Judith A. Ritchie

Children's psychological responses after critical illness and exposure to invasive technology

ABSTRACT. Children hospitalized in pediatric intensive care units (PICUs) are subjected to highly invasive interventions necessary in overcoming the critical period of their illness, yet little is known about their subsequent psychological adjustment. The purposes of this study were to compare the psychological responses of children hospitalized in a PICU with those of children hospitalized on a general ward and to identify clinically relevant factors that might be associated with psychological outcome. A prospective cohort design was used to follow 120 children for 6 months after PICU and ward discharge. Groups were compared on the children’s sense of control over their health, their medical fears, posttraumatic stress, and changes in behavior. Relationships between children’s responses and their age, the invasive procedures to which they were exposed, severity of illness, and length of hospital stay were also examined. No significant group differences were found. However, children who were younger, more severely ill, and who endured more invasive procedures had significantly more medical fears, a lower sense of control over their health, and ongoing posttraumatic stress responses for 6 months postdischarge. Findings indicate that regardless of the hospital setting, invasiveness coupled with length of stay and severity of illness in young children may have adverse long-term effects.

A Multisite Study of Health Professionals’ Perceptions and Practices of Family-Centered Care

Family-centered care (FCC) has been promoted as the optimal philosophy for children and families in their interactions with health professionals. Furthermore, FCC is a health care delivery model that seeks to fully involve families in the care of children through an approach that is respectful and supportive. This multisite survey was undertaken to determine the differences in health professionals’ perceptions and practices of FCC and to examine factors that influence those perceptions and practices. Findings revealed that although advances have been made in recognizing the key elements of FCC, difficulties remain in implementing these elements. The “dilemma of helping,” the potential lack of interprofessional collaboration, the design of the health care delivery system, as well as the potential lack of continuing education and mentoring programs are proposed as explanations for these findings.

Improving Quality of Care through Routine, Successful Implementation of Evidence-Based Practice at the Bedside: An Organizational Case Study Protocol Using the Pettigrew and Whipp Model of Strategic Change

BackgroundEvidence-based practice (EBP) is an expected approach to improving the quality of patient care and service delivery in health care systems internationally that is yet to be realized. Given the current evidence-practice gap, numerous authors describe barriers to achieving EBP. One recurrently identified barrier is the setting or context of practice, which is likewise cited as a potential part of the solution to the gap. The purpose of this study is to identify key contextual elements and related strategic processes in organizations that find and use evidence at multiple levels, in an ongoing, integrated fashion, in contrast to those that do not.MethodsThe core theoretical framework for this multi-method explanatory case study is Pettigrew and Whipps Content, Context, and Process model of strategic change. This framework focuses data collection on three entities: the Why of strategic change, the What of strategic change, and the How of strategic change, in this case related to implementation and normalization of EBP. The data collection plan, designed to capture relevant organizational context and related outcomes, focuses on eight interrelated factors said to characterize a receptive context. Selective, purposive sampling will provide contrasting results between two cases (departments of nursing) and three embedded units in each. Data collection methods will include quantitative tools (e.g., regarding culture) and qualitative approaches including focus groups, interviews, and documents review (e.g., regarding integration and “success”) relevant to the EBP initiative.DiscussionThis study should provide information regarding contextual elements and related strategic processes key to successful implementation and sustainability of EBP, specifically in terms of a pervasive pattern in an acute care hospital-based health care setting. Additionally, this study will identify key contextual elements that differentiate successful implementation and sustainability of EBP efforts, both within varying levels of a hospital-based clinical setting and across similar hospital settings interested in EBP.

‘If we can't do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better health care work environments

AIM To examine the use of appreciative inquiry to promote the emergence of innovative ideas regarding the reorganization of health care services. BACKGROUND With persistent employee dissatisfaction with work environments, experts are calling for radical changes in health care organizations. Appreciative inquiry is a transformational change process based on the premise that nurses and health care workers are accumulators and producers of knowledge who are agents of change. METHODS A multiple embedded case study was conducted in two interdisciplinary groups in outpatient cancer care to better understand the emergence and implementation of innovative ideas. RESULTS The appreciative inquiry process and the diversity of the group promoted the emergence and adoption of innovative ideas. Nurses mostly proposed new ideas about work reorganization. Both groups adopted ideas related to interdisciplinary networks and collaboration. A forum was created to examine health care quality and efficiency issues in the delivery of cancer care. CONCLUSION This study makes a contribution to the literature that examines micro systems change processes and how ideas evolve in an interdisciplinary context. IMPLICATIONS FOR NURSING MANAGEMENT The appreciative inquiry process created an opportunity for team members to meet and share their successes while proposing innovative ideas about care delivery. Managers need to support the implementation of the proposed ideas to sustain the momentum engendered by the appreciative inquiry process.

Boundary work and the introduction of acute care nurse practitioners in healthcare teams

AIM This article is a report of a study of boundary work following the introduction of an acute care nurse practitioner role in healthcare teams. BACKGROUND Acute care nurse practitioners enacting their roles in healthcare teams have faced a number of challenges including a mix of positive and negative views of the acute care nurse practitioner role from healthcare team members and acute care nurse practitioner roles crossing the boundaries between the medical and nursing professions. Understanding the process by which the boundaries between professions changed following the introduction of an acute care nurse practitioner role was important since this could affect scope of practice and the teams ability to give patient care. METHODS The study was conducted in two university-affiliated teaching hospitals in Canada. A descriptive multiple case study design was used. Data were collected from March to May 2009. RESULTS Participants (N = 59) described boundary work as a process that included: (1) creating space; (2) loss of a valued function; (3) trust; (4) interpersonal dynamics; and (5) time. The development of trust among team members was essential. The co-location of team members working on common projects, and medical and nursing leadership facilitated boundary work. CONCLUSION The micro-level processes of boundary work in healthcare teams have important implications for the development of full scope of practice for acute care nurse practitioners, effective inter-professional teamwork and the integration of new roles in healthcare systems. Future research needs to be undertaken in different contexts, and with patients and families.

Impact of a Pivot Nurse in Oncology on Patients With Lung or Breast Cancer: Symptom Distress, Fatigue, Quality of Life, and Use of Healthcare Resources

PURPOSE/OBJECTIVES To examine the impact on continuity of nursing care delivered by a pivot nurse in oncology to improve symptom relief and outcomes for patients with lung or breast cancer. DESIGN Randomized controlled trial in which participants were randomly assigned to an intervention group (n = 93) with care by a pivot nurse in oncology and usual care by clinic nurses or to a control group (n = 97) with usual care only. SETTING Three outpatient ambulatory oncology clinics in a large university health center in Quebec, Canada. SAMPLE 113 patients with lung cancer and 77 patients with breast cancer. METHODS Participants in both groups completed the Symptom Distress Scale, Brief Fatigue Inventory, and Functional Assessment of Cancer Therapy Scale-General version 4 at eight intervals over six months. Healthcare usage was evaluated through a review of hospital records. MAIN RESEARCH VARIABLES Symptom distress, fatigue level, quality of life, and healthcare usage. FINDINGS Researchers found no significant differences in symptom distress, fatigue, quality of life, and healthcare usage between groups. CONCLUSIONS The new nursing role did not have an impact on the patient outcomes under study. IMPLICATIONS FOR NURSING Experienced nurses with specialized knowledge of oncology symptom assessment and management may reduce the symptom burden experienced by ambulatory patients with breast or lung cancer during active treatment.

Leadership for Evidence‐Based Practice: Strategic and Functional Behaviors for Institutionalizing EBP

Background Making evidence-based practice (EBP) a reality throughout an organization is a challenging goal in healthcare services. Leadership has been recognized as a critical element in that process. However, little is known about the exact role and function of various levels of leadership in the successful institutionalization of EBP within an organization. Aims To uncover what leaders at different levels and in different roles actually do, and what actions they take to develop, enhance, and sustain EBP as the norm. Methods Qualitative data from a case study regarding institutionalization of EBP in two contrasting cases (Role Model and Beginner hospitals) were systematically analyzed. Data were obtained from multiple interviews of leaders, both formal and informal, and from staff nurse focus groups. A deductive coding schema, based on concepts of functional leadership, was developed for this in-depth analysis. Results Participants’ descriptions reflected a hierarchical array of strategic, functional, and cross-cutting behaviors. Within these macrolevel “themes,” 10 behavioral midlevel themes were identified; for example, Intervening and Role modeling. Each theme is distinctive, yet various themes and their subthemes were interrelated and synergistic. These behaviors and their interrelationships were conceptualized in the framework “Leadership Behaviors Supportive of EBP Institutionalization” (L-EBP). Leaders at multiple levels in the Role Model case, both formal and informal, engaged in most of these behaviors. Linking Evidence to Action Supportive leadership behaviors required for organizational institutionalization of EBP reflect a complex set of interactive, multifaceted EBP-focused actions carried out by leaders from the chief nursing officer to staff nurses. A related framework such as L-EBP may provide concrete guidance needed to underpin the often-noted but abstract finding that leaders should “support” EBP.

Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting.

The purpose of this study was to obtain a comprehensive understanding of how nurses respond to medication errors and identify strategies that nurses believe may improve reporting of these errors within hospitals. The findings suggest that nurses use a decision-making process when reporting medication errors. Medication error reporting may be improved by instituting a problem-solving approach to respectfully manage the event and providing nurses with clear guidelines, remedial education, and timely feedback.

Practice patterns and perceived impact of clinical nurse specialist roles in Canada: Results of a national survey

BACKGROUND Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists. OBJECTIVE To identify the practice patterns of clinical nurse specialists in Canada. DESIGN A descriptive cross-sectional survey. PARTICIPANTS Self-identified clinical nurse specialists in Canada. METHODS A 50-item self-report questionnaire was developed, pilot-tested in English and French, and administered to self-identified clinical nurse specialists from April 2011 to August 2011. Data were analyzed using descriptive and inferential statistics and content analysis. RESULTS The actual number of clinical nurse specialists in Canada remains unknown. The response rate using the number of registry-identified clinical nurse specialists was 33% (804/2431). Of this number, 608 reported working as a clinical nurse specialist. The response rate for graduate-prepared clinical nurse specialists was 60% (471/782). The practice patterns of clinical nurse specialists varied across clinical specialties. Graduate-level education influenced their practice patterns. Few administrative structures and resources were in place to support clinical nurse specialist role development. The lack of title protection resulted in confusion around who identifies themselves as a clinical nurse specialist and consequently made it difficult to determine the number of clinical nurse specialists in Canada. CONCLUSIONS This is the first national survey of clinical nurse specialists in Canada. A clearer understanding of these roles provides stakeholders with much needed information about clinical nurse specialist practice patterns. Such information can inform decisions about policies, education and organizational supports to effectively utilize this role in healthcare systems. This study emphasizes the need to develop standardized educational requirements, consistent role titles and credentialing mechanisms to facilitate the identification and comparison of clinical nurse specialist roles and role outcomes internationally.

The sustainability of healthcare innovations: a concept analysis

AIM To report on an analysis of the concept of the sustainability of healthcare innovations. BACKGROUND While there have been significant empirical, theoretical and practical contributions made towards the development and implementation of healthcare innovations, there has been less attention paid to their sustainability. Yet many desired healthcare innovations are not sustained over the long term. There is a need to increase clarity around the concept of innovation sustainability to guide the advancement of knowledge on this topic. DESIGN Concept analysis. DATA SOURCES We included literature reviews, theoretical and empirical articles, books and grey literature obtained through database searching (ABI/INFORM, Academic Search Complete, Business Source Complete, CINAHL, Embase, MEDLINE and Web of Science) from 1996-May 2014, reference harvesting and citation searching. METHODS We examined sources according to terms and definitions, characteristics, preconditions, outcomes and boundaries to evaluate the maturity of the concept. RESULTS This concept is partially mature. Healthcare innovation sustainability remains a multi-dimensional, multi-factorial notion that is used inconsistently or ambiguously and takes on different meanings at different times in different contexts. We propose a broad conceptualization that consists of three characteristics: benefits, routinization or institutionalization, and development. We also suggest that sustained innovations are influenced by a variety of preconditions or factors, which are innovation-, context-, leadership- and process-related. CONCLUSION Further conceptual development is essential to continue advancing our understanding of the sustainability of healthcare innovations, especially in nursing where this topic remains largely unexplored.