Article review and critical analysis

Nursing Critique

Today's nurses have a new, expanding and vital role to play in the delivery of optimal healthcare. Proactive, evidence-based nursing could drastically reduce adverse events in the clinical setting and improve the quality of care along the entire spectrum of care giving.

Successful implementation of this change would necessitate a revamp of the organizational structure and dynamics to permit smooth and effective communication and to create an environment where the nurse could participate more independently as well as in excellent coordination with other caregivers.

Healthcare has changed dramatically over the last decade or so and the changes in healthcare environment have placed new demands on the nurse. Aging population places severe stress on our hospitals and is in itself an increasing risk factor for adverse events. Nurses are no longer relegated to the role of supportive care but are expected to be actively involved in every stage of the care giving process by applying reflective and contextual thinking to improve the outcome for the patient. Critical thinking and its application into the nursing process is essential for the nurse to be innovative and efficient in her day-to-day responsibilities of care giving. The following discussion of three independent but relevant articles suggests that proactive and critical thinking are indispensable in modern nursing practice. A brief overview and a discussion of some of the important nursing issues focused in these articles would provide us a better perspective of the transforming role of the new age nurse.

Article review

Considine and Botti (2004)

Considine and Botti (2004) is an exhaustive review of literature that analyzed the occurrence of adverse events in hospitals and how proactive nursing practice could have prevented most of them. In this review work the authors provide several vital statistics obtained from previous research studies to highlight the existing shortcomings in nursing practice. One Harvard study, reported that 41% of Adverse Events are preventable and yet occur due to clinical negligence. [Leape et al., 1991] Another study reviewed in the article reported that proactive monitoring of patient vital signs when combined with immediate and effective interventions would have averted as much as 27% of hospital deaths. The authors explain that early recognition and identification of physiological abnormality is a very crucial aspect of nursing care and would affect the outcome for the patient significantly. The authors cite McGloin et al., a study that reported that 81% of patients who succumbed to sudden cardiac arrests had documented evidence of physiological abnormalities preceding cardiac arrest. Despite these abnormalities they were poorly managed. Similarly, 42% of patients who suffered cardiac arrests had documented evidence of altered consciousness prior to the attack. [McGloin et al., 1999]

The authors analyzed and reported several studies to clearly show that suboptimal treatment of physiological abnormalities is one big cause for the occurrence of adverse events in the clinical setting. For example, Schein et al. identified that 84% of patients who had cardiac arrests had at least one complaint in the 8 hours prior to the event, while 66% of patients were documented with abnormal vital signs 6 hours prior to a cardiac arrest. However, all these patients still had cardiac arrest, which goes to show that the interventions were totally lacking or rather delayed. [Schein et al., 1990] it is also concluded that the nursing staff who had documented these changes could not discern these changes as potential emergency situation. Buist et al. also reported respiratory distress for more than an hour preceding AE in 1/3 rd of the patients. [Buist et al., 1999]

The authors report that response to a physiological abnormality is quite varied among nursing staff. It is found that only 17% of staff nurse who notice changes in physiological parameters initiate MET (medical emergency team) action while almost 41.5% of nurses wait for medical advice from resident medical doctors. In other words delayed intervention is a big problem in a hospital setting, which tends to worsen the patient condition leading to an adverse event. For instance Crispin and Daffurn (1998) observed that medical intervention was delayed for more than an hour in 14. 3% of patients and for more than 3 hours in 8.9% of patients even though they had exhibited signs of physiological abnormalities that were classified as requiring immediate MET intervention. [Daffurn et.al, 1994]

Nurses' failure to initiate interventions quickly is a problem, which has to be focused more if we are to avoid many preventable AE. There are other inferences, which could be drawn from these observations. It is clear that some nursing staff may face organizational barriers which makes them hesitate in calling for the intervention of the emergency medical personnel for reasons of fear of disturbing senior staff, lack of self-confidence in observations, etc. Nurses should be trained and helped in developing confidence in themselves to initiate life saving interventions if the patient's parameters call for such an intervention. Though this article clearly identified the existing limitations and discrepancies and suggests a more dynamic role of the nurse in delivering optimal care it does not touch upon evidence-based nursing practice which is the growing trend in the new world of health care delivery.

Pipe et.al (2005)

This article by Pipe et.al (2005) describes the issues surrounding the implementation of evidence-based nursing practices in the clinical setting. Like Cosidine and Botti (2004) this article also stresses the vital role of the nurse in preventing adverse events and the need for a proactive nursing approach. Particularly, the researchers focused on the issue of using an 'early warning scoring system' to collect and detect abnormal patterns that could be used to trigger communication and facilitate decision making in the clinical setting. In this review of literature the authors cite previous research (knaus et.al, 1986) that reported that mortality in the ICU was directly associated with communication and coordination between the staff. It was found that time could also be used as a useful parameter for early identification of deterioration of the patient. One of the studies reviewed in the article suggests that developing a clinical pattern which could be followed to compare the actual changes in the patients' physiological parameters to the expected variations over time would improve the quality of nursing care. (Peden-McAlpine & Clark, 2002). A model for change into the evidence-based nursing practice is also briefly discussed in the article. [Rosswurm and Larrabee (1999)]

The authors also reviewed (Minick & Harvey, 2003) which had an in depth interview of 8 nurses in an urban hospital. This study reported that understanding the changing status of the patient's parameters outside the expected levels is very vital for effective nursing intervention. This particular study concluded "nurses learn subtle patterns from individual patients...as well as groups of patients...learning the subtle patterns of differences from patients is crucial to the early recognition of patient problems" (Minick & Harvey, 2003 p. 296). Mink and Harvey, 2003 also reported that in this particular case the nurses did not hesitate in asking for immediate physician intervention when they recognized the deviation of the patients' physiological data from the expected values and that physicians mostly responded positively to the recommended intervention without having to corroborate the data.

The authors of the study found that though such an early warning screening system would be very effective in promptly identifying the changing patient parameters and providing early interventions there was not much evidence suggesting the adoption of such a practice in a clinical setting. The main reason being the development of such a scoring system was thought impossible as it required an in depth knowledge of the patient which could not be adequately reflected in a simple scoring system. The authors concluded that effective and timely communication between the various care providers is crucial for delivering optimal care in a clinical setting. This study however suffers from the lack of consideration of organizational cultural parameters, which might inhibit the communication process between the nurses, doctors and other caregivers. It would be more appropriate if future studies that focus on this expanding new role of the clinical nurse also consider the different power structures and cultural dynamics within the hospital settings and suggest methods that facilitate easy and effective communication.

Ryan et al. (2006)

The research work by Ryan et al. (2006) is very relevant to current nursing practice as there is an increasing shift towards evidence-based nursing interventions. In this evolving nursing paradigm, the role of the Clinical-nursing specialist is paramount in improving clinical outcome. The results from the study clearly support this vital role of the clinical nursing specialist. Besides improving patient outcome, nursing experts also play an integral role in training other nursing personnel, which is crucial for increasing the overall standards of care provision. Also, since there is a distinct lack of research devoted to studying the impact of clinical nursing specialists on patient outcomes, the present study has important implications for nursing practice and nursing research. This is a quantitative research wherein the subjects are randomly chosen and data gathered from questionnaires at baseline and at regular intervals. The data gathered is subjected to statistical analysis using statistical methods of linear regression and chi square testing.

The main purpose of the study was to confirm the hypothesis that consultation with CNS or RN in a drug-monitoring clinic has a significant positive impact on the well being of patients with rheumatoid arthritis. The study involved a single blinded randomized controlled trial over a period of three years. Subjects were chosen from the rheumatology out patient setting in a district general hospital with a drug monitoring service. A total of 71 subjects who were starting out on anti-rheumatic therapy were randomly assigned to either the interventional or the control group. While the interventional group was supervised by the CNS to assess patient needs (using Pendelton's framework) alongside drug safety evaluation, the control group was seen by an outpatient staff nurse purely for drug safety concerns. Both the groups were assessed periodically for their scores on the Arthritis impact measurement scales (AIMS) and Rhematology Attitude Index (RAI) as well as the Disease Activity Score. The interventional group fared well in all these indexes during the course of the study and at the endpoint. The research has definite bearings for evidence-based nursing approach and the positive outcome of the study attests that the integration of clinical practice and scientific evidence is the key to improving the quality of health care. This study has clearly shown how evidence-based nursing could optimize treatment and outcome in a hospital outpatient setting. [Ryan et al., 2006]

The clinical implications are profound. The emergence of the nurse as a specialist caregiver creates a dynamic leap in terms of improving standards across the whole spectrum of health care. Evidence-based nursing approach is a vital link in bridging the existing chasm between advancements in medical technology and healthcare delivery. This research is relevant for nurse specialists as important members of the healthcare workforce who are more and more involved in evidence-based decision-making. Ultimately the research also impacts the patients as receivers of care as evidence-based medicine is the new platform of care delivery that calls for resource optimization at every level in the healthcare setting. This research is another supporting evidence to the cause of evidence-based practice, which the hospital administration should promote. This would also give new impetus for the nursing force as evidence-based nursing would motivate nurses and increase their job satisfaction. This is particularly important at a time when hospitals are struggling with high attrition rate and nursing shortage. The success of this study could be emulated in other clinical settings. This would involve a coordinated approach from the nursing staff, doctors and the hospital administration.