Nurses' role in detecting deterioration in ward patients: systematic literature review

Title.  Nurses' role in detecting deterioration in ward patients: systematic literature review.
Aim.  This paper is a report of a review conducted to identify and critically evaluate research investigating nursing practice in detecting and managing deteriorating general ward patients.
Background.  Failure to recognize or act on deterioration of general ward patients has resulted in the implementation of early warning scoring systems and critical care outreach teams. The evidence of effectiveness of these systems is unclear. Possible mechanisms for low effectiveness may be inconsistent recording of patient observations by ward staff, or inconsistent application of 'calling criteria' for outreach teams, even when observations have been recorded.
Methods.  The literature was searched between 1990 and 2007 using four sources: electronic databases, reference lists, key reports and experts in the field. Three broad search categories were used: nursing observations, physiological deterioration and general ward patients. All research designs describing nursing observations (vital signs) on deteriorating adult patients in general hospital wards were included.
Results.  Fourteen studies met the inclusion and quality criteria. The findings were grouped into four main themes: recognition; recording and reviewing; reporting; and responding and rescuing. The main findings suggest that intuition plays an important part in nurses' detection of deterioration, and vital signs are used to validate intuitive feelings. The process is highly complex and influenced by many factors, including the experience and education of bedside nurses and their relationship with medical staff.
Conclusion.  Greater understanding of the context within which deterioration is detected and reported will facilitate the design of more effective education and support systems.     

Multi-parameter vital sign database to assist in alarm optimization for general care units

Continual vital sign assessment on the general care, medical-surgical floor is expected to provide early indication of patient deterioration and increase the effectiveness of rapid response teams. However, there is concern that continual, multi-parameter vital sign monitoring will produce alarm fatigue. The objective of this study was the development of a methodology to help care teams optimize alarm settings. An on-body wireless monitoring system was used to continually assess heart rate, respiratory rate, SpO₂ and noninvasive blood pressure in the general ward of ten hospitals between April 1, 2014 and January 19, 2015. These data, 94,575 h for 3430 patients are contained in a large database, accessible with cloud computing tools. Simulation scenarios assessed the total alarm rate as a function of threshold and annunciation delay (s). The total alarm rate of ten alarms/patient/day predicted from the cloud-hosted database was the same as the total alarm rate for a 10 day evaluation (1550 h for 36 patients) in an independent hospital. Plots of vital sign distributions in the cloud-hosted database were similar to other large databases published by different authors. The cloud-hosted database can be used to run simulations for various alarm thresholds and annunciation delays to predict the total alarm burden experienced by nursing staff. This methodology might, in the future, be used to help reduce alarm fatigue without sacrificing the ability to continually monitor all vital signs.     

Non-psychiatric hospitalization of people with mental illness: systematic review

Title.  Non-psychiatric hospitalization of people with mental illness: systematicreview.
Aim.  This paper is a report of a literature review of the evidence regarding outcomes experienced by severely mentally ill individuals hospitalized in general medical-surgical settings for non-psychiatric conditions.
Background.  Severely mentally ill individuals experience chronic medical illnesses at a rate greater than the general population. When hospitalized in non-psychiatric settings, they tend to be experienced as 'difficult' by nurses and to have longer lengths of stay.
Data sources.  The CINAHL and PUBMED databases were searched from 1 to 9 March 2008 to identify studies published between 1998 and 2008 investigating outcomes among people with mental illness hospitalized for non-psychiatric illness in general hospitals.
Methods.  Included studies were those published in English in peer reviewed journals and investigating patient outcomes. The studies were reviewed for relevance and inclusion criteria; the methodological quality of studies was not evaluated.
Results.  Twelve studies met inclusion criteria. All studies examining length of stay, costs of care or resource utilization showed increased measures for patients with psychiatric comorbidity. Interventions described included psychiatric liaison psychiatry and nursing, which failed to demonstrate improvement in outcomes.
Conclusion.  Nurses play a pivotal role in improving the inpatient care of this vulnerable population, but they struggle in their attempts to do so. Research to determine the best approaches to promote nurses' knowledge, positive attitudes and self-confidence in caring for patients with psychiatric comorbidity is needed. Investigation of the patient perspective on the inpatient experience might also provide insight for designing effective care processes.     

Clinicians' opinions on alarm limits and urgency of therapeutic responses

To survey the routine use of bedside multivariable monitors in monitoring cardiac postoperative patients, 23 experienced anesthesiologists and cardiac surgeons were first asked to list which variables and what limit alarms they used. Then they defined to what extent the variables' values were allowed to deviate before therapeutic actions were needed. Typically, limit alarms were applied to heart rate and end-tidal CO₂. For clinical assessment of a patient's state, the clinicians usually observed the heart rate and the systemic arterial blood pressures, but placed less emphasis on the pulmonary arterial pressures. Clinicians had similar opinions on alert limits for monitoring less extensive physiological deviations and on alarm limits for warning of a critical situation. Person-to-person tolerance of suboptimal monitored values varied.No correlation was found between the limit values and how long these values were tolerated without therapeutic response. However, the inquiry provided information on setting limits for alerts and alarms, and on experienced clinicians' decision-making during postoperative intensive care of cardiac patients.     

Quality of life in partners of people with congestive heart failure: gender and involvement in care

Title.  Quality of life in partners of people with congestive heart failure: gender and involvement in care.
Aim.  This paper is a report of a study conducted to investigate quality of life in partners of people with congestive heart failure in comparison to individuals living with a healthy partner.
Background.  Congestive heart failure is a chronic debilitating disease with severe symptoms and complex treatment. The support of partners is essential in the management of congestive heart failure. Living with a chronic illness generally affects the quality of life of patients and their partners.
Method.  Data were collected using a cross-sectional, comparative design between October 2002 and February 2005 with 303 partners of people with congestive heart failure. Reference data were collected in 304 age- and gender-matched individuals living with a healthy partner, drawn from the general population. All respondents completed questionnaires at home on quality of life and general well-being. Analysis of variance was used to analyse the data.
Findings.  Overall, differences in quality of life between partners of people with heart failure and matched controls were small. However, substantial variation in the quality of life of partners was found by exploring the role of gender and involvement in care. Quality of life scores varied strongly for male and female partners who had to perform caregiving tasks. The performance of these caregiving tasks was negatively associated with the quality of life of female partners but not with that of male partners.
Conclusion.  Female partners especially should not be overlooked when they become involved in personal care tasks. Nurses should not be reluctant to involve male partners in caring for women with heart failure.     

Using gaming workshops to prepare nursing students for caring for older people in clinical practice

mclafferty e., dingwall l. & halkett a. (2009)   Using gaming workshops to prepare nursing students for caring for older people in clinical practice. International Journal of Older People Nursing   5 , 51–60
doi: 10.1111/j.1748-3743.2009.00176.x
Background.  Older people are the least satisfied with the care they receive when they are acutely ill. Furthermore, within nurse education, nursing older people has been submerged rather than embedded in the acute focus of nursing curricula. Lecturers designed a 1-day gaming workshop to stimulate interest in nursing older people.
Aim.  To explore the influence of gaming workshops on undergraduate nursing students' learning about nursing older people.
Methods.  Both quantitative and qualitative methods were used. A survey questionnaire was distributed pre- and postgaming workshops to a cohort of second year nursing students ( n  = 100, 86% response rate). Students ( n  = 9) were invited to participate in a semi-structured interview on completion of their placement.
Findings.  Responses were significantly more positive for the questionnaire postworkshop when compared with the responses of preworkshop. Five themes were identified from the interviews, they included teacher interaction; level of student engagement with the topic; the effect of the teaching method; influence of the workshops on practice; working with older people.
Implications for practice.  Nursing students preferred this novel teaching method to lectures. They learned about appropriate and relevant care of older people, however, they seem to struggle to apply concepts related to caring for older people in the acute settings.     

Comfort as a basic need in hospitalized patients in Iran: a hermeneutic phenomenology study

Title.  Comfort as a basic need in hospitalized patients in Iran: a hermeneutic phenomenology study.
Aim.  This paper is a report of a study conducted to explore the comfort experiences of hospitalized patients during their admission to medical–surgical wards in an Iranian hospital.
Background.  Comfort has various definitions, ranging from a basic human need, to a process, function or an outcome of nursing. As comfort is a substantive need throughout life in health and illness, providing comfort is a major function and challenge for holistic nursing care.
Method.  This hermeneutic phenomenological study was conducted between July 2006 and April 2007 in six medical–surgical wards of one of a university hospital in Iran. Data were generated with 22 participants (16 hospitalized patients and six nurses), using in-depth interviews to capture their detailed experiences of comfort. Analysis based on the framework of Diekelmann enabled data interpretation and elaboration of shared themes.
Findings.  One constitutive pattern, 'Comfort: a need of hospitalized patients' and four related themes – A friend in hospital, Relief of suffering within a calm environment, Seeking God, and Presence among family – were identified in the data.
Conclusion.  These findings offer unique insight for planning and implementing appropriate clinical practices in Iran, especially in caring for Muslim patients. Two major implications are to: (1) consider comfort criteria during nursing assessment and planning of care during a patient's hospitalization and (2) note that Shiite people in particular are more comfortable and feel better when they are able to follow their religious principles.     

Patient-centred care and nurses' health: the role of nurses' caring orientation

Title.  Patient-centred care and nurses' health: the role of nurses' caring orientation.
Aim.  This paper is a report of a study of the moderating effect of caring orientation on the relationship of patient-centred care to nurses' physical and mental health.
Background.  Providing effective patient-centred care is well-accepted as an important contributor to a host of patients' health outcomes. Based on two theoretical perspectives – person–environment fit and emotional labour – I suggest that providing patient-centred care per se does not potentially harm nurses' health; the cause is the fit (or non-fit) of a nurse's caring orientation and the displayed patient-centred care behaviours.
Method.  Data were collected in 2007 with a random sample of 325 registered nurses working in the Israeli public healthcare sector in in-patient units. Caring orientation, health and control variables were measured via validated questionnaires. Patient-centred care behaviours were assessed by structured observations.
Results.  The mental health of nurses who exhibited high caring orientation combined with high patient-centred care, or that of nurses who exhibited low caring orientation combined with low patient-centred care, was statistically significantly higher in comparison with the mental health of nurses who exhibited incongruent (low/high or high/low) caring orientation and patient-centred care behaviours. For nurses' physical health, the findings revealed that providing patient-centred care was associated with worsened health, and possessing a caring orientation was associated with better health.
Conclusions.  The findings support the hypotheses that were derived from person–environment fit and emotional labour only with regard to mental health. Separate theory needs to be developed on how to maintain nurses' physical health.     

Care of patients with chronic obstructive pulmonary disease in primary health care

Aim.  This paper is a report of a study of nurses' perceptions of caring for patients with chronic obstructive pulmonary disease.
Background.  Chronic obstructive pulmonary disease is a global health problem and the number of patients being treated with this disease in primary healthcare settings is increasing. This places new demands on the nurses involved.
Method.  A phenomenographic approach was adopted, using a purposive sample. Data were generated between February and May 2003 from 20 interviews with district nurses and general nurses who cared for patients in primary healthcare settings with chronic obstructive pulmonary disease.
Findings.  In most cases, nurses cared for older people with moderate to severe chronic obstructive pulmonary disease. They described this care from two overall orientations: task and individual. The nurses' perceptions of the care of these patients were described as creating commitment and participation by establishing a good relationship with patients and supporting them in their personal care, educating patients by supplying information and knowledge in various ways, co-operation by co-operating with or referring to other caregivers, and arranging and implementing clinical examinations and treatments.
Conclusion.  The type of care depended on who the patient met: either a task-oriented nurse or an individual-oriented nurse. Therefore, nursing programmes should pay special attention to the support and guidance of new and inexperienced and task-oriented nurses. Healthcare planners should take into consideration the need for individualized care when organizing care and allocating resources for chronically ill people.     

Prevalence of heart failure in nursing homes: a systematic literature review

Scand J Caring Sci; 2010; 24; 202–208
Prevalence of heart failure in nursing homes: a systematic literature review
Introduction:  Heart failure is an important problem in western countries. In nursing home residents heart failure is expected to be highly prevalent. However, accurate diagnosis of heart failure in these patients is often hampered due to atypical findings and concomitant co-morbidity. In order to deliver adequate nursing care and medical treatment, it is important to get insight into the prevalence of heart failure in this target group of patients.
Objectives:  To assess the prevalence of heart failure as well as the co-morbidity interfering with heart failure in nursing home residents.
Methods and results:  A systematic literature review was conducted in Medline, Embase, Cinahl and the Cochrane Library. Ten studies were ultimately included. Findings indicate that the mean prevalence of heart failure is 20% (range 15–45%) and that there is a significant level of co-morbidity (dementia, diabetes mellitus and chronic obstructive pulmonary disease) in nursing home residents with heart failure.
Conclusion:  The reported prevalence of heart failure in nursing home residents is higher than in the general population and is associated with considerably co-morbidity. However there are also indications that the prevalence of heart failure in nursing home residents is underestimated, negatively affecting quality of life and quality of care. Therefore, prospective prevalence studies and studies aiming to improve the care for nursing home residents with heart failure are warranted.     

Optimization of alarms: a study on alarm limits,alarm sounds,and false alarms,intended to reduce annoyance

Alarms in the operating room remain a major source of annoyance and confusion. Nearly all alarms result from a transgression of certain alarm limits. We surveyed manufacturers at a major meeting of anesthesiologists for their default alarm limits. We also conducted a mail survey of anesthesiologists in the United States, Finland, and the Netherlands, to learn their chosen alarm limits, reasons for turning off the alarms, and estimates of the number of false alarms. The surveys of medical monitoring manufacturers demonstrated a wide variety of default alarm settings. Anesthesiologists' chosen alarm limits tended to parallel the manufacturers' defaults. Fewer than 30% of anesthesiologists stated that they did not turn off the alarms. The leading reason for turning off alarms was the large number of false alarms. Estimates of the number of false alarms varied from 30% to 76%. The desired role of alarms in anesthetic practice and some suggestions for the general improvement of alarms are discussed.     

Analysis using fluorescence polarization immunoassay for unbound teicoplanin concentration in serum

Objectives:  The aim of this study was to develop a simpler and more rapid analytical method for unbound teicoplanin in serum.
Methods:  A new analytical method was developed by modifying an existing fluorescence polarization immunoassay (FPIA) method. The validation of the developed FPIA method was compared in the quantification of unbound teicoplanin with that of the high-performance liquid chromatography (HPLC) method reported previously. The developed FPIA method was employed for the measurement of 36 clinical samples collected from patients with methicillin-resistant Staphylococcus aureus (MRSA) infection.
Results:  The limits of detection and quantification were 0·5 and 0·8 μg/mL, respectively. The recovery rate was 97·5–106·6%. The developed FPIA method showed better accuracy than the HPLC method. The within-run and interday reproducibility of the assay was good, with relative standard deviation values of 4·76–18·75% (within-run) and 5·68–13·95% (interday). Precision and accuracy of this method were within the acceptable limits defined in the US FDA Guidance for bioanalytical method validation. The correlation between the developed FPIA method and the HPLC method was good ( r ² = 0·87). A positive bias with the FPIA method was observed from the result of the Bland–Altman difference plot.
Conclusion:  We firmly believe that the present method is useful for the adjustment of teicoplanin dosages for patients under various conditions.     

A caring relationship with people who have cancer

Title.  A caring relationship with people who have cancer.
Aim.  This paper is a report of a study conducted to elucidate the meaning of a caring relationship with people with cancer.
Background.  A caring relationship becomes the most important focus of caregiving when treatment of the body has reached the limits where cure is no longer expected. Caring as perceived by people with cancer involves nurses having professional attitudes and skills in order to provide good care, including emotional and practical support.
Methods.  A phenomenological hermeneutic approach influenced by Ricoeur was used. Eight nurses working in an oncology unit in Iran were interviewed in 2007 about their experiences of caring relationships with people who have cancer.
Findings.  The findings were interpreted as getting involved in a mutual/demanding close relationship. Closeness demanded nurses to be present, to listen to patients, and to be compassionate. Closeness was also mutual and characterized both caregiving and receiving new insights into values in the nurses' own lives. The close relationship was at times frustrating when they were faced with situations that they could not handle and were out of their control.
Conclusion.  Closeness is an important foundation for caring, and acquires a special dimension in the care of people with cancer and their relatives. It derives from the personal and professional experiences of nurses in their own life stories. Nursing education should include a reflective approach in order to develop caring skills in oncology nursing that are not merely attuned to medical care.     

Cardiorespiratory physical assessment for the acutely ill: 1

This article, the first of two parts, aims to develop core cardiovascular and respiratory knowledge and to enhance practice for the practitioner caring for an acutely ill patient on a general ward setting. The second part will focus on advanced cardiorespiratory assessment. With increasing acuity of illness in general ward settings, patients' needs are becoming more complex in terms of their nursing and medical management. Nurses must be able to respond to subtle clinical signs and symptoms and act appropriately to ensure that a safe, patient-focused environment is maintained and that the care delivered is evidence-based. By increasing knowledge of the theory and practice of nursing physical assessment, and the ensuing management, acutely ill patients nursed in general ward areas may be provided with timely and appropriate care and may avoid further deterioration and an intensive care admission. This article describes core physical assessment skills, the normal physiology of the cardiovascular system, and the management of cardiovascular and respiratory dysfunction.     

Exploring the quality of dying of patients with chronic obstructive pulmonary disease in the intensive care unit: a mixed methods study

Rationale for the study:  Improving the quality of end-of-life (EOL) care in critical care settings is a high priority. Patients with advanced chronic obstructive pulmonary disease (COPD) are frequently admitted to and die in critical care units. To date, there has been little research examining the quality of EOL care for this unique subpopulation of critical care patients.
Aims:  The aims of this study were (a) to examine critical care clinician perspectives on the quality of dying of patients with COPD and (b) to compare nurse ratings of the quality of dying and death between patients with COPD with those who died from other illnesses in critical care settings.
Design and sample:  A sequential mixed method design was used. Three focus groups provided data describing the EOL care provided to patients with COPD dying in the intensive care unit (ICU). Nurses caring for patients who died in the ICU completed a previously validated, cross-sectional survey (Quality of Dying and Death) rating the quality of dying for 103 patients.
Data analysis:  Thematic analysis was used to analyse the focus group data. Total and item scores for 34 patients who had died in the ICU with COPD were compared with those for 69 patients who died from other causes.
Results:  Three primary themes emerged from the qualitative data are as follows: managing difficult symptoms, questioning the appropriateness of care and establishing care priorities. Ratings for the quality of dying were significantly lower for patients with COPD than for those who died from other causes on several survey items, including dyspnoea, anxiety and the belief that the patient had been kept alive too long. The qualitative data allowed for in-depth explication of the survey results.
Conclusions:  Attention to the management of dyspnoea, anxiety and treatment decision-making are priority concerns when providing EOL care in the ICU to patients with COPD.     

Case Study: Home Nursing Care for a 62-Year-Old Woman with Multiple Health Problems

PURPOSE.  This case study illustrates the characteristics of, and challenges for, a woman in the United States with multiple health problems.
DATA SOURCES.  Data were obtained through the authors' experience and knowledge of community health nursing and from published literature.
DATA SYNTHESIS.  NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification were utilized to identify appropriate nursing diagnoses, interventions, and outcomes for the client.
CONCLUSION.  This case study illustrates and provides appropriate nursing diagnoses, interventions, and outcomes relevant to a woman with many health concerns. It provides guidance for nurses in community health settings when caring for patients with multiple health problems.
IMPLICATIONS FOR NURSING PRACTICE.  Utilizing the standardized nursing languages of NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification can provide the necessary framework for enhancing and improving the management of care for patients with many health concerns in the community setting.     

Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review

Title.  Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review.
Aim. This paper is a report of a literature review conducted to examine current research studies into attitudes of nursing students towards caring for people with HIV/AIDS and to identify factors that influenced those attitudes to inform current nursing practice and to develop nursing education regarding care provided to people with HIV/AIDS.
Background. Attitudes of nurses towards people living with HIV/AIDS have long been scrutinized. Studies show that some nurses have negative attitudes and are reluctant to provide care to people with HIV/AIDS, resulting in poorer quality nursing support being provided. Attitudes of nursing students towards caring for people with HIV/AIDS is thus of vital importance since they become the future practising nurses.
Data sources.  Eight electronic data bases were searched from 1996–2008.
Review methods.  Criteria used for study selection were: attitudes of nursing students towards caring for people with HIV/AIDS, primary research studies, published in English language in peer reviewed journals from 1996 to June 2008. Sixteen studies were identified for inclusion in this thematic review.
Results.  The following themes were identified: education and knowledge of HIV/AIDS; fear of contracting HIV/AIDS; reluctance to care for people with HIV/AIDS; homophobia; and stigma associated with HIV/AIDS.
Conclusion. There is reluctance on the part of some nursing students in specific regions of the world to provide care for people with HIV/AIDS. Educational programmes based on research evidence must play a leading role in developing strategies to help nursing students understand and overcome such attitudes.     

Workplace empowerment, job satisfaction and job stress among Italian mental health nurses: an exploratory study

Aim  The purpose of the present study was to investigate the relationship between staff nurses' structural empowerment, work stress and job satisfaction in two health care settings in Italy using Kanter's Empowerment Theory.
Background  With the current scarcity of economic resources and shortage of nurses, it is essential to empower nurses to perform at a high level to ensure high-quality patient care. Structural empowerment is a process that can optimize use of nursing skills and professional expertise, thereby increasing job satisfaction among nurses.
Method  A convenience sample of 77 nursing staff employed in the Department of Mental Health in central Italy was used in this study (return rate 64%).
Results  Structural empowerment was significantly related to their job satisfaction ( r  = 0.506, P  < 0.001), as was global empowerment ( r  = 0.62). Empowerment also had a significant negative relationship to nurses' work stress ( r  = −0.28, P  < 0.05).
Conclusion  The results of this study support Kanter's theory of structural empowerment in an Italian nursing sample – a previously unstudied population.
Implications for nursing management  Organizational administration must make every effort to create organizational structures and systems that empower nurses to practice according to professional standards and optimize the use of their knowledge and expertise.     

Reynolds Adolescent Depression Scale – Second Edition: initial validation of the Korean version

Title.  Reynolds Adolescent Depression Scale – Second Edition: initial validation of the Korean version.
Aim.  This paper is a report of a study conducted to test the validity and reliability of the Reynolds Adolescent Depression Scale – Second Edition in Korean culture.
Background.  Depression is a significant mental health problem in adolescents. The Reynolds Adolescent Depression Scale – Second Edition has been shown to be a useful tool to assess depression in adolescents, with extensive research on this measure having been conducted in western cultures. Measures developed in western cultures need to be tested and validated before being used in Asian cultures.
Method.  The participants were a convenience sample of 440 Korean adolescents with a mean age of 13·78 years ( sd  = 0·95) from grades 7 to 9 in three public middle schools in South Korea. A cross-sectional design was used. Back-translation was used to create the Korean version, with additional testing for cultural meaning and comprehension. The data were collected at the end of 2004.
Results.  Internal consistency reliability for the Korean version of the Reynolds Adolescent Depression Scale – Second Edition was 0·89, with subscale reliability ranging from 0·66 to 0·81. Evidence for criterion-related, convergent and discriminant validity for the Korean version of the Reynolds Adolescent Depression Scale – Second Edition was found. Confirmatory factor analysis supported the 4-factor structure of Reynolds Adolescent Depression Scale – Second Edition.
Conclusion.  Our results support the validity and reliability for the Korean version of the Reynolds Adolescent Depression Scale – Second Edition as a measure of depression and suggest that it can be used to screen students and to evaluate the effectiveness of preventive interventions in school settings.