Factors supporting career pathway development amongst advanced practice nurses in Thailand: A cross-sectional survey.

BACKGROUND: Thailand has recently reformed its health care system and this change has contributed to the rapidly increasing need for skilled and experienced specialist nurses and in 2003 a new Advanced Practice Nursing role was formally introduced. While Advanced Practice Nursing is now accepted as a clinical career option, there is little understanding of the factors conducive to successful career development. This study offers the first examination of factors associated with successful career progression for Advanced Practice Nurses in Thailand. OBJECTIVES: 1. To provide a description of the Advanced Practice Nurse population in Thailand, as represented by a purposive stratified national sample. 2. To examine the factors influencing successful career pathway development of Advanced Practice Nurses in Thailand. 3. To examine the factors which influence the extent to which Advanced Practice Nurses in Thailand engage in evidence-based practice and research. DESIGN: National cross-sectional survey. SETTING: Thailand. PARTICIPANTS: 333 currently practicing Advanced Practice Nurses. METHODS: A national cross-sectional survey was conducted in Thailand in order to identify and examine key influencing factors on the successful development of Advanced Practice Nurses. The research tool was a specifically designed questionnaire in the Thai language, informed by international academic literature on the development of the Advanced Practice Nurse role, validated and piloted with 30 Advanced Practice Nurses to assess its reliability using Cronbach's alpha. The data were analysed in SPSS (version 21). Initial parametric testing was done using the Kolmogorov-Smirnov test and Pearson's correlation analysis was performed to examine the relationship between the independent variables (those measuring demographic and support factors) and the dependent variables (measuring career pathway development). RESULTS: A response rate of 90% was achieved. A lack of clear progression routes in the Advanced Practice Nurse structure was identified along with inconsistent patterns of working including variation in the number of days per week (range: 1-5 days) that nurses dedicated to the Advanced Practice Nurse role and the amount of autonomy achieved in this role. The study highlighted a lack of research productivity in and production of outputs (59% had never published) and given the expectation of Advanced Practice Nurses to both produce and utilise research evidence, this constitutes a significant gap in current practice. Other factors reported as important for career pathway development of Advanced Practice Nurses related to the environment, peer networks, institutional (hospitals) and external (government and the Thai Nursing Council) support. CONCLUSIONS: Our study offers insights for national and local policymakers and highlights the need to firmly establish, standardised career pathways in Advanced Practice Nursing to support career progression and the implementation of evidence into practice. These findings also have implications for clinical departments which have a responsibility to ensure they provide an enabling environment for Advanced Practice Nurses to fully carry out their roles. Tweetable abstract: Our study reports findings from a first national survey in Thailand investigating the factors which support career development in Advanced Practice Nurses.

Healthcare Quality Improvement and 'work engagement'; concluding results from a national, longitudinal, cross-sectional study of the 'Productive Ward-Releasing Time to Care' Programme.

BACKGROUND: Concerns about patient safety and reducing harm have led to a particular focus on initiatives that improve healthcare quality. However Quality Improvement (QI) initiatives have in the past typically faltered because they fail to fully engage healthcare professionals, resulting in apathy and resistance amongst this group of key stakeholders. Productive Ward: Releasing Time to Care (PW) is a ward-based QI programme created to help ward-based teams redesign and streamline the way that they work; leaving more time to care for patients. PW is designed to engage and empower ward-based teams to improve the safety, quality and delivery of care. METHODS: The main objective of this study was to explore whether PW sustains the 'engagement' of ward-based teams by examining the longitudinal effect that the national QI programme had on the 'work-engagement' of ward-based teams in Ireland. Utilising the Utrecht Work Engagement Scale questionnaire (UWES-17), we surveyed nine PW (intervention) sites from typical acute Medical/Surgical, Rehabilitation and Elderly services (representing the entire cohort of a national phase of PW implementation in Ireland) and a cohort of matched control sites. The numbers surveyed from the PW group at T1 (up to 3 months after commencing the programme) totalled 253 ward-team members and 249 from the control group. At T2 (12 months later), the survey was repeated with 233 ward-team members from the PW sites and 236 from the control group. RESULTS: Overall findings demonstrated that those involved in the QI initiative had higher 'engagement' scores at T1 and T2 in comparison to the control group. Total 'engagement' score (TES), and its 3 dimensions, were all significantly higher in the PW group at T1, but only the Vigour dimension remained significantly higher at T2 (p = 0.006). CONCLUSION: Our results lend some support to the assertions of the PW initiative itself and suggest that when compared to a control group, ward-based teams involved in the QI programme are more likely to be 'engaged' by it and its associated improvement activities and that this is maintained over time. However, only the Vigour dimension of 'engagement' remained significantly higher in the PW over time.

Reported implementation lessons from a national quality improvement initiative; Productive Ward: Releasing Time to Care™. A qualitative, ward-based team perspective.

AIM: To explore the experiences of participants involved in the implementation of the Productive Ward: Releasing Time to Care™ initiative in Ireland, identifying key implementation lessons. BACKGROUND: A large-scale quality improvement programme Productive Ward: Releasing Time to Care™ was introduced nationwide into Ireland in 2011. We captured accounts from ward-based teams in an implementation phase during 2013-14 to explore their experiences. METHODS: Semi-structured, in-depth interviews with a purposive sample of 24 members of ward-based teams from nine sites involved in the second national phase of the initiative were conducted. Interviews were analysed and coded under themes, using a seven-stage iterative process. RESULTS: The predominant theme identified was associated with the implementation and management of the initiative and included: project management; training; preparation; information and communication; and participant's negative experiences. The most prominent challenge reported related to other competing clinical priorities. CONCLUSIONS: Despite the structured approach of Productive Ward: Releasing Time to Care™, it appears that overstretched and busy clinical environments struggle to provide the right climate and context for ward-based teams to engage and interact actively with quality improvement tools, methods and activities. IMPLICATIONS FOR NURSING MANAGEMENT: Findings highlight five key aspects of implementation and management that will help facilitate successful adoption of large-scale, ward-based quality improvement programmes such as Productive Ward: Releasing Time to Care™. Utilising pre-existing implementation or quality frameworks to assess each ward/unit for 'readiness' prior to commencing a quality improvement intervention such as Productive Ward: Releasing Time to Care™ should be considered.

Specialties valued.

In your article on the NMC education consultation (feature, 12 July), Dame June Clark says 'nurses who support premature specialisation are not patient-centred - their selfish aim is to protect their specialty'.

Undergraduate nurse education in trouble.

Earlier in my career I had the great privilege of working alongside Baroness Jean McFarlane at the University of Manchester. The leader of the first undergraduate nursing programme at an English university, she was a fierce proponent and defender of nurses being educated in universities. I cannot imagine her response to the persistent offensive on nursing in higher education.

Priorities for the professional development of registered nurses in nursing homes: a Delphi study.

Objective: To establish a consensus on the care and professional development needs of registered nurses (RNs) employed by UK care homes. Design: Two-stage, online modified Delphi study. Setting and Participants: A panel (n = 352) of individuals with experience, expertise or interest in care home nursing: (i) care home nurses and managers; (ii) community healthcare professionals (including general practitioners, geriatricians, specialist and district nurses); and (iii) nurse educators in higher education. Results: RNs employed by nursing homes require particular skills, knowledge, competence and experience to provide high-quality care for older residents. The most important responsibilities for the nursing home nurse were: promoting dignity, personhood and wellbeing, ensuring resident safety and enhancing quality of life. Continuing professional development priorities included personal care, dementia care and managing long-term conditions. The main barrier to professional development was staff shortages. Nursing degree programmes were perceived as inadequately preparing nurses for a nursing home role. Nursing homes could improve by providing supportive learning opportunities for students and fostering challenging and rewarding careers for newly RNs. Conclusion: If nurses employed by nursing homes are not fit for purpose, the consequences for the wider health and social-care system are significant. Nursing homes, the NHS, educational and local authorities need to work together to provide challenging and rewarding career paths for RNs and evaluate them. Without well-trained, motivated staff, a high-quality care sector will remain merely an aspiration.

The impact of a large-scale quality improvement programme on work engagement: preliminary results from a national cross-sectional-survey of the 'Productive Ward'.

BACKGROUND: Quality improvement (QI) Programmes, like the Productive Ward: Releasing-time-to-care initiative, aim to 'engage' and 'empower' ward teams to actively participate, innovate and lead quality improvement at the front line. However, little is known about the relationship and impact that QI work has on the 'engagement' of the clinical teams who participate and vice-versa. OBJECTIVE: This paper explores and examines the impact of a large-scale QI programme, the Productive Ward, on the 'work engagement' of the nurses and ward teams involved. DESIGN/METHODS: Using the Utrecht Work Engagement Scale (UWES), we surveyed, measured and analysed work engagement in a representative test group of hospital-based ward teams who had recently commenced the latest phase of the national 'Productive Ward' initiative in Ireland and compared them to a control group of similar size and matched (as far as is possible) on variables such as ward size, employment grade and clinical specialty area. RESULTS: 338 individual datasets were recorded, n=180 (53.6%) from the Productive Ward group, and n=158 (46.4%) from the control group; the overall response rate was 67%, and did not differ significantly between the Productive Ward and control groups. The work engagement mean score (±standard deviation) in the Productive group was 4.33(±0.88), and 4.07(±1.06) in the control group, representing a modest but statistically significant between-group difference (p=0.013, independent samples t-test). Similarly modest differences were observed in all three dimensions of the work engagement construct. Employment grade and the clinical specialty area were also significantly related to the work engagement score (p<0.001, general linear model) and (for the most part), to its components, with both clerical and nurse manager grades, and the elderly specialist areas, exhibiting substantially higher scores. CONCLUSIONS: The findings demonstrate how QI activities, like those integral to the Productive Ward programme, appear to positively impact on the work engagement (the vigour, absorption and dedication) of ward-based teams. The use and suitability of the UWES as an appropriate measure of 'engagement' in QI interventions was confirmed. The engagement of nurses and front-line clinical teams is a major component of creating, developing and sustaining a culture of improvement.

The transition of a large-scale quality improvement initiative: a bibliometric analysis of the Productive Ward: Releasing Time to Care programme.

AIMS AND OBJECTIVES: To examine the literature related to a large-scale quality improvement initiative, the 'Productive Ward: Releasing Time to Care', providing a bibliometric profile that tracks the level of interest and scale of roll-out and adoption, discussing the implications for sustainability. BACKGROUND: Productive Ward: Releasing Time to Care (aka Productive Ward) is probably one of the most ambitious quality improvement efforts engaged by the UK-NHS. Politically and financially supported, its main driver was the NHS Institute for Innovation and Improvement. The NHS institute closed in early 2013 leaving a void of resources, knowledge and expertise. UK roll-out of the initiative is well established and has arguably peaked. International interest in the initiative however continues to develop. METHODS: A comprehensive literature review was undertaken to identify the literature related to the Productive Ward and its implementation (January 2006-June 2013). A bibliometric analysis examined/reviewed the trends and identified/measured interest, spread and uptake. RESULTS: Overall distribution patterns identify a declining trend of interest, with reduced numbers of grey literature and evaluation publications. However, detailed examination of the data shows no reduction in peer-reviewed outputs. There is some evidence that international uptake of the initiative continues to generate publications and create interest. CONCLUSIONS: Sustaining this initiative in the UK will require re-energising, a new focus and financing. The transition period created by the closure of its creator may well contribute to further reduced levels of interest and publication outputs in the UK. However, international implementation, evaluation and associated publications could serve to attract professional/academic interest in this well-established, positively reported, quality improvement initiative. RELEVANCE TO CLINICAL PRACTICE: This paper provides nurses and ward teams involved in quality improvement programmes with a detailed, current-state, examination and analysis of the Productive Ward literature, highlighting the bibliometric patterns of this large-scale, international, quality improvement programme. It serves to disseminate updated publication information to those in clinical practice who are involved in Productive Ward or a similar quality improvement initiative.

The Productive Ward: releasing Time to Care(™)--what we can learn from the literature for implementation.

AIM: This paper reviews the Productive Ward: Releasing Time to Care™ literature, identifying and discussing the key characteristics that may contribute to successful implementation. BACKGROUND: It is 5 years since the official UK launch of the Productive Ward, and the Republic of Ireland commenced a phased, national implementation programme in 2011. Thus it is timely to reflect on the implementation lessons learned to date and described in the literature. EVALUATION: Using taxonomic mapping, this paper evaluates the current state of the literature that pertains to Productive Ward implementation experience; success factors; reports, and assessments. KEY ISSUES: Seven common contextual characteristics were identified: robust and engaging communication; enabling and empowering roles; appropriate training; project planning and management; leadership; corporate/management engagement and support; and financial and human resource commitment. CONCLUSION: The key characteristics identified have a direct impact on the implementation of the Productive Ward. The interplay between these key characteristics and how this interplay influences successful implementation of the Productive Ward warrants further research. IMPLICATIONS FOR NURSING MANAGEMENT: Acknowledging and embracing the seven characteristics during implementation will positively improve the progress and success of the initiatives implementation.

Deconstruction is easy, the hard part is offering alternatives.

Jane Wright's article (Art & Science September 19) is a decent academic exercise that highlights the shortcomings of clinical supervision, but offers little by way of advancing our thinking. What is offered by Ms Wright to take its place? Sadly she offers no alternative.

Mission impossible?

THERE ARE MOMENTS when experience tells you to be less earnest and direct, and a little more Delphic in style. At these times, half ideas can be useful and a little lack of clarity can be effective.