Maria Flynn

Nurse staffing levels revisited: a consideration of key issues in nurse staffing levels and skill mix research

AIMnThis paper revisits the published evidence relating to how nurse staffing levels impact on patient, nurse and service outcomes and considers the implications of this body of research for nurse managers in their quest to determine optimum nursing numbers.nnnBACKGROUNDnWithin the context of the recognized global nursing shortage and particular local pressures within international health services, questions of appropriate nurse staffing levels and skill mix are once again becoming increasingly important. It would seem that the determination of optimum nurse staffing levels and skill mix is a central issue in relation to health service governance, service user involvement, as well as in the recruitment, retention and well-being of nursing staff across the service sectors.nnnMETHODSnA review of published evidence was carried out, applying key principles of the systematic method, in order to facilitate the identification of current factors and issues in nurse staffing levels research. The review did not seek to address a specific research question. The search covered 10 years from 1998 to 2008 and identified more than 500 relevant papers, giving a wide international perspective.nnnKEY ISSUESnThe majority of research in the field relates to the acute service sector and there are considerable similarities in issues that transcend international boundaries. Much of the research focuses on the impact on patients and nurses of poor nurse staffing levels. More recent studies have explored the impact of nurse staffing levels on the service organization itself. However, while there may be an association between models of nurse staffing and outcomes, there is insufficient evidence to establish a causal relationship between these factors. In this context it is perhaps time to reconsider how nursing outcomes are defined and measured. IMPLICATIONS FOR NURSING MANAGEMENT AND CONCLUSION: Nurse managers, commissioners of services and workforce planners need to be cognisant of key issues and analyses in the consideration of nurse staffing levels. Not least of these is the need for a healthy degree of caution regarding the supposed objectivity, scientific basis, or evidence base, for rational calculation of optimum nurse staffing levels.

A review of the efficacy of neuromuscular electrical stimulation in critically ill patients

Abstract Background: Muscle wasting in critical illness has been identified as a major clinical concern which can lead to persistent muscle weakness, impede recovery and limit physical function and quality of life in survivors. Neuromuscular electrical stimulation (NMES) has been suggested as an alternative to active exercise in critically ill patients. Objectives: To evaluate the efficacy of NMES in critically ill patients by evaluating the research literature. Methods: Structured database searches of the Cochrane Library, Ovid (Medline), CINHAL, Scopus and PEDro were completed. Results: Eight papers were retrieved and methodological quality evaluated using the Critical Appraisal and Skills Program tool. The NMES protocols, outcomes and findings were analysed and, given the methodological heterogeneity, the study findings were synthesised as a narrative. Analysis showed minimal adverse effects in the use of NMES and some potential benefits of NMES on preservation of muscle strength, decreased duration of mechanical ventilation and shorter Intensive Care Unit (ICU) length of stay. Conclusions: Evidence of the clinical benefits of NMES in the ICU is inconclusive and provides minimal guidance for use in clinical practice. There is a need for further research in this area.

A review of pain management interventions in bone marrow biopsy

AIMSnThis review was designed to evaluate the evidence relating to pain management interventions for patients having bone marrow biopsy.nnnBACKGROUNDnBone marrow biopsy is an invasive procedure causing considerable pain and anxiety for adult patients, yet there are no guidelines to inform effective nursing care. Although this is an under-researched area, a range of pain interventions have been tested on this patient group, but this evidence has not been synthesised.nnnDESIGNnStructured evidence review.nnnMETHODnThe Cochrane Library and databases Medline, Scopus and Cinahl were searched for original research reports. Reference lists of retrieved papers were hand-searched and researchers in the field were contacted. Retrieved papers were analysed using the CASP framework. A narrative data synthesis considered the strengths and limitations of included studies and findings were collated and interpreted.nnnRESULTSnNo systematic reviews of evidence have been undertaken and the search strategy identified twelve research studies eligible for inclusion in the review. Hand-searching did not identify any additional studies, and emails to researchers confirmed this is an under-researched field. Analysis shows three main interventions, intravenous midazolam, premedication with analgesia and/or anxiolysis and the use of Entonox™ are used to manage the pain experience for patients undergoing a bone marrow biopsy.nnnCONCLUSIONSnEvidence is inconclusive and provides little guidance for practice. There is an urgent need for research into effective interventions for pain management in bone marrow biopsy and in understanding the patient experience.nnnRELEVANCE TO CLINICAL PRACTICEnNurses have a central role to play in the assessment and management of the pain and anxiety associated with bone marrow biopsy. There is little evidence to guide this aspect of care, but it is important that nurses involved with bone marrow biopsy are aware of the best evidence to facilitate the most effective management of their patients pain.

Using the prone position for ventilated patients with respiratory failure: a review

AIMSnthis review explored the evidence relating to prone positioning in ventilated patients diagnosed with respiratory failure, including acute lung injury (ALI) or adult respiratory distress syndrome (ARDS).nnnBACKGROUNDnmortality rates for ventilated patients with ALI or ARDS are high, and there is a growing body of evidence suggesting that the position these patients are nursed in may influence clinical outcomes. However, there are no guidelines to inform nursing practice in positioning these patients.nnnMETHODnMedline, Scopus, Cinahl and the Cochrane Library databases were searched for original research reports or systematic reviews of evidence between 2000 and 2009. Reference lists of retrieved papers were hand searched and included studies were analysed using the Critical Appraisal and Skills Programme framework. A narrative data synthesis considered the strengths and limitations of studies, and findings were collated and interpreted.nnnRESULTSnApplication of the search strategy identified a systematic review, currently underway, which has not yet reported and 14 relevant studies eligible for inclusion in this review. Analysis showed considerable variation in study design, but suggests that PaO(2) /FiO(2) ratio, incidence of VAP and mortality may be positively affected by prone positioning.nnnCONCLUSIONSnevidence of the clinical benefits associated with prone positioning is inconclusive and provides little guidance for nursing practice. There is a need for further research into the clinical outcomes of prone positioning, and greater understanding of the practicalities of prone positioning critically ill patients is required.nnnRELEVANCE TO CLINICAL PRACTICEnnurses have a central role to play in the continual assessment and management of this patient group, including the position they are nursed in, not only to ensure the best clinical outcomes but also to provide care and comfort to the patient and their family. It is therefore important that their nursing practice and interventions are informed by the best available evidence.

Care, compassion and competence in critical care: A qualitative exploration of nurses’ experience of family witnessed resuscitation

This exploratory study was grounded in a local initiative promoting family witnessed resuscitation in the critical care units of a regional cardio-thoracic centre in the United Kingdom (UK). Research in this field has focussed on the perceived benefits, or otherwise, of family involvement, but little is known about the impact this has on critical care nurses or their practice. This study aimed to gain insights into nurses experience of family witnessed resuscitation and identify any implications for critical care practices. The study employed a phenomenological approach and interviewed six nurses who had been involved in family witnessed resuscitation. Data from the transcribed interviews were analysed thematically and organised into descriptive categories which reflected the nursing experience of these resuscitation events. The three thematic categories generated by data analysis illustrate the challenges nurses faced in seeking to balance compassionate care and technical competence in emergency situations on critical care units. They also showed how nurses sought to reconcile unsettling emotions with their professional practice and responsibilities. The findings of this study are consistent with what is already known about the challenges of critical care nursing, but suggest that more research is needed to understand the practical and emotional complexities of family witnessed resuscitation.

Searching for the new normal: Exploring the role of language and metaphors in becoming a cancer survivor

PURPOSEnThis qualitative exploratory study was grounded in local patient and service user experiences and was designed to investigate how the language and metaphors of cancer influence personal and social adjustment after completion of a course of treatment.nnnMETHODSnThe study employed a focus group design, in which eighteen people, recruited through regional networks and support groups, participated. Meetings elicited participants stories and focused discussion on key words and common phrases in the cancer lexicon. Data from transcribed focus group recordings were analysed thematically and organised into descriptive categories concerned with the interpretations of common terms and how these influenced the management of identity and emotions.nnnRESULTSnThe thematic categories emphasised the importance of language in the way participants managed their illness and sought to control their feelings and their interactions with others. Interpretation of findings revealed a strong central idea linking participants accounts, which was that language, metaphor and euphemism are central to adjustment and the forging of an altered identity as a survivor of cancer diagnosis and treatment.nnnCONCLUSIONSnThe findings are consistent with what is already known about the language and metaphors of cancer, with language being an important mechanism for managing uncertainty. From participants accounts it also appears that there may be subtle but important differences in professional and lay understandings of cancer language and metaphor. This suggests a need for oncology nurses to elaborate their broad understanding of communication skills and move toward a more detailed understanding of the language used during interactions with patients.

An exploratory study of physiotherapists' views of early rehabilitation in critically ill patients

BACKGROUND: Early rehabilitation has been identified as key to improving physical function and aiding in long-term recovery in critically ill patients. Surveys of physiotherapy practice have highlighted variations and issues with the provision of rehabilitation services in this patient population. However, there have been no qualitative studies exploring physiotherapist’s views of implementing early rehabilitation in critically ill patients. AIM: To explore physiotherapist’s understanding and experiences of early rehabilitation in critically ill patients. METHODS: A qualitative exploratory design using semi-structured interviews with six physiotherapists from one NHS hospital trust. RESULTS: Thematic content analysis identified how participants conceptualised early rehabilitation in two broad themes of adherence and collaborative working. CONCLUSIONS: Physiotherapists identified that adherence is an issue in clinical practice and collaborative working is integral to patient care. Awareness of the barriers to adherence and collaborative working and strategies that can be used to overcome them is central to improving rehabilitation in critically ill patients.

Prevention of pregnancy-related lumbopelvic pain, using a single exercise and advice-based physiotherapy intervention in early pregnancy: A pilot study

Pregnancy-related lumbopelvic pain is a term used to describe pain emanating from the lumbar spine or pelvic girdle that develops either during pregnancy or in the immediate post-partum period. Although it is estimated that up to 70% of pregnant women will report lumbopelvic pain at some point during their pregnancy, there is a paucity of literature pertaining to the prevention of the condition. This study was therefore undertaken in order to explore the feasibility of a larger-scale study into the prevention of pregnancy-related lumbopelvic pain using a single exercise and advice-based physiotherapy intervention in early pregnancy. Several aspects of feasibility were addressed and it was highlighted that several modifications would have to be made to the protocol in order to ensure successful completion of a larger-scale study. The tendency towards improved outcomes in the study group was however an encouraging finding and supports the need for further research in this field.

Management of anaphylaxis in the ED: A clinical audit

Anaphylaxis is one of the potentially life threatening conditions which present to the ED however there is no universal understanding or definitive diagnostic test to aid ED practitioners in its management. Evidence suggests this leads to confusion for ED staff and may compromise patient care. This paper reviews the existing evidence around the effective diagnosis, emergency treatment and long term management of anaphylaxis. It then describes a clinical audit which was carried out in the ED of a large UK University hospital. A retrospective audit design sampled all patients presenting with anaphylaxis in one calendar year, 146 cases were eligible for inclusion. The audit results were consistent with the existing understanding and showed widespread inconsistencies in the diagnosis and treatment of this patient group. The implications the findings may have for the wider ED nursing community are discussed and we conclude that further research and service development is needed to ensure the best possible care for patients with anaphylaxis.