Sean Clarke

Abstract

Background: Nurse practitioner (NP) education was originally reserved for experienced nurses, but it has gradually opened to nurses with little to no clinical experience at the registered nurse (RN) level as well as to non-nurses. The existence of multiple paths to NP training and practice raises questions about the role of generalist RN experience in learning clinical decision-making and other aspects of the NP role. Purpose: To describe educators’ perceptions of the role of prior nursing experience in the development of clinical judgment during NP graduate education. Methods: In this qualitative descriptive study, 27 NP faculty from four universities participated in individual interviews. Transcripts were analyzed using a thematic approach. Results: According to participants, previous nursing experience—or any relevant experience—can either be helpful or detrimental in the development of NP students’ clinical judgment. Three themes were generated: variations in students’ baseline knowledge and skills, different frames of reference to grasp new content and skills, and challenges related to professional identity. In addition, participants described factors that they believe can affect the impact of different types of experience. Conclusion: Students with and without prior nursing experience face distinct challenges in learning NP-level clinical decision-making and judgment, but they reach similar end-of-program competence. Educators are confronted with contradictions between generally held wisdom, their professional socialization, and first-hand observations regarding the role of experience (inside and outside nursing) in preparing students to become NPs.

Abstract

The nurse workforce-the nurses available to provide care to a group of patients or a population and the characteristics of these nurses-provides a critical context for the Quality Health Outcomes Model (QHOM). This chapter begins with a brief consideration of workforce issues within the QHOM. Two forces at the heart of workforce analysis (supply and demand) and how these forces play out in various arenas for nursing practice are discussed. This chapter does not focus on managers' decisions regarding coverage of patient care responsibilities by nursing staff and nursing personnel qualifications, which fall within the realm of staffing (see Chaps. 4 and 13). Instead, it will focus on the size and composition of the body of nurses providing care, the forces that influence this body of nurses, and how workforce parameters act as an element of context for staffing, practice environments, and nursing care delivery. The chapter concludes with discussions of ongoing and emerging trends likely to influence the nurse workforce, especially in relation to healthcare quality and safety considerations.

Abstract

Aims: To explore nurses' experience and describe how they manage various contextual factors affecting the nurse-to-nurse handoff at change of shift. Design: Qualitative descriptive study. Methods: A convenience sample of 51 nurses from four medical and surgical care units at a university-affiliated hospital in Montreal, Canada, participated in one of the 19 focus group interviews from November 2017 to January 2018. Data were analysed through a continuous and iterative process of thematic analysis. Results: Analysis of the data generated a core theme of ‘sharing accountability for knowing and safeguarding the patient’ that is achieved through actions related to nurses' role in the exchange. Specifically, the outgoing nurse takes actions to ensure continuity of care when letting go, and the incoming nurse takes actions to provide seamless care when taking over. In both roles, nurses navigate each handoff juncture by mutually adjusting, ensuring attentiveness, managing judgements, keeping on track, and venting and debriefing. Handoff is also shaped by contextual conditions related to handoff norms and practices, the nursing environment, individual nurse attributes and patient characteristics. Conclusions: This study generated a conceptualization of nurses' roles and experience that details the relationship among the elements and conditions that shape nurse-to-nurse handoffs. Impact: Nursing handoff involves the communication of patient information and relational behaviours that support the exchange. Although many factors are known to influence handoffs, little was known about nurses' experience of dealing with these at the point of care. This study contributed a comprehensive conceptualization of nursing handoff that could be useful in identifying areas for quality improvement and guiding future educational efforts.

Abstract

Background: The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. Purpose: To present a Nursing Health Services Research (NHSR) agenda for the 2020s. Method: A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. Findings: Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. Discussion: The Agenda can act as a foundation for new NHSR – which is more important than ever – in the 2020s.

Abstract

Background: Nurses begin forming judgments regarding patients’ clinical stability during change-of-shift handoffs. Objectives: To examine the agreement between incoming and outgoing nurses’ judgments of deterioration risk following handoff and compare these judgments to commonly used early warning scores (MEWS, NEWS, ViEWS). Methods: Following handoffs on three medical/surgical units, nurses completed the Patient Acuity Rating. Nurse ratings were compared with computed early warning scores based on clinical data. In follow-up interviews, nurses were invited to describe their experiences of using the rating scale. Results: Sixty-two nurses carried out 444 handoffs for 158 patients. While the agreement between incoming and outgoing nurses was fair, correlations with early warning scores were low. Nurses struggled with predicting risk and used their impressions of differential risk across all the patients to whom they had been assigned to arrive at their ratings. Conclusion: Nurses shared information that influenced their clinical judgments at handoff; not all of these cues may necessarily be captured in early warning scores.

Abstract

Aims and objectives: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. Background: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. Design: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. Methods: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. Results: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. Conclusions: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. Relevance to clinical practice: This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.