Direct Care Nurses Research Articles

Delivering Person-Centered Care During a Pandemic: Stakeholder Perspectives

Person-centered care (PCC) is an approach to care that both nursing homes (NH) and assisted living (AL) communities strive to provide. PCC is a philosophy that recognizes knowing the person and honoring individual preferences. However, when COVID-19 emerged, the NH and AL environments were ground zero for infection spread and disproportionate numbers of deaths among residents. As a result, many practices changed dramatically in efforts to reduce the transmission of COVID-19 in these communities. The purpose of this symposium is to discuss several projects that can speak to the impact of the pandemic on stakeholder efforts to provide PCC. First, Dr. Roberts presents feedback from residents and family members on the challenges COVID-19 created for family involvement in care conferences. In the second study, Dr. Behrens examines focus group data from direct-care nurses on their perceptions of delivering PCC related to risk of harm to staff and residents. The third study presents the voices of activities professionals who were implementing a PCC quality improvement project to communicate resident preferences, which illustrates both the importance of PCC during the pandemic, but also the challenges implementing during the pandemic. Fourth, the Kansas PEAK 2.0 program used provider feedback to direct and inform program responses through components such as consistent staffing. Finally, Dr. Zimmerman presents qualitative data from over 100 AL administrators, medical, and mental health care providers on their experiences pivoting during COVID-19. Our discussant will explore the implications of these studies in terms of the future of PCC in residential settings.

Self-Efficacy: Nurses’ Perceptions of Caring for Patients Living with Diabetes

Introduction: Diabetes is an epidemic that affects over 415 million people worldwide. In the United States, the number of people diagnosed with diabetes is projected to triple to over 60 million by 2060. With this surge, the number of hospitalizations across the country has significantly increased. Direct care nurses play a vital role in the management of patients living with diabetes. The purpose of this research study was to explore and describe medical-surgical nurses’ perceptions of self-efficacy related to caring for patients living with diabetes. This study's guiding research question was: What are nurses’ perceptions on the influences that impact self-efficacy in caring for patients living with diabetes on a medical-surgical unit? Methods: Bandura’s Self-Efficacy Theory provided the conceptual framework of this study and guided the development of the interview questions and the analysis of the data. A qualitative descriptive design using a constant comparative analysis method, as described by Strauss and Corbin (1990), was utilized. A purposive, convenience sampling plan was used to recruit eight medical-surgical nurses from two acute care hospitals in the Southeastern United States. Results: Four major themes were revealed in this study: (a) educational preparation, (b) biases towards patients, (c) current clinical environment, and (d) patients’ behaviors affect nurses’ emotions. Additionally, six subthemes were identified. Discussion: This study's results may inform targeted interventions that promote improved self-efficacy among medical-surgical nurses resulting in optimal patient outcomes for people living with diabetes.

Nurse-to-Patient Ratios in Tele-Critical Care.

Nurse-to-Patient Ratios in Tele-Critical Care.

Direct care nurses’ perceptions of their roles in clinical research: An integrated review of the literature

To review the extant literature relevant to perceptions by direct care nurses toward clinical research endeavors. An integrative review guided by the socioecological model was conducted. Five databases were searched to identify relevant peer-reviewed articles; there was no limitation on publication date. The final sample (N=9) was systematically appraised. Numerous barriers to direct care nurses' ability to perform study activities on clinical research trials were encountered at all levels: (1) personal-comprehension, education, and training; (2) interpersonal-communication issues within or from the study team, failure to advocate for the patient; (3) organizational-lack of leadership support, knowledge, and time; and (4) community-insufficient guidance and oversight by research-governing bodies. Direct care nurses report numerous barriers to completing protocol-administered activities for their patients participating in clinical research. A dearth of robust research exists in describing the reasons for, or persistence of, barriers faced by direct care nurses to assisting with research, and there have been little to no interventions to address them. As translational research evolves and becomes more complex, there is the need to ensure both the care of clinical research participants and the integrity of the research. Direct care nurses are critical to this endeavor, and potential barriers they face may have significant ramifications for the research enterprise. Recognition of these barriers and eventual interventions designed to address them are needed.

Identifying the most important workplace factors in predicting nurse mental health using machine learning techniques

ObjectivesNurses are at a high risk of developing mental health problems due to exposure to work environment risk factors. Previous research in this area has only examined a few factors within nurses’ work environments, and those factors were not conceptualized with the goal of improving workplace mental health. The purpose of this study is to identify the most important work environment predictors of nurse mental health using a comprehensive and theoretically grounded measure based on the National Standard of Psychological Health and Safety in the Workplace.MethodsThis is an exploratory cross-sectional survey study of nurses in British Columbia, Canada. For this study, responses from a convenience sample of 4029 actively working direct care nurses were analyzed using random forest regression methods. Key predictors include 13 work environment factors. Study outcomes include depression, anxiety, post-traumatic stress disorder (PTSD), burnout and life satisfaction.ResultsOverall, healthier reports of work environment conditions were associated with better nurse mental health. More specifically balance, psychological protection and workload management were the most important predictors of depression, anxiety, PTSD and emotional exhaustion. While engagement, workload management, psychological protection and balance were the most important predictors of depersonalization, engagement was the most important predictor of personal accomplishment. Balance, psychological protection and engagement were the most important predictors of life satisfaction.ConclusionsRoutine assessment with standardized tools of nurses’ work environment conditions and mental health is an important, evidence-based organizational intervention. This study suggests nurses’ mental health is particularly influenced by worklife balance, psychological protection and workload management.

Nurses' Intent to Leave their Position and the Profession During the COVID-19 Pandemic.

The aim of this study was to describe the relationships between perceptions of the pandemic impact on clinical nurses' and nurse leaders' intent to leave their current position and the profession and the differences in pandemic impact and intent to leave variables based on background factors. There is much discussion and concern about the COVID-19 pandemic impact on nurses' health and the nursing workforce. More than 5000 nurses from a national sample participated in a cross-sectional, descriptive study. Participants rated their perceptions of the pandemic impact on their practice and their intent to leave their position and profession. Pandemic impact was rated high overall and was highest in nurses with 25+ years of experience and in managers/directors. Eleven percent of the total sample indicated they intended to leave their position, and 20% were undecided. Nurses who rated pandemic impact at the highest level had higher intent to leave their position. Of the respondents, less than 2% indicated they were leaving the nursing profession, whereas 8% were undecided. This is the 1st quantitative report of perceived level of pandemic impact on direct care nurses and nurse managers/directors at the time of this writing. The combination of those who intend to leave and those who are uncertain about leaving their positions could cause instability in the workforce if not reversed. Organizational attention to nurse well-being, work environment and staffing is imperative.

Workplace Predictors of Quality and Safe Patient Care Delivery Among Nurses Using Machine Learning Techniques.

Background:Working in unhealthy environments is associated with negative nurse and patient outcomes. Previous body of evidence in this area is limited as it investigated only a few factors within nurses' workplaces.Purpose:The purpose of this study was to identify the most important workplace factors predicting nurses' provision of quality and safe patient care using a 13-factor measure of workplace conditions.Methods:A cross-sectional correlational survey study involving 4029 direct care nurses in British Columbia was conducted using random forest data analytics methods.Results:Nurses' reports of healthier workplaces, particularly workload management, psychological protection, physical safety and engagement, were associated with higher ratings of quality and safe patient care.Conclusion:These workplace conditions are perceived to impact patient care through influencing nurses' mental health. To ensure a high standard of patient care, data-driven policies and interventions promoting overall nurse mental health and well-being are urgently required.

Setting the Research Agenda for Nursing Administration and Leadership Science: A Delphi Study.

The aim of this study was to identify and prioritize research topics for nursing administration and leadership science. Nursing administration and leadership research priorities should provide a framework for building the science needed to inform practice. The Association for Leadership Science in Nursing (ALSN) and American Organization for Nursing Leadership (AONL) Foundation (AONL-F) for Nursing Leadership and Education collaborated on a Delphi study. Initial input on research priority items were received from ALSN and AONL members. National experts participated in a 3-round Delphi study. Top-ranked priorities included: 1) nurses' health, well-being, resiliency, and safety in the workplace; 2) developing and managing a nursing workforce to meet current and future healthcare needs; 3) healthy work/practice environments for direct care nurses; 4) healthy work/ practice environments for nurse leaders; 5) quantification of nursing's value across the healthcare delivery system; and 6) nurse leader development and essential competencies. Researchers and funders should use these priorities to guide future studies.

Cultivating joy: Improving nurse resilience through use of a practice playbook

Purpose/aimsThe purpose of this study was to determine whether resiliency activities, compiled into a practice playbook designed for implementation by nurse leaders and self-initiation by clinical nurses, improves resilience in both the nurse leaders and direct care nurses who implement them. BackgroundEvidence indicates strengthening nurse resilience increases well-being, protects against burnout, improves retention and increases patient safety. MethodsA resilience playbook was assembled to include stress-reduction activities. Resilience was measured at baseline and after two phases during which participants engaged in leader-led and self-initiated activities. The Connor-Davidson Resilience Scale (CD-RISC) was used to measure resilience. ResultsA total of 118 nurses completed both phases; 17 leaders and 101 clinical nurses. A significant increase in mean CD-RISC scores was detected among those who participated in self-initiated activities (p = 0.01). Initiating or participating in leader-led activities did not positively impact resilience scores. Further, clinical nurses who participated in leader-led activities were not more likely to participate in self-initiated activities. ConclusionsThis study supports self-initiated resilience-strengthening activities as beneficial to nurses, but not leader-led initiatives. These results are especially important for nursing leaders as they strive to reduce burnout, improve nurse retention and achieve exceptional practice quality.

Acute and chronic fatigue in nurses providing direct patient care and in non-direct care roles: A cross-sectional analysis.

Nurses are at risk for work-related fatigue, which can impact their health, well-being, and job readiness. The purpose of this study was to examine the levels, types, and factors associated with fatigue in registered nurses (RNs) in direct patient care (DCRNs) and in non-direct patient care (non-DCRNs) roles. A cross-sectional survey was administered to 313 RNs. Measures included: Multidimensional Fatigue Symptom Inventory, Occupational Fatigue Exhaustion Recovery, Brief COPE, PROMIS® Global Sleep Disturbance, and Job Content Questionnaire. Acute fatigue levels in RNs were similar to those in diseased populations, and nearly 50% reported moderate/high levels of chronic fatigue. DCRNs reported higher levels of acute and chronic fatigue than non-DCRNs, but the differences were small and disappeared when accounting for other factors associated with fatigue including sleep disturbance, job strain, workplace support, maladaptive coping, and especially intershift recovery, which accounted for 20%-41% of fatigue variability. This study suggests that it may not be only nurses providing direct patient care who are at risk for acute and chronic fatigue. Intershift recovery may be particularly important in alleviating acute and chronic fatigue in nurses.

“Go back to your country”: Exploring nurses' experiences of workplace conflict involving patients and patients' family members in two Canadian cities

This study explores nurses' experiences of workplace conflict with patients and their family members, how it differs by ethnic/racial identity, and highlights the coping strategies engaged to lessen these conflicts. Using a qualitative research design, this study draws on phenomenology and in-depth interviews of 66 registered nurses and registered practical nurses from multiple sites in two Canadian cities to explore the experiences of nurses with multiple marginalized identities in relation to nurse-patient and nurse-patient's family member conflicts in direct care practice. The results show that horizontal conflicts, especially, ones involving nurses, patients, and their family members are quite pervasive in the nursing profession. Direct care nurses, especially, ethnic minorities relative to majority groups experience excessive physical assaults, verbal aggressive behaviors, racial stereotyping and discrimination, and sexual harassment from patients and patients' family members. Institutional support through policies and practices designed to de-escalate aggressive behavior from patients and their family members were identified as important support systems. We conclude that policies aimed at creating a safe and strong health-care system call for holding patients and th'eir family members legally responsible for uncivil and aggressive behavior against caregivers.

Contemporary Engagement Strategies for Nurse Leaders

It is irrefutable that nurse engagement is linked to patient outcomes and the patient experience. The literature demonstrates that nurses who are highly engaged invest more of themselves in their role, conduct their work with energy, are committed to their work with enthusiasm, and feel a profound connection to their employer. These attributes translate to quality care and positive patient outcomes. Engagement is not a new concept as an important strategy in building a satisfied, productive workforce in the nursing profession and others. As nurse demographics and work environments have evolved and changed, however, it is necessary to revisit what engagement looks like and how to foster it. Contemporary nurse leaders are challenged to adapt their practice to offset current threats to workforce engagement including changing demographics in the nursing workforce, hospital financial strain, nurse burnout and staffing shortages. This article discusses key strategies for nurse leaders to promote nurse engagement in the current health care climate. The voice of both nurse leaders and nurses in direct patient care are included and validate these strategies and the need to adopt and apply them. It is irrefutable that nurse engagement is linked to patient outcomes and the patient experience. The literature demonstrates that nurses who are highly engaged invest more of themselves in their role, conduct their work with energy, are committed to their work with enthusiasm, and feel a profound connection to their employer. These attributes translate to quality care and positive patient outcomes. Engagement is not a new concept as an important strategy in building a satisfied, productive workforce in the nursing profession and others. As nurse demographics and work environments have evolved and changed, however, it is necessary to revisit what engagement looks like and how to foster it. Contemporary nurse leaders are challenged to adapt their practice to offset current threats to workforce engagement including changing demographics in the nursing workforce, hospital financial strain, nurse burnout and staffing shortages. This article discusses key strategies for nurse leaders to promote nurse engagement in the current health care climate. The voice of both nurse leaders and nurses in direct patient care are included and validate these strategies and the need to adopt and apply them. Lori Armstrong, DNP, RN, NEA-BC, is CEO and chief clinical officer, Inspire Nurse Leaders, and adjunct professor at Drexel University College of Nursing and Health Professions in Philadelphia, Pennsylvania. She can be reached at [email protected] . Pamela Spivey, MSN, CCNS, RNC-NIC, CCFP, is certified leadership coach at the coaching and positive Psychology institute to Lead of Wellness/Resilience Program, Inspire Nurse Leaders and certified leadership coach Wake Forest, North Carolina. Michelle Doran, DNP, RN, NPD-BC, is professional development specialist at Massachusetts General Hospital and lead nurse planner at Elite Healthcare in Boston, Massachusetts.

The Missing Link: Exploring the History of Harm Reduction Nursing in Canada 1998-2018 to Provide Recommendations for Inpatient Mental Health Nurses.

Harm reduction is becoming integrated into the hospital setting, yet there is a dearth of published academic literature on the topic of harm reduction in mental health nursing practice. No results were found in a literature search focused specifically on harm reduction policies in the inpatient psychiatric settings using the databases CINAHL, Google Scholar, and PubMed. The purpose of this article was to provide a historical overview of harm reduction in Canadian nursing from 1998 to 2018. The aim was to help direct care nurses, educators, and administrators understand past and present trends and to identify future possibilities for integration in inpatient mental health care. A historical perspective was used to identify and explore Canadian harm reduction literature published from 1998 to 2018 to establish the significance to inform nursing practice. The exploration began with a brief description of outreach nursing in early Canada. Focus shifted to the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic of the 1980s and 1990s, on to the 2000s when a broader lens of harm reduction was adopted, looking beyond the goal of reducing sexually transmitted illnesses. Literature published in the mid-2000s focused on marginalized populations, highlighting the connection between ethical practice and harm reduction philosophy. At the beginning of the 2010s, the Canadian Nursing Association released position statements that explicitly identified the role of harm reduction in nursing practice. Toward the end of the 2010s, the opioid overdose crisis promoted harm reduction nurses taking a broader focus, entering the hospital settings.

Psychometric Testing of Family Centered Care (FCC) Instrument: A Mixed Methods Analysis of Pediatric Nurses and Their Workplace Perceptions of FCC

Background/purposeFamily-Centered care (FCC) is a model used in pediatric healthcare delivery wherein planning care for children incorporates the family, but questions remain whether there has been effective FCC implementation in practice. The purpose of this study was to examine the importance of FCC to pediatric nurses and their view of their organizations' support of FCC implementation. MethodA survey with FCC descriptor statements was distributed electronically to the Society of Pediatric Nurses. Direct care nurses (N = 132) responded to demographic questions including their education level and organization size, and 26 items rating the importance of elements of FCC in their care (as it applies to themselves) and in their organizations (as it applies to their hospital or organization) using a 5-point Likert scale. Open ended questions supplemented the survey to yield narrative comments to triangulate the findings. ResultsThe nurses' personal responses and their rating of their organizations were analyzed separately. The Cronbach alphas were 0.867 and 0.938, respectively. Factor analyses revealed the same three factors in the two foci of questions for (a) the nurse's own practice and (b) the organization's support of FCC: Philosophy of FCC, Implementation of FCC and Environment Variations of FCC. A qualitative process of narrative analysis added support to the factors with clarity in thematic triangulation. Additionally, there was a significant difference in the mean scores between nurses' personal responses and the mean scores for their organizations for all three factors (p = .000) and for self-reported FCC by nursing education to validate the utility of the tool. ConclusionsThis instrument quantified the importance of FCC to pediatric nurses and their workplace support of FCC and can be used in future studies to evaluate FCC.

The National Standard of Psychological Health and Safety in the Workplace: A Psychometric and Descriptive Study of the Nursing Workforce in British Columbia Hospitals.

In 2013, the Mental Health Commission of Canada created a National Standard that includes 13 workplace factors associated with employee mental health. This study (a) examined the psychometric properties of Guarding Minds at Work (GMW), the instrument used to measure the Standard's 13 workplace factors and (b) assessed BC nurses' workplace risk factors. A province-wide survey study of 3,077 direct care nurses working in acute care settings was conducted. Subscale internal consistencies were acceptable. For most items, the original alphas were greater than the alpha-if-item-deleted. All corrected item-subtotal correlations were moderate to high. The 13-factor structure showed an adequate model fit based on absolute fit indices (SRMR = 0.057 and RMSEA = 0.054) but the relative fit indices were lower than the recommended cutoff (CFI = 0.827 and TLI = 0.815). Nurses identified nine of the 13 GMW factors as serious or significant concern in their workplace. The findings were consistent with a plethora of evidence pointing to shortcomings in nurses' work environments. This was the first study partially supporting the reliability and validity of the GMW. More work is required to refine the GMW and gain a better understanding of its psychometric properties.

Does the Type of Exposure to Workplace Violence Matter to Nurses' Mental Health?

Workplace violence is a prevalent phenomenon in healthcare, particularly among nursing professionals. Exposure to workplace violence may be direct through firsthand involvement, indirect through secondhand witnessing, or both. Even though implications for victims of workplace violence have been well-studied, less is known about the various types of exposure and their effects on nurse mental health. The purpose of this study is to examine the impact of workplace-violence exposure types on the mental health of nurses, while accounting for the intensity of the incident/s. This study employs an exploratory correlational design with survey methods. Nurses from British Columbia (BC), Canada, were invited by the provincial nurses’ union to complete an electronic survey in Fall 2019. A total of 2958 responses from direct-care nurses in acute-care settings were analyzed using logistic regression. The results showed that mental-health problems increased with cumulative exposure; even though nurses with solely indirect exposure to workplace violence did not report greater mental-health problems, those experiencing solely direct exposure, or both direct and indirect exposure, were two to four times more likely to report high levels of post-traumatic stress disorder (PTSD), anxiety, depression and burnout compared to their counterparts with no exposure. There is an urgent need for better mental-health support, prevention policies and practices that take into account the type of workplace-violence exposure.

Factors Affecting Post-Traumatic Stress of Nurses in Direct Care for COVID-19 Patients

Factors Affecting Post-Traumatic Stress of Nurses in Direct Care for COVID-19 Patients

Original Research: Nurses' Perspectives on Caring for Patients with Do-Not-Resuscitate Orders.

Confusion about what a do-not-resuscitate (DNR) order means, including its misinterpretation as "do not treat," has been extensively documented in the literature. Yet there is a paucity of research concerning nurses' perspectives on DNR orders. This mixed-methods study was designed to explore nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders. Direct care nurses on three units in a large urban hospital were asked to respond online to a case study by indicating how they would prioritize care based on the patient's DNR designation. These nurses were then invited to participate in open-ended interviews with a nurse researcher. Interviews were audiotaped, transcribed, and analyzed. A total of 35 nurses responded to the case study survey. The majority chose to prioritize palliative care, despite no indication that any plan of care was in place. Thirteen nurses also completed a one-on-one interview. Analysis of interview data revealed this overarching theme: varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Participants also reported perceived variances among health care team members, patients, and family members. Such misinterpretations resulted in shifts in care, varying responses to deteriorating status, tension, and differences in role expectations for health care team members. Nurses have opportunities to address misconceptions about care for patients with DNR orders through practice, education, advocacy and policy, and research.

Putting Restraint on Chemical Restraint: Exploring the Complexity of Acute Inpatient Mental Health Nurses' Experience of Chemical Restraint Interventions

While there is a growing body of research available on general restraint intervention in acute adult psychiatric settings, relatively little is known about nurses’ experiences of administering chemical restraint. The research question explored in this study was: what are mental health nurses’ experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? Through this Canadian study understanding of direct care nurses’ first-hand experiences of the use of chemical restraint interventions was sought. Eight adult acute inpatient mental health nurses were interviewed using hermeneutic phenomenological method. Two major themes that emerged from data analysis are explored to illuminate the existing tension between therapeutic, person-centred care and coercive control to maintain safety: taking control to maintain safety and working within constraints. Integral ways that nurses make meaning from administering chemical restraint were found, as well as some of the complex clinical and ethical decision-making aspects involved in psychiatric nursing care. Implications for practice, education, and policy are discussed. Research findings indicated a need for further focus on medication best practice, policy development and nurse education. These exploratory research findings can be used to both inform and challenge dominant inpatient mental health practice to guide nurses, health care leaders, and policy makers by increased understanding of the complex ethical decision making required for use of chemical restraint interventions.

Mealtime Care for People With Dementia: What Do Nursing Home Staff Think?

More and more people with dementia are living in nursing homes (NH). Often, they depend on NH staff for help with eating and drinking. It is important that staff have the skills and support they need to provide good care at mealtimes. This qualitative study explores mealtime care for people with dementia, from the perspective of NH staff. Semi-structured interviews with NH staff (n=16) were carried out in two nursing homes. The homes were chosen to have diverse characteristics: one home had a large number of beds and was part of a small local organization; the other had a small number of beds and was part of a large national organization. Various staff members were interviewed, including direct care staff, senior carers, nurses, managers, and kitchen staff. Interviews were audio-recorded and transcribed verbatim. A constant comparison approach was taken, so that data from early interviews were explored in more depth subsequently. From the analysis, five themes emerged as important in mealtime care for people with dementia living in nursing homes: Setting the right tone; Working well as a team; Knowing the residents; Promoting autonomy and independence; Gently persevering. This work forms part of a larger ethnographic study on the topic, which includes data from residents with dementia, and family carers. Results will inform the development of a staff training intervention to optimize mealtime care for this population.