We have gone full circle

In 1983 I qualified as a state enrolled nurse (SEN). Our role was supposed to be complementary to the registered nurses, but most SENs carried out the same duties as their registered colleagues. We were valued members of the nursing team.

Readers' panel - Should staff extend their roles to meet rising demand?

Our experts consider a hot topic of the day.

Program outcomes following implementation of a hybrid curriculum at the certificate level

AIM

This study examined satisfaction levels and learning outcomes before and after implementation of a hybrid curriculum.

BACKGROUND

Increased competition for clinical sites pressured a practical nursing program to explore alternative placement solutions. A hybrid curriculum, defined as offering 50 percent of second-semester theory course content online, was implemented in order to free students from place-bound instruction and thereby open new clinical opportunities.

METHODS

A summative evaluation was conducted to compare NCLEX-PN pass rates, grade outcomes, student satisfaction, and attrition rates between a prehybrid group of 119 practical nursing students and a hybrid group of 106 practical nursing students.

RESULTS

Findings indicate no significant differences in NCLEX pass rates and grade outcomes between the groups and an improvement in satisfaction and attrition rates.

CONCLUSION

It was concluded that use of a hybrid curriculum can open new clinical opportunities while maintaining the learning outcomes of NCLEX-PN pass rates and course grades.

Blood pressure determination by traditionally trained personnel is less reliable and tends to underestimate the severity of moderate to severe hypertension

OBJECTIVE

Blood pressure determined by nurses has been observed to be unreliable. This study was conducted to compare the reliability of blood pressure measurements performed by traditionally trained nurses with those performed by a well-trained nurse and by an automatic device.

METHODS

Hypertensive patients in an outpatient clinic were studied. Each individual was subjected to three blood pressure measurements: the first one was performed by the traditionally trained nurse on duty at the time of study (TT nurse BP), the second one by a specifically trained nurse (ST nurse BP), both using sphygmomanometer; and the third one was done using Omron HEM-907 (digital BP).

RESULTS

A total of 907 participants were enrolled. More than 99% of both systolic and diastolic TT nurse BP ended with zero, demonstrating that they had terminal digit preference. ST nurse BP was in better agreement with digital blood pressure measurement than with TT nurse BP. The number of differences of < or =5 mmHg between ST nurse BP and digital blood pressure measurement was approximately 60% for both systolic and diastolic blood pressure. Overall, traditionally trained nurses overestimated, rather than underestimated, blood pressure. However, systolic blood pressure underestimation was extremely prominent in participants with moderate to severe hypertension. Systolic blood pressure underestimation of >5 mmHg was as high as 57.5% by traditionally trained nurses versus 33.8% by the automatic device, indicating that traditionally trained nurses tended to underestimate blood pressure in participants with more severe hypertension.

The academization of nursing: implications for Arab enrolled nurses in Israel

BACKGROUND

The trend towards the abolition of second level (practical) nurse education, begun decades ago in Western countries, is being adopted in Israel. In 2004 practical (enrolled) nurses constituted approximately one-third of the Israeli nursing labour force, many of whom were Arab-Israelis. Practical nurses in Israel are now expected to upgrade their education to fi rst (registered) level nurse.

AIM

To understand the current situation of Arab-Israeli practical nurses, taking into account the cultural, ethnic, socio-economic and gender aspects of their lives.

METHODS

A qualitative, ethnographic approach, using in-depth interviews with 13 Arab-Israeli nurses.

FINDINGS

The women's negative attitudes to the conversion course were not related to their otherwise positive attitudes to education in general. The conversion course was affected by adverse material conditions; cultural factors and feeling of helplessness. The threat of loss of professional nursing status as a result of the changes in nursing gave rise to a great sense of personal loss.

CONCLUSION

As reported in other countries, the academization of nursing in Israel is obstructing one of the major routes of social mobility for women in the weaker sections of society. This situation is experienced as particularly harsh, because of the overall oppressive situation that Arab women in Israel suffer.

Promotion of evidence-based practice by professional nursing associations: literature review

AIM

This paper reports a literature review examining the activities of professional nursing associations in the promotion of evidence-based practice.

BACKGROUND

Professional nursing associations can play a role in the implementation and achievement of evidence-based practice as such associations aim to develop and further educate nurses professionally, build professional networks representing the interests of nurses and the nursing profession, influence the government and policymakers, and support and protect the basic values of nurses. The exact role of professional nursing associations in the promotion of evidence-based practice is as yet unclear, along with just how the role of such associations can be expanded and which strategies can be used to promote evidence-based practice among members.

METHOD

A literature and Internet search was undertaken using the PUBMED, CINAHL, SCIRUS, INVERT, and the Cochrane databases using the terms evidence-based practice(s)* or EBP*, which were then combined with Nursing Society*, Nursing Organization*, Nursing Organisation*, Nursing Association* or Nursing Council*. Other sources included a Google search of the Internet, and the sites of various members of the International Council of Nurses. Publications in English, French or German from 1993 to 2004 were used, and the Internet search was conducted on 17 July 2003.

RESULTS

Sixty nursing associations described the dissemination of evidence-based practice using one or more types of activities (179 activities in total). All of these activities were of a voluntary nature, with a predominant focus (132/179 activities) on intrinsic motivation of nurses. More specifically, most of the activities were aimed at nurses' competences and attitudes in relation to evidence-based practice.

CONCLUSION

Professional nurses' associations are active in promoting evidence-based practice among their nurse members, but only those focusing on changing competences and attitude by addressing intrinsic motivation are well used. Other types of activities deserve to be explored, including behaviour-oriented approaches, approaches using structural, social or financial influence measures and perhaps methods based on 'involuntary involvement'.

The outcomes of an intervention study to reduce the barriers experienced by people with intellectual disabilities accessing primary health care services

BACKGROUND

People with intellectual disabilities (IDs) experience significant health inequalities compared with the general population. The barriers people with IDs experience in accessing services contribute to these health inequalities. Professionals' significant unmet training needs are an important barrier to people with IDs accessing appropriate services to meet their health needs.

METHOD

A three group, pre- and post-intervention design was used to test the hypothesis that a training intervention for primary health care professionals would increase the knowledge and self-efficacy of participants. The intervention had two components - a written training pack and a 3-hour face-to-face training event. One group received the training pack and attended the training event, a second group received the training pack only, and a third group did not participate in the training intervention. Research measures were taken prior to the intervention and 3 months after the intervention. Statistical comparisons were made between the three groups.

RESULTS

The participants in the training intervention reported that it had a positive impact upon their knowledge, skills and clinical practice. As a result of the intervention, 35 (81.4%) respondents agreed that they were more able to meet the needs of their clients with IDs, and 33 (66.6%) reported that they had made changes to their clinical practice. The research demonstrated that the intervention produced a statistically significant increase in the knowledge of participants (F = 5.6, P = 0.005), compared with the group that did not participate in the intervention. The self-efficacy of the participants that received both components of the intervention was significantly greater than the group that did not participate in the training (t = 2.079, P = 0.04). Participation in the two components of the training intervention was associated with significantly greater change in knowledge and self-efficacy than those receiving the training pack alone.

CONCLUSION

This intervention was effective in addressing the measured training needs of primary health care professionals. Future research should directly evaluate the positive benefits of interventions on the lives of people with IDs.

Enhancing primary health care services for adults with intellectual disabilities

BACKGROUND

Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training needs, and self-efficacy in their work with people with ID.

METHODS

All practice nurses working in a defined area were identified. A purpose-designed questionnaire to measure nurse attitudes, knowledge, training needs and self-efficacy was developed and piloted. All practice nurses were then invited to participate. Data from completed questionnaires were entered onto PC and analysed.

RESULTS

Of a total of 292 practice nurses 201 (69%) participated. Whilst 89% (n=179) of participants reported having infrequent contact, 25% (n=50) reported a growing workload with people with ID. Only 8% (n=16) had ever received any training in communicating with people with ID. A knowledge gap regarding the health needs of people with ID was identified. Eighty-six per cent reported having experienced specific difficulties during previous appointments, and only 23% thought they had sufficient case note information at appointments, but 68% did not modify the duration of their appointments with people with ID. Conversely, responses demonstrated that practice nurses have a high level of experience and qualification in general nursing, have positive attitudes to working with people with ID, and high self-efficacy scores were identified for work with people with ID. The practice nurses viewed ID to be a high priority area for future training.

CONCLUSIONS

Primary health care teams have a key role in tackling the unmet health needs of people with ID. Whilst this project has identified factors that may impact on the accessibility of services, it has also identified practice nurses as having positive attitudes and high self-efficacy scores in their work with people with ID. This indicates that they should be targeted for specific training in this area, which may make an important contribution in enhancing future accessibility of primary health care services for people with ID.

Occupational changes in nursing: the situation of enrolled nurses

BACKGROUND

The move to one level of qualified nurse in the United Kingdom (UK) is, in part, a consequence of professionalizing strategies. Registered nurses now undertake technical work previously performed by doctors. The role of enrolled nurses, and their career intentions, have not been considered in light of these changes, despite the fact that many still work in the National Health Service.

AIM

This paper considers the pursuit of professionalization by nurses, illustrating the argument with findings from an empirical study of conversion to registered nurse by enrolled nurses.

METHODS

The paper is based on a secondary analysis of a large data set, originally used to explore ethnic inequalities in nursing. Data from 2968 respondents were analysed to answer a number of research questions relating to the characteristics of different groups of enrolled nurses and predictors of conversion to registered nurse. These included demographic characteristics, markers of career orientation, career progression and job satisfaction.

STUDY LIMITATIONS

This study used secondary analysis of data and, therefore, exploration of issues was limited, not least because the data were 10 years old. Also, the design was cross-sectional and respondents' experiences related to different stages of the phenomenon under study and the same group was not studied over time.

FINDINGS

Enrolled nurses who had converted to registered nurse were more likely than those who had no intention of converting to: be male, be younger, have been nursing longer, not be working on elderly care wards, have a high career orientation, not have taken a career break, and work full-time. Most of these factors predicted likelihood to convert. Although nurses who converted to registered nurse were more likely to anticipate career progression, they were less likely to be satisfied with their work.

CONCLUSION

In attempts to define rewarding nursing work, the importance of ensuring that qualified nurses continue to retain basic nursing care skills should be acknowledged. This may offer an uncomfortable view to those seeking to further the professional status of nursing.

Nurse Staffing and Mortality for Medicare Patients with Acute Myocardial Infarction

CONTEXT

Recent hospital reductions in registered nurses (RNs) for hospital care raise concerns about patient outcomes.

OBJECTIVE

Assess the association of nurse staffing with in-hospital mortality for patients with acute myocardial infarction (AMI).

DESIGN, SETTING, AND PATIENTS

Medical record review data from the 1994-1995 Cooperative Cardiovascular Project were linked with American Hospital Association data for 118,940 fee-for-service Medicare patients hospitalized with AMI. Staffing levels were represented as nurse to patient ratios categorized into quartiles for RNs and for licensed practical nurses (LPNs).

MAIN OUTCOME MEASURES

In-hospital mortality.

RESULTS

From highest to lowest quartile of RN staffing, in-hospital mortality was 17.8%, 17.4%, 18.5%, and 20.1%, respectively (P < 0.001 for trend). However, from highest to lowest quartile of LPN staffing, mortality was 20.1%, 18.7%, 17.9%, and 17.2%, respectively P < 0.001). After adjustment for patient demographic and clinical characteristics, treatment, and for hospital volume, technology index, and teaching and urban status, patients treated in environments with higher RN staffing were less likely to die in-hospital; odds ratios (95% confidence intervals) of quartiles 4, 3, and 2 versus quartile 1 were 0.91 (0.86-0.97), 0.94 (0.88-1.00), and 0.96 (0.90-1.02), respectively. Conversely, after adjustment, patients treated in environments with higher LPN staffing were more likely to die in-hospital; odds ratios (95% confidence intervals) of quartiles 4, 3, and 2 versus quartile 1 were 1.07 (1.00-1.15), 1.02 (0.96-1.09), and 1.00 (0.94-1.07), respectively.

CONCLUSIONS

Even after extensive adjustment, higher RN staffing levels were associated with lower mortality. Our findings suggest an important effect of nurse staffing on in-hospital mortality.

Motivating LPNs

Follow one facility's approach to developing an LPN clinical ladder program.

Ethical practice guidelines: an evaluation

Ethical practice guidelines (EPGs) were developed for use in Central Sydney Area Mental Health Service to guide contemporary mental health nursing practice and serve as a resource for clinical mental health nurses in relation to their professional conduct and practice. This survey of mental health nurses aimed to ascertain feedback on the application of the EPGs in the clinical arena. Nurses from the Central Sydney Area Mental Health Service (n = 350) were asked to complete a 15-item survey developed by the authors. A total of 121 nurses completed the survey. Findings from the survey reveal that the information provided in the EPGs is useful (91%) and the EPGs provide sufficient guidance for practice (94%). Most respondents (96%) reported feeling confident dealing with ethical practice situations and 75% indicated interest in further education and training in this domain. Findings from this survey support the need to explore avenues to facilitate education, discussion and reflective practice in relation to ethical mental health nursing practice.

Making the transition from enrolled to registered nurse

Each year among the university graduates who become eligible to register as nurses for the first time, there are a number of people who have previously trained and practiced as enrolled nurses. There is little research that examines the experiences and needs of this unique group of simultaneously experienced and novice nurses. In this paper, a phenomenological approach was used to examine the lived experience of nine former enrolled nurses making the transition from nursing student to graduate nurse. Data from extensive interviews with these nine nurses was examined using van Manen's (1990) steps of thematic analysis. The grouping of concepts into subthemes led to the identification of three main themes that described the nurses' experiences of transition: responsibility and accountability, change, and job satisfaction. Excerpts from interview transcripts are used as exemplars in discussion of the meaning and importance of these findings. The findings of this study will inform nurse education and graduate transition support services.

Resolving ethical dilemas. Applying the institute for Global Ethics' Ethical Fitness model to occupational and environmental health practice issues

1. Technological advancements have rapidly increased the need for careful ethical choices to preserve life and environment of the global community. 2. No formula exists to resolve ethical dilemmas, but using an ethical decision making model can help maintain a state of ethical fitness. 3. The Ethical Fitness model relies on the assumption that certain core values are universal. Maintaining ethical fitness is essential to resolve ethical dilemmas. 4. The process of resolving ethical dilemmas consists of analyzing the dilemma using nine checkpoints, four dilemma paradigms, and three resolution principles.

Statutory and regulatory recognition for clinical nurse specialists in Oregon

Clinical nurse specialists (CNSs) in Oregon initiated the process of achieving statutory and regulatory recognition several years ago. Throughout this process, specific phases of activity and events helped CNSs to identify what was required to achieve this goal. The resulting lessons learned are shared in this report. Statutory recognition of CNSs in Oregon occurred in 1999, and the administrative rules for CNS practice were published in 2001. These administrative rules delineate the CNS scope of practice and other aspects of CNS practice consistent with national standards.

Non-physician practitioners in radiation oncology: advanced practice nurses and physician assistants

PURPOSE

With changes in reimbursement and a decrease in the number of residents, there is a need to explore new ways of achieving high quality patient care in radiation oncology. One mechanism is the implementation of non-physician practitioner roles, such as the advanced practice nurse (APN) and physician assistant (PA). This paper provides information for radiation oncologists and nurses making decisions about: (1) whether or not APNs or PAs are appropriate for their practice, (2) which type of provider would be most effective, and (3) how best to implement this role.

METHODS

Review of the literature and personal perspective.

CONCLUSIONS

Specific issues addressed regarding APN and PA roles in radiation oncology include: definition of roles, regulation, prescriptive authority, reimbursement, considerations in implementation of the role, educational needs, and impact on resident training. A point of emphasis is that the non-physician practitioner is not a replacement or substitute for either a resident or a radiation oncologist. Instead, this role is a complementary one. The non-physician practitioner can assist in the diagnostic work-up of patients, manage symptoms, provide education to patients and families, and assist them in coping. This support facilitates the physician's ability to focus on the technical aspects of prescribing radiotherapy.

Evaluating dispensing error detection rates in a hospital pharmacy

OBJECTIVES

The filling of unit dose orders and checking for filling errors are two essential distributive responsibilities of a hospital pharmacy. Previous studies have shown that nonpharmacists, usually technicians, are capable of assuming these distributive tasks traditionally performed by hospital pharmacists. The study tested whether nonpharmacists, in this case licensed practical nurses/medication nurses, were as competent as pharmacists in checking for errors in unit dose cassettes prepared for hospital patients.

METHODS

A university teaching hospital was used for the study. Artificial errors (n = 812) were introduced into the drug distribution system during a 4-month period in 1995. Included in the study were seven staff pharmacists and nine medication nurses (licensed practical nurses) involved in the decentralized drug distribution system. The primary measure was the ratio of errors detected to the number of artificial errors introduced into the system. This primary measure is different from those used in prior studies that do not separate dispensing errors and checking errors.

RESULTS

Overall, pharmacists were significantly more accurate in detecting errors (87.7% vs. 82.1%). In one category of serious errors, that of wrong strength, the difference between pharmacists and licensed practical nurses was even greater (93.3% vs. 83.3%).

CONCLUSIONS

This study's results do not support conclusions of prior studies that nonpharmacists can match the error detection accuracy of pharmacists. It demonstrates the importance of considering the types of errors under examination and of using appropriate measures of error checkers when drawing conclusions on relative competence.

Improving your bedside manner

Positive bedside manners are essential when caring for patients. Positive bedside manners should be utilized wherever patients and their significant others are encountered. Putting your best foot forward is the first step in establishing a therapeutic relationship. Attention to one's professional image is important if the client is to see the licensed practical/vocational nurse as someone that can be trusted. Next is actively communicating interest and concern. It is also important to communicate empathy and respect through words and actions. The LP/VN must practice attending skills in order for the patient to experience the physical and psychological presence of the nurse. Communicating availability and following up on requests promote the establishment of trust. It is important for the nurse to avoid defensiveness, maintain a professional manner, answer questions honestly, demonstrate integrity, maintain a positive attitude and practice intentional encouragement. All the characteristics will demonstrate a positive bedside manner and will communicate caring and concern to clients and their significant others.

The role of the licensed practical nurse and the licensed vocational nurse in the clinical practice of intravenous nursing. The Intravenous Nurses Society

The Intravenous Nurses Society (INS) believes that the intravenous trained licensed practical nurse and the licensed vocational nurse can aid in the delivery of some aspects of intravenous therapy under the supervision of the registered nurse; however, the registered nurse shall be the primary practitioner in this specialty.

Finding a balance: client choice vs public protection

Choice should be a basic part of health care, yet questions arise when untrained individuals take on the responsibility of supervising their own care--questions of safety and appropriateness.

Screening for colorectal cancer by nurse endoscopists

BACKGROUND

Case-control studies have demonstrated that screening by sigmoidoscopy is effective in reducing mortality from colorectal cancer. If nurses performed screening examinations, more patients could be screened and, at current income levels, at a lower cost.

METHODS

Two registered nurses and two licensed practical nurses learned to perform examinations with the flexible fiberoptic sigmoidoscope in order to screen patients for colorectal tumors. They performed 1881 independent examinations of outpatients more than 45 years of age. During the same period, 730 examinations were performed by two gastroenterologists in similar patients.

RESULTS

The mean depth of insertion of the sigmoidoscope was slightly but significantly greater in the patients examined by the physicians than in those examined by the nurses (48 vs. 46 cm in men, P = 0.003; 41 vs. 38 cm in women, P = 0.002). Adenomas were found in 14 percent of the men and 8 percent of the women examined (P = 0.001). Nine cancers were found in men and four in women. There were no significant differences between the nurses and the physicians in the proportion of examinations that were positive for adenomas or cancer. No complications occurred during the initial examinations or during 894 follow-up sigmoidoscopic procedures. Among the patients whose initial examination results were normal, more of those examined by nurses returned for follow-up sigmoidoscopy after 12 months or more (45 percent, vs. 30 percent of those examined by physicians; P = 0.001).

CONCLUSIONS

Nurses can carry out screening by flexible sigmoidoscopy as accurately and safely as experienced gastroenterologists.