An Evidence-Based Educational Intervention to Improve Nursing Staff\u27s Critical Thinking and Decision-Making Skills

An Evidence-Based Educational Intervention to Improve Nursing Staff\u27s Critical Thinking and Decision-Making Skills by Rene N. Kagan MSN, University of New Mexico, 2009 BS, University of Phoenix, 2000 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University September 2016 Hospitalized patients in acute care settings are at a high risk of developing health complications that can eventually lead to failure to rescue (FTR) situations. The aim of this project was to deliver a structured comprehensive medical-surgical competency plan for acute care nurses to detect deterioration in a patient\u27s condition through the triad of assessment model to promote clinical reasoning among acute care nurses. Data were collected using pretest surveys, a demographic sheet, and an evaluation survey. A convenient sample of between 22 and 29 nursing staff was recruited from three medical-surgical inpatient units at a VA Hospital. The pretest survey, administered simultaneously with the educational modules, assessed participants\u27 baseline knowledge on components of the triad of assessment model and the processes involved in the prevention of FTR. The pretest scores for modules 1 to 6 were 2, 3, 3, 3, 2, and 3 respectively. The posttests scores for modules 1 to 6 were 4, 5, 5, 5, 4, and 5 respectively. The nurse\u27s aides also recorded posttest scores of 4.6 for both Pulse Oximetry and orthostatic hypotension modules. The t-test (p\u3c0.00) showed a significant difference between the pre and posttests scores, thus, indicating an improvement in nursing staff\u27s knowledge regarding the triad of assessment model. Thus, it is important to adopt a comprehensive medical-surgical plan for acute care nurses institutional-wide. This project contributes to social change through identification of a medical-surgical intervention that improves nurses\u27 critical thinking skills, thereby promoting patient satisfaction and safety. Because nurses play a significant role at the bedside, improved critical thinking skills will facilitate a significant reduction in FTR rates, heighten patient satisfaction, and enhance the nurse-patient relationship

Transfer to higher level of care : a retrospective analysis of patient deterioration, management as well as processes involved

In-patient deterioration is a global phenomena and timely recognition and action improves outcome. Intensive care facilities are scarce and expensive and therefore patient care must be optimal. A retrospective health record analysis was used for this study. The findings indicated that nursing personnel do not recognize patient deterioration timeuously. However, the implementation of an outreach team and clinical markers training program improved the recognition of patient deterioration in general wards with three hours and 40 minutes. It is recommended to implement a comprehensive hospital program that addresses the basic knowledge and skills of general ward personnel to observe, recognize, assess and intervene to patients with clinical deterioration. Together with an extensive training program, a basic physiological parameters guideline to activate a team of experts to the bedside, such as an Outreach team, assist nursing personnel to recognize and manage those patients timeuously and ensure treatment in an appropriate level of care.Health StudiesM. A. (Health studies

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

Structural and Care Process Improvement of Ward-based Postoperative Care to Optimise Surgical Outcomes

Much of the variation seen in surgical outcomes can be explained by differences in the quality of management of post-operative complications and ward-based care. The surgical ward round (WR) is critical to determining post-operative care and serves as the primary point of interaction between clinician and patient. Despite this, it is an area not subject to training or assessment at present. This thesis demonstrates the high degree of variability which exists in the conduct of WRs. It establishes the link between suboptimal patient assessment and increased risk of preventable post-operative complications. These place patients not only at risk of short-term deterioration, but result in reduced long-term survival as well. In order to quantify WR quality, a novel assessment tool has been developed and validated within a simulated environment. Ward simulation is a nascent branch of simulation which has been only preliminarily explored to date. A simulation environment was developed to take advantage of the known benefits of simulation such as controllability, reproducibility, and recordability, whilst maintaining a high level of fidelity and realism. An evidence-based curriculum for surgical WR training was designed and implemented in a simulation-based course. By focusing on structured generic processes of patient assessment and management, this resulted in significant improvement of trainee performance in routine WRs. To ensure standardised and optimum management of specific conditions, checklists have proven themselves to be of great value in a number of surgical and medical disciplines. Surgical complications are common, yet their management often suboptimal. As part of this thesis, evidence-based protocols for the management of the six most common complications were designed and validated. The implementation of these in a simulation-based randomised, controlled trial has resulted in greatly increased adherence to evidence-based standards of care, as well as improved communication and clinician performance. This thesis explores the variance currently present in surgical ward rounds, and the potentially grave consequences of this for patient outcomes. To date, WRs have been one of the last areas of surgical care still dependent on the Halstedian principle of experiential learning alone. The tools have now been developed with which to assess, improve, and standardise critical structures and care processes in the assessment and management of the post-operative surgical patient. Future implementation of these and integration into surgical curricula will benefit clinician training, patient care, and surgical outcomes alike.Open Acces

Patient observation skills in critical care nursing : A Theoretical construction and evaluation

This two-phase study focused on critical care nurses’ skills. The purpose was first to describe and create a theoretical construction of patient observation skills in critical care nursing, and second, to evaluate the current level of Finnish critical care nurses’ patient observation skills using subjective and objective assessment and investigate the factors associated with the skills. The aim was to deepen the understanding of critical care nurses’ skills, and ultimately to develop their skills to enhance quality of care and patient safety in intensive care units. In the first study phase, patient observation skills were described and a preliminary theoretical construction was created based on the semi-structured interviews among experienced critical care nurses (n=20). Thematic analysis was used to analyse the data. The second phase utilized cross-sectional correlational design to evaluate critical care nurses’ patient observation skills and to investigate associated factors. An instrument, Patient Observation Skills in Critical Care Nursing (POS-CCN) consisting of self-assessment and knowledge test, was developed. Critical care nurses (n=372, response rate 49%) in Finnish intensive care units in university hospitals answered the questionnaire. The methods of data analysis included descriptive and inferential statistics and general linear model. Patient observation skills in critical care nursing consist of information-gaining, information-processing, decision-making and co-operation skills. The evaluation of critical care nurses’ skills was limited to information-gaining and informationprocessing skills. Critical care nurses assessed their information-gaining skills as excellent, whereas knowledge test assessment suggested that information-processing skills are suboptimal. Critical care nurses who were highly confident in their competence and educated for special tasks in intensive care units had higher level of patient observation skills. There is a need for improving critical care nurses’ patient observation skills especially in information processing. Systematic education and training in patient observation is needed in intensive care units, and skills evaluation practices need to be developed further.Potilaan kliinisen tilan tarkkailutaidot tehohoitotyössä – Teoreettinen rakenne ja arviointi Tämä kaksivaiheinen tutkimus kohdentui tehosairaanhoitajien taitoihin. Tarkoituksena oli ensin kuvailla ja muodostaa teoreettinen rakenne tarkkailutaidoille tehohoitotyössä ja sitten arvioida tehosairaanhoitajien tarkkailutaitojen tasoa subjektiivisesti ja objektiivisesti sekä tunnistaa taitoihin yhteydessä olevia tekijöitä. Tavoitteena oli syventää ymmärrystä tehosairaanhoitajien taidosta, ja lopulta kehittää taitoja hoidon laadun ja potilasturvallisuuden varmistamiseksi. Ensimmäisessä vaiheessa tarkkailutaidot kuvailtiin ja alustava teoreettinen rakenne luotiin kokeneiden tehosairaanhoitajien (n=20) puolistrukturoitujen haastattelujen perusteella. Aineisto analysoitiin temaattisella analyysilla. Tutkimuksen toisessa vaiheessa korrelatiivisessa poikkileikkeusasetelmassa arvioitiin tehosairaanhoitajien tarkkailutaitoja ja tunnistettiin niihin yhteydessä olevia tekijöitä. Arviointia varten kehitettiin mittari Tarkkailutaidot Tehohoitotyössä (TarkkaTeho), joka koostui taitojen itsearvioinnista ja tietotestistä. Suomalaisten yliopistosairaaloiden teho-osastoilla työskentelevät sairaanhoitajat vastasivat kyselyyn (n=372, vastausprosentti 49%). Aineisto analysoitiin tilastollisin menetelmin hyödyntäen yleistä lineaarista mallia monimuuttujamenetelmänä. Potilaan kliinisen tilan tarkkailutaidot koostuvat taidoista hankkia ja käsitellä tietoa, taidoista tehdä päätöksiä sekä yhteistyötaidoista. Arviointi rajoittui tiedonhankinta- ja -käsittelytaitoihin. Tehosairaanhoitajat arvioivat tiedonhankintataitonsa eriomaiseksi, kun taas tietotestin perusteella tiedonkäsittelytaidot eivät olleet optimaalisella tasolla. Taidot olivat paremmat tehosairaanhoitajilla, jotka olivat luottavaisia omaan tehohoitotyön osaamiseensa, ja jotka olivat saaneet koulutuksen erityistehtäviin teho-osastolla. Tehosairaanhoitajien tarkkailutaitoja tulisi parantaa erityisesti tiedonkäsittelyn osalta. Potilaan tilan tarkkailun koulutusta tulisi olla järjestelmällisesti tarjolla teho-osastoilla, ja taitojen arviointia on tarve kehittää edelleen

Wicked complexity in surgical services: analysing perioperative high-risk, work practice organisation and context for future policy implementation

Background: Knowledge of perioperative risk and context are important as year-on-year the global volume of surgery is increasing. Despite decades of policy responses to surgical demand, national registries and local evidence report that a distinct cohort of surgical patients have a higher-than-average risk of complications with added costs to quality of life and service sustainability. The research aim was to examine the impact of context on how in practice the perioperative workforce (comprising clinicians and managers) understand risk, and how this knowledge influences their work practices and use of resources. Three questions were investigated: what has been the impact of health policy on the organisation and practice of perioperative care; how is perioperative work practice organised around low, intermediate and high-risk patients; and what do individuals, teams and organisations require to implement appropriate models of perioperative care for the high-risk patient? Methods: Mixed methods study. The research setting was four university adult general hospitals (113, 360, 440, 547 bed capacity) in a health district in NSW, Australia. Institutional ethics approved a mixed methods study – site observation (187 hours), secondary documents (223 documents: paper and electronic), survey (113 completed) and interviews (143 conducted). Purposive sampling targeted 129 participants in 167 roles, including multidisciplinary clinicians (nurses, doctors and allied health) in senior and junior roles, and managers. Data collection (September 2017 – June 2019) and analysis was conducted using a parallel convergent design through triangulation with descriptive statistics and thematic analysis. Results: National and state health policies that focused on access and efficiency successfully addressed high volume surgical demand for low and intermediate risk patients in predictable, reliable and linear perioperative business process models (BPMs). However, the policies are now three decades old, have resulted in unintended consequences and not addressed the clinical and organisational complexity evident in the three larger hospitals today. The high-risk complex care surgical patient traversed parallel BPMs that were not linear but rather, unpredictable complex adaptive systems. High-risk patients had more invasive surgery and the challenges of chronic multisystem disease and ageing. Complications were more common and cumulative with increased utilisation of hospital resources across multiple fragments of perioperative care; increasing specialty specific expertise were co-opted from multiple clinical disciplines, multiple ‘one-off’ teams were deployed for rescue, resuscitation, and critical care. Complications were associated with months-long hospital stays, discharge to a care level higher than home and readmissions. For high-risk patients the impact of context on the perioperative workforce caring for them could be synthesised as a wicked complexity in perioperative context (WCPC). Wicked complexity is a complexity that was unintended, unwarranted and promulgated by the behaviours of the practice environment. Three research arcs were identified. In the policy arc, at the intersections of the three themes of compression of time and space, fragmentation of care and clinical complexity, there was a wicked complexity in competing priorities and demands (WCCPD) arising from the pressure on clinicians and managers to deal with the ‘here and now’ and not delay care processes downstream. In the risk and practice arc, at the intersections of the three themes of multiple incomplete understandings of high-risk, work practice organisation and an unclear patient outcome measure, there was a wicked complexity in gaps in fully comprehending high-risk (WCGFCHR). In the interprofessional arc, at the intersections of the three themes of professional immersion, multiple formations of perioperative teams and using technology, there was a wicked complexity in gaps in perspective (WCGP). Service sustainability in the perioperative system evolved to encompass WCPC. WCPC was the outcome and rendered solutions clinicians, managers and the organisation derived by continually adjusting elements of care to address current challenges. Wicked complexity in perioperative context is represented by the equation: WCPC = WCCPD +WCGFCHR + WCGP Discussion: Continually adjusting elements of perioperative care to address current challenges is supported by frontline clinicians and the initiatives of local and international medical colleges and societies However, the consequences of continuing this strategy alone without acknowledging and addressing WCPC, include: the potential practical inability of the majority of clinicians and clinician managers to be involved with new initiatives as they continue to struggle with competing priorities and demands in day-to day practice, the organisational gaps in fully comprehending high-risk and the cultural gaps in perspective. The research shows that what is critically needed is a commonly agreed and complete definition of perioperative high-risk that considers the impact of context and culture. The impact of context on the perioperative workforce and their patients can be clearly analysed and articulated. Addressing WCPC systematically enables the charting of an evolving course to equip clinicians and managers to: deal with the impact of context, face economic challenges to service sustainability and address the needs of the high-risk complex care perioperative patient. It is necessary and time to revisit a policy strategy that was successful short-term, a workforce generation ago when surgical services were first re-engineered. Namely, an investment in leadership for the future, capable of generating the solutions to optimising care for the high-risk surgical patient, both clinically and contextually. This may only be achieved through interprofessional education and collaboration at all levels of policy enactment, across all professions. The health services research perspective that enabled defining WCPC could work to simultaneously address clinical complexity, context and culture

Nurse Practitioner Impact on Quantitative Patient Outcomes in Four Healthcare Settings' System Context: A Systematic Review and Meta-Analysis

Nurse Practitioners (NPs) are frequently integrated into interprofessional teams to improve quality and efficiency of healthcare delivery, especially in complex systems. Research on the NP role has grown dramatically, yet an aggregate analysis had never been performed. The purpose of this review was to systematically describe the nature and impact of NP interventions in healthcare settings, to establish a comprehensive understanding of NPs with respect to healthcare delivery, including discovery of information gaps. The specific objectives of the study were to describe the types of: 1) intervention activities that NPs have performed in randomised controlled trials (RCTs); 2) quantitative study endpoints measured in RCTs; and 3) impact of NPs on all quantitative patient outcomes in four settings: primary health care, long term care, outpatient care, and acute care, conducting meta-analysis where possible. Eligible studies included low risk of bias RCTs that tested NP interventions on quantitative endpoints in healthcare settings; data sources included peer reviewed or grey literature in English, from the year 2000 forth. The literature search performed by a professional librarian (MH) yielded 1,188 unique citations. Screening for relevance and risk of bias by two independent reviewers (LT and NL) resulted in a set of included studies comprised of 39 articles (29 different RCTs). Data extraction by LT was cross-checked by the second independent reviewer NL. Findings were systematically summarized according to pre-specified protocol. Out of 89 classes of endpoint-outcomes, results for 43 patient outcome classes (43/89; 48%) were statistically significant, associated with 26/29 (90%) interventions. Meta-analysis was conducted to compare the proportion of hospitalizations between intervention and control groups of two homogenous studies, systematically completing the review’s data analysis. Transparent data presentation within an explicit, reproducible methodology minimizes bias, resulting in reliable findings that were organized, synthesized and summarized in a clear and comprehensive fashion. To the extent of its findings, this systematic review may support improvements in access to quality healthcare, and may provide insight into long term strategies that have potential to contribute toward enhanced balance within the healthcare continuum, from delivery of preventive primary health care services to treatment in acute care

Off-Shift Nursing and Quality Patient Outcomes

Acute care hospitals function 24-hours-a-day, 7-days-a-week. A majority of that time is characterized as off-shifts (i.e., nights, weekends, and/or holidays). Researchers have found that patient outcomes are generally worse on off-shifts as compared to regular hours. However, the underlying mechanism of why these outcomes are worse remains unclear. This dissertation explores off-shift care including nurse staffing and human capital variables and their impact on patient safety in acute care hospitals. The importance of off-shift quality care in acute care hospitals is discussed in the first chapter. In the second chapter, findings from a systematic literature review are presented. The third chapter describes mixed methods and the theoretical framework that guided the development of an interview guide and the quantitative portion of the dissertation. The fourth chapter includes the qualitative study of off-shift nursing and the fifth chapter, is a quantitative study of testing variations in nursing inputs (i.e., staffing and human capital variables) by shift and their impact on length of stay. Finally, in the sixth chapter, the findings from Chapter 2, 4, and 5 are summarized and synthesized into a concluding chapter of the dissertation

THE IMPACT OF WORK UNIT AND ORGANIZATION SUPPORT ON HOSPITAL PATIENT SAFETY

Based on the construct of a culture of safety, the study purpose was to discern the relationships between Organization Support (OS) and Work Unit Support (WS) on Hospital Patient Safety. OS and WS were operationalized using the National Database for Nursing Quality Indicators® (NDNQI®) RN Survey with Job Satisfaction Scales. Patient Safety was operationalized using four Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators: Decubitus Ulcer, Selected Infections due to Medical Care, Failure to Rescue (FTR), and Deep Vein Thrombosis. A structural equation model was developed with adequate fit indices (χ2 = 40.811, df= 27, p= 0.234; CFI= 0.930; RMSEA= 0.065; SRMR= 0.074). Unexpectedly, increased OS was associated significantly (p= .030) with increase Patient Safety events. A promising, though non-significant finding, was increased WS and OS were associated with decreased FTR rates. Teamwork, a component of WS was associated with decreased rates of FTR and Patient Safety events