The significance of primary nursing

The work of nurses to provide good and safe services to children receiving hospital-at-home: A qualitative interview study from the perspectives of hospital nurses and physicians

AIM

To explore and describe the work performed by the nurses providing hospital-at-home care to children and their families from the perspectives of hospital nurses and physicians.

BACKGROUND

To reduce capacity pressure on hospitals, various ambulatory services combining hospital and home treatment have emerged. Studies have shown that children and their families are satisfied with hospital-at-home when the parents experienced the professionals possessed the necessary competences. Knowledge is limited about nurses and physicians' perspectives on the work performed and competence needed when children receive hospital treatment in the family's home.

DESIGN

A qualitative descriptive design with semi-structured interviews was used. Sixteen nurses and physicians from two hospitals in Norway working in hospital-at-home for children were recruited to interview. Data were analysed using systematic text condensation. In preparing the manuscript, we applied the COREQ guidelines. The theory on 'expert nursing' supported the discussion of results.

RESULTS

We identified three categories through analysis; building a trustful relationship with the family and the sick child; performing essential skills in paediatric nursing care in hospital-at-home; and nurses serving as the 'hub' between the different parties.

CONCLUSION

The results demonstrate the complexity of the work performed by hospital nurses when children received hospital-at-home. Building a trustful relationship and alliance with the child and the family formed the cornerstone of accomplishing good and safe paediatric care. The nurses became a coordinating and collaborating 'hub' for actors involved, taking care of patient safety on a daily basis.

RELEVANCE TO CLINICAL PRACTICE

The way the nurses approached the children and their families, was the core element of the paediatric nursing expertise and important for the service quality and patient safety. The importance of building a trustful relationship needs to be more acknowledged, and the services would benefit to organise this through continuity of care.

Family Involvement in Managing Violence of Mental Health Patients

PURPOSE

This study aimed to explore relatives' perceptions of violent episodes and their suggestions on managing violence.

DESIGN AND METHODS

Qualitative design with focus groups including relatives (n = 8) was carried out. Data were analyzed using inductive content analysis.

FINDINGS

The relatives described patient violence in different contexts: at home, in a psychiatric hospital, and after discharge from the psychiatric hospital. They suggested interventions to achieve safer and more humane management of violent episodes.

PRACTICE IMPLICATIONS

Relatives are a valuable source of information in developing strategies to manage patient violence humanely. Their views on developing the quality of psychiatric care merit more attention.

Awareness of the Care Team in Electronic Health Records

OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.

Traditional models of care delivery: what have we learned?

Traditional models of patient care delivery include total patient care and functional, team, and primary nursing. These models differ in clinical decision making, work allocation, communication, and management, with differing social and economic forces driving the choice of model. Studies regarding quality of care, cost, and satisfaction for the models provide little evidence for determining which model of care is most effective in any given situation. Despite lack of evidence, newer models continue to be implemented. This article compares the advantages and disadvantages of models, critiques the existing studies, and offers recommendations regarding the evidence needed to make informed decisions regarding care delivery models.

Resident-oriented care in nursing homes: effects on nurses

BACKGROUND

In a resident-oriented care model the assignment of patients to primary nurses takes place. These primary nurses are responsible for the total nursing care of their patients and make use of the nursing process. According to job demand-control models, these enlarged and enriched jobs can be described in terms of autonomy, job demands and social support, and the presence of these work characteristics has a positive influence on workers' psychological and behavioural outcomes.

AIMS

This paper reports a study to investigate the extent to which the various features of resident-oriented care were implemented and its effects nurses' on work characteristics and on psychological and behavioural outcomes in three Dutch nursing homes.

METHODS

In a quasi-experimental design, experimental and control groups were followed over 22 months, using a pretest and two post-tests with questionnaires, interviews and qualitative observations.

RESULTS

The quantitative data showed significant increases in resident assignment, the two variables measuring the nursing process and, in the psycho-geriatric experimental group, on resident-oriented tasks. The qualitative data showed that a partly task-oriented division of labour was still used and that the planned delegation of coordination tasks to primary nurses was not fully achieved. Effects on work perceptions were limited. After implementation of the new system, the experimental group showed an increase in job autonomy.

CONCLUSIONS

The intervention appeared to be only partly successful. Most of the expected results regarding work characteristics and psychological and behavioural outcomes did not materialize. Theoretical and methodological reflections are presented in the light of these findings.

Teamworking in nursing homes

BACKGROUND

Nursing homes have an important role in the care of frail older people, but concerns have been raised about the quality of care. High standards of care appear to be facilitated when nurses work in effective teams. Greater understanding of teamworking in nursing homes could have implications for training and policy-making.

AIM

The aim of the study was to explore the experiences and perceptions of teamworking with qualified nurses working in nursing homes.

METHOD

This was a small, exploratory focus group study. The sample was 12 qualified nurses working in nursing homes in the south of England. Transcriptions of the focus groups were coded by the research team and agreement was achieved by discussion.

FINDINGS

Teams described were constructed in 'vertical', hierarchical terms rather than as 'flat', collaborative structures. The achievement of good teamworking was hindered by inadequate communication, particularly as many staff worked part-time and on shifts. Management was perceived as remote, and lines of authority were ambiguous and unfocused.

CONCLUSIONS

This group of nurses were aware of the difficulties of working in a hierarchical, profit-making culture. Individually, they tried to provide good quality care for patients and aspired to teamworking, but seldom succeeded to their satisfaction. There may be considerable potential to improve the working lives of staff and quality of patient care by effective teamworking. However, significant barriers, particularly concerning organizational culture, need to be overcome.

Team nursing and ITU--a good combination?

Deficits in 'measurable care', in an 11-bedded intensive care unit, prompted a pilot study of team nursing. Team nursing was introduced for three beds out of the total 11 for a period of six months. In order to evaluate the effects, aspects of care and job satisfaction were measured and compared between the team nursing beds and the rest of the unit. The study revealed that job satisfaction and the levels of 'measurable care' did not improve whilst team nursing was practised. Based on this evidence, the authors question the relevance of team nursing in this particular intensive therapy unit (ITU) and maintain that the best method of delivering nursing care in ITU remains unclear.

Individualized care: its conceptualization and practice within a multiethnic society

This paper reports on the selected findings from a larger ethnographic study of the provision of individualized care by district nurses to patients from different ethnic backgrounds. Undertaken in an English community National Health Service (NHS) Trust serving an ethnically diverse population, the study comprised two stages. First, an organizational profile of the Trust was undertaken in order to analyse the local policy context. Data were collected by means of in-depth interviews with managers and a review of policy documentation and caseload profiles. Second, a participant observational study was undertaken focusing on six district nursing teams. Purposive sampling was used to identify four teams with high minority ethnic caseloads and two teams with predominantly white ethnic majority caseloads. Interview transcripts and field notes were analysed by drawing upon the principles of dimensional analysis. This paper focuses upon aspects of the second stage, namely how the nurses' conceptualized and practised individualized care. Six principles underpinning the philosophy of individualized care expounded by the nurses were identified: respecting individuality; holistic care; focusing on nursing needs; promoting independence; partnership and negotiation of care; and equity and fairness. Each is examined in turn and consideration given to how they were modified in their transformation into practice. Some implications for patients from minority ethnic backgrounds of the nurses' conceptualization and practice of individualized care are discussed. The lack of internal consistency within the nurses' discourse, the impact of policy directives on care delivery and the influence of factors outside the nurses' control, served to illuminate the complexity whereby the ideals of individualized care were adjusted and reworked in the realities of everyday nursing practice. This in turn raised questions about the appropriateness of the current interpretation and practice of individualized care in a multi-ethnic society.

Outcomes of implementing primary nursing in the care of people with chronic lung diseases: the nurses' experience

AIM

This study describes the outcomes of an action research project carried out to implement primary nursing in the care of people with chronic lung diseases at two hospital units in Iceland.

METHODS

The methodological approach was the interpretative perspective. Data from transcribed interviews with 21 nurses and a research journal written by the author were analysed. Themes were generated according to dialectical procedures of interpretation.

FINDINGS

The following themes were identified: close relationships with patients, continuity of care, reports of satisfied and secure patients, centrality of individual patient's needs, constant refinement of the system, sensitivity to staffing load and ambitious and responsible nurses.

CONCLUSIONS

The nurses participating in this study clearly valued the possibilities that primary nursing brought in terms of higher quality of care for their patients. One of the most important components of high quality care is to know and understand patients' experiences, which is the main outcome of this study. This indicates that implementing primary nursing in the care of people with chronic lung diseases was beneficial from the point of view of the nurses. However, concerns were raised that primary nursing is more sensitive to low staffing than the system it was meant to replace.

Lost in the crucible of supportive clinical supervision: supervision is not therapy

Clinical supervision as a mechanism that supports both professional and personal development is a concept that has captured the imagination of nurses. Though nurses generally agree that 'supervision is not therapy', a clear distinction cannot be enunciated between these two processes when both aim at personal growth. In combining personal and professional growth, the rationale for clinical supervision is unnecessarily confused, with the unfortunate result that supervision may, unwittingly, become a form of therapy for nurses. This paper examines a model of supportive clinical supervision qua Chambers and Long's example of a facilitative therapeutic supervisory style, that reflects nurses' conceptualization of clinical supervision as enhancing personal and professional growth. However, it could be argued that this stance is in crucial respects incorrect, and needs to be rethought if clinical supervision is to be established as credible in nursing. Subsequently, it is important to remember that the utilization of certain techniques rather than their stated goals, will dictate the form that supervision, or therapy, will take. The purpose of this paper is to demonstrate the logical unacceptability in combining two processes as one, while developing a conceptual framework that differentiates supervision from therapy.

Named nursing: in whose best interest?

This paper explores certain influences and issues surrounding the implementation and application of the named nurse concept. The author critically examines the proposals that primary nursing increases job satisfaction, cost effectiveness and quality of care, and suggests that as primary nursing appears to be the template for named nursing, these are factors which may have influenced the former British government's decision to implement the concept of named nursing. Owing to problems regarding the reliability and validity of much of the research, the author draws the conclusion that the direct extrapolation from one concept (such as primary nursing) to another (such as named nursing) is perhaps open to question. The author also analyses other issues related to the implementation and use of the named nurse concept including advocacy and accountability, and proposes that the introduction of individualized care, and in particular named nursing, perhaps serves the drive towards the professionalization of nursing first, and the patient second, and if so questions whether there is a need to reconsider the aim of nursing.

Developing an audit tool for primary nursing

Despite the proliferation of research on primary nursing, most studies have investigated the effects of primary nursing on quality of care, job satisfaction and collegial relationships. Few researchers have attempted to isolate the key dimensions of primary nursing in an observable and measurable form. The purpose of this exploratory study was to devise an audit tool for primary nursing that builds on Mead's research and incorporates views of patients/clients, relatives, nurses and other members of the multidisciplinary team. Preliminary findings suggest that the audit is a useful indicator of the extent to which the crucial elements of primary nursing are present or absent in any clinical setting. Furthermore it suggests that while many wards claim to practise primary nursing there is a considerable variation in the extent to which this is actually carried out.

Record-keeping and routine nursing practice: the view from the wards

This paper examines general nurses' views of the nursing record and its routine usage in contemporary hospital practice. It draws on ethnographic data generated on a surgical ward and a medical ward in a single District General Hospital in the United Kingdom (UK). A key research finding was ward nurses' equivocal attitudes to the nursing record. On the one hand, because of its links with the nursing process, the nursing record was highly valued as a symbol of professionalism and ward staff were loathe to criticise it directly. On the other hand, however, the nurses in this study clearly found it difficult to reconcile their professional ideals with the ways in which the nursing record was routinely employed on the wards. In this paper it is suggested that at one level, nurses' ambivalence towards the nursing record reflected the distortion of its founding philosophy by the new managerialism in the contemporary UK health care context. At another level, however, there are also difficulties which arise from the tension between the assumptions about the nature of nursing work which underpin the nursing record and the workplace reality on hospital wards.

Organizing context: nurses' assessments of older people in an acute medical unit

The paper presents findings from a study of how older people are assessed and cared for in an acute medical unit. The aim of the study was to reconsider nurses' assessment practices in relation to organisational context. Drawing together ethnographic methods with discourse analysis, the study develops an approach to studying nurses' assessment practices and aims to demonstrate that nurses go beyond entering their relationships with patients as individuals. Rather, nurses' assessments of patients can be considered as processes of alignment that help nurses accomplish complicit managerial and medical objectives, and shape their own identities.

Individual vs collective activity: a primary nursing paradox

Primary nursing has been proclaimed as a way of providing nursing care that benefits both the patient and the nurse. This article supports this view; however, a pragmatic approach is taken to identify some of the paradoxes and contradictions that may be encountered. These include: conflicts of loyalty; planning psychological care; empowerment of patients; empowerment of nurses; and competition. By using examples from practice the issues surrounding these concepts are explored, examining the impact both on practice and on nursing as an occupation. Nurses must address these paradoxes if they are to prevent conflict and frustration. The future goal of fully implementing primary nursing will, however, provide great opportunity and potential for improving patient care.

Action research as a professionalizing strategy: issues and dilemmas

This paper identifies the need for a debate about the appropriateness of action research for nursing as it seeks to achieve the status of a research-based profession. It also identifies a related need to inform such a debate by bringing together three sets of writings that are not normally united in the nursing research literature-those of action research, organizational culture and professionalization. In nursing, as in education, action research is being deployed as part of a professionalizing strategy, since amongst other things it seems to offer a means of developing reflective practitioners and of producing knowledge for practice. The increasing popularity of action research amongst nurse researchers suggests that it is seen to reflect the attributes to which nursing aspires as a profession, including a concern to realize humanistic values. Action research was embraced by the teaching profession before nursing, and nurse researchers are increasingly drawing on the ideas of influential educationalists in defining action research as an emancipatory strategy and a form of collaborative enquiry rooted in reflective practice. This paper argues that in the managerialist context of the British National Health Service action research may be reduced from a participatory methodology into a method for getting people to collaborate with managerial goals and internalize the values of the corporate culture. The danger is that in the name of reflective practice nursing work may become increasingly individualized. The challenge for action research in nursing is how to respond to this dilemma, and this may require looking critically at the managerial values underpinning the NHS reforms and at the organizational context in which action research strategies are deployed.

Planning for continuity of carer in nursing

The introduction of primary nursing and the named nurse reflects a growing recognition of the importance of continuity of carer in nursing rather than simply continuity of care. Continuity of carer is fundamental to the development of therapeutic inter-personal relationships with patients. Hospital nursing, however, provides a 24-hour service and therefore continuity of carer must be maintained within a system of nurse substitution. This paper identifies some of the organizational tensions experienced by nurses attempting to promote continuity of carer within a nursing development unit that is simultaneously striving to offer nurses personal development opportunities.

Advantages of primary nursing in geriatric day hospitals

This article presents a rationale for the introduction of primary nursing as the most suitable method of organisation in geriatric day hospitals. Working conditions, the status of the nurse within the multidisciplinary team and the opportunities afforded by primary nursing for enhancing the nurse-patient relationship are examined.

Patient autonomy and the politics of professional relationships

Debate in the health care professions about the politics of interpersonal relationships between professionals and their patients or clients is increasingly organized around proxy measures of the quality of professional services such as patient satisfaction, or the extent to which the provision of care avoids routines and is genuinely individualized. This paper explores some of the problems which arise from this in relation to patients' autonomy and nurses' authority.

The ethics of smoke-free zones: an exploration of the implications and effectiveness of a non-smoking policy as a health-promotion strategy in the context of an orthopaedic trauma ward

Pressure to reduce the incidence of smoking is increasing and widespread, coming from health professionals, independent research groups and Government policy objectives. Moves to introduce non-smoking policies within health-service premises are gaining acceptance, and form an element of the Government's overall health plan. This paper considers the background to smoking prohibition in hospitals, its merits and drawbacks as a health-promotion strategy, and some of the health and ethical issues that may arise. In particular, the paper explores the application of non-smoking policies in the speciality of orthopaedic trauma, the benefits and conflicts that may occur, and the scope for nurses in this area to resolve problems resulting from these policies.

The role of the paid non-professional nursing helper: a review of the literature

This paper presents an overview of research into the role of paid non-professional nursing helpers. This term refers to auxiliaries, ward clerks, healthcare assistants and support workers. The focus of the review is on work carried out on attitudes of qualified staff to the role of the helper, role descriptions and the role of the helper in different organizational modes of work. Some of the research reviewed in relation to the role description and attitudes to the helper date back to 1978. However, the emphasis of the paper is on research published in the past 3 years. The research is reviewed against the background of two theoretical frameworks, both of which are perceived to be useful in analysing the division of labour between the nurse, the patient and the helper.

The development of a measure of job satisfaction for use in evaluating change in the system of care delivery

The aim of the study was to produce a reliable, valid measure of job satisfaction in order to monitor the effect of a change in the method of care delivery. Principal components analysis of questionnaire responses by 121 nurses yielded two scales labelled "Intrinsic Job Satisfaction" and "Patient Focus". Cronbach's alpha was 0.88 and 0.82 respectively. Further analyses revealed significant differences in scores on both scales for different grades of staff and significant differences in scores on "Patient Focus" for nurses working in different specialties. Significant increases in scores on both scales were found for registered nurses following changes in organisation on a surgical ward. This increase was maintained over time. For enrolled nurses an increase in "Intrinsic Job Satisfaction" was less well maintained and no differences were found over time on "Patient Focus". The two scales are reliable and sufficiently sensitive to monitor the relationship between job satisfaction and system of care delivery for different grades of staff working in different specialties.