Development of clinical competence - a longitudinal survey of nurse practitioner students.

BACKGROUND: In order to achieve a sustainable standard of advanced clinical competence for nurse practitioners leading to a credible role, it is important to investigate the development of clinical competence among nurse practitioner students. AIM: The aim of the present study is to analyse the development of nurse practitioner students' self-assessed clinical competence from the beginning of their education to after completion of their clinical studies. DESIGN: The study involved the application of a longitudinal survey design adhering to STROBE guidelines. METHODS: The participants consisted of 36 registered nurses from a nurse practitioner programme at a Norwegian university. The Professional Nurse Self-Assessment Scale II was used for data collection during the period August 2015 to May 2020. RESULTS: The students developed their clinical competence the most for direct clinical practice. Our findings are inconclusive in terms of whether the students developed clinical competence regarding consultation, coaching and guidance, and collaboration. However, they do indicate a lack of development in some aspects of clinical leadership. The students with the lowest level of clinical competence developed their clinical competence regarding direct clinical practice significantly more than the students with the highest level of clinical competence. The differences between students with high and low levels of clinical competence were levelled out during their education. Thus, the students as a whole became a more homogenous group after completion of their clinical studies. Previous work experience in primary healthcare was a statistically significant, yet minor, predictor of the development of clinical competence. CONCLUSION: Our findings indicate that the students developed their clinical competence for direct clinical practice in accordance with the intended learning outcomes of the university's Master's programme and international standards for nurse practitioners. It is imperative that the clinical field supports nurse practitioners by facilitating extended work-task fits that are appropriate to their newly developed clinical competence. We refrain from concluding with a recommendation that prior clinical work experience should be an entry requirement for nurse practitioner programmes. However, we recommend an evaluation of the nurse practitioner education programme with the aim of investigating whether the curriculum meets the academic standards of clinical leadership expected in advanced level of nursing.

Time in care for older people living in nursing homes.

In order to measure actual care needs in relation to resources required to fulfill these needs, an instrument (Time in Care) with which to evaluate care needs and determine the time needed for various care activities has been developed with the aim of assessing nursing intensity in municipal care for older people. Interreliability (ICC = 0.854) of time measurements (n = 10'546) of 32 nursing activities in relation to evaluated care levels in two nursing homes (staff n = 81) has been determined. Nursing intensity for both periods at the two nursing homes comprised on average a direct care time of 75 (45%) and 101 (42%) minutes, respectively. Work time was measured according to actual schedule (462 hours per nursing home during two weeks). Given that the need for care was high, one must further investigate if the quality of care the recipients received was sufficiently addressed.

Developing the scope of practice and education for advanced practice nurses in Finland.

BACKGROUND: The reorganization of Finnish healthcare services has required a restructuring of the areas of responsibility between healthcare professionals. AIM: To describe the need for Advanced Practice Nurses in Finland and the development process of a Master's programme in Health Promotion, Advanced Clinical Care. METHODS: The study consisted of a survey of nurse managers (24) and focus group interviews with clinical nurse specialists (46). FINDINGS: The expanded role includes advanced clinical skills and responsibility for health prevention and promotion, education, supervision, leadership, research and development. CONCLUSIONS: The legislation, scope and models have to be supported and further developed to promote the full scope of advanced practice.

Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery.

BACKGROUND: The aim of this study was to evaluate the significance of elevated postoperative Troponin T (TnT) levels in an elderly population undergoing non-cardiac surgery. METHODS: Five hundred and forty-six consecutive patients aged 70 years or older undergoing non-cardiac surgery of >30-min duration were enrolled in this prospective, observational study. A postoperative TnT measurement was obtained on the 5th to 7th postoperative day. Troponin T values greater than 0.02 ng ml(-1) were considered positive. Patients were followed over a 1-year period, and mortality and non-fatal cardiac events (acute myocardial infarction and coronary interventions) were recorded. RESULTS: Troponin T concentrations greater than 0.02 ng ml(-1) were detected in 53 of the study subjects (9.7%). Eleven per cent of the patients with elevated TnT had electrocardiographic or clinical signs of myocardial ischemia. One year after surgery, 17 (32%) of the patients with abnormal TnT concentrations had died. In a multivariate Cox regression analysis adjusting for baseline and perioperative data, a TnT value >0.02 ng ml(-1) was an independent correlate of the mortality adjusted hazard ratio (HR): 14.9 (95% CI 3.7-60.3). Other independent predictors of death were tachycardia (HR, 14.9 95% CI 3.45-64.8), ASA 4 (HR, 8.1 95% CI 1.3-50.0), reoperation (HR, 6.4 95% CI 1.1-36.9), and use of diuretics (HR, 4.2 95% CI 1.3-13.8). CONCLUSION: We conclude that elevated TnT levels in the postoperative period confer a 15-fold increase in mortality during the first year after surgery. Our findings also provide evidence that silent myocardial ischemia is common in an elderly population. Routine perioperative surveillance for TnT might therefore be of use in detecting patients at an increased risk of mortality during the first postoperative year.

Validation of a new method for patient classification, the Oulu Patient Classification.

At Vasa Central Hospital in Western Finland a further development of the Oulu Patient Classification (OPC) has been made by the development of weight coefficients and by estimating the nursing care intensity per nurse. The daily level of nursing care intensity of a ward is expressed by the number of nursing care intensity points per nurse. This article presents results from a validity test of the OPC at Vasa Central Hospital. The test was carried out by comparing the daily patient classifications by means of the OPC against measurements made by means of a new measuring instrument, the 'Professional Assessment of Optimal Nursing Care Intensity Level' (PAONCIL) developed at the Vasa Central Hospital. The study was implemented in eight wards during a period of 3 months. The data material consisted of two parts, the daily patient classifications based on the OPC (n = 19 324) and the measurements by means of the PAONCIL forms (n = 8458). Simple and multiple linear regression analyses were used as statistical methods in quantifying the linear relationship between the two interval-scaled variables. In the test of concurrent validity the coefficient of determination was 0.366, i.e. the association between these two indicators is fairly strong (36.6%). The testing of construct validity showed that the construct validity of the indicator hardly deteriorates as a result of the patients being placed in separate nursing care intensity categories. There was a clear correlation between the scores allotted by the indicator to the six different sub-areas of nursing care. When examining the construct validity of the OPC, no factors with independent explanatory power in predicting PAONCIL values were discovered other than those of the OPC. The OPC proved on the basis of this research material and these statistical methods to possess fairly adequate validity, and thus there is a good basis for further research and a development of nursing care.

Professional assessment of optimal nursing care intensity level. A new method for resource allocation as an alternative to classical time studies.

In the article a new method is presented for allocation of staff resources, 'Professional Assessment of Optimal Nursing Care Intensity Level' (PAONCIL). This method is presented as an alternative to classical time study, which has traditionally been considered to belong to systems for patient classification. By means of this method the optimal nursing care intensity level for individual wards can be established. The study comprised 8 wards, and the nurses working in these wards provided a total of 8,458 professional assessments of optimal nursing care intensity levels. The material was analysed by means of simple linear regression analysis. The nursing care intensity scores per nurse in a single ward were used as independent variables and the average PAONCIL score for the same calendar day was used as a dependent variable. The average determination coefficient for different wards were 0.37; the PAONCIL instrument thus explained 37% of the nursing care intensity/nurse variation. This corresponded to a linear correlation of 0.60. In five out of six wards for adults the optimal nursing care intensity/nurse scores were close to each other, ranging from 3.0 to 3.6. The advantage of the PAONCIL method is that it can be easily implemented in a ward, can be used time and again, is advantageous and is based on quality aspects. The PAONCIL method has been developed on the basis of a caring science perspective and can be seen as an administrative method for the nurse manager, with whose help 'good care' can become possible.

The patient's perceived caring needs: measuring the unmeasurable.

The aim of this study is to elucidate the phenomenon of the caring need in the life-world of the patient and, on the basis of this, to compare patients' perceived caring needs with the six areas of need contained in a new instrument for patient classification, the Oulu Patient Classification (OPC). A total of 75 patients were interviewed and the data were analysed by means of a phenomenological-hermeneutical method. Seventeen perceived caring needs emerged from the process of interpretation. The patients experienced themselves as an indivisible unit that contained existential/spiritual needs and desires. The patients' caring needs are constituted from their problems, needs and desires, where human desire for life, love and meaningfulness may, express itself as bodily, psychical and existential/spiritual needs. A comparison between the patients' perceived caring needs and the OPC shows that patients' existential/spiritual needs do not emerge clearly enough and that the instrument should be supplemented by a caring perspective.

Professional assessment of optimal nursing care intensity level: a new method of assessing personnel resources for nursing care.

The primary aim of patient classification is to be able to respond to the constant variation in patients' caring needs. Systems of patient classification usually include some form of time study, e.g. work sampling or time-and-motion studies. This article deals with the pros and cons of traditional time studies and with the theoretical bases of a new method of assessing the need for staff resources for nursing, a method termed 'Professional Assessment of Optimal Nursing Care Intensity Level'. The main idea of the method is to arrive at an optimal level of nursing care intensity for a ward by means of professional assessment and daily patient classification. The optimal level of nursing care intensity is supposed to prevail when there is a balance between the patients' need for care and the hospital's staff resources. The development of this new method and an account of a pilot study carried out in two wards are presented. The results of the pilot study established that the development of the method is worth continuing in order to create an administrative tool which, by its nature, is more compatible than traditional time studies with the idea of caring from the perspective of caring science.

The patient's perceived caring needs as a message of suffering.

The aim of the study was to arrive at a deeper understanding of the patient's experience of caring needs, that is, of problems, needs and desires, by investigating and explaining how these will be expressed and shaped in the caring relation and to illuminate its implications for caring. The target population consisted of 38 patients in a medical ward and 37 patients in a surgical ward in a central hospital in Western Finland. The patients were interviewed in the wards and asked about perceived caring needs. By means of a hermeneutical process of interpretation a pattern emerged which was interpreted as pictures of themselves and of the nurses. These types of patients fell into three groups: the satisfied, the complaining and satisfied, and the complaining and dissatisfied patients. The types of nurses were divided into the competent and friendly, the competent and contact-creating and the competent and courageous. The patients' caring needs can be interpreted and understood from the standpoint of their experience of suffering, but also in relation to their experience of pleasure and comfort. The most conspicuous caring needs were experiencing confidence in the competence of the nurses, comfort, guidance, dialogue and closeness, which the patients expressed as problems, needs and desires. The patients' caring needs can contain new possibilities of growth and development. The nurse can relieve patients' suffering by promoting their experience of comfort. If the nurses' view of the limits of reality are extended to comprise the existential/ spiritual dimension of human beings as well, new possibilities will emerge of interpreting and understanding patients' caring needs as a message of suffering.

Measuring the unmeasurable: a caring science perspective on patient classification.

AIMS: To give a short historical survey of patient classification and its motives, to analyse patient classification and especially the instrument, The Oulu Patient Classification more closely from a caring science perspective. BACKGROUND: A survey of topical literature and research on patient classification show that economic and administrative justifications predominate and the caring science connection is weak, almost non-existent. ORIGINS OF INFORMATION: Topical literature and research on patient classification and the instrument, The Oulu Patient Classification. DATA ANALYSIS: Topical literature and research were evaluated from a caring science perspective in accordance with Eriksson's theory of caring and the basic concept of man as an entity of body, soul and spirit. KEY ISSUES: Patient classification is used in staff planning and is also justified from the viewpoint of content, that is, as a method of guaranteeing good quality in the care of patients and as an expression of the prevalent caring ideology. The concept of man is reduced in current literature and research on patient classification. The Oulu Patient Classification is based on a humanistic view of man, but man's spiritual and existential needs do not emerge clearly from the manual of the instrument. CONCLUSIONS: It is essential for patient classification to start from a caring perspective. Correctly dimensioned staffing based on patient classification is a prerequisite for good care. This should be combined with a caring culture that considers the whole complexity of man in order to make good care possible.

A comparison between patients' experiences of how their caring needs have been met and the nurses' patient classification--an explorative study.

AIM: To examine whether patient classification carried out in accordance with the Oulu Patient Classification (OPC) method can measure the patient's caring needs in a reliable manner as seen from the patient's perspective. BACKGROUND: On the basis of earlier research it can be established that there are differences between nurses' and patients' assessments of patients' caring needs. Research on patients' assessments of perceived caring needs and the care they receive in connection with patient classification does not seem to have interested researchers in caring science. METHODS: The reliability from the patient's perspective is gauged by comparing the patient's perceived caring needs with the nurse's patient classification during a 24-h bed-day. Data was collected during a semi-structured interview with a total of 73 patients. Documentary analysis was carried out on the basis of patient classifications by 30 ward nurses. FINDINGS: On the basis of the degree of correspondence between nursing care intensity experienced by the patients and the nurses' patient classification it was decided whether the patients' caring needs had been met. The results indicate, however, that patient classification as a gauging method has a built-in reductive function regarding the patient's need for care and nursing care intensity. CONCLUSIONS: Nevertheless the OPC offers possibilities from a patient perspective of providing an overall picture of the patient's nursing care intensity and can therefore serve as a reliable basis for decisions concerning staff planning.

[Opinions on health and integrating health processes--in theoretical and in psychiatric care context]. / Uppfattningar om hälsa och integrerande hälsoprocesser--teoretiskt och i psykiatrisk vårdkontext.

This study is a part of the research project "Multidimensional Health" and consists of a theoretical and on empirical part. The theoretical part analyzes the concepts of health and processes of health, taking as its theoretical frame of reference the theories of Eriksson. The empirical part is a study of the processes of health of fourteen patients in psychiatric health care and is a hermeneutical study. The aim is to describe and to understand multidimensional health, integrating processes of health and the factors guiding or directing them. The premise that health is relative is verified by the results. The dominating pattern of the processes of health suggests that they are integrating. Man's consciousness of his own potential wholeness, the experience of being accepted in relation to the concrete and the abstract other, and the experience of his own place are essential parts of integrating processes of health.