Interprofessional Collaboration Between Nurses and Physicians in the Perioperative Period

PURPOSE

To explore nurses' and physicians' experiences of the six dimensions of interprofessional (IP) collaboration when using Goal-Directed Therapy (GDT), and to examine how existing protocols on GDT facilitate the six dimensions of IP collaboration.

DESIGN

A qualitative design using individual semi-structured interviews and participant observations.

METHODS

A secondary analysis of data from participant observation and semi-structured interviews with nurses (n= 23) and physicians (n=12) in three departments of anesthesiology. Observations and interviews were carried out from December 2016 to June 2017. A deductive, qualitative content analysis using the Inter-Professional Activity Classification as a categorization matrix was used to explore interprofessional collaboration as a barrier to implementation. This analysis was supplemented by a text analysis of two protocols.

FINDINGS

Four dimensions were identified to influence IP collaboration: commitment, roles and responsibilities, interdependence, and integration of work practices. Negative factors included hierarchical boundaries, traditional nurse-physician relationship, unclear responsibility, and lack of shared knowledge. Positive factors included physician involvement of nurses in decisions and bedside education. The text-analysis showed a lack of clear directions of specific action and responsibility.

CONCLUSIONS

Commitment and roles and responsibilities were dominant aspects of interprofessional collaboration in this context, causing problems for enhanced collaboration. Lack of clear guidance in the protocols might detract nurses' feelings of responsibility.

Nurse-assisted and multidisciplinary outpatient follow-up among patients with decompensated liver cirrhosis: A systematic review

BACKGROUND AND OBJECTIVE

Liver cirrhosis represents a considerable health burden and causes 1.2 million deaths annually. Patients with decompensated liver cirrhosis have a poor prognosis and severely reduced health-related quality of life. Nurse-led outpatient care has proven safe and feasible for several chronic diseases and engaging nurses in the outpatient care of patients with liver cirrhosis has been recommended. At the decompensated stage, the treatment and nursing care are directed at specific complications, educational support, and guidance concerning preventive measures and signs of decompensation. This review aimed to assess the effects of nurse-assisted follow-up after admission with decompensation in patients with liver cirrhosis from all causes.

METHOD

A systematic search was conducted through February 2022. Studies were eligible for inclusion if i) they assessed adult patients diagnosed with liver cirrhosis that had been admitted with one or more complications to liver cirrhosis and ii) if nurse-assisted follow-up, including nurse-assisted multidisciplinary interventions, was described in the manuscript. Randomized clinical trials were prioritized, but controlled trials and prospective cohort studies with the intervention were also included. Primary outcomes were mortality and readmission, but secondary subjective outcomes were also assessed.

RESULTS AND CONCLUSION

We included eleven controlled studies and five prospective studies with a historical control group comprising 1224 participants. Overall, the studies were of moderate to low quality, and heterogeneity across studies was substantial. In a descriptive summary, the 16 studies were divided into three main types of interventions: educational interventions, case management, and standardized hospital follow-up. We saw a significant improvement across all types of studies on several parameters, but currently, no data support a specific type of nurse-assisted, post-discharge intervention. Controlled trials with a predefined intervention evaluating clinically- and practice-relevant endpoints in a real-life, patient-oriented setting are highly warranted.

Automated Oxygen Administration Alleviates Dyspnea in Patients Admitted with Acute Exacerbation of COPD: A Randomized Controlled Trial

Objective

Devices for Automated Oxygen Administration (AOA) have been developed to optimize the therapeutic benefit of oxygen supplementation. We aimed to investigate the effect of AOA on multidimensional aspects of dyspnea and as-needed consumption of opioids and benzodiazepines, as opposed to conventional oxygen therapy, in hospitalized patients with Acute Exacerbation of COPD (AECOPD).

Method and Patients

A multicenter randomized controlled trial across five respiratory wards in the Capital Region of Denmark. Patients admitted with AECOPD (n=157) were allocated 1:1 to either AOA (O2matic Ltd), a closed loop device automatically delivering oxygen according to the patient's peripheral oxygen saturation (SpO₂), or conventional nurse-administered oxygen therapy. Oxygen flows and SpO₂ levels were measured by the O2matic device in both groups, while dyspnea, anxiety, depression, and COPD symptoms were accessed by Patient Reported Outcomes.

Results

Of the 157 randomized patients, 127 had complete data for the intervention. The AOA reduced patients' perception of overall unpleasantness significantly on the Multidimensional Dyspnea Profile (MDP) with a difference in medians of -3 (p=0.003) between the intervention group (n=64) and the control group (n=63). The AOA also provided a significant between group difference in all single items within the sensory domain of the MDP (all p-values≤0.05) as well as in the Visual Analogue Scale - Dyspnea (VAS-D) within the past three days (p=0.013). All between group differences exceeded the Minimal Clinical Important Difference of the MDP and VAS-D, respectively. AOA did not seem to have an impact on the emotional response domain of the MDP, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, or use of as-needed opioids and/or benzodiazepines (all p-values>0.05).

Conclusion

AOA reduces both breathing discomfort and physical perception of dyspnea in patients admitted with AECOPD but did not seem to impact the emotional status or other COPD symptoms.

Dialogue is a prerequisite for the nurse-patient relationship in nutritional care: A secondary analysis using the fundamentals of care framework

BACKGROUND

Providing good nutritional care is complex as it goes beyond assessing and ensuring the patients' dietary needs. So far, nutritional research has mainly focused on establishing evidence for the nutritional treatment, while less attention has been on the complexity of providing nutritional care. The Fundamentals of Care (FoC) describes five elements (focus, knowledge, anticipate, evaluate and trust) essential for establishing a nurse-patient relationship as a foundation for quality care. By studying how these elements shape nutritional care and dialogue, we can explore and describe the complexity of nutritional care.

AIM

By using the FoC framework as an analytic framework, this study explores how the nurse-patient relationship shapes the nutritional care of orthopaedic patients.

METHOD

This study is a secondary analysis using deductive content analysis of interviews with patients undergoing major orthopaedic surgery, nursing staff and observations of interactions between nursing staff and patients. The core dimension of the FoC framework, 'Establishment of relationship,' was used as an analytic framework.

RESULT

The nurses perceived serving meals and providing nutritional supplements as an essential part of the nutritional care. Still, the nutritional care was organised as a routine task to be less time-consuming. Appropriate care was initiated when the nursing staff explored patients´ food preferences. When the nursing staff failed to familiarise themselves with the patient's preferences, the patients interpreted nutritional care as unrelated to their needs, resulting in a lack of trust.

CONCLUSION

The need for efficiency within nutritional care must not compromise the patients' need for dialogue with the nurse. Establishing a trusting relationship between nurses and patients prevents nutritional care from becoming a routine task unrelated to the patients' needs.

Patients' Perspective on Automated Oxygen Administration during Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Qualitative Study Nested in a Randomized Controlled Trial

Recently, health technology systems offering monitoring of the peripheral oxygen saturation level and automated oxygen administration (AOA) have emerged. AOA has been shown to reduce duration of hypoxemia and the length of hospital stay, but the patients' perspective on AOA has not been investigated. This qualitative study, based on the interpretive description methodology, aimed to explore how patients hospitalized with exacerbation of chronic obstructive pulmonary disease (COPD) experience being treated with AOA. Eighteen patients treated with AOA were included in the study. Data was collected during admission or in the patients' homes using semi-structured interviews focusing on patients' experiences of AOA using the word "robot" as used by patients. The findings revealed two themes "adaptation of behavior to the robot" and "robots can make patients feel safe but not cared for" and six subthemes. Our findings illustrate how patients were willing to compromise their own therapy and thereby safety by avoiding behavior triggering AOA alarms and disturbing their fellow patients and the health care professionals. Adherence, defined as patients' consistency in taking their medications as prescribed, becomes an important point of attention for health professionals when applying individualized robotic therapies such as AOA to patients with COPD. To support patients in the process of managing adherence to therapeutic technology, we propose a person-centered care approach that, through education and communication with the patients, generates an understanding of how they can self-manage AOA and its alarms without activating avoiding behavior that threatens their treatment and recovery.

Understandings of and experiences with evidence-based practice in practice among nurses in a surgical department: A constructivist approach

AIM AND OBJECTIVES

To explore nurses' constructions of the concept of evidence-based practice through their understandings of and experiences with evidence-based practice in a clinical care setting.

BACKGROUND

The primary purpose of evidence-based practice is high-quality patient outcomes. However, the adoption of evidence-based practice is described as a complex process, and research shows that evidence-based practice is not translated into practice. Research often explores facilitators and barriers of implementing and adopting evidence-based practice. Yet there is limited knowledge on how nurses construct the concept in practice.

DESIGN

This study has a constructivist approach and follows COREQ guidelines.

METHOD

Ten semi-structured interviews with 26 nurses were conducted in 2019. Data were analysed with an emic and inductive approach.

RESULTS

Three key constructions emerged. Understandings of evidence-based practice were based on the original concept of evidence-based medicine. This included the hierarchy of evidence which was perceived as an inflexible concept not encompassing the nursing care. However, while not using the term evidence-based practice, the nurses were doing evidence-based practice portrayed through outcomes from management-supported nursing-based projects and incorporated reflections and discussions into weekly meetings. A discrepancy between a theoretical understanding and a practical doing of evidence-based practice appeared and was especially evident when the nurses' primary evidence sources consisted of the immediate options, for example asking colleagues or following accessible guidelines. Searching for evidence was central in their theoretical understanding but not an incorporated part of their daily work tasks.

CONCLUSION

The nurses' constructions of evidence-based practice indicate a discrepancy between the theoretical understanding of evidence-based practice and the practical doing of evidence-based practice, which hinders the basis of working according to the concept.

RELEVANCE TO CLINICAL PRACTICE

Theoretical discussions of evidence-based practice within the nursing field remain academic, as nurses in practice construct the concept on standards from evidence-based medicine.

Nurse and Physician Perceptions of Working With Goal-Directed Therapy in the Perioperative Period

PURPOSE

To explore nurse and physician perceptions of working with and collaborating about arterial wave analysis for goal-directed therapy to identify barriers and facilitators for use in anesthesia departments, postanesthesia care units, and intensive care units.

DESIGN

A qualitative study drawing on ethnographic principles in a field study using the technique of nonparticipating observation and semistructured interviews.

METHODS

Data collection occurred using semistructured interviews with nurses (n = 23) and physicians (n = 12) and field observations in three anesthetic departments. An inductive approach for content analysis was used.

FINDINGS

The results showed one overarching theme Interprofessional collaboration encourage and impede based on three categories: (1) interprofessional and professional challenges; (2) obtaining competencies; and (3) understanding optimal fluid treatment.

CONCLUSIONS

Several barriers identified related to interprofessional collaboration. Nurses and physicians were dependent on each other's skills and capabilities to use arterial wave analysis. Education of nurses and physicians is important to secure optimal use of goal-directed therapy.

Nurses' Indications for Administration of Perioperative Intravenous Fluid Therapy-A Prospective, Descriptive, Single-Center Cohort Study

PURPOSE

To examine whether nurse anesthetists and postanesthesia nurses' administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit is based on evidence. Secondarily to investigate if providing indications for IV fluid administration changed nursing practice.

DESIGN

Prospective, descriptive, single-center study in Scandinavia comparing two cohorts.

METHODS

Descriptive, fluid volume, and type data were obtained in both cohorts. Cohort 1 (n = 126) was used as baseline data. In cohort 2 (n = 130), nurses recorded indications for type and volume of fluid therapy using a validated list. Analysis compared median volumes of crystalloid or colloid fluids of surgical types by cohort. Analysis compared frequency of given indication reasons for each IV fluid by surgical type.

FINDINGS

Basic static variables were chosen most frequently for indications of IV fluid needed for all surgeries except high-risk abdominal surgery where dynamic variables were more frequent. Signs and symptoms of inadequate tissue perfusion were only sparsely indicated. The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort 2.

CONCLUSIONS

Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signs of inadequate tissue perfusion when they make decisions about fluid administration. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. This indicates the need of a stronger intervention to change practice to follow evidence-based clinical guidelines.

"It is two worlds" cross-sectoral nurse collaboration related to care transitions: A qualitative study

AIMS AND OBJECTIVES

To explore how the hospital and home care nurses talk about and experience cross-sectoral collaboration related to the transitional care of frail older patients.

BACKGROUND

Effective communication and collaboration between nurses involved in care transition are crucial for a safe patient handover. Organisational systems to support cross-sectoral collaboration have been developed but do not always promote the intended dialogue and precise and useful exchange of information. Other factors may also be of importance to an effective and constructive cross-sectoral nurse collaboration.

DESIGN

A qualitative design using thematic analysis.

METHODS

Data were extracted from 24 focus group interviews conducted with registered nurses from eight hospital wards and six municipalities and a total of 165 hr of observations conducted in three hospital wards and three municipalities. The study was reported according to the COREQ guidelines.

RESULTS

The perception of nursing and care differed across sectors. The nurses expressed having shared goals for the patients-however, these goals derived from different values, the perception of nursing and approach to the patients. The lack of knowledge of each other's working conditions created assumptions and preconceptions, which affected communication and collaboration related to planning and executing care transition negatively.

CONCLUSIONS

The nurses perceived the hospital and home care as" two worlds". The collaboration between the nurses was characterised by insufficient communication and preconceptions rather than concrete knowledge and different cultures and professional identities. It can be questioned whether cross-sectoral collaboration between nurses should be characterised as interprofessional rather than intraprofessional collaboration as the features of the nurses' collaboration.

RELEVANCE TO CLINICAL PRACTICE

Organisational and political systems should recognise that nurses in different sectors are taking care of various aspects of nursing when planning on policies to support cross-sectoral collaboration. More possibilities for nurses across sectors to meet should be made available.

Nurses' perspectives on how an e-message system supports cross-sectoral communication in relation to medication administration: A qualitative study

AIMS AND OBJECTIVES

To describe nurses' perspectives on how an e-message system supports communication between hospital and home care nurses in relation to medication administration.

BACKGROUND

Medication administration is a complex process involving a high risk of error. Unclear communication and lack of updated information about medication have been identified as the leading cause of medication errors during care transitions. E-message systems are progressively being used to improve information exchange across sectors, yet little is known about their usage for exchange of medication information between nurses.

DESIGN

A qualitative design using content analysis.

METHODS

Focus group interviews were conducted with nurses from eight hospital wards and six municipalities (n = 79). Participant observations were conducted in three hospital wards and in three municipalities (165 hr).

RESULTS

The e-message system did not provide the information needed by the home care nurses to ensure safe medication administration after discharge due to (1) limitations of the system, (2) hospital nurses' lack of knowledge about home care nurses' information needs and (3) hospital nurses' lack of access to medication information. Due the home care nurses' perception of responsibility, they bypassed the e-message system to get the information.

CONCLUSIONS

The home care nurses perceived themselves as the last link in the safety chain. As such, access to adequate information was essential for the nurses to ensure safe medication administration; however, the e-message system did not support exchange of the information needed.

RELEVANCE TO CLINICAL PRACTICE

E-message systems must meet home care nurses' need for information to ensure that safe medication administration does not depend on the knowledge of the individual nurse. Moreover, other system factors that influence interprofessional collaboration and nurses' cross-sectoral communication must be addressed.

Stuck in tradition-A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff

AIMS AND OBJECTIVES

To explore the barriers for nutritional care as perceived by nursing staff at an acute orthopaedic ward, aiming to implement evidence-based nutritional care.

BACKGROUND

Previous studies indicate that nurses recognise nutritional care as important, but interventions are often lacking. These studies show that a range of barriers influence the attempt to optimise nutritional care. Before the implementation of evidence-based nutritional care, we examined barriers for nutritional care among the nursing staff.

DESIGN

Qualitative study.

METHODS

Four focus groups with thirteen members of the nursing staff were interviewed between October 2013-June 2014. The interview guide was designed according to the Theoretical Domains Framework. The interviews were analysed using qualitative content analysis.

RESULTS

Three main categories emerged: lacking common practice, failing to initiate treatment and struggling with existing resources. The nursing staff was lacking both knowledge and common practice regarding nutritional care. They felt they protected patient autonomy by accepting patient's reluctance to eat or getting a feeding tube. The lack of nutritional focus from doctors decreased the nursing staffs focus leading to nonoptimal nutritional treatment. Competing priorities, physical setting and limited nutritional supplements were believed to hinder nutritional care.

CONCLUSION

The results suggest that nutritional care is in a transitional state from experience- to evidence-based practice. Barriers for nutritional care are grounded in lack of knowledge among nursing staff and insufficient collaboration between nursing staff and the doctors. There is a need for nutritional education for the nursing staff and better support from the organisation to help nursing staff provide evidence-based nutritional care.

RELEVANCE TO CLINICAL PRACTICE

This study contributes with valuable knowledge before the implementation of evidence-based nutritional care. The study provides an understanding of barriers for nutritional care and presents explanations to why nutritional care has failed to become an integrated part of the daily treatment and care.

[Measuring the quality of life of mentally-ill patients: is it possible to compare with quality of life of healthy population?]

Investigations of the quality of life of mentally-ill patients can be conducted with illness-specific assessment tools, e.g. Lehmans Quality of Life Interview guide. The present article reviews WHOQOL, which is the questionnaire method of the WHO, developed on the basis of a multidimensional quality of life concept. WHOQOL has been translated into Danish and validated by both patient groups and the Danish population. Data from the population investigations can be used as a reference when interpreting data from groups of patients. The WHOQOL-BREF questionnaire has been used in an investigation of schizophrenic patients.

Quality of life assessment in schizophrenia: applicability of the Lehman Quality of Life Questionnaire (TL-30)

The aim of the present study was to investigate the applicability of a quality of life self-rating scale - the Lehman Quality of Life Questionnaire TL-30 - to evaluate the test-retest reliability of the TL-30 and finally to test the quality of life in schizophrenic patients compared with a general population. Patients with ICD-10 F20 schizophrenia were included. An interviewer-administrated quality of life instrument, the Lehman's QoLI interview guide, and two questionnaires, the Lehman TL-30 and the Medical Outcome Study (SF-36) were used at baseline. Hereafter the two questionnaires were completed again 2 weeks after discharge from hospital for the evaluation of test-retest reliability. A total of 56 patients were interviewed and 40 patients (or 71%) completed the questionnaires. Statistically significant correlation was found between the interview form and the questionnaire version. The test-retest coefficients were at the same level (approximate 0.70 for most Lehman subscales) as found for the SF-36 subscales. Compared with the general population, lower health-related quality of life (SF-36) was found in schizophrenia (P<0.01). The results of the present study confirm that the Lehman Quality of Life questionnaire can be validly used in stable schizophrenics.

Quality of life in schizophrenic patients: association with depressive symptoms

The objective of this study was to examine to what extent depressive symptoms are associated with reduced quality of life in schizophrenia by using a general population sample as control group. Patients with ICD-10 schizophrenia stabilized during hospitalization with antipsychotics were compared with a general population sample by use of self-reported scales for quality of life (the WHO Quality of Life Short Form, WHOQOL- BREF) and for depression (the Major Depression Inventory, MDI). Of the schizophrenic patients screened for ability to participate in the study, 40, or 71%, completed the two questionnaires as psychometrically valid as the control group. Within the group of schizophrenic patients, no association was seen with the types of antipsychotic medication prescribed (typical vs. atypical antipsychotics). Both in the group of schizophrenic patients and in the general population sample, those persons scoring on the MDI to have depressive symptoms had significant reduced quality of life. In conclusion, approximately 70% of the schizophrenic patients stabilized during hospitalization with antipsychotics are able to validly complete self-report scales measuring quality of life and depressive symptoms. In these patients, depressive symptoms, as in the general population, was found to have association with reduced quality of life.

The WHO Quality of Life (WHOQOL) Questionnaire: Danish validation study

The objective of this pilot study was to evaluate the Danish translation of the WHO Quality of Life Questionnaire, the WHOQOL, by means of the psychometric properties of the Danish version. The translation method followed the WHO standard procedures, including forward and backward translation, focus group discussions, and assessment of response choice weighting through visual analogue scales. In the study we evaluated the applicability of the WHOQOL in patients with physical and mental disorders compared with a sample of healthy controls. The WHOQOL was compared with health-related quality of life questionnaire SF36 (Short Form 36). The internal consistency or homogeneity of the Danish WHOQOL was found adequate, and its applicability and its performance in distinguishing between population groups were satisfactory. The abbreviated version of WHOQOL-100, the WHOQOL-BREF, was analysed separately and was also found psychometrically valid. The WHOQOL is a questionnaire that is easy to administer, and it seems applicable for use.

Reliability and validity of the Danish version of the Calgary Depression Scale for Schizophrenia

Depressive symptoms within the range of schizophrenic syndromes constitute a major diagnostic and therapeutic problem. Earlier research has indicated that available depression scales are not adequate when examining mood disturbances in patients with schizophrenia. We have made an attempt to estimate the reliability and validity of the Danish version of the Calgary Depression Scale for Schizophrenia. The external validity has been analysed in relation to the Major Depression Inventory (MDI). The internal validity has been analysed by using Loevinger's coefficient of homogeneity as the primary statistic. For the inter-observer reliability the intra-class coefficients have been calculated. It was shown that a subscale of the Calgary scale has sufficient reliability and validity.