the six-step protocol of Intervention Mapping. Consumers joined the development group to address important and relevant issues for the target group. Decisions during the six-step development process were based on qualitative evaluations of the Illness Management & Recovery programme, structured interviews, discussion in the development group, and literature reviews on qualitative papers concerning consumers with severe mental illness, theoretical models, behavioural change techniques, and telemedicine for consumers with severe mental illness. The aim of the e-IMR intervention is to help consumers with severe mental illness to involve others, manage achieving goals, and prevent relapse. The e-IMR intervention consists of face-to-face delivery of the Illness Management & Recovery programme and an e-health application containing peer-testimonials on videos, follow up on goals and coping strategies, monitoring symptoms, solving problems, and communication opportunities. We designed an early cluster randomized controlled trial that will evaluate the e-IMR intervention. In the control condition the Illness Management & Recovery programme is provided. The main effect-study parameters are: illness management, recovery, psychiatric symptoms severity, self-management, quality of life, and general health. The process of the IMR program will be evaluated on fidelity and feasibility in semi-structured interviews with participants and trainers. Discussion: Intervention Mapping provided a systematic procedure for the development of this e-health intervention for consumers with severe mental illness and the preparation of an early randomized controlled trial

Beyond transformational leadership in nursing:A qualitative study on rebel nurse leadership‐as‐practice

Most nurse leadership studies have concentrated on a classical, heroic, and hierarchical view of leadership. However, critical leadership studies have argued the need for more insight into leadership in daily nursing practices. Nurses must align their professional standards and opinions on quality of care with those of other professionals, management, and patients. They want to achieve better outcomes for their patients but also feel disciplined and controlled. To deal with this, nurses challenge the status quo by showing rebel nurse leadership. In this paper, we describe 47 nurses’ experiences with rebel nurse leadership from a leadership-as-practice perspective. In eight focus groups, nurses from two hospitals and one long-term care organization shared their experiences of rebel nurse leadership practices. They illustrated the differences between “bad” and “good” rebels. Knowledge, work experience, and patient-driven motivation were considered necessary for “good” rebel leadership. The participants also explained that continuous social influencing is important while exploring and challenging the boundaries set by colleagues and management. Credibility, trust, autonomy, freedom, and preserving relationships determined whether rebel nurses acted visibly or invisibly. Ultimately, this study refines the concept of rebel nurse leadership, gives a better understanding of how this occurs in nursing practice, and give insights into the challenges faced when studying nursing leadership practices

Five pathways into one profession:Fifty years of debate on differentiated nursing practice

The persistence of multiple educational pathways into the nursing profession continues to occupy scholars internationally. In the Netherlands, various groups within the Dutch healthcare sector have tried to differentiate nursing practice on the basis of educational backgrounds for over 50 years. Proponents argue that such reforms are needed to retain bachelor-trained nurses, improve quality of care and strengthen nurses' position in the sector. Opponents have actively resisted reforms because they would mainly benefit bachelor-trained nurses and neglect practical experience and technical skills. This historical case study aims to provide insight in this apparent stalemate. Our analysis of this debate is informed by literature on institutional work and current debates within the historiography of nursing. This study contributes to a better understanding of this contemporary debate by examining a broader timeframe than is usually studied, and by highlighting nurses' roles in complex processes of change. We argue that, rather than being stuck in their professional development, different groups of nurses have forged their own path forward in their professional development, albeit via different strategies.</p

Five pathways into one profession:Fifty years of debate on differentiated nursing practice

The persistence of multiple educational pathways into the nursing profession continues to occupy scholars internationally. In the Netherlands, various groups within the Dutch healthcare sector have tried to differentiate nursing practice on the basis of educational backgrounds for over 50 years. Proponents argue that such reforms are needed to retain bachelor-trained nurses, improve quality of care and strengthen nurses' position in the sector. Opponents have actively resisted reforms because they would mainly benefit bachelor-trained nurses and neglect practical experience and technical skills. This historical case study aims to provide insight in this apparent stalemate. Our analysis of this debate is informed by literature on institutional work and current debates within the historiography of nursing. This study contributes to a better understanding of this contemporary debate by examining a broader timeframe than is usually studied, and by highlighting nurses' roles in complex processes of change. We argue that, rather than being stuck in their professional development, different groups of nurses have forged their own path forward in their professional development, albeit via different strategies.</p

Understanding rebel nurse leadership-as-practice: Challenging and changing the status quo in hospitals

Some nurses are responding rebelliously to the changing healthcare landscape by challenging the status quo and deviating from suboptimal practices, professional norms, and organizational rules. While some view rebel nurse leadership as challenging traditional structures to improve patient care, others see it as disruptive and harmful. These diverging opinions create dilemmas for nurses and nurse managers in daily practice. To understand the context, dilemmas, and interactions in rebel nurse leadership, we conducted a multiple case study in two Dutch hospitals. We delved into the mundane practices to expand the concept of leadership-as-practice. By shadowing rebel nurse practices, we identified three typical leadership practices which present the most common "lived" experiences and dilemmas of nurses and nurse managers. Overall, we noticed that deviating acts were more often quick fixes rather than sustainable changes. Our research points to what is needed to change the status quo in a sustainable manner. To change unworkable practices, nurses need to share their experienced dilemmas with their managers. In addition, nurse managers must build relationships with other nurses, value different perspectives, and support experimenting to promote collective learning

Patient perceptions and understanding of pressure ulcer risk in the community: Empirical Research Qualitative

AIMS: To explore patient perceptions and understanding of their pressure ulcer risk and how information is communicated between a nurse and patient in the home setting. DESIGN: A pragmatic qualitative research design including community-dwelling patients, who were deemed at risk of developing a pressure ulcer. METHODS: Observation of routine interactions between nurse and patient regarding their pressure ulcer risk and semi-structured interviews with 15 community patients following the nursing interaction. RESULTS: Four key overarching themes emerged from the data analysis that were related to patient perceptions and understanding of pressure ulcer risk. These included Pressure Ulcer Awareness, Importance of Repositioning, Healthy Eating and Risk Interpretation. CONCLUSION: Patient perception and understanding of pressure ulcer risk is different from the scientific, professional view. Patient risk perception was based on heuristics and wider personal factors and social influences. IMPACT: The study provides important new insights into clinical practice in relation to how pressure ulcer advice and information are provided and interpreted in the community setting. REPORTING METHOD: Adhered to the Standards for Reporting Qualitative Research (SRQR) PATIENT OR PUBLIC CONTRIBUTION: A small selection of patients within the NHS Trust in which the research was conducted contributed to the design of the study, in particular some of the interview questions and timing