The scope of emergency nursing viewed through the lens of complex adaptive systems: A discussion paper

Across the world, emergency department nurses care for patients around the clock all year long. They perform tasks ranging from direct nursing care to managing patient flow, working in an environment characterised by interdependencies among numerous actors. The complex context in which emergency nurses operate has not been thoroughly described or discussed, indicating a knowledge gap. Hence, the aim of this discussion paper is to describe and discuss nursing in the emergency department and the connection between patient flow and nursing care, drawing on the concept of complex adaptive systems. The acts of direct patient care and patient flow, when viewed through the lens of complex adaptive systems, are central components of emergency nursing. Through a stepwise description of these two perspectives, based on literature and clinical experience from European countries, the paper illustrates the complexity of the emergency nursing context in a novel manner. We argue that direct patient care and patient flow, combined as patient flow management, constitute essential parts of the core of emergency department nursing. Further studies are needed to challenge or confirm this assertion.

The Nursing Theory of Complex Adaptive Systems: A New Paradigm for Nursing

BACKGROUND/OBJECTIVES

This article explores the theoretical and practical implications of the meaning of thinking, living, and acting within the framework of nursing in Complex Adaptive Systems. The Nursing Theory of Complex Adaptive Systems is grounded in the principles of Complex Adaptive Systems (CASs). It seeks to offer a new paradigm for nursing practice that addresses healthcare's dynamic and evolving nature.

METHODS

The Nursing Theory of Complex Adaptive Systems represents a new nursing paradigm capable of addressing the challenges of a constantly evolving healthcare environment. This theory promotes personalized care plans adaptable to patients' changing needs by emphasizing a holistic and interactive approach to care.

RESULTS

It also underscores the importance of interprofessional collaboration and effective communication in improving the quality of care. The Nursing Theory of Complex Adaptive Systems has significant implications for nursing practice, education, and research.

CONCLUSIONS

It provides a robust framework for developing adaptive and resilient nursing practices that can respond to the complexities of modern healthcare. By integrating the principles of CASs into nursing, the Nursing Theory of Complex Adaptive Systems fosters a more flexible, interdependent, and holistic approach to patient care, ultimately enhancing patient outcomes and improving healthcare systems. This theory has practical applications in various healthcare settings, offering a framework for personalized and adaptable care plans that respond to the dynamic needs of patients while improving overall system efficiency. Future research should focus on the empirical validation of the Nursing Theory of Complex Adaptive Systems and its practical implementation in various healthcare settings.

Relationship between care dependency, adverse events, trust in nurses and satisfaction with care: The mediating role of patient-reported missed care

AIM

The aim of the study was to investigate the mediating effect of patient-reported missed care in the relationship between care dependency, adverse events, trust in nurses and satisfaction with nursing care.

DESIGN

A cross-sectional and correlational study.

METHODS

A total of 374 patients were recruited from the medical and surgical inpatient units of two public university hospitals in Türkiye using a convenience sampling method from May to August 2022. The data were collected using the Care Dependency Scale, MISSCARE Survey-Patient, Trust in Nurses Scale and Newcastle Satisfaction with Nursing Care Scale. The relationships between the variables were analysed using a sequential mediation model (Model 6) in Hayes' PROCESS macro.

RESULTS

Care dependency was found to have a significant negative effect on misscare-communication; however, it had no significant effect on misscare-basic care. Misscare-communication had a significant positive effect on the experience of adverse events, while misscare-basic care had no significant effect. Misscare-communication and basic care had a significant negative effect on trust in nurses and satisfaction with nursing care. Misscare-communication was found to have a partial mediating effect on the relationship between care dependency and experiencing adverse events, trust in nurses and satisfaction with nursing care.

CONCLUSION

The results emphasize the importance of misscare-basic care, communication and patients' care dependency in improving patient outcomes such as experiencing adverse events, trust in nurses and satisfaction with nursing care, and they extend existing nursing studies by addressing missed care and care dependency together from the perspective of patients.

IMPACT

We urge nurse managers to consider the role of misscare in the impact of patients' level of care dependency on patient outcomes. Accordingly, nurse managers should focus first on interventions to eliminate misscare-communication. Effective interventions to address factors that impact communication and fulfilment of basic care are necessary to achieve better patient outcomes.

REPORTING METHOD

EQUATOR guidelines were followed using the STROBE reporting method.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. Patients only contributed to data collection. Data were obtained from patients hospitalized in the medical and surgical inpatient units of two public university hospitals.

The relevance of the contribution of psychoneuroendocrinoimmunology and psychology of reasoning and decision making to nursing science: A discursive paper

AIM

Patients' death or adverse events appear to be associated with poor healthcare decision-making. This might be due to an inability to have an adequate representation of the problem or of the connections among problem-related elements. Changing how a problem is formulated can reduce biases in clinical reasoning. The purpose of this article is to explore the possible contributions of psychoneuroendocrinoimmunology (PNEI) and psychology of reasoning and decision-making (PRDM) to support a new nursing theoretical frame.

DESIGN

Discursive paper.

METHOD

This article discusses the main assumptions about nursing and nurses' ability to face patient's problems, suggesting a new approach that integrates knowledge from PNEI and PRDM. While PNEI explains the complexity of systems, highlighting the importance of systems connections in affecting health, PRDM underlines the importance of the informative context in creating a mental representation of the problem. Furthermore, PRDM suggests the need to pay attention to information that is not immediately explicit and its connections.

CONCLUSION

Nursing recognizes the patient-nurse relationship as the axiom that governs care. The integration of PNEI and PRDM in nursing theoretics allows the expansion of the axiom by providing essential elements to read a new type of relationship: the relationship among information. PNEI explains the relationships between biological systems and the psyche and between the whole individual and the environment; PRDM provides tools for the nurse's analytical thinking system to correctly process information and its connections.

IMPACT ON NURSING PRACTICE

A theoretical renewal is mandatory to improve nursing reasoning and nursing priority identification. Integrating PNEI and PRDM into nursing theoretics will modify the way professionals approach patients, reducing cognitive biases and medical errors.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement in the design or writing of this discursive article.

Missing nurses cause missed care: is that it? Non-trivial configurations of reasons associated with missed care in Austrian hospitals - a qualitative comparative analysis

BACKGROUND

Errors of omissions affect the quality of nursing care in hospitals. The Missed Nursing Care Model explains that the reasons for missed care are linked with 1) demand for patient care, 2) labor resource allocation, 3) material resource allocation, and 4) relationship and communication factors. Scientific evidence points to a lack of adequate nursing staffing as the most important factor triggering missed care. However, it remains unclear how the different theoretical reasons for missed care are interlinked with reports on missed care from the perspective of nurses in acute care settings. The aim of this study was to explore non-trivial configurations of reasons for missed care that are associated with missed care interventions from the perspective of nurses working in general units in Austrian hospitals.

METHODS

A cross-sectional study was conducted. Data collection was performed using the revised MISSCARE-Austria questionnaire. Our sample consisted of 401 nurses who provided complete data. Data were analyzed using qualitative comparative analysis. Configurational models of contextual factors, reasons for missed care, and missed nursing interventions were analyzed.

RESULTS

In our study contextual factors were not consistent precursors of the reasons for missed care. Missed care was consistently present when the demand for patient care was high. A lack of labor resources, in combination with the other known reasons for missed care, was consistently observed when missed care occurred. Different configurations of reasons were found to be non-trivially associated with different types and frequencies of missed care.

CONCLUSIONS

To understand the complexity of the causal mechanisms of missed care, complexity theory may be necessary. Accordingly, a theoretical framework that acknowledges that complex systems, such as missed care, are composed of multiple interacting causal components must be further developed to guide new methodical approaches to enlighten its causal mechanisms.

External influencing factors on missed care in Austrian hospitals: Testing the theoretical antecedents of missed care using structural equation modelling

PROBLEM

Missed Nursing Care (MNC) is an error of omission which occurs when a necessary nursing intervention is not initiated, is not completed, or when it is delayed. The MNC model explains this problem and describes four antecedents that can lead to MNC: (1) demand for patient care, (2) available human resources, (3) material resources, and (4) and relationship and communication factors.

AIMS

This study aims to test the relationship between the theoretical antecedents of MNC and their impact on MNC.

DESIGN

A quantitative cross-sectional study.

METHODS

The Austrian version of the revised MISSCARE Survey was completed by nurses working in general hospital units between May and July 2021. Recruitment followed a respondent-driven sample via Austrian nursing education institutions and social media. One thousand six nurses fulfilled inclusion criteria. The structure of the theoretical constructs of the MNC model was tested using a confirmatory factor analysis approach. The relationships between the four antecedents and MNC were explored using structural equation modelling with 427 complete cases.

RESULTS

The results support the structural validity of the revised MISSCARE Austria concerning the defined theoretical constructs, although discriminant validity and measurement error should be further investigated. The antecedent "resource allocation: labor" had a statistically significant impact on MNC: The lack of adequate nursing staff played the most important role to explain missed care in our model.

CONCLUSION

In our study in Austria, MNC was mostly influenced by a lack of appropriate labor resources. Further studies exploring mediation effects and non-linear relationships may contribute to better understanding of reasons for MNC.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.