Critical care nurses: professional development in the private sector.

The purpose of this study was to gain a greater understanding of the experiences and perceptions of private hospital critical care nurses regarding critical care education delivery. It addressed the question of whether rural private hospital critical care nurses have different experiences and perceptions of critical care education delivery than metropolitan private hospital critical care nurses, and the implication these differences may have for the providers of continuing professional education for critical care nurses. The study used a phenomenographic approach to identify participants' common sense conceptions of their experiences and perceptions of critical care education delivery. A focus group session was held at a rural private hospital and a metropolitan private hospital, where interviewees were encouraged to reflect on previously unthematised aspects of the phenomenon in question. In addition, questionnaires were distributed to critical care staff in each unit and interviews were held with key stakeholders. Nineteen nurses participated in the study, providing a cross section of the experiences and qualifications present within these units. A number of issues were identified from the data, namely the need for clinical educators within critical care units to support students undertaking critical care courses and the desire for a move back to hospital based courses supported by the tertiary system. Education providers need to look closely at the issues of access, cost and organisation of courses to make them more appealing and relevant for both rural and metropolitan critical care nurses.     

Barriers to participation in continuing education activities among rural and remote nurses

BACKGROUND: This article examines the barriers to participation in continuing education activities that are perceived by rural and remote registered nurses in Canada. METHODS: The data are drawn from a national survey that was part of a larger national project, "The Nature of Nursing Practice in Rural and Remote Canada." RESULTS: Perceived barriers to participation in continuing education activities include the isolation of rural nurses and time and financial constraints. Nurses who perceived barriers to participation were more likely to be middle-aged, unmarried, and working full-time than nurses who did not perceive barriers. They were also more likely to possess higher levels of nursing education and have children or dependents. The perception of barriers to participation was also associated with lower job and scheduling satisfaction. CONCLUSIONS: Rural and remote registered nurses have moderately high levels of participation in continuing education; however, participation and job satisfaction can be improved if some of the barriers identified are addressed.     

Development of a postbasic critical care program for registered nurses: a collaborative venture between education and practice

This article describes a collaborative venture between nursing education and nursing practice focused on continuing education. A province-wide assessment of the educational needs of registered nurses identified the need to create a critical care education program. A critical care project team was established to develop a Postbasic Critical Care Program for registered nurses. The development of the project team, initiation of the program, and the mutual benefits and challenges posed by this collaborative venture are presented.     

Innovations and issues in the delivery of continuing education to nurse practitioners in rural and northern communities.

This paper addresses the need to provide rural nurse practitioners (NPs) with the distance education that is considered vital to the upgrading of their professional skills. The method of delivering the courses is a critical aspect of their success. The authors trace and describe the innovative delivery of the Rural Ontario Nurse Practitioner Continuing Education Initiative, from the initial needs assessment study through to the implementation and evaluation study. In each study, a multi-method action research model was used. The respondents showed a preference for face-to-face modalities that were perceived to be constrained by barriers. These barriers were subsequently addressed by the pilot project. Those living in rural areas recognized the benefits of information technologies. Implementation was effectively weighted on multiple modes of online course delivery and the use of constructivist pedagogy. The findings suggest that the delivery of continuing education to rural and remote NPs is still wrought with challenges.     

We cannot staff for 'what ifs': the social organization of rural nurses' safeguarding work

MACKINNON K. Nursing Inquiry 2012; 19: 259-269 We cannot staff for 'what ifs': the social organization of rural nurses' safeguarding work Rural nurses play an important role in the provision of maternity care for Canadian women. This care is an important part of how rural nurses safeguard the patients who receive care in small rural hospitals. This study utilized institutional ethnography as an approach for describing rural nursing work and for exploring how nurses' work experiences are socially organized. Rural nurses advocated for safe healthcare environments by ensuring that skilled nurses were available for every shift, day and night, at their local hospital. Rural nurses noted that this work was particularly difficult for the provision of maternity care. This article explores two threads or cues to institutional organization that were identified in our interviews and observations; namely staffing and safety standards, and the need for flexibility in staffing in small rural hospitals. Rural nurses' concerns about ensuring that skilled nurses are available in small rural hospitals do not enter into current management discourses that focus on efficiency and cost savings or find a home within current discourses of patient safety 'competencies'.     

Information resources and knowledge needs of rural nurses regarding Alzheimer's disease

BACKGROUND: The need for current information on Alzheimer's disease (AD) is apparent as medical research, diagnostic, and treatment guidelines are advancing at a rapid rate. METHOD: A needs assessment survey determined what educational topics related to dementia nurses perceived they most need, would be most likely to attend, and what information they likely would solicit in a telephone consultation. RESULTS: Nurses in Iowa were interested in continuing education programming and teleconferences on major topics regarding AD provided through the state's fiberoptic system such as: (a) challenging behaviors over the course of illness; (b) family needs such as education, support, respite, referral, and safety; (c) case management services for patients and families; (d) long-term care services from adult care to hospice; and (e) new developments in AD. CONCLUSION: Rural nurses experiencing professional isolation and lack of resources can access up-to-date information via continuing education programs transmitted by telecommunication strategies.     

What critical care nurses need to know about health care access when caring for elders in acute care settings

Health care system issues, in general, and access to care, in particular, are not problems typically studied by critical care nurses. Rather, initial and continuing education focuses on clinical aspects of care. This focus is necessary to assure that critical care nurses have the expertise to care for patients who need astute surveillance for complicated physical problems and their emotional sequelae, as well as in-depth knowledge and skills related to care coordination for patient stabilization and transfer. However, evidence is growing that patients benefit when critical care nurses expand their knowledge about access to care. This article provides insights regarding access to health care and how it relates to many of the admission and readmission patterns that critical care nurses observe.     

Meeting the continuing education needs of nurses in rural settings

Access to continuing education (CE) for rural nurses is hampered by distance, cost factors, and the lack of sufficient personnel to provide coverage when nurses are away from work. Additionally, because rural nurses function as generalists rather than specialists, CE programs should focus on the generalist perspective. The Nevada Area Health Education Center (AHEC) has developed a partnership model for providing CE that addresses these considerations, bringing educational programs to the rural site eliminates travel, cost, and coverage problems for the hospitals. In turn, a close working relationship between AHEC and rural personnel to assess needs and coordinate the planning is critical. Attention to logistical detail is critical. The partnership model described is the foundation of a year-round CE program for nurses working in rural and frontier areas.     

Predictors of rural critical care nurses' willingness to care for people with AIDS.

The purpose of this study was to examine the relationship between rural critical care nurses' attitudes about acquired immunedeficiency syndrome (AIDS) and people with AIDS (PWAs), and their willingness to provide care to AIDS patients. Sixty-one critical care nurses in nine rural counties in the northeastern USA completed a mailed questionnaire as part of a larger study of 957 rural nurses. A bivariate logistic regression analysis revealed a relationship between willingness to provide care and positive attitudes about homosexuality, nursing care concerns, and professional-societal concerns. However, a multivariate logistic regression indicated that the most significant factors influencing rural critical care nurses' willingness to care were their feelings of not being prepared to care for people with AIDS, and their anxiety and fears about contracting the disease from their patients. These findings add insight into the care of critically ill AIDS patients and support the need for continuing educational efforts in rural areas of the USA to address critical care nurses' concerns.     

The importance of assessing symptoms and symptom clusters in critical care units

In the highly technological environment of critical care, a comprehensive symptom assessment from the patient's perspective is routine. There is a paucity of research related to symptom management in the critical care environment. The lack of understanding of the symptom experience for critical care patients could represent missed opportunities to manage symptoms and minimize suffering. This article discusses the importance of assessing symptoms and symptom clusters in critical care patients and challenges surrounding the assessment of symptom clusters. By understanding symptom clusters, critical care nurses can develop more comprehensive assessments, as well as more tailored intervention strategies.     

Long-term care nurses' knowledge of end-of-life care

Long-term care (LTC) facilities usually contract with hospice agencies to provide palliative (comfort) care to their terminally ill residents, yet only 1% of nursing home residents enroll in hospice care. Integrating hospice services with nursing home services presents many challenges. One of the most critical challenges is the lack of education in palliative care among physicians, licensed nurses, and certified nursing assistants in LTC settings. A study of 164 licensed nurses from 24 LTC facilities in north central Texas found deficiencies in their knowledge of palliative care. The mean score on the Palliative Care Quiz for Nursing was 12.3 of a possible 20 (62%, SD = 2.7). Implications for practice include a critical need for in-service education on end-of-life content for practicing LTC nurses and integration of such content in all curricula for future nurses.     

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

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

Knowledge and skill acquisition for critical care nursing practice

In many critical care units, extended orientation or education programs have been offered to prepare the registered nurse to work in this specialty area. Current shortages of nurses and less experienced nurses applying for critical care positions have augmented the need for educational programs. In the Edmonton region, a partnership between two public institutions led to the development and implementation of an innovative educational program. In this article, we describe challenges and strategies to prepare critical care nurses to integrate knowledge, and meet the standards and expectations of both partners. In particular, methods are described to achieve theoretical and clinical outcomes. This article contributes to the discussion and implementation to offer knowledge and skill acquisition for a novice critical care nurse.     

Making gerontic continuing education accessible for rural nurses

Special approaches need to be developed and used to make gerontic continuing education accessible to nurses in rural settings. Traditional workshops are time-intensive, and expensive to deliver, and are out of the reach of many nurses in rural settings because of great distances, inclement weather, expense, and lack of work coverage. The use of self-study modules featuring in-depth conversations with and demonstrations by gerontological experts is one way to economically deliver current gerontic continuing education to nurses in rural settings.     

The experience of general nurses in rural Australian emergency departments

Australia is a geographically unique country with large areas classed as rural. Nurses providing emergency care in rural hospitals face a number of challenges, with rural communities expecting multi-skilled nurses, prepared for a wide range of unannounced situations. Using a mixed method approach, involving questionnaires and focus groups, the study was undertaken in two rural health services in Victoria, Australia. The aim was to explore the experiences of general nurses working in rural hospital settings, with regards to their emergency department responsibilities. The findings indicate that nurses lacked confidence, which they attributed to the sporadic nature of working in the area and the diversity of people who presented. A resultant ‘skills rusting’ was described and nurses identified the need to be a diverse ‘specialist’. Some lack of confidence, particularly in the mental health area, was related to feelings of isolation and lack of context specific education and training. While some excellent emergency specific education and training is available for rural nurses, access is limited by a multitude of constraints. This study found there is an urgent need for local emergency education and training; with nurses showing a strong preference for ongoing professional development incorporating scenario based and context specific education.     

The Last Frontier: Rural Emergency Nurses' Perceptions of End-of-Life Care Obstacles

Introduction: Caring for dying patients is part of working in a rural emergency department. Rural emergency nurses are prepared to provide life-saving treatments but find there are barriers or obstacles to providing end-of-life (EOL) care. This study was completed to discover the size, frequency, and magnitude of obstacles in providing EOL care in rural emergency departments as perceived by rural emergency nurses. Methods: A 57-item questionnaire was sent to 52 rural hospitals in Idaho, Wyoming, Utah, Nevada, and Alaska. Respondents were asked to rate items on size and frequency of perceived obstacles to providing EOL care in rural emergency departments. Results were compared with results from 2 previous emergency nurses' studies to determine if rural nurses had different obstacles to providing EOL care. Results: The top 3 perceived obstacles by rural emergency nurses were: (1) family and friends who continually call the nurse for an update on the patient's condition rather than calling the designated family member; (2) knowing the patient or family members personally; and (3) the poor design of emergency departments that does not allow for privacy of dying patients or grieving family members. The results of this study differed from the other 2 previous studies of emergency nurses' perceptions of EOL care. Discussion: Nurses in rural emergency settings often work in an environment without many support personnel. Answering numerous phone calls removes the nurse from the bedside of the dying patient and is seen as a large and frequent obstacle. Personally knowing either the patient or members of the family is a common obstacle to providing EOL care in rural communities. Rural nurses often describe their patients as family members or friends. Caring for a dying friend or family member can be intensely rewarding but also can be very distressing. Conclusion: Rural emergency nurses live and work on the frontier. Little EOL research has been conducted using the perceptions of rural emergency nurses possibly because of the difficulty in accurately accessing this special population of nurses. Rural emergency nurses report experiencing both similar and different obstacles compared with their counterparts working in predominately non-rural emergency departments. By understanding the obstacles faced by emergency nurses in the rural setting, changes can be implemented to help decrease the largest obstacles to EOL care, which will improve care of the dying patient in rural emergency departments. Further research is needed in the area of rural emergency nursing and in EOL care for rural patients.     

Clinical decision making by nurses when faced with third-space fluid shift. How well do they fare?

Nurses' use of knowledge, the connection of this knowledge to treatment decisions and information actually used to reach such decisions, delineates nurses' level of expertise. Previous research has shown that nurses in their clinical decision-making use the hypothetico-deductive method and intuitive judgment or pattern recognition. This interpretive study explored experienced critical care nurses' (n = 5) and gastrointestinal surgical nurses' (n = 5) clinical decision-making processes through ascertaining their knowledge and understanding of third-space fluid shift in elderly patients undergoing major gastrointestinal surgery. Both groups of nurses, because of their experience with elderly patients undergoing gastrointestinal surgery, were assumed to be experts. Data collection techniques included semi-structured interviews and the use of think aloud protocol for clinical scenario analysis. The findings demonstrated that the gastrointestinal surgical nurses used the hypothetico-deductive method to recognize critical cues and the existence of a problem but could not name the problem. The critical care nurses, on the other hand, used a combination of the hypothetico-deductive method and pattern recognition as a basis for identification of critical cues. The critical care nurses also possessed in depth knowledge of third-space fluid shift and were able to use pivotal cues to identify the actual phenomenon. Ultimately, it would appear that the structure of critical care nurses' work, their increased educational qualifications and the culture of the critical care unit promote a more proactive approach to reasoning in the physiological domain. The findings have implications for the development of practice guidelines and curriculum development in both tertiary and continuing nurse education.     

Teaching basic ethical concepts and decision-making: a staff development application

Academic nursing programs are increasing the amount of ethical instruction presented to undergraduate and graduate students. However, nurses who graduated several years ago may find themselves without the background and skills needed to discuss the complex bioethical dilemmas they now face. This article presents the development of a continuing education program to acquaint nurses with basic ethical concepts and bioethical decision-making processes. Presentations were piloted with a small group of nurses from the outpatient department of a pediatric tertiary care hospital.     

Impact of rural hospital environments on patients and nurses

Rural hospitals provide life-saving acute care from a consistent group of care providers. Rural hospitals with financial difficulties operate under tight margins as an attempt to prevent closure, which could contribute to not completing repairs needed to the hospital building. This paper explores an ethical dilemma for rural hospital nurse administrators, which is, “Is it better for a rural hospital building is disrepair to remain open so that it can provide a place for some degree of acute care services to be offered in the rural community–or–if a hospital building has structural problems that could lead to harm, should hospital operations cease until a solution is found?" To illustrate this dilemma, I will discuss the challenges of rural hospital administrators and a first-hand experience I had as a bedside nurse who experienced a dangerous near miss related to the built environment. Rural hospitals operating in a built environment in disrepair might need to consider nontraditional, even unusual, solutions to provide safer care given financial constraints. Rural businesses and institutions could consider sharing their building space to provide a safer built environment for nurses and patients while also not placing hospitals at further risk of financial distress.