Wendy Chaboyer

Development of a theoretically derived model of resilience through concept analysis

Abstract Background: Resilience refers to a dynamic process that results in adaptation in the context of significant adversity (Margalit 2004). The concept of resilience has been of interest to various professional groups for many years; however, it is only recently that the nursing profession has begun to recognise its potential contribution in diverse clinical contexts. Objective: First, to identify current theoretical and operational definitions of resilience and second, to identify and describe defining attributes of resilience. Methods: The method of inquiry was guided byWalker and Avant’s (1995) approach to concept analysis. Findings: From this analysis, a conceptual model of resilience postulates that the constructs of self-efficacy, hope and coping are defining attributes of resilience. Discussion: Resilience appears to be a process that can be developed at any time during lifespan, and thus is not an inherent characteristic of personality. Further, the development of resilience is based on the synergy shared between individuals and their environments and experiences. Conclusions: Further theoretical clarification of the ways in which individuals transform stressful experiences into opportunities for increased growth may contribute to nursing knowledge in the form of better understanding of the resilience concept in the context of identifying strategies that build it.

Bedside handover: quality improvement strategy to "transform care at the bedside".

This quality improvement project implemented bedside handover in nursing. Using Lewins 3-Step Model for Change, 3 wards in an Australian hospital changed from verbal reporting in an isolated room to bedside handover. Practice guidelines and a competency standard were developed. The change was received positively by both staff and patients. Staff members reported that bedside handover improved safety, efficiency, teamwork, and the level of support from senior staff members.

A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study

BACKGROUND The past decade has seen increasing patient acuity and shortening lengths of stays in acute care hospitals, which has implications for how nursing staff organise and provide care to patients. OBJECTIVE The aim of this study was to describe the activities undertaken by enrolled nurses (ENs) and registered nurses (RNs) on acute medical wards in two Australian hospitals. DESIGN This study used structured observation, employing a work sampling technique, to identify the activities undertaken by nursing staff in four wards in two hospitals. Nursing staff were observed for two weeks. The data collection instrument identified 25 activities grouped into four categories, direct patient care, indirect care, unit related activities and personal activities. SETTING Two hospitals in Queensland, Australia. RESULTS A total of 114 nursing staff were observed undertaking 14,528 activities during 482h of data collection. In total, 6870 (47.3%) indirect, 4826 (33.2%) direct, 1960 (13.5%) personal and 872 (6.0%) unit related activities were recorded. Within the direct patient care activities, the five most frequently observed activities (out of a total of 10 activities) for all classifications of nursing staff were quite similar (admission and assessment, hygiene and patient/family interaction, medication and IV administration and procedures), however the absolute proportion of Level 2 RN activities were much lower than the other two groups. In terms of indirect care, three of the four most commonly occurring activities (out of a total of eight activities) were similar among groups (patient rounds and team meetings, verbal report/handover and care planning and clinical pathways). The six unit related activities occurred rarely for all groups of nurses. CONCLUSION This study suggests that similarities exist in the activities undertaken by ENs and Level 1 RNs, supporting the contention that role boundaries are no longer clearly delineated.

The impact of organisational and individual factors on team communication in surgery: a qualitative study.

BACKGROUND Effective teamwork and communication is a crucial determinant of patient safety in the operating room. Communication failures are often underpinned by the inherent differences in professional practices across disciplines, and the ways in which they collaborate. Despite the overwhelming international support to improve team communication, progress has been slow. OBJECTIVE The aim of this paper is to extend understanding of the organisational and individual factors that influence teamwork in surgery. DESIGN This qualitative study used a grounded theory approach to generate a theoretical model to explain the relations between organisational and individual factors that influence interdisciplinary communication in surgery. SETTING AND PARTICIPANTS A purposive sample of 16 participants including surgeons, anaesthetists, and nurses who worked in an operating room of a large metropolitan hospital in south east Queensland, Australia, were selected. METHODS Participants were interviewed during 2008 using semi-structured individual and group interviews. All interviews were recorded and transcribed. Using a combination of inductive and deductive approaches, thematic analyses uncovered individual experiences in association with teamwork in surgery. RESULTS Analysis generated three themes that identified and described causal patterns of interdisciplinary teamwork practices; interdisciplinary diversity in teams contributes to complex interpersonal relations, the pervasive influence of the organisation on team cohesion, and, education is the panacea to improving team communications. CONCLUSIONS The development of shared mental models has the potential to improve teamwork in surgery, and thus enhance patient safety. This insight presents a critical first step towards the development teambuilding interventions in the operating room that would specifically address communication practices in surgery.

Bedside nursing handover: A case study

A case study of six wards in two hospitals was undertaken to describe the structures, processes and perceptions of outcomes of bedside handover in nursing. A total of 532 bedside handovers were observed and 34 interviews with nurses were conducted. Important structural elements related to the staff, patients, the handover sheet and the bedside chart. A number of processes before, during and after the handover were implemented. They included processes for managing patients and their visitors, sensitive information, and the flow of communication for variable shift starting times. Other key processes identified were the implementation of a safety scan and medication check. The situation, background, assessment and recommendations approach was used only in specific circumstances. Perceived outcomes were categorized as improving accuracy and service delivery, and promoting patient-centred care. Although the move to bedside handover is not the norm, it reflects a patient-centred approach.

Multicentre study of delirium in ICU patients using a simple screening tool.

Traditionally, intensive care unit (ICU) delirium was viewed as benign and was under-diagnosed in the absence of ICU-appropriate screening tools. Research suggests that up to half of all ICU patients experiencing delirium will continue to do so after discharge to the ward, and half of those experiencing delirium in the ward will die within 1 year of delirium diagnosis. ICU-specific screening tools are now available. The purpose of this study was to identify the incidence of delirium in ICU and explore its associations to clinical factors and outcomes. A secondary aim was to evaluate the usefulness of the intensive care delirium screening checklist (ICDSC). A total of 185 patients in six ICUs in Australia and New Zealand were screened for delirium using the ICDSC over two 12-hour periods per day for the duration of their ICU admission. Some 84 patients (45%) developed delirium. Development of delirium was associated with increased severity of illness (acute physiology and chronic health evaluation--APACHE II--and sequential organ failure assessment--SOFA), ICU length of stay (LOS), and use of psycho-active drugs. Delirious patients showed no statistically significant difference in ICU and hospital mortality rates, nor prolonged hospital LOS. The ICDSC was found to be user-friendly. The incidence of delirium, observed characteristics and outcomes for patients admitted to Australian and New Zealand ICUs for > 36 hours without any history of altered mental state fell in the mid-range and were generally consistent with previous literature. An ICU-specific delirium assessment, such as the ICDSC, should be included in routine ICU observations to minimise under-diagnosis of this serious phenomenon.

Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis.

Background:Previous before-and-after studies indicate that the use of safety checklists in surgery reduces complication rates in patients. Methods:A systematic review of studies was undertaken using MEDLINE, CINAHL, Proquest, and the Cochrane Library to identify studies that evaluated the effects of checklist use in surgery on complication rates. Study quality was assessed using the Methodological Index for Nonrandomized Studies. The pooled risk ratio (RR) was estimated using both fixed and random effects models. For each outcome, the number needed to treat (NNT) and the absolute risk reduction (ARR) were also computed. Results:Of the 207 intervention studies identified, 7 representing 37,339 patients were included in meta-analyses, and all were cohort studies. Results indicated that the use of checklists in surgery compared with standard practice led to a reduction in any complication (RR, 0.63; 95% CI, 0.58 to 0.72; P < 0.0001; ARR, 3.7%; NNT, 27) and wound infection (RR, 0.54; 95% CI, 0.40 to 0.72; P = 0.0001; ARR, 2.9%; NNT, 34) and also reduction in blood loss (RR, 0.56; 95% CI, 0.45 to 0.70; P = 0.0001; ARR, 3.8%; NNT, 33). There were no significant reductions in mortality (RR, 0.79; 95% CI, 0.57 to 1.11; P = 0.191; ARR, 0.44%; NNT, 229), pneumonia (RR, 1.03; 95% CI, 0.73 to 1.4; P = 0.857; ARR, 0.04%; NNT, 2,512), or unplanned return to operating room (RR, 0.75; 95% CI, 0.56 to 1.02; P = 0.068; ARR, 0.52%; NNT, 192). Conclusion:Notwithstanding the lack of randomized controlled trials, synthesis of the existing body of evidence suggests a relationship between checklist use in surgery and fewer postoperative complications.

Transfer out of intensive care: A qualitative exploration of patient and family perceptions

OBJECTIVE To examine perceptions of ICU transfer held by patients and their family members, focusing specifically on those aspects of transfer perceived as difficult and those perceived as helpful. DESIGN Descriptive qualitative case study design. SETTING General ICU of a large regional Australian teaching hospital. PATIENTS A total of 7 patients and 6 family members were purposefully recruited at one-month post-discharge from hospital. Participants were selected for their ability to recall ICU transfer, the involvement of family members and their ability to articulate their experiences. MAIN OUTCOME MEASURES Two focus groups (one for patients and one for families) were conducted in the hospital setting, aimed at capturing the individual and collective perceptions of transfer out of intensive care. RESULTS Four themes emerged from the data that reflected the complex and emotional nature of transfer out of intensive care. These themes included (1) a sense of sudden abandonment (2) pervasive feelings of vulnerability and helplessness, (3) a loss of importance and (4) ambivalence about the experience. CONCLUSIONS The need for ICU nurses, ward nurses and affiliated healthcare professionals to provide emotional support throughout ICU transfer is the most significant implication of the study. Strategies to provide this support must be developed, implemented and evaluated.

Clinical handover of patients arriving by ambulance to the emergency department – A literature review

AIM To provide a critical review of research on clinical handover between the ambulance service and emergency department (ED) in hospitals. METHOD Data base and hand searches were conducted using the keywords ambulance, handover, handoff, emergency department, emergency room, ER, communication, and clinical handover. Data were extracted, summarised and critically assessed to provide evidence of current clinical handover processes. RESULTS From 252 documents, eight studies fitted the inclusion criteria of clinical handover and the ambulance to ED patient transfer. Three themes were identified in the review: (1) important information may be missed during clinical handover; (2) structured handovers that include both written and verbal components may improve information exchange; (3) multidisciplinary education about the clinical handover process may encourage teamwork, a shared common language and a framework for minimum patient information to be transferred from the ambulance service to the hospital ED. CONCLUSION Knowledge gaps exist concerning handover information, consequences of poor handover, transfer of responsibility, staff perception of handovers, staff training and evaluation of recommended strategies to improve clinical handover. Evidence of strategies being implemented and further research is required to examine the ongoing effects of implementing the strategies.

ICU nurses’ perceptions of discharge planning: a preliminary study

The role that intensive care unit (ICU) nurses could play in hospital discharge planning remains relatively unexplored. Using a case study, all ICU nurses in one hospital were surveyed about their perceptions of their role in the discharge process. Over 70% of the 58 nurses who responded thought that discharge planning was both appropriate in the ICU and not premature. However, several obstacles including patient acuity, time constraints and limited experience with this process were evident. While ICU nurses are aptly placed to manage discharge planning, they cannot be expected to undertake this important role without a systematic approach to its implementation.