Better documentation improves patient care

Midwives' perspectives about using individualized care plans in the provision of immediate postpartum care in Uganda; an exploratory qualitative study

INTRODUCTION

Individualized care planning has been slowly integrated into practice in Uganda with minimal documentation of how the concept is applied in providing care. This study explored the perceptions of midwives about the use of individualized care plans (ICPs) in the provision of immediate postpartum care.

METHODS

An exploratory descriptive qualitative approach was used in this study. We interviewed fifty midwives from 37 health facilities in Uganda's greater Mpigi region. The midwives, who were certificate and diploma holders, were purposively enrolled in the selected facilities. Deductive content analysis was done based on the COM-B model.

RESULTS

Four themes emerged from the data namely; compatibility, motivation, opportunities, and the midwives' suggested strategies and targets for improved individualized care planning. The midwives were aware of individualized care planning and they utilized it in their provision of immediate postpartum care especially when assessing clients for risks, preparing clients for referral, caring for Human Immunodeficiency virus (HIV) exposed babies and their mothers, and educating/ supporting first-time mothers (automatic motivation). Having a good nurse-patient relationship, privacy, and ample time to care for the clients were noted as motivators for individualized care plan use, while poor documentation of care, high patient load, and perceived patients' lack of understanding of the complexities of illness in the immediate postpartum period were the barriers (social opportunity) identified by midwives to the use of individualized care planning.

CONCLUSION

There are still capability, motivation, and opportunity hindrances to the use of individualized care planning. Staff recruitment, training, and harmonization of the documentation forms may improve the use of care plans in the postpartum period.

Pediatric Nurses' Person-Centered Approach to Nausea Management in Children With Cancer

Background: Nausea is a problematic side effect of childhood cancer treatment. However, it is not clear what interventions and assessments pediatric oncology nurses make when caring for a child with nausea. A person-centered approach can illuminate nausea management in pediatric care. The aim was to investigate how pediatric nurses retrieve the patient's narrative, establish partnership, and document nausea in hospitalized children with cancer. Methods: Individual interviews with nurses were conducted and analyzed using deductive content analysis with the framework of person-centered care. Results: The pediatric nurses described retrieving the patient's narrative regarding their nausea by listening to and observing the child. The pediatric nurses tried to establish a partnership with the child by allowing previous knowledge and the child's own preferences guide the interventions that focus on decreasing the child's nausea. The pediatric nurses also documented the effect of the given interventions and described the child's nausea using subjective words. When planning for the child's care it was rare for the nurses to have a documented care plan, but they did review documentation of previously administered interventions to plan for future care. Discussion: The results highlight the pediatric nurses' willingness to listen to the child, but also emphasize the need to further include the child and the parents in the partnership and documentation of nausea management. Collaboration with the child and the parents contributes to higher quality care and a partnership with trust.

An integrative review of supportive relationships between child-bearing women and midwives

AIMS

To review and evaluate the literature on the factors related to developing supportive relationships between women and midwives, including facilitators and barriers.

DESIGN

An integrative review.

METHOD

The search used CINAHL, MEDLINE, Embase, EMcare, Maternity and Infant Care, PsycINFO, and Google Scholar from January 2009-June 2020. Two reviewers screened the eligible studies, and 2,399 records were identified. Quality was assessed with the mixed methods appraisal tool, and 14 articles were included.

RESULTS

The findings highlight that successful relationships require therapeutic communication, trust, respect, partnership, and shared decision-making. Supportive relationships improve women's satisfaction and birth outcomes, and continuity of care model is an enabling factor. Further research is required to understand supportive relationships in non-continuity of care models and when different cultural backgrounds exist.

Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department

AIMS AND OBJECTIVES

To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors.

BACKGROUND

The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors.

DESIGN

A prospective cohort study.

METHODS

The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013-December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies.

RESULTS

Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group.

CONCLUSION

Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture.

RELEVANCE TO CLINICAL PRACTICE

Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.

Medical Assistance in Dying: Patients', Families', and Health Care Providers' Perspectives on Access and Care Delivery

Background: Medical assistance in dying (MAID) became legal in Canada in 2016. Although the legislation is federal, each province is responsible for establishing quality care. Objective: To explore patient, family, and health care provider (HCP) perspectives on MAID access and care delivery and improve regional MAID care delivery. Design: Qualitative exploratory. Setting/Subjects: We interviewed 5 patients (4 met the legislated MAID criteria and 1 did not), 11 family members (4 spouses, 5 children, 1 sibling, and 1 friend), and 14 HCP (3 physicians, 4 social workers, and 7 nurses) from June to August 2017. Measurement: Semistructured interviews, content analysis, and thematic summary. Results: Patients, families, and HCPs highlighted access and delivery concerns regarding program sustainability, care pathway ambiguity, lack of support for care choices, institutional conscientious objection (CO), navigating care in institutions with a CO, and postdeath documentation. Patients and families expressed additional concerns regarding lack of ability to provide advanced MAID consent, and the requirement of independent witnesses on MAID request forms and consent immediately before MAID administration. HCPs were additionally uncertain about professional roles and responsibilities. Ten recommendations to improve regional MAID care and the resultant practice change are presented. Conclusion: Quality improvement (QI) processes are essential to devise an accessible dignified patient- and family-centered MAID program. Ensuring patient and family perspectives are integrated into QI initiatives will assist programs in ensuring the needs of all are considered in structuring and staffing a program that is accessible, easy to navigate, and provides dignified end-of-life care in supportive and respectful work environments.

Evaluating the Implementation of a Multi-Component Intervention to Prevent Surgical Site Infection and Promote Evidence-Based Practice

BACKGROUND

Published clinical practice guidelines on surgical site infection prevention are available; however, adherence to these guidelines remains suboptimal.

AIMS

The aim of this study was to evaluate the effectiveness and perceived benefits of intervention and implementation strategies co-created by researchers and clinicians to prevent surgical site infections.

METHODS

This mixed-method evaluation study involved an audit of nurses' wound care practices, followed by focus group and individual interviews to understand the perceived benefits of the intervention and implementation strategies. Descriptive statistical analyses were used to compare post-intervention audit data with baseline results. Deductive and inductive content analyses were undertaken on the qualitative data.

RESULTS

The audit showed improvements in using aseptic technique and wound care documentation practices following intervention implementation. Nurses perceived the change champion as effective in role-modelling good practice. Education strategies including a poster and using a scenario-based quiz were viewed as easy to understand and helpful for nurses to apply aseptic technique in practice. The instructions and education conducted to improve documentation were considered important in the success of the Wound Care Template implementation.

LINKING EVIDENCE TO ACTION

The integrated knowledge translation approach used in this study ensured the intervention and the implementation strategies employed were appropriate and meaningful for clinicians. Such strategies may be used in other intervention studies. The change champion played an important role in driving change and acted as a vital partner during the co-creation and the implementation processes. Ongoing education, audit and feedback became integrated in the ward nurses' routine practice, which has the potential to continuously improve and sustain evidence-based practice.

Use of Electronic and Paper-based Standardized Nursing Care Plans to Improve Nurses' Documentation Quality in a Nigerian Teaching Hospital

PURPOSE

To evaluate the effect of electronic and paper-based standardized nursing care plans (SNCPs) use on quality of nurses' documentation.

METHODS

Using quasi-experimental design, two wards were grouped into electronic and paper-based wards. Nurses were trained to use electronic- and paper-based SNCPs for care-planning and documentation. Data was collected before, 3, and 6 months postintervention and analyzed with SPSS version 20.

FINDINGS

There was improvement in documentation quality in the two wards after introducing SNCPs with higher quality scores in the electronic ward postintervention.

CONCLUSION

Providing SNCPs in electronic and paper formats is critical to improving nursing documentation.

IMPLICATION FOR NURSING PRACTICE

Adequate training and support for nurses are needed for successful implementation of SNCPs in electronic health records (EHRs) in developing nations.

The Status of Nursing Documentation in Slovenia: a Survey

Health documentation is a prerequisite for good and sustainable health and social care. It is especially important for patient involvement and their empowerment. A transition from paper to e-documentation together with the electronic patient record should be based on thorough knowledge of the current state of documentation and its usages. The main objective of this paper was to analyse which documents and work methods of documenting processes within nursing are being used within different environments. Furthermore, what are the main reasons for their discrepancies from theoretical approaches and best practices. The analysis is based on a survey carried out on all three levels of healthcare. The survey questionnaire consisted of 12 questions to which responded 286 nursing teams from community health centres, hospitals and retirement homes in Slovenia. The results point to diversity in documenting as well as lack of interoperability. This is reflected in a great number of different documents. All phases of the nursing process were being documented in only 31.8 % of cases. The main reasons for this can be attributed to work organisation, different definitions of data-set requirements and inadequate knowledge by nurses. Survey results pointed out a need for the renewal of nursing documentation towards a more uniform system based on contemporary health technologies.

How Does Managed Care Improve the Quality of Breast Cancer Care Among Medicare-Insured Minority Women?

PURPOSE

The aim of this study is to investigate if evidence-based clinical guidelines are implemented equitability among ethnic minority breast cancer patients using Medicare Advantage and investigate if presumed advantages of managed care over fee-for-service are greater for minorities than for Whites.

METHODS

Data from the Surveillance, Epidemiology, and End Results and Medicare were used to examine 70,755 women over age 65 diagnosed with early stage breast cancer between 2005 and 2009. Implementation of two clinical guidelines was assessed: receipt of radiation therapy after breast conserving surgery and estrogen receptor status documentation. Multilevel logistic regression and inverse propensity weighting controlled for confounding.

RESULTS

African Americans are still less likely than Whites to receive radiation therapy after breast-conserving surgery, whether they use Medicare fee-for-service (OR 95 % CI) = 0.90 (0.83, 0.98) or managed care (OR 95 % CI) = 0.87 (0.76, 1.00). Differences between receipt of radiation therapy by insurance plan type was nonexistent. Relative to FFS, the use of managed care improved the odds of having estrogen receptor status documented by 44 % in African Americans, (OR 95 % CI) = 1.44 (1.15, 1.83) and by 42 % in Latina patients (OR 95 % CI) = 1.42 (1.17, 1.78).

CONCLUSIONS

Compared to Medicare fee-for-service, ethnic and racial disparities among Medicare Advantage users were reduced. We observed fewer disparities, but not an elimination of disparities, among Medicare Advantage enrollees receiving breast cancer care with an organizational and patient component of care. This suggests managed care may still need to focus on minority patient empowerment and involvement in care.