Changes in practice at the nurse-doctor interface. Using focus groups to explore the perceptions of first level nurses working in an acute care setting

A unique combination of factors has recently triggered a rapid change in the clinical practice of nurses in the UK. This study was carried out to explore the consequences of changing practice at the nurse-doctor interface, as perceived by first level nurses working in an acute care setting in the UK. Qualitative data were collected using focus group interviews and analysed thematically. Findings suggest that role change to these nurses is represented by a 'shift' in the practice of technical activities from junior doctors and a corresponding delegation of nursing activity to care assistants. It is suggested that the wholesale incorporation of technical interventions into the role of the nurse without an increase in the number of qualified nurses is turning nursing back to a task system of care delivery. This has the potential to depersonalize patients and reduce work satisfaction for nurses.     

Family Nursing Practice in Public Health: Finland and Utah

Abstract This exploratory study of family nursing practice in public health care was conducted in Finland and Utah. Staff nurses were interviewed in focus groups and asked to describe their practice of family nursing, the factors promoting and restraining practice, and the impact of the changes in health care delivery on practice. Thirty-six Finnish and 30 Utah nurses participated. Pressure to do more activities with fewer nurses and resources, changes in family problems, and skill level of the nurses were common themes. However, differences were evident. Finnish public health nurses used emotional support and information to help families empower themselves to use resources and to strengthen their family unit. Utah nurses focused first on individual level goals and then family cohesion and health. Nurseinitiated referrals and direct physical care were the primary intervention strategies of Utah nurses. Unlike the U.S. health care system, access for all in maternal and child health care and school health allowed Finnish nurses to develop long-term relationships with families, thus advancing family nursing practice. This study identifies several potential variables for further study particularly related to the organization of health care and nurse-family relationships.     

Research activities and perceptions of barriers to research utilization among critical care nurses in Korea.

BACKGROUND: Research utilization is vital to promote evidence-based practice in the critical care area, where nursing practice continues to grow in complexity and nurses have greater responsibility and accountability for patient care. However, information about research activities and barriers to research utilization of critical care nurses is limited. AIMS: This study aimed to describe research activities, to identify barriers to research utilization for practice and to examine factors related to research barriers among critical care nurses. METHODS: Data from 63 critical care nurses were analyzed from a national study examining research utilization of clinical nurses working in university affiliated and educational hospitals in Korea. FINDINGS: Research activities were relatively low. A lack of guidance for clinical implication and insufficient time to implement new ideas in the clinical area were identified as the highest-ranking barriers to use of research in this group. Perceptions of barriers to research utilization were significantly higher in those staff nurses with lesser clinical experience. The critical care nurses in this study shared a strong sense of valuing the contribution of research, but also shared perceptions on barriers for administrative aspects. Organizational support is crucial for critical care nurses to achieve evidence-based practice.     

Quality of care in postoperative pain management: what is realistic in clinical practice?

This paper presents a study describing nurses' assessment of whether it was realistic to carry out good quality of care in postoperative pain management. Further, the study compared their assessment with the quality of care actually performed in clinical practice as assessed by both patients and nurses. Three questionnaires were used; one for patients (n = 198) and two for nurses (n = 63). Nurses and patients responded to similar questions; the patients assessed the quality of care they had received, and the nurses assessed the quality of care they had delivered. The nurses also responded to questions concerning whether the different aspects of good quality of care were realistic to carry out in practice. The results show that in several important aspects of postoperative pain management, both patients and nurses assessed the quality of care to be lower than the nurses' assessment of what was actually possible to effectuate in clinical practice, e.g. pain assessment and information. This finding highlights the problem of applying evidence-based care in actual clinical practice.     

Clinical practice of doctorally prepared nurses

This study describes the clinical experiences of doctorally prepared nurses whose primary professional role is providing care as advanced practice nurses. Telephone interviews were conducted with 20 participants who lived and practiced in 13 states. Practice settings for these nurses included inpatient acute care and various outpatient/community health settings. Several themes describe the nature of the participants' practice: management of patient care, interwoven partnerships, leadership, and practice values. Major themes relating to the contribution of doctoral education to practice were abilities gained and changes in image and status. The findings of this study demonstrate that doctorally prepared nurses are actively involved in nursing practice by affecting patient outcomes, promoting cost-effective care, and using clinical research.     

So you want to change practice: recognizing practice issues and channeling those ideas

Applying the best evidence to support nursing practice and generating new knowledge for use in practice are the hallmarks of excellence and allow practitioners to meet patient care quality and safety priorities. Although identifying a patient care problem comes easily to staff nurses, the process of clarifying the problem and channeling those ideas through to a practice change can be daunting for bedside nurses. This article provides guidance to staff nurses who want to identify a clinical problem and change practice.     

Moral resilience through harmonised connectedness in intensive care nursing: A grounded theory study

ObjectivesTo examine intensive care nurses’ main concerns in respect of ethical practice, and to investigate how nurses continue to practise in an ethical way despite challenges in order to offer a conceptualisation of moral resilience.Research methodology/designThis qualitative study followed Glaser and Strauss’ version of grounded theory. The study was reviewed, and approved, by research ethics committees in Switzerland and in England.Main outcome measuresData consisted of field notes and in-depth interviews with 16 nurses working in intensive care in Switzerland and memos developed during the analysis. Data analysis followed the constant comparative method. This study took place between 2014 and 2017.FindingsThis study identified new understanding in how intensive care nurses manage their concerns and challenges regarding moral practice. The main category for moral resilience is harmonising connectedness, which represents intensive care nurses’ main concern with regard to their moral life, and at the same time, represents the pattern of behaviour in their social interactions and what they yearn for.ConclusionsThis study offers new insight into intensive care nurses’ moral practice, moral resilience and strategies nurses use to achieve moral wellbeing.     

The pioneer spirit in perioperative advanced practice--two practice examples

Perioperative nurses have options in advanced practice instead of leaving the acute care setting. One of the newest advanced practice roles is the acute care nurse practitioner (ACNP). This role may be ideal for perioperative nurses who want to remain in perioperative practice and grow clinically by pursuing advanced practice. This article presents two collaborative practice examples for the ACNP in the perioperative setting. The authors describe new frontiers in advanced perioperative practice and analyze the emerging advanced practice role of the ACNP. This challenging and exciting role is well suited to perioperative practice in a general and trauma surgery practice. The academic preparation, certification, and credentialing necessary to practice as an ACNP are explained.     

Knowledge, skills and experiences for community health nursing practice: the perceptions of community nurses, administrators and educators

Nursing in Canada is committed to preparing all new graduates at the baccalaureate level for entry to nursing practice by the year 2000 This goal has major implications for community health nursing education and practice Health care reform is also expected to move care out of the hospital and into the community It was against this backdrop that the researchers mounted a study on the educational preparation needed for graduates to begin to practice community health nursing In this paper, the knowledge, professional and personal skills, and experiences that graduates need to begin community practice are reported The study was carried out within an action-research framework All major groups of stakeholders involved in community health nursing throughout the study province were involved in the project This included nurses and administrators from two public health agencies (provincial and municipal), home care nurses, home health nurses (l e non-governmental visiting nurses), community health centres, provincial health care and nursing consultants, and faculty from two universities In addition to the generation of relevant research findings for use by the educational institutions, the study was initiated to set the stage for future and ongoing interactions between the researchers and community experts to implement the findings from the project Data were collected from 118 participants by means of 27 focus groups of community nurses, administrators and educators Interviews were tape-recorded transcribed and analysed using latent content analysis and constant comparison techniques Findings indicated that qualified nurses from university programmes need a wide range of knowledge, skills and experiences to begin to practice community health nursing Detailed accounts of these requirements are outlined and the implications for practice and education put forward     

An evidence-based curriculum to prepare students for global nursing practice

This article describes a curriculum designed to prepare nurses for global public health practice. Designed to be adapted to meet the needs of either undergraduate or graduate students, the curriculum uses the Internet to provide the knowledge and skills needed by nurses to effectively practice in areas around the globe. This course offering integrates the disciplines of nursing and public health with state-of-the-art technology to teach nurses how to identify the health care needs of populations, prioritize national and international responses, and design health care delivery services to meet these needs.     

Practice nurses and older people: a case management approach to care

Aim. This paper reports on aspects of a study designed to answer the research questions: (i) To what extent do practice nurses use the five cyclical elements of a case management approach when caring for people aged over 75 years? (ii) What determines or deters practice nurses’ use of the cyclical elements of a case management approach in caring for older people? Background. Case management is an approach that uses a cyclical process of assessment, planning, implementation, monitoring and evaluation to provide systematic proactive care to people with complex health and social care needs. In England, specialist practice nurse case managers for older people have been piloted in ten primary care trusts and the posts are to be implemented nationally by 2008. No baseline work has, however, considered the applicability of developing the existing generalist practice nurse workforce. Method. A 26‐item structured postal questionnaire was used to explore both practice nurses’ use of a case management approach when working with older people, and what factors influenced the care provided. A random sample of 500 practice nurses was selected from the Royal College of Nursing Practice Nurse Association member database. Results. A 45% response rate was achieved. Practice nurses assessed, planned and implemented care, but reviewing medication opportunistically and evaluating the care were uncommon. A case management approach was significantly (P = 0·005) more likely to be used in on‐going management activities than in one‐off treatment room care. Practice nurses with postregistration education in district nursing were significantly (P = 0·016) more likely to refer patients to social care services. Lack of time and the central role of the general practitioner were the main reasons for not incorporating case management into practice. Conclusions. The extent to which practice nurses used elements of a case management approach was highly variable and influenced by individual professional expertise, the nature of the consultation and the practice nurse's position in the general practice.     

New Zealand general practice nurses' roles in mental health care

MCKINLAY E., GARRETT S., MCBAIN L., DOWELL T., COLLINGS S., & STANLEY J. (2011) New Zealand general practice nurses' roles in mental health care. International Nursing Review 58 , 225–233 Aim: To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions. Background: Supporting mental health and well‐being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government‐funded, time‐limited projects using different service delivery models. Methods: An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29‐month external evaluation. Findings: Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles. Conclusions: Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.     

Working relationships between practice nurses and general practitioners in Australia: a critical analysis

This research set out to explore shared care between practice nurses and general practitioners in South Australia. Nine practice nurses (PNs), two nurse practitioners and 10 general practitioners (GPs) were interviewed in urban and rural practices in order to build up a picture of how GPs and PNs worked together. The interviews showed that shared care was not a reality, although practice nurses were very busy, enjoyed their work and were no longer performing as receptionists doing a little nursing on the side, but as highly skilled nurses. Questions that emerged included whether or not practice nurses are specialists or generalists; their relationship to nurse practitioners; the extent to which the doctor–nurse game explains the relationship between practice nurses and general practitioners; and the potential for expanding the practice nurse role.     

Listening to nurses' moral voices: building a quality health care environment

In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.     

The need for a new advanced nursing practice role for Australian adult critical care settings

The current deficit of knowledge related to advanced nursing practice in Australian adult critical care settings presents a barrier to future role development. This paper reports the findings of one theme identified by a research study that explored issues related to the potential for a new advanced nursing practice role for these settings. The qualitative approach of focus group methodology was used to collect data from a purposive sample of regional Queensland critical care nurses (n=26). Thematic content analysis of the data identified concepts that progressively contributed to five major themes. This paper will report the findings related to the theme that there is a need for a new advanced nursing practice role for adult critical care settings.

Participants perceived that nurses are already practising at advanced levels that may predetermine a new role. There was believed to be a need for recognition of and legal sanction for critical care nurses' present practices that extend beyond the current scope of nursing practice. Participants proposed that critical care nurses may be more competent than inexperienced medical personnel in this environment and participants wanted consistent levels of autonomy for advanced practices. The current career structure was seen to be a failure and many participants perceived the lack of opportunities for critical care nurses to advance up the clinical career pathway as problematic in recruitment and retention issues. The findings of this study provide new information that makes an important contribution to further exploration of advanced nursing practice role development for Australian adult critical care settings.     

Palliative care nursing in rural Western Australia

This article presents the findings of a study of rural palliative care nurses in Western Australia. The number of rural centres in Western Australia offering palliative care services is increasing; however, at present there is little empirical data available about the roles of the nurses involved. This study was undertaken to begin to correct this deficit. The study examined basic social processes associated with the role of rural palliative care nurses, and identifies issues that affect the nurses' professional practice. A modified grounded theory approach was used to form a conceptual framework that describes rural palliative care nursing. Theoretical sampling techniques were used to identify the six palliative care nurses working in rural Western Australia who participated in the study. Data were generated using in-depth interview and participant observation techniques. Constant comparative analysis of the data was employed to allow concepts to emerge from the data. The central theme that developed is the all-consuming nature of the rural palliative care nurse's role. Three subthemes relating to multiple roles, expectations of nurses, and coping strategies are also discussed. This research explored issues that rural palliative care nurses feel are relevant to their professional practice, and it describes the basic social processes inherent in the rural palliative care nurse's role. Recommendations for nursing research, education, administration and clinical practice are presented.     

Bridging the gap: can a link nurse initiative influence palliative care in an acute hospital?

With 90% of people needing some inpatient hospital care in the final year of life, it is evident that the provision and awareness of palliative care, and education surrounding this, are widely needed. This study aims to evaluate a palliative care link nurse initiative (PCLN) in an NHS acute hospital, identifying key factors affecting link nurses' ability to influence palliative care practice. This qualitative study used semi-structured interviews and a focus group to show the anticipated and actual influence of link nurses on practice. Findings suggest that link nurses had increased knowledge and skills in palliative care due to education provided. Link nurses were seen to have an influence on the presence and quality of palliative care practice in hospital wards. Factors that could help link nurses to have greater influence are reported, as are difficulties in providing care and accessing training.     

Critical care competencies

In the absence of nationally accepted critical care competencies, each educational institution providing critical care programmes is forced to define the essential competencies necessary for practice, leading to variations in expected practice and the emergence of 'postcode' competencies. This research report aims to build upon competency activity for all areas of nursing practice within critical care levels 1, 2 and 3. A functional analysis to elicit core critical care competency statements was conducted and a modified Delphi technique was used to generate consensus opinion from a pan-London purposive sample of nurses working in critical care. The functional analysis group identified four competency statements and elements of competencies. Consensus agreement of 80% was achieved with mean agreement scores that exceed 97%. A core critical care competency framework was refined and developed by expert nurses drawing on their own experience and knowledge of critical care nursing. The framework could be useful to: educationalists designing competency-based curricula; critical care managers as a tool for recruitment and retention and for education and training of staff; individual critical care nurses to facilitate continuous professional development.     

The puzzle of spirituality for nursing: a guide to practical assessment

Increasingly nurses are called upon to meet patients' spiritual needs. However, there is evidence to suggest that nurses are unable to do this adequately because of confusion about the notion of spirituality. This is compounded by the uncertainty surrounding the role of nurses in spiritual care interventions. Emerging research suggests that nurses, as primary carers, may have to initiate spiritual care interventions. This article offers practical guidance to nurses seeking to improve spiritual care for their patients. A working definition of spirituality is offered and spiritual needs are explained in the context of a case scenario. Practical guidance is given on how spiritual care can be put into action, using the Actioning Spirituality and Spiritual care in Education Training (ASSET) model as a framework for assessment of spiritual needs, planning, implementing and evaluation spiritual care, and a spiritual assessment tool for practice is outlined.     

Design of a postgraduate course in palliative care

BACKGROUND: Although palliative care is multidisciplinary in nature, nurses play an essential role in terminal care. Because new nurses frequently lack the specific skills for palliative nursing care as well as competence in interdisciplinary practice, there is a need for continuing education in palliative care. This article describes a postgraduate course in palliative care for nurses. METHOD: A postgraduate course was developed based on the needs of palliative patients and the subjective and objective needs of nurses. FINDINGS: Four roles assumed by nurses in palliative care were identified: bureaucratic, biomedical, social-therapeutic, and informal. The actual results of the course were influenced by the contextual aspects, which were determined by the nursing environment. Assignments were formulated according to the needs of the nursing unit, and a number of peer review meetings were organized. CONCLUSION: Successful implementation of a postgraduate course in palliative care increases nurses' expertise and offers an opportunity for nurses to exchange experiences and search for solutions to problems together.