Kim Sears

The Relationship Between the Nursing Work Environment and the Occurrence of Reported Paediatric Medication Administration Errors: A Pan Canadian Study

Paediatric medication administration errors (PMAEs) occur frequently, with devastating consequences for children and their families. This study explored the relationship between the nursing work environment and the occurrence of reported PMAEs. In total, 127 potential and 245 actual PMAEs were reported. Workload, distraction, and ineffective communication were identified as significant contributors to the occurrence of PMAEs. Medical/surgical units reported more errors than critical care environments (p=.000) and a 2.9% increase in the frequency of reported PMAEs was noted for each additional bed on units (p=.001). This study supports the awareness that a systems reform is required to reduce PMAEs.

Conducting systematic reviews of association (etiology): The Joanna Briggs Institute's approach.

ABSTRACTThe systematic review of evidence is the research method which underpins the traditional approach to evidence-based healthcare. There is currently no uniform methodology for conducting a systematic review of association (etiology). This study outlines and describes the Joanna Briggs Institutes approach and guidance for synthesizing evidence related to association with a predominant focus on etiology and contributes to the emerging field of systematic review methodologies. It should be noted that questions of association typically address etiological or prognostic issues.The systematic review of studies to answer questions of etiology follows the same basic principles of systematic review of other types of data. An a priori protocol must inform the conduct of the systematic review, comprehensive searching must be performed and critical appraisal of retrieved studies must be carried out.The overarching objective of systematic reviews of etiology is to identify and synthesize the best available evidence on the factors of interest that are associated with a particular disease or outcome. The traditional PICO (population, interventions, comparators and outcomes) format for systematic reviews of effects does not align with questions relating to etiology. A systematic review of etiology should include the following aspects: population, exposure of interest (independent variable) and outcome (dependent variable).Studies of etiology are predominantly explanatory or predictive. The objective of reviews of explanatory or predictive studies is to contribute to, and improve our understanding of, the relationship of health-related events or outcomes by examining the association between variables. When interpreting possible associations between variables based on observational study data, caution must be exercised due to the likely presence of confounding variables or moderators that may impact on the results.As with all systematic reviews, there are various approaches to present the results, including a narrative, graphical or tabular summary, or meta-analysis. When meta-analysis is not possible, a set of alternative methods for synthesizing research is available. On the basis of the research question and objectives, narrative, tabular and/or visual approaches can be used for data synthesis. There are some special considerations when conducting meta-analysis for questions related to risk and correlation. These include, but are not limited to, causal inference.Systematic review and meta-analysis of studies related to etiology is an emerging methodology in the field of evidence synthesis. These reviews can provide useful information for healthcare professionals and policymakers on the burden of disease. The standardized Joanna Briggs Institute approach offers a rigorous and transparent method to conduct reviews of etiology.

Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data

This is a prospective cohort study using population‐level administrative data to describe the scope of pressure ulcers in terms of its prevalence, incidence risk, associating factors and the extent to which best practices were applied across a spectrum of health care settings. The data for this study includes the information of Ontario residents who were admitted to acute care, home care, long term care or continuing care and whose health care data is contained in the resident assessment instrument‐minimum data set (RAI‐MDS) and the health outcomes for better information and care (HOBIC) database from 2010 to 2013. The analysis included 203 035 unique patients. The overall prevalence of pressure ulcers was approximately 13% and highest in the complex continuing care setting. Over 25% of pressure ulcers in long‐term care developed one week after discharge from acute care hospitalisation. Individuals with cardiovascular disease, dementia, bed mobility problems, bowel incontinence, end‐stage diseases, daily pain, weight loss and shortness of breath were more likely to develop pressure ulcers. While there were a number of evidence‐based interventions implemented to treat pressure ulcers, only half of the patients received nutritional interventions.

Trends in nurse practitioners' prescribing to older adults in Ontario, 2000-2010: a retrospective cohort study.

BACKGROUND Nurse prescribing is a practice that has evolved and will continue to evolve in response to emerging trends, particularly in primary care. The goal of this study was to describe the trends and patterns in medication prescription to adults 65 years of age or older in Ontario by nurse practitioners over a 10-year period. METHODS We conducted a population-based descriptive retrospective cohort study. All nurse practitioners registered in the Corporate Provider Database between Jan. 1, 2000, and Dec. 31, 2010, were identified. We identified actively prescribing nurse practitioners through linkage of dispensed medications to people aged 65 years or older from the Ontario Drug Benefit database. For comparison, all prescription medications dispensed by family physicians to a similar group were identified. Geographic location was determined based on site of nurse practitioner practice. RESULTS The number and proportion of actively prescribing nurse practitioners prescribing to older adults increased during the study period, from 44/340 (12.9%) to 888/1423 (62.4%). The number and proportion of medications dispensed for chronic conditions by nurse practitioners increased: in 2010, 9 of the 10 top medications dispensed were for chronic conditions. There was substantial variation in the proportion of nurse practitioners dispensing medication to older adults across provincial Local Health Integration Networks. INTERPRETATION Prescribing by nurse practitioners to older adults, particularly of medications related to chronic conditions, increased between 2000 and 2010. The integration of nurse practitioners into primary care has not been consistent across the province and has not occurred in relation to population changes and perhaps population needs.

Exploring conceptual and theoretical frameworks for nurse practitioner education: a scoping review protocol.

Review question/objective The objective of this review is to examine conceptual and/or theoretical frameworks that are relevant to nurse practitioner education. The specific review question is: What conceptual and/or theoretical frameworks are available that are relevant to the structuring of nurse practitioner education? Background The use of conceptual and theoretical frameworks to organize the educational curriculum of nursing programs is essential to protect and preserve the focus and clarity of nursings distinct contribution to health care.1 Conceptual frameworks of nursing provide a means to look at nursing in relationship to external factors, thereby assigning meaning to the practice.1 Graduate level nursing education in the preparation of Nurse Practitioners (NPs) specifically and Advanced Practice Nurses (APNs) in general, is significantly compromised by the tendency to conceptualize the learning in these complex programs as being primarily related to skills‐based tasks and competencies alone. According to Baumann,2 advanced nursing education must focus on the uniqueness of the NP position, in contrast to other health care professions. To do this, Baumann2 suggests using a conceptual nursing model and nursing theory as opposed to a strictly biomedical model. This allows NPs to interpret information in a way that differs from the strict biomedical model, providing opportunities for the NPs to be truly present in the lives of their patients. Canadian Nurse Practitioner (NP) practice competency documents are based primarily on the Canadian Nurses Association (CNA) Nurse Practitioner (NP) Core Competency Framework.3 This document defines the core set of entry‐level competencies required for all NPs to practice in all Canadian jurisdictions, settings and client populations. The Core Competencies in the CNA NP Framework are organized within four main categories: professional role, responsibility and accountability; health assessment and diagnosis; therapeutic management; and health promotion and prevention of illness and injury. Although vital to the organization of provincial entry‐level registration standards, this framework provides little direction to educational providers for curricula organization and philosophical perspectives. The Canadian Association of Schools of Nursing developed a national framework for NP education4 following a multi‐phase consultation and literature and curriculum synthesis project. While the task force addressed the guiding principles and essential components of NP education along with contextual factors that impact on the delivery of curricula in Canadian jurisdictions, the philosophical approaches guiding and organizing the education were not addressed. A similar set of documents has been created in the United States by the National Organization of Nurse Practitioner Faculties (NONPF).5 These documents are organized by six population level foci (including the specialty of family/individual across the lifespan) and outline core competencies for entry to practice and registration and educational standards. The Core Competency documents provided by the NONPF are presented in the same manner as the CNA NP Framework and likewise, do not provide a guiding or organizing framework or philosophy for NP education. A full curriculum overhaul based on the NONPF competency requirements was performed at a university center in Oregon.6 The new curriculum was based on competencies that students must acquire, rather than learning objectives.6 While the NONPF Framework does provide an extensive list of entry‐level requirements for NPs, the challenges faced by the institution as it aimed to incorporate the framework into the curriculum clearly provide evidence that these overarching frameworks need to include both a philosophical and organizational component to help guide educators. Conceptual frameworks in graduate nursing education Conceptual frameworks are useful for establishing a congruent relationship between program curricula, objectives and content. Walker and Avant7 advance the utility of conceptual frameworks as providing the logic behind the interrelationships of terms and variables, and improving explanation and understanding. Gold, Haas & King1 assert that conceptual frameworks facilitate grounding of a nursing lens in the curricula of advanced practice nursing programs. It has been noted that newly practicing NPs have demonstrated an allegiance withmedical model thinking, second only in importance to wellness/health promotion considerations.8 Blasdell and colleagues9 surveyed 188 practicing NPs to investigate the relationship between education and the use of theory in clinical practice. Educated graduate NPs rated the importance of nursing theory to the NP practice role significantly higher than did diploma and baccalaureate degree NPs (4.05±2.06 versus 2.65±1.69, p<.001) but both groups rated the nursing models as less important for practice than a medical model approach. Huckabay10 highlighted the need for the use of a harmonized nursing model at the undergraduate level to ensure that students have a thorough understanding of what nursing is and what nursing care entails. At the graduate level, Huckabay10 suggested the use of multiple nursing models, depending on specialty. Regardless of the educational level, a conceptual framework used for education must enable nurse educators to have sufficient guidelines to construct a curriculum and determine what knowledge and skills are needed by the nursing students.11 Further, Furlong12 identified the need for Advanced Practice Nursing (APN) curriculae to be innovative and critically reflective, preparing students to be readily adaptable to challenges in the work place. Furlong12 suggests that to do this, the curriculum must rely upon an interdisciplinary framework to deliver content. Gold, Haas & King1 suggest that core curricula based on a medical model or a skill‐related task list do not reflect the critical thinking of nurses, nor the uniqueness of the profession. Thus, conceptual models used for curricula development must: encompass the distinct nursing worldview, promote learning, and be efficient and comprehensive. Frameworks have been proposed and tested to guide the development and implementation of inter‐professional education (IPE) and collaborative practice curricula for NP and medical students. A qualitative assessment of a framework guided IPE module illustrated the benefit of improving the focus on role awareness in participating students.10 However, this particular curriculum was limited to a two‐week period and not presented as a pervasive approach to the educational programs of each discipline. In education, an overarching philosophy can provide a road map for goal identification, teaching material development and the formulation of evaluation methods.1 For instance, when creating a curriculum that was a result of the collaboration of three different post‐secondary institutions, the SHARE (students, humor, administrative support, resources, and educational technology) model was used.13 This model brings together resources, students and faculty, surrounding them with humor, which was viewed as a fundamental part of the process while the program was still in its early stages.13 According to the authors, the program has been widely successful and the reliance on humor as an underlying philosophy has enabled the students and faculty to deal with problems arising in the new program.13 Focusing on evaluation, Kapborg & Fischbein14 promoted the use of the Education Interaction Model. The model identifies how educational influences can interact with abilities of students and how the consequences of this interaction can be evaluated by observing changes in both students and programs. The authors argue that, while the educational interaction model is effective, it is not the only model that can be used to carry out evaluations.14 The authors stress that the model chosen to perform an evaluation should be based upon what or who is going to be evaluated. The standards outlined in the CNA NP framework are an essential part of organizing the education process for NPs and ensuring that NPs have acquired the necessary skills to practice in Canada as an NP. However, the framework is lacking philosophy and organization regarding NP education programs to ensure that the curriculum is preparing the NPs for the ever‐changing work environment. An Australian survey of NP education documents from relevant universities as well as interviews with NPs and academic conveners from Australia and New Zealand found that, while NP educational programs need to have strong clinical and science based learning components, student directed and flexible learning models act to ensure the capability of NPs as they strive to adapt to practice situations.15 Capability, as an approach to the learning process, includes the flexibility to respond to the specific, self‐identified learning needs of students.15 Knowing how to learn, having high self‐efficacy, applying competencies to new tasks, collaborating with others, and being creative are all signs of a capable practitioner.16 Gardner et al.15 emphasized the need for a program that fosters both competent and capable NPs. In a follow‐up study, using the same data, Gardner et al.17 confirmed that NPs viewed the attributes of a capable NP as imperative to practice. Thus, a framework for NP education must include both competency building elements, such as those currently found in the CNA NP framework and capability building elements which can be fostered through self‐directed learning.17 Similarly, Schaefer18 investigated the role of caring in nursing practice through a class for APN students in which the students reflected on their narratives of caring for patients. This qualitative study revealed that when APN students provide care by meeting the complex needs of suffering patients, the art and science of nurs

Knowledge, Attitude, and Practice in the Management of Mixed Arteriovenous Leg Ulcers

Leg ulceration is a chronic health condition that constitutes a significant disease burden. In this cross-sectional descriptive study, a sample of wound care clinicians were asked to respond to a web-based survey. Based on a review of literature and recommended best practices in the management of mixed arteriovenous (AV) ulcers, a questionnaire was developed to examine the knowledge, attitude, and practice pattern in the management of AV ulcers. A total of 436 clinicians participated in the survey. A number of assessment techniques were perceived to be relevant for the assessment of AV ulcers; medical history and the appearance of ulcers were the most commonly used methods in clinical practice. While over 80% of the participants conceded that compression should be used to promote wound healing, half of them would consider using compression for AV ulcers if ankle brachial index was less than 0.8. Half of the participants considered an ankle brachial index of 0.8 or higher as the optimal cutoff value for safe compression. The majority of respondents disagreed with the perception that caring for people with AV ulcers was unrewarding. However, challenges to promote treatment adherence, address psychosocial concerns, and optimize symptom management are common.

The Relationship Between Nursing Experience and Education and the Occurrence of Reported Pediatric Medication Administration Errors

Medication errors are one of the most common incidents in the hospitals. They can be harmful, and they are even more detrimental for pediatric patients. This study explored the relationship between nursing experience, education, the frequency and severity of reported pediatric medication administration errors (PMAEs). The data for this study were collected from a larger pan Canadian study. A survey tool was developed to collect self-reported data from nurses. In addition to descriptive statistics, a Poisson regression or a multiple linear regression was completed to address the research questions, and a Boneferrai correction was conducted to adjust for the small sample size. Results demonstrated that on units with more nurses with a higher level of current experience, more PMAEs were reported (p=.001), however; the PMAEs reported by these nurses were not as severe (p=.003). Implications to advance both safe medication delivery in the pediatric setting and safe culture of reporting for both actual and potential errors are identified.

Development and Evaluation of an Epidural Analgesia Workshop for Senior Nursing Students

BACKGROUND Most prelicensure nursing students receive little to no training in providing care for patients who receive epidural analgesia, despite exposure in clinical settings and the potential for devastating adverse effects. To develop and pilot an epidural workshop for senior nursing students using standardized patients (SPs), and to evaluate feasibility and learner outcomes. METHOD A 4-hour epidural workshop consisted of a large group lecture and demonstration, small-group practice scenarios, and individual learner evaluation with SPs. Learning outcomes were evaluated using a performance checklist and critical thinking rubric, and pre- and posttests. RESULTS Participants scored well on the performance-based evaluation (mean score of 86% items performed correctly) and rated the workshop highly. However, learners and instructors made several recommendations for improving the learning module for future sessions. CONCLUSION This pilot project demonstrated that an epidural analgesia workshop using SPs is feasible and results in positive learning outcomes and high satisfaction with senior nursing students. [J Nurs Educ. 2018;57(6):359-365.].

Patient-Related Risk Factors for the Occurrence of Patient-Reported Medication Errors in One Community Pharmacy: A Local Perspective

Background: Medication errors have been shown to occur 4 times more often in the community compared to the hospital setting. Therefore, identifying the patient-related factors within the community that contribute to an increased occurrence of medication errors is required. Objective: To assess patients’ knowledge and understanding of their medications in order to determine risk for medication errors. Methods: This quantitative descriptive study used a convenience sample of participants filling their prescriptions at one independent pharmacy in Canada. The study used descriptive statistics including frequencies and correlations. Further multiple regressions were conducted to explore the relationship between the patient factors and medication knowledge and use. Results: A total of 33.5% of respondents indicated that they know what medication they are currently taking, and that they know why they taking their current medications. Decreased knowledge of medication taken was significantly associated with likelihood of a medication error by 3.6 times (P = .048). Increased age (P = .01) and the death of a spouse (P = .01) correspond to a decreased knowledge of medications. Those with less education appeared to have decreased understanding as to why they are taking their medications (P = .01). The odds of experiencing a medication error increased with multiple medications. Also, changes in medication dose increased the probability of experiencing a medication error by 2.2 times. This study however had a small sample size. Conclusions: With identification and understanding of patient factors that influence the incidence of medication error, we can increase awareness and determine solutions to decrease risk of medication error in clinical practice.

Medication Knowledge Among Older Adults Admitted to Home Care in Ontario During 2012-2013.

Background: Medication use among Canadian seniors is widespread and increases with the number of comorbidities. Limited evidence exists on medication knowledge among seniors, especially in home care. Purpose: The purpose of this retrospective cohort study was to describe medication knowledge and ability to take medication among seniors admitted to home care in Ontario. Results: Ten percent had little or no knowledge of what medication to take (n = 1,389/14,004) or an understanding of the purpose of their medications (n = 1,396/14,004). Increasing numbers of medications prescribed was associated with decreased knowledge of medications. The strongest predictor of limited knowledge and ability to take medication was dementia (odds ratio > 5.0). Discussion: Among Ontario seniors living at home, knowledge about medications decreases as the number of medications increases. Therefore, this group may be at high risk of medication errors. Conclusion: Better systems are required to allow healthcare professionals to review with patients, any medications with patients and caregivers, to assist in addressing the decreased knowledge of medications. Such a system would provide the capacity to target those individuals at high risk for a medication error, as well as the medications and drug–drug interactions that seem most likely to be harmful among older adults.