Utility of structured care approaches in education and clinical practice

Utility of a Diabetes Medication Poster in a Primary Care Clinic

Background: Diabetes with related complications is a common disease state seen in primary care and available therapies have increased exponentially. It is difficult for a busy primary clinician to know and utilize these options efficiently. Objective: The objective was to determine whether creating a diabetes medication poster that included costs, drug classification, adverse effects, and clinical outcomes/contraindications/cautions for use in an internal medicine/medicine-pediatric clinic improves resident and faculty knowledge, comfort, and awareness of those medications. Methods: This quality improvement prospective study was designed to evaluate the utility of a diabetes medication poster in a medicine/medicine-pediatric clinic over a 2-month period. A pre and post survey was electronically sent to all residents and faculty to assess their level of confidence and knowledge of diabetes medication treatment before and after the poster was distributed. This study was classified as exempt by the Institutional Review Board. Results: There were 40 physicians that responded to the pre survey and 31 to the post survey. Both surveys revealed >90% agreed or strongly agreed that the poster would decrease risk of adverse reactions, help control cost, and increase confidence to providers about diabetic medications. The knowledge score increased pre vs post survey (P = .0398). Conclusion: There are a myriad of tools that can be utilized to help navigate complex diseases. Posters have rarely been evaluated. Physicians viewed the diabetes medication poster as favorable to help decrease adverse effects and cost while increasing knowledge. Areas where visual aids could be effective without overwhelming the providers should be explored.

Towards standardisation of evidence-based clinical care process specifications

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

Barriers and Enablers to Implementing the Children's Hospital Early Warning Score: A Pre- and Post-Implementation Qualitative Descriptive Study

PURPOSE

The purpose of this study was to identify and compare barriers and enablers to the implementation of the Children's Hospital Early Warning Score (CHEWS) on a pediatric inpatient unit pre- and post-implementation.

DESIGN AND METHODS

A qualitative descriptive design, guided by the Theoretical Domains Framework, was used to conduct semi-structured focus groups and individual interviews with nurses on a pediatric inpatient unit to identify barriers and enablers in the pre- and post- CHEWS implementation phases. Data were analyzed using a directed content analysis approach followed by inductive thematic analysis.

RESULTS

Two pre-implementation focus groups (N = 15) and 8 post-implementation individual interviews with nurses were conducted. We identified pre- and post- CHEWS implementation barriers related to clinical decision making, interprofessional relationships, the unit context, and negative emotions, and enablers related to quality of care and patient safety. The identified barriers and enablers to implementation were categorized within 13 TDF domains.

CONCLUSIONS

Our findings illustrate a range of barriers and enablers to CHEWS implementation during the pre- and post-implementation phases. Tailored strategies are needed to overcome barriers related to nurses' perceptions of CHEWS impeding clinical decision-making and interprofessional collaboration. By addressing the identified barriers, we can leverage nurses' motivations for using CHEWS to improve the quality of patient care and enhance patient safety.

PRACTICE IMPLICATIONS

The barriers and enablers identified in this study can be used to select implementation strategies to support the use of early warning systems in pediatric nursing practice.

[Evaluation of nursing care systematization through the phases of nursing process performance and registration in a teaching hospital]

This descriptive study was carried out in a teaching hospital at São Paulo city and had as objective to identify the phases performance and registration of nursing care systematization and the most frequent nursing diagnoses. Data were collected retrospectively from 135 patients records of three units: Cardiology, Adult Infectious Diseases and Neurosurgery, from January to July, 2002. The phases: history, nursing diagnoses, prescription, evolution and assessment were performed and registered in the three units, however, it was verified systematization gaps performance related to nursing diagnoses registered without the realization of nursing history and nursing prescriptions without evolution. The most frequent nursing diagnosis in the three units was risk for infection.

Using evidence-based practice in providing care

Case managers are in prime positions that enable them to implement initiatives, which may lead to evidence-based practice. The possibilities abound regardless of the setting; case managers are charged with the delivery of patient care in the most efficient manner. When the best care is given to patients within the shortest time frame, everyone benefits--the patients and their families, case managers and other staff, and the entire organization. The various tools used to coordinate patient care--protocols and pathways--can be readily used to collect data in a standard way; this is a vital step in initiating evidence-based practice. Initiatives leading to evidence-based practice require several phases: obtaining evidence, monitoring the use of evidence, and evaluating the use of evidence in practice. This article will describe the use of evidence-based practice for case managers and demonstrate the steps to ensuring successful implementation in patient care activities.

Developing Nurses' Critical Thinking Skills With Concept Mapping

Observations and research in educational and practice settings suggest new nurses are not using critical thinking skills. Teaching strategies traditionally focused on linear modes of thinking--no longer as helpful in today's complex and crisis-driven contexts. Concept mapping has promise of promoting higher levels of thinking and may develop critical thinking--and decision-making skills--in less time and without intensive oversight by staff instructors. A case example is used to demonstrate the design of a concept map.

Developing Clinical Reasoning Strategies

Incorporating decision support research and technology, such as computerized "best practice" clinical pathways, into patient care management is recommended or decreasing cognitive demands on nurses. Criticized for not representing "real-time" patient care, these standardized approaches may be used in concert with strategies for developing nurses' own clinical reasoning. Real-time clinical information processing activities are offered for staff educators to augment the development of clinical reasoning for both experienced and less-experienced nurses' decision making.

Knowledge acquisition, synthesis, and validation: a model for decision support systems

BACKGROUND

Decision tools such as clinical decision support systems must be built on a solid foundation of nursing knowledge. However, current methods to determine the best evidence do not include a broad range of knowledge sources. As clinical decision support systems will be designed to assist nurses when making critical decisions, methods need to be devised to glean the best possible knowledge.

AIMS

This paper presents a comprehensive knowledge development process to develop a nursing clinical decision support system.

DISCUSSION

The Nurse Computer Decision Support Project (N-CODES) is developing a prototype for a prospective decision support system. The prototype is being constructed on rules and cases generated by the best available evidence. To accommodate the range of decisions made in practice, different types of evidence are necessary. The process incorporates procedures to uncover, evaluate, and assimilate information to develop the knowledge domain for a clinical decision support systems. Both formal and practice-based knowledge are included. The model contains several innovative approaches including the use of clinical experts and a network of practicing clinicians.

CONCLUSION

These strategies will assist scientists and practitioners interested in determining the best evidence to support clinical decision support systems.

Experienced and less-experienced nurses' diagnostic reasoning: implications for fostering students' critical thinking

PURPOSE

To compare the use of mental representations (heuristics) in diagnostic reasoning of expert (> or = 5 years' experience) and novice (< 5 years' experience) emergency nurses.

METHODS

Clinical simulations were completed by a nationwide randomly selected sample of 173 experienced and 46 less-experienced emergency nurses (N = 219).

FINDINGS

Experienced nurses used the heuristic, Judging by Causal Systems (diagnostic inferences deduced from systems of causal factors) significantly more did than less-experienced nurses.

PRACTICE IMPLICATIONS

Standardized nursing diagnoses may cut short the time needed to develop representational thinking and spare cognitive reserves for reasoning needed for complex patients. Faculty need to promote student's cognitive development through strategies that promote active, reflective, and integrative learning.