Determination of standard times of nursing activities based on a Nursing Minimum Dataset

Title.  Determination of standard times of nursing activities based on a NursingMinimum Dataset.
Aim.  This paper is a report of a study conducted to determine the standard time per nursing activity and the proportion of nursing time covered by the nursing activities of the Belgian Nursing Minimum Dataset compared to the total time of a nurse shift, and to evaluate the correlation between hospital size and standard times of nursing activities.
Background.  Because of a shrinking workforce and rising workload, nursing managers need tools that help them to allocate their staff to the wards. Such tools should be based on objective time measurements.
Methods.  The study was performed in surgical, internal medicine and elder care wards in an acute hospital care setting. In the first phase, a two-round Delphi-procedure was used to operationalize the definitions of nursing activities. In the second phase, the standard time for each nursing activity was determined, based on data collected over a 6-month period during 2006–2007. A combination of 13,292 work sampling observations by external observers, 3000 recordings of direct time measurement by self-recording and subjective time assessments yielded times that were used to analyse the duration of the nursing activities.
Results.  A standard time for 102 nursing activities was established. The coverage of the Belgian Nursing Minimum Dataset in the surgical, internal medicine and elder care wards was 47·5%, 46·4% and 51·0% respectively. The Belgian Nursing Minimum Dataset was found to cover almost 70% of direct and indirect nursing care.
Conclusion.  Further research is needed to assess the impact on the standard times of nursing activities of inefficient organizational structures and different cultural interpretations of the way an activity is conducted.     

Impact of a nursing information system on practice patterns in Taiwan

The purpose of this study was to measure changes in nursing practice patterns between the beginning stage and a later phase of implementing the nursing information systems. The study was a two-stage data comparison analysis. The data were collected during the first 2 weeks and 1 year after installing the nursing information system. Nursing activities were checked from a list with 83 items. Data were collected by a work sampling strategy during two 2-week periods in November 2004 and November 2005. For both stages, nurses spent about 20% of their time on direct care, 25% on indirect care, 9% on unit-related activities, 30% on documentation, and 15% on personal time. After 1 year of using the nursing information system, nurses spent more time on documentation but less on indirect care and unit-related activities. When unit patient census was high, nurses spent more time on direct care. Issues regarding evaluating the impact of information systems on practice patterns were explored.     

Coaching patients to self-care: a primary responsibility of nursing

Aim.  To explore the process nurses use to guide and support patients to actively re-establish self-care.
Background.  The movement of hospitalized patients from less to more independence is primarily a nursing responsibility. Studies of nursing practice in inpatient rehabilitation settings have begun to shed some light on this, but as yet there is limited understanding of the actual skills nurses use to support patients to re-establish self-care.
Method.  This study used grounded theory. Microanalysis and constant comparative analysis of data collected during interviews with, and observation of, registered and enrolled nurses during everyday nursing practice in five inpatient rehabilitation units facilitated open, axial and selective coding. Relevant literature was woven into the final theory.
Findings.  To facilitate patient transition from the role of acute care patient to rehabilitation patient actively reclaiming self-care, nurses engaged in a three-phase process known as coaching patients to self-care. The three phases were: easing patients into rehabilitation, maximizing patient effort and providing graduated assistance.
Conclusion.  Coaching patients to self-care is a primary activity and technology of rehabilitation nursing.
Relevance to clinical practice.  Patients in a variety of settings would benefit from nurses incorporating coaching skills into their nurse–patient interactions.     

What do nurses do? An observational survey of the activities of nurses on acute surgical and rehabilitation wards

Aim  The subject of the study described in this article is an activity analysis of nursing care given on an acute surgical ward at a District General Hospital as compared to that given on a rehabilitation ward at a Community Hospital.
Methods  Obtaining a global overview of nursing activities on the two study wards was a focal issue. The project consisted of undertaking in excess of 60 h of observation with 10 registered nurses (RNs) of various grades in the two settings.
Findings It was found that both sets of nurses undertook similar types of activities. Overall more indirect care activities than direct care occurred on both wards. These findings are similar to the findings of other studies where the majority of RNs' activities are said to relate to the co-ordinating and management aspects of patient care.
Conclusion  It is concluded that the 'glue function' or maintaining a holistic overview of patient care given by all members of the health care team is an important part of nursing care delivery.     

Coining and Defining Novel Nursing Terminology. Part 3: Critical Incident Control

PURPOSE.  In the third of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the Nursing Outcomes Classification (NOC)—Critical incident control (CIC)—defined as a response that attempts to reverse a life-threatening condition. Critical incident nursing diagnosis (CIND), defined as recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication, and critical incident nursing intervention, defined as any indirect or direct care registered nurse–initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND, were introduced in Parts 1 and 2 of this series, respectively.
DATA SOURCES.  The current literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article.
DATA SYNTHESIS.  The current nursing outcomes in the NOC are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations.
CONCLUSION.  Coining and defining novel nursing terminology, CIC, for patient care during life-threatening situations is important and fills the gap in the current standardized nursing terminology.
IMPLICATIONS FOR NURSING PRACTICE.  Refining the NOC will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel nursing terminology, CIC.     

Determining Critical Incident Nursing Interventions for the Critical Care Setting: A Pilot Study

PURPOSE.  The purpose of this research survey was to determine which Adult Critical Care Core Nursing Interventions (ACCCNIs) in the Nursing Interventions Classification constitutes a critical incident nursing intervention (CINI). A CINI is defined as any indirect or direct care registered nurse (RN)-initiated treatment performed in response to a life-threatening nursing diagnosis.
METHODS.  A list of ACCCNIs were sent to 50 critical care RNs in two survey rounds. Responses >80% for each ACCCNI was determined to be a CINI.
FINDINGS.  Forty-one ACCCNIs were determined to be CINIs.
CONCLUSIONS.  It is recommended that CINIs be included as a separate Nursing Intervention Classification category to reflect current nursing practice.
IMPLICATIONS FOR NURSING PRACTICE.  CINIs can enhance RN competency, education, and vigilance, thereby preventing or decreasing the number of deaths that occur from critical incidents.     

Cultural encounters in reflective dialogue about nursing care: a qualitative study

Title.  Cultural encounters in reflective dialogue about nursing care: a qualitative study.
Aim.  This paper is a report of a study to explore how students developed reflective nursing practice through cultural encounters between students from Tanzania and Norway.
Background.  Nursing students need to develop cultural care competence to care for patients in a globalized world. One way to achieve this goal may be through international practice experience. Previous studies have shown that students visiting developing countries matured personally and intellectually more than those who experienced encounters between developed countries.
Method.  The study was exploratory, using qualitative data about nursing practice and cultural encounters experienced by nursing students from Tanzania and Norway. Data were collected through participatory observation, students' logs and focus group interviews in 2006.
Findings.  The encounter was characterized with an open attitude facilitating a good context for co-learning between the students. Three main themes were identified. The Norwegian students emphasized nurse–patient relationships, individualized care, direct communication and emotional involvement. The Tanzanian nursing students demonstrated a collectivist approach in nursing characterized by nurse–relative–patient relationships, and they emphasized curing attributes with skilful performance of procedures.
Conclusion.  A cultural encounter between students from different culture proved to be a fruitful way of teaching nurses. The opportunity to share thoughts, reflect on value systems and personal practice through dialogue with students from a different culture offer possibility in terms of cultural competence, reflexivity and consciousness of various ways practising nursing. This may contribute to bringing the practice of nursing a step forward in both cultures.     

Emotional stability of nurses: impact on patient safety

Title.  Emotional stability of nurses: impact on patient safety.
Aim.  This paper is a report of a study conducted to examine the influence of the emotional stability of nurses on patient safety.
Background.  Individuals with greater emotional stability are less likely to exhibit strong emotional reactions to stressful situations, and tend to be more proactive and successful in problem-solving. Effectively managing patient safety is a priority concern in countries where nurses face high pressure. A heavy work load leads to burnout (a syndrome associated with negative emotions), reduced job satisfaction and increased turnover. While emotional stability influences job performance in various contexts, its influence on patient safety has not been addressed.
Method.  A cross-sectional design was adopted. The sample comprised 263 nurses working in two Taiwanese medical centres. The data were collected in 2007–2008, with a response rate of 92·6%. All participants were nursing college graduates aged below 50 years. Participants provided information on both their emotional stability and patient safety. Staffing adequacy, hospital, and years of nursing experience served as control variables.
Findings.  Hierarchical regression analysis indicated that emotional stability predicted patient safety (β = 0·18, P  < 0·01). The addition of emotional stability as a predictor of patient safety increased the associated explained variance (Δ R ² = 0·03, P  < 0·01).
Conclusion.  It is important for to managers create an organisational climate that promotes the emotional stability of nurses. This could help to improve global patient safety by reducing the frequency of adverse events.     

Impact of bar-code medication administration on nursing activity patterns and usage experience in Taiwan

As medication safety is a foremost goal of patient safety, the adoption of bar-code medication administration can help nurses ensure safe medication administration. The aims of the study were to explore the impact on nursing activity patterns of using this device and to understand the nurses' usage of this technology. The data collection was conducted in a medical center in northern Taiwan using work sampling observation and qualitative interviews. A total of 4940 observations were conducted on two groups of nurses who did or did not use the device, and six nurses were interviewed using a semistructured interview guide. The results showed that the nurses who used this device spent less time on medication-related activities and more on indirect care and unit-related activities, especially on the day and night shifts. Three themes were identified from the follow-up interviews: facilitating nursing workflow, improving medication safety, and encountering operational difficulties. Although the technology use could divert the nurses' practice patterns from medication-related activities to indirect care and unit-related activities, their direct care was not compromised. In addition, although the bar-code medication administration use could improve workflow and patient safety, hardware sufficiency and system functionality deserve more attention in the technology adoption process.     

Reorganizing nursing work on surgical units: a time-and-motion study

A time-and-motion study was conducted in response to perceptions that the surgical nursing staff at a Montreal hospital was spending an excessive amount of time on non-nursing care. A sample of 30 nurse shifts was observed by trained observers who timed nurses' activities for their entire working shift using a hand-held Personal Digital Assistant. Activities were grouped into four main categories: direct patient care, indirect patient care, non-nursing and personal activities. Break and meal times were excluded from the denominator of total worked hours. A total of 201 working hours were observed, an average of 6 hours, 42 minutes per nurse shift. The mean proportions of each nurse shift spent on the main activity categories were: direct care 32.8%, indirect care 55.7%, non-nursing tasks 9.0% and personal 2.5%. Three activities (communication among health professionals, medication verification/preparation and documentation) comprised 78.9% of indirect care time. Greater time on indirect care was associated with work on night shifts and on the short-stay surgical unit. Subsequent work reorganization focused on reducing time spent on communication and medications. The authors conclude that time-and-motion studies are a useful method of monitoring appropriate use of nursing staff, and may provide results that assist in restructuring nursing tasks.     

Knowing in nursing: a concept analysis

Title.  Knowing in nursing: a concept analysis.
Aim.  This paper is a report of an analysis of the evolution of the concept of knowing in nursing.
Background.  Following the seminal contribution of Carper in 1978, knowing has been discussed with increasing frequency in the nursing literature with reference to the development of nursing knowledge. Various patterns of knowing, as well as research focused on reflection on experience, have been the foundation for activities and research designed to improve practice as well as patient care in clinical, community, education, cultural and administrative settings.
Methods.  Rodgers' evolutionary method of concept analysis provided the framework for this analysis. The data source was a search of literature published from 1978 to 2007. Three aims guided the analysis: to understand how the concept of knowing is used in nursing, how it is used in other health-related disciplines and how the concept has evolved into the current interpretation.
Discussion.  Analysis revealed that knowing in nursing refers to a uniquely personal type of knowledge constructed of objective knowledge interfaced with the individual's subjective perspective on personal experience. Knowing is a dynamic process and a result of personal reflection and transformation as the individual lives and interacts in the world. Its antecedents are experience, awareness and reflection. The consequences are understanding, finding meaning and transformation.
Conclusion.  This analysis illuminates an area in which nursing has carved out its own niche in healthcare research. The concept of knowing in nursing practice and research reflects a focus on the individual experience of health and illness.     

Elderly peoples' experience of nursing care after a stroke: from a gender perspective

Title.  Elderly peoples' experience of nursing care after a stroke: from a gender perspective.
Aim.  This paper is a report of a study conducted to explore, from a gender perspective, older people's experiences of nursing care after a stroke.
Background.  Little attention has been given to gender differences in nursing care. The majority of people who have a stroke are older. Improving knowledge of the gender perspectives of older men and women regarding nursing care after stroke is crucial.
Method.  This was a qualitative study based on interviews with five women and five men between 66 and 75 years of age, who had received nursing care at a ward for stroke rehabilitation. The data were collected in 2006. Qualitative content analysis of the interviews was carried out.
Findings.  A main theme and five categories, all common to both men and women, were identified. The main theme, to promote recovery of the body, encompassed the categories. There were, however, gender differences in how the nursing care received was experienced. The ways patients experienced nursing care seemed to be linked with their lives as women and men before they had the stroke. Their perceptions are linked with their lives as women and men before they had their stroke. Both men and women will reclaim former abilities but what they perceive to be the goals of nursing care and rehabilitation may differ.
Conclusion.  Nurses need to increase their awareness and knowledge concerning the similarities and gender differences in the experiences and needs of older people, both men and women.     

Coining and Defining Novel Nursing Terminology. Part 1: Critical Incident Nursing Diagnosis

PURPOSE.  In the first of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the North American Nursing Diagnosis Association (NANDA) International Classification—Critical incident nursing diagnosis (CIND)—defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication.
DATA SOURCES.  The literature, research studies, and meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article.
DATA SYNTHESIS.  The current nursing diagnoses in the NANDA International Classification are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations.
CONCLUSIONS.  Coining and defining a novel nursing terminology, CIND, for patient care during life-threatening situations are important and fill the gap in the current standardized nursing terminology.
IMPLICATIONS FOR NURSING PRACTICE.  Refining the NANDA International Classification will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel nursing terminology: CIND. Parts 2 and 3 of this series will propose additional nursing terminology: critical incident nursing intervention and critical incident control, respectively.     

The use of conversational analysis: nurse–patient interaction in communication disability after stroke

Title.  The use of conversational analysis: nurse–patient interaction in communication disability after stroke.
Aim.  This paper is a report of a study to explore how nursing staff and patients with aphasia or dysarthria communicate with each other in natural interactions on a specialist stroke ward.
Background.  Nursing staff often talk with patients in a functional manner, using minimal social or affective communication. Little nursing research has been carried out with patients who have communication difficulties. Conversational analysis, used in other healthcare settings, is a way to explore these interactions in depth in order to gain further understanding of the communication process.
Method.  An observational study was carried out in 2005 and the data were 35·5 hours of videotape recording and field notes with 14 nursing staff and five patients with aphasia or dysarthria. The recordings were analysed using conversation analysis.
Findings.  Nursing staff controlled the conversations by controlling the topic and flow of conversations, creating asymmetry in all interactions. Patients had very little input because of taking short turns and responding to closed questions. These behaviours are related to the institutional context in which they occur.
Conclusion.  In rehabilitation, the focus for interaction may be thought to be patient goals, worries or plans for the future, but in this study nursing staff controlled the conversations around nursing tasks. This may be because they do not have the confidence to hold conversations with people with communication problems. Nursing staff need to receive training to reinforce communication rehabilitation programmes and to engage more fully with patients in their care, but also that a wider institutional culture of partnership is developed on stroke wards.     

Hospitals' organizational variables and patients' perceptions of individualized nursing care in Finland

Aim  To examine the association between hospitals' organizational variables and patients' perceptions of individualized care.
Background  There is lack of evidence related to the effects that the hospital environment has on patient perceptions of the individuality of care they receive.
Methods  A cross-sectional design was used. The questionnaire survey data were obtained from 861 (response rate 82%) hospital patients and 35 (100%) nurse managers in Finland.
Results  An inverse relationship between the size of the hospital and ward and patients' perceptions of individualized care was found. Increased staffing or skill mix failed to predict a higher patient perception of individualized care, but primary nursing care delivery did.
Conclusions  Instead of increasing the amount of nursing staff, there is a need to improve the quality of the nurse–patient interactions to facilitate individualized care. The generalizability of the study is limited by the regional nature of the setting.     

Missed nursing care: a concept analysis

Title.  Missed nursing care: a concept analysis.
Aim.  This paper is a report of the analysis of the concept of missed nursing care.
Background.  According to patient safety literature, missed nursing care is an error of omission. This concept has been conspicuously absent in quality and patient safety literature, with individual aspects of nursing care left undone given only occasional mention.
Method.  An 8-step method of concept analysis – select concept, determine purpose, identify uses, define attributes, identify model case, describe related and contrary cases, identify antecedents and consequences and define empirical referents – was used to examine the concept of missed nursing care. The sources for the analysis were identified by systematic searches of the World Wide Web, MEDLINE, CINAHL and reference lists of related journal articles with a timeline of 1970 to April 2008.
Findings.  Missed nursing care, conceptualized within the Missed Nursing Care Model, is defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed. Various attribute categories reported by nurses in acute care settings contribute to missed nursing care: (1) antecedents that catalyse the need for a decision about priorities; (2) elements of the nursing process and (3) internal perceptions and values of the nurse. Multiple elements in the nursing environment and internal to nurses influence whether needed nursing care is provided.
Conclusion.  Missed care as conceptualized within the Missed Care Model is a universal phenomenon. The concept is expected to occur across all cultures and countries, thus being international in scope.     

Nursing morale: predictive variables among a sample of registered nurses in Australia

Aim  This study investigates the determinants of morale among Registered Nurses in Queensland, Australia.
Background  In light of the public discussions on the issues facing the future of nursing, it is critical to understand the factors that influence morale.
Methods  A 160-question instrument sought information from Registered Nurses on their perceptions of 'self', work and morale. A response rate of 41% was achieved ( n  = 343) from a convenience sample of three acute hospitals.
Results  Following binary logistic regression modelling for organizational morale, significant relationships were found with patient care provision and team interaction. Binary logistic regression modelling for personal morale revealed positive relationships with team interaction, consultation, professional recognition and lower levels of patient abuse.
Conclusion  The results point to a number of organizational and professional issues that can be considered by health care administrators and policy makers to develop workplaces that have a positive impact on the morale of nurses.     

A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: an observational study

BACKGROUND: The past decade has seen increasing patient acuity and shortening lengths of stays in acute care hospitals, which has implications for how nursing staff organise and provide care to patients. OBJECTIVE: The aim of this study was to describe the activities undertaken by enrolled nurses (ENs) and registered nurses (RNs) on acute medical wards in two Australian hospitals. DESIGN: This study used structured observation, employing a work sampling technique, to identify the activities undertaken by nursing staff in four wards in two hospitals. Nursing staff were observed for two weeks. The data collection instrument identified 25 activities grouped into four categories, direct patient care, indirect care, unit related activities and personal activities. SETTING: Two hospitals in Queensland, Australia. RESULTS: A total of 114 nursing staff were observed undertaking 14,528 activities during 482h of data collection. In total, 6870 (47.3%) indirect, 4826 (33.2%) direct, 1960 (13.5%) personal and 872 (6.0%) unit related activities were recorded. Within the direct patient care activities, the five most frequently observed activities (out of a total of 10 activities) for all classifications of nursing staff were quite similar (admission and assessment, hygiene and patient/family interaction, medication and IV administration and procedures), however the absolute proportion of Level 2 RN activities were much lower than the other two groups. In terms of indirect care, three of the four most commonly occurring activities (out of a total of eight activities) were similar among groups (patient rounds and team meetings, verbal report/handover and care planning and clinical pathways). The six unit related activities occurred rarely for all groups of nurses. CONCLUSION: This study suggests that similarities exist in the activities undertaken by ENs and Level 1 RNs, supporting the contention that role boundaries are no longer clearly delineated.     

Determining nurse staffing needs: the workload intensity measurement system

hoi s.y., ismail n., ong l.c. & kang j. (2010) Journal of Nursing Management 18 , 44–53 Determining nurse staffing needs: the workload intensity measurement system
Objective  To develop a prototype nursing workload intensity measurement system (WIMS).
Background  Current nurse staffing was determined based on a development. The predetermined nurse-to-patient ratio of a measurement system in the present work environment was deemed essential.
Methods  The study was conducted in a 1500-bed acute care hospital in Singapore. A questionnaire was designed to identify critical indicators for workload measurement. Nineteen wards were observed over a period of 1 week on day shifts. The WIMS was developed using regression modelling.
Results  Nursing time required for a low-acuity ward increased from 90.5 to 177.1 hours per day. The WIMS was developed using nursing diagnoses as critical indicators of workload. The model (WIMS) yield R ² values ranging from 0.615 to 0.736 across the six key disciplines, rendering it a model with relatively good predictive ability of nursing time required.
Conclusion  In such a rapidly changing work environment, workload measurement systems should be reviewed periodically. The WIMS was developed as a potential methodology for measuring staffing needs.
Implication for Nursing Management  Workload predictions should de-link patient dependency with acuity status as both do not correlate, as evidenced by this study.