Policies and procedures: a tool to support the implementation of clinical guidelines?

OBJECTIVES: To explore the use of policies and procedures as a tool to support the implementation of clinical guidelines and to determine the relationship between organizational support and stability with nurses' perception of policy change. DESIGN: Secondary analysis of qualitative and quantitative data collected in the post-intervention phase of the study entitled Evaluation of the Dissemination and Utilization of Best Practice Guidelines by Registered Nurses in Ontario. SETTING: Eleven agencies across Ontario, Canada. PARTICIPANTS: Fifty nursing staff, 32 nurse administrators and 22 clinical resource nurses (90% response) participated in semi-structured interviews. A total of 316 randomly selected nursing staff from 23 participating units in 11 agencies completed questionnaires (65% response). METHODS: Qualitative data from semi-structured interviews were examined to determine whether participants had modified their policies and procedures as part of the implementation of clinical guidelines. Using SPSS 11.0 for Windows, the authors assessed, using independent t-tests, the relationship between the perception of modification of policies and procedures and the perceptions of organizational support an organisational stability. RESULTS: While modifications to policies and procedures were made at each agency as part of the implementation of clinical guidelines, 27% of staff disagreed that modifications had been made. Nursing staff who agreed that changes had been made to policies and procedures were significantly more likely to report positive organizational support for clinical guideline implementation. CONCLUSION: Findings suggest the need to increase nursing staffs' awareness of changes to policies and procedures during clinical guideline implementation. Furthermore, results indicate that organizational support may have a positive influence on modifications to policies and procedures that are guided by research-based clinical guideline recommendations.     

The theory-practice gap: impact of professional-bureaucratic work conflict on newly-qualified nurses

AIM: This paper reports the findings from a naturalistic enquiry undertaken in the United Kingdom into the extent to which the ideals and values of the preregistration nursing course are adopted by individual newly educated Registered Nurses. BACKGROUND: Research in several countries provides consistent evidence of the existence of a theory-practice gap in nursing. Clear disparities have been demonstrated between the best practice ideals and values that are taught and those actually encountered in everyday practice. Nurse education 'Project 2000' reforms in the United Kingdom were designed, in part, to address this issue. Few studies to date have examined the impact of these reforms on newly qualified Registered Nurses' ability to translate theory into practice. METHODS: A longitudinal study was carried out in three educational institutions in the United Kingdom from 1997 to 2000. Final year nursing students (n = 72) in three colleges of nursing completed questionnaires to elicit views on their ideals and values for practice. In-depth interviews with a purposive subsample of 26 participants (at 4-6 and 11-15 months postqualification) indicated the extent to which these ideals and values were adopted in practice. Interviews were tape-recorded, transcribed, and data were analysed using constant comparison and negative case analysis. FINDINGS: Although new nurses emerged from their programmes with a strong set of nursing values, a number of professional and organizational factors effectively sabotaged implementation. Professional sabotage includes obeying covert rules, lack of support and poor nursing role models. Organizational sabotage includes structural and organizational constraints such as time pressures, role constraints, staff shortages and work overload. CONCLUSION: The disparity between nursing as taught and as practised may have profound implications for the future of the profession both in the United Kingdom and internationally, in terms of morale, job satisfaction and retention. Measures to improve resources and reduce the professional-bureaucratic work conflict are discussed.     

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.     

Hindrance for patient participation in nursing care

THE STUDY'S RATIONALE: Patients' influence in health care through participation, freedom of choice and information, is laid down in laws, national and local directives. In nursing care situations, the degree to which a patient participates depends on the nursing staff. Accordingly, hindrances for patient's participation during nursing care is an important question for the nursing profession. AIMS AND OBJECTIVES: The aim was to focus on Swedish Registered Nurses opinion of hindrances for patient participation in nursing care and to uncover the informants' perspectives in depth. METHODOLOGICAL DESIGN AND JUSTIFICATION: The study was limited to inpatient somatic care and has a qualitative approach. Data were collected through seven focus group interviews with 31 Registered Nurses from five hospitals. An analysis of the tape-recorded interview material was made, combining elements of content analysis with aspects of the Grounded Theory approach. ETHICAL ISSUES AND APPROVAL: The ethics of scientific work was followed. The participants gave informed consent. Verbal and written information was given as a guarantee that all information would be treated confidentially outside the focus group. Formal approval by ethical committee was not required according to national and local directives. RESULTS: Hindrance for patient participation in nursing care comprised three themes: Competence, Influence of significant others and Organization and work environment, and their seven underlying subthemes. CONCLUSIONS: The study clarified factors, which individually or combined may be hindrance for patient participation in nursing practice. Professional nurses must be able to find a balance for their patients' participation in nursing care activities through identification and coping with the hindrances. The three themes and seven subthemes here identified, can be used in patient care and its' evaluation, like also quality assurance of care and work organization and in nursing education. For further development replication studies are needed, like additional studies of patients and significant others.     

Registered Nurses' perceptions of their work and professional development

AIM: This paper is a report of a study to elucidate Registered Nurses' perceptions of their work and professional development 6 years after graduation. BACKGROUND: Nursing education and health care has rapidly changed in the last two decades. Education and experience are important components in Registered Nurses' ability to promote a high quality of care, but a great deal depends on their work circumstances. This study emphasizes Registered Nurses' view of their work in health care, at a time in their career when they have several years of experience. METHOD: Data were collected in 2003 from in-depth interviews with 15 Registered Nurses 6 years after their graduation. The interviews were semi-structured and analysed with interpretive content analysis. FINDINGS: The findings revealed two themes and five sub-themes. The first theme, An appropriate but demanding profession, consisted of two sub-themes: 'having found one's niche' and 'growing old in nursing may be difficult'. The second theme, A profession with opportunities and obstacles, consisted of three sub-themes: 'being aware of Registered Nurses' potential', 'having knowledge that is seldom made use of' and 'attaining professional growth is no matter of course'. CONCLUSION: Keeping Registered Nurses' satisfied and avoiding their dissatisfaction is crucial for both educators and employers. It is essential that employers give priority to Registered Nurses' time with patients and to motivate and support them in professional development. Further intervention studies regarding a change of the balance between obstacles and opportunities are needed.     

Registered Nurses' perceptions of geriatric rehabilitation nursing in three Scandinavian countries

This study describes Registered Nurses' perceptions of geriatric rehabilitation nursing as well as their experiences of working in the rehabilitation of older patients in Denmark, Finland and Norway. The aim was to gain deeper insights into how Registered Nurses think about geriatric rehabilitation nursing and how their perceptions differ in these countries. The data were collected among 600 Registered Nurses using a structured questionnaire with five background items and 88 geriatric rehabilitation nursing items. The response rate was 65%. Data analysis was with SPSS statistical software. Geriatric rehabilitation nursing was experienced as something that required knowledge and experience, patience and creativity, as well as professional skills. The nurses talked with their patients about their rehabilitation goals, but not all nurses were aware of those goals. Progress in the rehabilitation process was evaluated on a daily basis and results were noted in the patients' records. The nurses motivated patients by giving them positive feedback, by preventing pain, by pausing to share with the patients their joy about progress, and by giving the patients the opportunity to cope with daily activities. The Registered Nurses in Denmark were more team oriented and they set out the goals in the patient's records more often than their colleagues did in Finland and Norway.     

Hope promoting strategies of Registered Nurses

AIM: This paper describes self-reported hope-promoting strategies used by Registered Nurses whilst providing care for older patients in acute and long-term care settings. BACKGROUND: The literature is replete with claims that Registered Nurses engage in hope facilitation with their patients. However, these claims are largely conjecture, with few studies empirically identifying the extent to which Registered Nurses use hope interventions with their patients. Further, some authors have questioned whether nurses have the necessary skills to undertake this vital aspect of care. METHODS: In this Gadamerian hermeneutic phenomenological study, undertaken in 2003 in Australia, we used in-depth audiotaped interviews to collect data with 14 Registered Nurses. The interviews were transcribed verbatim and analysed using the Turner method. FINDINGS: Whilst participants clearly reported that they engaged in hope facilitation with older patients, there were differences between the reported strategies used by Registered Nurses in acute and long-term care settings. Further, the strategies reported were not unique to hope promotion and have been variously described in the literature on caring, presencing, holistic nursing and therapeutic nursing. CONCLUSION: It is clear that participants considered hope promotion to be a vital aspect of their care. However, the strategies that they reported were limited and not inclusive of many and varied suggestions emerging from published studies on hope promotion. Therefore, we recommend that nursing curricula, professional development and in-service education programmes place hope facilitation on their agenda and foster a culture in which promoting hope is seen as a vital aspect of nursing care.     

Effects of an exercise programme on organizational/psychosocial and physical work conditions, and psychosomatic symptoms.

The aim of this study was to evaluate the effect of a weekly exercise programme among nursing staff on organizational/psychosocial and physical work conditions, and psychosomatic symptoms. Out of 106 nurses and nursing aides from four geriatric wards who were invited to participate in a cross-over study, 86 accepted. For the exercise periods the staff were invited to participate in an exercise programme twice a week for 8 weeks during work time. Fifty subjects participated > or = 8 times regularly during the exercise periods (participants). During the control periods, 78 subjects attended without intervention. The effect was followed-up with questionnaires before and after the intervention periods. The exercise programme did not affect perceived organizational/psychosocial or physical work conditions, with one exception. A higher change for the worse was seen in the factor "work planning" during the exercise periods compared with during the control periods. The result suggests that the organization of the training is important in order not to add extra stress.     

Barriers to nurse/nursing aide communication: the search for collegiality in a southeast Ohio nursing home

Aim  The aims of this study were: (1) to identify barriers to nurse/nursing aide communication and to discuss and provide solutions to some of these problems through a focus group; and (2) to determine the effectiveness of this focus group on job satisfaction-related outcomes.
Background  Numerous studies have attributed problems with nurse staffing and turnover to faulty communication between nursing supervisors and nursing aides.
Methods  Registered nurses (RNs) ( n  = 2), licensed practical nurses (LPNs) ( n  = 10) and nursing aides ( n  = 19) were interviewed; narrative themes from the interviews were then used to guide focus group discussions. A job satisfaction survey in a pre-test/post-test fashion was used to test the efficacy of the focus group.
Results  Qualitative data from the interviews highlighted: (1) anger and condescension in communication; and (2) lack of mentoring, empathy and respect. The job satisfaction survey data showed that the attitudes decreased significantly among participants in the focus group but not in the control group ( P  < 0.05).
Conclusion  Nurse supervisors, both RN and LPN, are key to educational reform and must be taught collegial methods when delegating authority.
Implications for nursing management  Findings from this study can be used to develop a multidisciplinary educational tool to foster communication and collegiality, thereby reducing job turnover in nursing homes.     

Communication enhancement: nurse and patient satisfaction outcomes in a complex continuing care facility

AIMS: This paper presents an evaluation of a communication enhancement intervention on staff and patients in a complex continuing care facility. BACKGROUND: The importance of effective communication as a fundamental element of nursing has been emphasized and is regarded as integral to the provision of quality patient care. For people residing in complex continuing care (similar to long-term care facilities), opportunities for socialization occur primarily during interactions or communication with staff, and these interactions have been found to be limited. One way to improve nursing staff communication is through a communication enhancement intervention. METHODS: Twenty-one nursing staff members (Registered Nurses, Registered Practical Nurses and healthcare aides) working in a complex continuing care environment and 16 patients participated in this study, conducted in the summer of 2003. A repeated measures design was used to evaluate the effects of the communication enhancement intervention on outcomes. Data were collected from patients and nurses at baseline, 5 weeks into the intervention and at 10 weeks after the intervention. Nurse outcome variables included nurses' job satisfaction and their relationships with patients; patient outcome variables included two measures of patient satisfaction with care. RESULTS: Nursing staff felt closer to their patients (F(2,40) = 3.0, P = 0.045) following the intervention and reported higher levels of job satisfaction (F(2,40) = 4.1, P = 0.02). No changes were found in the level of patient satisfaction with care. CONCLUSIONS: Our results suggest that nursing staff can feel better about their job and about their patients as they enhance their communication skills. Understanding the barriers to finding time to talk with patients for a few minutes a day, outside of direct hands-on caregiving, requires further exploration.     

Teaching and supporting nursing students on clinical placements: Doing the right thing

Problem

Pre registration nursing students do not always feel supported by Registered Nurses during their clinical placements. To help develop and refine clinical skills, in order to deliver safe, competent nursing care, nursing students rely on Registered Nurses to teach and support them in their clinical learning.

Registered Nurses' views on their professional role

Aim The aim is to study Registered Nurses’ opinions and reflections about their work tasks, competence and organization in acute hospital care. Background The definition of the role of nurses has changed over time and it is often discussed whether Registered Nurses have a professional status or not. Method A qualitative research design was used. Data were derived from written reflections on diaries and from focus group interviews. Results All respondents had difficulties in identifying the essence of their work. It can be argued that being ‘a spider in the web’ is an important aspect of the nursing profession. Conclusion Registered Nurses tend to regard their professional role as vague. Managers must be considered key persons in defining the professional role of Registered Nurses. Implications for nursing management This study contributes to an understanding of the managers’ and the importance of nursing education in Registered Nurses professional development.     

Role discrepancy: is it a common problem among nurses?

AIM: This paper reports a study of nurses' perceptions of the differences between ideal and actual nursing roles, how these perceptions differ according to length of experience and the factors that might contribute to these perceived differences. BACKGROUND: The literature suggests that nurses tend to experience role discrepancy or a mismatch between their ideal and actual roles. Although it has been assumed that experienced nurses perceive less role discrepancy than inexperienced nurses, either because the former adjust themselves to their actual practice or because they have the expertise to improve their practice, this assumption has not been tested. METHODS: A survey design was used and the data were collected in 2003. Selected items from the Jefferson Survey of Attitudes Toward Physician-Nurse Inventory and the Staff Nurse Role Conception Inventory were administered to 216 Registered Nurses in Victoria, Australia to measure their perceptions of ideal and actual nursing roles. Data were analysed using a t-test and regression analysis. RESULTS: Nurses with more clinical experience rated their ideal and actual nursing roles more positively than those with less experience. However, the results showed that both groups of nurses experienced the same degree of role discrepancy. Both groups perceived strong role discrepancy in the areas of organizational decision-making and provision of patient education. Experienced nurses also perceived moderate role discrepancy in developing nursing care plans and in the freedom to initiate referrals. CONCLUSIONS: Role discrepancy cannot be resolved by having more clinical experience. While clinical experience enhances nurses' conceptions of their ideal roles, it can also lead to role discrepancy if there are organizational barriers that prevent nurses from engaging in their ideal roles. It is important to find a way whereby nurses can actualize their ideal views of practice in the current healthcare environment.     

Client-centred empowering partnering in nursing

AIM: This paper explores nurses' experiences 1 year after an organization's commitment to providing a client-centred and client-empowering partnering approach to care. BACKGROUND: Historically, nurses' approach to providing care in all nursing contexts has been one of doing for clients, and previous studies have focused more on in-hospital care than on home care. However, the isolation inherent in in-home nursing and nurses' limited professional autonomy and power associated with physician control over patients in home care have been reported, as has their difficulty in finding the meaning and satisfaction of human connectedness and mutuality in nurse-client relationships. Overall, research to date does not inform us about how nurses might make a change toward a more client-centred and client-empowering approach to nursing. METHODS: An interpretive phenomenological design was used to elicit in-depth understanding about Registered Nurses' experiences of providing care using this innovative empowerment model. A purposefully selected sample of eight Registered Nurses participated in in-depth interviews. Data were generated during 2002. Hermeneutic analysis was used to elicit themes and patterns emerging from the data. FINDINGS: Caring, client-centredness and the context of in-home care were important in implementing the new partnering approach. Barriers encountered at system, organizational and personal levels distracted nurses from fully comprehending and enacting the approach. After a year, they had begun to contemplate potential strategies for partnering with clients, but had not yet explored the power of their professional autonomy. CONCLUSION: Nurses are inclined to practise within the expert model of service delivery. They need to work through issues of professional autonomy and rise to the challenge of exercising their autonomy within the current healthcare context if they are to attend more consistently to client-centred empowering partnering. The home care setting offers an excellent environment for achieving these aims.     

An evidence-based protocol for nurse retention

Registered nurse turnover can drastically affect the quality of patient care while costing more than 1 billion dollars. The ongoing nursing shortage makes it hard to replace nurses, necessitating a novel approach to reduce nurse turnover. The authors discuss an evidence-based protocol that improves organizational commitment among nurses as a way to retain nurses through facilitating autonomy, improving communication, and offering recognition and rewards to nursing staff.     

Effects of a range-of-motion exercise programme

AIM: This paper reports an evaluation of a range-of-motion exercise programme aimed at improving joint flexibility, activity function, perception of pain, and depressive symptoms in a sample of stroke survivors in long-term care facilities. BACKGROUND: The benefits of physical rehabilitation for stroke survivors have been well established. There is, however, little empirical data on the effects of a simple nurse-led range-of-motion exercise programme in improving function for these people. METHOD: A randomized controlled trial was conducted in 1999 with 59 bedridden older stroke survivors in residential care. Participants were randomly assigned to usual care or one of two intervention groups. The 4-week, twice-per-day, 6 days-per-week range-of-motion exercise protocols were similar in both intervention groups, and consisted of full range-of-motion exercises of the upper and lower extremities. To test the effect of different degrees of staff involvement, in intervention group I, a Registered Nurse was present to supervise participants performing the exercises, while intervention group II involved a Registered Nurse physically assisting participants to achieve maximum range-of-motion within or beyond their present abilities. RESULTS: Both intervention groups had statistically significant improvement in joint angles, activity function, perception of pain and depressive symptoms compared with the usual care group (P < 0.05). Post hoc comparison revealed that the joint angles in intervention group II were statistically significantly wider than in both the other groups (P < 0.01). CONCLUSIONS: A simple nurse-led range-of-motion exercise programme can generate positive effects in enhancing physical and psychological function of bedridden older people with stroke. Further studies are needed to investigate the long-term effects of the programme in maximizing function, reducing care utilization and enhancing quality of life for this population.     

Bridging the research–practice gap: exploring the research cultures of practitioners and managers

To ensure effective utilization of research in nursing more evidence is needed which illuminates the way nurses think about research, the value which they put on it, and how they envisage that it may help or hinder them in their everyday work. This English study aimed to meet these objectives by describing the research culture of practising nurses, health visitors and midwives, and their managers. It rests on two assumptions. Firstly that the reasons why practitioners do, or do not, base their practice on research are complex, and secondly, that interventions to increase research utilization must be grounded in an appreciation of this complex 'whole'. Thus the study took a qualitative approach to exploring: what participants thought and felt about research; the current status of research based practice; and the opportunities and constraints to increasing research based practice. The results confirm the hypothesis that many factors, both individual and organizational affect research utilization. Furthermore, practitioners and managers hold differing perceptions regarding the nature of research, its role, and the opportunities and constraints which effect its dissemination and utilization. The implications of the results for education, policy and practice are discussed.