Discharge planning process: applying a model for evidence-based practice

Discharge planning is an integral but ill-defined process in most acute care settings. The time available to a healthcare team to adequately prepare patients for discharge has virtually evaporated with decreasing lengths of hospital stay. A research utilization (RU) team at a tertiary care teaching institution reviewed the literature from 1990 to 2002 in search of a research-based practice regarding staff nurses' roles in the discharge process. Review of the literature revealed varied discharge planning processes using staff nurses, advanced practice nurses, or case managers specifically prepared to implement the discharge planning process. Insufficient evidence was found to support a change from the current staff nurse practice.     

Caring for patients dying at home from heart failure: a new way of working

This article explores the difficult journey that heart failure patients frequently experience when trying to access palliative care. It describes how a team of Macmillan and heart failure nurse specialists attempted to address the problem using the specialist role to effect change. Individual and group learning needs were identified and addressed while the use of reflective practice and group working helped the nurses to manage and implement change. This project, with management support, empowered the specialist teams to think creatively about nursing practice and improve patient care. It has encouraged working with clinical nurse specialists from other disciplines, thus avoiding a narrowness of outlook. Although this project initially focused on a small number of patients, it has enabled the teams to become established in partnership working; the collaborative approach to providing palliative care for end-stage cardiac failure patients has since continued to grow and flourish. It is hoped that, in the future, further studies can take place to gain more detailed information from patients and their families about how partnership working can continue to meet the needs of this group.     

Public health nursing: the generalist in a specialized environment

In implementing a generalist model of public health nursing (the Comprehensive Multi-level Nursing Practice Model) in a rural county health department, a research team encountered critical challenges. The framework for the model was a philosophy of public health nursing practice and action research to support the public health nurse generalist role. Challenges in implementing the model stemmed from conflicts between the research team and the health department that were rooted in philosophical differences about how to implement care and the nature of nursing and the public health nursing role. Key factors were the subtle forces operating in the public health environment that constrain the public health nurse generalist role. Based on conflicts that arose in implementing the model, implications for public health nursing practice are in opportunities to influence policy at health department and other levels and responsibility for assuring professional practice.     

Professional development for an advanced practice nursing team

Since its development in 1998, the Cardiology Advanced Practice Nurse team has been plagued by retention issues. The coordinator for the team developed this leadership project while participating in the 2008 to 2009 Maternal-Child Health Leadership Academy sponsored by Sigma Theta Tau International and Johnson & Johnson. The focus of this project was to develop, implement, and evaluate initiatives to empower the advanced practice nurse team, promote their professional development, and ultimately improve retention of team members. Although evaluation data show progress toward addressing work environment issues, retention remains an ongoing problem.     

The clinical nurse leader: a response from practice.

In October 2003, over 200 nurse leaders from education and practice met at the invitation of the American Association of Colleges of Nursing. A newly released white paper, describing the role of the clinical nurse leader, was discussed at the conference. This article outlines a response to that white paper from one practice setting. The article shares information about another role, that of team coordinator, that is similar to clinical nurse leader and has been implemented at an integrated not-for-profit health care system in 5 hospitals. The comparison of the team coordinator role to the clinical nurse leader role might assist in visualizing such a role in practice. Although the roles are not identical, many of the driving forces for change were similar; these included the need to meet the changing demands for improved patient outcomes and nurse retention. The team coordinator role has 4 domains of practice that are crosswalked against the clinical nurse leader 15 core competencies. An evaluation of the team coordinator role showed changes that need to be made, such as placing more emphasis on clinical progression of patients. Lessons learned are shared, including keeping the scope of the role manageable, providing documentation standards for new roles, and the leadership required of the nursing executive to implement change.     

The Advanced Nursing Practice Team as a model for HIV/AIDS caregiving in Switzerland.

To offer advanced nursing care for people living with HIV, a participatory action research project was initiated that enabled constant learning and change at the levels of (a) the culture and organization of an outpatient department, (b) clinical leadership and interdisciplinary collaboration, and (c) development of new services. In this project, the development of the Advanced Nursing Practice (ANP) Team not only affected the practice of individual nurses with advanced degrees but also created a team of nurses educated at different levels. Through a systematic process, the nurses on the team became more educated and refined their clinical expertise. An essential aspect of the ANP Team was the specialization of each nurse in a self-selected topic within HIV/AIDS care. As members of the ANP Team, the nurses offer state-of-the-art nursing care including patient assessment, medication management and adherence support, symptom management, health maintenance and prevention, and family support for persons living with HIV.     

Navigating the Path to a Sustainable “PACU Pause” and Standardized Perioperative Handoff: A Quality Improvement Project

PurposeThe purpose of this project was to develop and implement a pause and standardized perioperative handoff to improve the quality of the handoff and the satisfaction of the perioperative team in the postanesthesia care unit (PACU) setting.DesignThe Iowa Model for Evidence-Based Practice guided this evidence-based practice-quality improvement project.MethodsA team was formed of key nurses and other perioperative members to execute the project. The outcome of the evidence review, appraisal, and synthesis supported the change to a pause and standardized perioperative handoff. The project team educated perioperative staff on the practice change and new process. Baseline, 3-month and 1-year data were collected for adherence to the PACU PAUSE and handoff critical elements, and baseline and 3-months for satisfaction.FindingsPACU PAUSE adherence was 42.30% prepractice change, 92.3% postchange and 96.10% at 1-year. Adherence to the 17 critical elements in the standardized handoff was 40.16% prepractice change, 77.36% postchange and 71.78% at 1-year. Nurse satisfaction with the PACU PAUSE and handoff increased 59% and 50% respectively from pre to postpractice change. Operating room nurse and anesthesia provider satisfaction with PACU PAUSE and handoffs was greater than 85% at baseline and increased 14% and 8% respectively.ConclusionsThe PACU PAUSE allows for increased nurse concentration during the handoff and this can improve patient safety. Using a standardized handoff in situation, background, assessment, response format can decrease information loss and miscommunication, improve the quality of the handoff and the perioperative team members satisfaction with the handoff, and may mitigate patient safety events.     

Introducing an integrated care pathway for the last days of life

Integrated care pathways (ICPs) are multiprofessional documents designed to enable the implementation of evidence-based care and support the practical delivery of clinical governance. However, the implementation of care pathways is resource intensive and few evaluations have been conducted with respect to these areas or to the efficacy of care pathways to change practice and improve outcomes in care. This project sought to address these issues and the report outlines the approach taken by a palliative care team in South Wales, UK, to implement a care pathway for the dying throughout a district general hospital and six community hospitals. Dying can be a complex area of care and changing practice can be challenging, therefore a PRINCE Project management approach was taken and a full-time project nurse employed for the life of the project. This paper describes the strategies used to approach implementing a care pathway and provides a template for other teams who may embark on similar projects. At the end of the project, the care pathway was successfully implemented and provided demonstrable outcomes of care for those dying from cancer and nonmalignant diseases. Strikingly, a large number of patients dying from nonmalignant disease were cared for via the pathway, which was not expected.     

A method combination for Advanced Nursing Practice projects

In order to offer Advanced Nursing Practice (ANP) in Switzerland, some practice development projects have been established with the goal to enable entire nursing teams to become ANP Teams. These ANP Teams are led by ANP nurses with a high expertise in the specific practice area. The combination of the three methods action research, project management and evaluation research have proven useful for the ANP nurse as project leader. Action research is viewed as the leading force because of its scientific methods that allow focusing on practice problems and actions. With project management methods, the ANP project can be organized in an effective and efficient way. Evaluation research offers methods to systematically evaluate the project at the level of patients, team, and organization. The combination of these different methods allows the ANP nurse to work systematically and flexibly and improves results.     

Action research: A mechanism for active engagement of clinical nurses in a program of research

This study aimed to explore the outcomes of active participation in an action research project on building the research capacity of clinical nurses. In this qualitative research study, six registered nurses volunteered to participate in the action research team. None of the nurses reported having any prior research experience. This study was part of a larger three‐phase project. The nurses were required to reflect on the data about their medication practice of phase 1, develop and implement a bundle of interventions in phase 2 to improve medication safety, and evaluate the effectiveness of these interventions in phase 3. We report the nurses' participation in Action Research during phase 2. Meeting minutes and six semistructured interviews were thematically analyzed. The results showed that after receiving support to enhance their research skills from the research team, the nurses were empowered to perform and lead clinical nursing research project. Nurses were able to take ownership of the research process and outcomes and were then able to translate their new research knowledge and skills into their clinical practice by building their own research capacity.     

Intravascular therapy process improvement in a multihospital system: don't get stuck with substandard care

Using the process of FOCUS PDSA (a quality improvement format), two clinical nurse specialists reviewed the delivery of intravenous care at a multihospital (4-hospital) system. The clinical nurse specialists formed a multi-facility nursing team to lead the assessment, develop a plan, implement changes, and evaluate the process. This process reflects the use of clinical nurse specialists as experts in using research-based data, national recommendations, and benchmark data to ultimately improve practice and reduce risks and overall costs. This process allows the clinical nurse specialist to be viewed as an innovator, a project manager, and a program developer in a major system. The clinical nurse specialists were selected to lead this process improvement based on their knowledge and competencies in the specific area of intravenous therapy.     

What do community palliative care nurse specialists do? An activity analysis

A self-assessed activity analysis of a team of community palliative care nurse specialists was undertaken as part of a wider review of their service. Although it was not a research project, it proved to be a pragmatic and worthwhile means of analysing the work of individual nurse specialists and measuring what they actually do.The results and outcomes are presented in order to share the experience and to break down some of the isolation of community palliative nursing practice.The study found quite wide variations in practice between the individual nurse specialists but that most spent a high proportion of their time on clinical work at the expense of other aspects of the nurse specialist role, such as education, research and audit. It also found that most of the nurse specialists worked many more than their contracted hours and took very few breaks during the working day. The study promoted discussion within the team, changes have been introduced and the study will be repeated in two years' time.     

The impact of restructuring on professional nursing practice.

Through the 1990s most hospitals were involved in restructuring. As a result, maintaining professional nursing practice is challenging in these cost-constrained hospital environments. In new models of care, professional nursing practice expectations are often reconceptualized into multidisciplinary care team structures in which the team is empowered and becomes the focus rather than the individual nurse caring for her or his patient. Given that nurses provide the greatest part of patient care in hospitals, professional nursing practice has the potential to differentiate one hospital from another. Consequently, it is in the strategic interest of organizational policy makers to implement initiatives that support professional nursing practice.     

Collaborating with practitioners in teaching and research: a model for developing the role of the nurse lecturer in practice areas

Collaborating with practitioners in teaching and research: a model for developing the role of the nurse lecturer in practice areas The integration of nurse education with higher education in the United Kingdom, has highlighted an uncertainty over the clinical role of nurse lecturers. Although benefits have been identified from lecturers maintaining strong links with clinical practice, the evidence suggests that nurse lecturer participation in practice areas is limited. This paper reports a strategy for developing the clinical role of the nurse lecturer through collaborating with practitioners in teaching and research. An action research project designed to implement and evaluate a teaching programme for pre-registration nursing students was developed. The research aimed to evaluate the programme and identify the benefits for students, practitioners and the nurse lecturer in collaborating in teaching on the programme. Ethical approval was granted from the local research ethics committee. Data were collected in three ways: questionnaires to 17 students; focused interviews with nine practitioners; and analysis of the reflective diary kept by the lecturer. Findings identified the success of the teaching programme and also revealed substantial benefits for students, practitioners and the lecturer. Selected findings are used to demonstrate how the liaison, teaching, clinical practice and research elements of the nurse lecturer's clinical role could be developed. The project was small scale and grounded within a specific context and thus may not be applicable to other settings. However, it is suggested that collaboration between nurse educationalists and practitioners in this way offers a potential model for developing the clinical role of the nurse lecturer.     

It takes more than clinical effectiveness to change nursing practice: an unsuccessful project in the nurse promotion of urinary continence

Evidence base: primary care nurses have previously been shown to be effective at improving urinary incontinence in women under 60 years, by teaching pelvic floor exercises. We tried to apply this finding to practice.R&D project: this development project involved devising and delivering an evidence-based training package, ideally to one nurse member of every practice-based primary care team (about 70). Patient outcomes were to be assessed at 6 months, and the process of changing practice recorded. Despite extending the project, only 16 nurses received training, and only a handful of patients were recruited.Impediments to progress: the large number of factors which presented difficulties are discussed using the Clinical Standards Advisory Group’s framework for describing evidence-based service changes in primary care. These included lack of GP support, insufficient ‘grass roots’ enthusiasm, time constraints and the heavy workloads of primary care nurses, work not fitting into existing roles, no product champion, no supporting changes in secondary care.Conclusion: neither evidence nor education alone are sufficient to change practice. Current changes in primary care organisation may influence future attempts to change nurse practice in the promotion of continence.     

Access to care

This department highlights nursing leaders who have demonstrated the ability to inspire and lead change. This competency is seen in the ability to create, structure, and implement organizational change through strategic vision, risk taking, and effective communication. Each article showcases a project of a nurse leader who demonstrates change in a variety of environments ranging from acute care hospitals to home care and alternative practice settings. Included are several "lessons learned" applicable to multiple settings that provide insight for other nurses in executive practice.     

Politically engaging. Interview by Karen S Hill

This department highlights nursing leaders who have demonstrated the ability to inspire and lead change. This competency is seen in the ability to create, structure, and implement organizational change through strategic vision, risk taking, and effective communication. Each article showcases a project of a nurse leader who demonstrates change in a variety of environments ranging from acute care hospitals to home care and alternative practice settings. Included are several "lessons learned" applicable to multiple settings that provide insight for other nurses in executive practice.     

Developing and implementing a nursing research team in a clinical setting

The gap between research and practice that hinders the advancement of nursing practice is effected by knowledge, resources, perceptions, and expectations of nurses. The authors describe the development and implementation of a nursing research team in a large Midwest healthcare system, criterion used to identify the right personnel, nurse researcher roles that emerged after implementation, and infrastructure and administrative support that were essential to our success.     

Nursing leadership in professional organizations

This department highlights nursing leaders who have demonstrated the ability to inspire and lead change. This competency is seen in the ability to create, structure, and implement organizational change through strategic vision, risk taking, and effective communication. Each article showcases a project of a nurse leader who demonstrates change in a variety of environments, ranging from acute care hospitals to home care and alternative practice settings. Included are several "lessons learned" applicable to multiple settings that provide insight for other nurses in executive practice.