From educator to facilitator: Healthcare professionals' experiences of, and views about, delivering a type 1 diabetes structured education programme (DAFNEplus ) informed by behavioural science.

AIMS: The DAFNEplus programme incorporates behaviour change techniques into a modified educational intervention and was developed to help address the glycaemic drift observed amongst graduates of standard DAFNE programmes. As the programme's success will be contingent on staff buy-in, we explored healthcare professionals' experiences of, and views about, delivering DAFNEplus during a clinical trial to help inform decision making about rollout post-trial. METHODS: We interviewed n = 18 nurses and dieticians who delivered DAFNEplus during the trial. Data were analysed thematically. RESULTS: While many shared initial reservations, all described how their experiences of DAFNEplus programme delivery had had a positive, transformative impact upon their perceptions and working practices. This transformation was enabled by initial training and supervision sessions, the confidence gained from using scripts to support novel programme content delivery, and experiences of delivering the programme and observing DAFNEplus principles being well received by, and having a positive impact on, attendees. Due to these positive experiences, interviewees described a strongly felt ethical mandate to use some DAFNEplus techniques and curriculum content in routine clinical care. While being supportive of a national rollout, they anticipated a variety of attitudinal and logistical (e.g. workload) challenges. CONCLUSIONS: This study provides a vital dimension to the evaluation of the DAFNEplus programme. Interviewees found the intervention to be acceptable and expressed high levels of buy-in. As well as offering potential endorsement for a national rollout, our findings offer insights which could help inform development and rollout of future behaviour change interventions to support diabetes self-management.

Barriers and facilitators to nurse practitioner buprenorphine prescribing for opioid use disorder in primary care settings.

BACKGROUND: Increasing access to opioid use disorder (OUD) treatment is critical to curbing the opioid epidemic, particularly for rural residents who experience numerous health and health care disparities, including higher overdose death rates and limited OUD treatment access compared with urban dwellers. Buprenorphine-naloxone is an evidence-based treatment for OUD that is well suited for rural areas. However, providers must have a specialized federal waiver to prescribe the medication. Despite the acceleration of the opioid epidemic in rural areas and the recent liberalization of federal buprenorphine-naloxone prescribing laws, few providers hold buprenorphine-naloxone prescribing waivers and even fewer prescribe the medication. PURPOSE: This study explores barriers and facilitators to buprenorphine-naloxone prescribing among nurse practitioners (NPs) working in primary care settings in eastern North Carolina. METHODOLOGY: Individual interviews were conducted with 13 NPs working in primary care settings in eastern North Carolina. Qualitative thematic analysis was used to identify perceived barriers and facilitators to buprenorphine-naloxone prescribing. RESULTS: Analysis found prescribing barriers related to OUD stigma, perceived knowledge, federal and state regulation, and prescribing resources and found facilitators related to adopting a person-centered approach, developing prescriber skills, and access to prescribing resources. CONCLUSIONS: The barriers and facilitators that NPs experience related to buprenorphine prescribing for OUD are similar to those faced by physicians, although the barriers arguably more profound. Future research should consider how to mitigate these prescribing barriers to facilitate NP buprenorphine prescribing for OUD. IMPLICATIONS: To our knowledge, this is the first qualitative study of NP buprenorphine-naloxone prescribing in rural areas. Given the prominence of OUD in rural regions and the key role NPs play in primary care provision, this study lays import groundwork for developing interventions to support buprenorphine-naloxone prescribing by NPs practicing in rural regions.

Career Adaptability: An Innovative Measurement to Aid Professional Development of New Graduate Nurses.

This cross-sectional quantitative study explored career adaptability and career intentions in newly licensed nurses working in acute care hospitals throughout North Carolina. Data were analyzed from 277 registered nurses completing an online study instrument. Findings demonstrate a relationship between levels of career adaptability and career intentions, offering career adaptability as a new measurement to explore newly licensed nurses' desire to pursue career and educational change and expand transition programs to include developing career trajectories within organizations.

Relational Quality Between the RN and Nursing Assistant: Essential for Teamwork and Communication.

OBJECTIVE: Nurse (RN) and nursing assistant (NA) relational quality was examined along with associations between relational quality and evaluations of teamwork and communication. BACKGROUND: RN and NA teams constitute the primary nursing care delivery method, and the quality of their relationship affects system capacity for improving patient outcomes; adverse events are linked to communication and teamwork breakdowns. METHODS: RN (N = 889) and NA (263) relational quality was examined using a cross-sectional secondary analysis from system assessment with the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. RESULTS: RN and NA perceived relational quality indicated significant differences in teamwork and safety grade ratings, with both groups reporting perceived teamwork as high when patient safety grade was low. CONCLUSIONS: This study supports the benefits of improving the RN-NA teamwork-communication relationship. An enhanced RN-NA relational quality can be used by nurse leaders to optimize patient care delivery outcomes.

Manager's influence on the registered nurse and nursing assistant relational quality and patient safety culture.

AIMS: The purpose of this study is to describe the perceptions of relational quality of the registered nurse and nursing assistant and examine how their view of the manager's influence impacts overall patient safety culture of a unit. BACKGROUND: The primary delivery of nursing care within acute care systems uses teams of registered nurses and nursing assistants. METHODS: A cross-sectional secondary analysis of data collected in the spring of 2018 using the Agency for Healthcare and Quality Hospital Survey of Patient Safety Culture and a seven-item questionnaire measuring relational quality was conducted. The sample included 1,152 responses. RESULTS: The manager influenced overall perceptions of safety regardless of the relational quality between the registered nurse and nursing assistant. CONCLUSIONS: This study found manager behaviours that promote patient safety and also influence overall perceptions of patient safety culture regardless of the relational quality between the registered nurse and nursing assistant. IMPLICATIONS FOR NURSING MANAGEMENT: Positive registered nurse and nursing assistant relational quality amplifies perceptions of patient safety culture, yet it is the manager's behaviours regarding safety that make the stronger contribution in building a culture of safety.

Troublesome knowledge for entry-level PhD nursing students: Threshold concepts essential for the research-focused doctorate.

BACKGROUND: Evidence supports that PhD doctoral students experience conceptually difficult knowledge, or troublesome knowledge, during their studies. These areas of troublesome knowledge are often associated with threshold concepts, those ideas specific to a discipline that must be understood to advance ways of thinking and making knowledge in the discipline. PURPOSE: To examine troublesome knowledge identified by a group of PhD nursing students during an introductory course and to consider threshold concepts related to that knowledge. METHOD: Design: Case study research methodology. SAMPLE: 18 entry-level PhD nursing students recruited with convenience sampling. DATA COLLECTION: Content analysis was used to analyze data collected from student reflective learning journals. Journal data was triangulated with formative and summative faculty assessments of student learning. RESULTS: Three essential threshold concepts for entry-level PhD nursing students were identified: developing new ways of knowing, constructing researcher and writer identity, and positioning within the nursing research community. Analysis indicates that entry-level students found the threshold concept of constructing researcher and writer identity most troublesome. CONCLUSION: A PhD introductory nursing course which includes metacognitive activities, scaffolding of assignments, and early positioning within the research community can assist students with mastery of threshold concepts for the research-focused doctorate.

Relational Quality of Registered Nurses and Nursing Assistants: Influence on Patient Safety Culture.

Registered nurses (RNs) working within acute care hospitals have an incredible responsibility to provide safe care in a complex environment which requires trust, teamwork, and communication. Nursing assistants (NAs) play a critical role in working with RNs to meet these growing demands of inpatient care. Minimal evidence exists exploring the relational quality between RNs and NAs within hospitals. The aim of this study is to explore RN and NA behaviors and experiences that promote patient safety and teamwork and enhance communication between RNs and NAs within the hospital environment. Qualitative analysis was used, with two focus groups which included six participants within each group (three RNs and three NAs) from two separate inpatient units. Transcripts were reviewed and coded for themes. Collaborative teamwork and two-way communication were commonly reported as behaviors that promote patient safety. Trust between RNs and NAs was identified as a key component of positive relationships between RNs and NAs. Participants identified four common behaviors that build trust, which were accountability, effective conflict resolution, collaborative teamwork, and prioritizing patient needs. Finally, teamwork was identified as a common strategy to increase communication effectiveness between RNs and NAs. High relational quality (RQ) between the RN and NA is an important component of teamwork and patient safety culture.

Protocol for a cluster randomised controlled trial of the DAFNEplus (Dose Adjustment For Normal Eating) intervention compared with 5x1 DAFNE: a lifelong approach to promote effective self-management in adults with type 1 diabetes.

INTRODUCTION: The successful treatment of type 1 diabetes (T1D) requires those affected to employ insulin therapy to maintain their blood glucose levels as close to normal to avoid complications in the long-term. The Dose Adjustment For Normal Eating (DAFNE) intervention is a group education course designed to help adults with T1D develop and sustain the complex self-management skills needed to adjust insulin in everyday life. It leads to improved glucose levels in the short term (manifest by falls in glycated haemoglobin, HbA1c), reduced rates of hypoglycaemia and sustained improvements in quality of life but overall glucose levels remain well above national targets. The DAFNEplus intervention is a development of DAFNE designed to incorporate behavioural change techniques, technology and longer-term structured support from healthcare professionals (HCPs). METHODS AND ANALYSIS: A pragmatic cluster randomised controlled trial in adults with T1D, delivered in diabetes centres in National Health Service secondary care hospitals in the UK. Centres will be randomised on a 1:1 basis to standard DAFNE or DAFNEplus. Primary clinical outcome is the change in HbA1c and the primary endpoint is HbA1c at 12 months, in those entering the trial with HbA1c >7.5% (58 mmol/mol), and HbA1c at 6 months is the secondary endpoint. Sample size is 662 participants (approximately 47 per centre); 92% power to detect a 0.5% difference in the primary outcome of HbA1c between treatment groups. The trial also measures rates of hypoglycaemia, psychological outcomes, an economic evaluation and process evaluation. ETHICS AND DISSEMINATION: Ethics approval was granted by South West-Exeter Research Ethics Committee (REC ref: 18/SW/0100) on 14 May 2018. The results of the trial will be published in a National Institute for Health Research monograph and relevant high-impact journals. TRIAL REGISTRATION NUMBER: ISRCTN42908016.

Interventions to promote teamwork, delegation and communication among registered nurses and nursing assistants: An integrative review.

AIMS: To understand the strategies to influence patient outcomes by synthesizing existing evidence on effective interventions for teamwork, delegation and communication between registered nurses and nursing assistants. BACKGROUND: Three-quarters of deaths in hospitals are related to breakdowns in teamwork and communication. Acute care systems utilize teams of registered nurses and nursing assistants for primary delivery of nursing care. Research has been conducted to improve the partnership between the dyad. Literature reviews are needed to synthesize the effectiveness of delegation and communication interventions between registered nurses and nursing assistants on patient outcomes. METHODS: The authors applied Whittemore and Knafl's integrative review methodology to conduct an integrative review of the literature. Databases searched included Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed along with reference searches. Included articles were intervention studies related to teamwork, delegation or communication between registered nurses and nursing assistants, and published from 2000 to 2019. Methodological quality was assessed utilizing the Mixed Methods Appraisal Tool. The Systems Engineering Initiative for Patient Safety model 2.0 was applied as a guiding framework to analyse the findings. RESULTS: Seven articles met the inclusion criteria. The interventions in these articles focused on building a foundation of trust and respect through simulation, education and mindful communication. Four of the seven articles measured patient outcomes including patient falls, hospital-acquired pressure injuries and patient satisfaction. Three articles reported decreased patient falls, two articles reported increased patient satisfaction, while one article reported a reduction in pressure injury. Five of the studies reported improved teamwork and/or communication, and two studies reported improved job satisfaction. CONCLUSIONS: There has been limited research on the impact of the registered nurse-nursing assistant relationship on patient safety and care outcomes. The existing research demonstrates a need for interventions to foster a dynamic and effective relationship between registered nurses and nursing assistants. There is a need for more interventional studies linking improved teamwork, delegation and communication between the registered nurse and nursing assistant to patient outcomes such as falls and hospital-acquired pressure injury. IMPLICATIONS FOR NURSING MANAGEMENT: Several interventions exist to improve teamwork and communication between the registered nurse-nursing assistant dyad. Leaders need to assess their own culture and develop interventions to build and maintain high-functioning teams. Future research is necessary to develop interventions aimed at improving delegation from registered nurses to nursing assistants for applicable activities.

New Graduate Nurses' Perceptions of Patient Safety: Describing and Comparing Responses With Experienced Nurses.

BACKGROUND: A significant proportion of the acute health system workforce is composed of new graduate nurses, yet there is a limited understanding of patient safety perceptions among new graduate nurses and how they compare with nurses who have more experience. METHOD: This study used a descriptive approach to complete secondary analysis on two sources of data containing new graduate nurses' (n = 1,613) and experienced nurses' (n = 64,906) responses to the Hospital Survey on Patient Safety Culture. RESULTS: New graduate nurses had a more positive perception of safety culture than more experienced nurses. The greatest differences were observed in perceptions of how nurse managers respond to mistakes. Similarities in perceptions were observed on items associated with communication. CONCLUSION: Educational systems and transitional programs must prepare new graduate nurses for patient care. There is an opportunity for academic and practice partners to collaborate on programs that facilitate the transition of new graduate nurses to the workforce. [J Contin Educ Nurs. 2020;51(7):309-315.].

Strategies for progression in a PhD nursing program within a transition model.

BACKGROUND: There is a need for interventions to improve the PhD pipeline for nursing program enrollment. PhD nursing students who have navigated the program successfully are in a strategic position to help by sharing their stories. Several strategies for successful completion of a PhD program and some common expected barriers have been documented in the literature. METHOD: The authors used personal reflections from their first and second years of study in a PhD nursing program to identify strategies to progress through a program. The personal reflections were analyzed by their student cohort and a faculty advisor using the Bridges' Transition Model as a theoretical framework. The cohort members included five females and one male, ages 29-48, attending a PhD nursing program in the Southeastern, US. RESULTS: The following strategies were identified from the personal reflections: seeking and offering support within your cohort; establishing a relationship with mentors; identifying and using a reference manager; mastering time management; soaking up statistics; and focusing on your focus. The strategies listed above occurred within the ending and/or neutral zone phases of the Bridges' Transition Model. CONCLUSION: It is important to note the early phases of transition and need for success strategies in these specific phases of transition. PhD nursing students are in a strategic position to positively influence the PhD pipeline by providing personal reflections that inform future PhD nursing students as well as PhD nursing programs.

Help or hindrance: Exploring nurse practitioners' perceptions of transition to practice legislation.

BACKGROUND: Fourteen states have adopted transition to practice (TP) legislation, which requires newly certified nurse practitioners (NPs) to practice under a senior clinician. States have adopted such legislation despite vast evidence indicating NPs provide safe care. PURPOSE: The purpose of this study is to explore NPs' perceptions of the effects of this legislation and to describe communication between NPs and senior clinicians working in TP states. METHODS: Using a cross-sectional, descriptive design, we surveyed a convenience sample of NPs working in TP states. Descriptive statistical analysis and qualitative content analysis were conducted. RESULTS: Most respondents believed TP legislation posed unnecessary regulatory barriers but also believed it promoted professional development. No statistically significant relationships between professional characteristics, regulatory variations, and these perceptions were identified. IMPLICATIONS FOR PRACTICE: Given the increasing number of states considering TP legislation, and the vast variability in TP models, additional research into the effects of this regulation is needed.

Getting work done: a grounded theory study of resident physician value of nursing communication.

Poor communication between nurses and physicians results in patient injury and increased healthcare costs. While multiple attempts have been made to improve communication between the two professions, evidence confirms little progress has been made. Previous research focused on standardizing communication processes and protocols between nurses and physicians rather than examining the relational component of these human interactions. The purpose of this study was to explore physician valuing of nursing communication in the context of patient care. Interviews were conducted with 15 internal medicine resident physicians. A constructivist grounded theory approach was used to develop the substantive theory of Getting Work Done. Getting Work Done incorporated three major categories: discerning the team, shifting communication, and accessing nurse knowledge and abilities. Hierarchical behaviors and language, and nurse collusion in both, characterized nurse-physician communication and situated the nurse outside the decision-making team. Complex work environments further devalued nurse-physician communication. Interprofessional education and practice must advance the unique and essential role of all health care professionals such that mutual valuing replaces hierarchical actions with collaborative systems for determining the most effective approaches to patient care.

Leveraging the Power of Board Leadership in Professional Nursing Organizations.

Nurses who aspire to lead a professional nursing organization can significantly influence the future of the nursing profession. This article describes 4 essential responsibilities required in a board leadership position as identified by a group of nurse leaders who have each served as the board president of a national or international professional nursing organization.

Strategies to promote the professional transition of new graduate nurse practitioners: A systematic review.

New graduate nurse practitioner (NP) postgraduate support programs and interventions have proliferated, sparking controversy. The Institute of Medicine/National Academy of Medicine recommends residency programs for new graduate NPs; however, the NP community debates whether new graduate NPs need additional training and whether such training compromises patient access to care. This systematic review aimed to synthesize evidence regarding the effectiveness of interventions and strategies to promote the professional transition of new graduate NPs. Interventions identified in the current literature included fellowship programs and a webinar. Strategies included mentorship, experiential learning, interprofessional training, and professional socialization. The studies reviewed primarily evaluated NPs' perceptions of the interventions' effects on their professional transitions. The findings from this systematic review highlight challenges in evidencing postgraduate support programs. The small number of available studies underscores a critical problem for the NP community: additional evidence is needed to inform whether and how to support new graduate NPs as they transition to practice.

A New Leadership Development Model for Nursing Education.

BACKGROUND: Leadership competency is required throughout nursing. Students have difficulty understanding leadership as integral to education and practice. A consistent framework for nursing leadership education, strong scholarship and an evidence base are limited. PURPOSE: To establish an integrated leadership development model for prelicensure nursing students that recognizes leadership as a fundamental skill for nursing practice and promotes development of nursing leadership education scholarship. METHOD: Summarizing definitions of nursing leadership, conceptualizing leadership development capacity through reviewing trends, and synthesizing existing leadership theories through directed content analysis. DISCUSSION: Nine leadership skills form the organizing structure for the Nursing Leadership Development Model. Leadership identity development is supported via dimensions of knowing, doing, being and context. CONCLUSION: The Nursing Leadership Development Model is a conceptual map offering a structure to facilitate leadership development within prelicensure nursing students, promoting student ability to internalize leadership capacity and apply leadership skills upon entry to practice.

Changing New Graduate Nurse Profiles and Retention Recommendations for Nurse Leaders.

OBJECTIVE: This study compares and contrasts new graduate nurse attributes and perceptions using findings from a 2010 study and a recent analysis of new graduate nurses participating in the same residency program. BACKGROUND: As millennials saturate the healthcare work environment, their unique views and needs will influence the evolution of new graduate nurse residencies. METHODS: This study used previously reported data on new graduate nurses between 1999 and 2009 and compared it with a secondary analysis of data collected on new graduate nurses between 2011 and 2016. RESULTS: This study provides evidence that millennial new graduate nurses' levels of commitment and satisfaction do not moderate turnover intentions in the 1st 2 years of practice as they did in the previous group of new graduate nurses. CONCLUSIONS: Job embeddedness, a construct that measures the likelihood of whether a person is going to stay, may be a better measurement among new graduate nurses than commitment or satisfaction because millennials, a generation that is predominant in current new graduate nurses, are more engaged than loyal.

Threshold Concepts in Doctoral Education: A Framework for Writing Development in Novice Nurse Scientists.

Pedagogical practices for writing development in doctoral programs are often the by-product of completing dissertation research and may lack deliberate strategies to assist students with complex genres of writing. This article proposes a framework for doctoral education to assist students with mastery of threshold concepts in writing. Threshold concepts in writing are examined for their applicability to the evolution of writing in PhD nursing students as they begin to think and write like nurse scientists.

The Impact of New Graduate Nurse Transition Programs on Competency Development and Patient Safety: An Integrative Review.

Stronger evidence on the value of new graduate nurse transition programs is needed to justify the cost and warrant expansion of these programs to more health systems. The aim of this integrative review was to critically analyze published research on the relationship between new graduate nurse transition programs and patient safety outcomes. Limited evidence was found on actual safety improvement; rather, transition programs have predominately measured the development of competency as a process outcome variable for improving patient safety. A systems model is proposed to guide future research examining structure, process, and outcome variables, linking transition programs with patient outcomes.

Valuing breastfeeding: a qualitative study of women's experiences of a financial incentive scheme for breastfeeding.

BACKGROUND: A cluster randomised controlled trial of a financial incentive for breastfeeding conducted in areas with low breastfeeding rates in the UK reported a statistically significant increase in breastfeeding at 6-8 weeks. In this paper we report an analysis of interviews with women eligible for the scheme, exploring their experiences and perceptions of the scheme and its impact on breastfeeding to support the interpretation of the results of the trial. METHODS: Semi-structured interviews were carried out with 35 women eligible for the scheme during the feasibility and trial stages. All interviews were recorded and verbatim transcripts analysed using a Framework Analysis approach. RESULTS: Women reported that their decisions about infant feeding were influenced by the behaviours and beliefs of their family and friends, socio-cultural norms and by health and practical considerations. They were generally positive about the scheme, and felt valued for the effort involved in breastfeeding. The vouchers were frequently described as a reward, a bonus and something to look forward to, and helping women keep going with their breastfeeding. They were often perceived as compensation for the difficulties women encountered during breastfeeding. The scheme was not thought to make a difference to mothers who were strongly against breastfeeding. However, women did believe the scheme would help normalise breastfeeding, influence those who were undecided and help women to keep going with breastfeeding and reach key milestones e.g. 6 weeks or 3 months. CONCLUSIONS: The scheme was acceptable to women, who perceived it as rewarding and valuing them for breastfeeding. Women reported that the scheme could raise awareness of breastfeeding and encourage its normalisation. This provides a possible mechanism of action to explain the results of the trial. TRIAL REGISTRATION: The trial is registered with the ISRCTN registry, number 44898617 , https://www.isrctn.com.