Collaborative care: Using six thinking hats for decision making.

AIM: To apply six thinking hats technique for decision making in collaborative care. BACKGROUND: In collaborative partnerships, effective communications need to occur in patient, family, and health care professional meetings. The effectiveness of these meetings depends on the engagement of participants and the quality of the meeting process. The use of six thinking hats technique to engage all participants in effective dialogue is proposed. DESIGN: Discussion paper. DATA SOURCES: Electronic databases, CINAHL, Pub Med, and Science Direct, were searched for years 1990 to 2017. IMPLICATIONS FOR NURSING: Using six thinking hats technique in patient family meetings nurses can guide a process of dialogue that focuses decision making to build equal care partnerships inclusive of all participants. Nurses will need to develop the skills for using six thinking hats technique and provide support to all participants during the meeting process. CONCLUSION: Collaborative decision making can be augmented by six thinking hat technique to provide patients, families, and health professionals with opportunities to make informed decisions about care that considers key issues for all involved. Nurses who are most often advocates for patients and their families are in a unique position to lead this initiative in meetings as they network with all health professionals.

Clients with chronic conditions: community nurse role in a multidisciplinary team.

AIMS AND OBJECTIVES: To define and validate the role of the community nurse in a multidisciplinary team caring for clients with chronic and complex needs. BACKGROUND: A key factor in optimising care for clients with chronic and complex conditions in the community is the use of multidisciplinary teams. A team approach is more effective as it enables better integration of services. The role of the community nurse in the multidisciplinary team has as yet not been delineated. DESIGN: A modified Delphi technique was used in this study. METHODS: A group of 17 volunteer registered nurses who were experienced in the care of clients with chronic conditions and complex care needs in the community formed a panel of experts. Experts were emailed a series of three questionnaires. RESULTS: Main findings show that the role of the community nurse in a multidisciplinary team for clients with chronic conditions has six main domains - advocate, supporter, coordinator, educator, team member and assessor. CONCLUSION: A consensus on the role of the community nurse in the multidisciplinary team is described. The six key role domains reaffirm the generic role of the nurse and the validation of the role clarifies and reinforces the centrality of the community nurse in the team. Further refinement of the community nurse role is indicated to increase comprehensiveness of role descriptors particularly for the role domain, advocate. RELEVANCE TO CLINICAL PRACTICE: Community nurses working in multidisciplinary teams caring for clients with chronic conditions can define their role as a team member. The working relationship of the community nurse with other health professionals in the multidisciplinary team as a key approach to more integrated care for clients and carers enables the use of this approach to be better understood by all team members. With this increased understanding, community nurses are in a position to build stronger and more effective care teams.

Being inclusive of diversity in nursing care: a discussion paper.

The Australian health care system is responsible for delivering health services to an increasingly diverse health population. Nurses are in a position to positively influence health-related outcomes by actively addressing the differences individuals bring to their health care experiences. By focusing diversity on health inequities, nurses can play an important role in identifying those at risk of poorer health. This paper discusses diversity in the health population through health inequities and proposes directions for nursing practice. These suggested directions include application of a definition of diversity that include health determinants; targeting specific groups with programmes and services designed to reduce health inequalities; engaging in political action to promote effective policy development; preparing nurses at an undergraduate and graduate level to build capacity for addressing diversity and health inequities; and identifying effective interventions through research studies that address inequities in the health population.

Loss of clinical nursing expertise: a discussion paper.

There is evidence to suggest that there is a general decline in clinical expertise in nursing as a result of experienced clinicians leaving the profession. The expertise of clinical nursing practice is an important resource and needs to be captured and made available to others as loss of this knowledge and expertise has implications for clinical outcomes. This paper aims to discuss the current nursing workforce, loss of clinical expertise, the nature of expertise and the way it can be captured. Clarification and articulation of clinical knowledge of nursing experts provides the means for knowledge to be transferred to a less experienced workforce and be available in an accessible form in the workplace. Leverage of nursing expertise in this manner has the potential to benefit less experienced staff, hold clinical nursing expertise in the workplace and improve clinical outcomes and satisfaction with performance.

Expanding the scope of decision-making research for nursing and midwifery practice.

Decision making embedded in clinical situations is studied to inform nursing and midwifery practice and to enhance clinical effectiveness. To date this knowledge has mainly been derived from classical decision-making research approaches that are limited in capturing cognition in rapidly changing 'real-world' clinical environments. A naturalistic decision making approach can strengthen the ecological validity of descriptive investigations in certain dynamic clinical decision situations that include urgency and complexity. This paper presents a discussion about naturalistic decision making, its relevance for studying certain clinical decision situations in the 'real world' of nursing and midwifery practice and its application in a midwifery decision-making situation. In conclusion classical decision-making research approaches can be extended to include the naturalistic decision making approach that can capture decision making in dynamic clinical situations and show the underlying knowledge that distinguishes more experienced clinicians.

Defining pastoral care for older people in residential care.

The concept and definition of pastoral care in aged care remains ambiguous. This paper reports on the defining characteristics and meaning of pastoral care from the perspective of older recipients, their family members and pastoral care workers. Using a qualitative descriptive approach semi-structured in-depth interviews were conducted with 18 pastoral care workers and 11 older people. Transcribed data were analysed using NVivo software and coded for emerging themes. The defining characteristics of pastoral care that emerged from analysis of transcribed interviews were: a trusting relationship, spiritual support, emotional support and practical support. Findings also portray the role of the pastoral care worker as spiritual guide, confidante, and emotional and practical supporter acting within a trusting relationship. Future studies should confirm these results by exploring the perceptions of experts in the field of pastoral care.

Physical activity in pregnancy: women's perceptions, practices, and influencing factors.

INTRODUCTION: Evidence shows that physical activity during and after pregnancy results in health gains for women. There is no clear understanding apparent in the literature of women's experiences with physical activity during their pregnancy. The aim of this study was to describe women's perceptions and participation in physical activity during pregnancy and identify factors influencing participation. METHODS: In this qualitative descriptive study, face-to-face interviews were conducted with 19 women, all at different stages of pregnancy, who were asked about their experiences with physical activity. RESULTS: Data analysis resulted in four categories describing "meaning of physical activity," "perceived benefits of physical activity in pregnancy," "barriers to and motives for participation in physical activity," and "process of engagement in physical activity." The process of engagement in physical activity by women was shown to have three marked phases: "uncertainty," "engaging," and "compromise." DISCUSSION: To facilitate women's self-management across these phases, support is needed that focuses on providing strategies to strengthen individual approaches by women. Such support might promote activities of daily living as a specific entity of physical activity, expose myths about activity during pregnancy, and endorse the benefits of weight management arising from physical activity, not just during pregnancy, but across the lifespan.

'Changes of concern' for detecting potential early clinical deterioration: A validation study.

BACKGROUND: The criteria used for calling emergency response teams to patients at-risk of clinical deterioration in the acute care adult hospital population include the criterion 'patient of concern'. When calling teams to patients of concern, some 'changes of concern' used by nurses have been identified; however the validity of these 'changes of concern' is unknown. PURPOSE: This study aimed to determine the content validity of 'changes of concern' used by nurses to call emergency response teams. METHODS: Ten nurses who had 5 years or more experience with emergency response teams formed an expert group. This expert group examined content validity of the 'changes of concern' nurses used for calling emergency response teams using criterion, 'patient of concern' with a questionnaire based on Bausell's content validity criteria of necessity and sufficiency. Data were summarized using descriptive statistics. FINDINGS: The main findings indicate that the 10 'changes of concern' are agreed to be necessary to possibly identify early deterioration in adult patients that may require a call using criterion, 'patient of concern'. The associated factors that relate to these 'changes of concern' are also confirmed to be necessary to assess when these changes are present in patients. CONCLUSION: Assessment underpinned by these changes of concern (indicators) can provide more complete clinical information for clinicians to recognise possible early deterioration of patients and to coach others so building capacity to appropriately call emergency response teams resulting in increased patient safety. Research is indicated that further explores and identifies the use of 'patient of concern' criterion and that examines the effectiveness of clinical information being used to detect potential early clinical deterioration.

Multidisciplinary teams caring for clients with chronic conditions: experiences of community nurses and allied health professionals.

In Western societies the community prevalence of chronic conditions is increasing rapidly. Evidence has shown the benefits of care given to these clients by multidisciplinary teams. However, the experience of diverse health professionals working in these teams is not well understood. This study presents the experiences of members in multidisciplinary teams caring for clients with chronic conditions in the community. A qualitative descriptive study was used with a purposive sample of 34 multidisciplinary team members who participated in focus groups that were audio-taped, transcribed and analysed. Team members' experiences of working in multidisciplinary teams are described within three categories: shared purpose, working in the team, and tensions within the team. The findings provide direction for addressing team effectiveness, including issues of team leadership and evaluation of team performance.

The decision to suture after childbirth: cues, related factors, knowledge and experience used by midwives.

OBJECTIVE: to present critical cues, related factors, knowledge and experience used by midwives when deciding whether or not to suture perineal and associated trauma after childbirth. DESIGN: an exploratory descriptive study using in-depth interviews to collect data using the Critical Decision Method. SETTING: birth units in Greater Western Sydney. PARTICIPANTS: 19 volunteer midwives experienced in deciding whether or not to suture or in making referrals to suture childbirth trauma. FINDINGS: the main findings were the cues of bleeding and trauma with their accompanying specific attributes, and woman- and midwife-centred factors considered when deciding whether or not to suture perineal and associated trauma. Furthermore, the knowledge and experience that supported decision-making, such as detailed knowledge of anatomical structures, workshops and observing highly skilled clinicians, were identified. CONCLUSION: the cues and related factors can be formed into an inventory and tested for content validity using a panel of expert midwives. IMPLICATIONS FOR PRACTICE: such an inventory has the potential to minimise inappropriate intervention and alleviate unnecessary discomfort, thus increasing safety and quality of care for women following childbirth. In addition, midwifery educators and those coaching less-experienced midwives can use the collected clinical information to aid the development of students' and midwives' decision-making skills regarding whether or not to suture childbirth trauma.

'Patients of concern' to nurses in acute care settings: a descriptive study.

BACKGROUND: Nurses are required to recognise early clinical deterioration in patients and call emergency support. Nurses often use the subjective non-specific criterion, 'concerned about the patient' as the indication for calling. No study has identified cues of relevance to this criterion. PURPOSE: The purpose of this study is to identify cues of potential early clinical deterioration used to recognise 'a patient of concern' who is not meeting the current objective physiologic emergency response team calling criteria. METHOD: An exploratory descriptive approach was used involving interviews with a purposive sample of 17 experienced registered nurses who recalled incidences of calling the team to adult patients based on the criterion, 'concerned about patient'. The transcribed audio tapes of interviews were coding to identify cues. FINDINGS: Main findings are ten identified changes of concern (cues): noisy breathing, inability to talk in sentences, increasing supplemental O(2) requirements to maintain SaO(2), agitation, impaired mentation, impaired cutaneous perfusion, not expected trajectory, new or increasing pain, new symptom, and new observation that nurses used to recognise potential early clinical deterioration. Two mediating factors were also identified that influenced the decision-making process. CONCLUSION: The ten changes of concern (cues) can be considered precursors of potential early deterioration that may assist nurses to detect patients at possible risk. Nurses are also aware that some patient groups are at higher risk as they are not able to communicate potential deterioration as perhaps other patients can. This study has only identified two patient groups and it is possible others should be considered. The availability of identified precursors indicates their validity for recognizing possible early clinical deterioration should be investigated further.

Team nursing in acute care settings: nurses' experiences.

A shift to the practice of team-based models of nursing care has occurred as a response to skill mix changes in acute health care settings. Little is known about nurses' experience of working in team-based models of nursing care delivery. This paper reports the findings of a qualitative study of the experiences of nurses working in teams in acute care settings in an area health service. Main findings are benefits of team nursing, team approach, team effectiveness, increased responsibility, availability of support and engagement with the multidisciplinary team. These findings have implications for understanding the essential elements of team nursing as experienced by team members; providing key messages for health services implementing team nursing and giving direction for further research.

Clinical decision-making for repair of spontaneous childbirth trauma: validation of cues and related factors.

From recalled childbirth cases, a series of cues and related factors were previously identified that were used by midwives when making decisions to suture or not suture perineal and associated trauma incurred during spontaneous vaginal delivery. This study aimed to determine the validity of these cues and related factors. A panel of 18 experienced midwives evaluated their content validity using the criteria of "necessity" and "sufficiency." The two main cue categories-"bleeding" and "birth trauma"-were considered by 18 (100%) of the panel members to be necessary to assess. At least 16 (89%) panel members considered the following specific cues necessary to assess: in the bleeding category-type, flow, amount, and effect of application of pressure or ice; in the birth trauma category-trauma sites, trauma types, dimensions of trauma, types of tissue, alignment of tissue, edema, and bruising. Seventeen (94%) panel members considered seven woman-centred related factors that were necessary to assess and 14 (78%) considered the combination of all cues in bleeding, birth trauma, and related factors sufficient for making the decision to suture or not. The availability of these validated cues and related factors has the potential to guide a comprehensive assessment on which the decision to suture or not suture depends. This addition to the domain of midwifery knowledge enables educational preparation of midwives who will have the capacity to more adequately support women in childbirth.

Clients with chronic and complex conditions: their experiences of community nursing services.

AIM: This qualitative study aimed to explore and describes clients' experiences of receiving care from community nurses. BACKGROUND: Understanding of the experiences of clients with chronic and complex conditions receiving community nursing care can provide insight into their needs. International studies have identified experiences clients have had of receiving care from community nurses. However, no Australian study was found that had specifically explored with clients who had chronic and complex conditions and their experiences of receiving care from community nurses in an area health service. DESIGN: A qualitative descriptive study conducted during 2005 explored and described clients' experiences of the nursing care provided by community nurses. METHOD: A purposive sample of 13 volunteer participants with chronic and complex conditions was interviewed and the transcripts analysed. RESULTS: Three main categories were identified that clients used to describe their experiences. These were: the client's relationship with the nurse, care process and being able to stay out of hospital. CONCLUSIONS: Clients strongly indicated their satisfaction with care provided by experienced community nurses and acknowledged that nurses are playing a key role in fostering their self-management and avoiding their readmission to hospital. Areas that require further attention are the professional development of less-experienced community nurses, services at the weekend, the scope of nursing management of clients with chronic conditions and the education needs of community nurses to meet the goals of these clients. RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for nurses who work in strong autonomous clinical roles in the community to have experience in assessment, education, planning and delivery of client care before they can be competent community nurses. The possibility of adverse occurrences during weekends provides the opportunity for managers to review and plan weekday and weekend workloads and staffing.

Change process during redesign of a model of nursing practice in a surgical ward.

AIM: This paper reports a case study of nursing practice model redesign in a surgical ward at a large metropolitan acute care hospital in Sydney, Australia. BACKGROUND: Literature suggests that factors such as financial restraints and shortage of nurses necessitate redesign of nursing care. METHOD: A descriptive case study design was used. The nursing practice model was changed from a patient allocation model to a team-nursing model and a new role of Clinical Activities Coordinator was introduced. RESULTS: This study has confirmed that people need to be able to empower themselves to ensure an effective change process. It was also apparent in the case study that the staff were resistant to the redesign. CONCLUSIONS: Change is a difficult process, which needs to involve all stakeholders. The planning process needs to consider the characteristics of the context such as workload and skill required, and the measures such as patient and staff satisfaction and health outcomes.

Culturally diverse patient--nurse interactions on acute care wards.

The nurse-patient interaction is central to providing nursing care. This qualitative study explores nurses' and culturally diverse patients' experiences within nurse-patient relationships in acute care wards. Eight nurses and their respective patients volunteered to join the study and were interviewed. The three themes identified in relationships between nurses and culturally diverse patients were shared tension, perceived difference and held awareness. It is concluded from the study that relationships between nurses and culturally diverse patients in acute care wards during short episodes of hospitalization are not easy for nurses and need to receive deeper consideration as to how they can be developed more effectively. It is recommended that educational support be provided to develop more effective interactions between nurses and patients with research being carried out to investigate factors that can strengthen culturally diverse patient-nurse interactions in acute care settings.

Culturaly diverse family members and their hospitalised relatives in acute care wards: a qualitative study.

OBJECTIVE: To describe the experiences of culturally diverse family members who make the decision to stay with their relatives in acute care wards. DESIGN: A qualitative descriptive study. SETTING: Medical and surgical wards in an acute care hospital with a 70% non-English speaking background patient population. SUBJECTS: Eight culturally diverse family members who stayed with their hospitalised relatives for at least four shifts or the equivalent hours. METHOD: In-depth interviews of approximately 45 minutes. FINDINGS: Three main categories described the experience of family members. These categories were carrying out in-hospital roles, adhering to ward rules, and facing concerns. CONCLUSIONS: Findings indicate nurses and family members could benefit from negotiating active partnerships; family friendly ward environments need to be fostered, supported by appropriate policies; and further research is needed into culturally diverse family members' partnerships with nurses in acute care settings.

Clinicians' responses to abnormal vital signs in an emergency department.

The importance of observing patient vital signs in emergency department (ED) practice has been stressed in the literature. Failure of clinicians to respond to abnormal vital signs (AVS) has been described as a potential reason for delayed management in ED practice, with a likelihood of increased morbidity. This study aimed to explore and describe clinicians' responses to AVS in a busy ED. A qualitative descriptive approach was used with three focus groups being conducted with 18 volunteer registered nurses (RNs) and medical officers (MOs) who worked in the ED of an area health service in Western Sydney. Transcribed focus group interviews were analysed using a process of constant comparison and contrast and a description of clinicians' responses to AVS written. An analysis of text from focus groups revealed three main categories of clinicians' responses to AVS: identification, reporting and implementing action. Clinicians in this study recognised, reported and acted on AVS. However, delays in responding to AVS occurred due to a variety of reasons. The main reasons identified were issues with documentation and the ability to seek advice of appropriate staff, ineffective communication, fear of reprimand, inexperience of working in EDs, workload, distractions and interruptions. In conclusion, environmental and human factors contribute to inappropriate delays regarding AVS in the ED. These factors can be acted on by initiating appropriate education programmes and establishing improved communication networks. Better use of the existing medical emergency team (MET) in the ED can act to alleviate situations associated with delays in managing AVS.

Redesign of the model of nursing practice in an acute care ward: nurses' experiences.

OBJECTIVE: to describe nurses' experiences of the change associated with redesign of the model of nursing practice in an acute care ward in the preparatory and implementation phases. DESIGN: descriptive case study SETTING: a surgical ward in an acute care hospital in Greater Western Sydney SUBJECTS: fourteen registered and six enrolled nurses working on the surgical ward volunteered to be interviewed, eight in the preparatory phase and twelve six months into the implementation phase MAIN OUTCOME MEASURE: descriptions of nurses' experiences in the preparatory phase and six months into the implementation phase of the redesigned nursing practice model RESULTS: many nurses felt apprehensive in the preparatory phase, however, six months into implementation phase their willingness to trial the model was evident. Negativity pervaded both phases, as did their concerns for the quality of care being given. In the preparatory phase nurses described the clinical activities coordinator (CAC) role as having potential to be beneficial and this was realised to some degree six months into implementation phase. A preference for registered nurses over enrolled nurses as a dominant component of the staff was evident in both phases CONCLUSIONS: the struggle with the change that nurses experienced suggests redesign needs to be a more collaborative process involving strong communication and supportive education so nurses can empower themselves within the change.