Registered nurses' clinical reasoning in home healthcare clinical practice: A think-aloud study with protocol analysis

BackgroundThe home healthcare context can be unpredictable and complex, and requires registered nurses with a high level of clinical reasoning skills and professional autonomy. Thus, additional knowledge about registered nurses' clinical reasoning performance during patient home care is required.ObjectivesThe aim of this study is to describe the cognitive processes and thinking strategies used by recently graduated registered nurses while caring for patients in home healthcare clinical practice.DesignAn exploratory qualitative think-aloud design with protocol analysis was used.SettingsHome healthcare visits to patients with stroke, diabetes, and chronic obstructive pulmonary disease in seven healthcare districts in southern Norway.ParticipantsA purposeful sample of eight registered nurses with one year of experience.MethodsEach nurse was interviewed using the concurrent think-aloud technique in three different patient home healthcare clinical practice visits. A total of 24 home healthcare visits occurred. Follow-up interviews were conducted with each participant. The think-aloud sessions were transcribed and analysed using three-step protocol analysis.ResultsRecently graduated registered nurses focused on both general nursing concepts and concepts specific to the domains required and tasks provided in home healthcare services as well as for different patient groups. Additionally, participants used several assertion types, cognitive processes, and thinking strategies.ConclusionsOur results showed that recently graduated registered nurses used both simple and complex cognitive processes involving both inductive and deductive reasoning. However, their reasoning was more reactive than proactive. The results may contribute to nursing practice in terms of developing effective nursing education programmes.     

Simulation-based training for nurses: Systematic review and meta-analysis

BackgroundSimulation-based training is a widespread strategy to improve health-care quality. However, its effect on registered nurses has previously not been established in systematic reviews. The aim of this systematic review is to evaluate effect of simulation-based training on nurses' skills and knowledge.MethodsWe searched CDSR, DARE, HTA, CENTRAL, CINAHL, MEDLINE, Embase, ERIC, and SveMed + for randomised controlled trials (RCT) evaluating effect of simulation-based training among nurses. Searches were completed in December 2016. Two reviewers independently screened abstracts and full-text, extracted data, and assessed risk of bias. We compared simulation-based training to other learning strategies, high-fidelity simulation to other simulation strategies, and different organisation of simulation training. Data were analysed through meta-analysis and narrative syntheses. GRADE was used to assess the quality of evidence.ResultsFifteen RCTs met the inclusion criteria. For the comparison of simulation-based training to other learning strategies on nurses' skills, six studies in the meta-analysis showed a significant, but small effect in favour of simulation (SMD − 1.09, CI − 1.72 to − 0.47). There was large heterogeneity (I² 85%). For the other comparisons, there was large between-study variation in results. The quality of evidence for all comparisons was graded as low.ConclusionThe effect of simulation-based training varies substantially between studies. Our meta-analysis showed a significant effect of simulation training compared to other learning strategies, but the quality of evidence was low indicating uncertainty. Other comparisons showed inconsistency in results. Based on our findings simulation training appears to be an effective strategy to improve nurses' skills, but further good-quality RCTs with adequate sample sizes are needed.     

Development and evaluation of a clinical simulation for new graduate nurses: A multi-site pilot study

BackgroundNew nursing graduates have revealed that they perceive a gap between theory and practice with reference to their education and the real workplace setting. Additionally, many nurses experience a reality shock when they participate in clinical practice.PurposeThe purpose of this study was to develop and test the effects of a scenario-based simulation training program on new graduate nurses' competency, critical thinking dispositions, and interpersonal communication skills.MethodThis pilot multi-site study used a pretest-posttest control group design. It was conducted at four sites of a university-affiliated simulation center in Korea. Participants were recruited utilizing a convenience sample from four tertiary hospitals in Korea. Twenty-four new graduate nurses participated in this study.ResultsAt the three-month follow-up, the levels of communication skills used in practice among the intervention group were statistically significantly higher than those of the control group participants (U = 151.50, p = .005). However, there were no significant differences between the groups in changes in nursing competency (U = 287.50, p = .992) or critical thinking disposition scores (U = 269.50, p = .702). The participants' mean rating scores concerning the objectives, intentions, and recommendations for other nurses were positive and high.ConclusionThe involvement of current practicing of nursing in certain scenarios and the implementation of simulation learning could enhance the readiness of new graduate nurses.     

Patient safety in practical nurses' education: A cross-sectional survey of newly registered practical nurses in Canada

BackgroundPractical nurses have experienced an increasing scope of practice, including an expectation to care for complex patients and function on interdisciplinary teams. Little is known about the degree to which patient safety principles are addressed in practical nursing education.PurposeTo examine self-reported patient safety competencies of practical nurses.DesignA cross-sectional online survey (July 2014) and face-to-face interviews (June 2015).SettingOntario, Canada.ParticipantsSurvey participants were practical nurses newly registered with the College of Nurses of Ontario between January 2012 and December 2013. Interview participants were faculty and students in a practical nursing program in Ontario.MethodsSurvey respondents completed the Health Professional Education in Patient Safety Survey online. Self-reported competencies in various patient safety domains were compared between classroom and clinical settings. Faculty members were interviewed about educational preparation of practical nurses and students were interviewed to provide insight into interpretation of survey questions.ResultsThe survey response rate was 28.4% (n = 1104/3883). Mean domain scores indicated a high level of confidence in patient safety competence (< 4.0/5.0). Confidence was highest in respondents registered with the College of Nurses of Ontario > 2 years and in those who obtained their education outside of Canada. Faculty believed their approach to teaching and learning instilled a deep understanding of the limits to practical nurse autonomous practice.ConclusionsPractical nurses were confident in what they learned about patient safety in their educational programs. The high degree of patient safety competence may be a true reflection of practical nurses understanding of, and comfort with, the limits of their knowledge and, ultimately, the limits of their individual autonomous practice. Further exploration as to whether the questionnaire requires additional modification for use with practical nurse populations is warranted. However, this study provides the first examination of practical nurses' perspectives and perceptions about patient safety education.     

Telephone nurses' communication and response to callers' concern—a mixed methods study

AimsThe aim of this study was to describe telephone nurses' and callers' communication, investigate relationships within the dyad and explore telephone nurses' direct response to callers' expressions of concernBackgroundTelephone nurses assessing callers' need of care is a rapidly growing service. Callers with expectations regarding level of care are challenging.MethodRIAS and content analysis was performed on a criterion sampling of calls (N = 25) made by callers who received a recommendation from telephone nurses of a lower level of care than expected.ResultsTelephone nurses mainly ask close-ended questions, while open-ended questions are sparsely used. Relationships between callers' expressions of Concern and telephone nurses responding with Disapproval were found. Telephone nurses mainly responded to concern with close-ended medical questions while exploration of callers' reason for concern was sparse.ConclusionTelephone nurses' reluctance to use open-ended questions and to follow up on callers' understanding might be a threat to concordance, and a potential threat to patient safety.     

Nurses’ personal and ward accountability and missed nursing care: A cross-sectional study

BackgroundMissed nursing care is considered an act of omission with potentially detrimental consequences for patients, nurses, and organizations. Although the theoretical conceptualization of missed nursing care specifies nurses’ values, attitudes, and perceptions of their work environment as its core antecedents, empirical studies have mainly focused on nurses’ socio-demographic and professional attributes. Furthermore, assessment of missed nursing care has been mainly based on same-source methods.ObjectivesThis study aimed to test the joint effects of personal and ward accountability on missed nursing care, by using both focal (the nurse whose missed nursing care is examined) and incoming (the nurse responsible for the same patients at the subsequent shift) nurses’ assessments of missed nursing care.DesignA cross-sectional design, where nurses were nested in wards.ParticipantsA total of 172 focal and 123 incoming nurses from 32 nursing wards in eight hospitals.MethodsMissed nursing care was assessed with the 22-item MISSCARE survey using two sources: focal and incoming nurses. Personal and ward accountability were assessed by the focal nurse with two 19-item scales. Nurses' socio-demographics and ward and shift characteristics were also collected. Mixed linear models were used as the analysis strategy.ResultsFocal and incoming nurses reported occasional missed nursing care of the focal nurse (Mean = 1.87, SD = 0.71 and Mean = 2.09, SD = 0.84, respectively; r = 0.55, p < 0.01). Regarding the focal nurse's assessment of his/her own missed nursing care, findings showed that, above and beyond nurses’ overload and personal socio-demographic characteristics, higher personal accountability was significantly associated with decreased missed care (β = −0.29, p < 0.01), whereas ward accountability was not (β = −0.23, p > 0.05). The interaction effect was significant (β = −0.31, p < 0.05); the higher the ward accountability, the stronger the negative relationship between nurses' personal accountability and missed nursing care. Similar patterns were obtained for the incoming nurses' assessment of focal nurse's missed care.ConclusionsUse of focal and incoming nurses' missed nursing care assessments limited the common source bias and strengthened our findings. Personal and ward accountability are significant values, which are associated with lower missed nursing care, beyond scarce resources. Implementation of local and national education programs for nurses and managers, accompanied with empirical research, might increase personal and ward accountability, thereby decreasing missed nursing care. This might help to create a safety culture and reduce negative outcomes for patients, nurses, and organizations.     

The impact of training program on nurses' attitudes toward workplace violence in Jordan

BackgroundNurses' attitudes toward workplace violence are still inadequately explored, and possess an impact in preventing, and managing the violent incidents and the quality of nursing care. Creating a demand for an effective intervention program to improve nurses' knowledge of and attitudes toward workplace violence.ObjectiveTo study the impact of the training program on nurses' attitudes toward workplace violence in a military hospital in Jordan.MethodsOne group before–after design was employed. A stratified random sample of 100 nurses working in three shifts was recruited. Data were collected earlier and after the preparation program using the Attitudes Toward Patient Physical Assault Questionnaire. “The Framework Guidelines for addressing workplace violence in the health sector”, was adopted in this work. The preparation sessions were for one day each week over five weeks. The post-test assessment was over five weeks using the same questionnaire.ResultsA total of 97 nurses completed the survey. The outcomes demonstrated the significant impact of the training program on nurses' attitudes towards workplace violence (t = 6. 62, df = 96, p = 0.000). The prevalence of verbal abuse by patients and visitors was 63.9% and for physical abuse, 7.2% were from patients and 3.1% of visitors. Most violent incidents occurred during day duty and during delivering nursing care (40.2% and 32%, respectively). Major source of emotional support for abused nurses was from the nursing team (88.7%), while the legal support was from nursing management (48.5%).ConclusionThe study highlights a general concern among nursing staff about workplace violence. Confirming that violence prevention education for staff is a necessary step forward to deescalate the problem. A significant effect of the training program was evident in this study.     

Similarity and accuracy of mental models formed during nursing handovers: A concept mapping approach

BackgroundShared mental models are crucial for constructing mutual understanding of the patient’s condition during a clinical handover. Yet, scant research, if any, has empirically explored mental models of the parties involved in a clinical handover.ObjectivesThis study aimed to examine the similarities among mental models of incoming and outgoing nurses, and to test their accuracy by comparing them with mental models of expert nurses.DesignA cross-sectional study, exploring nurses’ mental models via the concept mapping technique.Participants40 clinical handovers.Data collectionData were collected via concept mapping of the incoming, outgoing, and expert nurses’ mental models (total of 120 concept maps). Similarity and accuracy for concepts and associations indexes were calculated to compare the different maps.ResultsAbout one fifth of the concepts emerged in both outgoing and incoming nurses’ concept maps (concept similarity = 23% ± 10.6). Concept accuracy indexes were 35% ± 18.8 for incoming and 62% ± 19.6 for outgoing nurses’ maps. Although incoming nurses absorbed fewer number of concepts and associations (23% and 12%, respectively), they partially closed the gap (35% and 22%, respectively) relative to expert nurses’ maps. The correlations between concept similarities, and incoming as well as outgoing nurses' concept accuracy, were significant (r = 0.43, p < 0.01; r = 0.68 p < 0.01, respectively). Finally, in 90% of the maps, outgoing nurses added information concerning the processes enacted during the shift, beyond the expert nurses’ gold standard.Discussion and conclusionsTwo seemingly contradicting processes in the handover were identified. “Information loss”, captured by the low similarity indexes among the mental models of incoming and outgoing nurses; and “information restoration”, based on accuracy measures indexes among the mental models of the incoming nurses. Based on mental model theory, we propose possible explanations for these processes and derive implications for how to improve a clinical handover.     

The impact of undergraduate clinical teaching models on the perceptions of work-readiness among new graduate nurses: A cross sectional study

BackgroundClinical Placements are an essential component of bridging the gap between academic theory and nursing practice. There are multiple clinical models designed to ease the transition from student to professional, yet there has been little exploration of such models and their impact on graduates' perceptions of work-readiness.ObjectivesThis cross sectional study examined perceptions of work-readiness of new graduate nurses who attended one of the following clinical teaching models: the University Fellowship Program (UFP), the Traditional Multi-facility Clinical Model (TMCPM), and the Mixed Program (MP).MethodsThree groups of first year graduate nurses (UFP, TMCPM, and MP) were compared using the Work-readiness Scale, a validated and reliable tool, which assessed nurses' perceptions of work-readiness in four domains: organizational acumen, personal work characteristics, social intelligence, and work competence. A multivariable Generalized Estimating Equations regression investigated socio-demographic and teaching-modelrelated factors associated with work-readiness.ResultsOf 43 nurses approached, 28 completed the survey (65% response rate) of whom 6 were UFP attendants, 8 attended the TMCPM and 14 the MP. Those who had attended the UFP scored higher than the other two in all four domains; however, the crude between-group comparisons did not yield statistically significant results. Only after accounting for age, gender, teaching setting and prior work experience, the multivariable model showed that undertaking the UFP was likely to increase perceptions of work-readiness by 1.4 points (95% CI 0.11–2.69), P = 0.03). The UFP was superior to the other two placement models.ConclusionThe study suggests that the UFP may enhance graduate nurses' perceptions of work readiness.     

Explicating Filipino student nurses' preferences of clinical instructors' attributes: A conjoint analysis

The role of clinical instructor in student nurses' preparation for the professional nursing practice cannot be underestimated. The extent to which such role is achieved depends highly on the instructors' ability to realize the desired qualities expected of them. While a number of empirical studies have qualitatively explored the attributes of an effective clinical instructor, no attempt has ventured yet on the power of experimental vignettes for conjoint analysis in explicating the preferences of a select group of Filipino student nurses relative to their clinical instructors' attributes. Junior and senior nursing students (n = 227), recruited from one of the comprehensive universities in the Philippines, were asked to sort out orthogonal cards generated by Sawtooth Software. As shown, the full-profile conjoint analysis was considerably fit for this study: Pearson's R = 0.988, (p < 0.05) and Kendall's t = 0.944, (p < 0.05). Results indicated that the student nurses are one in terms of their most preferred clinical instructor attribute, which was clinical teaching capacity (38.14%) followed by interpersonal relationship and caring behavior (33.17%). In regard to the clinical teaching capability, a clinical instructor who parallels clinical teaching skills with the students' understanding and experience (0.089) was the highest part-worth. As for the interpersonal relationship and caring behavior, the highest part-worth was a clinical instructor who respects a student nurse as an individual and cares about him/her as a person (0.114). Findings of this study can be a basis for clinical instructors as to which qualities to cultivate best to facilitate a first-rate clinical nursing instruction. Likewise, the results of this study can inform current practices of clinical instructors by making them aware of how they can nurture a pedagogical approach consistent with the student nurses' preferences.     

"It depends": viewpoints of patients, physicians, and nurses on patient-practitioner prayer in the setting of advanced cancer

ContextAlthough prayer potentially serves as an important practice in offering religious/spiritual support, its role in the clinical setting remains disputed. Few data exist to guide the role of patient-practitioner prayer in the setting of advanced illness.ObjectivesTo inform the role of prayer in the setting of life-threatening illness, this study used mixed quantitative-qualitative methods to describe the viewpoints expressed by patients with advanced cancer, oncology nurses, and oncology physicians concerning the appropriateness of clinician prayer.MethodsThis is a cross-sectional, multisite, mixed-methods study of advanced cancer patients (n = 70), oncology physicians (n = 206), and oncology nurses (n = 115). Semistructured interviews were used to assess respondents’ attitudes toward the appropriate role of prayer in the context of advanced cancer. Theme extraction was performed based on interdisciplinary input using grounded theory.ResultsMost advanced cancer patients (71%), nurses (83%), and physicians (65%) reported that patient-initiated patient-practitioner prayer was at least occasionally appropriate. Furthermore, clinician prayer was viewed as at least occasionally appropriate by the majority of patients (64%), nurses (76%), and physicians (59%). Of those patients who could envision themselves asking their physician or nurse for prayer (61%), 86% would find this form of prayer spiritually supportive. Most patients (80%) viewed practitioner-initiated prayer as spiritually supportive. Open-ended responses regarding the appropriateness of patient-practitioner prayer in the advanced cancer setting revealed six themes shaping respondents’ viewpoints: necessary conditions for prayer, potential benefits of prayer, critical attitudes toward prayer, positive attitudes toward prayer, potential negative consequences of prayer, and prayer alternatives.ConclusionMost patients and practitioners view patient-practitioner prayer as at least occasionally appropriate in the advanced cancer setting, and most patients view prayer as spiritually supportive. However, the appropriateness of patient-practitioner prayer is case specific, requiring consideration of multiple factors.     

Exploring the clinical decision-making used by experienced cardiorespiratory physiotherapists: A mixed method qualitative design of simulation,video recording and think aloud techniques

BackgroundThe ability of physiotherapists to make clinical decisions is a vital component of being an autonomous practitioner, yet this complex phenomenon has been under-researched in cardiorespiratory physiotherapy. The purpose of this study was to explore clinical decision-making (CDM) by experienced physiotherapists in a scenario of a simulated patient experiencing acute deterioration of their respiratory function.ObjectivesThe main objective of this observational study was to identify the actions, thoughts, and behaviours used by experienced cardiorespiratory physiotherapists in their clinical decision-making processes.DesignA mixed-methods (qualitative) design employing observation and think-aloud, was adopted using a computerised manikin in a simulated environment.SettingThe participants clinically assessed the manikin programmed with the same clinical signs, under standardised conditions in the clinical skills practice suite, which was set up as a ward environment.ParticipantsExperienced cardiorespiratory physiotherapists, recruited from clinical practice within a 50-mile radius of the University(*).MethodsParticipants were video-recorded throughout the assessment and treatment and asked to verbalise their thought processes using the 'think-aloud' method. The recordings were transcribed verbatim and managed using a Framework approach.ResultsEight cardiorespiratory physiotherapists participated (mean 7 years clinical experience, range 3.5–16 years. CDM was similar to the collaborative hypothetico-deductive model, five-rights nursing model, reasoning strategies, inductive reasoning and pattern recognition. However, the CDM demonstrated by the physiotherapists was complex, interactive and iterative. Information processing occurred continuously throughout the whole interaction with the patient, and the specific cognitive skills of recognition, matching, discriminating, relating, inferring, synthesising and prediction were identified as being used sequentially.ConclusionsThe findings from this study were used to develop a new conceptual model of clinical decision-making for cardiorespiratory physiotherapy. This conceptual model can be used to inform future educational strategies to prepare physiotherapists and nurses for working in acute respiratory care.