The impact structured patient assessment frameworks have on patient care: an integrative review

Systems-Based Physical Assessments: Earlier Detection of Clinical Deterioration and Reduced Mortality

BACKGROUND

Despite efforts to improve early detection of deterioration in a patient's condition, delays in activating the rapid response team remain common.

OBJECTIVES

To evaluate delays in activating the rapid response team and the occurrence of serious adverse events before and after implementation of a quality improvement initiative aimed at nurses' performing systems-based physical assessments.

METHODS

A retrospective observational cohort design was used to evaluate all patients who had a rapid response team activation during the study period.

RESULTS

A total of 1080 patients were included in the analysis: 536 patients before the quality improvement initiative and 544 patients after the quality improvement initiative. The delay in activating the rapid response team decreased from 11.7 hours in the before group to 9.6 hours in the after group (P < .001). In the after group, fewer patients were transferred to the intensive care unit (36% vs 41%, P = .02) and those who were transferred had 3.58 times greater odds of death than those who stayed at the same level of care. The after group had a 44% reduction in the odds of mortality compared with the before group.

CONCLUSIONS

When nurses focus on conducting a systems-based physical assessment early in their shift, delays in recognizing a patient's deteriorating condition are reduced, fewer patients are admitted to the intensive care unit, and mortality is significantly reduced.

Improving Nursing Assessment in Adult Hospitalization Units: A Secondary Analysis

The main objective of this study was to analyze the impact of a multifaceted strategy to improve the assessment of functional capacity, risk of pressure injuries, and risk of falls at the time of admission of patients in adult hospitalization units. This was a secondary analysis of the VALENF project databases during two periods (October-December 2020, before the strategy, and October-December 2021, after the strategy). The quantity and quality of nursing assessments performed on patients admitted to adult hospitalization units were evaluated using the Barthel index, Braden index, and Downton scale. The number of assessments completed before the implementation of the new strategy was n = 686 (28.01%), versus n = 1445 (58.73%) in 2021 (p < 0.001). The strategy improved the completion of the evaluations of the three instruments from 63.4% (n = 435) to 71.8% (n = 1038) (p < 0.001). There were significant differences depending on the hospitalization unit and the assessment instrument (p < 0.05). The strategy employed was, therefore, successful. The nursing assessments show a substantial improvement in both quantity and quality, representing a noticeable improvement in nursing practice. This study was not registered.

The Emergency nurse Protocols Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) trial: protocol for a stepped wedge implementation trial

INTRODUCTION

Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes.

METHODS AND ANALYSIS

This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped-wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys.

ETHICS AND DISSEMINATION

Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022.

TRIAL REGISTRATION

Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.

Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I)

Nursing assessment is the basis for performing interventions that match patient needs, but nurses perceive it as an administrative load. This research aims to develop and validate a meta-instrument that integrates the assessment of functional capacity, risk of pressure ulcers and risk of falling with a more parsimonious approach to nursing assessment in adult hospitalization units. Specifically, this manuscript presents the results of the development of this meta-instrument (VALENF instrument). A cross-sectional study based on recorded data was carried out in a sample of 1352 nursing assessments. Socio-demographic variables and assessments of Barthel, Braden and Downton indices at the time of admission were included. The meta-instrument's development process includes: (i) nominal group; (ii) correlation analysis; (iii) multiple linear regressions models; (iv) reliability analysis. A seven-item solution showed a high predictive capacity with Barthel (R2adj = 0.938), Braden (R2adj = 0.926) and Downton (R2adj = 0.921) indices. Likewise, reliability was significant (p < 0.001) for Barthel (ICC = 0.969; τ-b = 0.850), Braden (ICC = 0.943; τ-b = 0.842) and Downton (ICC = 0.905; κ = 7.17) indices. VALENF instrument has an adequate predictive capacity and reliability to assess the level of functional capacity, risk of pressure injuries and risk of falls.

A Study of How Moral Courage and Moral Sensitivity Correlate with Safe Care in Special Care Nursing

Background

Nursing is a caring profession, and nurses who have moral sensitivity and moral courage presumably can provide safe and better care for patients. This study aims at investigating how moral courage and moral sensitivity correlate with safe care in special care nursing.

Methods

This study is a descriptive work of research. The participants consisted of 524 nurses who were in practice in the ICU (intensive care unit), CCU (C\coronary care unit), post-CCU (postcoronary care unit), and dialysis of four hospitals located in the south of Iran selected via census sampling. Data were collected from April to September 2020 using the moral sensitivity questionnaire (MSQ), professional moral courage questionnaire (PMCQ), and the assessment of safe nursing care questionnaire (ASNCQ). The collected data were analyzed using descriptive statistics, t-test, chi-square, multiple regression analysis, and Pearson's correlation coefficient in SPSS v. 22.

Results

The mean ± SD of the nurses' age was 33.89 ± 6.91 years, and the mean ± SD of their work experience was 9.16 ± 4.67 years. The total mean score ± SD of the nurses' moral sensitivity was found to be 93.41 ± 2.68, the total mean score ± SD of their moral courage was found to be 96.38 ± 3.63, and the total mean score ± SD of their safe care scores was found to be 321.80 ± 9.76. The values of Pearson's correlation coefficients showed significant correlations between moral courage and safe care (r = 0.54, p < 0.001), moral sensitivity and safe care (r = 0.59, p < 0.001), and moral sensitivity and moral courage (r = 0.52, p < 0.001).

Conclusion

There is a positive correlation between moral sensitivity and moral courage. Both positively correlated with special care nursing. Accordingly, through effective planning, education, and giving their support, nurse administrators can promote the abovementioned ethical virtues in the nursing staff, thereby improving the quality of care.

Strengthening Community End-of-Life Care through Implementing Measurement-Based Palliative Care

The increasing demand for palliative care in New Zealand presents a potential threat to the quality of service delivery. One strategy to overcome this is through the implementation of valid and reliable patient-reported outcome measures. This mixed-methods study aimed to (1) implement measurement-based palliative care (MBPC) in a community palliative care service in Auckland, New Zealand; (2) evaluate the clinical utility of MBPC perceived by clinicians; (3) describe patient characteristics as measured by the Integrated Palliative Care Outcome Scale (IPOS), the Australasian Modified Karnofsky Performance Scale (AKPS), and Phase of Illness (POI); and (4) evaluate the internal consistency of the IPOS. Participants were over 18 years of age from a community outpatient palliative care service. In a phased approach to implementation, healthcare staff were educated on each instrument used for patient assessment. Uptake and internal consistency were evaluated through descriptive statistics. An interpretive descriptive methodology was used to explore the clinical utility of MBPC through semi-structured interviews with seven clinical staff members. Individual patient assessments (n = 1507) were undertaken predominantly on admission, with decreasing frequency as patients advanced through to the terminal phase of their care. Mean total IPOS scores were 17.97 (SD = 10.39, α = 0.78). The POI showed that 65% of patients were in the stable phase, 20% were in the unstable phase, 9% were in the deteriorating phase, and 2% were in the terminal phase. Clinicians reported that MBPC facilitated holistic and comprehensive assessments, as well as the development of a common interdisciplinary language. Clinicians expressed discomfort using the psychosocial and spiritual items. Measurement-based palliative care was only partially implemented but it was valued by staff and perceived to increase the quality of service delivery. Future research should determine the optimal timing of assessments, cultural responsivity for Māori and Pacific patients, and the role of MBPC in decision support for clinicians.

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Background

Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.

Objectives

The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.

Design

A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.

Setting

The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.

Participants

A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.

Interventions

The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.

Main outcome measures

The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.

Data sources

National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.

Review methods

Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).

Limitations

Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.

Conclusions

Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.

Future work

Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.

Trial registration

This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.

Funding

The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

Physical assessment competencies for nurses: A quality improvement initiative

As the only healthcare providers caring for hospitalized patients every hour of every day, nurses have a responsibility to keep patients safe. Physical assessment is a basic but essential nursing skill that fosters patient safety. Assessing a patient's current status enables nurses to recognize early patient deterioration. Contemporary nursing practice relies on vital signs and technology to aid in the detection of patient deterioration. The aim is to describe the Methodist Proficient Assessment Competency (MPAC^©) quality improvement initiative. Surveys and directly observed patient assessment data were used to evaluate attitudes and practices. One hundred and seventy‐nine pre‐MPAC audits were conducted, followed by 1391 post‐MPAC audits. Pre‐ compared with post‐MPAC audits showed significant improvements in complete physical assessments (78% vs. 94%; p < .001), timeliness (within 4 h; 64% vs. 91%; p < .001) and accuracy (67% vs. 95%; p < .001) of documentation. In conclusion, nurses have a responsibility to quickly identify changes in a patient's condition and intervene to prevent serious adverse events. Taking the needed time to perform a full physical assessment at the beginning of the shift along with timely and accurate documentation, allows nurses to acquire the knowledge they need to establish a patient's current clinical status and usual behaviors, thereby facilitating early recognition of subtle changes that could indicate deterioration.

Implementation of a structured emergency nursing framework results in significant cost benefit

Background

Patients are at risk of deterioration on discharge from an emergency department (ED) to a ward, particularly in the first 72 h. The implementation of a structured emergency nursing framework (HIRAID) in regional New South Wales (NSW), Australia, resulted in a 50% reduction of clinical deterioration related to emergency nursing care. To date the cost implications of this are unknown. The aim of this study was to determine any net financial benefits arising from the implementation of the HIRAID emergency nursing framework.

Methods

This retrospective cohort study was conducted between March 2018 and February 2019 across two hospitals in regional NSW, Australia. Costs associated with the implementation of HIRAID at the study sites were calculated using an estimate of initial HIRAID implementation costs (AUD) ($492,917) and ongoing HIRAID implementation costs ($134,077). Equivalent savings per annum (i.e. in less patient deterioration) were calculated using projected estimates of ED admission and patient deterioration episodes via OLS regression with confidence intervals for incremental additional deterioration costs per episode used as the basis for scenario analysis.

Results

The HIRAID-equivalent savings per annum exceed the costs of implementation under all scenarios (Conservative, Expected and Optimistic). The estimated preliminary savings to the study sites per annum was $1,914,252 with a payback period of 75 days. Conservative projections estimated a net benefit of $1,813,760 per annum by 2022–23. The state-wide projected equivalent savings benefits of HIRAID equalled $227,585,008 per annum, by 2022–23.

Conclusions

The implementation of HIRAID reduced costs associated with resources consumed from patient deterioration episodes. The HIRAID-equivalent savings per annum to the hospital exceed the costs of implementation across a range of scenarios, and upscaling would result in significant patient and cost benefit.

Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi-experimental study

AIMS AND OBJECTIVES

To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation.

BACKGROUND

Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown.

DESIGN

A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist.

METHODS

HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data.

RESULTS

The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly.

CONCLUSION

Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations.

RELEVANCE TO CLINICAL PRACTICE

The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.

Relevance of assessment items in community paramedicine home visit programmes: results of a modified Delphi study

OBJECTIVE

Guidelines for a structured assessment in community paramedicine home visit programmes have not been established and evidence to inform their creation is lacking. We sought to investigate the relevance of assessment items to the practice of community paramedics according to a pre-established clarity-utility matrix.

DESIGN

We designed a modified-Delphi study consisting of predetermined thresholds for achieving consensus, number of rounds of for scoring items, a defined meeting and discussion process, and a sample of participants that was purposefully representative.

SETTING AND PARTICIPANTS

We established a panel of 26 community paramedics representing 20 municipal paramedic services in Ontario, Canada. The sample represented a majority of paramedic services within the province that were operating a community paramedicine home visit programme.

MEASURES

Drawing from a bank of standardised assessment items grouped according to domains aligned with the International Classification on Functioning, Disability, and Health taxonomy, 64 previously pilot-tested assessment items were scored according to their clarity (being free from ambiguity and easy to understand) and utility (being valued in care planning or case management activities). Assessment items covered a broad range of health, social and environmental domains. To conclude scoring rounds, assessment items that did not achieve consensus for relevance to assessment practices were discussed among participants with opportunities to modify assessment items for subsequent rounds of scoring.

RESULTS

Resulting from the first round of scoring, 54 assessment items were identified as being relevant to assessment practices and 3 assessment items were removed from subsequent rounds. The remaining 7 assessment items were modified, with some parts removed from the final items that achieved consensus in the final rounds of scoring.

CONCLUSION

A broadly representative panel of community paramedics identified consensus for 61 assessment items that could be included in a structured, multidomain, assessment instrument for guiding practice in community paramedicine home visit programmes.

TRAIL REGISTRATION NUMBER

ISRCTN58273216.

How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review

BACKGROUND

The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice.

OBJECTIVE

The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions.

METHODS

We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis.

RESULTS

A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable.

CONCLUSION

Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.

Practices and Barriers towards Physical Assessment among Nurses Working in Intensive Care Units: Multicenter Cross-Sectional Study

Background

In the intensive care units, patients need special consideration and monitor frequently with appropriate physical assessment skills. Nurses working in the intensive care units play a fundamental role in detecting patients at risk of deterioration through ongoing assessment and action in response to changing health status. Most of the nursing activities were poorly assessed in low-income countries including Ethiopia. Therefore, this study was aimed to assess the nurses' practice and barriers to physical assessment among critically ill patients in Northwest Ethiopia.

Methods

An institution-based multicenter cross-sectional study was conducted at Amhara regional state referral hospitals from March to September 2019. A total of 299 nurses working in the intensive care units were recruited through the convenience sampling method. A 30-item physical assessment practice and 36-item barriers to nurses' use of the physical assessment scale inventory were used. The linear regression analysis model was fitted, and the adjusted unstandardized beta (β) coefficient with a 95% confidence interval was used. A p value < 0.05 was considered statistically significant.

Results

The mean score of the nurses' practice towards physical assessment among critically ill patients was 101.26 ± 24.99. Greater perceived reliance on others and technology (β = −0.78, 95% CI (-1.07, -0.48)), ward culture (β = −0.48, 95% CI (-0.85, -0.11)), specialty area (β = −1.46, 95% CI (-2.01, -0.90)), lack of nursing role model (β = −0.54, 95% CI (-1.06, -0.02)), being unmarried (β = −6.10, 95% CI (1.75, 10.46)), taken training (β = 11.53, 95% CI (6.34, 16.72)), and knowledge score (β = 2.81, 95% CI (2.00, 3.63)) were the factors significantly associated with the nurses' practice score towards physical assessment. Reliance on others and technology towards physical assessment practice was the most important barrier followed by ward culture and specialty area.

Conclusion

Nurses working in the intensive care units had a good practice towards physical assessment among critically ill patients. Hence, to increase the practice towards physical assessment in intensive care settings, especially for married nurses, experienced critical care nurses, and specialist professionals, practice support training, modifying ward environment, and educational support care are recommended.

The Value of New Fields in the Medical Record for Quality Improvement

Introduction

Quality in healthcare delivery is important for the safety and experience of patients with cancer. Effective documentation is an integral component of quality improvment, and accurate documentation can be affected by prompts in the medical record, potentially improving quality of services.

Methods

The Contemporary Oncology Team (COT) is a Greek private oncology practice that participated in the American Society of Clinical Oncology's (ASCO's) Quality in Oncology Practice Initiative (QOPI). Between 2014 and 2019, COT implemented changes in its paper patient medical record, in order to improve quality of care and documentation. Fields regarding pain, emotional well-being and psychosocial assessment, discussions with the patient and consent about treatment and disease, medication details and cumulative dose, treatment goals, side-effect grading, pregnancy screening, treatment adherence and anticipated duration were added. In this report, we present the association of these improvements with COT performance in QOPI.

Results

Pain and emotional well-being assessment and documentation were significantly improved by the development of a structured patient follow-up form. In contrast, the assessment of fertility issues, tobacco use, and the documentation of treatment plan and intent did not present a drastic change, because COT performance was already above QOPI average.

Conclusion

A thorough reform of COT paper medical record according to QOPI standards improved QOPI scores, but more importantly effected a shift in the team's culture to safer and more standardized quality based care.

The implementation of an emergency nursing framework (HIRAID) reduces patient deterioration: A multi-centre quasi-experimental study

INTRODUCTION

Timely recognition and treatment of acutely ill patients at appropriate levels of the health system are fundamental to the quality and safety of healthcare. This study determines if the implementation of an emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves patient safety.

METHODS

A quasi-experimental cohort study was conducted in two emergency departments in [Anonymised], Australia. HIRAID was implemented using a multi-pronged behaviour change intervention. Data of 920 patients (374 pre and 546 post) who deteriorated within 72-hours of ED departure were collected. Statistical tests were conducted as two-sided, with a 95% confidence interval to determine pre/post cohort association.

RESULTS

Patients in the post group had more comorbidities, but experienced less deterioration associated with care delivered in the ED (27% to 13%). There was a reduction in treatment delays [ 28.3% to 15.1%, p = 0.041, 95% CI (1.1%-25.3%)], and delay or failure to escalate care when abnormal vital signs were identified [20.2% to6.9%, p = 0.014, 95% CI (3.5%-23.1%)]. Isolated nursing-related causal factors decreased from 20 (21%) to 6 (8%).

CONCLUSIONS

Implementing a standardised emergency nursing framework is associated with a reduction in clinical deterioration related to emergency care.

An integrative review of comprehensive nursing assessment tools developed based on Gordon's Eleven Functional Health Patterns

PURPOSE

To evaluate the content and psychometric properties of comprehensive nursing assessment tools developed based on The Eleven Functional Health Patterns Assessment Framework.

METHODS

An integrative literature review following Whittemore and Knafl's method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches on PubMed, Cinahl, and Virtual Health Library were conducted between September and December 2018.

FINDINGS

Six out of 146 records were included for review. Four articles were methodological studies and two were descriptive reports of the development of the tools. Tools were heterogenous in terms of their purpose, development, characteristics, and testing. Only one study provided data about construct validity. However, there were commonalities regarding the data that should be assessed in each tool.

CONCLUSIONS

Few comprehensive nursing assessment tools using The Eleven Functional Health Patterns Assessment Framework are available. Purpose, process of development, characteristics, and testing varied among the tools, and most lack robust psychometric testing.

IMPLICATIONS FOR NURSING PRACTICE

This review provided a synthesis of the literature regarding the use of a discipline-specific framework to guide comprehensive nursing assessment. The differences across the tools and the lack of psychometric testing compromise the visibility of nursing and make it difficult to emphasize the contribution of nursing knowledge to patient care.

Comprehensive geriatric assessment among elderly people in a convalescence unit: a best practice implementation project

AIM

The aim of this project was to audit the usual assessment practices employed when admitting patients to a convalescence unit on the outskirts of Barcelona, Spain. The project implemented strategies to improve evidence-based practice using the Joanna Briggs Institute methodology. The specific objectives of this project were (1) to improve completion of the comprehensive geriatric assessment (CGA) record, (2) to improve professionals' CGA knowledge, (3) to promote interdisciplinary work, (4) to improve tailored therapeutic plan generation by implementing evidence-based practice criteria within the instrument, and (5) to evaluate the records and action plans derived from the CGA.

METHODS

Pre-/post-implementation audit methodology was used the Practical Application of Clinical Evidence System and Getting Research into Practice, and was developed in multiple phases. The implementation phase took 6 months. A sample of 34 consecutive admissions had their CGA patient records evaluated. Descriptive statistics were calculated.

RESULTS

A total of 64 records (34 pre/30 post) were reviewed to assess CGA completion. The baseline audit results showed that only two audit criteria were higher than 50%, indicating poor knowledge about the concept of CGA and poor compliance with the current program. Following the implementation of the strategies, which included education and the development of a checklist, there was an improvement in all the criteria audited: the record was correctly completed in 67% of cases, and 80% of team members were knowledgeable and competent in CGA.

CONCLUSION

Several barriers were identified at baseline, and various strategies were implemented to improve CGA compliance. The results show that the project increased awareness of the importance of a comprehensive assessment of the care that patients receive, resulting in better CGA completion.

An Arabic Translation, Reliability, Validity, and Feasibility of the Richards-Campbell Sleep Questionnaire for Sleep Quality Assessment in ICU: Prospective-Repeated Assessments

BACKGROUND AND PURPOSE

To translate Richards-Campbell Sleep Questionnaire (RCSQ) into the Arabic language (RCSQ-A), to assess content validity of the translated tool, to analyze the internal consistency, and to evaluate its feasibility.

METHODS

A rigorous translation was completed using the process of translation by World Health Organization. Cognitive debriefing interviews were performed. Repeated assessments using RCSQ-A was conducted in critical care patients in Saudi Arabia.

RESULT

Cronbach's alpha of .89 was seen in the RCSQ-A. The cognitive interviews showed that the RCSQ-A well understood and interpreted correctly and consistently. Fifty-seven participants reported their sleep using RCSQ-A a total of 110 times.

CONCLUSION

RCSQ-A has adequate translation validity, provided good internal consistency and content validity, making it suitable for use as a measurement tool in practice and research in Arabic-speaking countries.

Effective drain care and management in community settings

The literature indicates that drain monitoring is a frequently undervalued aspect of patient care, and that the drain care provided is often inconsistent and inadequate. There are numerous potential implications of suboptimal drain care for patients, nurses, teams and healthcare organisations. Since acute care is increasingly being delivered in the community, there is a greater need for nurses to have an understanding of effective drain care. This article describes the rationale for drain insertion and its associated complications. It uses a case study to illustrate how suboptimal drain monitoring and documentation can negatively affect patient care and safety. This article also discusses several important issues raised in the case study, such as suboptimal documentation, and how these may have consequences for nurses, teams and healthcare organisations. Recognition of these elements supports initiatives that nurses could apply to practice to reduce the occurrence of similar incidents.

Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis

Background

Intravenous thrombolysis is a key element of emergency treatment for acute ischaemic stroke, but hospital service delivery is variable. The Paramedic Acute Stroke Treatment Assessment (PASTA) multicentre cluster randomised controlled trial evaluated whether an enhanced paramedic-initiated stroke assessment pathway could improve thrombolysis volume. This paper reports the findings of a parallel process evaluation which explored intervention paramedics’ experience of delivering the enhanced assessment.

Methods

Interviewees were recruited from 453 trained intervention paramedics across three UK ambulance services hosting the trial: North East, North West and Welsh Ambulance Services. A semistructured interview guide aimed to (1) explore the stroke-specific assessment and handover procedures which were part of the PASTA pathway and (2) enable paramedics to share relevant views about expanding their role and any barriers/enablers they encountered. Interviews were audiorecorded, transcribed verbatim and analysed following the principles of the constant comparative method.

Results

Twenty-six interviews were conducted (11 North East, 10 North West and 5 Wales). Iterative data analysis identified four key themes, which reflected paramedics’ experiences at different stages of the care pathway: (1) Enhanced assessment at scene: paramedics felt this improved their skillset and confidence. (2) Prealert to hospital: a mixed experience dependent on receiving hospital staff. (3) Handover to hospital team: standardisation of format was viewed as the primary benefit of the PASTA pathway. (4) Assisting in hospital and feedback: due to professional boundaries, paramedics found these aspects harder to achieve, although feedback from the clinical team was valued when available.

Conclusion

Paramedics believed that the PASTA pathway enhanced their skills and the emergency care of stroke patients, but a continuing clinical role postadmission was challenging. Future studies should consider whether interdisciplinary training is needed to enable more radical extension of professional boundaries for paramedics.

Effective drain care and management in community settings

The literature indicates that drain monitoring is a frequently undervalued aspect of patient care, and that the drain care provided is often inconsistent and inadequate. There are numerous potential implications of suboptimal drain care for patients, nurses, teams and healthcare organisations. Since acute care is increasingly being delivered in the community, there is a greater need for nurses to have an understanding of effective drain care. This article describes the rationale for drain insertion and its associated complications. It uses a case study to illustrate how suboptimal drain monitoring and documentation can negatively affect patient care and safety. This article also discusses several important issues raised in the case study, such as suboptimal documentation, and how these may have consequences for nurses, teams and healthcare organisations. Recognition of these elements supports initiatives that nurses could apply to practice to reduce the occurrence of similar incidents.

The implementation and usability of HIRAID, a structured approach to emergency nursing assessment

BACKGROUND

Emergency nurses are responsible for the initial assessment, management and safety of critically ill patients. HIRAID, an evidence-informed emergency nursing assessment framework, is known to improve emergency nursing patient-assessment in the simulated environment however has not been evaluated in the clinical setting.

METHODS

A pre-post design was used to assess the usability and impact of HIRAID on emergency nurses self-efficacy in the emergency department (ED). Nursing and medical staff from three Australian EDs were surveyed. Descriptive and optimal pooled sample t-tests statistics were conducted.

RESULTS

One hundred and two emergency nurses completed the pre-intervention self-efficacy survey and 63 completed the post-intervention self-efficacy and satisfaction survey. Forty-two and 17 medical officers completed the pre- and post-intervention satisfaction surveys, respectively. Nursing staff self-efficacy levels were unchanged pre- and post-HIRAID implementation (Mean (SD): 8.8 (0.21) vs. 8.7 (0.20)) as was medical staff satisfaction (Mean (SD):7.5 (1.43) vs. 7.8 (1.07)), although there was a trend towards improved communication.

CONCLUSION

The HIRAID structured approach to patient assessment is acceptable, feasible, practical and appropriate for use in the clinical environment. Further research will demonstrate the direct effects of HIRAID on clinical performance.

Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care

Background:

Underpinning standards for developing comprehensive care in hospital is the need to identify, early in the admission process, functional and psychosocial issues which affect patient outcomes. Despite the value of comprehensive assessment of patients on admission, the process is often sub-optimal due to a lack of standardized assessment practices. This project aimed to develop a concise, integrated assessment for patients admitted to acute care and test its psychometric properties.

Methods:

Two international expert panels of clinicians and health scientists collaborated to establish design parameters. Using clinical observations and a variety of derivative applications sourced from the interRAI research collaborative repository, the panels constructed a draft instrument to examine feasibility, resource requirements, and inter-rater reliability. Field testing was conducted in Australia and Canada. Next, the system was revised to its final form, the interRAI Acute Care, after feedback and review from international interRAI members.

Results:

Constructed using 56 items, the interRAI Acute Care required a median of 15 minutes to complete. Inter-rater reliability tested on 130 paired assessments was substantial to almost perfect for 78% of the clinical items and moderate for the remaining 22% of items. A subset of 30 items from the admission assessment comprised the discharge assessment.

Discussion:

The interRAI Acute Care has been shown to be an efficient nursing assessment instrument with good psychometric properties. Implementation in a digital environment will enable documentation and care planning to comply with standards for quality of care in the general adult hospital population.

Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: protocol for an interrupted time-series study

INTRODUCTION

Millions of acute care hospital patients need a peripheral intravenous catheter (PIVC) each year. However, up to half of PIVCs remain in situ when not being used, and 30%-50% of intravenous (IV) catheters develop complications or stop working before treatment is finished, requiring the insertion of a new device. Improved assessment could prompt timely removal of redundant catheters and prevent IV complications. This study aims to validate an evidence-based PIVC assessment and decision-making tool called I-DECIDED and evaluate the effect of implementing this tool into acute hospital clinical practice.

METHODS AND ANALYSIS

The protocol outlines a prospective, multicentre, mixed-methods study using an interrupted time-series (multiple measures preintervention and postintervention) implementation at three Australian hospitals between August 2017 and July 2018. The study will examine the effectiveness of the I-DECIDED assessment and decision-making tool in clinical practice on prompting timely PIVC removal and early detection of complications. Primary outcomes are prevalence of redundant PIVCs (defined as device in situ without a clear purpose), IV complications (occlusion, dislodgement, infiltration, extravasation and phlebitis) and substandard dressings (loose, lifting, moist or soiled); device utilisation ratios; and primary bloodstream infection rates. Secondary outcomes including staff barriers and enablers to PIVC assessment and removal, patient participation, documentation of PIVC assessment and decisions taken to continue or remove the PIVC will be recorded. Using the Promoting Action on Research Implementation in Health Services framework, we will undertake staff focus groups, bedside patient interviews and PIVC assessments and chart audits. Patients aged 18 years or more with a PIVC will be eligible for inclusion.

ETHICS AND DISSEMINATION

Ethical approval from Queensland Health (HREC/17/QPCH/47), Griffith University (Ref No. 2017/152) and St Vincent's Health and Aged Care Human Research and Ethics Committee (Ref No. 17/28). Results will be published.

TRIAL REGISTRATION NUMBER

ANZCTR: 12617000067370; Pre-results.

Approaches to better engage parent-child in health home-visiting programmes: A content analysis

Home visiting is an evidence-based strategy used to enhance child and family health outcomes. Such primary healthcare endeavours demand the full participation of individual and families. We conducted a review to identify approaches to planning, executing and assessing home-visiting health promotion interventions to determine how parents and children can be best engaged. A structured search (2000-2015) was undertaken using a defined search protocol. The quality of the papers was assessed using standard appraisal tools. Sixteen studies were retrieved. A content analysis of the findings sections of the papers was undertaken and guided by the eight phases of the PRECEDE-PROCEED health promotion planning framework. The analysis found that while all the PRECEDE assessment areas were represented no studies included all phases. Parents and children did not appear to be actively involved in undertaking the assessments and evaluation of the home-visiting health promotion programmes. The findings suggest that there is a need to develop a consistent home-visiting approach that includes comprehensive assessments in the planning phases and parent and child involvement at each step of programme development, implementation and evaluation. This approach enables the development of tailored and sustainable health promotion intervention in order to achieve optimal child health outcomes.

Tension pneumothorax recurrence in COPD: a care study

This care study concerns a patient with chronic obstructive pulmonary disease, who endures the recurrence of a tension pneumothorax. A holistic and evidence-based approach is employed to critically discuss his assessment, pathophysiology, and nursing care. These discussions facilitate extrapolation of implications pertinent to nursing practice.

An Audit of Nursing Documentation at Three Public Hospitals in Jamaica

PURPOSE

Nursing documentation provides an important indicator of the quality of care provided for hospitalized patients. This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica.

METHODS

This cross-sectional study audited a multilevel stratified sample of 245 patient records from three type B hospitals. An audit instrument which assessed nursing documentation of client history, biological data, client assessment, nursing standards, discharge planning, and teaching facilitated data collection. Descriptive statistics were conducted using IBM SPSS, Version 19 (IBM Inc., Armonk, NY, USA).

FINDINGS

Records from three hospitals (Hospital 1, n = 119, 48.6%; Hospital 2, n = 56, 22.9%; Hospital 3, n = 70, 28.6%) were audited. Documented evidence of the patient's chief complaint (81.6%), history of present illness (78.8%), past health (79.2%), and family health (11.0%) were noted; however, less than a third of the dockets audited recorded adequate assessment data (e.g., occupation or living accommodations of patients). The audit noted 90% of records had a physical assessment completed within 24 hr of admission and entries timed, dated, and signed by a nurse. Less than 5% of dockets had evidence of patient teaching, and 13.5% had documented evidence of discharge planning conducted within 72 hr of admission.

CONCLUSIONS

This study highlights the weakness in nursing documentation and the need for increased training and continued monitoring of nursing documentation at the hospitals studied. Additional research regarding the factors that affect nursing documentation practice could prove useful.

CLINICAL RELEVANCE

The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process.

A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation

AIMS AND OBJECTIVES

The aim of this study was to evaluate the effect of the new evidence-informed nursing assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) on the quality of patient assessment and fundamental nontechnical skills including communication, decision making, task management and situational awareness.

BACKGROUND

Assessment is a core component of nursing practice and underpins clinical decisions and the safe delivery of patient care. Yet there is no universal or validated system used to teach emergency nurses how to comprehensively assess and care for patients.

DESIGN

A pre-post design was used.

METHODS

The performance of thirty eight emergency nurses from five Australian hospitals was evaluated before and after undertaking education in the application of the HIRAID assessment framework. Video recordings of participant performance in immersive simulations of common presentations to the emergency department were evaluated, as well as participant documentation during the simulations. Paired parametric and nonparametric tests were used to compare changes from pre to postintervention.

RESULTS

From pre to postintervention, participant performance increases were observed in the percentage of patient history elements collected, critical indicators of urgency collected and reported to medical officers, and patient reassessments performed. Participants also demonstrated improvement in each of the four nontechnical skills categories: communication, decision making, task management and situational awareness.

CONCLUSION

The HIRAID assessment framework improves clinical patient assessments performed by emergency nurses and has the potential to enhance patient care.

RELEVANCE TO CLINICAL PRACTICE

HIRAID should be considered for integration into clinical practice to provide nurses with a systematic approach to patient assessment and potentially improve the delivery of safe patient care.

Supporting generalist nurses in the rural setting with the introduction of a clinical assessment process

The aim of this research was to evaluate the implementation of an assessment process for general nurses involved in providing end-of-life care. A mixed-method, three-phased study was conducted on a medical ward at a regional hospital in a rural setting. Participating nurses completed a questionnaire about their awareness levels of the five validated scales included in the assessment of patients receiving palliative care. Auditing of the completed assessment forms was conducted at the interim and post data collection points and focus groups were conducted in the final phase. Analysis of the data revealed that nurses were able to integrate the use of this assessment process into the care of this group of patients. The author concludes, while nurses working in rural settings require general clinical knowledge of a wide range of patient groups, validated assessment scales can assist them in the provision of evidence-based palliative care.

Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review

BACKGROUND

Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients.

METHODS

A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised.

RESULTS

Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule.

CONCLUSION

Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.

The development of a subjective assessment framework for individuals presenting for clinical exercise services: A Delphi study

OBJECTIVES

The American College of Sports Medicine and Exercise and Sports Science Australia recognise the importance of gathering a client history (subjective assessment) to inform clinical decisions for clients with chronic disease and/or disability. Despite the importance of the subjective assessment in problem-oriented exercise management, there is currently no primary evidence to indicate the important domains that should be addressed during the subjective assessment to guide safe and effective clinical decisions.

DESIGN

Modified e-Delphi METHODS: A panel of 32 experts was recruited with a median of 12 years of experience (Q₃=15.5 years; Q₁=10 years). The panel was asked to rate the importance of each domain in guiding clinical decisions on a 9-point Likert scale with consensus for inclusion or exclusion pre-defined at 80%.

RESULTS

The panel of experts elected that best practice for conducting the subjective assessment was a semi-structured approach using a combination of prompts and follow-up questions. The Delphi process resulted in an initial list of 36 domains that was identified by the panel of which 23 domains reached consensus for agreement after Round 3.

CONCLUSIONS

The subjective assessment is important for Clinical Exercise Physiologists to provide safe and effective services. Best practice for conducting the assessment is the semi-structured approach to prompt the clinician on the domains to include. Twenty three domains have been considered as important for a Clinical Exercise Physiologist to address in a subjective assessment to implement the delivery of safe and effective exercise assessment and/or prescription.

Findings From a Nursing Care Audit Based on the Nursing Process: A Descriptive Study

Background:

Although using the nursing process improves nursing care quality, few studies have evaluated nursing performance in accordance with nursing process steps either nationally or internationally.

Objectives:

This study aimed to audit nursing care based on a nursing process model.

Patients and Methods:

This was a cross-sectional descriptive study in which a nursing audit checklist was designed and validated for assessing nurses’ compliance with nursing process. A total of 300 nurses from various clinical settings of Tehran university of medical sciences were selected. Data were analyzed using descriptive and inferential statistics, including frequencies, Pearson correlation coefficient and independent samples t-tests.

Results:

The compliance rate of nursing process indicators was 79.71 ± 0.87. Mean compliance scores did not significantly differ by education level and gender. However, overall compliance scores were correlated with nurses’ age (r = 0.26, P = 0.001) and work experience (r = 0.273, P = 0.001).

Conclusions:

Nursing process indicators can be used to audit nursing care. Such audits can be used as quality assurance tools.

Patient participation in nursing care on medical wards: An integrative review

BACKGROUND

Patient participation is a way for patients to engage in their nursing care. In view of the possible link between patient participation and safety, there is a need for an updated review to assess patient participation in nursing care.

OBJECTIVES

To investigate patients' and nurses' perceptions of and behaviours towards patient participation in nursing care in the context of hospital medical wards.

DESIGN

Integrative review.

DATA SOURCES

Three search strategies were employed in August 2013; a computerised database search of Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, Medline and PsychINFO; reference lists were hand-searched; and forward citation searching was executed.

REVIEW METHODS

After reviewing the studies, extracting study data and completing summary tables the methodological quality was assessed using the Mixed-Methods Assessment Tool by two reviewers. Reviewers met then to discuss discrepancies as well as the overall strengths and limitations of the studies. Discrepancies were overcome through consensus or a third reviewer adjudicated the issue. Within and across study analysis and synthesis of the findings sections was undertaken using thematic synthesis.

RESULTS

Eight studies met inclusion criteria. Four themes were identified - enacting participation, challenges to participation, promoting participation and types of participation. Most studies included were conducted in Europe. The majority of studies used qualitative methodologies, with all studies sampling patients; nurses were included in three studies. Data were largely collected using self-reported perceptions; two studies included observational data. Methodological issues included a lack of reflexivity, un-validated data collection tools, sampling issues and low response rates.

CONCLUSIONS

On medical wards, patients and nurses desire, perceive or enact patient participation passively. Challenging factors for patient participation include patients' willingness, nurses' approach and confusion around expectations and roles. Information-sharing was identified as an activity that promotes patient participation, suggesting nurses encourage active communication with patients in practice. Involving patients in assessment and care planning may also enhance patient participation. For education, enhancing nurses' understanding of the attributes of patient participation, as well as patient-centred care approaches may be beneficial for medical ward nurses. From here, researchers need to examine ways to overcome the barriers to patient participation; further nurse participants and observational data is required on medical wards.