Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines

Aim. This study aimed at evaluating the outcome of implemented evidence‐based clinical guidelines by means of surveying the frequency of thrombophlebitis, nurses’ care, handling and documentation of peripheral intravenous cannulae. Background. Peripheral intravenous cannulae are frequently used for vascular access and, thereby, the patients will be exposed to local and systemic infectious complications. Evidence‐based knowledge of how to prevent these complications and how to care for patients with peripheral intravenous cannula is therefore of great importance. Deficient care, handling and documentation of peripheral intravenous cannulae have previously been reported. Design. A cross‐sectional survey was conducted by a group of nurses at three wards at a university hospital before and after the implementation of the evidence‐based guidelines. Method. A structured observation protocol was used to review the frequency of thrombophlebitis, the nurses’ care, handling and the documentation of peripheral intravenous cannulae in the patient's record. Results. A total of 107 and 99 cannulae respectively were observed before and after the implementation of the guidelines. The frequency of peripheral intravenous cannulae without signs of thrombophlebitis increased by 21% (P < 0·01) and the use of cannula size 0·8 mm increased by 22% (P < 0·001). Nurses’ documentation of peripheral intravenous cannula improved significantly (P < 0·001). Conclusion. We conclude that implementation of the guidelines resulted in significant improvements by means of decreased frequency of signs of thrombophlebitis, increased application of smaller cannula size (0·8 mm), as well as of the nurses’ documentation in the patient's record. Relevance to clinical practice. Further efforts to ameliorate care and handling of peripheral intravenous cannulae are needed. This can be done by means of increasing nurses’ knowledge and recurrent quality reviews. Well‐informed patients can also be more involved in the care than is common today.     

Effect of education on evidence-based care and handling of peripheral intravenous lines

Deficient routines in use, care, handling and documentation of peripheral intravenous vein cannulae (PIV) have previously been reported, and complications have been noted in 50-75% of the patients. The aim of the study was to examine whether specially trained nurses change their actions to decrease complications when using cannulae. The study included 36 nurses assigned to experimental and control groups. The experimental group followed an education programme explaining how to use and take care of a PIV. To evaluate the intervention document analysis, observations and patient interviews were performed in 99 patients with 172 PIVs in situ for less than 24 h. After the education programme, fewer complications, more carefully performed care and handling, and better documentation and information were found in the experimental group. Nurses in the control group followed current routines, which resulted in a greater degree of complications. Education in evidence-based care and handling gives nurses the opportunity to improve their ability to use theoretical knowledge in clinical problems.     

Nurses’ experiences of guideline implementation: a focus group study

Aims. The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines? Background. The implementation of clinical guidelines seems to be dependent on multiple context‐specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation. Design. Qualitative interview. Methods. Data were generated by four focus group interviews involving nurses working in out‐patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data. Results. Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses’ awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation. Conclusions. Clinical guidelines can be promising tools in enhancing evidence‐based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices. Relevance to clinical practice. Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.     

Conceptions of evidence, evidence-based medicine, evidence-based practice and their use in nursing: independent nurse prescribers' views

Aim. The purpose of this study was to explore nurses’ conceptions of evidence and evidence‐based practice, whether there are differences between evidence‐based practice and evidence‐based medicine and to identify the uptake of research evidence in the workplace. Background. The use and comprehension of the term ‘evidence‐based practice’ in relation to nursing shows remarkable variation. Numerous definitions are provided, some tend to be closely related to the concept ‘evidence‐based medicine’. Independent nurse prescribers need to be able to understand the concept of evidence‐based practice to utilize and apply this concept in order to provide adequate medication management of their patients. Method. Data were generated by focus group interview and open question questionnaire and analysed by analytical abstraction. Results. Nurses offered a variety of views on the use and uptake of evidence in the workplace. Some nurses acknowledged that they did not read research papers but were aware that they used a lot of evidence in their practice. Nurses had difficulty differentiating evidence‐based practice from evidence‐based medicine. Conclusions. Nurses were familiar with the research process but not the canons of evidenced‐based practice. The data generated indicate different levels of evidence are used by nurses. This may be a reflection of the level of intrigue of the nurses involved. Relevance to clinical practice. The education and training of independent nurse prescribers should include the exploration of evidence from randomized controlled trials and from naturalistic studies and their contribution to evidenced‐based practice and evidence‐based medicine. Both concepts need to be explored in relation to the medication management of patients.     

Infection control in peripheral cannulae

Cannulation is a procedure that is increasingly being performed by nurses, therefore it is important that they are aware of the complications associated with care and management. This article focuses on the infection risks associated with peripheral cannulae and how nurses can adapt their practice to care effectively for patients with peripheral lines.     

Host and guest: an applied hermeneutic study of mental health nurses' practices on inpatient units

The metaphor of host and guest has value for exploring the practice and role identity of nurses on inpatient mental health units. Two complementary texts, one from the ancient Zen record of Lin‐chi, and the other from the contemporary hermeneutic philosopher Richard Kearney, are used to elaborate meanings of host and guest that can be applied to the situation of mental health nurses. In a doctoral study with a hermeneutic design, I addressed the topic of nurse–patient relationship using an interpretive framework that included sources from Buddhist thought. The positions of host and guest emerged from interviews with nurses as one interpretive theme to open up new understanding of the topic. The two texts, originally distant in era and culture, both employ the host and guest metaphor. They are applied to extracts from interviews to open up discussions of hierarchy, status, patients' perspectives, otherness and resistances as features of nurses' complex experience. These provide insights into understanding practice and suggest implications for how institutional environments shape practice. An intercultural reading of texts can provide a source of new understanding of nurse–patient relationships.     

Betwixt and between: a critical ethnography of comfort in New Zealand residential aged care

Aims and objectives. This research sought to explore the nature of comfort within the context of three New Zealand nursing homes and examine how nursing and other actions contribute to residents’ comfort. Background. Comfort has been acknowledged as a key nursing goal since the days of Florence Nightingale, but the nature of comfort and how nurses can contribute to and enhance patient/resident comfort is unclear. Comfort is often considered to be merely the absence of discomfort. Design. A critical ethnographic approach was used to facilitate understanding of nursing home residents’ comfort. Fieldwork included 90 days of participant observation, interviews with 27 residents and 28 staff and extensive document examination. Results. Comfort was multidimensional, idiosyncratic, dynamic and context dependent, rather than merely the absence of discomfort. This multidimensional nature meant residents could be ‘betwixt and between’ comfort and discomfort simultaneously. The constraints of one‐size‐fits‐all care delivery practices and the tensions inherent in communal living compounded residents’ discomfort. Conclusions. Individualized care, based on comprehensive and accurate nursing assessment, is fundamental to the comfort of residents. Relevance to clinical practice. Staff working in nursing homes must re‐examine their care delivery practices to ensure these do not disempower residents. Ensuring the comfort of each resident is a nursing priority and the key component of individualized care.     

Standardized care plans: experiences of nurses in Taiwan

Background. Nursing care plans have been viewed as structured plans of action for patient care. Studies have investigated the outcomes or effectiveness of using different types of care plans, but have seldom reported nurses’ perceptions of using care plans in daily practice. Aims and objectives. The purpose of this study was to explore nurses’ experiences using a standardized care plan. Design. Nineteen clinical nurses at a teaching hospital in Taiwan were interviewed one‐on‐one and in depth from April to June 2000. Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process to identify themes and concepts that represented nurses’ experiences using a care plan. Results. The following themes emerged from the interview data: being reminded of care procedures, time‐saving in making care plans, time‐consuming in making shift reports, undesirable content design, and paperwork‐oriented/not patient‐centered. Conclusion. With the considerable amounts of money spent on education and training to meet nurses’ needs, a careful examination of nurses’ experiences in using care plans, should assist in care plan development and lead to observable effects on patient care. Relevance to clinical practice. Nursing documentation reflects nurses’ observations, assessments, and interventions. It is expected that better use of standardized care plans will enhance nurses’ access to appropriate and accurate information in decision‐making, thus improving the charting process and care quality.     

Restraint use in elder care: decision making among registered nurses

? This study aimed to illuminate nurses’ reasons for using physical restraint in nursing practice, and in addition, to explore the relationship between nurses’ attitudes and decisions regarding physical restraint use. ? To provide data about nurses’ reasoning when deciding whether or not to use restraints, 30 registered nurses working in two nursing homes were asked to read a written clinical vignette describing a fall‐prone person with dementia who refused to be physically restrained. The association between the decision made and the nurses’ attitudes toward restraint use was measured by Perceptions of Restraint Use Questionnaire (PRUQ). ? Twenty‐one nurses would at first disregard the patient’s wish and use the restraint in the given situation while nine would not. When new relevant facts were provided all nurses except two were ready to change their decision. A significant relationship between nurses’ decisions and their attitudes toward restraint use was also found. ? The results showed that, although nurses endeavour to decide what they consider to be in the patient’s best interests, this ambition is affected by a variety of variables, especially in relation to the working conditions and the nurses’ willingness to take the risk when not restraining the patient.     

What constitutes a dignified death? The voice of oncology advanced practice nurses

PURPOSE: The purpose of this study was to explore the concept of dignified dying from the perspective of oncology advanced practice nurses. METHODOLOGY: A naturalistic, hermeneutic approach was used to interview the study participants. A sample of 19 oncology advanced practice nurses was obtained by combining data sets from 2 larger studies of patient control and end-of-life care. Audiotaped interviews of the nurses were transcribed verbatim and were analyzed using a phenomenological approach. RESULTS: The analysis revealed that dignified dying is an experience that includes the following themes: going in peace, maintaining bodily integrity, and dying on their own terms. CONCLUSIONS: Advanced practice nurses lend an important perspective that expands understanding of the concept of dignified dying. Future studies of patient and family perceptions will enhance knowledge of their needs and lead to intervention studies to promote an end-of-life experience that is consistent with patient priorities and values.     

Swedish ambulance nurses' experiences of nursing patients suffering cardiac arrest

Effective pre‐hospital treatment of a person suffering cardiac arrest is a challenging task for the ambulance nurses. The aim of this study was to describe ambulance nurses’ experiences of nursing patients suffering cardiac arrest. Qualitative personal interviews were conducted during 2011 in Sweden with seven ambulance nurses with experience of nursing patients suffering cardiac arrests. The interview texts were analyzed using qualitative thematic content analysis, which resulted in the formulation of one theme with six categories. Mutual preparation, regular training and education were important factors in the nursing of patients suffering cardiac arrest. Ambulance nurses are placed in ethically demanding situations regarding if and for how long they should continue cardio‐pulmonary resuscitation (CPR) to accord with pre‐hospital cardiac guidelines and patients’ wishes. When a cardiac arrest patient is nursed their relatives also need the attention of ambulance nurses. Reflection is one way for ambulance nurses to learn from, and talk about, their experiences. This study provides knowledge of ambulance nurses’ experiences in the care of people with cardiac arrest. Better feedback about the care given by the ambulance nurses, and about the diagnosis and nursing care the patients received after they were admitted to the hospital are suggested as improvements that would allow ambulance nurses to learn more from their experience. Further development and research concerning the technical equipment might improve the situation for both the ambulance nurses and the patients. Ambulance nurses need regularly training and education to be prepared for saving people's lives and also to be able to make the right decisions.     

Passing the audition - the appraisal of client credibility and assessment by nurses at triage

Aim. This paper presents the findings of one aspect of a larger study aiming to build a substantive grounded theory of the process of initial assessment at triage. Background. Prioritisation at triage within emergency departments centres primarily on assessing the threat to physiological function of people presenting with health‐care problems. This approach presumes that clinical reasoning strategies reside exclusively within the health‐care practitioner, with the patient playing no active part in the process. Design. A grounded theory/symbolic interactionist methodology. Methods. Thirty‐eight recordings were made of live triage encounters involving 14 emergency nurses from two demographically distinct emergency departments. At the end of the relevant shift, those encounters in which the nurses were involved were replayed to them. The recording was stopped after each question or comment by the nurse who was then asked to say what they were thinking at the time. The nurses’ thoughts were recorded, transcribed and analysed using the constant comparative method, in which hypotheses are generated and continually modified in the light of incoming data until a conceptual story line, or theory, is produced. Results. The findings suggest that the outward clinical signs of problems presenting to the emergency department were not viewed by nurses as neutral manifestations of the pathology itself but as a conscious or unconscious portrayal of patients’ physical discomfort and their perception of the nature of the problem. The way in which patients and carers depict their problems is used by triage nurses to determine the credibility of the clinical information they provide. Conclusion. Triage can be regarded as a process in which nurses act as an adjudicating panel, judging the clinical data before them through the appraisal of the way patients act out their problems and narrate their stories. Relevance to clinical practice. Nursing practice and research need to account for the patient's contribution to the decision‐making process at triage.