Challenges of de-implementing feeding tube auscultation: A qualitative study.

AIM: This qualitative study explored de-implementation of feeding tube auscultation practice in adult patients by critical care nurses. BACKGROUND: Despite years of evidence suggesting inaccuracy and harm, auscultation (air bolus method) continues to be used by the majority of critical care nurses to verify small-bore feeding tube placement in adults. DESIGN: This descriptive qualitative study used thematic analysis with telephone interview data. METHODS: Fourteen critical care nurses from four stratified groups within the United States (by hospital type and auscultation practice) participated in telephone interviews. RESULTS: Two major themes of individual influence and organizational leadership emerged from the data. Categories identified key components required for auscultation de-implementation. CONCLUSIONS: Nurses feel obligated to follow hospital policies and expressed less accountability for their own practice. Organizational leadership involvement is recommended to facilitate de-implementation of this tradition-based, low-value practice and mitigate harm events.

An Ethos of Inclusion for Global Nursing Practice.

The Year of the Nurse and Midwife, 2020, is an opportunity for global nurses to realize the ethos of inclusion for transformative global nursing partnerships. Including all partners in developing and maintaining the relationship provides the foundation for bidirectionality whereby all partners learn and grow personally and professionally from each other. Guidelines, theoretical models, and Codes of Ethics are suggested for applying an ethos of inclusion in all global nursing partnerships.

Accelerating Our Global Impact in the Year of the Nurse and Midwife.

Confronting global health crises requires nurses who demonstrate leadership and the ability to collaborate with other disciplines. Regional partnerships can act as "accelerant synergists" to develop the capacity of nurses locally benefiting the region as a whole.

National Survey of Feeding Tube Verification Practices: An Urgent Call for Auscultation Deimplementation.

BACKGROUND: Harm events such as pneumothoraces and pneumonia continue to be associated with feeding tube insertion. Most bedside verification methods are not accurate to discriminate pulmonary from gastrointestinal system. Evidence-based clinical practice guidelines do not support auscultation of feeding tubes in adults, yet auscultation is the most common method used. OBJECTIVES: Our survey assessed national feeding tube verification practices used by critical care nurses, including progress in auscultation method deimplementation, and stylet reinsertion and cleansing practices. METHODS: A national survey of 408 critical care nurses was performed. RESULTS: The majority performed auscultation (311 of 408 [76%]) to verify feeding tube placement. In the final multivariable model, nursing education, facility type, observation of colleagues performing auscultation, and awareness of an institutional policy were associated with auscultation of feeding tubes. Thirty-five percent used enteral access devices to verify initial feeding tube placement. Stylet cleansing methods were variable; 38% of reinserted stylets were not cleansed. DISCUSSION: Minimal progress has been made in deimplementation of auscultation in the past 7 years despite passive knowledge dissemination in research articles, clinical practice guidelines, and procedure manuals. Although pH measure is used as a first-line feeding tube verification method in the United Kingdom, it is rarely used in the United States. Clinical practice guidelines should be updated to incorporate new research on enteral access systems. CONCLUSIONS: Tradition-based practices such as auscultation and certain stylet cleansing methods should be deimplemented. A focused interdisciplinary, multifaceted program is needed to deimplement auscultation practice for adult feeding tubes.

Looking toward 2030: Strengthening midwifery education through regional partnerships.

AIMS: The purpose of this paper is to describe the impact of a regional capacity-building project between Thailand and Laos that supports the United Nation's sustainable development goal 3 through midwifery education. DESIGN: Discussion paper based on an exemplar. DATA SOURCES: The International Confederation of Midwifery's standards of midwifery education and World Health Organization midwifery educator core competencies provided the framework for capacity-building of Lao midwifery educators. IMPLICATIONS FOR NURSING: Knowledge gained from this 2-year project (October 2015-November 2017) increased the teaching confidence of midwifery educators while linking international standards and competencies to curriculum revision. In addition, capacity-building projects based on a needs assessment and implementation from regional partners may result in policy changes at the local and national level. CONCLUSION: Partnerships are essential to meeting the sustainable development goals. These regional partnerships may be highly effective in creating sustainable capacity-building projects. IMPACT: Maternal mortality and preventing deaths of children under 5 years old continues to be a challenge across the globe despite progress made in recent years. Progress toward sustainable development goal 3, requires efforts addressed in sustainable development goal17, partnership. Laos has one of the highest maternal mortality rates in Southeast Asia. A project to increase capacity of midwifery educators demonstrated the benefit of regional partnerships in Laos to have an impact on sustainable development goal 3 ultimately improving maternal outcomes throughout the country. Partnerships especially those between countries in the same region, are crucial to the success of meeting the sustainable development goals.

Global citizens, healthy communities: Integrating the sustainable development goals into the nursing curriculum.

BACKGROUND: Integrating the Sustainable Development Goals (SDGs) into the nursing curriculum is an ethical response and facilitator developing students into global citizens. Nurse educators can promote global citizenship through the concept of "glocal" experiences in local communities as students work in partnership with communities to address social determinants of health and begin to achieve SDG targets. PURPOSE: This paper explores the process of integrating the SDGs into the nursing curriculum emphasizing the strategic vision of international agencies and national nursing organizations. DISCUSSION: Distinct pedagogical and clinical approaches for implementing SDG content into the curriculum are provided including an exploration of global health competencies and their relationship to the SDGs. Finally, an academic-community partnership is described as a clinical exemplar to strengthen the health of communities and begin realizing the SDGs at a local level.

The United Nations Sustainable Development Goals: The Ethic and Ethos of Holistic Nursing.

Holistic nursing is founded on the values of integrality and the awareness of whole-people and whole-system interconnectedness. These concepts are foundational to the broader global health agendas and initiatives of our time, which seek to improve human, animal, and planetary health. The United Nations 2030 Agenda for Sustainable Development represents the most remarkable transnational initiative in history: a 15-year plan (2015-2030) rallying the efforts of all countries, governments, and concerned citizens worldwide to foster human-planet thriving and survival. The purpose herein is to substantiate the United Nations 2030 Agenda as a holistic nursing priority and theory-practice opportunity for current and future professional maturation. This article provides a background of the 17 Sustainable Development Goals (SDGs), a discussion regarding their relevance to holistic nursing, and an explanation of the essential nature of partnerships in attaining each of these "Global Goals." We link the discussion of the SDGs directly to the American Holistic Nurses Association's Core Values and identify implications for practice, education, research, and policy. Holistic nursing is ideally situated throughout the health care system and in the broader global context to advocate and advance the SDGs.

De-implementation of tradition-based practices in critical care: A qualitative study.

AIM: To explore the process of tradition-based practice (TBP) de-implementation by critical care nurses. BACKGROUND: Ritualistic and routine practices have been described as sacred cows or TBPs. Many clinical practices have insufficient or no evidence and may lead to poor patient outcomes. De-implementation (termination) of potentially harmful, ineffective, or non cost-effective TBP is necessary to facilitate evidence-based practice (EBP) in the clinical setting. DESIGN: Descriptive qualitative inquiry guided this study. METHODS: Twenty-two critical care nurses from an acute care hospital in central Florida participated. Individual and focus group interviews were performed March to July 2016 and analysed using thematic analysis. RESULTS: Three themes were identified: (a) uncertainty, (b) desire to know, and (c) preparing for practice change. Nurses were uncertain about the scientific underpinnings of everyday clinical practices and had difficulty differentiating TBP from EBP. De-implementation processes and strategies appeared to replicate implementation processes. CONCLUSION: More research is needed to evaluate de-implementation processes and strategies used for de-implementation. An emphasis should be placed on ensuring that nurses are knowledgeable about fundamental EBP skills to encourage assessment of clinical practices for supporting research evidence. Awareness and understanding of TBPs will facilitate a more comprehensive approach towards achieving the gold standard of EBP.

Exemplars Illustrating De-implementation of Tradition-Based Practices.

Clinical practice must be based on evidence. When evidence suggests that a certain practice may be ineffective or even harmful, that practice should be discontinued. The Choosing Wisely campaign, an initiative of the ABIM (American Board of Internal Medicine) Foundation, is intended to bring attention to tradition-based practices, or "sacred cows," which lack evidence to support their ongoing use. The complex process of discontinuing or reducing the use of tradition-based practices is known as "de-implementation." Recognizing the importance of de-implementation is necessary to fully understand evidence-based practice. This article explores the de-implementation process, examining its barriers and facilitators. Three critical care exemplars of tradition-based practices are presented and examined through the lens of de-implementation. Barriers and facilitators related to de-implementing these tradition-based practices are described, with an emphasis on the roles of various stakeholders and the need to overcome cognitive dissonance and psychological bias.

The case for a paradigm shift: from global to planetary nursing.

The purpose of this paper is to propose a paradigm shift from "global nursing" toward "planetary nursing" to more effectively engage worldwide health initiatives, such as the United Nations 2030 Agenda for Sustainable Development. Such a shift expands the understanding of "health" from a phenomenon focused solely on humanity toward one of interdependent animal, environment, and overall planetary well-being, recalibrating the future roles and responsibilities of nursing accordingly. While there is limited data that discusses nursing-focused contributions to planetary health, the advancement of planetary nursing has been the focus of scholarly dialogue. Knowledge regarding the planet's systems, species, ecosystems, and myriad environmental dimensions must be integrated throughout nursing education to be translated to practice and social justice initiatives. As the profession deepens collaborations with international policymakers, nurses will become integral to advancing planetary health through social justice and health equity efforts. Nursing research must evolve to contribute to the goal of planetary health for the next generation and beyond. Ultimately, these authors call for a shift toward One Mind-One Health-One Planet to move the disciplinary stance from one of "global nursing" to a more expansive view of "planetary nursing" in alignment with initiatives to promote and sustain planetary health.

Building Transformative Global Nursing Partnerships.

BACKGROUND AND PURPOSE: Global nursing is a relatively new term identifying nurses contributing to global health. While personally and professionally rewarding, global health projects present unique challenges to global nurses that impact partnerships. The aim of this article was to describe the role of global nursing, and focus on relational-cultural theory as the foundation of transformative partnerships. METHODS: This article is based upon a review of literature related to global health and relational inquiry. Peer-reviewed papers and research articles published within the past 10 years were used to support this discussion. Publications considered to be classics in the field of relationship inquiry were also utilized. RESULTS: Global nursing is a relatively recent conceptualization in describing the role of nursing. Global nursing practice based upon relational-cultural theory and mediated by cultural humility provides a strong foundation for the development of transformative global nursing partnerships. IMPLICATIONS FOR PRACTICE: This article provides a theoretical foundation for global nurses practicing in local and global contexts with diverse populations. Nursing partnerships in both local and global contexts can be challenging to initiate and manage, but global nurses are responsible for creating partnerships which are ethically sound, based on theory, and transformative in nature. Cultural humility plays a central role in the ongoing process of disconnecting and re-connecting for transformational partnerships with individuals, communities, and other health-care providers.

Using Gemba Boards to Facilitate Evidence-Based Practice in Critical Care.

BACKGROUND: Tradition-based practices lack supporting research evidence and may be harmful or ineffective. Engagement of key stakeholders is a critical step toward facilitating evidence-based practice change. Gemba, derived from Japanese, refers to the real place where work is done. Gemba boards (visual management tools) appear to be an innovative method to engage stakeholders and facilitate evidence-based practice. OBJECTIVES: To explore the use of gemba boards and gemba huddles to facilitate practice change. METHODS: Twenty-two critical care nurses participated in interviews in this qualitative, descriptive study. Thematic analysis was used to code and categorize interview data. Two researchers reached consensus on coding and derived themes. Data were managed with qualitative analysis software. RESULTS: The code gemba occurred most frequently; a secondary analysis was performed to explore its impact on practice change. Four themes were derived from the gemba code: (1) facilitation of staff, leadership, and interdisciplinary communication, (2) transparency of outcome data, (3) solicitation of staff ideas and feedback, and (4) dissemination of practice changes. Gemba boards and gemba huddles became part of the organizational culture for promoting and disseminating evidence-based practices. CONCLUSIONS: Unit-based, publicly located gemba boards and huddles have become key components of evidence-based practice culture. Gemba is both a tool and a process to engage team members and the public to generate clinical questions and to plan, implement, and evaluate practice changes. Future research on the effectiveness of gemba boards to facilitate evidence-based practice is warranted.

De-implementation: A concept analysis.

AIM: The purpose of this concept analysis is to explore the meaning of de-implementation and provide a definition that can be used by researchers and clinicians to facilitate evidence-based practice. BACKGROUND: De-implementation is a relatively unknown process overshadowed by the novelty of introducing new ideas and techniques into practice. Few studies have addressed the challenge of de-implementation and the cognitive processes involved when terminating harmful or unnecessary practices. Also, confusion exists regarding the myriad of terms used to describe de-implementation processes. DESIGN: Walker and Avant's method (2011) for describing concepts was used to clarify de-implementation. DATA SOURCE: A database search limited to academic journals yielded 281 publications representing basic research, study protocols, and editorials/commentaries from implementation science experts. After applying exclusion criterion of English language only and eliminating overlap between databases, 41 articles were selected for review. REVIEW METHODS: Literature review and synthesis provided a concept analysis and a distinct definition of de-implementation. RESULTS: De-implementation was defined as the process of identifying and removing harmful, non-cost-effective, or ineffective practices based on tradition and without adequate scientific support. CONCLUSIONS: The analysis provided further refinement of de-implementation as a significant concept for ongoing theory development in implementation science and clinical practice.

Revising a conceptual model of partnership and sustainability in global health.

OBJECTIVES: Models to guide global health partnerships are rare in the nursing literature. The Conceptual Model for Partnership and Sustainability in Global Health while significant was based on Western perspectives. The purpose of this study was to revise the model to include the voice of nurses from low- and middle-resource countries. DESIGN AND SAMPLE: Grounded theory was used to maintain fidelity with the design in the original model. A purposive sample of 15 participants from a variety of countries in Africa, the Caribbean, and Southeast Asia and having extensive experience in global health partnerships were interviewed. MEASURES: Skype recordings and in-person interviews were audiotaped using the same questions as the original study. Theoretical coding and a comparison of results with the original study was completed independently by the researchers. RESULTS: The process of global health partnerships was expanded from the original model to include engagement processes and processes for ongoing partnership development. New concepts of Transparency, Expanded World View, and Accompaniment were included as well as three broad themes: Geopolitical Influence, Power differential/Inequities, and Collegial Friendships. CONCLUSION: The revised conceptual model embodies a more comprehensive model of global health partnerships with representation of nurses from low- and middle-resource countries.

Promoting synergistic partnerships in low resource countries: a case study exemplar.

OBJECTIVES/AIMS: The purpose of this discussion is to explore the dynamics of partnership and its impact on both nursing faculty at Hue University of Medicine and Pharmacy (HueUMP) and Health Volunteers Overseas (HVO) volunteers. DESIGN: A case study approach was used to promote understanding of partnerships in global health. DISCUSSION: Collaboration between HueUMP's nursing program and HVO is one of the most dynamic HVO nurse educator programs with five volunteer visits to Vietnam within a two-year period. Volunteer efforts include workshops to meet the diverse needs and interests of nursng faculty. We also emphasize the potential for ongoing strategic program planning integrating components from other nursing partnerships in the Southeast Asian region. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: If we are to continue meeting partnership goals, we must recognize that partnerships should evolve according to the goals of HueUMP nursing faculty and the context of nursing in Vietnam.

A Mobile Phone HIV Medication Adherence Intervention: Acceptability and Feasibility Study.

We present the findings of a qualitative pilot study designed to describe the experience of HIV medication adherence using a mobile phone application. Nine semi-structured focus group discussions were conducted over a 3-month period at an AIDS Services Organization in Central Texas. The data were analyzed following the principles of thematic analysis. During analysis, four themes were identified, and relations between these themes were delineated to reflect the experiences of the 23 participants. The mobile phone application, Care4Today™ Mobile Health Manager, was the intervention tool. Collection of focus group discussion outcomes over a 3-month period with baseline versus end-of-study data determined the feasibility and acceptability of this medication adherence intervention. The findings suggest that when individuals are offered the necessary resources, such as a mobile phone medication reminder application, they may have greater success in performing the behavior.

Perspectives of Somali Bantu refugee women living with circumcision in the United States: a focus group approach.

BACKGROUND: The purpose of this study was to explore healthcare perspectives of Somali Bantu refugees in relation to their status as women who have been circumcised and recently resettled in the United States. These women and their families were already uprooted from Somalia to Kenya for over 10 years, increasing their vulnerability and marginal status beyond that of women who have been circumcised. METHODS AND PARTICIPANTS: A purposive, inclusive sample of 23 resettled Somali women in southwestern Pennsylvania of the United States participated in focus group sessions for data collection. A supplemental interview with a physician who provided care to the women was also conducted. Verbatim audio taped transcripts from the focus groups and physician interview were coded into primary and secondary levels. RESULTS: Implications for development of culturally competent healthcare providers include attention to providing explanations for routine clinic procedures and accepting the Somali women regardless of anatomical difference, not focusing on the circumcision. Healthcare providers must also develop their skills in working with interpreters and facilitate trust to minimize suspicion of the health care system. CONCLUSION: Circumcision is considered a normal part of everyday life for the Somali Bantu refugee woman. Communication skills are fundamental to providing culturally competent care for these women. Finally, healthcare providers must take responsibility for acquiring knowledge of the Somali women's challenges as refugees living with circumcision and as immigrants in need of healthcare services.

The journey to the DNP program and beyond: what can we learn from pharmacy?

Advanced practice nursing has been elevated to a new level with the introduction of the DNP (Doctorate of Nursing Practice). One of the justifications for its implementation is the promotion of parity between nurses and other health care providers who require a practice doctorate. Concerns surrounding parity, the ability of DNP-prepared nurses to affect health care outcomes, equitable salary issues, and the DNP program's effect on the academic PhD (Doctorate of Philosophy) program have been expressed. The purpose of this analysis is to explore these issues using pharmacy as an example for implementing a practice doctorate. Similarities and differences between the professions are examined, and lessons that nursing can learn from pharmacy are discussed.