The delivery of compassionate nursing care in a tick-box culture: Qualitative perspectives from a realist evaluation of intentional rounding

Perceived Value of Holistic Needs Assessment in Supporting the Needs of Women With Breast Cancer

BACKGROUND

Holistic needs assessments (HNAs) were designed to identify and support the physical, psychological, and social impacts of cancer, yet delivery methods vary significantly.

OBJECTIVE

The study aimed to explore views of HNAs from the perspectives of healthcare professionals and women with breast cancer, including how the HNA contributed to providing support.

METHODS

A qualitative case study approach was adopted, with 4 hospitals in England. Twenty-four women with cancer and 24 staff were recruited. Data from interviews, observations, and HNA-related documentation were compiled into cases around use of the HNA in each organization. Principles of framework analysis and Normalization Process Theory enabled identification of conclusions.

RESULTS

The contribution of HNA to women's experiences of support was complex and dependent on various influences: (1) how the woman's own views and judgments influenced her perceptions of the assessment, (2) how the views of staff delivering the HNA influenced both their own approach to the assessment and patient views, and (3) the organizational context and culture.

CONCLUSION

Apparent superficial implementation of HNAs seemed to facilitate organizational cultures of evidencing the actions of staff and achieving management targets. Women's views toward the HNA appeared paradoxical; most women perceived the HNA to be meaningful "in principle" but reported little benefit of the assessment, and some reported negative outcomes.

IMPLICATIONS FOR PRACTICE

Holistic needs assessment implementation in clinical settings requires a greater focus on quality over targets, and healthcare professional training should be centered around delivering HNAs in a meaningful way that prioritizes individual patient benefit.

Structured interactions between nurses and patients through intentional rounding: A scoping review

AIM

To synthesize existing literature describing the impact of intentional rounding on patient outcomes among hospitalized adults.

BACKGROUND

Intentional rounding has been described as purposeful therapeutic communication between nurses and patients during regular checks with patients using standardized protocols. Despite the widespread adoption of intentional rounding, the current understanding of the benefits of these structured interactions between nurses and patients is limited.

INTRODUCTION

The critical role of nurses in ensuring high-quality and safe care in acute hospitals is often noted only when things go wrong. This was highlighted by investigations into the reasons for the failures in patient care at the Mid Staffordshire National Health Services.

METHODS

A scoping review was performed and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines.

FINDINGS

Sixteen studies were included in the final review. Various rounding models were noted among different clinical settings; four studies reported a significant reduction in falls, and a further three reported a decrease in pressure injuries. Two studies reported a reduction in call bell usage. Significant improvements in patients' satisfaction with intentional rounding were reported in three studies.

DISCUSSION

Promoting intentional rounding without solid evidence of its acceptability, feasibility, and suitability in different clinical settings could compromise nurses' ability to provide safe care.

CONCLUSION AND IMPLICATIONS FOR NURSING

There is weak evidence of the effectiveness of intentional rounding on patient outcomes because of the diversity of methods employed and methodological limitations in many studies. Our findings identify the need for robust studies to explore the acceptability and feasibility of a rounding protocol that can be implemented in different clinical settings.

Implementing interventions to improve compassionate nursing care: A literature review

AIM

To identify strategies which support the implementation of interventions to promote compassionate nursing care with a focus on interventions designed to support improved patient outcomes and/or patient experience in acute hospitals.

METHODS

An integrative review using the PRISMA guidelines and a 5-stage framework consisting of problem identification, literature search, data evaluation, data analysis and presentation. CINAHL, Embase, Medline, PsychInfo and Web of Science were systematically searched using key search terms. Hand searches were conducted of the reference lists of eligible articles and searching key journals.

RESULTS

Six articles met the inclusion criteria with six different interventions described. A thematic analysis of the findings identified three key themes relating to the implementation of interventions which promote compassionate nursing care: (1) the importance of evidence; (2) support for nursing development; and (3) planning for and leading implementation.

CONCLUSION

Compassionate care improves quality of life, the hospital experience and overall recovery. Strong nursing leadership and a supportive team environment are facilitators for delivery of compassionate care in acute settings. Excessive workload, overly rigid reporting and organisational indifference are barriers to delivery of compassionate care.

IMPLICATIONS FOR NURSING POLICY

Health policy is used to inform the systematic implementation and delivery of patient care informed by best evidence. Health setting, environment and culture are important facets of the implementation of a compassionate care framework. Furthermore, nurse engagement, teamwork and nurse leadership are key facilitators for delivery of compassionate care in acute hospital settings. These findings need to be taken into consideration by policy makers and nursing leaders when designing and implementing compassionate care interventions.

IMPLICATIONS FOR NURSING POLICY

Implementing interventions to improve compassionate nursing care can be challenging. This review identified the factors which should be considered by policy makers when implementing these interventions systematically throughout the healthcare system.

A facilitator's reflection on the democratizing potential of emancipatory practice development

Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

Nurse manager intentional rounding and outcomes: Findings of a systematic review

AIM

To summarize the evidence available on Nurse Manager Intentional Rounding (NMIR) describing the main characteristics and methodological quality of studies available, the features of rounding and the outcomes as measured to date.

DESIGN

A systematic review.

DATA SOURCES

Electronic databases, including MEDLINE-EBSCHOST, PubMed, CINAHL, Scopus, Cochrane, Clinicalkey, ScienceDirect, OVID, Sage Journals and Web of Science, were searched up to June 2021.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guideline was used to summarize methods and report findings. The Joanna Briggs Institute Critical Appraisal tools were used to evaluate the methodology quality of the studies included.

RESULTS

Seven studies were included with pre-post-test (n = 3), longitudinal, two-group post-tests, quasi-experimental, and retrospective study designs (n = 1, respectively). In five studies, the nurse managers were trained to conduct the rounding, which was shaped according to three main features: a structured (n = 4), a semi-structured (n = 1) and an unstructured rounding (n = 2) delivered from high (twice a day 7/7) to low intensity (once a day, 5/7). Two main outcomes have been measured to date, the patient satisfaction and some aspects related to the care quality. Five studies reported that the satisfaction scores of patients who received rounding were significantly higher than that perceived by patients not receiving rounding. About the other aspects of the quality of care, two studies documented significant improvements as a consequence of the NMIR (e.g. information accessibility, discharge instructions, coordination of care after discharge).

CONCLUSION

Studies available report in general a low methodological quality, mainly due to their pragmatic nature as quality improvement projects. Therefore, transforming this field of research by establishing a methodological rigour and a theoretical foundation in both interventions and outcomes and by designing experimental approaches, might expand the evidence available on the effects of nurse managers intentional rounding.

An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse-patient interactions and communication

AIM

To explore how nurses' use of electronic health records impacts on the quality of nurse-patient interactions and communication.

DESIGN

An integrative review.

DATA SOURCES

MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022.

REVIEW METHODS

Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach.

RESULTS

One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face-to-face communication, promotes task-orientated and formulaic communication and impacts on types of communication patterns.

CONCLUSION

Research examining nurse-patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse-patient communications, reflecting a task-driven approach, were predominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient.

IMPACT

The move to electronic health records has taken place largely without consideration of the impact that this might have on nurse-patient interaction and communication. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse-patient interactions and communication.

PATIENT OR PUBLIC CONTRIBUTION

Studies examined within this review included patient participants that informed the analysis and interpretation of data.

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: A cross-sectional survey

BACKGROUND

Preventable harms during hospitalization pose a major challenge for health systems globally. Nurse-led strategies provide comprehensive harm prevention to keep the most vulnerable patients safe in hospital, but gaps in care are common. Nursing roles and activities to prevent harm to patients during acute hospitalization are poorly understood.

AIM

The aim of this study was to identify nurses' perceived enablers and barriers to the implementation of comprehensive harm prevention for older people admitted to an acute hospital setting.

DESIGN

Anonymous, online, cross-sectional survey.

METHODS

The adapted Influences on Patient Safety Behaviours Questionnaire (IPSBQ) was used to collect data from nurses working on five general medicine wards across three hospitals of a single tertiary health service in Australia in 2019. Participants also rated their perceptions of overall quality of care, missed care and awareness of strategies for an eight-factor framework for comprehensive harm prevention. The STROBE reporting checklist was used.

RESULTS

Ward response rates between 35% and 58% resulted in 132 complete questionnaires for analyses. High mean scores for behavioural regulation (3.28), beliefs about capabilities (2.96) and environmental context and resources (2.73) indicated these domains were perceived by nurses as enablers. Low mean scores for the domains of intentions (1.65), beliefs about consequences (1.69), optimism (1.72) and professional role and identity (1.85) indicated these were barriers to comprehensive harm prevention by nurses. High perceived quality of care (scored 9-10/10) (p = .024), and awareness of strategies for the eight-factor framework (p = .019) were significant enablers of comprehensive harm prevention.

CONCLUSION

Targeted evidence-based strategies that include education, persuasion, incentivization, coercion and modelling would be most useful for promoting comprehensive harm prevention by nurses. However, to be most effective the harm prevention strategy may need to be tailored for each ward.

Nurses' harm prevention practices during admission of an older person to the hospital: A multi-method qualitative study

BACKGROUND

Nurses' harm prevention practices during the admission of older persons to hospital have important consequences for patient safety, preventable patient harm and length of hospital stay. Novel solutions are needed to assist nurses to balance complexity, high workload burden and patient safety during admission processes.

AIM

Explore the nurses' experiences of harm prevention practices during the admission of an older person to the hospital.

DESIGN

A multi-method qualitative study informed by frameworks of behaviour change and human-centred co-design.

METHODS

The purposive sample included 44 nurses, 5 clinicians from other disciplines and 3 consumers recruited from five general medicine wards across three hospitals of a large public health service in metropolitan Melbourne, Australia. Data were collected over 12 h of naturalistic observations of nurses during eight patient admissions, and during four participatory human-centred co-design workshops between August 2019 and January 2020. Observation, field notes and workshop artefact data were integrated for qualitative content and thematic analysis.

RESULTS

Analysis revealed a 5-step journey map, with a temporal logic, that captured nurses' experiences, as well as the enablers and barriers to harm prevention practices when admitting an older person to the hospital. The consensus was reached on three priority features to assist nurses to implement harm prevention practices when they admit an older person to the hospital: (1) prioritize important care; (2) tailor care to the individual and (3) see the big picture for the patient.

CONCLUSION

The novel research approach identified five steps in nurses' activities and harm prevention practices during admission of an older person to the hospital, and key features for a solution to assist nurses to keep patients safe. The findings provide the foundation for further research to develop interventions to assist nurses to manage high workloads during this complex activity.

Nurses’ Experiences After Implementation of an Organization-Wide Electronic Medical Record: Qualitative Descriptive Study

Background

Reports on the impact of electronic medical record (EMR) systems on clinicians are mixed. Currently, nurses’ experiences of adopting a large-scale, multisite EMR system have not been investigated. Nurses are the largest health care workforce; therefore, the impact of EMR implementation must be investigated and understood to ensure that patient care quality, changes to nurses’ work, and nurses themselves are not negatively impacted.

Objective

This study aims to explore Australian nurses’ postimplementation experiences of an organization-wide EMR system.

Methods

This qualitative descriptive study used focus group and individual interviews and an open-ended survey question to collect data between 12 and 18 months after the implementation of an EMR across 6 hospital sites of a large health care organization in Victoria, Australia. Data were collected between November 2020 and June 2021, coinciding with the COVID-19 pandemic. Analysis comprised complementary inductive and deductive approaches. Specifically, reflexive thematic analysis was followed by framework analysis by the coding of data as barriers or facilitators to nurses’ use of the EMR using the Theoretical Domains Framework.

Results

A total of 158 nurses participated in this study. The EMR implementation dramatically changed nurses’ work and how they viewed their profession, and nurses were still adapting to the EMR implementation 18 months after implementation. Reflexive thematic analysis led to the development of 2 themes: An unintentional divide captured nurses’ feelings of division related to how using the EMR affected nurses, patient care, and the broader nursing profession. This time, it’s personal detailed nurses’ beliefs about the EMR implementation leading to bigger changes to nurses as individuals and nursing as a profession than other changes that nurses have experienced within the health care organization. The most frequent barriers to EMR use by nurses were related to the Theoretical Domains Framework domain of environmental context and resources. Facilitators of EMR use were most often related to memory, attention, and decision processes. Most barriers and facilitators were related to motivation.

Conclusions

Nurses perceived EMR implementation to have a mixed impact on the provision of quality patient care and on their colleagues. Implementing technology in a health care setting was perceived as a complex endeavor that impacted nurses’ perceptions of their autonomy, ways of working, and professional roles. Potential negative consequences were related to nursing workforce retention and patient care delivery. Motivation was the main behavioral driver for nurses’ adoption of EMR systems and hence a key consideration for implementing interventions or organizational changes directed at nurses.

Compassion in healthcare: an updated scoping review of the literature

BACKGROUND

A previous review on compassion in healthcare (1988-2014) identified several empirical studies and their limitations. Given the large influx and the disparate nature of the topic within the healthcare literature over the past 5 years, the objective of this study was to provide an update to our original scoping review to provide a current and comprehensive map of the literature to guide future research and to identify gaps and limitations that remain unaddressed.

METHODS

Eight electronic databases along with the grey literature were searched to identify empirical studies published between 2015 and 2020. Of focus were studies that aimed to explore compassion within the clinical setting, or interventions or educational programs for improving compassion, sampling clinicians and/or patient populations. Following title and abstract review, two reviewers independently screened full-text articles, and performed data extraction. Utilizing a narrative synthesis approach, data were mapped onto the categories, themes, and subthemes that were identified in the original review. Newly identified categories were discussed among the team until consensus was achieved.

RESULTS

Of the 14,166 number of records identified, 5263 remained after removal of duplicates, and 50 articles were included in the final review. Studies were predominantly conducted in the UK and were qualitative in design. In contrast to the original review, a larger number of studies sampled solely patients (n = 12), and the remainder focused on clinicians (n = 27) or a mix of clinicians and other (e.g. patients and/or family members) (n = 11). Forty-six studies explored perspectives on the nature of compassion or compassionate behaviours, traversing six themes: nature of compassion, development of compassion, interpersonal factors related to compassion, action and practical compassion, barriers and enablers of compassion, and outcomes of compassion. Four studies reported on the category of educational or clinical interventions, a notable decrease compared to the 10 studies identified in the original review.

CONCLUSIONS

Since the original scoping review on compassion in healthcare, while a greater number of studies incorporated patient perspectives, clinical or educational interventions appeared to be limited. More efficacious and evidence-based interventions or training programs tailored towards improving compassion for patients in healthcare is required.

Nurses' Perceptions of Hourly Rounding in Jordanian Hospitals: A National Survey

AIM

To explore nurses' perceptions of hourly rounding in Jordanian hospitals.

BACKGROUND

Hourly rounding is a standardized and systematic process conducted by nurses to anticipate and address needs in hospitalized patients. The evidence on hourly is mixed, and research is needed to affirm the benefits of implementing hourly rounding across different contexts.

METHOD

A cross-sectional correlational design was used. A convenient sample of 1378 nurses was recruited from one Military hospital, two university-affiliated hospitals, four governmental hospitals, and four private hospitals in Jordan. The Hourly Rounding Questionnaire was used to collect data. Descriptive statistics, T-test, one-way ANOVA, and Kruskal-Wallis H test were used to analyze the data.

RESULTS

The highest agreements between nurses were on the items related to the implementation of hourly rounding in terms of preventing patient falls" 1211(87.9%), "preventing hospital-acquired pressure ulcers" 1201(87.2%) and addressing patients' position" 1199(87%). The lowest agreements between nurses were on the items related to the involvement of nurses in the decision-making process and sense of ownership 268(19.4%), and the availability of continued support and resources 239(17.3%). Female nurses, nurses who often work on a shift rotation, nurses working in private hospitals and respiratory units had a positive perception of hourly rounding.

IMPLICATIONS FOR NURSING PRACTICE

Findings will inform nursing leaders and policy developers about the implementation of hourly rounding from nurses' perspectives. A protocol should accompany hourly rounding for robust evaluation to measure the impact of this process change with the involvement of nurses in the decision-making process.

Illuminating Nursing's Value: The 12 Anthroposophic Nursing Gestures

Nursing care historically has not been separated from institutional care costs. Organizations seek to quantify nursing care with no assignation of the value or uniqueness of the individual patient-nurse encounter. New models point to measuring care at this level. Nursing care encompasses tangible evidence that can be easy to quantify but, in the paradigm of healing and caring, and more specifically within the knowledge pool of holistic nursing, significant contributions are intangible and thus hard to measure. Anthroposophic nursing's 12 nursing gestures offer an integration by making intangible nursing practice tangible. They incorporate addressing the whole person and more clearly show the caring and healing aspects of nursing care. Making such intangibles of care tangible contribute to the discussion of nursing value and how it is measured in healthcare organizations. More research is needed, however, to refine and value nursing care to more accurately reflect the connection between caring, healing, and patient outcomes.

Building safety cultures at the frontline: An emancipatory Practice Development approach for strengthening nursing surveillance on an acute care ward

AIM

To evaluate an emancipatory Practice Development approach for strengthening nursing surveillance on a single medical-surgical ward.

BACKGROUND

Registered nurses keep patients safe in acute care settings through the complex process of nursing surveillance. Our interest was understanding how frontline teams can build safety cultures that enable proactive nursing surveillance in acute care wards.

DESIGN

A year-long emancipatory Practice Development project.

METHODS

A collaborative relationship was established around a shared interest of nursing surveillance capacity and researcher embedded on a medical-surgical ward. Critical analysis of workplace observations and reflection with staff generated key sites for collective action. Ward engagement was supported by creative Practice Development methods including holistic facilitation, critical reflection and action learning. An action learning set was established with a group of clinical nurses, facilitating practitioner-led change initiatives which strengthened nursing surveillance and workplace learning. Evaluation supported an iterative approach, building on what worked in an acute care context. Immersive researcher evaluation, drawing on multiple data sources, generated an analysis of how ward nursing surveillance capacity can be strengthened. COREQ criteria guided reporting.

RESULTS

The ward moved through a turbulent and transformative process of resistance and retreat towards a new learning culture where nursing surveillance was visible and valued. Staff developed and sustained innovations including the 'My MET Call series', a 'Shared GCS initiative', an enhanced 'Team Safety Huddle', and staff-led Practice Development workshops. These new practices affirmed nurses' agency, asserted nurses' clinical knowledge, positioned nurses to participate in team decision-making and humanised care.

CONCLUSION

Working collaboratively with frontline staff enabled bottom-up sustainable innovation to strengthen nursing surveillance capacity where it mattered most, at the point of care.

RELEVANCE TO CLINICAL PRACTICE

Emancipatory Practice Development enables the profound impact of small-scale, microsystem level practice transformation. It is an accessible methodology for clinical teams to develop effective workplace cultures.

A thematic analysis of the prevention of future deaths reports in healthcare from HM coroners in England and Wales 2016–2019

Background

The Coroners and Justice Act allows coroners in England or Wales to issue reports after inquest, if they believe that action should be taken to prevent a future death. Coroners are under a statutory duty to issue a Prevention of Future Death (PFD) report to persons or organisations that they believe have the power to act. Cumulatively, these reports may contain useful intelligence for patient safety. The aim of this study was to examine the feasibility of extracting data from these reports and to evaluate if learning was possible from any common themes.

Methods

Reports were extracted from 2016 to 2019 for deaths in hospitals, care homes and the community in England and Wales. These were subjected to descriptive statistics and thematic analysis of coroner’s concerns. Application of data mining techniques was not possible due to data quality.

Results

710 reports were examined, with 3469 concerns being raised (mean 4.88, range 1–33). 36 reports expressed concern about having to issue repeat PFDs to the same organisation for the same or similar concerns. Thematic analysis reliability was high ( κ 0.89 unweighted) with five emerging primary themes: deficit in skill or knowledge, missed, delayed or uncoordinated care, communication and cultural issues, systems issues and lack of resources. A codebook of 53 subthemes were identified.

Conclusions

PFD reports offer valuable insight. Aggregation and continued analysis of these reports could offer more informed patient safety, workforce development and organisational policy. Improved data quality would allow for possible automation of analysis and faster feedback into practice.