Julie Scholes

FIRST2ACT: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education.

Delayed assessment and mismanagement of patient deterioration is a substantial problem for which educational preparation can have an impact. This paper describes the development of the FIRST(2)ACT simulation model based on well-established theory and contemporary empirical evidence. The model combines evidence-based elements of assessment, simulation, self-review and expert feedback, and has been tested in undergraduate nurses, student midwives and post-registration nurses. Participant evaluations indicated a high degree of satisfaction and substantial self-rated increases in knowledge, confidence and competence. This evidence-based model should be considered for both undergraduate and post-registration education programs.

Using portfolios in the assessment of learning and competence: the impact of four models

This paper discusses the diversity of portfolio use highlighted in a study funded by the English National Board for Nursing, Midwifery and Health Visiting exploring the effectiveness of portfolios in assessing learning and competence (). Data collection was undertaken in two stages: through a national telephone survey of Higher Education Institutions (HEIs) delivering nursing programmes (stage 1); and through four in-depth case studies of portfolios use (stage 2). Data collection for stage two was undertaken through field work in four HEIs purporting to use portfolios as an assessment strategy, and their associated clinical placement settings. Four approaches to the structure and use of portfolios were evident from the stage 2 case study data; these were characterised as: the shopping trolley; toast rack; spinal column and cake mix. The case study data also highlighted the evolutionary nature of portfolio development and a range of additional factors influencing the effectiveness of their use, including language of assessment, degree of guidance and expectations of clinical and academic staff.

Managing Deteriorating Patients: Registered Nurses’ Performance in a Simulated Setting

Aim: To examine, in a simulated environment, rural nurses’ ability to assess and manage patient deterioration using measures of knowledge, situation awareness and skill performance. Background: Nurses’ ability to manage deterioration and ‘failure to rescue’ are of significant concern with questions over knowledge and clinical skills. Simulated emergencies may help to identify and develop core skills. Methods: An exploratory quantitative performance review. Thirty five nurses from a single ward completed a knowledge questionnaire and two video recorded simulated scenarios in a rural hospital setting. Patient actors simulated deteriorating patients with an Acute Myocardial Infarction (AMI) and Chronic Obstructive Pulmonary Disease (COPD) as the primary diagnosis. How aware individuals were of the situation (levels of situation awareness) were measured at the end of each scenario. Results: Knowledge of deterioration management varied considerably (range: 27%-91%) with a mean score of 67%. Average situation awareness scores and skill scores across the two scenarios (AMI and COPD) were low (50%) with many important observations and actions missed. Participants did identify that ‘patients’ were deteriorating but as each patient deteriorated staff performance declined with a reduction in all observational records and actions. In many cases, performance decrements appeared to be related to high anxiety levels. Participants tended to focus on single signs and symptoms and failed to use a systematic approach to patient assessment. Conclusion: Knowledge and skills were generally low in this rural hospital sample with notable performance decrements as patients acutely declined. Educational models that incorporate high fidelity simulation and feedback techniques are likely to have a significant positive impact on performance.

The resilient subject: Exploring subjectivity, identity and the body in narratives of resilience

International research and policy interest in resilience has increased enormously during the last decade. Resilience is now considered to be a valuable asset or resource with which to promote health and well-being and forms part of a broader trend towards strength based as opposed to deficit models of health. And while there is a developing critique of resilience’s conceptual limits and normative assumptions, to date there is less discussion of the subject underpinning these notions, nor related issues of subjectivity, identity or the body. Our aim in this article is to begin to address this gap. We do so by re-examining the subject within two established narratives of resilience, as ‘found’ and ‘made’. We then explore the potential of a third narrative, which we term resilience ‘unfinished’. This latter story is informed by feminist poststructural understandings of the subject, which in turn, resonate with recently articulated understandings of an emerging psychosocial subject and the contribution of psychoanalysis to these debates. We then consider the potential value of this poststructural, performative and embodied psychosocial subject and discuss the implications for resilience theory, practice and research.

The FIRST2ACT simulation program improves nursing practice in a rural Australian hospital

OBJECTIVE To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST(2) ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital. DESIGN Interrupted time series analysis. SETTING A rural Australian hospital. PARTICIPANTS All registered nurses (Division 1) employed on an acute medical/surgical ward. INTERVENTION The FIRST(2) ACT simulation program. OUTCOME MEASURES Appropriate frequency of a range of observations and administration of oxygen therapy. RESULTS Thirty-four nurses participated (83% of eligible nurses) in the FIRST(2) ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis. CONCLUSION FIRST(2) ACT was associated with measurable improvements in nursing practice.

Coping with the professional identity crisis: is building resilience the answer?

Recruitment and retention of specialist nurses in critical care has been a perennial problem resulting in worldwide shortages in the critical care workforce as identified by Rose et al. (2008). Rose et al. clearly identify educational preparation as one remedy to address the nursing shortage and argue that a range of pedagogic strategies and methods is necessary to adequately prepare the workforce. Educators have been charged to deliver programmes that fit practitioners with competencies that enable them to adjust to the challenges of contemporary practice (McKenna et al., 2006). However, one competence to enable nurses to adapt to the changing dynamic of healthcare receives less attention and that is resilience to cope with the realities of their work and challenges to their professional identity. The contemporary healthcare context challenges the way nurses practice and this in turn tests the fundamental assumptions of what it is to be a nurse and their ‘privileged position beside a patient in their suffering’ (Benner and Wrubel, 1989). This is causing a crisis in ideology, espoused theory of nursing and the reality of clinical practice (Keighly, 2006). In short nurses are having an identity crisis. The dissonance this creates for the individual practitioner is causing many to leave the profession, some before they have taken up their first qualified post (Nelson and Gordon, 2006). This suggests that measures to upskill our staff academically and clinically will be fruitless to redress the staffing shortage if this is done without coaching to bolster the individual’s capacity to deal with change fatigue. The factors creating this role strain can be conceptualised under four main headings; they are

The impact of a musculoskeletal masters course: Developing clinical expertise

A common aim of Masters (MSc) courses in the UK, accredited by the Manipulation Association of Chartered Physiotherapists (MACP), is to promote the clinical expertise of practitioners. Few studies have explored the extent to which this is achieved and understanding is further hampered by the contested nature of expertise. This paper reports on the impact of an MACP approved MSc on practitioners and offers a conceptual model of their development towards clinical expertise. A qualitative theory-seeking case study was used, drawing on the procedures and processes of grounded theory. Twenty-six semi-structured interviews were conducted with eleven alumni from one MACP approved MSc programme. Dimensional analysis and the constant comparative method of data analysis, was used to build the conceptual model. Prior to enrolment, practitioners uncritically accepted knowledge from others and followed habitual routines with their patients. Their diet of informal CPD appeared ineffective in developing these attributes. The impact of the MACP approved MSc involved three developmental aspects of clinical expertise: critical understanding of practice knowledge, patient centred practice and capability to learn in, and from, clinical practice. These inter-related aspects of knowledge, practice and learning offer a conceptual model of the development towards clinical expertise. The most powerful experience to trigger change was direct observation and feedback of their clinical practice by an MACP educator; this highlights the value of clinical mentors facilitating less experienced colleagues. The implementation of such mentorship within departments may offer a cost effective and manageable way to support CPD within the workforce.

Why health care needs resilient practitioners

INTRODUCTION Frank (2004) argues that when we enter into a relationshipwith apatient in aoneto-one interaction we can give to that therapeutic moment all our attention, knowledge compassion and care. The moment a third party enters the roomwe are required to invoke justice to ensure that all three are party to the same rights, privileges and observe similar obligations. To satisfy this end, systems are introduced to ensure fairness and equity. In health care, providers must demonstrate their accountability to the taxpayer and provide assurance that services are delivered according to prescribed standards. This requires there to be greater precision in collecting and collating data (paperwork) to evidence theseoutcomes. The systems, tools and methods by which fairness, equityandaccountability are evidenced have reached exponential proportions and are increasingly burdensome to practitioners attempting to deliver care at the bedside (Bowen and Kriendler, 2008). Frequently, new systems that quantify and risk manage care can reconstruct practice into a set of competing and contradictory demands that rarely captures the caringmomentof a one to one therapeutic interaction with a patient. The system then becomes something that distances the practitioner from the patient, or can be used to shield the practitioner from taking responsibility for the care that is provided because they act according to the determinants of the system not necessarily their own professional or personal values (Coombs, 2008). In this editorial I wish to explore the following issues:

Building emotional resilience: small steps towards big change

Nurses are currently the subject of negative media attention and criticism. This can leave practitioners feeling overwhelmed and despondent. This is not conducive to energized, high quality nurse engagement to confront the issues and change practice to address the critique. In this editorial I shall examine the issues and offer some suggestions to help remediate the potential spiral of negativity and consider ways in which critical care nurses can build resilient strategies to defend themselves. Importantly, to help nurses to think about how they can remain positive and optimistic. Reports authored by Francis (2010) and Keogh (2013) have highlighted poor standards of care that have compromised patient safety. Recently, the media have focused on standards of care in Accident and Emergency departments suggesting they are on a ‘cliff edge’ (Triggle, 2013); that ‘safety cannot be guaranteed’ (Manning, 2013). Other headlines declare: National Health Service (NHS) wards and departments subject to: ‘toxic overcrowding’; ‘ institutional exhaustion’; ‘over whelmed by bureaucracy’, job cuts, cost savings and hospitals subject to rapid turnover at executive level, poor leadership and a culture of intimidation, compliance and job insecurity (Berwick, 2013). Nurses have been openly criticized for being too busy meeting targets and a recent Royal College of Nursing (RCN) report has highlighted that one fifth of nurses’ time is taken up completing paper work (Carter, 2013); time that could be better spent caring for patients (McFarlane, 2013). This media attention has led to a crisis in public confidence and has left nurses feeling ‘beleaguered’ (Cummings, 2013) and doubtful about their capacity to redress this decline. It is not surprising that a hard job is made harder by such negativity and concern. There is a risk in the face of such criticism, that more bureaucratic strategies are introduced to manage the way out of crisis. At an institutional level, there needs to be change and strong leadership, but that is not always best effected by the introduction of yet more ‘tools’ designed to raise standards, raise awareness, focus attention and address specific quality initiatives. Health care practitioners in the NHS are overwhelmed with these tools, and experience a conflict between caring conscientiously and making a record of that caring activity (Carter, 2013). Fundamentally, in reconstructing compassion into a tool that makes compassion auditable, we basically reconstruct the act (Rankin and Campbell, 2006). A reduction in bureaucracy is called for to create the space to ‘listen, tackle, ensure and change’, but the rhetoric is directly oppositional to the driver to ensure compliance with standards. Unison, in response to the findings of a staff survey, argued that it is not possible for staff to treat patients with respect and dignity if they do not experience this from the organizations in which they work (Lezard, 2013). Others have suggested that nursing should abandon the ‘virtue script’ in favour of a more realistic construction of contemporary nursing practice (Nelson and Gordon, 2006). The debate on the place of caring and how it can be made sustainable has been refreshed in the light of the Francis report. Now we are urged to embrace the six Cs as a remedy to address the current misgivings about standards of care and safety. Cummings’ (2012) solution to exercise compassion, courage, communication, care, competence and commitment demand that practitioners re-examine their values and beliefs and how these correspond with those espoused and practiced in the hospitals. Staff in the human relations department, the finance director of the hospital and other colleagues in managerial positions may be striving towards different goals. However, Berwick’s (2013) response is to put the safety of patients at the centre of all initiatives and compassionate care at the heart of quality improvements. He contests: ‘this is the safest and best route to lower cost’. Despite these challenges, many nurses manage to achieve high standards of care and make significant difference to the patient’s experience (Carter, 2013). These individuals might well experience the same pressures as their colleagues who are disenfranchised and practice depleted caring. So what are the characteristics that distinguish those practitioners who can successfully sustain consistent, compassionate care? What makes them resilient? Resilience is a set of personal attributes and adaptive skills that enable an individual to cope with adversity, trauma or chronic stress despite their vulnerability (Jackson et al., 2007). Linking resilience to personal attributes can suggest that those who are not resilient are somehow inadequate or failing (McCann et al., 2013). This might well lead an organization to assume that responsibility for resilience is invested in an individual: that an organization has no responsibility to support their staff to build

Research in Nursing in Critical Care 1995–2009: a cause for celebration

AIM The purpose of this article is to analyse the research papers published in Nursing in Critical Care (n = 168) over the past 15 years to examine trends in methodology, theoretical contribution and authorship. BACKGROUND Research is a contested term and the paper starts with defining the criteria by which papers were selected for the review. METHODS The approach undertaken was a documentary review based on an adaptation of Schatzmans dimensional analysis. Papers were loaded into a matrix then categorized and grouped to determine trends and frequency. CONCLUSION Research papers published in the journal reflect a wide range of interests and broad spread of research methods. Qualitative and quantitative data are used by authors but to distinguish papers into these two categories would be over simplistic. Systematic reviews along with randomized control trials and studies using a quasi-experimental design are the least frequently occurring approaches in the published papers, although they are growing in number in recent years. All the papers make explicit the implications for clinical practice and as such contribute to the growing body of knowledge to inform critical care nursing practice.