Implementation of nurse-delivered vestibular rehabilitation in primary care: a qualitative study of nurses' views on involvement in an innovative service

Aim: To explore practice nurses’ perceptions of vestibular rehabilitation and its place in relation to their general role development. Background: Vestibular rehabilitation has been known for a long time to be effective for chronically dizzy patients in secondary care, but its use in primary care has been limited. A recent pragmatic trial of vestibular rehabilitation delivered by practice nurses in primary care has confirmed its utility in a community setting. This type of role is increasingly common for practice nurses, but few studies explore the nurses’ perspective. Methods: A qualitative study was undertaken; 19 nurses took part in focus group sessions. Participants discussed their views on vestibular rehabilitation and its potential for integration with their existing role. A thematic analysis of the data was undertaken. Findings: Four main themes were identified: creating a unique nursing role; the therapeutic role; responsibility and role boundaries; and time. Nurses were positive about developing extended roles, but sought ways to achieve this without eroding fundamental nursing skills. Vestibular rehabilitation was seen as fulfilling both the need for a distinct nursing identity and professional development. Concerns over responsibility for patient assessment and time management constraints are potential obstacles to overcome in the wider development of this therapy in primary care. Conclusions: Understanding the perspective of nurses will be vital in future development of chronic disease management within primary care. Whilst nurses may be positive about such role expansion, the implementation of services of this type will require clarity about nurses’ responsibilities and flexibility in managing workload. Relevance to clinical practice: Vestibular rehabilitation is simple, low‐tech and appropriate for widespread development in primary care. Nurses wishing to provide vestibular rehabilitation or similar chronic disease management activities will need to work with medical colleagues to define role boundaries.     

Registered nurses'' experiences of caring for the elderly in different health-care areas

Caring for elderly patients is an undertaking for a majority of Swedish nurses in different health-care sectors. The purpose of the study was to understand how nurses experienced the meaning of caring for elderly patients after 2 years as Registered Nurses. Interviews were conducted with 20 nurses 2 years after graduation. Data were analysed with a phenomenological-hermeneutic method and resulted in two themes: (i) providing the elderly with a sense of trust; and (ii) commitment to elderly patients. Each theme was made up of four subthemes, expressing both positive and negative aspects. Caring for the elderly means that the core of caring is in focus. Nurses need a supportive context for their care of the elderly, especially when they experience that they or their staff cannot provide the optimal quality of care for the patients.     

A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication

Aims and objectives. To systematically review the research regarding communication between nurses and patients with complex communication needs (CCN). The research was reviewed with respect to the following themes: (a) the importance of communication; (b) the barriers to effective communication; (c) the supports needed for effective communication; and (d) recommendations for improving the effectiveness of communication between nurses and patients with CCN. Augmentative and alternative communication (AAC) strategies that can be used by nurses to facilitate more effective communication with patients with CCN are discussed. Background. Effective nurse‐patient communication is critical to efficient care provision. Difficulties in communication between nurses and patients arise when patients are unable to speak. This problem is further complicated because nurses typically receive little or no training in how to use AAC to communicate with patients with CCN. Design. Systematic review. Method. This paper reviewed the published research focusing on the perspectives of nurses, patients with CCN and their caregivers regarding the challenges to effective communication between nurses and patients with CCN. Further, specific strategies (i.e., using AAC) that nurses can use to improve and facilitate communication with patients with CCN are provided. Conclusions. Communication between nurses and patients is critical to providing and receiving quality care. Nurses and patients have reported concern and frustration when communication is not adequate. Using AAC strategies will help nurses and patients better communicate with each other when speech is not an option. Relevance to clinical practice. Communication with all patients is very important to the provision of quality nursing care. Communication cannot always be achieved using the speech modality. Nurses need to have tools and skills that will allow them to communicate with all of their patients whether or not they can speak.     

Experiences of AIDS-dedicated nurses in alleviating the stress of AIDS caregiving

From the beginning of the AIDS epidemic, there have been individuals dedicated to the care of patients with AIDS. However, there has been little research regarding their perceptions and experiences of AIDS caregiving and the strategies they use to alleviate the stress and promote their willingness to care. Based on the experiences of 12 nurses at one hospital, who had chosen to work on an AIDS-dedicated unit, this exploratory study, conducted in 1998, explored the following: the physical, emotional or spiritual risks and stresses associated with AIDS caregiving; factors that provide resistance to the stresses of AIDS caregiving and promote a willingness to care; and strategies recommended by AIDS-dedicated nurses in caring for patients with AIDS. The data reveal important themes related to the physical stress of AIDS caregiving, specifically being aware of risks, but not paralysed by fear, and bombardment of the senses. The coping strategies of nurses included taking the risk in their stride, reframing the risk, and protecting oneself. The emotional stress of AIDS caregiving included witnessing suffering, experiencing unresolved grief, accepting diversity, being emotionally connected, distress from the dismantling of the AIDS unit and work demands, and declining team spirit. Coping strategies included balancing personal and professional life, releasing pain, respecting yet controlling feelings, managing demands, and asking for help. Nurses maintained their spiritual perspective. They experienced through AIDS caregiving a greater sense of shared humanity and a new perspective of life. Findings indicate that AIDS-dedicated nurses use many coping strategies. The experiences of these nurses can assist clinicians, educators and administrators in supporting nurses' caregiving and promoting the quality of care offered to patients with AIDS.     

Nurses’ perceived facilitators and barriers to assessing for alcohol use in Taiwan

Aims. To explore nurses’ perceived facilitators and barriers to assessing for alcohol use in Taiwan. Background. Excessive alcohol use has been associated with health, social and legal problems. Helping health care providers to detect and treat hazardous or harmful drinkers is an important worldwide issue. Design. A cross‐sectional design was used. Methods. Nurse participants (n = 741) were recruited from 10 randomly selected hospitals in Taiwan. In these hospitals, nurses were selected from the Emergency Department, psychiatric and gastrointestinal medical–surgical units where most patients with alcohol problems are seen. Data were collected by facilitator and barrier scales as well as a background information form. Results. Nurses identified the top facilitator and barriers to assessing for alcohol use as ‘want to know if patients’ drinking problems are related to their illness’ and ‘patients’ purposefully conceal information’, respectively. Older nurses and those with longer general clinical experience had more perceived facilitators to assessing for alcohol use. Nurses’ perceived facilitator scores were significantly and positively related to their intention scores, whereas their perceived barrier scores were significantly and negatively related to their intention scores. In addition, scores for perceived facilitators and barriers differed significantly by nurses’ education level, work unit, experiences with assessing for alcohol use and previous attendance at training courses for assessing alcohol use. Conclusions. Our results suggest a need to strengthen nurses’ education and training on the assessment of alcohol use in Taiwan. Relevance to clinical practice. Education and training programmes should aim to enhance Taiwanese nurses’ alcohol knowledge, to emphasise the impact of alcohol use on illness and treatment and to enhance nurses’ perceived facilitators and decrease their perceived barriers to assessing for alcohol use.     

Student nurses’ experiences of communication in cross‐cultural care encounters

Scand J Caring Sci; 2010; 24; 436–444
Student nurses’ experiences of communication in cross‐cultural care encounters Background: Communication is a fundamental component of cross‐cultural care encounters. Nurses experience communication difficulties in situations where they do not speak the same language as their patients. Communication difficulties are a major obstacle for immigrant patients and can lead to insufficient information and poor quality nursing care in contrast to the majority population. Aim: To explore student nurses’ experiences of communication in cross‐cultural care encounters. Methods: Semi‐structured interviews were undertaken a purposive sample of 10 final year students from one university in Sweden: five participants were from a Swedish background and five from an immigrant background. Interviews explored participant’s experiences of communication in cross‐cultural care encounters. Interviews were tape recorded, transcribed and analysed using ‘framework’ approach. Results: Four themes were identified: conceptualizing cross‐cultural care encounters, difficulties in communication, communication strategies and factors influencing communication. ‘Culture’ was equated with country of origin. Cross‐cultural care encounters involved patients from a different immigrant background to the nurse. Student nurses experienced particular difficulties communicating with patients with whom they did not share a common language. This led to care becoming mechanistic and impersonal. They were fearful of making mistakes and lacked skills and confidence in questioning patients. Various strategies were used to overcome communication barriers including the use of relatives to interpret, nonverbal communication, gestures and artefacts. Other factors which influenced communication included the student’s attitude, cultural knowledge acquired through education and life experience. Conclusion: Although student nurses seek creative ways to communicate with patients from different cultural backgrounds they lack skills and confidence in cross‐cultural communication. Nursing programmes need to address this deficit to ensure that nurses are equipped with the knowledge and skills to provide quality care to patients from different cultural backgrounds.     

Nursing attitudes to the care of elderly patients at risk of continuing hospital care

This study assesses changes in nurses' attitudes to the process of decision-making regarding the care of elderly patients identified as being at risk of continuing (long-term) hospital care It was undertaken during the course of an evaluation of an intervention programme which involved a new approach to decision-making concerning the long-term care of dependent elderly patients Complementary components of the intervention programme were (a) an early discharge planning service, and (b) an extended home care programme The programme involved close liaison of specially trained community health nurses with staff members of the general medical wards of a large general hospital At the onset of the evaluation, it was perceived by management that the staff of the general medical wards favoured continuing hospital care for very dependent elderly patients rather than community care It was hypothesized that the intervention programme would result in a change in ward staffs' attitudes concerning the feasibility of home-based care and how decisions about care should be made To test this, attitude changes of community health nurses and ward nurses were assessed over the period of implementation of the programme Following the introduction of the programme, the study found that some of the ward nurses' attitudes became closer to those of community health nurses There was a shift in ward nurses' attitudes away from a professional approach to decisions about the care and placement of very dependent elderly patients to a 'patient choice' approach Nurses felt more strongly that they had an important role in patient care Implications of the research are considered in relation to the process of discharge planning     

Acute care nurses' perceptions of barriers to using research information in clinical decision-making

AIM: To examine the barriers that nurses feel prevent them from using research in the decisions they make. BACKGROUND: A sizeable research literature focusing on research utilization in nursing has developed over the past 20 years. However, this literature is characterized by a number of weaknesses: self-reported utilization behaviour; poor response rates and small, nonrandom sampling strategies. DESIGN: Cross-case analysis involving anonymised qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 h, and 122 nurses were involved in the Q modelling exercise (response rate of 64%). RESULTS: Four perspectives were isolated that encompassed the characteristics associated with barriers to research use. These related to the individual, organization, nature of research information itself and environment. Nurses clustered around four main perspectives on the barriers to research use: (1) Problems in interpreting and using research products, which were seen as too complex, 'academic' and overly statistical; (2) Nurses who felt confident with research-based information perceived a lack of organizational support as a significant block; (3) Many nurses felt that researchers and research products lack clinical credibility and that they fail to offer the desired level of clinical direction; (4) Some nurses lacked the skills and, to a lesser degree, the motivation to use research themselves. These individuals liked research messages passed on to them by a third party and sought to foster others' involvement in research-based practice, rather than becoming directly involved themselves. CONCLUSIONS: Rejection of research knowledge is not a barrier to its application. Rather, the presentation and management of research knowledge in the workplace represent significant challenges for clinicians, policy-makers and the research community.     

Converting to insulin in primary care: an exploration of the needs of practice nurses

BACKGROUND: In order to optimize glycaemic control, substantial numbers of people with type 2 diabetes may require transfer from oral medication to insulin therapy. Although insulin conversion is traditionally a specialist secondary care function, as nursing roles change and expand there is growing pressure for this to be performed within primary care. However, little is known about the potential barriers to such a change, particularly from the standpoint of the frontline staff involved. AIMS: The study aimed to explore the views of practice nurses in the United Kingdom (UK) about converting diabetic patients from oral hyperglycaemic agents to injected insulin within primary care, and to investigate what structures and resources might be useful in supporting such a change. METHODS: Semi-structured interviews were conducted with 25 practice nurses, and interpreted using content analysis to extract key conceptual themes from the transcribed interview texts. FINDINGS: Most of the nurses felt that converting to insulin in primary care had considerable benefits for patients. However, issues of time, training, confidence about performing the change, and the adequacy of support systems, both for patient and nurse, emerged as the main perceived barriers to performing insulin conversions in primary care. Worries about legal and accountability issues surrounding the nurse prescribing elements were also raised. CONCLUSIONS: Where insulin conversion within primary care is being considered, it is suggested that specific training is provided for practice nurses and general practitioners, protected time is made available, and a team-working approach is fostered to prevent isolation and boost patient support. Formal mentoring or supervision support for practice nurses may also help them to adapt to this new approach. LIMITATIONS: These findings are based on the views of nurses from a single UK locality, and so widespread consultation is recommended before applying them in other settings.     

Toward understanding evidence uptake: semirecumbency for pneumonia prevention

OBJECTIVE: Randomized trials show that the semirecumbent position compared with the supine position is associated with less gastroesophageal aspiration and pneumonia in patients receiving mechanical ventilation. However, semirecumbency is inconsistently used in practice. The objective of this study was to understand the perspectives of intensive care unit clinicians regarding the determinants and consequences of semirecumbency. DESIGN: Qualitative study using semistructured interviews and focus groups. SETTING: Three university-affiliated intensive care units. PARTICIPANTS: A total of 93 intensive care unit clinicians, including bedside nurses, respiratory therapists, physiotherapists, nutritionists, residents, fellows, and intensivists. METHODS: We elicited perceptions about benefits and harms of semirecumbency, factors promoting and deterring use, and health systems changes to encourage semirecumbency. Interview and focus group notes were analyzed inductively to identify emerging themes. Validation methods involved triangulation by multidisciplinary analysis of several data sources collected through multiple methods and member checking. MEASUREMENTS AND MAIN RESULTS: Intensivists and nutritionists were familiar with semirecumbency as a potential pneumonia prevention strategy, whereas other clinicians were not. When made aware of the evidence, all participants endorsed semirecumbency. Nurses perceived that the main determinant of semirecumbency was physicians' orders, whereas intensivists perceived that the main determinant was nursing preference. Participants identified barriers to semirecumbency related to useful alternative positions (e.g., lateral position), contraindications (e.g., hemodynamic instability), risk of harm (e.g., decubitus ulcers), safety (e.g., sliding out of the bed), and resources (e.g., insufficient beds facilitating semirecumbency). Education, guidelines, reminders, audit and feedback, charting, and quality improvement initiatives were advocated to promote semirecumbency. CONCLUSIONS: Under-utilization of semirecumbency for pneumonia prevention is influenced by insufficient awareness of its benefit, real and perceived deterrents, poor agreement about implementation responsibility, and lack of enabling and reinforcing strategies. Cognitive, behavioral, and administrative approaches to enhancing evidence uptake may be needed in the complex, dynamic intensive care unit setting.     

Access to Physical Health Care for People with Serious Mental Illness: A Nursing Perspective and a Human Rights Perspective-Common Ground?

Relative to the general population, people with serious mental illness (SMI) experience elevated risks of physical disease and illness and live shorter lives. A human rights perspective argues that people with serious mental illness have a right to equal access to physical health care. Nurses in mental health services can contribute to improving the availability and accessibility of physical health care. This study, involving focus group interviews with nurses in a large regional and rural mental health care district of Queensland, Australia, revealed significant problems in access to physical health care for service users. The current article reports on our exploratory analysis of nurses’ views and perceptions to identify (1) orientation of nurses to human rights, and (2) access of consumers with SMI to general practitioner services. It was rare for nurses to raise the topic of human rights, and when raised, it was not as a strategy for improving access to physical health care services that they felt consumers with SMI greatly needed. Two main themes were identified as causes of poor access: clinical barriers to physical care and attitudinal barriers to physical care. In light of these results, the authors explore a human rights perspective on access and how this provides an inclusive lobbying umbrella under which nurses and other groups can pursue access to physical health services that are adequate, accessible, and non-discriminatory. The article then discusses the implications for these findings for the value of human rights as a perspective and means of increasing physical health of people with SMI.     

Client-centered home care: balancing between competing responsibilities

This study explores and describes the perceptions of nurses with respect to everyday client-centered care. A grounded theory study was conducted with 10 Dutch nurses and auxiliary nurses giving home care to chronically ill clients. Participatory observations and semistructured interviews were held. Nurses perceived roles and responsibilities competing with the role as a responsive professional to the client demand: a critical professional, developer of client competencies, individual, and employee. Strategies in balancing between competing responsibilities were distinguished: pleasing, dialoguing, directing, and detaching. Directing (related to impaired client competencies) and detaching (related to organizational barriers) were also used as second choice strategies. Effectively balancing between competing responsibilities was seen in dialoguing and directing as second choice. Conditions identified related to these strategies are awareness of, and responsibility taking for competing responsibilities. Recommendations for practice concern a care relationship and a dialogue with the client, critical ethical reflection, professional autonomy, self-assertiveness and organizational support.     

Nurses' adoption of the AWHONN/NANN Neonatal Skin Care Project

The purpose of this project was to evaluate the nurses' adoption of the AWHONN/NANN Neonatal Skin Care Project Protocols that were implemented at 54 clinical sites across the United States, and to examine perceived barriers in the implementation process. One hundred thirty-six nurses from 26 hospitals returned the survey packets that included the Neonatal Nurse Opinion Survey and the Barriers Scale. Nurses had a higher-than-average level of education, describing themselves as leaders and innovators. In general, the protocols were well accepted and adopted into practice. Some protocols were not perceived as better than pre-existing practice, and nurses reported difficulty in the implementation of some protocols. The main barriers were a lack of skill in reading and understanding research, lack of authority, and lack of support from physicians and other staff. The project raised national awareness about neonatal skin care, involved nurses from the beginning and throughout the process, and removed several barriers to research utilization. Copyright © 2001 by W.B. Saunders Company