Trevor Murrells

‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care

Background There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure—‘missed care’. Aim To examine the nature and prevalence of care left undone by nurses in English National Health Service hospitals and to assess whether the number of missed care episodes is associated with nurse staffing levels and nurse ratings of the quality of nursing care and patient safety environment. Methods Cross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England. Results Most nurses (86%) reported that one or more care activity had been left undone due to lack of time on their last shift. Most frequently left undone were: comforting or talking with patients (66%), educating patients (52%) and developing/updating nursing care plans (47%). The number of patients per registered nurse was significantly associated with the incidence of ‘missed care’ (p<0.001). A mean of 7.8 activities per shift were left undone on wards that are rated as ‘failing’ on patient safety, compared with 2.4 where patient safety was rated as ‘excellent’ (p <0. 001). Conclusions Nurses working in English hospitals report that care is frequently left undone. Care not being delivered may be the reason low nurse staffing levels adversely affects quality and safety. Hospitals could use a nurse-rated assessment of ‘missed care’ as an early warning measure to identify wards with inadequate nurse staffing.

The validity and reliability of methods to assess the competence to practise of pre-registration nursing and midwifery students.

This paper reports findings from a study funded by the National Board for Nursing, Midwifery and Health Visiting for Scotland to test selected nursing and midwifery clinical competence assessment tools for reliability and validity. The study, which took place over two years from July 1997, involved comparing items in the selected tools with statutory competencies for nurses and midwives, collecting assessment data from a sample of 257 nursing and 43 midwifery students in four educational institutions and administering additional assessment measures (the Nursing Competencies Questionnaire (NCQ) (Bartlett et al., An evaluation of pre-registration nursing education: a literature review and comparative study of graduate outcomes, Oxford Centre for Health Care Research & Development, Oxford Brookes University, Oxford, 1998) and the Key Areas Assessment Instrument-KAAI) to the total student sample (and to their lecturers and practice assessors) at two time points which were six months apart. Our focus was the programme-specific clinical competence assessment tools but by testing these tools we also provide evidence on the validity of other methods of competence assessment. Validity of the methods was assessed, primarily, by calculating multivariate and univariate correlation coefficients between them. The NCQ and KAAI were analysed for internal consistency. The NCQ and the versions of KAAI for lecturers and practice assessors were found to have good internal consistency. The version of the KAAI tool developed for students showed reasonable internal consistency for nursing students, but less consistency for midwifery students. Correlational analysis of data collected on students showed that there is little or no relationship between most of the clinical competence assessment methods in current use, or between these methods and those introduced by the research team. This finding supports previous research, particularly in medical education and confirms that the different methods address different abilities.A clear finding from this study is that no single method is appropriate for assessing clinical competence. A multi-method UK-wide strategy for clinical competence assessment for nursing and midwifery is needed if we are to be sure that assessment reveals whether or not students have achieved the complex repertoire of knowledge, skills and attitudes required for competent practice.

Assessing competence to practise in nursing: a review of the literature

Recent reforms of nursing education have led to calls for assessment of clinical performance to contribute to academic qualifications that incorporate professional awards. Questions then follow concerning the psychometric quality of methods available for assessing competence and performance and the ability of the methods to distinguish between different levels of practice. The purpose of this review of the literature is to analyse methods of assessing competence to practise in nursing and draw conclusions on their reliability and validity. The methods reviewed include questionnaire rating scales, ratings by observation, criterion-referenced rating scales, simulations including the objective structured clinical examination (OSCE), Benners model of skill acquisition, reflection in and on practice, self-assessment and multi-method approaches. Methodological challenges to competence assessment are raised. Findings of the review are as follows. Questionnaire rating scales used to assess competence in nursing have not been rigorously tested for reliability and validity. The methodological limitations of observation can be overcome with use of criterion-referenced scales or simulations such as the OSCE or its variations, as has been found in research on competence assessment in medicine. The Barts Nursing OSCE, designed for the end of the common foundation programme of the nursing diploma course, has promise because it provides a close simulation to real life and is grounded in an interpretive approach to skill acquisition. Reflection on practice using portfolios, learning contracts and self-assessment is valid if based on rigorous analysis of critical incidents rather than simple description. Reflective approaches have the advantage of being located in real-life settings and can integrate theory with practice but they need skilled collaboration between teachers, employers and practitioners. The conclusion is that a multimethod approach enhances validity and ensures comprehensive assessment of the complex repertoire of skills required of students in nursing.

Altered intestinal microbiota and blood T cell phenotype are shared by patients with Crohn's disease and their unaffected siblings

Objective Crohns disease (CD) is associated with intestinal dysbiosis, altered blood T cell populations, elevated faecal calprotectin (FC) and increased intestinal permeability (IP). CD-associated features present in siblings (increased risk of CD) but not in healthy controls, provide insight into early CD pathogenesis. We aimed to (1) Delineate the genetic, immune and microbiological profile of patients with CD, their siblings and controls and (2) Determine which factors discriminate between groups. Design Faecal microbiology was analysed by quantitative PCR targeting 16S ribosomal RNA, FC by ELISA, blood T cell phenotype by flow cytometry and IP by differential lactulose-rhamnose absorption in 22 patients with inactive CD, 21 of their healthy siblings and 25 controls. Subjects genotype relative risk was determined by Illumina Immuno BeadChip. Results Strikingly, siblings shared aspects of intestinal dysbiosis with patients with CD (lower concentrations of Faecalibacterium prausnitzii (p=0.048), Clostridia cluster IV (p=0.003) and Roseburia spp. (p=0.09) compared with controls). As in CD, siblings demonstrated a predominance of memory T cells (p=0.002) and elevated naïve CD4 T cell β7 integrin expression (p=0.01) compared with controls. FC was elevated (>50 μg/g) in 8/21 (38%) siblings compared with 2/25 (8%) controls (p=0.028); whereas IP did not differ between siblings and controls. Discriminant function analysis determined that combinations of these factors significantly discriminated between groups (χ2=80.4, df=20, p<0.001). Siblings were separated from controls by immunological and microbiological variables. Conclusions Healthy siblings of patients with CD manifest immune and microbiological abnormalities associated with CD distinct from their genotype-related risk and provide an excellent model in which to investigate early CD pathogenesis.

Survey of British clinicians' views on management of patients in persistent vegetative state

BACKGROUND The best care and management of patients in persistent vegetative state (PVS) has been the subject of sustained moral and legal debate for a number of years. However, the views of clinicians in the UK involved in caring for patients in PVS are largely unknown. METHODS A postal questionnaire was sent to 1882 consultant members of the British Association of Orthopaedic Surgeons, the Association of British Neurologists, the Society of British Neurosurgeons, and the British Society of Rehabilitation Medicine. Their views were sought on various aspects of the management and care of PVS, in particular the appropriateness of a decision not to treat and a decision to withdraw artificial nutrition and hydration (ANH). FINDINGS 1027 doctors responded (55%) of whom 558 (54%) had experience of managing patients in PVS. Over 90% of responding doctors considered that it could be appropriate not to treat acute infections and other life-threatening conditions. 65% of doctors considered that withdrawal of ANH could be appropriate. About two-thirds of doctors who thought treatment-limiting decisions could be appropriate thought that such decisions could be considered with the first 12 months of the patient being in PVS. Despite recent case law, less than half the doctors responding to the survey thought that an advance directive made by the patient should have a decisive influence in determining treatment-limiting decisions. Most doctors would like decisions about withdrawing ANH to be made in conjunction with family members and in accordance with agreed guidelines but without the need to go to court. INTERPRETATION There is a broad consensus among doctors that treatment-limiting decisions are sometimes appropriate for patients in PVS, irrespective of whether they have experience of the condition or of the specialty to which they belong. However, two thirds of doctors said that such decisions can be considered at a time earlier than that recommended by the British Medical Association. It is not clear why some doctors thought a decision not to treat could be appropriate while a decision to withdraw ANH would not be.

Is satisfaction a direct predictor of nursing turnover?: Modelling the relationship between satisfaction, expressed intention and behaviour in a longitudinal cohort study.

BackgroundThe theory of planned behaviour states that attitudinal variables (e.g. job satisfaction) only have an indirect effect on retention whereas intentions have a direct effect. This study uses secondary data from a longitudinal cohort of newly qualified nurses to test for the direct and indirect effects of job satisfaction (client care, staffing, development, relationships, education, work-life interface, resources, pay) and intentions to nurse on working as a nurse during the 3 years after qualification.MethodsA national sample (England) of newly qualified (1997/98) nurses (n = 3669) were surveyed at 6 months, 18 months and 3 years. ANOVA and MANOVA were used for comparison of mean job satisfaction scores between groups; intentions to nurse (very likely, likely vs. unlikely, very unlikely and unable to say at this stage); working (or not working as a nurse) at each time-point. Indirect and direct effects were tested using structural equation and logistic regression models.ResultsIntentions expressed at 6 months to nurse at 18 months were associated with higher scores on pay and relationships, and intentions at 3 years were associated with higher scores on care, development, relationships, work-life interface, resources, pay respectively. Intentions expressed at 18 months to nurse at 3 years were associated with higher scores on development, relationships, education and work-life interface. Associations with actual nursing were fewer. Those working as a nurse had higher satisfaction scores for development (18 months) and relationships (3 years). Regression models found significant associations between the pay and staffing factors and intentions expressed at 6 months to nurse at 18 months, and between pay and intentions to nurse at 3 years. Many of the associations between intentions and working as a nurse were significant. Development was the only job satisfaction factor significantly associated with working as a nurse and just at 18 months.ConclusionResults partially support the theory of planned behaviour. Intentions expressed by nurses are stronger predictors of working as a nurse than job satisfaction. Retention strategies should focus on identifying nurses showing early signs of departure with emphasis on developmental aspects, mentoring and support.

Returning to work after maternity leave UK nurses’ motivations and preferences

In the UK, the implementation of flexible working is seen as a key strategy in retention of nurses in the National Health Service (NHS) once they have children. However, Preference Theory argues that the majority of women returners are driven by motivations other than career or work, and that part-time workers are not as committed as full-timers, a perception held by some managers in the NHS. This article examines the motivations of 112 nurse returners after their first child, the differences between nurses returning part time or full time and between nurses preferring to work full time, part time or not at all.The findings suggest that neither hours worked nor preferred hours are good indicators of whether nurses are committed to work or a career, except for respondents who prefer not to work. The main differences are between nurses who would prefer not to work and all others.The findings that nurses returning part time at their preferred hours are motivated by their work and career challenge the view that they are not committed.The policy implications point to the importance of NHS organizations providing both flexible working and flexible career and training opportunities to retain returners’ commitment to nursing.

A randomised controlled trial comparing low dose vaginal misoprostol and dinoprostone vaginal gel for inducing labour at term

Objective  To compare the efficacy of low dose vaginal misoprostol and dinoprostone vaginal gel for induction of labour at term.

Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study

Objectives To examine associations between mortality and registered nurse (RN) staffing in English hospital trusts taking account of medical and healthcare support worker (HCSW) staffing. Setting Secondary care provided in acute hospital National Health Service (NHS) trusts in England. Participants Two data sets are examined: Administrative data from 137 NHS acute hospital trusts (staffing measured as beds per staff member). A cross-sectional survey of 2917 registered nurses in a subsample of 31 trusts (measured patients per ward nurse). Outcome measure Risk-adjusted mortality rates for adult patients (administrative data). Results For medical admissions, higher mortality was associated with more occupied beds per RN (RR 1.22, 95% CI 1.04 to 1.43, p=0.02) and per doctor (RR 1.10, 95% CI 1.05 to 1.15, p <0.01) employed by the trust whereas, lower HCSW staffing was associated with lower mortality (RR 0.95, 95% CI 0.91 to 1.00, p=0.04). In multivariable models the relationship was statistically significant for doctors (RR 1.08, 95% CI 1.02 to 1.15, p=0.02) and HCSWs (RR 0.93, 95% CI 0.89 to 0.98, p<01) but not RNs (RR 1.14, 95% CI 0.95 to 1.38, p=0.17). Trusts with an average of ≤6 patients per RN in medical wards had a 20% lower mortality rate compared to trusts with >10 patients per nurse (RR 0.80, 95% CI 0.76 to 0.85, p<0.01). The relationship remained significant in the multivariable model (RR 0.89, 95% CI 0.83 to 0.95, p<0.01). Results for surgical wards/admissions followed a similar pattern but with fewer significant results. Conclusions Ward-based RN staffing is significantly associated with reduced mortality for medical patients. There is little evidence for beneficial associations with HCSW staffing. Higher doctor staffing levels is associated with reduced mortality. The estimated association between RN staffing and mortality changes when medical and HCSW staffing is considered and depending on whether ward or trust wide staffing levels are considered.

The policy–practice divide Who has clinical supervision in nursing?

The role of the NHS in supporting qualified nurses is important for the development and retention of staff. Although there is a general perception that clinical supervision is beneficial and leads to better outcomes of patient care, most literature focuses on the main functions of the supervisory role, the interactions between supervisee and supervisor, or the supervisory process. There is limited large-scale empirical evidence on nurses’ receipt of clinical supervision or their perceived need of its various dimensions. This paper reports findings from a large-scale nationally representative sample of diplomate nurses who qualified between 1997 and 1998. Using Proctor’s model, it discusses the experiences of clinical supervision of 1,918 nurses in early career, 18 months after qualification, from the adult, child, learning disability and mental health branches. The findings show that the receipt of clinical supervision varied among the branches. Just over half of learning disability and mental health diplomates were receiving supervision, compared with approximately one-third of diplomates graduating from the adult and child branches. Sizeable proportions of nurses had never had a clinical supervisor in their current job. It is generally agreed that clinical supervision should enable the development of new skills through reflection on practice. However, many supervisees identified that they were not given the opportunity to do this in their supervision sessions. There was a perceived need for more supervision in these and other aspects. These findings are particularly important given the increased expectation of organisational support for staff development under Agenda for Change, a new pay and grading system introduced in 2004 throughout the NHS.