Congruency Between Planned and Performed Procedures and Adherence to Recommended Perioperative Practices: A Chart Audit of High-Risk Surgical Patients

Documentation in an electronic health record system helps ensure that perioperative personnel provide appropriate treatment and care to surgical patients. A retrospective chart review performed with an audit instrument sought to describe the extent to which the documented preoperative plan for a surgery corresponded to the procedure performed. The secondary aim was to describe to what extent perioperative nurses' and physicians' documented care was in accordance with national and international guidelines. Extracted data consisted of physicians' and nurses' documentation of 24 high-risk surgical patients who died within 30 days after a procedure at two hospitals within a single health system. Surgeons documented a planned surgical method for 23 of the 24 patients and the surgical team performed 20 surgeries as planned. Perioperative nurses' and anesthesia professionals' documentation showed a lack of adherence to recommended practices: compliance with guidelines concerning antibiotic prophylaxis and preoperative hygiene preparation were low.

Perceptions and experiences of nurses involved in quality-improvement processes in acute healthcare facilities: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to understand the perceptions of nurses working in acute healthcare environments in relation to quality-improvement processes.

INTRODUCTION

Quality improvement requirements and processes are firmly embedded in contemporary healthcare practice; however, the evidence is unclear on the extent to which nurses are engaged across the continuum of quality improvement. Nurses are required to consult these processes, but clinical nurses in particular may have limited input into the planning and implementation of quality improvement.

INCLUSION CRITERIA

The population to be reviewed is nurses working in acute healthcare settings. The phenomena of interest is the perceptions and experiences of these nurses in relation to quality-improvement processes.

METHODS

A defined search strategy will be used. PubMed, CINAHL, Embase, and SCOPUS will be searched. Informit, MedNar, and ProQuest will be searched to identify gray literature. The search will be limited to studies published in English. No date limits will be set. After screening the titles and abstracts of identified citations, potentially relevant studies will be retrieved in full. The review will be conducted following the JBI methodology for qualitative evidence. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the findings. Synthesis of the data will be presented in a table with accompanying narrative.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019146833.

Introducing standardised care plans as a new recording tool in municipal health care

AIMS AND OBJECTIVES

To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions.

BACKGROUND

In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence-based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting.

DESIGN

An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research.

METHODS

Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records.

RESULTS

Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes "balancing between the old and the new care planning system," "considering the usefulness of standardised care plans as a source of information" and "balancing between overview and detail" reflect these findings.

CONCLUSIONS

Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan.

RELEVANCE TO CLINICAL PRACTICE

The structuring of nursing records is a fast-growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.

Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

OBJECTIVE

To identify and classify the barriers and facilitators of the individualisation process of the standardised care plan in hospitalisation wards.

BACKGROUND

The administration of individualised care is one of the features of the nursing process. Care plans are the structured record of the diagnosis, planning and evaluation stages of the nursing process. Although the creation of standardised care plan has made recording easier, it is still necessary to record the individualisation of the care. It is important to study the elements that influence the individualisation process from the nurses' perspective.

DESIGN

Qualitative study with the grounded theory approach developed by Strauss and Corbin.

METHODS

Thirty-nine nurses from three hospitals participated by way of theoretical sampling. In-depth interviews were conducted, as well as participant observation, document analysis and focus group discussion. The analysis consisted of open, axial and selective coding until data saturation was reached. EQUATOR guidelines for qualitative research (COREQ) were applied.

RESULTS

For both barriers and facilitators, three thematic categories emerged related to organisational, professional and individual aspects. The identified barriers included routines acquired in the wards, the tradition of narrative records, lack of knowledge and limited interest in individualisation. The identified facilitators included holding clinical care sessions, use of standardised care plan and an interface terminology, the nurse's expertise and willingness to individualise.

CONCLUSION

The individualisation process of the standardised care plan involves multiple barriers and facilitators, which influence its degree of accuracy.

RELEVANCE TO CLINICAL PRACTICE

Implementing strategies at an organisational level, professional level and individual level to improve the way the process is carried out would encourage individualising the standardised care plan in a manner that is consistent with the needs of the patient and family; it would improve the quality of care and patient satisfaction.

Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: a grounded theory study

BACKGROUND

Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context.

METHODS

The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data.

RESULTS

A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational.

CONCLUSIONS

The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.

Patients' Experiences of Their Recovery Process After Minor Physical Trauma

Injuries due to trauma are the leading cause of death in Sweden among people younger than 45 years, and more than 120,000 patients were admitted to hospitals in 2014 as a result of trauma. Patients suffering from less serious physical trauma are often discharged directly from the trauma unit, commonly without any follow-up plans. There is a lack of knowledge about how these patients experience their recovery process.Eight women and 6 men were interviewed 3 months after being directly discharged from a trauma unit. Data were analyzed using the constructive grounded theory approach.The main finding was the core category of social support, the key to recovery. Patients' roads to recapturing their health and to recovery had several barriers, which can be clustered together to either physical or psychological symptoms that enhanced their feelings of ill health and delayed their recovery. Participants described different strategies that they used to deal with these barriers. Most important was the support of others, that is, family, social life, work, and health care (primary health care).The participants in this study described managing the recovery process by themselves as troublesome. This is partly because they do not view themselves as healthy, as the health care providers do, and many are in need of further health care after discharge. Health care providers should give better information on the expected process of recovery and the importance of social support, as it might enable patients to better overcome physical and psychological barriers in their recovery.

Standardised care plans for in hospital stroke care improve documentation of health care assessments

AIMS AND OBJECTIVES

To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record.

BACKGROUND

Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital.

DESIGN

Quantitative, comparative.

METHODS

Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record.

RESULTS

Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged.

CONCLUSIONS

An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis.

RELEVANCE TO CLINICAL PRACTICE

Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.