Brigid Mary Gillespie

Development of a theoretically derived model of resilience through concept analysis

Abstract Background: Resilience refers to a dynamic process that results in adaptation in the context of significant adversity (Margalit 2004). The concept of resilience has been of interest to various professional groups for many years; however, it is only recently that the nursing profession has begun to recognise its potential contribution in diverse clinical contexts. Objective: First, to identify current theoretical and operational definitions of resilience and second, to identify and describe defining attributes of resilience. Methods: The method of inquiry was guided byWalker and Avant’s (1995) approach to concept analysis. Findings: From this analysis, a conceptual model of resilience postulates that the constructs of self-efficacy, hope and coping are defining attributes of resilience. Discussion: Resilience appears to be a process that can be developed at any time during lifespan, and thus is not an inherent characteristic of personality. Further, the development of resilience is based on the synergy shared between individuals and their environments and experiences. Conclusions: Further theoretical clarification of the ways in which individuals transform stressful experiences into opportunities for increased growth may contribute to nursing knowledge in the form of better understanding of the resilience concept in the context of identifying strategies that build it.

The impact of organisational and individual factors on team communication in surgery: a qualitative study.

BACKGROUND Effective teamwork and communication is a crucial determinant of patient safety in the operating room. Communication failures are often underpinned by the inherent differences in professional practices across disciplines, and the ways in which they collaborate. Despite the overwhelming international support to improve team communication, progress has been slow. OBJECTIVE The aim of this paper is to extend understanding of the organisational and individual factors that influence teamwork in surgery. DESIGN This qualitative study used a grounded theory approach to generate a theoretical model to explain the relations between organisational and individual factors that influence interdisciplinary communication in surgery. SETTING AND PARTICIPANTS A purposive sample of 16 participants including surgeons, anaesthetists, and nurses who worked in an operating room of a large metropolitan hospital in south east Queensland, Australia, were selected. METHODS Participants were interviewed during 2008 using semi-structured individual and group interviews. All interviews were recorded and transcribed. Using a combination of inductive and deductive approaches, thematic analyses uncovered individual experiences in association with teamwork in surgery. RESULTS Analysis generated three themes that identified and described causal patterns of interdisciplinary teamwork practices; interdisciplinary diversity in teams contributes to complex interpersonal relations, the pervasive influence of the organisation on team cohesion, and, education is the panacea to improving team communications. CONCLUSIONS The development of shared mental models has the potential to improve teamwork in surgery, and thus enhance patient safety. This insight presents a critical first step towards the development teambuilding interventions in the operating room that would specifically address communication practices in surgery.

Resilience: The Power Within

PURPOSE/OBJECTIVES To advance understanding of resilience as an innate resource and its potential and relevance in the management of workplace stress for oncology nurses. DATA SOURCES Journal articles and research results, particularly seminal literature from a variety of Australian and international journals and published texts, including government and nursing organizations. DATA SYNTHESIS Resilience is defined as an innate energy or motivating life force present to varying degrees in every individual, exemplified by the presence of particular traits or characteristics that, through application of dynamic processes, enable an individual to cope with, recover from, and grow as a result of stress or adversity. Literature from a wide variety of fields, including physics, medicine, theology, philosophy, psychology, and spirituality, was reviewed to build an overview of existing knowledge and evolving theories on the subject of resilience and further the understanding of resilience as an innate personal resource. CONCLUSIONS Innate resilience can be developed or enhanced through cognitive transformational practices, education, and environmental support. Such processes may have use in ameliorating the effects of workplace stress. IMPLICATIONS FOR NURSING The complex nature of oncology and other specialty nursing roles creates a certain amount of inevitable stress that depletes the self and may lead to compassion fatigue and burnout. A greater understanding of resilience as an innate stress response resource highlights the need for processes that support resilience development and organizational and personal stress-management strategies for nurses to be part of mainstream nursing education.

Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis.

Background:Previous before-and-after studies indicate that the use of safety checklists in surgery reduces complication rates in patients. Methods:A systematic review of studies was undertaken using MEDLINE, CINAHL, Proquest, and the Cochrane Library to identify studies that evaluated the effects of checklist use in surgery on complication rates. Study quality was assessed using the Methodological Index for Nonrandomized Studies. The pooled risk ratio (RR) was estimated using both fixed and random effects models. For each outcome, the number needed to treat (NNT) and the absolute risk reduction (ARR) were also computed. Results:Of the 207 intervention studies identified, 7 representing 37,339 patients were included in meta-analyses, and all were cohort studies. Results indicated that the use of checklists in surgery compared with standard practice led to a reduction in any complication (RR, 0.63; 95% CI, 0.58 to 0.72; P < 0.0001; ARR, 3.7%; NNT, 27) and wound infection (RR, 0.54; 95% CI, 0.40 to 0.72; P = 0.0001; ARR, 2.9%; NNT, 34) and also reduction in blood loss (RR, 0.56; 95% CI, 0.45 to 0.70; P = 0.0001; ARR, 3.8%; NNT, 33). There were no significant reductions in mortality (RR, 0.79; 95% CI, 0.57 to 1.11; P = 0.191; ARR, 0.44%; NNT, 229), pneumonia (RR, 1.03; 95% CI, 0.73 to 1.4; P = 0.857; ARR, 0.04%; NNT, 2,512), or unplanned return to operating room (RR, 0.75; 95% CI, 0.56 to 1.02; P = 0.068; ARR, 0.52%; NNT, 192). Conclusion:Notwithstanding the lack of randomized controlled trials, synthesis of the existing body of evidence suggests a relationship between checklist use in surgery and fewer postoperative complications.

Intention-to-treat in randomized controlled trials: Recommendations for a total trial strategy

Intention-to-treat (ITT) in randomized controlled trials involves keeping participants in the treatment groups to which they were randomized regardless of whether they withdraw following randomization. Intention-to-treat is a strategy for maintaining the integrity of randomization and strengthening the trials internal validity. Although ITT is advocated by the Consolidated Standards of Reporting Trials (CONSORT) guidelines, there is confusion about what ITT means and little specific advice on how to achieve it. The purpose of this article is to present definitions of ITT and to suggest strategies for implementing ITT as a total design strategy in nursing clinical trials. Recommendations are offered regarding study planning, study design, subject retention, sampling, data collection, data analysis, and reporting within the context of ITT.

Enhancing communication in surgery through team training interventions: a systematic literature review.

In surgery, up to 70% of adverse events are attributable to failures in communication. The purpose of this systematic literature review was to critically assess the results of team training interventions used in the OR. In the 12 studies that met the inclusion criteria, there were statistically significant before-and-after improvements in teamwork practices and in some secondary outcomes such as complication rates. Our findings suggest that team training interventions have utility in enhancing team communication and cohesion. Team training interventions that are developed in response to the nuances of the context are more likely to become embedded in clinical practice. The introduction of more complex interventions has implications for resources and staffing. Further research is needed to identify and evaluate strategies that address the sustainability of complex team training interventions across multiple OR contexts.

Team communications in surgery – creating a culture of safety

Abstract As a key department within a healthcare organisation, the operating room is a hazardous environment, where the consequences of errors are high, despite the relatively low rates of occurrence. Team performance in surgery is increasingly being considered crucial for a culture of safety. The aim of this study was to describe team communication and the ways it fostered or threatened safety culture in surgery. Ethnography was used, and involved a 6-month fieldwork period of observation and 19 interviews with 24 informants from nursing, anaesthesia and surgery. Data were collected during 2009 in the operating rooms of a tertiary care facility in Queensland, Australia. Through analysis of the textual data, three themes that exemplified teamwork culture in surgery were generated: “building shared understandings through open communication”; “managing contextual stressors in a hierarchical environment” and “intermittent membership influences team performance”. In creating a safety culture in a healthcare organisation, a team’s optimal performance relies on the open discussion of teamwork and team expectation, and significantly depends on how the organisational culture promotes such discussions.

Nurse‐sensitive indicators suitable to reflect nursing care quality: a review and discussion of issues

AIMS AND OBJECTIVES To review nurse-sensitive indicators that may be suitable to assess nursing care quality. BACKGROUND Patient safety concerns, fiscal pressures and patient expectation create a demand that healthcare providers demonstrate the quality of nursing care delivered. As a result, nurse managers are increasingly encouraged to provide evidence of nursing care quality. Nurse-sensitive indicators are being proposed as a means of meeting this need. DESIGN Literature review. METHODS A review of the literature was conducted using CINAHL and MEDLINE from 2002-2011. Key search terms were nurs* and sensitive indicators, outcome measures, indicators, metrics and patient outcomes. RESULTS Most of the research has examined the relationship between nursing structural variables and patient outcomes in acute care settings and have explored potential indicators for specific patient groups and nursing roles. When using nurse-sensitive indicators, issues concerning the selection, reporting and sustained use are important for nurse managers to consider. CONCLUSION Evidence for the nurse-sensitivity of some commonly used indicators is inconsistent due to the disparity in definitions used, data collection and analysis methods. Further research on the application and implementation of these indicators is required to assist nurse managers in attempting to quantify the quality of nursing care. Nurses need to continue to strive to achieve agreement on the definitions of indicators, gather strong consistent evidence of nurse-sensitivity, resolve issues of regular data collection and consider selection, reporting and sustainment when implementing nurse-sensitive indicators. RELEVANCE TO CLINICAL PRACTICE Once identified, nurse-sensitive indicators can be applied for quality improvement purposes, but consensus is required to fully realise their potential. Nurse managers need to be aware of the factors that can influence the use of indicators at unit level. Strategies need to be implemented to promote these indicators becoming integrated with routine nursing care.

Factors that influence the expected length of operation: results of a prospective study

Background In the operating room, factors such as interruptions, communication failures, team familiarity and the unpredictability of unplanned cases can prolong the length of an operation, and lead to inefficiency and increased costs. However, little is known about the extent to which such factors contribute to extending the expected length of an operation. Aim To describe factors that prolong the expected length of an operation. Methods Structured observations were performed on a purposive sample of 160 surgical procedures across 10 specialties of planned and unplanned surgeries. During the 6-month period, a trained observer structured observations. Bivariate correlations and a standard multiple regression model were developed to describe associations among unplanned operations, interruptions, prebriefings, team familiarity, communication failures and the outcome, and deviation from expected operation time. Results Of the three explanatory variables entered into the regression model, the only significant predictor of deviation in expected length of operation was the number of communication failures (p=0.013). This model explained 4.5% of the variance in deviation in expected length of operation (p=0.018). Conclusions The results of this study validate the role of prospective observational research methods in unveiling critical factors that contribute to deviation in expected length of operation. These results have the potential to inform evidence-based interventions aimed at ameliorating the effects of miscommunications, hence improve patient safety.

Implementation of safety checklists in surgery: a realist synthesis of evidence

AimThe aim of this review is to present a realist synthesis of the evidence of implementation interventions to improve adherence to the use of safety checklists in surgery.BackgroundSurgical safety checklists have been shown to improve teamwork and patient safety in the operating room. Yet, despite the benefits associated with their use, universal implementation of and compliance with these checklists has been inconsistent.Data sourcesAn overview of the literature from 2008 is examined in relation to checklist implementation, compliance, and sustainability.Review methodsPawson’s and Rycroft-Malone’s realist synthesis methodology was used to explain the interaction between context, mechanism, and outcome. This approach incorporated the following: defining the scope of the review, searching and appraising the evidence, extracting and synthesising the findings, and disseminating, implementing, and evaluating the evidence. We identified two theories a priori that explained contextual nuances associated with implementation and evaluation of checklists in surgery: the Normalisation Process Theory and Responsive Regulation Theory.ResultsWe identified four a priori propositions: (1) Checklist protocols that are prospectively tailored to the context are more likely to be used and sustained in practice, (2) Fidelity and sustainability is increased when checklist protocols can be seamlessly integrated into daily professional practice, (3) Routine embedding of checklist protocols in practice is influenced by factors that promote or inhibit clinicians’ participation, and (4) Regulation reinforcement mechanisms that are more contextually responsive should lead to greater compliance in using checklist protocols. The final explanatory model suggests that the sustained use of surgical checklists is discipline-specific and is more likely to occur when medical staff are actively engaged and leading the process of implementation. Involving clinicians in tailoring the checklist to better fit their context of practice and giving them the opportunity to reflect and evaluate the implementation intervention enables greater participation and ownership of the process.ConclusionsA major limitation in the surgical checklist literature is the lack of robust descriptions of intervention methods and implementation strategies. Despite this, two consequential findings have emerged through this realist synthesis: First, the sustained use of surgical checklists is discipline-specific and is more successful when physicians are actively engaged and leading implementation. Second, involving clinicians in tailoring the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership.