Part one: Restoring patients to health outcomes and indicators of advanced nursing practice in adult critical care

The key characteristics of advanced nursing practice have been a subject of international debate over the past decade. To address this debate, a grounded theory study was undertaken by one of the authors which sought to identify the key characteristics of advanced nursing practice in adult critical care. The outcome of the main study was a theory of legitimate influence in which enhancing patient stay and improving patient outcome represented the dual purpose of advanced nursing practice in critical care. Fundamental to these factors is strategic activity. This encompasses improving patient care, facilitating continuity of care and engaging in patient education. The outcome of these strategic activities can be evaluated through evidence of eased transition across complex hospital networks, patient satisfaction and enabling of independence. The findings reflect a change in the focus and delivery of care to the critically ill and their relatives by nurses practising at an advanced level. In the second paper of this series, the intervening conditions that affect the expression of legitimate influence will be discussed.     

ICU护士进阶培养的临床实践与效果

目的:探索ICU护士进阶培养模式并评价其效果。方法:以Benner护士职业发展理论与Hamric高级护理实践理论为基础,结合我院的"三轨道五阶梯"层级体系构建ICU护士的进阶培养方案,并在2010—2020年对ICU护士实施五层级进阶培养方案进行职业发展管理。结果:实施ICU护士进阶培养方案后,ICU护士学历有明显提升,专科护士人数比例稳步上升,各专项团队成功构建且发展良好,科研产出也逐年上涨。结论:分层级的ICU护士进阶培养与实践能较好促进临床护理质量提升和专业化发展。     

Part two: The core components of legitimate influence and the conditions that constrain or facilitate advanced nursing practice in adult critical care

This paper describes intervening conditions that might constrain or facilitate the exercise of Legitimate Influence: The Key to Advanced Nursing in Adult Critical Care, the foundation of which is credibility and advanced clinical nursing practice. Constraining conditions are conflict, resistance, gender bias, political awareness and established values. Credibility, advanced clinical nursing practice and strategic activity are required to enhance patient stay in hospital and improve patient outcome. Intervening conditions that facilitate these are overcoming resistance, political awareness and established values. In a previous paper, it was indicated that enhanced patient stay and improved patient outcome were achieved primarily through strategic activity that emphasized restoring patients to a former, or improved, health status. This paper portrays how intervening conditions can impinge upon this and the exercise of legitimate influence.     

The lived experience of a tracheostomy tube change: a phenomenological study

Aim. To investigate the lived experience patients have of a tracheostomy tube change. Background. Few interpretive studies have looked at specific nursing interventions in relation to nursing practice. This study has investigated the lived experience of patients from an intensive care unit that have had a tracheostomy tube change. The tracheostomy is a significant intervention for many patients within critical care. Method. Using a phenomenological approach, guided by the insights of Martin Heidegger and Max van Manen, participants were interviewed with their responses being transcribed into a text. This text has been subject to hermeneutic analysis using the theories of Paul Ricoeur. This hermeneutic approach has required using the text (discourse) as the focus of the interpretation. Findings. The findings of this study imply that the experience of a tracheostomy tube change is more complex than that of simply a physical sensation. There is a need for participants to prepare themselves psychologically, a process that requires not only the trust of nursing staff but also the assessment by the participant that the nursing staff member has a level of competence to perform the task. The need for maintaining communication and the ability to speak were at times more significant for participants than even the risk of other airway complications. Relevance to clinical practice. This study has highlighted the potential for further interpretive studies into some of the more specific aspects of caring for patients that have been or are critically ill. The themes revealed will enable the nurse, required to change a tracheostomy tube, to do so with an improved level of empathy and understanding.     

An innovative approach to peer review for the advanced practice nurse--a focus on critical incidents

Purpose: To provide an overview of the development and implementation of a peer review process for advanced practice nurses (APNs) based on critical incidents that provide meaningful evaluation of practice and meets the needs of APNs across multiple care specialties and practice situations.
Data sources: A review of the literature and evaluation of the existing peer review process currently in place at a large tertiary care facility.
Conclusions: Peer review is central to self-regulation and professional practice for APNs. It has been proposed that APNs of similar rank and clinical expertise should participate in peer review. APN peer review and evaluation have traditionally existed as a component of performance evaluation, evaluation of practice patterns, and compliance monitoring, and to evaluate quality indicators. We found no examples of peer review in the context of evaluating a critical incident in the literature. The APN Peer Review Committee and the review process were developed at our institution to provide peer input and communication to all credentialed APNs in incidents regarding appropriateness of care and scope of practice.
Implications for practice: APNs must assure that they have a voice in the peer review process. Representation by peers of similar specialty and rank is an important component in the peer evaluation process. The establishment of the APN Peer Review Committee served this purpose for our institution.     

Nurses’ experiences of guideline implementation: a focus group study

Aims. The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines? Background. The implementation of clinical guidelines seems to be dependent on multiple context‐specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation. Design. Qualitative interview. Methods. Data were generated by four focus group interviews involving nurses working in out‐patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data. Results. Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses’ awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation. Conclusions. Clinical guidelines can be promising tools in enhancing evidence‐based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices. Relevance to clinical practice. Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.     

A literature review of principles, policies and practice in extended nursing roles relating to UK intensive care settings

Aims. To provide an overview of the literature relating to the principles, policy and practice of extended nursing roles in UK intensive care settings to date; to review and critically assess evidence of impact, outcomes and effect on practice and provide suggestions for future research. Background. It is known that career development opportunities, new technologies, patient needs, as well as the reduction in junior doctors’ hours, are driving the development of new roles for nurses. Policy initiatives aim to expand nursing roles to support professional substitution. In adult, neonatal and paediatric intensive care, specialist trained nurses and designated advanced nursing practitioners are increasingly taking on extended practice of clinical tasks previously undertaken by medical staff. As yet there are no statutory regulations on the perceived scope and definition of the role of extended and advanced roles. Design. Systematic review. Methods. Search of electronic databases and selection of policy and peer‐reviewed reports and reviews of extended nursing roles or advanced nursing practitioners in UK intensive care settings. Results. Chronological review shows policy development proceeding in a relatively ad hoc way. There is limited information available about how extensively or effectively extended nursing roles are being implemented in intensive care settings in the UK, particularly in adult and paediatric intensive care. To test local initiative findings for reliability and generalisability, a more robust evidence base is required. Conclusions. More data are needed on definition and outcomes of extended nursing roles in intensive care and care process measures should be developed to better inform implementation of nurse role development in the UK. Relevance to clinical practice. The review of policy and research evidence in this paper may better inform clinicians working in adult, neonatal or paediatric intensive care, as they continue to be challenged by expansion and development of their role. It may also help to form a basis and evaluation for future research into extended and advanced nursing roles in intensive care settings.     

A systematic review of the effectiveness of advanced practice nurses in long‐term care

Aim

To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long‐term care residential settings.

Background

Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted.

Design

Quantitative systematic review.

Data sources

Twelve electronic databases were searched (1966–2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group.

Review methods

Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria.

Results

Four prospective studies conducted in the USA and reported in 15 papers were included. Long‐term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.

Conclusion

Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long‐term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.     

A qualitative analysis of how advanced practice nurses use clinical decision support systems

PURPOSE: The purpose of this study was to generate a grounded theory that will reflect the experiences of advanced practice nurses (APNs) working as critical care nurse practitioners (NPs) and clinical nurse specialists (CNS) with computer-based decision-making systems. DATA SOURCES: A study design using grounded theory qualitative research methods and convenience sampling was employed in this study. Twenty-three APNs (13 CNS and 10 NPs) were recruited from 16 critical care units located in six large urban medical centers in the U.S. Midwest. Single-structured in-depth interviews with open-ended audio-taped questions were conducted with each APN. Through this process, APNs defined what they consider to be relevant themes and patterns of clinical decision system use in their critical care practices, and they identified the interrelatedness of the conceptual categories that emerged from the results. Data were analyzed using the constant comparative analysis method of qualitative research. CONCLUSIONS: APN participants were predominantly female, white/non-Hispanic, had a history of access to the clinical decision system used in their critical care settings for an average of 14 months, and had attended a formal training program to learn how to use clinical decision systems. "Forecasting decision outcomes," which was defined as the voluntary process employed to forecast the outcomes of patient care decisions in critical care prior to actual decision making, was the core variable describing system use that emerged from the responses. This variable consisted of four user constructs or components: (a) users' perceptions of their initial system learning experience, (b) users' sense of how well they understand how system technology works, (c) users' understanding of how system inferences are created or derived, and (d) users' relative trust of system-derived data. Each of these categories was further described through the grounded theory research process, and the relationships between the categories were identified. IMPLICATIONS FOR PRACTICE: The findings of this study suggest that the main reason critical care APNs choose to integrate clinical decision systems into their practices is to provide an objective, scientifically derived, technology-based backup for human forecasting of the outcomes of patient care decisions prior to their actual decision making. Implications for nursing, health care, and technology research are presented.     

Consensus and diversity: an action research study designed to analyse the roles of a group of mental health consultant nurses

Aim. The purpose of this action research study was to enable a group of mental health consultant nurses in the UK to map the scope and dimensions of their roles. This initial benchmarking exercise is a precursor to the development of plans for role improvement and evaluation. Background. There is a growing body of literature that addresses advanced nursing practice roles. There is, however, no international agreement on what constitutes an advanced practice role. A few countries have addressed the statutory requirements governing such roles. Consultant nurses’ roles in the UK are relatively new innovations that aim to enhance care. However, only a few investigations have evaluated the dimensions and impact of these roles. Methods. The study was framed by use of action research as a form of self‐reflective enquiry. Initial data were generated through use of four focus group discussions, which were held with a group of consultant nurses employed predominately at a mental health National Health Service Trust. Five structured confirmatory questionnaires developed from the focus group data were also administered. Findings. Analysis of the focus group data gave five themes, 71 categories and 271 items that were used to inform development of the questionnaires. Responses to the questionnaire showed that 61% (n = 166) of the items had non‐consensus responses. It was found there was most consensus relating to leadership theme with 63% (n = 19) items having consensus responses. Least agreement was found in the education theme where there was <15% (n = 5) agreement to individual items. Conclusions. The study demonstrated complexity and variety in how the consultant nurses’ roles in the UK are being developed. Relevance to clinical practice. The potential for consultant nurse roles to enhance patient care is tremendous. This study provides initial indicators, which the practitioners involved, can use to plot future developments and changes to their roles.     

护生基础护理实习现状及对策

综述了护生的职业态度、对基础护理的认知及能力现状,提示应重视护生专业思想和职业道德教育、培养护生服务意识及加强护生临床带教管理等对策,以提高和完善护生对基础护理的认知,规范其临床基础护理实践,促进个人发展,利于其牢固专业思想。     

Literature review of nursing practice in managing obesity in primary care: developments in the UK

Aims and objectives. To review empirical studies reporting primary care nursing practice in relation to obesity management for adults in the UK; to place these in the context of policy and professional developments. Background. Obesity is recognized as a public health problem in many parts of the world. The UK has a well‐developed system of primary care nursing with experience of initiatives to tackle obesity. Methods. Searches of electronic databases supplemented by hand‐searching of identified leads and key journals. Data extracted and analysed following methods for an integrative literature review. Findings. Eleven empirical studies were reviewed. Obesity management developed as part of the role of general practice nurses after 1990. Nurses’ role has been mainly in providing one‐to‐one support to within surgery or clinic consultations; and to a lesser extent group based support sessions. The interventions could be characterized as general oral advice about nutrition and lifestyle. There was no evidence of positive outcomes for patients from these interventions. In some contexts, oral advice extended to calorie deficit diets and more developed referral options about physical activity. Two studies examined outcomes of practice following attempts to implement evidence‐based protocols. The evidence of outcomes from these is mixed. At best, perhaps 10% of patients entering a nurse led support programme may achieve a clinically significant weight loss. Conclusions. There is potential in primary care nursing to help patients manage obesity but caution is needed. Despite practice developments in the UK the outcomes for patients remain unclear. Relevance to clinical practice. It is important to follow a structured programme in supporting patients with weight loss within an holistic assessment of their needs.