A nurse staffing model for an unprecedented event

Lessons learned from one hospital's COVID-19 experience.

Patient Care During Minimally Invasive Lateral Spine Surgery: 1.7 www.aornjournal.org/content/cme

Perioperative nurses care for patients undergoing a wide range of surgical procedures. One fast-growing surgical specialty is spine surgery performed using minimally invasive techniques. Patients may be candidates for minimally invasive spine surgery based on their presenting signs and symptoms and medical imaging test results. Open anterior and posterior surgical approaches to spine surgery are how surgeons traditionally have performed these procedures. However, new technology has enabled a minimally invasive lateral approach to the spine. This approach minimizes many of the risks and challenges associated with both the anterior and posterior approaches. Minimally invasive lateral interbody fusion requires the perioperative nurse to have a thorough understanding of the necessary patient positioning, spinal anatomy, and OR suite setup to ensure a safe and successful surgical experience for the patient.

Redefining Perioperative Advanced Practice the Nurse Specialist in Anaesthesia and Emergency Surgery

The development of the specialist nursing role was born out of an honest and clinically-driven review of the system that emergency patients experienced. The approaches taken during this review consistently returned facts that this pathway was less than optimal, and a great many improvements could be made. It is important to identify at this stage that simply adding more resources, i.e.: theatre space and beds, would not have improved the patient's experience. The pathway needed greater continuity and better co-ordination. This required a great deal of cooperation between clinical and managerial staff, including some fundamental re-examination of traditionally held beliefs about the role that perioperative nursing could have in managing this patient group. Part Two of the paper (Radford et al 2003) will present the details of how the development of this post challenged the care delivery system for emergency surgical patients. Particular reference will be made to the scope of practice, clinical and organisational impacts and future directions.

Understanding and Visualizing Multitasking and Task Switching Activities: A Time Motion Study to Capture Nursing Workflow

A fundamental understanding of multitasking within nursing workflow is important in today's dynamic and complex healthcare environment. We conducted a time motion study to understand nursing workflow, specifically multitasking and task switching activities. We used TimeCaT, a comprehensive electronic time capture tool, to capture observational data. We established inter-observer reliability prior to data collection. We completed 56 hours of observation of 10 registered nurses. We found, on average, nurses had 124 communications and 208 hands-on tasks per 4-hour block of time. They multitasked (having communication and hands-on tasks simultaneously) 131 times, representing 39.48% of all times; the total multitasking duration ranges from 14.6 minutes to 109 minutes, 44.98 minutes (18.63%) on average. We also reviewed workflow visualization to uncover the multitasking events. Our study design and methods provide a practical and reliable approach to conducting and analyzing time motion studies from both quantitative and qualitative perspectives.

Increasing operating room efficiency through electronic medical record analysis

We used electronic medical record (EMR) analysis to determine errors in operating room (OR) time utilisation. Over a two year period EMR data of 44,503 surgical procedures was analysed for OR duration, on-time, first case, and add-on time performance, within 19 surgical specialties. Maximal OR time utilisation at our institution could have saved over 302,620 min or 5,044 hours of OR efficiency over a two year period. Most specialties (78.95%) had inaccurately scheduled procedure times and therefore used the OR more than their scheduled allotment time. Significant differences occurred between the mean scheduled surgical durations (101.38 ± 87.11 min) and actual durations (108.18 ± 102.27 min; P < 0.001). Significant differences also occurred between the mean scheduled add-on durations (111.4 ± 75.5 min) and the actual add-on scheduled durations (118.6 ± 90.1 minutes; P < 0.001). EMR quality improvement analysis can be used to determine scheduling error and bias, in order to improve efficiency and increase OR time utilisation.

Compassion and Responsibility in Surgical Care

Ten nurses at a university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and physicians about being in ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The main theme in the narratives was being close to and moved by the suffering of patients and relatives. The nurses' responsibility for patients and relatives was expressed as a commitment to act, and they needed to ask themselves whether their responsibility had been fulfilled, that nothing had been left undone, overlooked or neglected, before they could leave the unit. When there was confirmation by the patients, relatives, colleagues and themselves that the needs of patients and relatives had been attended to in a morally and professionally satisfying manner, this increased the nurses' confidence and satisfaction in their work, and their strength to live with the burden of being in ethically difficult situations.

Central Line Placement for the Pediatric Oncology Patient: A Model of Advanced Practice Nurse Collaboration

Central lines are commonly placed in pediatric oncology patients during their therapy. Advanced practice nurses (APNs) play an important role in the coordination and facilitation of line placements so that they may be inserted in an expeditious manner. Collaboration between the Divisions of Oncology and Surgery is often key to attaining this goal. At the Children’s Hospital of Philadelphia, the APNs in Oncology and Surgery have developed a collaborative approach to the placement of central lines in oncology patients. Many positive changes ensued between these divisions after collaboration occurred and a system for line placements was put into place. A well-defined process for central line placement is currently being utilized that meets the needs of the patients. Central lines are being placed in a timelier manner, procedures are coordinated, and treatment is started earlier, which has increased the satisfaction of patients, families, and health care providers. Finally, this collaboration led to an improved relationship and better communication between the Divisions of Oncology and Surgery.

Just a routine operation: a critical discussion

This article has summarised a critical discussion of the human factors that contributed to the death of a patient from a failure to respond appropriately to a 'can't intubate, can't ventilate' scenario. The contributory factors included the clinical team's inability to communicate, prioritise tasks and demonstrate effective leadership and assertive followership. The film Just a routine operation has now been in circulation for several years. When a system is designed and introduced with the intention of making a change to clinical practice, it can quickly become just another component of an organisation's architecture and complacency around its use can develop. This article has been written specifically for perioperative practitioners to renew the debate around the human factors that contribute to patient harm. By critically discussing Just a routine operation and attempting to review why the incident occurred, this article has attempted to emphasise that some of the conditions and behaviours that contributed to the death of Elaine Bromiley may be latent within our organisations and teams, and may continue to contribute to failures that affect patient safety.

Regional uptake an variations in orthopaedic enhanced recovery pathways in knee and hip total arthroplasty

The use of enhanced recovery (ER) pathways for hip and knee arthroplasty has increased over the last decade, and the adoption within orthopaedics is becoming more common. We have demonstrated a regional variation and institutional inconsistency of uptake and delivery of ER pathways in our region. Units that have a unified pathway were more likely to have consistency in treatment and early analgesia for patients. We would advocate that units use an agreed enhanced recovery pathway to optimise patient recovery from hip and knee arthroplasties.

Part two: Qualitative research

This second article in the series Spotlight on Research focuses on qualitative research, its applications, principles and methodologies. It provides an insight into how this approach can be used within the perioperative setting and gives advice for practitioners looking to undertake a qualitative research study.

[Organization of nurses' work in day surgery]

Day surgery articulates strongly the dimensions of time, space and work organisation. This modifies the nursing practice itself, the visibility and the recognition of the tasks: maintaining the flow of the pathways, monitoring, informing the patient and seeing to their comfort.

How do perioperative nurses cope with stress?

In recent years there has been broad discussion on the nature of stressors experienced by members of "high risk" occupations and professions, for instance nursing and emergency workers, whose role is to support others through traumatic scenarios (Lam et al, 1999:23). Perioperative nursing is a major specialization in nursing practice in which there is an increased risk of exposure to traumatic events (Schwann, 1998:645). Moreover, the cumulative nature of critical events, if left undealt with that will potentiate attrition among nurses in the perioperative environment (Michael and Jenkins, 2001:39). This triangulated study using self-administered questionaires focused on how theatre nurses coped with contextual stressors in the work milieu. A purposive sample of 46 registered and enrolled nurses who worked at a major Brisbane hospital were asked to describe a recent stressful workplace event, and rate it using Horowitz's (1993) Impact of Event Scale (IES). Results indicated that nurses with the least general theatre experience, demonstrated the highest negative impacts. 25% of females demonstrated avoidance tendencies when stressed, while 83% of males used problem-solving strategies. Reactions following trauma among the nurses were predominantly negative, and included feelings of frustration and self-doubt. These findings support the eminent need for hospital organizations to take a more person-centered approach when dealing with workplace stress.

The impact of the enhanced recovery after surgery (ERAS) programme on community nursing

Early discharge from hospital as a result of enhanced recovery after surgery (ERAS) programmes can be both positive and frightening experiences for surgical patients. In a recently published article by the authors in the British Journal of Nursing, participants described mixed reactions to the ERAS programme, highlighting the period of home convalescence as being particularly challenging. In this article the concept of ERAS is explained, followed by an overview of the research study which led to the authors highlighting the issue of home convalescence. The interventions that have already been established locally as a result of this research are explored, as is the potential impact that both these short hospital stays and further necessary interventions might have on community nursing. The article examines whether health professionals are sufficiently easing the pressures of self-recoveryto fill the apparent'void' that the study participants described as existing between hospital care and community follow-up.

Surgical swab counting: a qualitative analysis from the perspective of the scrub nurse

The aim of the study was to conduct a qualitative exploration of the sociotechnical processes underlying retained surgical swabs, and to explore the fundamental reasons why the swab count procedure and related protocols fail in practice. Data was collected through a set of 27 semistructured qualitative interviews with scrub nurses from a large, multi-site teaching hospital. Interview transcripts were analysed using established constant comparative methods, moving between inductive and deductive reasoning. Key findings were associated with interprofessional perspectives, team processes and climate and responsibility for the swab count. The analysis of risk factors revealed that perceived social and interprofessional issues played a significant role in the reliability of measures to prevent retained swabs. This work highlights the human, psychological and organisational factors that impact upon the reliability of the process and gives rise to recommendations to address contextual factors and improve perioperative practice and training.

Decision-making models used by medical-surgical nurses to activate rapid response teams

Medical-surgical nurses were queried about the decision-making process used to request assistance from the rapid response team (RRT). Results indicated the type of process is correlated to the frequency of RRT calls made.

The challenge of creating a 'we're all this together' culture in Addenbrooke's theatres

In the wake of seven consecutive never events in theatres during 2011-2012, senior managers at Addenbrooke's had a challenge--to raise morale and support staff to fully support the WHO surgical safety checklist process. Theatres operations manager Maggie Ward and the theatres team took some innovative steps to change culture in theatres.

What's in my buckets today? Foreseeing and forestalling patient harm

Operating theatre teams work in an imperfect system characterised by time pressure, goal conflicts, lack of team stability and steep authority gradients between consultants and other team members. Despite this, they often foresee and forestall errors that could harm patients. The paper discusses the strengths and limitations of using Reason's three buckets model of error prevention as a framework for training operating theatre staff how to foresee and forestall incidents.