Using trauma informed care as a nursing model of care in an acute inpatient mental health unit: A practice development process

Without agreeing on an explicit approach to care, mental health nurses may resort to problem focused, task oriented practice. Defining a model of care is important but there is also a need to consider the philosophical basis of any model. The use of Trauma Informed Care as a guiding philosophy provides a robust framework from which to review nursing practice. This paper describes a nursing workforce practice development process to implement Trauma Informed Care as an inpatient model of mental health nursing care. Trauma Informed Care is an evidence‐based approach to care delivery that is applicable to mental health inpatient units; while there are differing strategies for implementation, there is scope for mental health nurses to take on Trauma Informed Care as a guiding philosophy, a model of care or a practice development project within all of their roles and settings in order to ensure that it has considered, relevant and meaningful implementation. The principles of Trauma Informed Care may also offer guidance for managing workforce stress and distress associated with practice change.     

Appreciating and developing compassionate care in an acute hospital setting caring for older people

dewar b. & MacKay R. (2010) Appreciating and developing compassionate care in an acute hospital setting caring for older people. International Journal of Older People Nursing
5 , 299–308
doi: 10.1111/j.1748-3743.2010.00251.x Background. There is increasing emphasis in policy, research and practice on the importance of caring in health care. Indeed there is much debate about how to enhance the caring cultures within which health care is provided. This paper argues that a proper systematic analysis of caring practice that works well in care environments may help us to move towards a realistic model for the future which supports staff, patients and families to give and receive compassionate care. Aim. The aim of the project was to explore, develop and articulate strategies that enhanced compassionate relationship centred care in an acute hospital setting, caring for older people. Methods. Appreciative action research informed the development and evaluation of the project. A range of data generation activities were used to examine what worked well. Following detailed analysis key processes emerged as being central to delivery of compassionate care. Specific action projects were implemented and evaluated to enhance these processes necessary for compassionate caring. Findings. Data from the project helped to articulate the special and often hidden acts that make up compassionate care. In relation to the process of ‘knowing who I am and what matters to me’ data provided evidence of the value of this process and the potential impact to care. In addition data about the process of doing appreciative action research helped to realise its application and relevance in the health care setting. Conclusions. Findings from this work suggest that there are a number of significant processes that help people to deliver compassionate care. These need to be articulated, shared more widely across practice, policy and education so that we can build on this excellent practice. Implications for practice. Appreciative action research adopted in this project is an important methodology to supporting practitioners to identify what it is they do well and develop practice to try to make the best caring practice happen most of the time. Academics, policy makers and practitioners should consider the approach of appreciative action research as key to supporting developments in care.     

Achieving Magnet accreditation in the UK: a case study at Rochdale NHS Trust

AIMS: This study explored the Magnet accreditation process in the first health care organization outside the USA to attempt to gain the award, Rochdale NHS Trust United Kingdom. The development was supported by the American Nurses Credentialing Center as a pilot project and the research conducted as a case study in organizational response to the requirements of a new accreditation system. METHOD: Information was collected via 23 face-to-face and three telephone interviews carried out with 11 senior figures at Rochdale during the 2-year period of the Magnet project, from field notes of meetings attended by the researchers and from analysis of documents associated with the project. RESULTS: The work of applying for Magnet accreditation built upon a previous 2-3 year programme of shared governance and clinical leadership throughout the Trust which senior staff felt had been an essential foundation for the Magnet project. The process enabled staff to assemble evidence which held up a mirror to their practice and contributed to other quality-related initiatives. The experience at Rochdale suggests that Magnet enables care areas to identify and celebrate examples of good practice and for lessons to be learned and shared within the organization. Although the Magnet concept is primarily nursing oriented, medical and allied health professionals were able to contribute and benefit. The application was successful and Rochdale was awarded Magnet status in April 2002. CONCLUSIONS: The Magnet project at Rochdale was essentially a process of collecting evidence to formally recognize previous leadership initiatives and their effects within the organization. The emergent approach to implementing the Magnet project was one which attempted to integrate and utilize existing systems and resources. The project provides evidence that Magnet can be transferred to non-US health care systems. The principal issues associated with this transfer were the costs incurred, the interpretation of terminology and the engagement of medical and allied health professionals.     

Improving care planning in oncology nursing practice

This article describes a practice development project undertaken in an acute oncology unit in a large teaching hospital in Scotland. The project was designed to address care planning practice in the unit by introducing a pilot intravenous access care plan. The article discusses the review and audit process of the care plans previously used in the unit. The findings are discussed and areas for improvement and recommendations for future practice are outlined.     

Using evidence-based practice to create a venous access team: the Venous Access Task Force of the Children's Hospital of Denver

The following article is an example of evidence-based practice applied to an institutional Quality Improvement (QI) project. QI originated in the 1980s and is best associated with the work of W. Deming (1986). It is also known as Continuous Quality Improvement, because a major principle of this approach is constant improvement of services or products. This improvement process contains other critical components: scientific method, employee participation and teamwork, accountable leadership, appropriate training and ongoing education, and client focus (Demming, 1986). QI has been globally successful and has helped transform American industry, including health care services. The following clinically based project illustrates the application of QI concepts and evidence-based practice to enhance outcomes.     

Using evidence-based practice to create a venous access team

The following article is an example of evidence-based practice applied to an institutional Quality Improvement (QI) project. QI originated in the 1980s and is best associated with the work of W. Deming (1986). It is also known as Continuous Quality Improvement, because a major principle of this approach is constant improvement of services or products. This improvement process contains other critical components: scientific method, employee participation and teamwork, accountable leadership, appropriate training and ongoing education, and client focus (Demming, 1986). QI has been globally successful and has helped transform American industry, including health care services. The following clinically based project illustrates the application of QI concepts and evidence-based practice to enhance outcomes.     

Development of a framework for person-centred nursing

This paper presents the development and content of a person-centred nursing framework. BACKGROUND AND RATIONALE: Person-centred is a widely used concept in nursing and health care generally, and a range of literature articulates key components of person-centred nursing. This evidence base highlights the links between this approach and previous work on therapeutic caring. METHODS: The framework was developed through an iterative process and involved a series of systematic steps to combine two existing conceptual frameworks derived from empirical studies. The process included the mapping of original conceptual frameworks against the person-centred nursing and caring literature, critical dialogue to develop a combined framework, and focus groups with practitioners and co-researchers in a larger person-centred nursing development and research project to test its face validity. FINDINGS: The person-centred nursing framework comprises four constructs -prerequisites, which focus on the attributes of the nurse; the care environment, which focuses on the context in which care is delivered; person-centred processes, which focus on delivering care through a range of activities; and expected outcomes, which are the results of effective person-centred nursing. The relationship between the constructs suggests that, to deliver person-centred outcomes, account must be taken of the prerequisites and the care environment that are necessary for providing effective care through the care processes. CONCLUSION: The framework described here has been tested in a development and research project in an acute hospital setting. Whilst there is an increasing empirical base for person-centred nursing, as yet little research has been undertaken to determine its outcomes for patients and nurses. The framework developed can be described as a mid-range theory. Further testing of the framework through empirical research is required to establish its utility for nursing practice and research.     

Best practices in stroke care

In 2001, the Ontario Ministry of Health and Long-Term Care introduced the Ontario Stroke Strategy by designating regional stroke centres across the province. The primary role of these centres is to coordinate stroke care within the region and across the care continuum in keeping with best practices. Concurrently, Trillium Health Centre was identifying best practice projects to support its ongoing quest for excellence. With Trillium designated as a regional stroke centre, acute ischemic stroke care was an obvious choice for a best practice project. The aim of the project was to improve access to care and quality of care for stroke patients from emergency through acute care to in-patient rehabilitation. The team chose the rapid cycle change methodology. This approach to quality improvement advocates the testing of a series of small changes (i.e., process improvement ideas) in tandem with measurements to assess the impact of the change to drive further process improvements. The project was deemed a success, resulting in significant improvements in the timeliness and quality of care.     

Developing preceptorship through action research: Part 1

Clinical preception in practice plays a significant role in both registered and practical nurse studies. As such, the cooperation between the faculty and working life is important to narrow the theory–practice gap, with emphasis being placed on a student‐oriented approach promoting self‐direction and lifelong learning. The aim of this project was to develop the preceptorship at five different units within the health‐care sector in western Finland by implementing an action research (AR) approach. This article is the first of a two‐part article on the project, focusing on a cultural analysis and the development of preception models conducted within the project. The five units participating in the study were the following: a long‐term care ward in the community, a ward for people with dementia, a geriatric ward, a medical ward and a surgical ward representing specialised care. The starting point of the study was a cultural analysis, which was made in all the five units to obtain a ‘bottom‐up’ perspective. In each of the five units 3–5 nurses were appointed to become members of the core groups. This meant that all the units would start from the perspective of their own working environment when creating a preception model that would fit into their particular workplace. During this process, the participants received continuous support from the researchers. Several workshops and seminars were also arranged to further support the core groups and staff. The models were implemented and tested during the academic year 2010–2011 followed by an evaluation of the project. The evaluation results will be presented in the second part of the two‐part article. The project showed that reflective practice and critical thinking can be improved through an AR approach.     

Outcomes steering practice: When the ends determine the means

Carberry C. International Journal of Nursing Practice 1998; 4: 2–8
Outcomes steering practice: When the ends determine the means
A discussion of outcomes and outcomes measurement will be presented through an examination of achievements of a collaborative project awarded a federal best practice grant in 1995. The project, which established a new service for women of nonEnglish-speaking background, was part of a national venture which sought to benchmark best practice in the primary health care field. The process of benchmarking demanded that the approach to outcomes and outcomes measurement adopted by the project participants be articulated. The approach adopted acknowledges that outcomes are affected by the processes involved in care, which in turn are dependent upon the organisational environment in which care is offered and experienced. Both these contributing factors to outcomes can be hard to measure and, therefore, could be at risk of being omitted from the outcome equation in these economically stringent times. This paper aims to contribute to debate on the topic by recommending an approach to outcomes measurement which is comprehensive, values quality and embraces the short, medium and longer term.     

A decade on: has the use of integrated care pathways made a difference in Lanarkshire?

This article aimed to: (1) review the work carried out in Lanarkshire between 1996 and 1999 on a Scottish Executive funded project and (2) to discuss the situation from 1999 to 2006. (1) This 3-year project led to the successful development and implementation of over 100 integrated care pathways in an urban teaching hospital (Glasgow) and a district general hospital (Lanarkshire) and was the first in-depth study of integrated care pathways to be undertaken in Scotland. The main report on the project was produced in 1999 (Clinical Audit and Quality using Integrated Pathways of Care) and reported increased adherence to British Thoracic Society and Scottish Intercollegiate Guidelines Network guidelines and multiple best practice statements, and improved standards of documentation. The general findings were that process indicators were improved by integrated care pathway use and there was some suggestion of improved length of stay with no apparent effect on outcome. Evidence was found that integrated care pathways have made a difference for both patients and staff. (2) This provides an update of integrated care pathway development in a changing environment within NHS Lanarkshire and examines some of the key factors for success.     

The development of a conceptual framework for advancing cancer nursing practice in Europe

Continued professional development through formal education programmes is essential for improving the quality of care provided to patients with cancer. This paper describes a European Oncology Nursing Society project concerned with advanced cancer nursing education. While the development of an education programme for advanced cancer nursing practice in Europe proves difficult at this time, this project has provided the opportunity to examine some of the key elements of advanced cancer nursing work. In turn, the information gained has enabled the development of a conceptual framework for advancing cancer nursing practice in Europe to be constructed.     

Sharing good practice in the care of older people

Good nursing care, informed by best practice, is an integral part of achieving positive health outcomes for older people. The first article in a two-part series on gerontological nursing discusses collaboration between higher education and clinical practice which aims to improve practice in the specialty. It outlines the development of a Scottish project that promoted such an exchange of information by holding regular forums. The project has been a success and it is hoped that it will lead to the establishment of a centre of excellence for gerontological care. Next week's article focuses on the shared approach to care.     

Re-thinking approaches to undergraduate health professional education: Interdisciplinary Rural Placement Program

The Interdisciplinary Rural Placement Program involved the development, implementation and evaluation of a common rural primary health care module. Designed for undergraduate nursing, medical and pharmacy students of the University of Tasmania, students undertook clinical experiences and a collaborative primary health care project at two different Rural Health Teaching Sites across Tasmania. The aim of the project was for interdisciplinary students to work and learn together to enhance their understanding of the cooperative and collaborative nature of professional practice among rural health care workers. This paper will describe the development and implementation of the Interdisciplinary Rural Placement Program and critically discuss the outcomes in relation to nursing. In this paper, three issues will be explored. Firstly, how student nurses questioned their sense of subordination when in fact the level of recognition by their interdisciplinary peers led them to refute this. Secondly, concerns with overcoming the difficulties of coordinating student recruitment and conflicting timetables, while working within existing curricula, will be discussed. The final issue explores the student nurses' recognition that despite inherent tensions and conflict, the need to work as a cohesive and cooperative interdisciplinary team was vital. This project highlighted the challenges that health professions continue to work through in contemporary practice and education sectors. A key recommendation for education providers is that true interdisciplinary education must be achieved through an experiential framework.     

Moving forward together: evaluation of an action group involving staff and relatives within a nursing home for older people with dementia

Background.  This paper describes the implementation and evaluation of an action group within a nursing home for older people with dementia. Over a two-year period, researchers worked with staff, residents and relatives on a series of initiatives aimed at improving experiences of living and working within the home. The action group, involving staff, residents and their relatives was the vehicle through which a number of important changes were achieved. The project was underpinned by ideas about relationship-centred care and the Senses Framework.
Methods.  A constructivist methodology informed both the initial development and the evaluation of the project. This paper reports findings from interviews with staff and relatives and process recordings of group discussions.
Findings.  Data from the evaluation provide evidence of ways in which the project has contributed to creating the senses (security, significance, belonging, purpose, continuity and achievement) for each of the key stakeholder groups. Factors supporting and hindering the project were also identified.
Conclusions.  The development approach using the Senses Framework adopted within the project is a useful model for partnership working in settings providing continuing care for older people.
Relevance to clinical practice.  Findings from this small-scale but intensive project suggest that staff within care homes should seek to engage with a range of stakeholders in order to improve experiences for all involved in long-term care. Academic staff within schools of nursing should consider innovative, action-oriented approaches to supporting developments within care homes.     

The characteristics,qualities and skills of practice developers

There is a growing interest in practice development as a systematic process for the development of quality patient care. Whilst there is a range of accounts of practice development in the literature, little work has been undertaken to develop an understanding of the systems and processes involved and there is even less on the roles involved in practice development. This paper explores in particular the characteristics, qualities and skills of practice developers, i.e. professionals who have formal responsibility for developing practice in organizations. The paper represents part of a larger study exploring the conceptual basis of the term 'practice development'. Data for this part of the project were collected through literature analysis, seven focus groups involving 60 practice developers and telephone interviews with 25 practising nurses with experience of working with practice developers. The data were analysed using cognitive mapping processes. Four role functions are presented in the paper, as well as qualities and skills needed to operationalize the identified role functions. A clear picture of the skills and qualities required by practice developers emerges from the data.     

Admiral nursing competency project: practice development and action research

Aims and background. Admiral Nurses are specialist dementia care nurses working in the community with carers of those who have a dementia. The aim of the competency project (2000–2003) was threefold. Firstly to work collaboratively with these specialist nurses to facilitate the development a competency framework that reflects the needs of the Admiral Nursing Service. Secondly, to provide a way to structure evidence demonstrating evolving competency. Thirdly, to specifically enable the nurses to demonstrate evidence of achieving the UK Nursing and Midwifery Council's Higher Level Practice standard. Design and methods. The two complementary approaches of emancipatory action research and systematic practice development were adopted. Methods were taken from action research and systematic practice development approaches with an emphasis on promoting and enabling enlightenment, critical reflection, ownership and creating the best conditions for long‐term commitment to the competency framework. Results. The main outcome from this project was the development of a specialist nursing competency framework. The Admiral Nurses’ Competency Framework is made up of a set of eight core competencies with three levels of competency statements, loosely structured around the Higher Level Practice standard, and guidance documentation to illustrate how work‐based evidence can be generated to demonstrate competence. There were also process‐derived outcomes associated with combining systematic practice development with emancipatory action research that had an impact on the culture. The main outcomes here were that practitioners engaged in and experienced learning about how to research their own practice and the consequences of doing this. They also learnt about specialist nursing practice more widely than Admiral Nursing. Finally, there was some increase in awareness about the culture within their teams and organizations. The final competency framework reflects the needs of the service, is owned by the majority of practitioners and project commissioners and this has had a positive impact on implementation. Conclusion. In this paper, we report on combining systematic practice development with action research to achieve immediate project aims. In addition we show how a project of this nature can contribute to developing skills in practitioners necessary for cultural changes in practice and contributes to wider issues of modernization within nursing and health care. Relevance to clinical practice. This competency framework will enable Admiral Nurses to demonstrate their level of specialist practice, as individuals and collectively as a service and it also promotes the principles of nurses as life long learners. This may have relevance to other groups of specialist nurses. The project has widespread relevance for two reasons. Firstly, it shows that nurses can be involved in designing and testing a competency framework as collaborators. Secondly, that to achieve this within the spirit of approaches, such as systematic practice development and action research, can be testing for all collaborators even were there is a shared or espoused aim.     

Introducing guided group reflective practice in an Irish palliative care unit

This paper describes the processes involved over one year in introducing, facilitating and evaluating a project of guided reflective practice for a group of eight palliative care nurses in Milford Care Centre, Republic of Ireland. While literature has tended to concentrate on critical discussion relating to reflection, less attention has been directed towards the organisation and facilitation of reflective processes in practice. In addressing this deficit, a detailed account of the collaborative processes and challenges involved in this project are presented. Group evaluation of the project is discussed under the following themes: understanding the process of reflective practice; the value of keeping a reflective diary; guided group reflection and moving forward. The introduction of guided reflection for palliative care nurses has afforded both the facilitators and the participants an opportunity to meet away from the clinical environment, and to work together, finding fresh insights to inform practice. The valuing and promotion of reflective processes by an organisation arguably provides a fundamental strategy to support nurses in a quality palliative care setting.     

An Approach to Fulfilling the Systems-based Practice Competency Requirement

The Accreditation Council for Graduate Medical Education (ACGME)-identified core competency of systems-based practice requires the demonstration of an awareness of the larger context and system of health care, and the ability to call on system resources to provide optimum care. This article describes an approach to teaching and fulfilling the requirement of this core competency in an emergency medicine residency. Beginning residents are oriented to community resources that are important to the larger context of care outside the emergency department. Each resident completes a community project during his or her residency. Readings and discussions concerning community-oriented medical care and the literature of research and injury prevention in emergency medicine precede the project development. Several projects are described in detail. Such projects help to teach not only awareness of the community resources of the greater context of medical practice outside the emergency department, but also how to use those resources. Projects could be a main component of a resident portfolio. This approach to teaching the core competency of systems-based practice is proposed as an innovative and substantial contribution toward satisfying the requirement of the core competency.     

Clinical practice placements in the community: a survey to determine if they reflect the shift in healthcare delivery from secondary to primary care settings

With the worldwide strategic shift of health care delivery from secondary to primary care settings, more newly qualified nurses are working in primary care, making exposure to the variety of roles available to nurses essential for future workforce development. The aim of this small research project was to explore whether English universities' programmes are providing clinical practice placement experiences which reflect the breadth and complexity of nursing roles available in primary care. A survey of academic staff highlighted that universities designed curricula based on local placement and mentor availability and while a variety of primary care teams are being used, district nursing teams continue to be used the most, particularly for substantive placements. The need for specified staff to work across university and placement settings was deemed essential for identifying and supporting community based clinical placements. Recommendations from the project include: an increasingly collaborative approach amongst clinical, academic and managerial staff to create a learning culture for all health professional students' practice experience; robust strategic systems to ensure clinical placements are offered by services on the periphery of a national health service; and focussing of resources on students with a desire to pursue a primary care career.