Burdensome situations in everyday nursing: an explorative qualitative action research on a medical ward

Everyday nursing care is under marked constraint in the current healthcare environment due to decreasing time resources and competing financial demands. Burden along with stress and burnout is increasing. Stress not only does occur on the individual and organizational level, as has been studied, but also is a significant factor at the team level, particularly with regard to interactions at this level. This project aimed at eliciting nurses' view on burden; identifying areas for intervention on team level; and evaluating the interventions implemented at this level. Focus groups were conducted with 2 nursing teams (n = 36). Data were analyzed with Atlas Ti, Version 4.2. On the basis of the results of the focus groups, interventions were developed and implemented observing the tenets of problem-based learning and evidence-based nursing. Verbal feedback was used to evaluate the impact of the interventions on the nursing team. Fourteen themes were identified for each ward as areas for improvement. Oral evaluation of the group-specific interventions revealed a benefit for the nursing team as a whole. Findings indicate that team actions played an important role when addressing stressful nursing situations. To improve stressful nursing situations, team action needs to be considered.     

Implementation of an interprofessional communication and collaboration intervention to improve care capacity for heart failure management in long-term care

Heart failure affects up to 20% of nursing home residents and is associated with high morbidity, mortality, and transfers to acute care. A major barrier to heart failure management in nursing home settings is limited interprofessional communication. Guideline-based heart failure management programs in nursing homes can reduce hospitalisation rates, though sustainability is limited when interprofessional communication is not addressed. A pilot intervention, ‘Enhancing Knowledge and Interprofessional Care for Heart Failure’, was implemented on two units in two conveniently selected nursing homes to optimise interprofessional care processes amongst the care team. A core heart team was established, and participants received tailored education focused on heart failure management principles and communication processes, as well as weekly mentoring. Our previous work provided evidence for this intervention’s acceptability and implementation fidelity. This paper focuses on the preliminary impact of the intervention on staff heart failure knowledge, communication, and interprofessional collaboration. To determine the initial impact of the intervention on selected staff outcomes, we employed a qualitative design, using a social constructivist interpretive framework. Findings indicated a perceived increase in team engagement, interprofessional collaboration, communication, knowledge about heart failure, and improved clinical outcomes. Individual interviews with staff revealed innovative ways to enhance communication, supporting one another with knowledge and engagement in collaborative practices with residents and families. Engaging teams, through the establishment of core heart teams, was successful to develop interprofessional communication processes for heart failure management. Further steps to be undertaken include assessing the sustainability and effectiveness of this approach with a larger sample.     

Factors related to aggressive behaviors among older adults in nursing homes of Korea: A cross-sectional survey study

BackgroundAggressive behavior is one of the most challenging behavioral psychological symptoms for older adults and their caregivers in nursing homes.ObjectivesThe purpose of this study was to examine and identify contributing factors of aggressive behaviors among older adults in nursing homes in South Korea.DesignThis is a secondary analysis of a national survey on health and functional status among older nursing home residents.SettingsParticipants were recruited from 91 nursing homes.ParticipantsA total of 1447 older adults were included for final analysis and they were randomly selected from a nationally representative sample of people 65 years and older at the sampled nursing homes.MethodsPresence of aggressive behaviors was identified when participants showed at least one of the five symptoms in the Korean interRAI Long-Term Care Facility Assessment Tool such as physical abuse, verbal abuse, socially inappropriate or destructive behaviors, and resistance to care. Theory-based contributing factors were selected and examined. Multivariate logistic regression analyses were performed.ResultsAbout 19% of older nursing homes residents had aggressive behaviors, and several health and social factors including social engagement are associated with aggressive behaviors.ConclusionsAggressive behavior is prevalent in older nursing home residents with and without dementia in South Korea and individual and institutional level interventions are necessary.     

Were Clinical Routines for Good End-of-Life Care Maintained in Hospitals and Nursing Homes During the First Three Months of the Outbreak of COVID-19? A National Register Study

ContextAlthough the coronavirus disease 2019 (COVID-19) pandemic might affect important clinical routines, few studies have focused on the maintenance of good quality in end-of-life care.ObjectivesThe objective was to examine whether adherence to clinical routines for good end-of-life care differed for deaths because of COVID-19 compared with a reference cohort from 2019 and whether they differed between nursing homes and hospitals.MethodsData about five items reflecting clinical routines for persons who died an expected death from COVID-19 during the first three months of the pandemic (March–May 2020) were collected from the Swedish Register of Palliative Care. The items were compared between the COVID-19 group and the reference cohort and between the nursing home and hospital COVID-19 deaths.ResultsAbout 1316 expected deaths were identified in nursing homes and 685 in hospitals. Four of the five items differed for total COVID-19 group compared with the reference cohort: fewer were examined by a physician during the last days before death, pain and oral health were less likely to be assessed, and fewer had a specialized palliative care team consultation (P < 0.0001, respectively). Assessment of symptoms other than pain did not differ significantly. The five items differed between the nursing homes and hospitals in the COVID-19 group, most notably regarding the proportion of persons examined by a physician during the last days (nursing homes: 18%; hospitals: 100%).ConclusionThis national register study shows that several clinical routines for end-of-life care did not meet the usual standards during the first three months of the COVID-19 pandemic in Sweden. Higher preparedness for and monitoring of end-of-life care quality should be integrated into future pandemic plans.     

Comparing undergraduate student nurses' understanding of sustainability in two countries: A mixed method study

AimTo explore sustainability education in nursing students in two countries.DesignMixed methods including a sustainability survey and focus groups.MethodsFirst-year undergraduate nursing students from two countries were invited to participate. 69 students from China and 32 students from England agreed to take part. Data were collected between December 2015 and February 2016. Students completed the Sustainability Attitudes in Nursing Survey (SANS_2) and a purposive sample were invited to participate in focus groups in each country.ResultsAll students had a positive attitude towards sustainability. However, for these four items, the results indicated that Chinese nursing students rate them significantly higher in importance than English students:Climate change is an important issue for nursingIssues about climate change should be included in the nursing curriculumSustainability is an important issue for nursingSustainability should be included in the nursing curriculum.The qualitative data identified four themes:Student nurses' conceptual understanding of sustainability focused mostly on environmental aspects and clinical waste management;Promoting sustainability within nursing education: teaching and learning methods.Promoting sustainability within nursing education: evaluating and certifying learning.Factors to consider when introducing sustainability to nursing education.The paper outlines the similarities and differences between Chinese and English nursing students' perceptions.ConclusionSustainability in nurse education has similar concerns across countries.ImpactSustainability is an important issue for student nurses but strategies promoting incorporation of sustainability issues within nursing curricula are needed.     

Residencias de ancianos en Portugal durante la COVID-19: desafíos para el futuro

ObjectiveThis study sought to explore the perceptions of experts about the performance of nursing homes during the COVID-19 outbreak.MethodA qualitative study was developed in two stages: (1) a focus group, conducted in May 2020, with 5 experts; (2) a modified e-Delphi, implemented in September 2020 with 22 experts, both in the area of assistance in nursing homes from Northern and Center of Portugal.ResultsThe results allowed identifying three main areas that influenced the performance of nursing homes during the COVID-19 outbreak: organization models and resources; physical and mental health of residents and; family as a support.ConclusionsOlder adults residing in nursing homes are particularly vulnerable to severe disease or death from COVID-19. It is emergent that nursing homes prevent physical and mental frailty in older residents and the loneliness aggravated by the pandemic circumstances. Decision-makers need to recognize that older people living in nursing homes have several health needs, which should determine the implementation of new strategies namely the increase in the number of professionals with appropriate skills.     

Maintaining dignity in vulnerability: A qualitative study of the residents’ perspective on dignity in nursing homes

BackgroundOlder people, living in nursing homes, are exposed to diverse situations, which may be associated with loss of dignity. To help them maintain their dignity, it is important to explore, how dignity is preserved in such context. Views of dignity and factors influencing dignity have been studied from both the residents’ and the care providers’ perspective. However, most of these studies pertain to experiences in the dying or the illness context. Knowledge is scarce about how older people experience their dignity within their everyday lives in nursing homes.AimTo illuminate the meaning of maintaining dignity from the perspective of older people living in nursing homes.MethodThis qualitative study is based on individual interviews. Twenty-eight nursing home residents were included from six nursing homes in Scandinavia. A phenomenological-hermeneutic approach, inspired by Ricoeur was used to understand the meaning of the narrated text.ResultsThe meaning of maintaining dignity was constituted in a sense of vulnerability to the self, and elucidated in three major interrelated themes: Being involved as a human being, being involved as the person one is and strives to become, and being involved as an integrated member of the society.ConclusionThe results reveal that maintaining dignity in nursing homes from the perspective of the residents can be explained as a kind of ongoing identity process based on opportunities to be involved, and confirmed in interaction with significant others.     

Why do they fall? Monitoring risk factors in nursing homes

A pilot study identified 40 falls involving 29 patients from incident reports in a nursing home. About one fourth of the fallers fell more than once and accounted for about one fourth of the falls. The majority of research studies on falls were conducted in hospital settings on a one-time basis. Studies are needed in nursing homes to monitor risk factors on a continuous basis to design remedial nursing interventions. Age, male gender, mental impairment, and short stay were risk factors identified in this study. The association of dementia with falls is especially significant because of the increasing numbers of dementia patients in nursing homes. This pinpoints the need for special surveillance of these patients.     

Interventions to improve suboptimal prescribing in nursing homes: A narrative review

Background: Appropriate medication prescribing for nursing home residents remains a challenge. Objective: The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes.Methods: The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents.Results: Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in ≥1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions.Conclusions: Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.     

Ethics in nursing homes: experience and casuistry

The purpose of the study was to further explore the methods that nurses use to solve ethically difficult care situations in nursing homes while the aim of this article was to present a model for nursing practice in such situations. Fourteen nurses from three nursing homes in Norway were observed and interviewed in order to discern the strategies they used to deal with ethically difficult care situations. To analyse this information, we used a constant comparative method until a grounded theory emerged. The nurses' principal strategy was to apply earlier experiences while striving for the best outcome for the elderly patients. This article discusses this strategy and compares it to a theory of ethics called casuistry. We suggest that by using the method of experiences combined with casuistry in a more systematic way, nurses can develop acceptable solutions for difficult care situations in nursing homes.     

Solving ethically difficult care situations in nursing homes

Patients in nursing homes sometimes give accounts of episodes in which they feel their autonomy and/or self-respect are violated as a result of the care they receive from nursing staff. In these ethically difficult care situations nurses use strategies such as negotiation, explanation and, in some cases, restraint. This study investigates how nurses apply these strategies to resolve ethical dilemmas in such a way that patients experience respect rather than violation. Critical issues that will be discussed include the definition of ethically difficult care situations in nursing homes and the identification of strategies for resolving such situations. Examples of the use of three strategies are presented. The use of negotiation, restraint and explanation are discussed in order to ensure respect for patients' autonomy and thus to optimize health care outcomes.     

Value of implementation science and hybrid implementation research designs for nursing education research: A discussion paper

IntroductionNursing education research is complex and contextualized. The evaluation and impact of educational innovations on students, educators, and educational outcomes are influenced by the complexity of environments. Most interventional research in nursing is designed and implemented without considering the behavioral and contextual issues affecting educational innovations, uptake and change processes, and outcomes. Implementation science has emerged as a valuable methodology for designing and conducting interventional research that has the potential to translate evidence and innovations quickly into practice.PurposeThis paper aims to explore the value of implementation science theories, models, and frameworks and hybrid designs for interventional nursing education research and illustrate how these can be used in nursing education research.MethodsA brief overview of implementation science, the various types of theories, models and frameworks and Hybrid designs are provided. Illustrative examples demonstrating the incorporation of these methodologies in interventional nursing education research are provided.ResultsA brief overview of implementation and its key concepts namely context, implementation strategies, fidelity, outcomes, adaptation, and sustainability is provided. Three types of hybrid designs are discussed with examples in nursing education research.DiscussionThe implications of implementation science for nursing education research are: a) Accelerating uptake of innovations to improve educational outcomes, b) targeting systematic change in individual and organizational behaviour and c) ensuring the sustainability of teaching and learning innovations.ConclusionIncorporating implementation science in nursing education research can optimize the uptake of educational innovations in practice in a sustainable manner. Nurse educators should equip themselves with implementation science skills and develop competencies to enhance the delivery of effective and quality nursing education.     

Healthcare professionals’ experiences with highly qualified nurses working in acute care teams in primary healthcare settings

ObjectiveStrengthening primary healthcare with highly qualified nurses in acute care units or teams is a new Danish initiative intended to detect acute diseases and the deterioration of chronic diseases and to develop treatment for outpatients. This study explores healthcare professionals’ experiences with this initiative.DesignQualitative semi-structured interviews conducted in 2019–2020. Analysis was conducted with a systematic text condensation.SettingThis study is based on an acute care team in one Danish municipality called Acute Team Odense (ATO). ATO delivers acute nursing in patients’ own homes (including nursing homes) in collaboration with different healthcare professionals.SubjectsIndividual interviews with general practitioners (GPs) (n = 15), five focus-group interviews with nurses and nursing assistants from the municipality (n = 19) and one focus-group interview with staff from the emergency department (ED) (n = 10).Main outcomesExperiences of different healthcare professionals’ experiences with ATO.ResultsIn general, all of the participants were very satisfied with the new acute care team and the cross-sectorial possibilities. The GPs usually referred ATO to assessments in which paraclinical equipment, competencies, accessibility, response time and communication were important. The municipal nurses and nursing assistants tended to use ATO if they needed second opinions or acute nurse assistance. The ED most often used ATO to assist with intravenous therapy after an ED visit. All participants reported that ATO increased what could be assessed and treated in patients’ homes, which is central to preventing unnecessary hospitalisations.ConclusionsATO created new possibilities in patient’s homes which potentially might prevent unnecessary hospitalisations.

KEY POINTS

• Acute care units or teams are mandatory in Danish health care, but limited knowledge in the area is found.
• Healthcare professionals found that the acute care teams provided new possibilities to assess and treat patients in their own homes.
• Healthcare professionals experienced that the acute care team potentially prevented hospitalisations by fast clinical nurse assessments with paraclinical tests.

     

Improving healthcare and outcomes for high-risk children and teens: formation of the National Consortium for Pediatric and Adolescent Evidence-Based Practice

Although major healthcare and professional organizations as well as key leaders have long emphasized the importance of evidence-based practice (EBP) in improving patient care and outcomes, the majority of healthcare professionals do not implement EBP. There is a huge gap in time that exists between the generation of research findings and the translation of those findings into clinical practice. Many efficacious interventions are not being used in clinical practice even though research findings suggest that they improve child and adolescent health and development. Conversely, many clinical practices are being implemented without sufficient evidence to support their use. Because of the need to accelerate EBP and to generate evidence to support best practices, the first EBP Leadership Summit focused on children and adolescents was conducted in February 2007. Several nationally recognized EBP experts and healthcare leaders from a number of children's hospitals and colleges of nursing across the U.S. participated in the Summit. This article describes the process used and outcomes generated from this landmark event in child and adolescent healthcare, including the launching of the new National Consortium for Pediatric and Adolescent EBP (NCPAEP). Future directions of the consortium also are highlighted.     

Justifying continuous sedation until death: A focus group study in nursing homes in Flanders,Belgium

Continuous Sedation until Death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, has become a common practice in nursing homes in Flanders (Belgium). Quantitative research has suggested that CSD is not always properly applied. This qualitative study aims to explore and describe the circumstances under which nursing home clinicians consider CSD to be justified. Six focus groups were conducted including 10 physicians, 24 nurses, and 14 care assistants working in either Catholic or non-Catholic nursing homes of varying size. Refractory suffering, limited life expectancy and respecting patient autonomy are considered essential elements in deciding for CSD. However, multiple factors complicate the care of nursing home residents at the end of life, and often hinder clinicians from putting these elements into practice. Nursing home clinicians may benefit from more information and instruction about managing CSD in the complex care situations which typically occur in nursing homes.