Exploring adaptations to the clinical reasoning cycle for forensic mental health nursing: A qualitative enquiry

Forensic mental health nurses (FMHN) provide care to address the needs of people who have mental illnesses across a range of diverse settings. The Clinical Reasoning Cycle (CRC) has been identified as a potential framework to assist FMHNs; however, adaptations were required to reflect the unique nature of the clinical setting. This study aimed to explore adaptations made to determine suitability prior to implementation in practice. Nominal Group Technique was used to explore suggested adaptations determined from a previous study and reach a consensus on the changes. Fourteen senior nurses from a state-wide Forensic mental Health (FMH) service participated. A consensus was reached for two proposed changes. Data were analysed using thematic analysis. Three main themes were interpreted from the data; FMH adaptations are warranted, the focus of the CRC, and who owns the cycle? Nurses in this study considered the need to include offence and risk issues due to the impact these factors have on the therapeutic relationship and cognitive bias; however, they also identified the need to focus on recovery-oriented care while engaging in clinical reasoning. Nurses in this study also expressed some reluctance for nursing to ‘own' the model, due to concern that ownership may cause division among the team or result in inconsistency in care. However, some participant's suggested the CRC with adaptations assisted FMH nurses to articulate their specialist skills and knowledge to others and highlight the nursing contribution to care. Further work is needed to finalize adaptations with a focus on engaging the consumer carer workforce and interdisciplinary team.     

Venous thromboembolism (VTE) prophylaxis: implications for medical-surgical nurses.

Nurses are responsible for continual patient evaluation as they address patient needs, provide essential input into evaluation and risk stratification, and make recommendations regarding prevention-oriented strategies (American Health Consultants, 2002a). As a result, nurses are in a pivotal role to prevent VTE. Education about all aspects of VTE prevention should be included in basic nursing programs and must continue throughout a nurse's career through continuing education, reading, and dissemination of information from current health care literature.     

Warfarin use in the elderly: the nurses' perspective.

OBJECTIVE: To explore the barriers to warfarin use from the perspective of nurses working in aged care. DESIGN: A qualitative study, involving a semi-structured group interview, during March-April 2001. SETTING AND SUBJECTS: Eleven nurses, employed within the catchment of the Northern Sydney Area Health Service, who were involved in the care of elderly warfarinised patients. MAIN OUTCOME MEASURE: Identification, via thematic analysis, of the main themes underpinning the nursing perspective on warfarin use in this setting, with regard to their perceived role/s, experiences with patients, and potential strategies for managing the therapy. RESULTS: Five main themes were identified: perceived patient attitude toward warfarin; barriers to the use of warfarin; expressed lack of confidence in the processes involved; nurses' role in warfarin use; and strategies to improve warfarin use. Nurses were concerned about warfarin use in the elderly, but felt they had a limited capacity to intervene. CONCLUSION: Nurses are potentially underutilised as a resource and support for both patients and prescribers, in the management of warfarin therapy.     

Patient safety to frame and reconcile nursing issues

Canadian nursing leadership is called to advance a national patient safety agenda for the delivery of safe, quality care in professional practice environments. Yet, the nursing discipline is burdened by issues and challenges related to clinical practice and workplace dilemmas that contribute to barriers and obstacles to safe, quality and humane care. We propose that the many clinical challenges faced by nurses in Canada can be more fully understood when framed by a patient safety perspective. Nurse executive leaders and nurse scientists are called to reform clinical practice and conduct research to reconcile patient care safety issues. This paper applies findings obtained from nurses via focus groups led by the Academy of Canadian Executive Nurses (ACEN) and integrates these findings into a patient safety perspective via a conceptual framework.     

Providing residential care to older Australians: issues for registered nurses

Contemporary nursing in residential aged care facilities poses many challenges. Issues impacting on registered nurses providing care to older Australians living in residential aged care settings are explored and described in this paper. Five broad themes emerged from the analysis of thirty interviews with Registered Nurses, eleven focus groups with participants who worked with registered nurses in the residential aged care facilities selected in the sample, and five nominal groups which consisted of key stakeholders from the aged care industry and professional nursing forums. These themes were: a changing and increasingly complex role; perceptions of the registered nurse in residential aged care and how to deal with them; the need for strategies to work with others; coping with the everyday demands; and dealing with a sense of powerlessness and lack of control. The identified themes form the basis of the discussion to follow.     

Personal safety, violence, and home health

A critical issue facing the health care industry today is the potential impact of community and interpersonal violence on home health care. The purposes of this study were to (1) serve as a source for understanding the personal safety risk issues facing home care staff in a large Midwest region and its surrounding rural areas; (2) provide an understanding of how perceived threats to personal safety may impact patient care and patient outcomes; (3) identify strategies for increasing the personal safety of direct care staff; and (4) identify organizational, educational, and procedural issues that impede or enhance staff safety. A triangulated qualitative design was used including focus groups, in-depth individual interviews, critical event narratives, and a participant self-report form. The study used a purposive sample consisting of 5 men and 56 women who were either administrators or direct care staff from 13 home health agencies. Seven major themes emerged: (1) unsafe conditions that direct care staff must face; (2) organizational and administrative issues that impede or promote the personal safety of staff; (3) ethical issues staff face daily; (4) protective factors associated with maintaining safety; (5) issues of gender, race, age, and experience; (6) education and training; and (7) the potential impact that staff's fear of interpersonal and community violence can have on patient care and patient outcomes.     

Work environment characteristics of high-quality home health agencies

This concurrent mixed-method study examines the nurse work environment of high-quality Medicare-certified home health agencies. High-quality (n=6) and low-quality (n=6) home health agencies were recruited using agency-level publicly reported patient outcomes. Direct care registered nurses (RNs) from each agency participated in a focus group and completed the Practice Environment Scale of the Nurse Work Index (PES-NWI). No significant differences were found in the PES-NWI results between nurses working in high- and low-quality agencies, though nurses in high-quality agencies scored higher on all subscales. Nurses working in all the high-quality agencies identified themes of adequate staffing, supportive managers, and team work. These themes were not consistently identified in low-quality agencies. Themes of supportive managers and team work are reflective of effective leadership at the manager level. Agencies struggling to improve quality of care might consider developing their managers' leadership skills.     

Nurses' perspectives of smoking initiation, addiction, and cessation

BACKGROUND: It is estimated that 18% of registered nurses smoke. Although nurses can make an important contribution to national cessation efforts, continuing smoking among nurses has been cited as one of the barriers against higher nursing involvement. OBJECTIVES: To develop a national program to assist nurses in smoking cessation through an in-depth understanding of issues related to nurses' attitudes toward smoking and quitting, and to explore nurses' preferences for smoking cessation interventions. METHODS: Eight focus groups were conducted in four states with nurses who were current or former smokers. Content analysis was used to identify major themes. RESULTS: Four themes were identified: initiation of smoking and addiction, myths and misconceptions about quitting, overcoming addictions, and strategies for enhancing successful cessation. Nurses described addiction and cessation efforts similar to those of the general population. However, nurses experienced guilt related to their smoking, and perceived a lack of understanding by nonsmoking colleagues and managers about their need of support for smoking cessation. Nurses who had successfully quit smoking were motivated by health concerns, pregnancy, and their children. Nurses suggested many interventions that would be supportive of their quit attempts, such as worksite services and Internet-based support groups. CONCLUSIONS: Nurses expressed the need for smoking cessation interventions similar to that of the general population, and for additional support that recognizes two concerns: confidentiality about their smoking in terms of the general public, and support along with counseling with regard to their feelings of shame and guilt in relation to their public image as nurses.     

Themes surrounding novice nurse near-miss and adverse-event situations

OBJECTIVE: The study purpose was to identify human performance factors that characterized novice nurse near-miss/adverse-event situations in acute-care settings. BACKGROUND: Increased focus on recruitment and retention of newly graduated registered nurses (RNs) in light of patient safety improvement goals will challenge healthcare educators and administrators. What we are beginning to learn about human performance issues during real work situations from patient safety research provides information related to human performance in complex environments that may guide education and system supports for novice RNs. METHODS: Data collected during 8 retrospective interviews of novice RNs about details surrounding their individual near-miss or adverse event were analyzed for common themes. RESULTS: Nine themes were identified. Seven themes were present in at least 7 of the 8 cases and included environmental and social issues, as well as novice lack of expertise. CONCLUSIONS: Findings suggest that support for novice nurses in acute care environments requires attention to the following: consistent availability of expertise in light of workload unpredictability, the social climate regarding expectations of novice performers, realistic expectations of novice decision-making ability during complex situations even up to a year after graduation, and strategies to recognize and intervene when novices are at risk for error.     

Child care health consultants' roles and responsibilities: focus group findings

PURPOSE: To describe the roles and responsibilities of newly trained health professionals, primarily nurses called Child Care Health Consultants. METHOD: Health professionals hired by county agencies to become Child Care Health Consultants enrolled in the California Training Institute (CTI) for Child Care Health Consultants, a 9-day educational training program divided into three modules. They participated in one focus group during each module. Research staff led the focus groups and the participants were asked, "What are your roles and responsibilities?" Qualitative analyses were conducted and common themes were identified. FINDINGS: The nine focus groups included 44 participants, 95% were nurses with an average of 20 years of work experience. The roles and responsibilities of the Child Care Health Consultants were described by five themes: network, education, sustainability, on-site service, and administration. CONCLUSION: These findings contribute to the new field of child care health consultation by defining the common roles and responsibilities of Consultants.     

Process and outcome measures using nursing sensitive indicators

Measuring the impact of high quality nursing care has become an imperative driven by several issues during the past several years. Current challenges surrounding the nursing shortage and the decreasing nursing workforce projected for the next decade alone have raised serious questions about the effect fewer registered nurses (RNs) will have on the quality of health care. In addition, heightened public attention to patient safety and adverse outcomes has prompted national organizations, such as the Joint Commission for Accreditation of Healthcare Organizations, the American Nurses Credentialing Center, and the National Quality Forum, to consider and implement recommendations for establishing and monitoring nursing quality indicators that focus on nursing-sensitive patient outcomes. These issues, now more than ever, have provided us with a burning platform to examine exactly what nurses do and their impact on patient health outcomes.     

Registered Nurses' personal rights vs. professional responsibility in caring for members of underserved and disenfranchised populations

Aims. Health disparities exist and refer to the chasms in health status between the advantaged and disadvantaged. Intense multiculturalism will require different approaches and moral obligations to work with these groups and urgency exists to develop nursing caring strategies when dealing with these populations. Development of nursing curricula which identify prejudicial thinking and intolerance for marginalized groups will help to decrease fears and increase nurses’ willingness to provide culturally competent health care for underserved and disenfranchised populations. Background. Caring for members of disenfranchised groups instills fear at some level in nurses who are working with these individuals. This fear may be due, in part, to the potential harm nurses perceive the patient may cause them, or perhaps it is because they feel they could possibly be in the individual's situation at some point in their lives. Prejudice and discrimination continue to exist in society and have adversely affected the health care system and the nursing profession. Discrimination may be based on differences due to age, ability, gender, race, ethnicity, religion, sexual orientation, or any characteristics by which people differ. Relevance to clinical practice. Registered Nurses are accountable for nursing decisions and actions regardless of personal preferences. Due to the rapidly changing healthcare system the nurse faces increasing ethical dilemmas and human rights issues. Nurses are individually accountable for caring for each patient and the right to refuse an assignment should be carefully interpreted to avoid patient abandonment. Nurses’ objections can be based on moral, ethical, or religious beliefs not on personal preferences and in an emergency the nurse must provide treatment regardless of any personal objections.     

Identifying nurse and health visitor priorities in a PCT using the Delphi technique

A three-stage Delphi investigation was undertaken over a 4-month period in a primary care trust to identify the perceived clinical needs of nurses. Practice nurses, district nurses, health visitors and community hospital nurses all participated. In round 1, there were 28 replies from these groups of nurses, in round 2 there were 31, and in round 3 there were 25 replies. In round 1, 77 issues (excluding duplications) were identified. These were separated into three themes according to the most appropriate method for addressing the issue: education (29 issues), research (16 issues) and management (32). In round 2, the issues were redistributed in the three areas and staff were asked to choose the ten most important issues from education, research and management. Finally, in round 3 the ten issues in education, research and management were prioritized in terms of the "most pressing". The most pressing education need was recognizing accountability; the most pressing research need was caseload/dependency scoring--matching staff levels to workload, and the most pressing management need was risk management, e.g. staff safety. The results have identified locally that there is a gap between the modernization agenda and what nursing staff consider to be the issues that need addressing locally. If measures are not put in place to address these local issues, there is a danger that nurses will not take a full and active role in the modernization of the NHS.     

Patient‐related violence against emergency department nurses

In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient‐related violence in the health‐care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under‐reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero‐tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy‐makers and administrators should recognize this issue as a priority for preventative action.     

Hindrance for patient participation in nursing care

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

Developing advanced rural nursing practice: a whole new scope of responsibility

Rural registered nurses’ experiences of advanced clinical nursing practice were explored whilst they were enrolled in an advanced primary care course of study. Thirty-two nurses employed in rural health services in Victoria, Australia, studied advanced practice nursing by distance education with a clinical component. At course conclusion, focus groups and a quantitative on-line survey were conducted to explore outcomes. Nurses reported positive self-perceptions of their educational preparation with scores of >7/10 for competence, confidence, preparedness for advanced practice and job satisfaction. Focus group discussions concurred with positive survey results. The course was valuable in developing skills and knowledge, enabling more holistic patient care. The main themes that emerged related to the advancement of the nurse as a professional, and enhancement of patient care. Within their scope of practice, nurses assessed, diagnosed and treated minor patient illness presentations either independently or collaboratively with medical advice. The context of rural health services dictated practice and levels of autonomy. Nurses perceived the new role reduced an overload of medical work, whilst increasing patients’ access to care. As a result of the course 24% of participants reported a change in their work role. Nurses employed in rural health services reported positive potential for advanced collaborative practice in rural health care, in association with medical professionals. Defined role boundaries, role responsibilities and dedicated advanced practice positions will be required to achieve implementation of the role.