Post-operative epidural analgesia: introducing evidence-based guidelines through an education and assessment process

Implementation of a patient-held urinary catheter passport to improve catheter management, by prompting for early removal and enhancing patient compliance

Over the past few years a number of strategic initiatives to improve catheter management and reduce associated infections have been introduced. This paper details the introduction of a patient-held catheter passport and an improved documentation record using the PDSA (Plan, Do, Study, Act) cycle of change implementation in one large acute National Health Service (NHS) trust and local health economy (NHS Institute for Innovation and Improvement, 2008).

The evolution and practice of acute pain medicine

BACKGROUND

In recent years, the field of acute pain medicine (APM) has witnessed a surge in its development, and pain has begun to be recognized not merely as a symptom, but as an actual disease process. This development warrants increased education of residents both in the performance of regional anesthesia as well as in the disease course of acute pain and the biopsychosocial mechanisms that define interindividual variability.

REVIEW SUMMARY

We reviewed the organization and function of the modern APM program. Following a discussion of the nomenclature of acute pain-related practices, we discuss the historical evolution and modern role of APM teams, including the use of traditional, as well as complementary and alternative, therapies for treating acute pain. Staffing and equipment requirements are also evaluated, in addition to the training requirements for achieving expertise in APM. Lastly, we briefly explore future considerations related to the essential role and development of APM.

CONCLUSION

The scope and practice of APM must be expanded to include pre-pain/pre-intervention risk stratification and extended through the phase of subacute pain.

Saving Lives audits: do they improve infection prevention and control practice?

Aretrospective audit evaluation was conducted to determine whether the introduction of two clinical skills trainers for four months in a district general hospital improved compliance with infection prevention and control practices. Saving Lives (Department of Health, 2010) peripheral venous cannula and urinary catheter high impact intervention audit data were analysed for six months before, four months during and six months after the clinical skills training was implemented for six control wards and seven intervention wards. Findings showed that although the control wards did not improve compliance significantly over the study period, the intervention wards improved compliance with the high impact intervention care bundles studied and that this practice was sustained for six months after the clinical skills training. The findings suggest that education is required to improve clinical skills surrounding cannulation and catheterisation, which can then be sustained by Saving Lives audits to reduce the risk of infection to patients.

Advanced practice nurses' scope of practice: a qualitative study of advanced clinical competencies

AIM

To describe and explore Advanced Practice Nurses' clinical competencies and how these are expressed in clinical practice.

BACKGROUND

Discussion concerning advanced clinical practice has been ongoing in the USA since the 1960s and in the UK since the late 1980s. Approximately 24 countries, excluding the USA, have implemented the role of Advance Practice Nurse (APN). In the Nordic countries, especially Sweden and Finland, APNs have been introduced in some organizations but their competency domains have not yet been clearly defined.

THEORETICAL FRAMEWORK

The study's theoretical framework emanates from Aristotle's three-dimensional view of knowledge that is epistêmê, technê, and phronesis.

METHODS

Between October 2005 and January 2006, focus group interviews of Clinical Nurse Specialists who provide expert functions in pediatric, internal medicine, and surgical units (n = 26) and APN students (n = 8) were conducted. The data material was analyzed using inductive content analysis.

FINDINGS

Grouped into five main themes, the study results indicate that APNs possess advanced level clinical competencies in: (A) assessment of patients' caring needs and nursing care activities, (B) the caring relationship, (C) multi-professional teamwork, (D) development of competence and nursing care, and (E) leadership in a learning and caring culture.

CONCLUSION

Clinical competencies consist of advanced skills, which typify an expanding role that offers new possibilities for holistic patient care practice. APNs' scope of practice is characterized by responsibility and competence in making autonomous judgments based on expanded clinical competence. On an advanced level, clinical competence consists not merely of advanced skills for assessing and meeting the needs of patients but also the creation of safe and trustful relationships with patients and collaboration with colleagues. APNs can realize advanced skills in their actions through their manner of knowing, doing, and being.

Caring for critically ill children within an adult environment--an educational strategy

Within the author's workplace, a predominantly adult general Intensive Care Unit (ICU), a small number of critically ill children are admitted each year. This causes difficulties for adult nurses because they are required to utilize specialist paediatric knowledge and skills that are practised on an infrequent basis only. This can lead them to experience feelings of stress, anxiety and a lack of confidence when caring for this distinct patient group. To address these issues, an education strategy was planned and implemented, which required staff members to attend a study day, organize a one day clinical placement and achieve a personal learning objective pertaining to paediatrics. This involved collaboration between key stakeholders, links to the lead paediatric centre, incorporation of local organizational strategy and the use of effective change management skills. Written candidate evaluation and low-level quantitative data demonstrate an increase in knowledge and confidence amongst nurses following the study day. Whilst the study day forms part of a more global educational concept, and not a 'stand alone' initiative, the full benefits of the encompassing programme are yet to be fully established. The author recommends the implementation of a similar programme within other acute care areas that occasionally admit critically ill children.

Registered nurse management and monitoring of analgesia by catheter techniques: position statement

The American Society for Pain Management Nursing believes that the administration of analgesia and the management of the associated effects are fundamental nursing responsibilities. This position statement will address the registered nurse's responsibilities for the management and monitoring of analgesia by catheter techniques in all patients of all ages and in all care settings. It will provide recommendations for the health care institution, licensed independent practitioner, and registered nurse to ensure the safe and effective implementation of these pain control methods. The position statement reinforces the American Society for Pain Management Nursing's belief that the administration of analgesia by catheter techniques is within the registered nurse scope of practice.

The effect of education on hypothetical and actual oxygen administration decisions

AIM

This study examined the effect of an education intervention on emergency nurses' decisions related to oxygen administration.

METHOD

A controlled pre-test/post-test quasi-experimental design was used. The intervention was a written self directed learning package. Outcome measures were (i) factual knowledge measured using parallel form multiple choice questions (MCQs) and (ii) clinical decisions measured using parallel form MCQs, parallel form patient scenarios and clinical practice observation.

RESULTS

Eighty-eight nurses from 4 Melbourne EDs participated in the study (control group: n=37 and experimental group: n=51). Subgroups of nurses from the experimental group also participated in the patient scenarios (n=20) and clinical practice observation (n=10). Emergency nurses' knowledge increased as a function of education. Both patient scenario data and clinical practice observation showed decreased selection of nasal cannulae, increased selection of air entrainment masks and a trend towards selection of higher oxygen flow rates following education.

CONCLUSIONS

Evaluation of educational interventions in nursing should focus on identifying strategies that enhance learning in a clinical environment, are valid in terms of the clinical context and culture in which they are being used and most importantly, produce sustained improvements in actual clinical practice.

Effect of an evidence-based paediatric fever education program on emergency nurses’ knowledge

INTRODUCTION

This study examined the effect of an educational intervention of factual knowledge on emergency nurses' knowledge and clinical decisions related to paediatric fever.

METHOD

A prospective pre-test/post-test design was used. Emergency nurses' factual knowledge was measured by parallel multiple choice questions and the intervention for the study was an educational intervention consisting of two tutorials. Pre-test data were collected in early June 2005 and post-test data were collected during August 2005.

RESULTS

Thirty-one emergency nurses completed the pre and post-test multiple choice questions. Emergency nurses' knowledge increased following the tutorials. Pre-test score was positively correlated with knowledge acquisition. Self-reports of independent decisions related to fever management were influenced by experience, hours of employment, level of appointment, postgraduate qualifications and pre-test score.

DISCUSSION

High levels of variability in knowledge and knowledge acquisition suggest a review of undergraduate and postgraduate curricula is warranted. Although this study identified associations between independent fever management decisions and participant characteristics, further research is pivotal to better understanding these relationships.

Continuing education at the cutting edge: promoting transformative knowledge translation

As the evidence-based practice movement gains momentum, continuing education practitioners increasingly confront the challenge of developing and conducting opportunities for achieving research uptake. Recent thinking invites new approaches to continuing education for health professionals, with due consideration of what knowledge merits uptake by practitioners, who should play what role in the knowledge transfer process, and what educational approach should be used. This article presents an innovative theory-based strategy that encompasses this new perspective. Through a facilitated experience of perspective transformation, clinicians are engaged in an on-the-job process of developing a deeply felt interest in research findings relevant to everyday practice, as well as ownership of that knowledge and its application. The strategy becomes a sustainable, integrated part of clinical practice, fitting naturally within its dynamic, unique environment, context, and climate and overcoming the barrier of time. Clinician experience of a top-down push toward prescribed practice change is avoided. With an expanded role encompassing facilitation of active learning partnerships for practice change, the continuing educator fosters a learning organization culture across the institution. The resultant role changes and leadership and accountability issues are elaborated.

The Pain Experience of Post Surgical Patients Following the Implementation of an Evidence-Based Approach

Effective pain management has been shown to promote earlier mobilization, adequate rest, reduced hospital stays, postoperative complications, and costs. A multidisciplinary quality improvement team worked together to develop and implement a comprehensive evidence-based program for postoperative pain management. The purpose of this study was to assess surgical patients' pain status, satisfaction, and beliefs with regard to pain management prior to (Phase 1) and following the implementation of the program (Phase II). On postoperative day two, patients rated their pain, its impact on their activity, and answered questions about pain management and their satisfaction with pain treatment. Significant differences were found between Phase I and Phase II patients. More patients in Phase II (83%) received evidence-based orders compared with patients in Phase I (35%). Patients in Phase II had lower pain scores and experienced fewer disturbances in sleep, walking, and general activities. Patients in Phase II were less likely to believe that good patients avoid talking about pain. The results suggest that addressing pain management through a variety of strategies targeted at the level of the institution, the clinician, and the patient may lead to desired changes in practice and better outcomes for patients.

Evidence-Based Perianesthesia Care: Accelerated Postoperative Recovery Programs

Prolonged stress response after surgery can cause numerous adverse effects, including gastrointestinal dysfunction, muscle wasting, impaired cognition, and cardiopulmonary, infectious, and thromboembolic complications. These events can delay hospital discharge, extend convalescence, and negatively impact long-term prognosis. Recent advances in perioperative management practices have allowed better control of the stress response and improved outcomes for patients undergoing surgery. At the center of the current focus on improved outcomes are evidence-based fast-track surgical techniques and what is commonly referred to as "accelerated postoperative recovery programs." These programs require a multidisciplinary, coordinated effort, and nurses are essential to their successful implementation.

Effect of a self-directed learning package on emergency nurses' knowledge of assessment of oxygenation and use of supplemental oxygen

Emergency nurses frequently and independently make decisions regarding supplemental oxygen. The importance of these decisions for patients is highlighted by the well documented association between respiratory dysfunction and adverse events. This study aimed to: (i) examine the effect of educational preparation on emergency nurses' knowledge of assessment of oxygenation, and the use of supplemental oxygen; (ii) explore the impact of existing knowledge on decisions related to the implementation of supplemental oxygen; and (iii) explore nurses' characteristics that were associated with effectiveness of the educational preparation. A pretest/post-test, controlled, quasi-experimental design was used in this study. Educational preparation was effective in increasing emergency nurses' knowledge. Baseline level of knowledge was predictive of reports of independent decisions regarding the implementation of oxygen. There was a significant positive relationship between postgraduate qualification in emergency nursing and the effect of education, and significant negative relationships between effect of education and baseline level of knowledge and daily decisions to implement supplemental oxygen.

Assessing the postoperative patient: Philosophy, knowledge and theory

The assessment of the postoperative patient is critical in identifying the patient's current condition and to monitor any complications that might occur. However, many nurses fail to realize the implications that philosophical paradigms, knowledge and theoretical concepts bring to the assessment practice and the manner in which assessment is conducted; in particular, within 24 h after surgery. This article seeks to explore the usefulness of philosophy, knowledge and theory as they relate to nursing assessment of the postoperative patient within the initial 24 h after surgery. It is the duty of nurses to select and effectively apply appropriate philosophical dimensions, knowledge and theories in practice and critically evaluate these areas with respect to assessment of the postoperative patient, thus aiming for a holistic assessment of the patient.

A discharge protocol for the postanaesthetic recovery unit

Despite guidelines from the Royal College of Anaesthetists, some hospitals still do not have a formal discharge policy. The author of this article works within an operating department in the dual role of anaesthetic and recovery sister and has a particular interest in discharge criteria for postanaesthetic recovery patients. She suggests that a discharge protocol, developed in a multidisciplinary setting, should be in place in the postanaesthetic recovery unit.