Sean Clarke

Abstract

Enacted scope of practice is a major issue for nursing administrators, given the potentially negative effect on accessibility, continuity, safety and quality of care, job satisfaction, and organizational costs of nurses working at reduced scope. Optimal deployment of nurses to a fuller enacted scope of nursing practice holds much promise for addressing all of these larger challenges. In this sense, new model of the Enacted Scope of Nursing Practice presented in this article provides a number of directions for interventions that could improve health system functioning.

Abstract

Context: In rural areas of Canada, people with acute coronary syndromes (ACS) can wait up to 32 hours for transfer for diagnostic cardiac catheterization (CATH). While awaiting CATH, it is critical that pain and anxiety management be optimal to preserve myocardial muscle and minimize the risk of further deterioration. Objectives: The aim of this study was to examine the relationship between clinical management, cardiac pain intensity, and state anxiety for rural ACS patients awaiting diagnostic CATH. Methods: In a prospective, descriptive-correlational repeated-measures design involving 121 ACS rural patients, we examined the associations of analgesic and nitroglycerin administration with cardiac pain intensity (numeric rating scale) and state anxiety (Spielberger State Anxiety Inventory) and also nurses' pain knowledge and attitudes (Toronto Pain Management InventoryYACS Version and Knowledge and Attitudes Survey Regarding Pain) using linear mixed models. Results: The mean age of patients was 67.6 T 13, 50% were men, and 60% had unstable angina and the remainder had non-ST-elevated myocardial infarction. During follow-up, cardiac pain intensity scores remained in the mild range from 1.1 T 2.2 to 2.4 T 2.7. State anxiety ranged from 44.0 T 7.2 to 46.2 T 6.6. Cumulative analgesic dose was associated with a reduction in cardiac pain by 1.0 points (numeric rating scale, 0Y10) (t108 = j2.5; SE, j0.25; confidence interval, j0.45 to j0.06; P = .013). Analgesic administration was not associated with state anxiety. Over the course of follow-up, ACS patients reported consistently high anxiety scores. Conclusions: Whereas cardiac pain declines in most patients in the early hours after admission, many patients experience a persistent anxious state up to 8 hours later, which suggest that development and testing of protocols for anxiety reduction may be needed. More urgently, the development and examination of a treatment intervention, early on in the ACS trajectory, are warranted that targets pain and anxiety for those for whom immediate angioplasty is not possible and who continue to experience cardiac pain and persistent high levels of anxiety. Moreover, a larger prognostic study is required to determine whether high levels of anxiety in rural ACS patients are predictive of major adverse cardiac events.

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The purpose of this study was to calculate the event rate for inpatients in the radiology department (RD) developing instability leading to calls for medical emergency team (MET) assistance (MET-RD) compared with general ward (MET-W) patients. A retrospective comparison was done of MET-RD and MET-W calls in 2009 in a US tertiary hospital with a well-established MET system. MET-RD and MET-W event rates represented as MET calls/hr/1,000 admissions, adjusted for length of stay (LOS); rates also calculated for RD modalities. There were 31,320 hospital ward admissions that had 1,230 MET-Ws, and among 149,569 radiology admissions there were 56 MET-RDs. When adjusted for LOS, the MET-RD event rate was two times higher than the MET-W rate (0.48 vs. 0.24 events/hr/1,000 admissions). Event rates differed by procedure: computed tomography (CT) had 38% of MET-RDs (event rate, 0.89), and magnetic resonance imaging (MRI) accounted for 27% of MET-RDs (event rate, 1.56). Nuclear medicine had 1% of RD admissions, but these patients accounted for 5% of MET-RD (event rate, 1.53). Interventional radiology (IR) had 6% of RD admissions but 16% of MET-RD admissions (event rate, 0.61). Although general X-ray comprised 63% of RD admissions, only 11% of MET-RD involved their care (event rate, 0.09). In conclusion, the overall MET-RD event rate was twice the MET-W event rate; CT, MRI, and IR rates were 3.7 to 6.5 times higher than on wards. RD patients are at increased risk for an MET call compared with ward patients when the time at risk is considered. Increased surveillance of RD patients is warranted.

Abstract

Cardiac pain and/or discomfort arising from acute coronary syndromes (ACS) can often be severe and anxiety-provoking. Cardiac pain, a symptom of impaired myocardial perfusion, if left untreated, may lead to further myocardial hypoxia, which can potentiate myocardial damage. Evidence suggests that once ACS patients are stabilized, their pain may not be adequately assessed. Lack of knowledge and problematic beliefs about pain may contribute to this problem. To date, no standardized tools are available to examine nurses' specific knowledge and beliefs about ACS pain that could inform future educational initiatives. To examine the content validity of the Toronto Pain Management Inventory-ACS Version (TPMI-ACS), a 24-item tool designed to assess nurses' knowledge and beliefs about ACS pain assessment and management. Eight clinical and scientific experts rated the relevance of each item using a four-point scale. A content validity index was computed for each item (I-CVI), as well as the total scale, expressed as the mean item CVI (S-CVI/AVE). Items with an I-CVI > or = 0.7 were retained, items with an I-CVI ranging from 0.5-0.7 were revised and clarified, and items with an I-CVI < or = 0.5 were discarded. I-CVIs ranged from 0.5-1.0 and the S-CVI/AVE was 0.90, reflecting high inter-rater agreement across items. The least relevant item was eliminated. Preliminary content validity was established on the TPMI-ACS version. All items retained in the TPMI-ACS version met requirements for content validity. Further evaluation of the psychometric properties of the TPMI-ACS is needed to establish criterion and construct validity, as well as reliability indicators.

Abstract

The Patient Protection and Affordable Care Act (PPACA, 2010) and the Institute of Medicine's (IOM, 2011) Future of Nursing report have prompted changes in the U.S. health care system. This has also stimulated a new direction of thinking for the profession of nursing. New payment and priority structures, where value is placed ahead of volume in care, will start to define our health system in new and unknown ways for years. One thing we all know for sure: we cannot afford the same inefficient models and systems of care of yesterday any longer. The Data-Driven Model for Excellence in Staffing was created as the organizing framework to lead the development of best practices for nurse staffing across the continuum through research and innovation. Regardless of the setting, nurses must integrate multiple concepts with the value of professional nursing to create new care and staffing models. Traditional models demonstrate that nurses are a commodity. If the profession is to make any significant changes in nurse staffing, it is through the articulation of the value of our professional practice within the overall health care environment. This position paper is organized around the concepts from the Data-Driven Model for Excellence in Staffing. The main concepts are: Core Concept 1: Users and Patients of Health Care, Core Concept 2: Providers of Health Care, Core Concept 3: Environment of Care, Core Concept 4: Delivery of Care, Core Concept 5: Quality, Safety, and Outcomes of Care. This position paper provides a comprehensive view of those concepts and components, why those concepts and components are important in this new era of nurse staffing, and a 3-year challenge that will push the nursing profession forward in all settings across the care continuum. There are decades of research supporting various changes to nurse staffing. Yet little has been done to move that research into practice and operations. While the primary goal of this position paper is to generate research and innovative thinking about nurse staffing across all health care settings, a second goal is to stimulate additional publications. This includes a goal of at least 20 articles in Nursing Economic$ on best practices in staffing and care models from across the continuum over the next 3 years.

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Employers are essential partners with health professions regulators in ensuring public safety and are critical to the success of discipline monitoring programs. However, working with discipline orders and the regulatory process often causes confusion and stress for employers.This article reviews the perspectives of regulators and employers regarding discipline monitoring in nursing as well as the legal and practical considerations. The article concludes by suggesting future directions for regulators and employers.

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Much has been written about interventions to improve the nursing work environment, yet little is known about their effectiveness. A Delphi survey of nurse experts was conducted to explore perceptions about workplace interventions in terms of feasibility and likelihood of positive impact on nurse outcomes such as job satisfaction and nurse retention. The interventions that received the highest ratings for likelihood of positive impact included: bedside handover to improve communication at shift report and promote patient-centred care; training program for nurses in dealing with violent or aggressive behaviour; development of charge nurse leadership team; training program focused on creating peer-supportive atmospheres and group cohesion; and schedule that recognizes work balance and family demands. The overall findings are consistent with the literature that highlights the importance of communication and teamwork, nurse health and safety, staffing and scheduling practices, professional development and leadership and mentorship. Nursing researchers and decision-makers should work in collaboration to implement and evaluate interventions for promoting practice environments characterized by effective communication and teamwork, professional growth and adequate support for the health and well-being of nurses.

Abstract

Background: Ensuring the safety of hospitalized patients remains a major challenge for healthcare systems, and nursing services are at the center of hospital care. Yet our knowledge about safety of nursing care is quite limited. In fact, most earlier studies examined one, or at most two, indicators, thus presenting an incomplete picture of safety at an institutional or broader level. Furthermore, methodologies have differed from one study to another, making benchmarking difficult. Objectives: The aim of this study was to describe the frequencies of six adverse events widely considered in the literature to be nursing-sensitive outcomes and to estimate the degree to which these events could be attributed to nursing care. Method: Cross-sectional review of charts of 2699 patients hospitalized on 22 medical units in 11 hospitals in Quebec, Canada. The events included: pressure sores, falls, medication administration errors, pneumonias, urinary infections, and inappropriate use of restraints. Experienced nurse reviewers abstracted patients' charts based on a grid developed for the study. Results: Patient-level risk for at least one of these six adverse events was 15.3%, ranging from 9% to 28% across units. Of the 412 patients who experienced an event, 30% experienced two or more, for a total of 568 events. The risk of experiencing an adverse event with consequences was 6.2%, with a unit-level range from 3.2% to 13.5%. Abstractors concluded that 76.8% of the events were attributable to nursing care. Conclusion: While the measurement approach adopted here has limitations stemming from reliance on review of documentation, it provided a practical means of assessing several nursing-sensitive adverse events simultaneously. Given that patient safety issues are so complex, tracking their prevalence and impact is important, as is finding means of evaluating progress in reducing them.