Nicole Phillips

A systematic review of nursing administration of medication via enteral tubes in adults

AIM This systematic review aimed to determine the best available evidence regarding the effectiveness of nursing interventions in minimising the complications associated with administering medication via enteral tubes in adults. BACKGROUND Giving enteral medication is a fairly common nursing intervention entailing several skills: verifying tube position, preparing medication, flushing the tube and assessing for potential complications. If not carried out effectively harmful consequences may result leading to increased morbidity and even mortality. Until now, what was considered to be best practice in this area was unknown. DESIGN Systematic review. METHODS CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO databases were searched up to September 2005. Reference lists of included studies were appraised. Two reviewers independently assessed study eligibility for inclusion. There were no comparable randomised-controlled trials; data were presented in a narrative summary. RESULTS Identified evidence included using 30 ml of water for irrigation when giving medication or flushing small-diameter nasoenteral tubes may reduce tube occlusion. Using liquid medication should be considered as there may be less tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastrostomy tubes. In addition, nurses may need to consider the sorbitol content of some liquid medications, for example elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. CONCLUSION The evidence was limited. There was a lack of high-quality research on many important issues relating to giving enteral medication. RELEVANCE TO CLINICAL PRACTICE Nurses have the primary responsibility for giving medication through enteral tubes and need knowledge of the best available evidence. Some of the nursing considerations and interventions relating to this skill have been researched in the clinical area and have implications for practice. There is a need for further studies to strengthen these findings.

A systematic review of reliable and valid tools for the measurement of patient participation in healthcare

Introduction Patient participation in healthcare is recognised internationally as essential for consumer-centric, high-quality healthcare delivery. Its measurement as part of continuous quality improvement requires development of agreed standards and measurable indicators. Aim This systematic review sought to identify strategies to measure patient participation in healthcare and to report their reliability and validity. In the context of this review, patient participation was constructed as shared decision-making, acknowledging the patient as having critical knowledge regarding their own health and care needs and promoting self-care/autonomy. Methods Following a comprehensive search, studies reporting reliability or validity of an instrument used in a healthcare setting to measure patient participation, published in English between January 2004 and March 2014 were eligible for inclusion. Results From an initial search, which identified 1582 studies, 156 studies were retrieved and screened against inclusion criteria. Thirty-three studies reporting 24 patient participation measurement tools met inclusion criteria, and were critically appraised. The majority of studies were descriptive psychometric studies using prospective, cross-sectional designs. Almost all the tools completed by patients, family caregivers, observers or more than one stakeholder focused on aspects of patient–professional communication. Few tools designed for completion by patients or family caregivers provided valid and reliable measures of patient participation. There was low correlation between many of the tools and other measures of patient satisfaction. Conclusion Few reliable and valid tools for measurement of patient participation in healthcare have been recently developed. Of those reported in this review, the dyadic Observing Patient Involvement in Decision Making (dyadic-OPTION) tool presents the most promise for measuring core components of patient participation. There remains a need for further study into valid, reliable and feasible strategies for measuring patient participation as part of continuous quality improvement.

Managing patient deterioration: a protocol for enhancing undergraduate nursing students' competence through web-based simulation and feedback techniques

AimsTo describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.BackgroundThere are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.Design/MethodsA mixed methods triangulated convergent design.In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.ConclusionThis project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

Medication administration via enteral tubes : a survey of nurses' practices

AIM This article is a report of a study examining the practices of acute care nurses when administering medication via enteral tubes. BACKGROUND Administering medication via enteral tubes is predominantly a nursing responsibility across countries. It is important to establish what nurses actually do when giving enteral medication to inform policy and continuing education development. METHOD In 2007, a survey was conducted using a random sample of acute care nurses at two large metropolitan hospitals in Melbourne, Australia. There were 181 Registered Nurses who participated in the study; 92 (50.8%) practised in intensive care units, 52 (28.7%) in surgical areas, 30 (16.6%) in medical areas and 7 (3.9%) were from combined medical-surgical areas. The questionnaire was developed by the researchers and a pilot study was conducted in August 2006 to test reliability, face validity and user-friendliness of the tool. RESULTS Nurses reported using a range of methods to verify enteral tube position prior to administering enteral medication; some were unreliable methods. A majority reported administering enteric-coated and slow or extended release forms of medication, and giving solid forms of medication when liquid form was available. Nearly all (96%) reported flushing a tube after giving medication, 28% before, and 12% always flushed between each medication. CONCLUSION Enteral medication administration practices are inconsistent. Some nurses are using unsafe practices and may therefore compromise patient care.

Use of videos to support teaching and learning of clinical skills in nursing education: A review

Information and communications technology is influencing the delivery of education in tertiary institutions. In particular, the increased use of videos for teaching and learning clinical skills in nursing may be a promising direction to pursue, yet we need to better document the current research in this area of inquiry. The aim of this paper was to explore and document the current areas of research into the use of videos to support teaching and learning of clinical skills in nursing education. The four main areas of current and future research are effectiveness, efficiency, usage, and quality of videos as teaching and learning materials. While there is a clear need for additional research in the area, the use of videos seems to be a promising, relevant, and increasingly used instructional strategy that could enhance the quality of clinical skills education.

Determining criteria to assess patient readiness for discharge from postanaesthetic care: an international Delphi study

AIMS AND OBJECTIVES To obtain expert consensus on essential criteria required to assess patient readiness for discharge from the postanaesthetic care unit. BACKGROUND A patients condition can deteriorate after surgery, and the immediate postoperative period is recognised internationally as a time of increased risk to patient safety. A recent systematic review identified evidence-based assessment criteria for the safe discharge of patients from the postanaesthetic care unit and identified gaps in the evidence. DESIGN Descriptive consensus study using the Delphi method. METHODS Members of international clinical specialist groups with expertise in anaesthesia or postanaesthetic care participated in three consultation rounds. Online surveys were used to determine expert consensus with regard to aspects of postanaesthetic care and specific criteria for assessing patient readiness for discharge. Three rounds of surveys were conducted from May 2011-September 2012. RESULTS Twenty-three experts contributed to the panel. Consensus, that is, at least 75% agreement, was reached in regard to 24 criteria considered essential (e.g. respiratory rate 100%; pain 100%; heart rate 95%; temperature 91%). Consensus was also reached for 15 criteria not considered essential (e.g. appetite 96%; headache 76%). Consensus was not obtained for a further 10 criteria. Participants (95%) agreed that a discharge tool was important to ensure safe patient discharge. CONCLUSION Consensus was achieved by a panel of international experts on the use of a tool to assess patient readiness for discharge from postanaesthesia care unit and specific variables to be included or excluded from the tool. Further work is required to develop a tool and test its reliability and validity. RELEVANCE TO CLINICAL PRACTICE The findings of this study have informed the development of an evidence-based tool to be piloted in a subsequent funded study of nursing assessment of patient readiness for discharge from the postanaesthetic care unit.

Measuring patient participation in health care: a comprehensive systematic review protocol

Review question/objective The primary objective of this review is to generate a list of evidence‐based determinants used for assessing patient participation. The review will synthesize the best available evidence for assessing patient participation in health care. Patient participation is the active involvement of the patient in planning, delivery, monitoring and evaluation of their own care. A patient is an individual receiving care services from an organization providing health care. In the context of this review, patient participation will include the active involvement of non‐professional carers/caregivers (e.g. family members and significant others) who support the patient, particularly adults who are unable to advocate on their own behalf (e.g. those with cognitive impairment). The review questions are: What are the available instruments that can be used to measure patient participation in healthcare? What criteria do available instruments incorporate? Are the identified instruments used to measure patient participation in healthcare reliable and valid? What is the feasibility of the identified instruments to measure patient participation in healthcare? What other available strategies can be used to assess patient participation in healthcare? What are the components of other available strategies? Are other identified strategies feasible to assess patient participation in healthcare? Background Promoting patient participation is recognized as a component of high quality health care, and there is evidence that a patient‐centered focus can result in significant benefits in terms of care quality and experience of care. Outcomes relating to quality of care include a reduction in mortality,1 readmission rates,2 length of stay and infection,3 as well as improved adherence to treatment regimens,4 and improved functional status.5 Involvement of the patient in quality improvement initiatives can lead to improved quality of care,6‐8 as well as better patient outcomes.9‐11 Hospitals that provide patient‐centered care have financial benefits including reduced length of stay, lower inpatient costs, decreased adverse events, higher employee retention rates, reduced operating costs and decreased malpractice claims.12 Measurement of patient participation in health care is a relatively new concept, introduced in western Europe, North America and Australia over the previous 25 years.13 The World Health Organization World Alliance for Patient Safety is actively focused on the role that patients and their families could play in the improvement of health care.14 Evidence is emerging that patient participation can enhance decision making processes, reduce medical errors, optimize self‐management for patients with chronic illness and improve patient adherence to health care practices.15 As such, health services internationally now include consumer‐centered care and partnering with consumers as an aspect of service delivery and design. In 1998, Cahill observed that a standardized definition of patient participation and reliable, valid measures for assessing the extent to which this concept is executed in practice are needed.16 Over a decade later, the concept of patient participation remains poorly defined. Various terms, including patient involvement, partnership, empowerment, collaboration and patient‐centered care are used interchangeably.15 Despite the now common practice of gathering feedback from patients, its use to stimulate quality improvement remains poorly characterized. In an overview of measurement of patient participation in health care, Coulter, Fitzpatrick et al., highlighted the first stage of the measurement process as being the development of agreed standards, each with a set of measureable indicators focused on patient‐centered care and patient priorities.17 Development of measurable indicators has been a focus of health service quality improvement internationally. In 2006, the Organization for Economic Co‐operation and Development (OECD) prepared an overview of health care quality indicators in 23 countries represented in the OECD; laying the foundation for international benchmark indicators that embrace and build upon health service quality frameworks already implemented in six major OECD countries (Australia, Canada, Denmark, the Netherlands, the United Kingdom and the United States).18 Within Australia, 10 National Safety and Quality Health Service (NSQHS) standards have been designed to protect the public from harm and to improve the quality of health service provision.19 These standards are integral to the Australian health care accreditation process, as they determine the criteria on which an organizations performance will be assessed, and indicators against which performance will be measured. Similarly, other OECD countries document standards and quality indicators that are comparable to those used in the Australian setting.18 The second Australian NSQHS standard, ‘Partnering with Consumers’, describes the systems and strategies to create a consumer‐centered health system through inclusion of consumers in the development and design of quality health care.19 This requires active involvement of consumers in the review, design and implementation of health services with a goal of improved safety, quality and efficiency. Thus, the first stage of the process defined by Coulter, Fitzpatrick et al., in which agreed standards are defined, is prescribed within the NSQHS Standards.17 Equally, health care quality indicators in other OECD countries prescribe to the principle of consumer involvement, variously referred to as patient centeredness, patient focus or responsiveness.18 The development of measureable indicators of patient participation is ongoing both in Australia and internationally. The Australian Institute of Health and Welfare (AIHW) includes ‘patient experience’ as a national quality indicator to be reported by health care facilities that encompasses patient satisfaction, involvement in and support for health care, but specific ways in which this should be measured and reported remain undefined.20 The OECD is also yet to finalize its work on measurable quality indicators of patient participation.18 Reliable strategies to measure and evaluate the achievement of quality indicators of patient participation have therefore received minimal attention within the NSQHS Standards structure; although work identifying the most appropriate measurement strategies is ongoing. As part of the OECD project on quality indicators in health care, the Norwegian Knowledge Center for Health Services reviewed surveys that have been used to measure patient experience in international health care settings. The reviewers identified numerous large scale patient surveys that have been undertaken in OECD and non‐OECD countries to measure patient experiences, and identified both qualitative and quantitative strategies that could be adopted by health care facilities, including some surveys that were under development at the time of the review.18 Elwyn, Edwards et al., reviewed instruments for measuring patient involvement in shared decision making and found existing instruments had not been specifically developed to measure patient involvement, were developed for different purposes and were not validated.21 In their comprehensive report on measuring patient experience with health care services, Coulter, Fitzpatrick et al., outlined a range of measurement strategies including surveys, interviews, focus groups, patient diaries, ‘mystery shopping’ and journey mapping.17 However, the authors did not report the implementation, validation or effectiveness of these tools. Health care services currently use a range of strategies to evaluate patient‐centered care and partnerships with patients and their significant others. The two primary approaches to measuring patient participation are external observation methods and self‐report instruments. Examples of tools using external observation for measuring patient involvement in shared decision making are the Option Scale,22 and Rochester Participatory Decision‐Making Scale (RPAD).23 More often, health care services rely on self‐report instruments for measuring patient satisfaction and experience. Surveys are often given to a patient when they leave hospital after a period of inpatient care, or the patient is asked to complete a questionnaire prior to discharge. Post discharge feedback may provide more reliable information about the quality of care because respondents have had time to reflect on their experiences.17 More recently, rapid feedback involving online surveys have also been used.24 Although some of the items in these surveys relate to patient participation in their health care, the focus is often patient satisfaction and experience, rather than involvement. A review of patient experience and satisfaction surveys conducted within public and private hospitals in Australia identified that 80% of surveys included items which related to patient participation in care decisions.25 The Australian Commission on Safety and Quality in Health Care has hosted a series of roundtable meetings where experts have provided advice towards the development of core common questions for hospital patient experience measurement. However, it is important to note that the evidence‐base for criteria to measure patient participation in health care and improvements as a result of patient participation was not established. This systematic review endeavors to provide an updated synthesis of evidence on effective strategies through which patient involvement in health care can be measured and assessed, with a goal of assisting health care services to demonstrate patient‐centered care in practice and benchmark their performance on the international stage. The primary outcome for this review will be a preliminary list of evidence‐based criteria used for assessing patient participation. Specifically, this will assist

Risk factors for incident delirium in an acute general medical setting: a retrospective case-control study.

AIMS AND OBJECTIVES To determine predisposing and precipitating risk factors for incident delirium in medical patients during an acute hospital admission. BACKGROUND Incident delirium is the most common complication of hospital admission for older patients. Up to 30% of hospitalised medical patients experience incident delirium. Determining risk factors for delirium is important for identifying patients who are most susceptible to incident delirium. DESIGN Retrospective case-control study with two controls per case. METHODS An audit tool was used to review medical records of patients admitted to acute medical units for data regarding potential risk factors for delirium. Data were collected between August 2013 and March 2014 at three hospital sites of a healthcare organisation in Melbourne, Australia. Cases were 161 patients admitted to an acute medical ward and diagnosed with incident delirium between 1 January 2012 and 31 December 2013. Controls were 321 patients sampled from the acute medical population admitted within the same time range, stratified for admission location and who did not develop incident delirium during hospitalisation. RESULTS Identified using logistic regression modelling, predisposing risk factors for incident delirium were dementia, cognitive impairment, functional impairment, previous delirium and fracture on admission. Precipitating risk factors for incident delirium were use of an indwelling catheter, adding more than three medications during admission and having an abnormal sodium level during admission. CONCLUSIONS Multiple risk factors for incident delirium exist; patients with a history of delirium, dementia and cognitive impairment are at greatest risk of developing delirium during hospitalisation. RELEVANCE TO CLINICAL PRACTICE Nurses and other healthcare professionals should be aware of patients who have one or more risk factors for incident delirium. Knowledge of risk factors for delirium has the potential to increase the recognition and understanding of patients who are vulnerable to delirium. Early recognition and prevention of delirium can contribute to improved patients safety and reduction in harm.

A systematic review of the effectiveness of current interventions to assist adults with heart failure to comply with therapy and enhance self-care behaviours.

Background Heart failure is a common chronic disease that is one of the leading causes of hospitalisations in many countries around the world. Poor compliance with recommended self‐care behaviours, for example managing medication and diet regimes, rather than the deterioration of the cardiac condition, have contributed to a significant proportion of heart failure exacerbations. Patients with heart failure can benefit from interventions that aim to increase their knowledge of the disease and support them in managing their care. There is a need, however, to determine which interventions, if any, are more effective in achieving the aims of self‐care. Objective This review examined the evidence to answer the question: What are the most effective interventions for helping adults with heart failure comply with therapy and enhance self care behaviours? Inclusion criteria Types of participants This review focused on adults (aged 18 years and over) diagnosed with heart failure. Types of interventions The review considered studies that evaluated interventions aimed to help people with heart failure to improve self‐care behaviours. Types of studies Randomised control trials, quasi‐randomised designs and pre‐test post‐test studies were included in the review. Types of outcomes The primary outcome measure was improvement in actual self‐care behaviours, including adherence to medications, maintaining a healthy diet, daily weighing, reducing salt intake, recognising symptoms and contacting health professionals when assistance may be required. Search Strategy The search sought to identify published and unpublished, English language studies from 1990 until 2010. Databases searched included Medline, EMBASE, CINAHL, PsycInfo, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews & JBI COnNECT, PubMed, Informit ‐ Health Collection, MEDNAR, Dissertations & Theses, and Google Scholar Methodological Quality Two independent reviewers independently used the standard critical appraisal tool, from the Joanna Briggs Institute, to assess the methodological quality of studies that matched with inclusion criteria. Data Collection The process of data extraction was undertaken independently by two reviewers using tools from the Joanna Briggs Institute Meta analysis of Statistic Assessment and Review Instrument. Data Synthesis Appropriate data were pooled for meta‐analysis. The remaining studies were grouped according to outcome measures and type of intervention and presented descriptively. Results The review included thirteen studies; eight were randomised controlled trials and five were pre‐test post‐test studies. Conclusions The review confirmed that education alone is less effective than a combination of education and the use of personal diaries to promote daily weighing. There is some evidence to suggest that motivational interviewing has potential for use in the heart failure population and may be more beneficial than standard education. Furthermore education should be tailored to individual learning needs. Implications for practice Clinicians should ideally work with patients to encourage the use of tools to reinforce the importance of self‐care behaviours. Tailoring interventions to suit the individual is also beneficial. Implications for Research Interventions that promote efficacy in self‐care behaviours through empowerment should be investigated in future studies. Further research needs to also consider the impact of an intervention/s over an extended timeframe (e.g. more than 12 months) as the majority of the research focuses on short time periods (e.g. 3 months).

Nursing administration of medication via enteral tubes in adults: a systematic review

Background  Enteral tubes are frequently inserted as part of medical treatment in a wide range of patient situations. Patients with an enteral tube are cared for by nurses in a variety of settings, including general and specialised acute care areas, aged care facilities and at home. Regardless of the setting, nurses have the primary responsibility for administering medication through enteral tubes. Medication administration via an enteral tube is a reasonably common nursing intervention that entails a number of skills, including preparing the medication, verifying the tube position, flushing the tube and assessing for potential complications. If medications are not given effectively through an enteral tube, harmful consequences may result leading to increased morbidity, for example, tube occlusion, diarrhoea and aspiration pneumonia. There are resultant costs for the health-care system related to possible increased length of stay and increased use of equipment. Presently what is considered to be best practice to give medications through enteral tubes is unknown. Objectives  The objective of this systematic review was to determine the best available evidence on which nursing interventions are effective in minimising the complications associated with the administration of medications via enteral tubes in adults. Nursing interventions and considerations related to medication administration included form of medication, verifying tube placement before administration, methods used to give medication, methods used to flush tubes, maintenance of tube patency and specific practices to prevent possible complications related to the administration of enteral medications. Search strategy  The following databases were searched for literature reported in English only: CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO. There was no date restriction applied. In addition, the reference lists of all included studies were scrutinised for other potentially relevant studies. Selection criteria  Systematic reviews of randomised controlled trials (RCTs) and RCTs that compared the effectiveness of nursing interventions and considerations used in the administration of medications via enteral tubes. Other research methods, such as non-randomised controlled trials, longitudinal studies, cohort and case control studies, were also included. Exclusion criteria included studies investigating drug-nutrient interactions or the bioavailability of specific medications. Data collection and analysis  Initial consideration of potential relevance to the review was carried out by the primary author (NP). Two reviewers independently assessed study eligibility for inclusion. A meta-analysis could not be undertaken, as there were no comparable RCTs identified. All data were presented in a narrative summary. Results  There is very limited evidence regarding the effectiveness of nursing interventions in minimising the complications associated with enteral tube medication administration in adults. The review highlights a lack of high quality research on many important nursing issues relating to enteral medication administration. There is huge scope for further research. Some of the evidence that was identified included that nurses should consider the use of liquid form medications as there may be fewer tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastronomy tubes. Nurses may need to consider the sorbitol content of some liquid medications, for example, elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. In addition, the use of 30 mL of water for irrigation when administering medications or flushing small-diameter nasoenteral tubes may reduce the number of tube occlusions.