Connecting With Adolescent Mothers: Perspectives of Hospital-Based Perinatal Nurses

Adolescent mothers are more likely to be dissatisfied with their perinatal nursing care than adult mothers. The purpose of this interpretive descriptive study was to explore adolescent-friendly care from the perspective of hospital-based perinatal nurses. Twenty-seven interviews were conducted with nurses with expertise caring for adolescent mothers. Open-ended questions were used to determine how they adapted their nursing practice when caring for adolescents, how they learned to provide adolescent-friendly care, and the facilitators and barriers to providing adolescent-friendly care. Nurses described two main goals: (a) delivering a positive experience and (b) ensuring mother and infant safety. They accomplished these goals by being nonjudgmental, forming a connection, and individualizing nursing care. The nurses described being mother-friendly, regardless of maternal age, and employing strategies to develop a nurse-adolescent mother therapeutic relationship. This research contributes to our understanding of how hospital-based perinatal nurses engage and support adolescent mothers.

Building to Make a Difference: Advanced Practice Nurses’ Experience of Power

Power is necessary for nurses to affect change in patient care and to move the nursing profession forward. Despite the evolving body of nursing research on power, there have been no studies that have investigated the nature of advanced practice nurses’ (APNs’) power. The purpose of this study was to explore the APNs’ lived experience of power. Interpretive phenomenology guided the method and analysis. Eight APNs employed in a single Canadian tertiary care teaching health-care organization engaged in in-depth interviews. The overarching theme, building to make a difference, reflected the APNs’ perception of power in their practice, which involved a passion to facilitate change in practice to improve patient care. Building to make a difference involved three themes: building on, building with, and building for. The APNs experienced more power—a process they described as power creep—when they used soft power that was shared with others to affect positive change in health care. These findings contribute to our understanding of how power is perceived and manifested in the APN role, thus further enabling organizations to create working conditions to support the APNs’ endeavors to empower others.

Building to Make a Difference: Advanced Practice Nurses' Experience of Power

Power is necessary for nurses to affect change in patient care and to move the nursing profession forward. Despite the evolving body of nursing research on power, there have been no studies that have investigated the nature of advanced practice nurses' (APNs') power. The purpose of this study was to explore the APNs' lived experience of power. Interpretive phenomenology guided the method and analysis. Eight APNs employed in a single Canadian tertiary care teaching health-care organization engaged in in-depth interviews. The overarching theme, building to make a difference, reflected the APNs' perception of power in their practice, which involved a passion to facilitate change in practice to improve patient care. Building to make a difference involved three themes: building on, building with, and building for. The APNs experienced more power-a process they described as power creep-when they used soft power that was shared with others to affect positive change in health care. These findings contribute to our understanding of how power is perceived and manifested in the APN role, thus further enabling organizations to create working conditions to support the APNs' endeavors to empower others.

The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity

BACKGROUND

Recent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP.

METHODS

This qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory's iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient's story. We studied how building the patient's story was impacted by the introduction and implementation of an EHR.

RESULTS

Clinicians described the patient's story as a cognitive awareness and overview understanding of the patient's (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient's story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Our data revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story.

CONCLUSIONS

We discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient's story.

The impact of adopting EHRs: how losing connectivity affects clinical reasoning

CONTEXT

As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development.

OBJECTIVES

We investigate this influence by studying clinician experiences of a hospital's move from paper charts to an EHR. We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning?

METHODS

This two-phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think-aloud (n = 13) and think-after (n = 11) sessions, interviews (n = 39) and document retrieval (n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis.

RESULTS

In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient's evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms.

CONCLUSIONS

Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHRs supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHRs, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity – the chronologically framed data interconnections upon which clinicians rely to provide patient care.

Information structure and organisation in change of shift reports: An observational study of nursing hand-offs in a Paediatric Intensive Care Unit

Patient hand-offs involve the exchange of critical information. Ineffective hand-offs can result in reduced patient safety by leading to wrong treatment, delayed diagnoses or other outcomes that can negatively affect the healthcare system. The objectives of this study were to uncover the structure of the information conveyed during patient hand-offs and look for principles characterising the organisation of the information. With an observational study approach, data was gathered during the morning and evening nursing change of shift hand-offs in a Paediatric Intensive Care Unit. Content analysis identified a common meta-structure used for information transfer that contained categories with varying degrees of information integration and the repetition of high consequence information. Differences were found in the organisation of the hand-off structures, and these varied as a function of nursing experience. The findings are discussed in terms of the potential benefits of computerised tools which utilise standardised structure for information transfer and the implications for future education and critical care skill acquisition.

Health care professionals' pain narratives in hospitalized children's medical records. Part 1: pain descriptors

BACKGROUND

Although documentation of children's pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children.

OBJECTIVES

To describe health care professionals' use of written language related to the quality and quantity of pain experienced by hospitalized children.

METHODS

Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used.

RESULTS

Pain narratives were documented a total of 5390 times in 1518 of the 3822 children's medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (e.g., vocal, motor, facial and activities cues), affective and physiological cues, and children's descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers.

CONCLUSIONS

The richness and complexity of vocabulary used by clinicians to document children's pain lend support to the concept that the word 'pain' is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children's pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

Pain assessment and intensity in hospitalized children in Canada

Numerous acute pediatric pain assessment measures exist; however, pain assessment is not consistently performed in hospitalized children. The objective of this study was to determine the nature and frequency of acute pain assessment in Canadian pediatric hospitals and factors influencing it. Pain assessment practices and pain intensity scores documented during a 24-hour period were collected from 3,822 children aged 0 to 18 years hospitalized on 32 inpatient units in 8 Canadian pediatric hospitals. Pain assessment was documented at least once within the 24 hours for 2,615/3,822 (68.4%) children; 1,097 (28.7%) with a pain measure alone, 1,006 (26.3%) using pain narratives alone, and 512 (13.4%) with both a measure and narrative. Twenty-eight percent of assessments were conducted with validated measures. The mean standardized pain intensity score was 2.6/10 (SD 2.8); however, 33% of the children had either moderate (4-6/10) or severe (7-10/10) pain intensity recorded. Children who were older, ventilated, or hospitalized in surgical units were more likely to have a pain assessment score documented. Considerable variability in the nature and frequency of documented pain assessment in Canadian pediatric hospitals was found. These inconsistent practices and significant pain intensity in one-third of children warrant further research and practice change.

PERSPECTIVE

This article presents current pediatric pain assessment practices and data on pain intensity in children in Canadian pediatric hospitals. These results highlight the variability in pain assessment practices and the prevalence of significant pain in hospitalized children, highlighting the need to effectively manage pain in this population.

Conflicting messages: examining the dynamics of leadership on interprofessional teams

PURPOSE

Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system.

METHOD

Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009.

RESULTS

Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors' observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams.

CONCLUSIONS

A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

Nurses' moral experience of administering PRN anti-seizure medications in pediatric palliative care

This article explores nurses' decision-making related to the administration of PRN anti-seizure medications to children with long-term seizure disorders in palliative care. Hermeneutic phenomenological inquiry guided by van Manen's approach was the method used. Six nurses participated in interviews. Data analysis revealed that not on my watch was the overarching theme in which nurses engaged in bearing witness, being attentive, creating connectedness, and finding the right thing to do. Four themes emerged: being in the know--what to know and ways of knowing; marking time--waiting and timekeeping; seeking a sense of personal comfort--developing a sense of comfort, experiencing distress, and responding to distress; and making the decision--recognizing a seizure, identifying options, weighing the options, and rethinking the decision. This study reveals the moral dilemmas and resulting moral distress that may be experienced in making this type of decision and advances our thinking about the corresponding tensions and rewards.

The Use of Resources during Shift Hand-offs in a Pediatric Intensive Care Unit

The nursing handoff is a fundamental aspect of continued patient care that involves the transfer of vital medical information through various means. This project qualitatively examined nursing dyads to determine the types of resources used during handoffs and their frequency through the theoretical framework of distributed cognition. Forty handoffs between nurses, with experience ranging from 3 to 40 or more years, were observed within the intensive care unit of a pediatric hospital. The findings revealed that a variety of resources were referred to and appear mildly correlated with handoff durations, where more experienced individuals displayed a greater frequency of resource use in prolonged handoffs.

The transformational journey of nurse practitioners in acute-care settings

This study explored the nature of the lived experience of being nurse practitioners (NPs) in acute-care settings in Canadian teaching hospitals using hermeneutic phenomenological inquiry guided by van Manen's approach. A total of 26 NPs were interviewed. Data analysis revealed that NPs experienced a transformational journey as they searched for being more, the overarching phenomenon that best characterizes their overall experience, which occurred in the context of being pioneers. Five themes emerged: being called to be more--being more connected, in control, visible, challenged, and able to make more of a difference; being adrift--being disconnected, uncertain, lost, and staying afloat; being an acute-care NP--being competent, confident, comfortable, committed, connected, and content; being pulled to be more--being a wearer of two hats; and being more--being an advanced practitioner. The NP journey reveals the complex, largely invisible experience of being an acute-care NP.

Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research

A systematic review of published research on children's psychological outcomes following Pediatric Intensive Care Unit (PICU) hospitalization was conducted. Of the 275 papers published between 1970 and April 2008 which were identified using keywords, reference lists and one author's collections, a total of 28 papers met the inclusion criteria for this review. The papers fell into four categories based on the focus of the research: (1) children's PICU perceptions and recall; (2) children's psychological outcomes, broadly defined; (3) post-traumatic stress responses; and (4) general health status and quality of life. The findings suggest that PICU hospitalization can result in negative psychological sequelae in children, which can manifest themselves up to one year post-discharge. While a small number of studies have attempted to identify predictors of psychological outcome, this work remains in its infancy. The importance of the child's interpretation of the illness experience in influencing subsequent behavioral and emotional responses is highlighted.

Implementation of a two-part unit-based multiple intervention: moving evidence-based practice into action

This study examined the impact of a 2-part unit-based multiple intervention on the use by pediatric critical care nurses of best practice guidelines for pressure-ulcer prevention. A total of 23 nurses participated in a repeated-measures design pre- and post-intervention to address 2 questions: Is there a difference in nurses' evidence-based practices following implementation of an educational intervention only versus implementation of both an educational and an innovative intervention? Are the changes sustained 6 months after completion of the intervention? A significant change occurred in the implementation of 2 of 11 recommended practices following both interventions: assessment of risk of pressure ulcers using an age-appropriate tool (p < or = 0.001), and the documentation of same (p < or = 0.001). These changes may have been sustained. The findings bring to light the real challenges encountered when attempting to implement and evaluate multiple knowledge translation strategies associated with complex best practice guidelines in clinical practice.

Validity in hermeneutic phenomenological inquiry: towards an ethics of evaluation

This article explores the relationship of ethics to validity in hermeneutic phenomenological inquiry. First, the authors present a brief overview of the various discourses on validity in qualitative research that have been variously applied to hermeneutic phenomenological inquiry. Next, they examine how relational ethics is a presence to bear within this form of inquiry. Finally, they offer a set of ethical reflections to help the researcher engage in a process of ethical questioning during each step of the research process.

Dwelling with stories that haunt us: building a meaningful nursing practice

The purpose of this article is to reflect on pediatric critical care nurses' experience of grief by focusing on the meaning of the stories that haunt them. It is suggested that these stories are the nurses' attempt to find ways to journey through their grief and to live with the mystery of life and death. It is also the task of these stories to throw light on their experiences, a task that is never entirely finished. Dwelling with the stories that haunt them helps to provide nurses with a moral structure of critical care nursing practice. Their reflections upon the meaning of their experiences of grief can lead to a view of death that is not always perceived as an evil to flee, but is upheld as a source of value and revelation as critical care nurses strive to build who they are and how they practice the art of nursing.

Knowing the nurse practitioner: dominant discourses shaping our horizons

The purpose of this paper is to examine the various discourses, particularly the dominant instrumental and economic discourses that have brought the phenomena of the nurse practitioner (NP) into being. It is proposed that NPs have been constituted as an object of nature and therefore understood metaphorically as a tool or instrument within the health care system to be used efficiently and effectively. Heidegger's philosophical analysis of the question concerning technology is used to argue that our current ways of knowing the NP through these discourses, with their emphasis on calculative logic, have resulted from our modern view of the essence of technology. It is also argued that there is now a need to shape our horizons concerning the NP in new and different ways. There is a need to engage in dialogical forms of research in order to evoke the richness and depth of what it means to be an NP, that is, to reveal the other modes of expression by which we define ourselves, understand others and nursing.

Medical and nursing clinical decision making: a comparative epistemological analysis

The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skillful conduct of clinical decision making.

Incorporating Educational Theory Into Critical Care Orientation

This article describes the development and implementation of a critical care total education system, which includes an orientation program. The educational process in this unit reflects Benner's model of novice to expert integrated with Schon's theory of reflective practice and Cranton's transformational learning theory. This program reflects an educational philosophy that facilitates learning on entry into the new workplace, and an established continuum of expected acquisition of knowledge, practice skills, attitudes, and critical thinking abilities promoting the transition from novice to expert.

Pediatric intensive care nurses and their grief experiences: a phenomenological study

OBJECTIVE

To describe the grief experience of pediatric intensive care nurses when their patients die.

DESIGN

Heideggerian phenomenological approach; nonprobability, purposive sampling; semistructured interviews; data analyzed using Colaizzi's method of phenomenology.

SETTING

Pediatric intensive care unit within a Canadian pediatric metropolitan university teaching hospital.

PARTICIPANTS

Six registered nurses, currently working in the pediatric intensive care unit, who had experienced the death of at least three children for whom they had cared. Nursing experience ranged from 2 to 20 years, intensive care nursing experience from 9 months to 19 years, and tenure on the unit from 9 months to 15 years.

RESULTS

Data were analyzed for recurring themes according to the procedure outlined by Colaizzi. These nurses acknowledged they suffered multiple exposures to children's death and experienced grief. The interviews revealed eight themes that included one about their grief responses--hurting; two that described the influencing contextual factors--nurse-family unit relationship and dissonance; and five that related to coping strategies used to manage their feeling of grief--self-expression, self-nurturance, termination of relationship activities, engaging in control-taking activities, and self-reflection. Further analysis revealed that managing grief effectively was an experiential learning process for the participants.

CONCLUSIONS

These results demonstrate that pediatric intensive care nurses' grief is different from that of surviving family member grief. Further research is required to document in further depth the experiential learning process to coping with multiple, accumulated losses for these professional caregivers. The findings of this study also could encourage further research that examines interventions designed to enhance the type of education and support needed in relation to the grief experience of nurses.

The evolution and implementation of a PICU standard nursing care plan. A nursing process

The staff of an intensive care unit in a Pediatric Hospital in Ottawa believed in the philosophy of nursing care plans. They decided to develop a pediatric critical care standard nursing care plan that would be useful for care giving and user friendly. This article describes the evolution and implementation of their plan.

Pediatric heart transplants

Interest in pediatric heart transplantation has increased since the early 1980's in large part due to the improvement in immunosuppression. At the University of Ottawa Heart Institute, Ottawa Civic Hospital/Children's Hospital of Eastern Ontario, Ottawa, six children between the ages of ten days and twelve years have received heart transplants between January 1988 and April 1990. Intensive care nursing staff synthesized their knowledge in areas of transplant and cardiovascular nursing to develop a plan of care for these children. The purpose of this article is to share the knowledge the nurses have gained through our clinical experience with these patients.

Acute bacterial meningitis. The pathophysiological sequence of events

Despite the availability of a new vaccine, acute bacterial meningitis continues to be a potentially life-threatening childhood disease. The mortality rate is approximately 5% and research suggests that many of the survivors suffer from various forms of morbidity. The pediatric intensive care nurse must immediately recognize the signs and symptoms of impending complications so that interventions can be implemented before it becomes impossible to reverse a critical situation and/or to prevent longterm sequelae. Therefore nursing care requires a thorough understanding of the pathophysiological sequence of events of this disease process.