Performance of Early Warning Scoring Systems Regarding Adverse Events of Unanticipated Clinical Deterioration in Complementary and Alternative Medicine Hospitals

PurposeThis study aims to examine the performance of early warning scoring systems regarding adverse events of unanticipated clinical deterioration in complementary and alternative medicine hospitals.MethodsA medical record review of 500 patients from 5-year patient data in two traditional Korean medicine hospitals was conducted. Unanticipated clinical deterioration events included unexpected in-hospital mortality, cardiac arrest, and unplanned transfers to acute-care conventional medicine hospitals. Scores of the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and National Early Warning Score 2 (NEWS2) were calculated. Their performance was evaluated by calculating areas under the receiver-operating characteristic curve for the event occurrence. Multiple logistic regression analyses were performed to determine the factors associated with event occurrence.ResultsThe incidence of unanticipated clinical deterioration events was 1.1% (225/21101). The area under the curve of MEWS, NEWS, and NEWS2 was .68, .72, and .72 at 24 hours before the events, respectively. NEWS and NEWS2, with almost the same performance, were superior to MEWS (p = .009). After adjusting for other variables, patients at low-medium risk (OR = 3.28; 95% CI = 1.02–10.55) and those at medium and high risk (OR = 25.03; 95% CI = 2.78–225.46) on NEWS2 scores were more likely to experience unanticipated clinical deterioration than those at low risk. Other factors associated with the event occurrence included frailty risk scores, clinical worry scores, primary medical diagnosis, prescribed medicine administration, acupuncture treatment, and clinical department.ConclusionsThe three early warning scores demonstrated moderate-to-fair performance for clinical deterioration events. NEWS2 can be used for early identification of patients at high risk of deterioration in complementary and alternative medicine hospitals. Additionally, patient, care, and system factors need to be considered to improve patient safety.     

The daily relationships between staffing,safety perceptions and personality in hospital nursing: A longitudinal on-line diary study

BackgroundThe association between poor staffing conditions and negative patient safety consequences is well established within hospital nursing. However, many studies have been limited to nurse population level associations, and have used routine data to examine relationships. As a result, it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis. Furthermore, personality may have direct and moderating roles in terms of work environment and patient safety associations, but limited research has explored personality in this context.ObjectiveTo further our understanding of these associations, this paper takes a within-person approach to examine nurses’ daily perceptions of staffing and patient safety. In addition, we explore the potential role of personality factors as moderators of daily level associations.MethodWe recruited eighty-three hospital nurses from three acute NHS Trusts in the UK between March and July 2013. Nurses completed online end-of-shift diaries over three–five shifts which collected information on perceptions of staffing, patient–nurse ratio and patient safety (perceptions of patient safety, ability to act as a safe practitioner, and workplace cognitive failure). Personality was also assessed within a baseline questionnaire. Data were analysed using hierarchical linear modelling, and moderation effects of personality factors were examined using simple slopes analyses, which decomposed relationships at high and low levels of the moderator.ResultsOn days when lower patient–nurse ratios were indicated, nurses reported being more able to act as a safe practitioner (p = .011) and more favourable perceptions of patient safety (p = <.001). Additionally, when staffing was perceived more favourably, nurses reported being more able to act as a safe practitioner (p = <.001), more favourable perceptions of patient safety (p = <.001) and experienced less workplace cognitive failure (p = <.001). Conscientiousness and emotional stability emerged as key moderators of daily level associations between staffing and patient safety variables, with many relationships differing at high and low levels of these personality factors.ConclusionThe findings elucidate the potential mechanisms by which patient safety risks arise within hospital nursing, and suggest that nurses may not respond to staffing conditions in the same way, dependent upon personality. Further understanding of these relationships will enable staff to be supported in terms of work environment conditions on an individual basis.     

Effectiveness of a training intervention to improve communication between/awareness of team roles: A randomized clinical trial

BackgroundInterprofessional teamwork training of nursing undergraduates is essential to improving healthcare. The absence of clear role definitions and poor interprofessional communications have been listed as the main reasons behind abandonment of the profession by recently graduated nurses.PurposeThe aim of this parallel randomized clinical trial was to evaluate the impact of Situation-Background-Assessment-Recommendation (SBAR) role-play training on interprofessional teamwork skills (role-related and communication-related) and non-technical skills (patient assessment, patient intervention, patient safety, and critical thinking).MethodThe intervention group were taught teamwork skills, role and task assignment skills, and use of the SBAR worksheet in a 1-hour role-play training session, while the control group received conventional lecture-based training. Teamwork and non-technical skills were then assessed in high-fidelity simulation scenarios using the KidSIM Team Performance Scale (teamwork skills) and the Clinical Simulation Evaluation Tool (non-technical skills). Cohen's d (d) was used to examine effect size differences.ResultsCompared to the control group, the intervention group improved in 4 teamwork items – ‘verbalize out loud’ (p < 0.001, d = 0.99), ‘paraphrase’ (p < 0.001, d = 0.77), ‘cross-monitoring’ (p < 0.001, d = 0.72), and ‘role clarity’ (p = 0.002, d = 0.66) – and in a single non-technical skill (patient intervention: p = 0.004, d = 0.66), while also reporting greater confidence in performing patient assessments (p = 0.02, d = 0.56).ConclusionsRole-play and SBAR training for undergraduate nurses improved patient intervention, enhanced information sharing in an interprofessional team, and raised awareness of their own and other team members' roles.     

Nursing student and faculty competency improvement through a nurse-bridging program in Cambodia

BackgroundAn adequate number of high-quality nurses are a key factor for superior patient outcomes. However, in 2015, Cambodia reported only 52 nurses with bachelor's degrees, three with master's degrees, and one with a doctorate. The fast track to getting a highly educated nursing workforce requires providing a bridging program for associate's degree nurses to achieve baccalaureate degrees.ObjectivesTo assess improvement in the competency of nursing students and faculty members through a program that prepares associate's degree nurses to obtain bachelor's degrees in Cambodia.DesignMixed methods.SettingEducational institutes in Phnom Penh, Cambodia.ParticipantsA total of 45 Cambodian nursing students participated in the Cambodian nurse-bridging program and 12 Cambodian faculty members served as co-teachers.MethodsWe conducted three surveys to compare the competence of nursing students and faculty members before, during, and after the bridging program. We conducted focus-group interviews to support the qualitative results and explored changes in student and faculty competencies after the program.ResultsQuantitative analysis revealed significant improvements in students' nursing competency (p < .001), critical thinking (p < .001), and research competency (p < .001) and faculty members' teaching competency (p < .001) and research competency (p < .001) after the program. Through qualitative analysis, students showed improvement in physical assessment, patient communication, critical thinking, evidence-based nursing, and research competency. Faculty members indicated they had experienced new teaching strategies and subjects, gained increased confidence in teaching, and even though research competency had been improved, more training was required.ConclusionsThis study provides evidence to support the effectiveness of higher nurse education in developing countries, and illustrates an opportunity to produce high-quality human resources in nursing.     

Mock trials and web-based education using malpractice cases: A randomised controlled trial

BackgroundWeb-based education using malpractice cases is increasingly used as an effective program to improve nurses' patient safety competency, and education on legal obligations is vital for nursing students.AimTo evaluate the effectiveness of web-based education using mock trials of medical malpractice cases in improving nursing students' legal obligations, patient safety competency, and critical thinking.MethodsForty-three senior nursing students were randomly assigned to be exposed to blended learning of mock trials (4 weeks) and web-based education (4 weeks) in experimental group (n = 23), and web-based education (4 weeks) alone in control group (n = 20). Pre-test (before randomisation) and post-test (after intervention) data were collected at a university in Korea between October and December 2019.ResultsThere were statistically significant differences in patient safety competencies (t = 3.59, P = 0.001), including skills (t = 2.89, P = 0.006) and knowledge (t = 2.60, P = 0.013), as well as a significant difference in critical thinking disposition (t = 3.09, P = 0.004) between the two groups in the pre−post changes. The two groups had no difference in knowledge and cognition of legal obligation.ConclusionBlended learning of mock trials and web-based education can enhance nursing students' patient safety competency. In particular, mock trials are an active participatory learning method that helps nursing students develop critical thinking skills to ensure patient safety competency compared to web-based education alone. Incorporating mock trial education using medical malpractice cases into the curriculum could enhance nursing students' patient safety competency and critical thinking disposition.     

Clinicians’ attitudes towards escalation and management of deteriorating patients: A cross-sectional study

BackgroundInternationally, rapid response systems have been implemented to recognise and categorise hospital patients at risk of deterioration. Whilst rapid response systems have been implemented with a varying amount of success, there remains ongoing concern about the lack of improvement in the escalation, and management of the deteriorating patient. It also remains unclear why some clinicians fail to escalate concerns for the deteriorating patient.ObjectiveThe objective of this study was to explore clinicians’ attitudes towards the escalation, and management of the deteriorating patient.MethodsA cross-sectional online survey of conveniently sampled clinicians from the acute care sector in a regional health district in Australia was conducted. The Clinicians’ Attitudes towards Responding and Escalating care of Deteriorating patients scale, was used to explore attitudes towards the escalation and management of the deteriorating patient.ResultsSurvey responses were received from medical officers (n = 43), nurses (n = 677), allied health clinicians (n = 60), and students (n = 57). Years of experience was significantly associated with more confidence responding to deteriorating patients (p < .001) and significantly less fears about escalating care (p < .001). Nurses (M = 4.16, SD = .57) and students (M = 4.11, SD = .55) in general had significantly greater positive beliefs that the rapid response system would support them to respond to the deteriorating patient than allied health (M = 3.67, SD = .64) and medical (M = 3.87, SD = .54) clinicians, whilst nurses and medical clinicians had significantly less fear about escalating care and greater confidence in responding to deteriorating patients than allied health clinicians and healthcare students (p < .001).ConclusionNurses and medical officers have less fear to escalate care and greater confidence responding to the deteriorating patient than allied health clinicians and students. Whilst the majority of participants had positive perceptions towards the rapid response system, those with less experience lacked the confidence to escalate care and respond to the deteriorating patient.     

Improving Door-to-Groin Puncture Time through Nursing Role Delineation during Emergent Endovascular Ischemic Stroke Thrombolysis Treatment

Although the associated mortality from acute ischemic stroke (AIS) is declining, stroke remains one of the leading causes of death and disability within the United States. Endovascular thrombectomy (EVT) is the standard of care for AIS in which patient outcomes remain dependent upon early, rapid, and efficient treatment. Due to the urgent nature of EVT, evidence-based safety measures were not completed by the nurses participating in emergent stroke care, breakdowns in teamwork and communication occurred, and patient safety was compromised. This process improvement project was undertaken to evaluate if communication and teamwork would improve through the implementation of evidence-based role delineation during emergent EVT, which in turn would lead to increased efficiency leading to improved door-to-groin puncture time (DTGP). The project was implemented in an interventional radiology department at a primary stroke center in Arizona. The participating radiology registered nurses (RNs) partook in a pre-intervention 10-point Likert scale survey to measure their perceptions of the current clinical teamwork skills and communication. The RNs then attended a 30-minute educational workshop, introducing the newly defined roles. Five weeks post-implementation of the defined roles the RNs completed the post-intervention survey. In order to evaluate the effect of improved nursing communication, and teamwork on DTGP, retrospective DTGP time data was extracted from the organizations internal stroke data quality improvement base prior to implementation of role delineation and 5 weeks of data post-implementation. The results showed a 20.17% change in responses to the post-intervention survey questions, indicating a positive statistically significant change (p = .002) toward teamwork and communication. The post-intervention DTGP time (M = 16.111 minutes) was 1.8998% less than the pre-intervention DTGP time (M = 16.4231 minutes). The results indicated that with a p-value of .850, there was no statistically significant difference in DTGP time after implementation of RN role delineation indicating that through defining nursing roles treatment remained timely and efficient.     

Role Delineation of the Code Blue Team: A Quasi-Experimental Study During COVID-19

IntroductionThe purpose of this study was to assess if implementing a code role delineation intervention in an emergency department would improve the times to defibrillation and medication administration and improve the nurse perception of teamwork.MethodsA quantitative quasi-experimental study used a retrospective chart review to gather data. A pre- and post-test measured nurse perception of teamwork in a code using the Mayo High Performance Teamwork Scale (MHPTS) after a code role delineation intervention using a paired samples t-test. Pearson r correlations were used to determine relationships between nurse participant (N = 30) demographics and results of the MHPTS scores.ResultsA significant increase in teamwork was noted in 5 of the 16 items on the MHPTS regarding improved communication and identified roles in a code: the team leader assures maintenance of an appropriate balance between command authority and team member participation (t = −5.607, P < .001), team members demonstrated a clear understanding of roles (t = −5.415, P < .001), team members repeat back instructions and clarifications to indicate that they heard them correctly (t = −2.400, P = .029), all members of the team are appropriately involved and participate in the activity (t = −2.236, P = .041), and conflicts among team members are addressed without a loss of situation awareness (t = −2.704, P = .016). There was significance between total pre- and post-test scores (t = −3.938, P = .001).DiscussionImplementation of code role delineation identifiers is an effective method of improving teamwork in a code in an emergency department setting.     

Delivering culturally competent care to the lesbian,gay, bisexual,and transgender (LGBT) population: Education for nursing students

PurposeDespite well-documented healthcare disparities in the lesbian, gay, bisexual, and transgender (LGBT) community, nursing education has lagged other health professions in promoting culturally competent care to members of this minority group.MethodsUsing national guidelines, the author developed an educational program for BSN students to improve competency in providing care for LGBT individuals. One hundred twenty-four students completed online modules and a simulation exercise, which explored LGBT healthcare topics. One hundred eight participants completed surveys pre-, post-, and 1 month after the intervention.ResultsOverall LGB competence scores improved from pre- (M = 4.42) to post-test (M = 5.20) and did not significantly decrease at one-month (M = 5.03, p < .001). Similar findings were observed in the transgender cultural competence scores (pre- (M = 4.02); post- (M = 5.08); one-month (M = 4.92, p < .001)).ConclusionEducational content focused on cultural competency for nurses may lead to improved health outcomes among the LGBT community.     

Effectiveness of a role-play simulation program involving the sbar technique: A quasi-experimental study

BackgroundAccurate, skilled communication in handover is of high priority in maintaining patients' safety. Nursing students have few chances to practice nurse-to-doctor handover in clinical training, and some have little knowledge of what constitutes effective handover or lack confidence in conveying information.ObjectivesThis study aimed to develop a role-play simulation program involving the Situation, Background, Assessment, Recommendation technique for nurse-to-doctor handover; implement the program; and analyze its effects on situation, background, assessment, recommendation communication, communication clarity, handover confidence, and education satisfaction in nursing students.DesignNon-equivalent control-group pretest-posttest quasi-experimental.ParticipantsA convenience sample of 62 senior nursing students from two Korean universities.MethodThe differences in SBAR communication, communication clarity, handover confidence, and education satisfaction between the control and intervention groups were measured before and after program participation.ResultsThe intervention group showed higher Situation, Background, Assessment, Recommendation communication scores (t = − 3.05, p = 0.003); communication clarity scores in doctor notification scenarios (t = − 5.50, p < 0.001); and Situation, Background, Assessment, Recommendation education satisfaction scores (t = − 4.94, p < 0.001) relative to those of the control group. There was no significant difference in handover confidence between groups (t = − 1.97, p = 0.054).ConclusionsThe role-play simulation program developed in this study could be used to promote communication skills in nurse-to-doctor handover and cultivate communicative competence in nursing students.     

The relationship between the undergraduate clinical learning environment and work readiness in new graduate nurses: A pre-post survey study

BackgroundDue to projected nurse shortages, it is necessary that undergraduate programs optimise work readiness outcomes in new graduate nurses. Research that quantitatively evaluates characteristics of clinical nursing programs that predict increased work readiness is required.ObjectivesTo explore the relationship between the undergraduate clinical learning environment and nurse perceptions of work readiness prior to and following, commencement as a new graduate nurse.DesignA pre-post follow-up study. Undergraduates were surveyed at the end of their Bachelor's degree (baseline) and at 8–10 weeks after commencement as a graduate nurse (Time 1).SettingA multi-site, metropolitan private hospital in Victoria, Australia.ParticipantsNursing graduates who completed a university fellowship program (n = 26), or were undertaking their graduate year and had completed placement blocks within (n = 18) or outside (n = 31) the healthcare organisation.MethodsParticipants self-completed the Clinical Learning Environment Inventory (CLEI) and Work Readiness Scale for Graduate Nurses (WRS-GN) at baseline and Time 1. Multiple regression analyses were performed.ResultsCLEI scores significantly predicted work readiness outcomes (all p-values<.05), accounting for 16–36% and 17–28% of the variance of WRS-GN scores at baseline and Time 1, respectively. After adjusting for clustering due to clinical placement groups, CLEI Individualisation (p = .023) and Valuing Nurses Work (p = .01) predicted improved Time 1 WRS-GN Organisational Acumen. CLEI Innovative and Adaptive Culture scores predicted poorer Time 1 Organisational Acumen (p = .001).ConclusionsLearning environments that offered high levels of individualised attention and valued nurses' work appeared to facilitate post-graduation engagement and identification with nursing practice. However, highly innovative and adaptive education may detract from optimal work readiness. Findings revealed that while important, the clinical learning environment only accounted for a small-to-moderate degree of nursing graduates' work readiness. To facilitate robust evidence-based improvement of clinical nursing education, future research should attempt to empirically establish the value of additional facilitators of work readiness.     

Evaluation of a nurse-led education program to improve cross-cultural care for older people in aged care

BackgroundCultural diversity is significant in aged care facilities. Registered nurses play a leading role in the care setting. Nurse-led education interventions to improve the cultural competence of aged care workers are in high demand.AimThe aims of the study were to evaluate the effect of a nurse-led cross-cultural care program on cultural competence of Australian and overseas-born care workers.DesignA pre- and post-evaluation design and a sub-group analysis.Settings and participantsThis study was undertaken in four large-sized aged care facilities in Australia. Direct care workers were invited to participate in the study.MethodsThe intervention lasted 12 months. Data were collected at baseline, 6 months and 12 months using the Clinical Cultural Competency Questionnaire and site champion reports. One-way ANOVA was applied to determine the changes of outcomes over time for the whole group. A mixed effect linear regression model was applied in the sub-group analyses to compare the differences of outcomes between the Australian-born and overseas-born groups.ResultsOne hundred and thirteen staff participated in the study including Australian-born (n = 62) and overseas-born (n = 51). Registered nurses were trained as site champions to lead the program. The results showed a statistically significant increase in participants' scores in Knowledge (p = .000), Skills (p = .000), Comfort Level (p = .000), Importance of awareness (p = .01) and Self-Awareness (p = .000) in a 12-month follow-up. The increased scores in the Skills (p = .02) and Comfort Level (p = .001) were higher in the Australian-born group compared to the overseas-born group. The results also showed a statistically significant increase in participants' overall satisfaction scores with the program at 12 months (p = .009). The overseas-born group demonstrated a higher score in Desire to Learn More (p = .016) and Impact of the Program on Practice (p = .014) compared to the Australian-born group.ConclusionA nurse-led cross-cultural care program can improve aged care workers' cultural competence.     

Strict versus liberal insulin therapy in the cardiac surgery patient: An evidence-based practice development,implementation and evaluation project

BackgroundHyperglycemia post-cardiac surgery is associated with poor clinical outcomes. Recent studies suggest maintaining liberal glycemic control (< 180 mg/dL) using a continuous insulin infusion (CII) versus strict control achieves optimal outcomes and prevents hypoglycemia.PurposeTo develop, implement and evaluate a nurse managed liberal CII protocol.MethodsRetrospective review of 144 strict CII patient records and 147 liberal CII patient records.ResultsMean blood glucose was 159.8 mg/dL (liberal CII) compared to 143.3 mg/dL (strict CII) (p ≤ 0.001). No surgical site infections occurred in either group. Mean ICU length of stay was 4.5 days (liberal) versus 4.4 days (strict) (p = 0.74). Two 30-day mortalities occurred for the liberal cohort compared to no deaths in the strict group (p = 0.49). Hypoglycemia incidence within 24 h after surgery was 0.1% (liberal) compared to 0.3% (strict) compared to (p = 0.16).ConclusionUse of a nurse managed liberal CII resulted in similar outcomes with fewer incidents of hypoglycemia.     

Impacto de la ratio paciente-enfermera en los resultados de salud en los hospitales públicos del Servicio Andaluz de Salud. Estudio ecológico

AimTo analyse the patient-nurse ratio and its association with health outcomes in public hospitals of the Andalusian Health Service (SAS).MethodCross-sectional ecological study carried out in adult units of 26 Andalusian public hospitals. Data on structure (beds, type of unit, nursing control), management (average stay, index of use of stays, complexity index) and nursing staff were collected. They were extracted from official sources: CMBDA, SAS/Health Council (CS) publications and specific respondents to Nursing Directorates. The patient-nurse ratio was calculated and related to 19 indicators of hospital quality, safety, and mortality. Measures of central tendency and Spearman's correlation coefficient were used for statistical analysis.ResultsA response was obtained from 100% of the Andalusian hospitals. The average patient-nurse ratio in the three shifts was lower in hospitals with a broader portfolio of services-regional scope (11.6), followed by those with a medium portfolio-specialties (12.7) and hospitals with a basic portfolio- county (13.5). By type of unit, the medical units were 11.8 (SD = 1.8) lower than the surgical ones 13.5 (SD = 2.7). Significant differences were only found in medical units of regional hospitals 10.5 (SD = 1.4) and district hospitals 13.03 (SD = 1.46) (p = .001). In critical care, the ratio was greater than 2 patients per nurse in the three groups. When relating the ratio to health outcomes, 5 significant associations were found: pressure ulcers (p = .005), prevalence of nosocomial infections (p = .036), postoperative sepsis (p = .022), zero bacteraemia verification (p = .045) and mortality from heart failure (p = .004).ConclusionsThe results indicate a high patient-nurse ratio in adult hospitalization units and that there is a positive association between the patient-nurse ratio and worse results related to nursing care.