A cognitive task analysis of final year nursing students' situation awareness in simulated deteriorating patient events: A mixed methods study.

AIM: The aim of this study was to: (1) use cognitive task analysis to describe final year nursing students situation awareness in recognising, responding and escalating care of deteriorating patients in ward settings; and (2) make recommendations for training and practice. DESIGN: A mixed methods cognitive task analysis with a convergent triangulation design. METHOD: Data collection involved observations of 33 final year nursing students in simulated deteriorating patient scenarios and retrospective cognitive interviews. A process tracing technique was applied to identify the cues to deterioration participants perceived; how cue perception altered as situational demands increased; the extent that participants made connections between perceived cues and reached a situational understanding; and the factors that influenced and constrained participants situation awareness. Qualitative and quantitative findings are woven together and presented using descriptive statistics, illustrative quotations and timeline extractions. RESULTS: The median cue perception was 65.4% and 57.6% in the medical and surgical scenarios, respectively. Perception was negatively influenced by incomplete vital sign monitoring as situations escalated; limited physical assessments; passive scanning behaviours; poor task automaticity; and excessive cognitive demands. Incomplete perception, poor cue integration and underdeveloped mental models influenced situational understanding. Escalation calls did not always accurately reflect situations and a reporting mindset was evident. Clinical exposure to deteriorating patients was described as variable and opportunistic. REPORTING METHOD: The study is reported in accordance with the Good Reporting of a Mixed Methods Study (GRAMMS) checklist. PATIENT OR PUBLIC CONTRIBUTION: Patients and public were not involved in this research.

Inequality in Health Care and the Experiences of Women From the Irish Traveller Community.

OBJECTIVE: To explore the health care experiences of women from the Irish Traveller community, which is an indigenous ethnic minority group in Ireland and Great Britain. DESIGN: A descriptive qualitative methodology underpinned by naturalistic inquiry was adopted. SETTING: Halting sites where the participating Traveller women permanently reside. PARTICIPANTS: The sample consisted of 24 women from the Traveller community in Ireland. INTERVENTION/MEASUREMENT: Data were collected via two focus group interviews using semi-structured interviews. Inductive content analysis was used to analyze the data. RESULTS: Three overarching themes emerged: Conceptualizing What It Means to Be in Receipt of Health Care; Respecting Ethnic Customs Around Death and Dying; and Strategies for Enhancing Cultural Competence. Women from the Traveller community experienced many challenges when requiring health care services. Some recalled a health care environment that lacked compassion and was discriminatory toward them. A lack of dignity and privacy afforded to women during the "passing" of a loved one was an important finding in this study. CONCLUSION: Strategies to improve Traveller women's access to and engagement with health services are urgently required. These include cultural awareness training for health care providers and visual aids for Travellers accessing health services.

Self-efficacy in the context of nursing education and transition to practice as a registered practitioner: A systematic review.

AIM: The aim of this systematic review is to identify, describe and synthesize evidence from experimental studies conducted to measure and conceptualize self-efficacy within the context of nursing education and the transition of nursing students to practice as a registered practitioners. DESIGN: Systematic review. METHODS: Papers were screened by four independent reviewers, and data were extracted using a standardized data extraction tool. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and checklists were used to guide this review. RESULTS: The review included 47 studies, using a quasi-experimental pre-test-post-test design (n = 39) and randomized control trials (n = 8). Various teaching and learning interventions were used to enhance self-efficacy; however, there is no definitive conclusion to be drawn regarding the most effective educational interventions. Various instruments were used in the studies to measure self-efficacy. 10 of these were related to general self-efficacy, while 37 instruments measured self-efficacy in the context of specific skills.

Virtual Reality Simulation in Nursing and Midwifery Education: A Usability Study.

Virtual reality simulation offers students the opportunity to acquire clinical and psychomotor skills in a safe and interactive environment. This study describes the usability of virtual reality simulation among undergraduate nursing and midwifery students. Participants were recruited using convenience and snowball sampling and engaged in a 20-minute virtual reality simulation scenario of their choice. They then completed a 21-item survey comprising a sociodemographic questionnaire, the System Usability Scale, a satisfaction questionnaire, and open-ended questions. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using deductive content analysis. Forty-three students participated in this study. The mean (SD) System Usability Scale score was 75.87 (13.7), indicating that virtual reality simulation was acceptable. Almost all participants were either "extremely satisfied" or "somewhat satisfied" with virtual reality simulation, which was perceived as informative and enjoyable, fostering safe and self-directed learning without causing patient harm. Participants recommended using virtual reality simulation to practice clinical skills, prepare for clinical placements, and learn about rare clinical situations. Virtual reality simulation needs to be underpinned by a strong pedagogy and aligned with learning outcomes. Educators and students should be trained in virtual reality simulation prior to its integration into the curriculum.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice.

BACKGROUND: Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments. AIM: Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts. METHODS: We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented. RESULTS: A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives. CONCLUSIONS: Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review.

OBJECTIVES: Patients are unintentionally, yet frequently, harmed in situations that are deemed preventable. Incident reporting systems help prevent harm, yet there is considerable variability in how patient safety incidents are reported. This may lead to inconsistent or unnecessary patterns of incident reporting and failures to identify serious patient safety incidents. This systematic review aims to describe international approaches in relation to defining serious reportable patient safety incidents. METHODS: Multiple electronic and gray literature databases were searched for articles published between 2009 and 2019. Empirical studies, reviews, national reports, and policies were included. A narrative synthesis was conducted because of study heterogeneity. RESULTS: A total of 50 articles were included. There was wide variation in the terminology used to represent serious reportable patient safety incidents. Several countries defined a specific subset of incidents, which are considered sufficiently serious, yet preventable if appropriate safety measures are taken. Terms such as "never events," "serious reportable events," or "always review and report" were used. The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for significant learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for inclusion in an incident reporting system; and (5) running the risk of recurrence. CONCLUSIONS: Variations in terminology and reporting systems between countries might contribute to missed opportunities for learning. International standardized definitions and blame-free reporting systems would enable comparison and international learning to enhance patient safety.

Ethical frameworks for quality improvement activities: an analysis of international practice.

PURPOSE: To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems. DATA SOURCES: We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries. STUDY SELECTION: National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada. DATA EXTRACTION: Data were extracted from 19 documents using an a priori framework developed from the published literature. RESULTS: We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement. CONCLUSION: Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics.

Effect of a proficiency-based progression simulation programme on clinical communication for the deteriorating patient: a randomised controlled trial.

OBJECTIVE: This study aimed to determine the effectiveness of a proficiency-based progression (PBP) training approach to clinical communication in the context of a clinically deteriorating patient. DESIGN: This is a randomised controlled trial with three parallel arms. SETTING: This study was conducted in a university in Ireland. PARTICIPANTS: This study included 45 third year nursing and 45 final year medical undergraduates scheduled to undertake interdisciplinary National Early Warning Score (NEWS) training over a 3-day period in September 2016. INTERVENTIONS: Participants were prospectively randomised to one of three groups before undertaking a performance assessment of the ISBAR (Identification, Situation, Background, Assessment, Recommendation) communication tool relevant to a deteriorating patient in a high-fidelity simulation facility. The groups were as follows: (i) E, the Irish Health Service national NEWS e-learning programme only; (ii) E+S, the national e-learning programme plus standard simulation; and (iii) E+PBP, the national e-learning programme plus PBP simulation. MAIN OUTCOME MEASURES: The primary outcome was the proportion in each group reaching a predefined proficiency benchmark comprising a series of predefined steps, errors and critical errors during the performance of a standardised, high-fidelity simulation assessment case which was recorded and scored by two independent blinded assessors. RESULTS: 6.9% (2/29) of the E group and 13% (3/23) of the E+S group demonstrated proficiency in comparison to 60% (15/25) of the E+PBP group. The difference between the E and the E+S groups was not statistically significant (χ2=0.55, 99% CI 0.63 to 0.66, p=0.63) but was significant for the difference between the E and the E+PBP groups (χ2=22.25, CI 0.00 to 0.00, p<0.000) and between the E+S and the E+PBP groups (χ2=11.04, CI 0.00 to 0.00, p=0.001). CONCLUSIONS: PBP is a more effective way to teach clinical communication in the context of the deteriorating patient than e-learning either alone or in combination with standard simulation. TRIAL REGISTRATION NUMBER: NCT02886754; Results.

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-Analysis.

STATEMENT: We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.

Acute surgical wound-dressing procedure: Description of the steps involved in the development and validation of an observational metric.

The aim of this study was to develop an observational metric that could be used to assess the performance of a practitioner in completing an acute surgical wound-dressing procedure using aseptic non-touch technique (ANTT). A team of clinicians, academics, and researchers came together to develop an observational metric using an iterative six-stage process, culminating in a Delphi panel meeting. A scoping review of the literature provided a background empirical perspective relating to wound-dressing procedure performance. Video recordings of acute surgical wound-dressing procedures performed by nurses in clinical (n = 11) and simulated (n = 3) settings were viewed repeatedly and were iteratively deconstructed by the metric development group. This facilitated the identification of the discrete component steps, potential errors, and sentinel (serious) errors, which characterise a wound dressing procedure and formed part of the observational metric. The ANTT wound-dressing observational metric was stress tested for clarity, the ability to be scored, and interrater reliability, calculated during a further phase of video analysis. The metric was then subjected to a process of cyclical evaluation by a Delphi panel (n = 21) to obtain face and content validity of the metric. The Delphi panel deliberation verified the face and content validity of the metric. The final metric has three phases, 31 individual steps, 18 errors, and 27 sentinel errors. The metric is a tool that identifies the standard to be attained in the performance of acute surgical wound dressings. It can be used as both an adjunct to an educational programme and as a tool to assess a practitioner's performance of a wound-dressing procedure in both simulated and clinical practice contexts.

The effect of adult Early Warning Systems education on nurses' knowledge, confidence and clinical performance: A systematic review.

AIMS: This review aims to determine the effect of adult Early Warning Systems education on nurses' knowledge, confidence and clinical performance. BACKGROUND: Early Warning Systems support timely identification of clinical deterioration and prevention of avoidable deaths. Several educational programmes have been designed to help nurses recognize and manage deteriorating patients. Little is known as to the effectiveness of these programmes. DESIGN: Systematic review. DATA SOURCES: Academic Search Complete, CINAHL, MEDLINE, PsycINFO, PsycARTICLES, Psychology and Behavioral Science Collection, SocINDEX and the UK & Ireland Reference Centre, EMBASE, the Turning Research Into Practice database, the Cochrane Central Register of Controlled Trials (CENTRAL) and Grey Literature sources were searched between October and November 2015. REVIEW METHODS: This is a quantitative systematic review using Cochrane methods. Studies published between January 2011 - November 2015 in English were sought. The risk of bias, level of evidence and the quality of evidence per outcome were assessed. RESULTS: Eleven articles with 10 studies were included. Nine studies addressed clinical performance, four addressed knowledge and two addressed confidence. Knowledge, vital signs recording and Early Warning Score calculation were improved in the short term. Two interventions had no effect on nurses' response to clinical deterioration and use of communication tools. CONCLUSION: This review highlights the importance of measuring outcomes using standardized tools and valid and reliable instruments. Using longitudinal designs, researchers are encouraged to investigate the effect of Early Warning Systems educational programmes. These can include interactive e-learning, on-site interdisciplinary Early Warning Scoring systems training sessions and simulated scenarios.

Using standardized patients to assess communication skills in medical and nursing students.

BACKGROUND: A number of recent developments in medical and nursing education have highlighted the importance of communication and consultation skills (CCS). Although such skills are taught in all medical and nursing undergraduate curriculums, there is no comprehensive screening or assessment programme of CCS using professionally trained Standardized Patients Educators (SPE's) in Ireland. This study was designed to test the content, process and acceptability of a screening programme in CCS with Irish medical and nursing students using trained SPE's and a previously validated global rating scale for CCS. METHODS: Eight tutors from the Schools of Nursing and Medicine at University College Cork were trained in the use of a validated communication skills and attitudes holistic assessment tool. A total of forty six medical students (Year 2 of 5) and sixty four nursing students (Year 2/3 of 4) were selected to under go individual CCS assessment by the tutors via an SPE led scenario. Immediate formative feedback was provided by the SPE's for the students. Students who did not pass the assessment were referred for remediation CCS learning. RESULTS: Almost three quarters of medical students (33/46; 72%) and 81% of nursing students (56/64) passed the CCS assessment in both communication and attitudes categories. All nursing students had English as their first language. Nine of thirteen medical students referred for enhanced learning in CCS did not have English as their first language. CONCLUSIONS: A significant proportion of both medical and nursing students required referral for enhanced training in CCS. Medical students requiring enhanced training were more likely not to have English as a first language.

Acute nursing episodes which challenge graduate's competence: perceptions of registered nurses.

On successful completion of nurse education programmes new graduate nurses are expected to meet the requirements for registration as a professional practitioner. Nurse educators need to collaborate with clinical colleagues to be responsive to changes in health care. Identifying challenging acute nursing episodes (CANE) that nurses' encounter in clinical practice and the aspect of competence that new graduate nurses require to manage these episodes effectively can inform undergraduate nursing curricula. Thus a qualitative, descriptive design was employed when undertaking a study to identify challenging acute nursing episodes which new graduates will encounter in clinical practice. Six focus groups were conducted in three university teaching hospitals in Ireland where a total of 28 registered nurses were recruited. Thematic analysis was used to extract themes from the focus group data. The results of this study identified 41 challenging acute nursing episodes and 4 key aspects of competence namely; patient assessment, technical/clinical skills; interactions and communications and clinical decision making. Findings of this study identify both the episodes which challenge new graduates and aspects of competence required by new graduates. These findings provide evidence for nurse educators to develop and deliver curricular content which is congruent with the realities of current day nursing practice.