Dr Clair Merriman

Background

A changing nursing workforce and an increase in demands for care together with more complex care, raise arguments that leading and guiding nursing practice is more challenging than ever. Therefore, nurses need to have a shared agenda and a common language to show the importance of nursing care and the consequences of not addressing this in an appropriate way. In response to this the Fundamentals of Care framework was developed to also contribute to the delivery of person-centred care in an integrated way. However, to gain acceptance and applicability we need to ensure the framework's relevance to clinical practice from bedside nurses' perspectives.

Objective

To describe bedside nurses' perspectives on the Fundamentals of Care framework and how it can be applied in clinical practice.

Design

A descriptive qualitative design informed by the Fundamentals of Care framework.

Setting(s).

The study was undertaken at seven hospitals in Sweden, Denmark and the Netherlands during 2019.

Participants

A total sample of 53 registered nurses working at the bedside participated. Participants had a wide variety of clinical experience and represented a range of different nursing practice areas.

Methods

Twelve focus group interviews were used to collect data and analysed with a deductive content analysis approach.

Abstract

Background and Aims

Interprofessional simulation has the potential to enhance the perceived realism of clinical simulation in the education of different healthcare professionals. This study considers how the inclusion of more than one profession in clinical simulation contributes to this psychological fidelity, defined as the subjective perception of the realism of a simulation, and the cues identified by medical and nursing students.

Methods

Eight focus groups were carried out with 27 medical and 18 nursing students in Newcastle and Oxford, UK. These were carried out immediately after students' participation in simulation sessions consisting of three acute scenarios. Focus group discussions encompassed perceptions of the realism of the simulation and of participants' own and other professional groups. Thematic analysis was carried out on transcripts.

Results

The analysis identified features of psychological fidelity that were influenced by the interprofessional element of the simulation. These included overall impressions of realism, and the perceived roles and expectations of doctors and nurses within the simulation. In particular, the presence of the other professional group afforded a more authentic response. Other features varied with the viewpoint of the student groups, in particular the realism of the patient manikin, which held lower psychological fidelity for the nursing students, because it did not allow them to fulfill their perceived role of delivering holistic, relational care.

Conclusion

Recognizing “psychological fidelity” as a subjective response to simulation allows greater consideration of the limitations of fidelity as a designed or engineered property of a simulation. While interprofessional involvement directly enhances psychological fidelity in some ways, potential differences in the views of students from different professional groups should be considered when implementing interprofessional simulation.

Background: There is an active strategy to recruit international nurses and midwives to help
manage vacancy gaps in the United Kingdom’s healthcare system. However, there is little
evidence detailing how recruiting organisations prepare new recruits for the Objective
Structured Clinical Exam (OSCE) they are required to pass.
Aims and objectives: To gather and analyse feedback from recruiting organisations on the
preparation offered to international nurses and midwives on arrival in the United Kingdom, prior
to undertaking an OSCE in order to gain Nursing and Midwifery Council professional registration.
Design and methods: An online cross-sectional questionnaire. The data was analysed using
thematic analysis.
Results: Four main themes were generated from thematic analysis of the qualitative data: SAME
IDEAS DIFFERENT PRACTICE; PASSING THE OSCE; INDIVIDUALISED SUPPORT;
SUPPORT NETWORKS.
Conclusion: Differences in how organisations prepare and support international nurses and
midwives to undertake the OSCE suggest standardised approaches could benefit new recruits.
Impact statement: Addressing an evidence gap, this research suggests recruits may benefit from
standardised support around working and living in the UK.

Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19.Design: A qualitative interview study informed by constructivism.

Method: Semi-    structured interviews were conducted and audio- recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework.

Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short-  and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer 

Support.

Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an under-standing of the holistic and long-term impacts on patient safety and recovery from critical illness.

Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing work-force modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

Objectives: During the SARS-CoV-2 pandemic, clinicians were instructed to move all but emergency consultations to remote means to reduce the spread of the virus. The aim of this study was to evaluate patients’ and clinicians’ experiences of moving to remote means of consultation with their health care professionals during the SARS-CoV-2 pandemic. Methods: The study design was a qualitative service evaluation. Twenty-six clinicians and forty-eight patients who met the inclusion criteria consented to be interviewed. Clinician participants were from either medical, nursing, or allied health professional backgrounds. Patients were recruited from diabetes, acute care, and haematology and cancer areas. Data analysis was conducted using a thematic analysis framework. Results: Following coding and thematic analysis of the data collected from clinicians, five themes were identified: personal and professional well-being; providing a safe and high-quality experience; adapting to a new way of working; making remote consultations fit for purpose and an awareness of altered dynamics during consultation. Patient data was coded into 3 themes: remote consultation adds value; remote consultation brings challenges and concerns about remote consultation. Conclusions: Clinician and patient experiences reported here are reflected in the literature. The study indicates that remote consultation is not suitable for all patients and in all contexts. Whilst maintaining the benefits to patients, remote means of consultation needs organisational support and preparation. A way forward that maintains the benefits whilst addressing concerns seems urgent.

Rationale, Aims and Objectives

Ward rounds (WRs) are complex social processes. Done well, WR discussions and decisions contribute to timely, safe, effective progression of care. However, literature highlights medical dominance; marginalisation or absence of other perspectives, safety risks and suboptimal resource use. This study examined leadership behaviours and what supported good interprofessional WRs, defined as enabling interprofessional collaboration and decision making which progresses patient care in a safe and timely manner. Deepening appreciation of this art should support learning and improvements.

Method

Mixed-method appreciative inquiry (AI) into how WRs go well and could go well more often. Context: daily interprofessional consultant-led WRs in a large adult critical care unit. Data: ethnographic and structured observations (73 h, 348 patient reviews); AI conversations and interviews (71 participants). Inductive iterative analysis shaped by Activity Theory. Participants: 256 qualified healthcare professionals working in the unit.

Results

Leadership of good WRs supported (and minimized contradictions to): making good use of expertise and time, and effective communication. These three key activities required careful and skilled orchestration of contributions to each patient review, which was achieved through four distinct phases (a broadly predictable script), ensuring opportunity to contribute while maintaining focus and a productive pace. This expertise is largely tacit knowledge, learnt informally, which is difficult to analyse and articulate oneself, or explain to others. To make this easier, and thus support learning, we developed the metaphor of a conductor leading musicians.

Conclusions

Whilst everyone contributes to the joint effort of delivering a good WR, WR leadership is key. It ensures effective use of time and diverse expertise, and coordinates contributions rather like a conductor working with musicians. Although WR needs and approaches vary across contexts, the key leadership activities we identified are likely to transfer to other settings.

Done well, ward rounds (WRs) promote effective, safe care and collaboration; but WR quality varies. An improvement-focused appreciative inquiry (AI) into a large intensive care unit’s WR practices identified a pivotal axis of collaboration between the most senior medical role (the consultant) and the bedside nurse (BSN). This paper examines that axis of interprofessional collaboration (IPC) to deepen understanding of its implications. Data included ethnographic observations, interviews, and co-constructed AI with groups of staff. Four key concepts emerged from cyclical interpretive analysis: “need,” “presence,” “ability” and “willingness.” BSNs and consultants needed the interprofessional WR to enable their work; WR effectiveness was affected by whether they were both present, then able and willing to participate in IPC. BSN presence was necessary for effective and efficient IPC between these key roles. Indirect contributions, based on prior exchanges with colleagues or through written notes, reduced the joint problem-solving through discussion and negotiation that characterizes IPC to less efficient asynchronous interprofessional coordination. Factors affecting “presence,” “ability” and “willingness” are discussed alongside potential mitigations and acknowledgment of asymmetric power. Appreciative examination of interprofessional WRs identified mechanisms supporting and undermining effective WR IPC and the centrality of consultants’ and BSNs’ collaboration.

Background.
Registered nurses perform numerous functions critical to the success of antimicrobial stewardship, but only 63% of pre-registration nursing programmes include any teaching about stewardship. Updated nursing standards indicate that nurses require antimicrobial stewardship knowledge and skills.

Aim.
To explore the delivery of key antimicrobial stewardship competencies within updated pre-registration nursing programmes.

Methods.
This study had a cross-sectional survey design. Data were collected between March and June 2021.

Findings.
Lecturers from 35 UK universities responsible for teaching antimicrobial stewardship participated in this study. The provision of antimicrobial stewardship teaching and learning was inconsistent across programmes, with competencies in infection prevention and control, patient-centred care and interprofessional collaborative practice taking precedent over competencies pertaining to the use, management and monitoring of antimicrobials. Online learning and teaching surrounding hand hygiene, personal protective equipment and immunization theory was reported to have increased during the pandemic. Only a small number of respondents reported that students shared taught learning with other healthcare professional groups.

Conclusion.
There is a need to ensure consistency in antimicrobial stewardship across programmes, and greater knowledge pertaining to the use, management and monitoring of antimicrobials should be included. Programmes need to adopt teaching strategies and methods that allow nurses to develop interprofessional skills in order to practice collaboratively.

​​​​​​​Aims and objectives:

To explore patients’ and healthcare professionals’ views and experiences of a pre- and post-operative rehabilitation intervention (SOLACE) for patients undergoing surgery for early stage lung cancer.

Background:

Considerable post-operative complications can occur after surgery. A specialist lung cancer service (SOLACE) was developed to optimise health and fitness levels prior to and following lung cancer resections, as well as reducing morbidity and mortality, and improving the physical and psychological wellbeing of patients.  

Design:

The design was an exploratory, descriptive qualitative interview study.

Methods:

Seventeen lung cancer patients and eight healthcare professionals were recruited from a large teaching hospital in South England. Data was collected through semi-structured telephone and face to face interviews. Transcribed interview data was analysed thematically. The COREQ checklist was used to report on the study process.

Results:

The SOLACE service was positively perceived by patients and healthcare professionals. Patients valued the provision of tailored support/advice and peer support and reported benefits to their health and wellbeing. Barriers to patient uptake of the classes included time constraints, motivation and access for patients who lived at a distance.

Conclusions:

There is benefit in providing a personalised approach through a pre and post-operative rehabilitation service for lung cancer patients. Virtual support may address equality of access to service for those who live at a distance from the hospital.

Relevance to clinical practice:

Introduction of a pre and post-operative rehabilitation service provided by specialist peri-operative rehabilitation nurses and practitioners can yield positive outcomes for patients undergoing surgical treatment of early stage lung cancer. Engagement of key healthcare professionals, consideration of virtual follow up services and making patients aware of services could maximise patient uptake. Further consideration is needed of the best way to promote patient self-management and long-term continuation of patient rehabilitation in the community.

Keywords: lung cancer, pre-habilitation, rehabilitation, patient experience, surgery, qualitative

Purpose: In recent years there has been an increase in international nurses and midwives (trained outside of the European Economic Area) recruited to work in the UK. The aim of this review was to synthesise the most recent qualitative research exploring the experiences of international nurses and midwives as they transition and adapt to living and working in the UK.

Findings: A systematic literature search using the databases psycINFO, CINAHL, MEDline, Web of Science, as well as Google Scholar, resulted in six studies meeting the criteria of primary qualitative research published since 2010 and focussing on the UK as the host country. A lack of research into the experiences of midwives meant that the participants in each of these six studies were international nurses. The findings of these six studies were synthesised into 4 analytical themes: (1) Cultural integration; (2) Individual challenges; (3) Support networks, and; (4) Communication issues. Participants reported difficulties adapting to their new life in the UK, including within their role as a nurse, but also in finding and building positive relationships that would help to ease their transition. Instances of discrimination, an undervaluing of international nurses' skillset, and problems around communication were all detrimental to this process.

Summary: These studies are in line with earlier findings that suggest international nurses face a challenging integration process when recruited to work in the UK, indicating no improvement in international nurse experience. With an increasing number of international nurses being recruited to work in the UK, this review raises concerns based on the need to effectively support these nurses to successfully integrate into work and the wider society.

The 2016 All Together Better Health VIII Oxford conference brought together interprofessional education (IPE) and values-based practice (VBP) communities. As there is a paucity of research and publications in the area, following the event a working party consisting of representatives from both communities continued to meet and has developed a joint community of practice. This report describes the work achieved by the group so far and is intended for those involved in the planning and implementation of IPE and collaborative working. The authors consider that incorporating principles of VBP within a framework of IPE can provide a different perspective and understanding of the complexities involved in delivering realistic, student centered learning for collaborative practice, relevant in the 21st century workplace. In particular the authors suggest that using the principles of values and VBP in this way can inform the transition between IPE and collaborative practice facilitating effective person centered collaborative care. This process will require not only the incorporation of these principles within IPE sessions, but also incorporation within the training and support of new and established teachers involved in IPE.

Objectives. To investigate nursing and medical students’ readiness for interprofessional learning before and after implementing geriatric interprofessional education (IPE), based on problem-based learning (PBL) case scenarios. To define the optimal number of geriatric IPE sessions, the size and the ratio of participants from each profession in the learner groups, the outcomes related to the Kirkpatrick four-level typology of learning evaluation, students’ concerns about joint learning and impact of geriatric IPE on these concerns. The study looked at the perception of roles and expertise of the ‘other’ profession in interprofessional teams, and students’ choice of topics for future sessions. Students’ expectations, experience, learning points and the influence on the understanding of IP collaboration, as well as their readiness to participate in such education again were investigated.

Design. A controlled before–after study (2014/2015, 2015/2016) with data collected immediately before and after the intervention period. Study includes additional comparison of the results from the intervention with a control group of students. Outcomes were determined with a validated ‘Readiness for Interprofessional Learning’ questionnaire, to which we added questions with free comments, combining quantitative and qualitative research methods. The teaching sessions were facilitated by experienced practitioners/educators, so each group had both, a clinician (either geratology consultant or registrar) and a senior nurse.

Participants. 300 medical, 150 nursing students.

Setting. Tertiary care university teaching hospital.

Results. Analysis of the returned forms in the intervention group had shown that nursing students scored higher on teamwork and collaboration post-IPE (M=40.78, SD=4.05) than pre-IPE (M=34.59, SD=10.36)—statistically significant. On negative professional identity, they scored lower post-IPE (M=7.21, SD=4.2) than pre-IPE (M=8.46, SD=4.1)—statistically significant. The higher score on positive professional identity post-IPE (M=16.43, SD=2.76) than pre-IPE (M=14.32, SD=4.59) was also statistically significant. Likewise, the lower score on roles and responsibilities post-IPE (M=5.41, SD=1.63) than pre-IPE (M=6.84, SD=2.75).

Medical students scored higher on teamwork and collaboration post-IPE (M=36.66, SD=5.1) than pre-IPE (M=32.68, SD=7.4)—statistically significant. Higher positive professional identity post-IPE (M=14.3, SD=3.2) than pre-IPE (M=13.1, SD=4.31)—statistically significant. The lower negative professional identity post-IPE (M=7.6, SD=3.17) than pre-IPE (M=8.36, SD=2.91) was not statistically significant. Nor was the post-IPE difference over roles and responsibilities (M=7.4, SD=1.85), pre-IPE (M=7.85, SD=2.1).

In the control group, medical students scored higher for teamwork and collaboration post-IPE (M=36.07, SD=3.8) than pre-IPE (M=33.95, SD=3.37)—statistically significant, same for positive professional identity post-IPE (M=13.74, SD=2.64), pre-IPE (M=12.8, SD=2.29), while negative professional identity post-IPE (M=8.48, SD=2.52), pre-IPE (M=9, SD=2.07), and roles and responsibilities post-IPE (M=7.89, SD=1.69), pre-IPE (M=7.91, SD=1.51) shown no statistically significant differences. Student concerns, enhanced understanding of collaboration and readiness for future joint work were addressed, but not understanding of roles.

Conclusions. Educators with nursing and medical backgrounds delivered geriatric IPE through case-based PBL. The optimal learner group size was determined. The equal numbers of participants from each profession for successful IPE are not necessary. The IPE delivered by clinicians and senior nurses had an overall positive impact on all participants, but more markedly on nursing students. Surprisingly, it had the same impact on medical students regardless if it was delivered to the mixed groups with nursing students, or to medical students alone. Teaching successfully addressed students’ concerns about joint learning and communication and ethics were most commonly suggested topics for the future.

Aims

To report the results of a randomised controlled trial which explored the effectiveness of clinical simulation in improving the clinical performance of recognising and managing an adult deteriorating patient in hospital.

Background

There is evidence that final year undergraduate nurses may lack the knowledge, clinical skills and situation awareness required to competently manage a deteriorating patient in hospital. The effectiveness of clinical simulation as an educational strategy to teach the skills required to recognise and effectively manage the early signs of clinical deterioration needs to be evaluated.

Method

This was a two centre, randomised, controlled trial with single blinded assessments. Data were collected in July 2013. Ninety- eight first year nursing students were randomised either into a control group where they received a traditional classroom lecture, or an intervention group where they received simulation training. Participants completed a pre and post- intervention objective structured clinical examination. General Perceived Self Efficacy and Self-Reported Competency scores were measured before and after the intervention. Student satisfaction with teaching was surveyed after the teaching intervention.

Results

The intervention group performed significantly better in the objective structured clinical examination after their simulation training. General Perceived Self Efficacy and Self-Reported Competency were not correlated with performance. There was no significant difference in the post intervention General Perceived Self Efficacy and Self-Reported Competency scores between the control and intervention group. The intervention group were significantly more satisfied with their teaching method.

Conclusion

Simulation based education may be an effective educational strategy to teach nurses the necessary skills to effectively recognise and manage a deteriorating patient.

BACKGROUND: Clinical skill development is essential to nurse education. Clinical skills are frequently taught in higher education institutions using clinical simulation. It is unclear if clinical skills are subsequently consolidated and developed in clinical placements.

OBJECTIVES: The aim of this survey was to evaluate pre-registration student nurses perceptions of the frequency of opportunities to practise, the level of supervision and assessment of, clinical skills in their clinical placements.

DESIGN: This was a cross-sectional survey design using an online, self-report questionnaire including a Likert-type scale and open ended comments.

PARTICIPANTS: Four hundred and twenty one students, from all year groups, from a university in the south of England on a wide variety of clinical placements participated.

METHODS:

Participants evaluated the frequency of opportunity to practise, level of supervision and assessment of and feedback on performance of specific clinical skills. Clinical skills evaluated were measurement of vital signs, aseptic non-touch technique, assisting with eating and drinking, and assisting with comfort and hygiene. Data were analysed utilising Statistical Package for the Social Sciences Version 19.

RESULTS:

The frequency of opportunities to practise skills in clinical placement was variable with some participants reporting that they never had opportunity to practise essential skills. Similarly the level of supervision and assessment was also inconsistent suggesting that participants frequently practised clinical skills unsupervised without being assessed as competent.

CONCLUSIONS: Inconsistencies in clinical skill development may lead to graduates who are not work ready and as a result, insufficient clinical competence potentially leads to unsafe practice and poor patient care. This calls for stronger partnerships between educators and clinical areas and the prioritisation of mentor preparation and education as well as organisational support in terms of mentor workload planning.

Background.  In 1979, major changes in nursing affected nurse education and preparation for competence. In the following two decades, it became clear that nurses lacked clinical skills. This paper examines subsequent changes and asks the question whether this crucial shortcoming has now been remedied. This paper considers the background and context of change in nursing and nurse education in the 1980s. It looks at the new ideology, to prepare the ‘knowledgeable doer’ and examines the consequences of the change on nursing competency from the 1990s to the present day.

Methods.  This is a position paper. Professional policy documents from the English National Board for Nursing, Midwifery and Health Visiting, United Kingdom Central Council for Nursing, Midwifery and Health Visiting and Nursing and Midwifery Council, government reports and legislation on nursing and relevant nursing literature are examined and critically analysed and conclusions drawn.

Conclusions.  From 1923–1977, mandatory nursing syllabuses set by the General Nursing Council of England and Wales required the registered nurse to have acquired certain specific clinical skills. These were rigorously tested to an explicit standard set by the General Nursing Council before a nurse was awarded state registration. Twenty-five years later, the loss of this system for ensuring this competence and the implications of this loss, have been widely recognised. As a result, many nurse training institutions have introduced clinical skills laboratories, simulation of practice and the Objective Structured Clinical Examination. However, to the authors’ surprise and contrary to their initial expectations, the Nursing and Midwifery Council has not made these systems uniform or mandatory and so still has no way of ensuring all nurse training is producing safe nurses in the United Kingdom. The authors conclude that the untested educational ideology that brought root and branch change to nurse training in 1983 and which failed to produce nurses ‘fit for practice and purpose’ may still prevail.

Relevance to clinical practice.  The present paper demonstrates that United Kingdom nurse training still has no uniform and mandatory system in place to ensure, as far as is possible, that all registered nurses are clinically competent and safe to practice.