Johanna Ulfvarson

Developing an assessment tool for intended learning outcomes in clinical practice for nursing students

This report describes the development of a new criterion based reference tool to assess nursing knowledge and competence in clinical practice. Nursing education has changed from educating a profession, based on tested experience, to being based on a scientific approach and research based knowledge. Assessment should be capable of measuring whether intended learning outcomes have been reached or not, and if the aims of a course have been fulfilled in order to ensure safe and competent nursing care. The intended learning outcomes from a first year course syllabus were integrated and formed into a three-graded criterion-referenced assessment tool, Assessment of Clinical Education, (AClEd). The AClEd is to be seen as a template, and may be tailor-made in accordance to the objectives, level and criteria of a specific course. The tool showed validity in assessing nursing skills not only the nursing students ability to perform a task but also, most importantly, the quality of nursing care.

Nurse-led medication reviews and the quality of drug treatment of elderly hospitalized patients.

PurposeTo evaluate if nurses after receiving training in clinical pharmacology can improve the quality of the drug therapy in elderly hospitalized patients.MethodsNurses were given a 1-day training in clinical pharmacology to identify drug-related problems (DRPs). All patients admitted to the ward aged 65 or more were studied. Patients at the same ward before the intervention were considered as control group. Outcome variables were re-hospitalized 3 months from discharge, drug-related re-admissions, the proportion of inappropriate drug use (IDU), and DRPs found by the nurses.ResultsOf 460 patients (250 intervention group and 210 in the control group) 38 and 36%, respectively, had at least one re-admission to hospital (p = 0.86) and 24% of the patients died. Eighteen and 17% (43/37), respectively, used one or more inappropriate drug (p 0.90). The nurses found 86 clinically significant DRPs not detected by the usual care. A substantial part of the DRPs detected by the nurses were revealed with assistance of Symptoms Assessment Form (SYM). There were no statistical difference in the number of drug-related re-admissions between the groups, 14/16, respectively, (p = 0.40).ConclusionsNurses are able to detect a high proportion of clinically relevant DRPs not detected by the usual care and thereby increase the quality of the drug treatment in elderly hospitalized patients. Our study showed no effect on re-hospitalization or IDU. By using a SYM nurses can find DRPs that computer-based decision support systems miss.

Perioperative bladder distension: a prospective study.

Objective. Postoperative urinary retention and bladder distension are frequent complications of surgery. The aim of this study was to determine the incidence of perioperative bladder distension in a surgical setting and to identify predisposing factors among patients undergoing common general and orthopaedic procedures. Material and methods. This was a prospective observational study of 147 adult patients admitted to orthopaedic and surgical departments. Bladder volumes were measured with an ultrasound scanner on three occasions: after emptying the bladder before being transported to the operating theatre, and then immediately before and after surgery. Results. Thirty-three patients (22%) developed bladder distension (>500 ml), eight preoperatively and 25 postoperatively. A total of 21 patients (14%) had a bladder volume >300 ml immediately before surgery. Orthopaedic patients were more likely to develop preoperative bladder distension than surgical patients and had significantly higher postvoid residual volumes. In the binary logistic regression analysis age, gender and time of anaesthesia could not predict bladder distension. Patients undergoing orthopaedic surgical procedures, however, were prone to bladder distension (odds ratio 6.87, 95% confidence interval 1.76 to 26.79, p=0.006). Conclusions. This study shows that orthopaedic surgical patients are more prone to bladder distension perioperatively. The conventional method of encouraging patients to void at the ward before being transported to the operating theatre does not necessarily mean an empty bladder at the start of the operation.

A nurse-led intervention for identification of drug-related problems

Drugs are important for treatment and prevention of symptoms and illnesses, but on the other hand, adverse drug reactions (ADRs) are a common cause for hospitalisation, especially among the elderly. The proportion of patients admitted to hospital due to ADRs, or when ADRs have been a contributing factor for admission, varies from 0.7% to 17 % [1–6]. Drugrelated problems (DRPs) are a broad category defined as “An event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes” [7, 8]. The majority of DRPs are predictable and potentially avoidable [3, 9]. There are methods aimed at the prevention of DRPs, such as medication reviews led by pharmacists or clinical pharmacologists. Nevertheless, there is no consistent evidence for the effectiveness of this kind of intervention [10–12]. There is a need for new methods for DRP detection and prevention. Although the medication process is multidisciplinary, there has been no progress in developing formal collaboration involving nurses. Nurses have a unique role as caregivers, educators, and administrators of drugs, and they are particularly well positioned to alert for DRPs [13]. One of the nurses’ responsibilities is indeed to observe patients’ response to drug treatment. Griffiths et al. [14] have shown that patients participating in a nurse-initiated intervention for medication review had a better knowledge of medication and were able to manage medication in a better way after the intervention. Other studies have shown that specialist nurses can reduce readmission to hospital of patients with heart failure [15, 16]. In Sweden, interested and specially educated nurses can detect and report suspected ADRs [17, 18] and contribute to approximately 12% of all ADR reporting [13]. The nurses’ reports are dominated by local reactions to vaccination [13]. To our knowledge, there are no studies published in which nurses are given a central role for identifying, preventing and resolving DRPs. The aim of this study was to investigate whether nurses can identify DRPs in patients during their hospital stay by using a new, structured, nurse-led medication review model and to assess the feasibility and effectiveness of this model.

A clinical evaluation of the Janus Web Application, a software screening tool for drug-drug interactions

PurposeTo evaluate the clinical relevance of the Janus Web Application (JWA) in screening for potential drug-drug interactions (DDIs).MethodsOne hundred and fifty patients taking two drugs or more were studied. Potential DDIs were identified by the JWA. Interviewing the patient and looking into his/her medical records provided complementing information. A clinical pharmacologist judged which potential DDIs were clinically relevant. Potentially relevant DDIs identified by the JWA were then correlated with clinically relevant DDIs.ResultsA total of 150 significant potential DDIs were found. Sixteen percent (24/150) were judged to be clinically relevant.ConclusionsA very small proportion of DDIs was considered clinically relevant in the specific clinical context. To optimise the software’s user-friendliness, the following points need to be considered: the possibility of eliminating trivial potential DDIs, individualising drug alerts, and providing written information, accessible via a hyperlink.

Preoperative ultrasound monitoring can reduce postoperative bladder distension: A randomized study

Abstract Objective. The aim of this study was to explore whether close preoperative ultrasound monitoring starting in the emergency room (ER) could prevent postoperative bladder distension among acute orthopaedic patients. Material and methods. A randomized controlled trial was conducted at a 650-bed level-2 centre in Sweden. Inclusion criteria were admittance via ER to an orthopaedic ward for acute surgery. Bladder volumes were measured with a portable ultrasound scanner (Bladderscan BVI 3000). In the intervention group, all patients were scanned in the ER and then regularly at the ward at predefined times until surgery. In the control group, no regular scanning was performed before surgery. During surgery, the same procedure was performed for both groups: bladder scanning immediately after arrival to the recovery room and continuous postoperative scanning until voiding. The primary outcome was postoperative bladder distension, defined as a bladder volume ≥500 ml. Secondary outcomes were postoperative urinary tract infection and hospital length of stay. Results. A total of 281 patients completed the study, 141 in the intervention group and 140 in the control group. Postoperative bladder distension was significantly higher in the control group (27.1% vs 17.0%; p = 0.045, 95% confidence interval 4.9–19.8) in the intention-to-treat, per-protocol and as-treated analyses. No statistical difference was found between the intervention group and the control group regarding the secondary outcomes. Conclusions. Frequent bladder monitoring starting in the ER can reduce postoperative bladder distension among acute orthopaedic patients. A preoperative bladder monitoring protocol should be implemented early in the ER for all patients admitted for acute orthopaedic procedures.

Micturition problems after bladder distension during hospitalization in Sweden: "I'm not ill, just damaged for the rest of my life".

BackgroundUrinary retention is a common complication following hospital care, which can result in overdistension of the bladder and, at worst, chronic bladder damage and persistent micturition difficulties. ObjectivesThe purpose of this study was to explore patients’ experiences of micturition problems after bladder distension and their effects on the patients’ everyday lives. MethodsThe Swedish Patient Insurance LÖF was used to identify patients from January 2007 to June 2010 who have reported micturition problems after hospital care and have had their injuries classified as avoidable bladder damage due to overdistension. Narrative interviews were conducted with 20 volunteers and analyzed by qualitative content analysis. ResultsThe micturition problems affected everyday life through constraints (dependence on disposables and access to toilets, clothing restrictions, limitations on social life and career), suffering (pain, infections, impaired sex life, leakage), and concerns for the future (fear of worsening symptoms and fear of losing control with age). Aspects related to having been harmed by the healthcare system were the harm could have been avoided (lack of knowledge, insufficient routines, mistrust), obstacles to overcome when reporting an injury (difficulties in obtaining knowledge about the possibility of reporting an injury, ambivalence toward reporting their healthcare providers), and a wish to improve care (raise awareness, prevent harm to others). DiscussionBladder distension is a healthcare-related injury that can cause suffering and practical, emotional, and psychosocial problems with a great impact on the life of the person affected and anxiety for the future. The healthcare system must, therefore, raise awareness and improve preventive routines.

Translation and validation of the wound‐specific quality of life instrument Cardiff Wound Impact Schedule in a Swedish population

PURPOSE To translate and validate the wound-specific health-related quality of life instrument, the Cardiff Wound Impact Schedule (CWIS) in a Swedish population. METHODS The instrument was first translated into Swedish, using the Standard Linguistic Validation Process. The Swedish version of the CWIS was then tested for its psychometric properties in a Swedish context. A total of 117 patients with acute and hard-to-heal wounds were included. The patients were asked to fill in the Swedish version of the CWIS and the generic instrument SF-36 at baseline and after 1 week. Patients with acute wounds were also asked to fill in both instruments after 6 weeks. RESULTS Face validity and content validity were assessed by patients and an expert group, and judged as good. Criterion validity was calculated with correlation between CWIS and SF-36, reaching moderate to high values. Reliability of the three domains of the CWIS measured with internal consistency and test-retest stability was acceptable to excellent. Internal responsiveness was assessed with standardised response mean and showed moderate to high sensitivity. CONCLUSIONS This study concludes that the Swedish version of CWIS is a valid and reliable tool for measuring health-related quality of life in patients with acute and hard-to-heal wounds.

Anhöriga i hemsjukvården

Nowadays it is possible for sick and dying patients to be cared for at home. In some parts of the country up to 90% of registered patient die at home. In the country as a whole 85% of all patients that die, do this in a hospital or some other institution. If the home care is connected to a hospital, resources are available all around the clock. Home care saves days of hospital treatment that otherwise should be necessary. When a patient is treated in the home great responsibility is layed on the relatives that carry out the main part of the care. In the literature the importance of being well informed in order to be able to cope with stress is emphasised. Stress develops in situations where we are feeling insufficient. If we understand what is happening and can foresee what is coming next it will be much easier to cope whit the situation. The objective of the study was to investigate if and to what extent relatives of patients in home care were given information and education. The results presented obtained by interviewing relatives and personnel around the families about their feelings and experiences in connection whit the home care. It was shown that information and education in an organised way occurred to a small degree or not at all. Therefore the report concentrates on the general situation for home care. The relatives agreed that availability and respect for integrity were fundamental in this connection.

Assessment in clinical education: A comparison between a generic instrument and a course-specific criterion-based instrument

Assessment of students’ clinical performance and reasoning raises critical questions of whether learning outcomes have been reached and whether the aims of a course/education programme have been fulfilled. The aim of this study was to compare two assessment instruments in clinical education. A cross-sectional, comparative design was used. Nursing students and supervisors from five universities and university colleges in Sweden were included in the study. A sample of 435 students was used. Data were collected with study-specific questionnaires targeted for the two groups, nursing students and supervisors, and were analysed using cross-tabulation, chi-square with WinSTAT. Students perceived supervisors using the instrument Assessment of Clinical Education (AClEd) to be more aware of what to assess and they experienced more support from the ‘AClEd supervisors’ as compared to the supervisors using the second instrument, the Assessment form for Clinical education (AssCe). Furthermore, the AClEd assessment was perceived to be fairer compared to the AssCe assessment. The criterion-referenced assessment instrument AClEd was perceived, by both nursing students and supervisors, to give a clearer view of the learning outcome and the possibility of a fair and comprehensive assessment.