Clinical decision-making processes among graduate nurses, specialist nurses and nurse practitioners A collaborative international study.

AIM: To explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. BACKGROUND: Clinical decision-making in an emergency department environment is a complex process often occurring in times of crisis. It is an important aspect contributing to the quality of care. However, empirical research is limited regarding the decision-making process in different nursing roles. METHODS: In accordance with the consolidated criteria for reporting qualitative research, a qualitative and observational study was conducted to explore clinical decision-making by comparing the processes used by three groups of nurses in the emergency departments of three hospitals: in Norway, Finland and Ireland. Six Registered Nurses, six Nurse Specialists and six Nurse Practitioners were observed. A total of 40 hours of observation was made at each setting according to a structured observation guideline, followed by clarifying questions. The data material was analysed by means of a qualitative manifest and latent content analysis. RESULTS: Three themes arose: acting in accordance with routines, previous experience and intuition; considering patient experience; and facilitating new alternatives based on critical thinking. The Registered Nurses mainly used the first approach, the Nurse Specialists used the first and the second approaches, and the Nurse Practitioners used all three approaches. CONCLUSIONS: The results highlight the differences in decision-making processes between these groups. Nurse Practitioners were the only group that facilitated and evaluated new alternatives using their clinical autonomy, such as stepping up and making independent and collaborative decision-making. IMPLICATION: The results can be used in countries developing advanced practice nursing education and defining their scope of practice to inform stakeholders.

Meeting the Needs of Older Adults with Mental Ill-Health in Non-Psychiatric Care Settings: Self-Rated Confidence in Helping and its Co-Variates within a Multiprofessional Study Sample.

In this paper we sought to explore health and social care professionals' self-rated confidence in helping older adults with mental ill-health in non-psychiatric care settings. A cross-sectional survey study was performed exploring the participants' (n = 480) confidence in helping. Confidence in helping was analyzed together with background characteristics and selected explanatory variables, such as the workplace and work experience of the participants, their personal experiences of and attitudes to mental ill-health, as well as their knowledge in mental ill-health among older adults, by means of descriptive statistics and logistic regression analysis. We found that approximately half (55%) of the participants were confident in helping older adults with mental ill-health. The odds ratios for being confident in helping were significantly associated to the workplace of the professionals, professionals' attitude to and experience of mental ill-health, and knowledge of mental health among older adults. To increase confidence in helping older adults with mental ill-health, we recommend confidence-building interventions, for example, educational programs, through which knowledge of mental health among older adults is increased and negative attitudes are challenged, especially within the context of specialist somatic healthcare.

Standing alone on the frontline. The meaning of being a nurse in the archipelago-A phenomenological hermeneutical study.

AIM: The aim of this study was to illuminate the meaning of being a nurse in the archipelago. METHODOLOGICAL DESIGN AND JUSTIFICATION: A phenomenological hermeneutical design was applied, as there is a need to understand the lifeworld and the meaning of being a nurse in the archipelago. ETHICAL ISSUES AND APPROVAL: Approval was granted by the Regional Ethical Committee and local management team. All participants provided consent to participate. RESEARCH METHOD: Individual interviews were conducted with 11 nurses (Registered Nurses or primary health nurses). The interviews were transcribed, and the text was analysed by means of phenomenological hermeneutical method. RESULTS: The analyses ended in one main theme: Standing alone on the frontline, and three themes: 1. Combating sea, weather and the clock with the sub-themes: Fighting to give care to patients despite harsh conditions and Fighting against time; 2. Standing firm but wavering with the sub-themes: Embracing the unexpected and Calling out for support; and 3. Being a lifeline throughout the entire lifespan with the sub-themes: Having responsibility for the islanders and Having an intertwined private and work life. STUDY LIMITATIONS: The interviews may be considered few, but the textual data were rich and assessed suitable for the analysis. The text may be interpreted differently, but we deemed our interpretation as more probable than others. CONCLUSION: Being a nurse in the archipelago means standing alone on the frontline. Nurses, other health professionals and managers need knowledge and insight about working alone and the moral responsibilities thereof. There is a need to support the nurses in their lonely work. Traditional means of consultations and support could preferably be supplemented by modern digital technology.

Transanal Irrigation for People With Neurogenic Bowel Dysfunction: An Integrative Literature Review.

Transanal irrigation has been introduced as a complement to standard bowel care for people with neurogenic bowel dysfunction. There is no contemporary integrative review of the effectiveness and feasibility of transanal irrigation from a holistic nursing perspective, only fragments of evidence to date. The aim was to investigate the effectiveness and feasibility of transanal irrigation for people with neurogenic bowel dysfunction. An integrative literature review was conducted. Nineteen studies were included. According to the results, transanal irrigation can reduce difficulties associated with defecation, episodes of incontinence, and the time needed for evacuation and bowel care. Transanal irrigation can increase general satisfaction with bowel habits and quality of life and decrease level of dependency. However, there are practical problems to overcome and adverse effects to manage. Discontinuation is relatively common. The results support the effectiveness of transanal irrigation, but feasibility is inconclusive. Users, including caregivers, report practical problems, and compliance was not always easy to achieve. It is important that users, including caregivers, are well informed and supported during transanal irrigation treatment, especially during introduction. The quality of the studies found was generally weak; therefore, high-quality quantitative and qualitative studies are needed on the topic.

The Ms. Olsen test: Measurement properties of a short test of nursing staffs' competence in clinical decision-making.

AIMS: To assess the measurement properties of the Ms. Olsen test for registered nurses and assistant nurses, respectively, and suggest cut-off points between competence levels. DESIGN: Cross-sectional study. The results were analysed by implementing the Rasch Measurement Theory. METHODS: Nursing staff working in various health care settings participated (n = 757). To measure the competence of nursing staff in clinical decision-making, a 19-item scale from the Nursing Older People-Competence Evaluation Tool-the 'Ms. Olsen test'-was used. Data were collected in October 2017, 2018 and 2019. RESULTS: The Ms. Olsen test showed reasonably good measurement properties for registered nurses and assistant nurses respectively. Results show slightly better measurement properties for registered nurses than for assistant nurses. The cut-off for registered nurses, 0.62, corresponds to managing approximately two-thirds of the items while, for assistant nurses, the cut-off of 0.01 corresponds to managing approximately half of the items. CONCLUSION: The Ms. Olsen test is a short (7- to 10-min) test measuring competence in clinical decision-making among nursing staff working in older people nursing. Despite reasonably good measurement properties, this should be considered an initial validation in the development of a short test for assessing clinical decision-making among nursing staff in various health care setting. IMPACT: Several scales aiming to measure nursing competence have been developed over the last decade, but measurement properties (beyond classical test theory) are seldom evaluated, few scales concern other staff groups than registered nurses and few scales have proposed or established cut-offs for safe practice. The Ms. Olsen test is a short test of clinical decision-making that demonstrates reasonably good measurement properties. Cut-off points for registered nurses and assistant nurses were established. The Ms. Olsen test may be used to measure and evaluate competence in clinical decision-making among nursing staff working in older people nursing and educational settings.

Implementation of advanced practice nursing for minor orthopedic injuries in the emergency care context: A non-inferiority study.

AIMS: To evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models. DESIGN: A non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use. METHODS: Patients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019. RESULTS: In total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06-1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21-0.97). CONCLUSION: Advanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Differences and similarities in scope of practice between registered nurses and nurse specialists in emergency care: an interview study.

BACKGROUND: Wide variation exists between the nursing competence requirements seen in the emergency care context and the subsequent design of nursing education programmes. Clarifying nursing roles and scope of practice may shed light on inconsistencies and encourage nurses to work to their full potential. AIM: Describe and clarify the overarching similarities and differences in registered nurses' and nurse specialists' scope of practice in emergency departments. METHODS: A qualitative study performed in Finland and Norway, based on 11 interviews analysed by means of qualitative content analysis. RESULTS: The results are presented in three main categories related to nurses' scope of practice: The nurses share the same role, Competence varies and Same accountability and responsibility, with potential for development of the specialist role. DISCUSSION: Given the varying educational systems that currently exist, management teams face a more or less impossible task if attempting to standardise the scope of practice for different professional nurse groups. Still, nurse specialists possess competence that could be utilised to improve patient care and some specialisations seem more suitable for emergency care than others. Individual skills and qualifications should be recognised, which would enable nurses to work to their full potential. CONCLUSION AND IMPLICATIONS: No differences were seen between registered nurses' and nurse specialists' role, and professional accountability and responsibilities in the context studied here, although the level of nursing competence differed. Before and even after consensus on uniform competence standards for the different professional nurse groups is reached, management teams should invest in reviewing nurses' competence in relation to different expertise levels, and strategically recruit so that current health needs in the emergency departments can be met.

Implementation of advanced practice nursing for orthopaedic patients in the emergency care context - A study protocol for outcome studies.

AIM: To evaluate the implementation of advanced practice nursing in emergency care in Norway for patients with orthopaedic injuries, including hip fractures. The outcomes relate to quality of care and patient trust. DESIGN: A non-inferiority study comparing an advanced practice nursing care model with a standard (physician-led) care model. METHODS: Data will be collected from patient records and through the Patient Trust Questionnaire, completed by patients. The data will be analysed by descriptive and inferential statistics. Funding for the research was granted in 2015 and the regional ethical committee approved the current study in February 2019. DISCUSSION: In Norway and the other Nordic countries, advanced practice nursing is still in its infancy, especially in the emergency care context. This study will evaluate advanced practice nursing in this new context. IMPACT: The study will add to knowledge on the quality of care provided for orthopaedic patients with minor orthopaedic injuries or hip fractures as delivered by advanced practice nurses and physicians, respectively. It will also evaluate how well-advanced practice nursing is accepted by patients in this new context.

'Thinking outside the box': advanced geriatric nursing in primary health care in Scandinavia.

BACKGROUND: Older people are frequent users of primary health care (PHC) services. PHC services have been critiqued, mainly regarding limited accessibility and continuity of care. In many countries, investment in nurse practitioners (NPs) has been one strategy to improve PHC services. In the North of Europe, the NP role is still in its infancy. The aim of this study was to explore the feasibility of introducing geriatric nurse practitioners (GNPs) in PHC in Scandinavia, from multiprofessional and older persons' perspectives. METHODS: The study had a qualitative design, including 25 semi-structured interviews with nurses, nurse leaders, physicians, politicians and older persons from several communities in Scandinavia. The material was analysed by means of qualitative content analysis. RESULTS: The results highlight current challenges in health services for the older population, i.e. comorbid older patients with complex care needs aging in place, lack of competent staff, and organisational challenges. The results present an envisioned GNP scope of practice in health services for the older population, including bringing advanced competence closer to the patient, an autonomous role including task-shifting, and a linking role. The results also present factors influencing implementation of the GNP role, i.e. GNP competence level, unclear role and scope of practice, and openness to reorganisation. CONCLUSIONS: The results indicate that it is feasible to implement the GNP role in primary health care in Scandinavia. Notwithstanding, there are factors influencing implementation of the GNP role that should be considered.

Inner strength and its relationship to health threats in ageing-A cross-sectional study among community-dwelling older women.

AIM: To explore the relationship between inner strength and health threats among community-dwelling older women. BACKGROUND: Inner strength is described as a resource that promotes experiences of health, despite adversities. Inner strength and its dimensions (i.e. connectedness, creativity, firmness and flexibility) can be assessed using the Inner Strength Scale (ISS). Exploring attributes of weaker inner strength may yield valuable information about areas to focus on in enhancing a person's inner strength and may ultimately lead to the perception of better health. DESIGN: Cross-sectional questionnaire survey. METHODS: The study is based on responses from 1270 community-dwelling older women aged 65 years and older; these were collected in the year 2010 and describe the situation that still exists today for older women. The questionnaire included the ISS, background characteristics and explanatory variables known to be health threats in ageing. Data were analysed using descriptive and inferential statistics. RESULTS: Poorer mental health was related to weaker inner strength in total and in all the dimensions. Symptoms of depressive disorders and feeling lonely were related to three of the dimensions, except firmness and creativity respectively. Furthermore, poor physical health was associated with the dimensions firmness and flexibility. Other health threats were significantly related to only one of the dimensions, or not associated at all. CONCLUSION: Mental ill health has overall the strongest association with weaker inner strength. Longitudinal studies are recommended to confirm the results. However, the ISS does not only estimate inner strength but can also be a tool for discovering where (i.e. dimension) interventions may be most profitable.

Inner strength as identified in narratives of elderly women: a focus group interview study.

By identifying sources of inner strength, health care personnel can be given valuable information about elderly people's capacities regardless of frailty. The focus of this interview-based study was to explore how inner strength and its dimensions can be identified in narratives of elderly women. The analysis was based on a theoretical model where inner strength is composed of 4 interacting dimensions of connectedness, creativity, firmness, and flexibility. Our findings add nuance to the notion of inner strength and deepen empirical knowledge about the concept.

Inner strength - associated with reduced prevalence of depression among older women.

OBJECTIVES: The aim of this study was to explore if inner strength is independently associated with a reduced prevalence of depression after controlling for other known risk factors associated with depression. METHODS: A population-based cross-sectional study was performed, where all women living in Åland, a Finnish self-govern island community in the Baltic Sea, aged 65 years or older were sent a questionnaire including the Geriatric Depression Scale and the Inner Strength Scale along with several other questions related to depression. Factors associated with depression were analyzed by means of multivariate logistic regression. RESULTS: The results showed that 11.2% of the studied women (n = 1452) were depressed and that the prevalence increased with age and was as high as 20% in the oldest age group. Non-depressed women were more likely to never or seldom feel lonely, have a strong inner strength, take fewer prescription drugs, feeling needed, being able to engage in meaningful leisure activities, as well as cohabit. CONCLUSION: Our results showed an association between stronger inner strength and being non-depressed. This can be interpreted to mean that inner strength might have a protective effect against depression. These findings are interesting from a health-promotion perspective, yet to verify these results, further longitudinal studies are required.