Implementation Strategies to Improve Knowledge and Adherence to Spinal Cord Injury Guidelines.

PURPOSE: The purpose of this study was to evaluate a bundle of implementation strategies (local opinion leaders, printed educational materials, and educational outreach) to increase neurocritical care nurses' knowledge of and adherence to spinal cord injury guidelines. DESIGN: A preprogram, postprogram, and follow-up design was used to evaluate outcomes. METHODS: Adherence was measured via self-reported anticipatory adherence; knowledge was measured by an author-developed assessment. Repeated-measures ANOVA was used for data analysis. FINDINGS: Improvements in nursing knowledge and adherence were found from preprogram to postprogram to follow-up time points. CONCLUSIONS: Outcomes noted in this study provide additional support for using this bundle of implementation strategies and were consistent with previous research documenting the usefulness of these strategies. CLINICAL RELEVANCE: Although further research is needed, this study highlighted a systematic way of implementing evidence-based practices to improve neurocritical care nurses' knowledge of and adherence to spinal cord injury guidelines.

Program evaluation of neuroscience competency programs to implement evidence-based practices.

RATIONALE: Program evaluation is essential to help determine the success of an evidence-based practice program and assist with translating these processes across settings. AIMS: The purpose of this study was to evaluate the usefulness of 2 competency programs that sought to improve neurocritical care nurses' knowledge of and adherence to evidence-based stroke and spinal cord injury guidelines. These programs consisted of 3 specific implementation strategies, including local opinion leaders, printed educational materials, and educational outreach. METHODS: A qualitative study using one-on-one interviews with 10 neurocritical care nurses was used. Semi-structured interview questions examined the nurses' perceptions of the competency programs and the implementation strategies used; themes were identified through first-level coding. The transcripts were deductively analyzed and categorized using a predetermined implementation outcomes framework, including the concepts of acceptability, appropriateness, adoption, and sustainability. RESULTS: Nurses reported that the 3 implementation strategies used for the competency programs were acceptable and appropriate. Further, the nurses perceived that the evidence-based practices reviewed during the programs were being adopted into practice and provided suggestions for sustaining improvements in nursing knowledge of and adherence to these evidence-based practices. CONCLUSIONS: Findings from this study support the success of the Stroke and Spinal Cord Injury Competency Programs, as well as the usefulness of the 3 implementation strategies used. This study provides insight for improvements for subsequent studies focused on implementing evidence-based practices.

Nurses' experiences with errors in nursing.

BACKGROUND: Health care organizations seek to maximize the reporting of medical errors to improve patient safety. PURPOSE: This study explored licensed nurses' decision-making with regard to reporting medical errors. METHODS: Grounded theory methods guided the study. Thirty nurses from adult intensive care units were interviewed, and qualitative analysis was used to develop a theoretical framework based on their narratives. DISCUSSION: The theoretical model was titled "Learning Lessons from the Error." The concept of learning lessons was central to the theoretical model. The model included five stages: Being Off-Kilter, Living the Error, Reporting or Telling About the Error, Living the Aftermath, and Lurking in Your Mind. CONCLUSION: This study illuminates the unique experiences of licensed nurses who have made medical errors. The findings can inform initiatives to improve error reporting and to support nurses who have made errors.

"Mr Smith's been our problem child today ": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.

BACKGROUND: Tools and procedures designed to improve end-of-shift handoffs through standardisation of processes and reliance on technology may miss contextually sensitive information about anticipated events that emerges during face-to-face handoff interactions. Such information, what we refer to as anticipatory management communication (AMC), is necessary to ensure timely and safe patient care, but has been little studied and understood. OBJECTIVE: To investigate AMC and the role it plays in nursing and medicine handoffs. RESEARCH DESIGN: Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. SUBJECTS: 27 nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. RESULTS: Heads-up information was the most frequent type of AMC across all handoff dyads (N=257; 108 resident and 149 nursing). Indirect instructions AMC was used in a little over half the resident handoff dyads, but occurred in all nursing dyads (292 instances). Direct instructions AMC occurred in roughly equal proportion across all dyads but at a modest frequency (N=45; 28 resident and 17 nursing). Direct (if/then) contingency AMC occurred in resident handoffs more frequently than in nursing handoffs (N=32; 30 resident and 2 nursing). CONCLUSIONS: The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs.

"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.

BACKGROUND: Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood. OBJECTIVE: To investigate questions and the functions they serve in nursing and medicine handoffs. RESEARCH DESIGN: Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. SUBJECTS: Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. RESULTS: Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals. CONCLUSIONS: Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created.

Advancing the science of research in nursing education: contributions of the critical decision method.

Advancing the science of nursing education will require the discipline to conduct research that investigates complex phenomena, such as students' clinical thinking and decision-making skills, using multiple methods. The research methods developed in other disciplines can provide nursing education researchers with new ways to investigate clinical teaching and learning in nursing. The critical decision method (CDM), derived from psychology and human factors engineering, is a technique by which researchers elicit experts' thinking and the cognitive work informing decision making in the context of practice. This article describes how the CDM was adapted to study nursing students' situation awareness, cues for action, and pattern recognition during clinical experiences. The CDM is a promising method for investigators to use to conduct research in nursing education and to inform the design of clinical experiences to promote these critical abilities.

Nurse manager cognitive decision-making amidst stress and work complexity.

AIM: The present study provides insight into nurse manager cognitive decision-making amidst stress and work complexity. BACKGROUND: Little is known about nurse manager decision-making amidst stress and work complexity. Because nurse manager decisions have the potential to impact patient care quality and safety, understanding their decision-making processes is useful for designing supportive interventions. METHODS: This qualitative descriptive study interviewed 21 nurse managers from three hospitals to answer the research question: What decision-making processes do nurse managers utilize to address stressful situations in their nurse manager role? Face-to-face interviews incorporating components of the Critical Decision Method illuminated expert-novice practice differences. Content analysis identified one major theme and three sub-themes. RESULTS: The present study produced a cognitive model that guides nurse manager decision-making related to stressful situations. Experience in the role, organizational context and situation factors influenced nurse manager cognitive decision-making processes. CONCLUSIONS: Study findings suggest that chronic exposure to stress and work complexity negatively affects nurse manager health and their decision-making processes potentially threatening individual, patient and organizational outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Cognitive decision-making varies based on nurse manager experience and these differences have coaching and mentoring implications. This present study contributes a current understanding of nurse manager decision-making amidst stress and work complexity.

Understanding nurse manager stress and work complexity: factors that make a difference.

OBJECTIVE: This study provided insight into nurse manager stress and coping experiences. BACKGROUND: Overwork and stress have been implicated in today's nursing shortage. Although nurse managers play a pivotal role in creating work environments that retain staff nurses, little is known about nurse manager work. METHODS: This qualitative descriptive study used a sample of 21 nurse managers to determine what situations contribute to their stress, individual coping strategies, and health-related outcomes. Content analysis identified 3 study themes. RESULTS: People and resources, tasks and work volume, and performance expectations affect nurse managers' perceptions of stress. When comparing novice nurse managers with experienced nurse managers, experienced nurse managers (especially comanagers) used more effective (problem focused) coping strategies and had fewer negative health-related outcomes. CONCLUSION: Findings from this study suggest that to impact stress, coping, and complexity in the nurse manager role requires a combination of strategies that address individual and organizational factors.

Impact of continuous vigilance monitoring on nursing workflow.

BACKGROUND: Increasing nursing time in patient care is beneficial in improving patient outcomes, but this is proving increasingly difficult with the nursing shortage, budgetary constraints, and higher patient acuity. OBJECTIVE: Nursing workflow was evaluated after the implementation of a continuous vigilance monitoring system to determine if the system enhanced patient-centric nursing care. METHODS: Work sampling observations were conducted at 3 hospitals for 6 categories of nursing activities (direct and indirect nursing, documentation, administrative, housekeeping, and miscellaneous) at baseline and at 3 and 9 months. RESULTS: Statistically significant increases in direct (3 months) and indirect nursing care (3 and 9 months) were found, with variability between sites. Statistically significant increases at 3 and 9 months for documentation of patient care activities and decreases in administrative activities were the most consistent findings for all sites. CONCLUSION: Continuous vigilance monitoring enhanced patient-centric care with increases in direct and indirect nursing care and documentation of those activities.

Exploring the persistence of paper with the electronic health record.

OBJECTIVE: Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR. METHODS: We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center. RESULTS: We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency; (2) knowledge/skill/ease of use; (3) memory; (4) sensorimotor preferences; (5) awareness; (6) task specificity; (7) task complexity; (8) data organization; (9) longitudinal data processes; (10) trust; and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR. CONCLUSIONS: In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation.

Sleepless in America: nurse managers cope with stress and complexity.

Although nurse managers play a pivotal role in creating work environments for staff nurses, performance expectations for nurse managers practicing in acute care hospitals may be unrealistic. The authors discuss nurse manager interview data showing that these expectations are increasing nurse manager perceptions of stress, making coping more difficult, and potentially harming nurse manager and work environment well-being.

Themes surrounding novice nurse near-miss and adverse-event situations.

OBJECTIVE: The study purpose was to identify human performance factors that characterized novice nurse near-miss/adverse-event situations in acute-care settings. BACKGROUND: Increased focus on recruitment and retention of newly graduated registered nurses (RNs) in light of patient safety improvement goals will challenge healthcare educators and administrators. What we are beginning to learn about human performance issues during real work situations from patient safety research provides information related to human performance in complex environments that may guide education and system supports for novice RNs. METHODS: Data collected during 8 retrospective interviews of novice RNs about details surrounding their individual near-miss or adverse event were analyzed for common themes. RESULTS: Nine themes were identified. Seven themes were present in at least 7 of the 8 cases and included environmental and social issues, as well as novice lack of expertise. CONCLUSIONS: Findings suggest that support for novice nurses in acute care environments requires attention to the following: consistent availability of expertise in light of workload unpredictability, the social climate regarding expectations of novice performers, realistic expectations of novice decision-making ability during complex situations even up to a year after graduation, and strategies to recognize and intervene when novices are at risk for error.

Understanding the complexity of registered nurse work in acute care settings.

Nursing shortages and patient safety mandates require nursing managers and administrators to consider new ways of understanding the complexity of healthcare provider work in actual situations. The authors report findings from a study guided by an innovative research approach to explore factors affecting registered nurse performance during real work on acute care medical-surgical units. Our findings suggest beginning targets for interventions to improve patient safety, as well as recruitment and retention, through support for registered nurse work.

The "New Look" approach to patient safety: a guide for clinical nurse specialist leadership.

This article describes a complex system model based on human performance factors that is borrowed from other industries but can be used by clinical nurse specialists for making progress in patient safety. Traditional approaches to investigation and follow-up of errors in healthcare organizations have not resulted in improvement in patient safety. The New Look approach described in this article emphasizes the complexity in which healthcare workers make decisions about patient c are every day and how increased learning about the resiliency of healthcare workers in the face of multiple system gaps and discontinuities will lead to long-lasting improvements in safety. The article describes how the clinical nurse specialist can lead efforts using the New Look human performance-based approach in 4 areas: changing to a nonpunitive culture, learning about system complexity, learning about healthcare worker resiliency, and preparing for the complexity of introducing change.

Understanding hope and factors that enhance hope in women with breast cancer.

PURPOSE/OBJECTIVES: To examine the extent to which antecedent variables and appraisals differentiate levels of hope in women during treatment for breast cancer. DESIGN: Descriptive, correlational. SETTING: Two large midwestern urban areas. SAMPLE: 73 Caucasian women between the ages of 20-73 with first-time diagnosis of breast cancer; recruited through five physician offices; within three months after surgical intervention with planned chemotherapy, radiation therapy, or tamoxifen; and able to read English. METHODS: Identical surveys mailed to participants 3 and 12 months after surgery. Instruments included Lazarus' Appraisal Components and Themes Scales, Herth Hope Index, Rosenberg's Self-Esteem Scale, Personal Resource Questionnaire 85-Part 2, Helpfulness of Religious Beliefs Scale, and demographics questionnaire. MAIN RESEARCH VARIABLES: Appraisal, hope, self-esteem, social support, and helpfulness of religious beliefs. FINDINGS: Variables influencing appraisals during breast cancer treatment on both surveys were self-esteem and helpfulness of religious beliefs. Potential for coping appraisals and self-esteem contributed to variation in hope at both time points. Social support was a significant contributor to hope in the 12-month survey. Appraisal themes reflected challenge but not fear. CONCLUSIONS: Self-esteem and helpfulness of religious beliefs influence women's appraisals regarding the potential for coping; appraisals and antecedent variables relevant for differentiating hope are beliefs about the potential for coping, self-esteem, and social support. IMPLICATIONS FOR NURSING: Care of women with breast cancer during the first year of treatment should include assessment of beliefs regarding the potential for coping. Results suggest that support for interventions related to self-esteem, social support, and helpfulness of religious beliefs increase confidence in coping abilities and hope.