Health Research Board Funded Programme of Research in Nursing Decision Making Phase 1 Study: Develop

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Health Research Board Funded Programme of
Research in Nursing Decision MakingPhase 1
Study Development of an Irish Nursing Minimum
Data Set

• Ms. Eilis Hayes
• Research Associate
• School of Nursing, DCU.

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• In 2002 the Health Research Board in Ireland
  granted funding for an innovative programme of
  research aimed at developing an Irish Minimum
  Data Set and investigating the nature of clinical
  judgement and decision making among nurses in
  Ireland.
• Collaborative programme between two Schools of
  Nursing Dublin City University (focus on mental
  health nursing) and University College Dublin
  (focus on general nursing)

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Aim Objectives of Study

• Explore how nurses in Ireland articulate their
  nursing contribution to care
• Focus and refine data to form the basis for an
  Irish Nursing Minimum Data Set
• Examine decision-making that underpins the
  nursing contribution to health and social care at
  individual, interpersonal and organisational
  levels

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Structure of Research Study

• First phase
• The development of an Irish Nursing Minimum Data
  Set (INMDS).
• Second phase
• The analysis of clinical judgement and decision
  making by nurses

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Phase 1 Nursing Minimum Data Set

• Defined as
• a minimum set of items of information with
  uniform definitions and categories concerning the
  specific dimension of nursing which meets the
  information needs of multiple data users in the
  healthcare system. It includes those specific
  items of information that are used on a regular
  basis by the majority of nurses in any care
  delivery setting. It is an abstraction, or tool,
  designed for the collection of uniform, standard,
  comparable, minimum nursing datafor use across
  various types of settings and patient groups
  (Werley, 1991, p. 422)

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NMDS method

• The NMDS method promises to tackle a key problem
  in nursing terminology
• If we cannot name it, we cannot control it,
  finance it, research it, teach it, or put it into
  practice
• (Clark Lang, 1992, p. 109)
• The validity of a NMDS is predicted on
  identifying and operationalising core elements
  of nursing practice

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Utilisation of NMDS

• National NMDS have been developed worldwide
• USA (Werley, Devine, Zorn, Ryan, Westra, 1991)
• Belgium (Sermeus Deleise, 1994)
• Switzerland (Berthou Junger, 2003)
• Australia (Gliddon, 1998)
• Netherlands (Goossen, 2000)
• Canada (Anderson Hannah 1993)
• Finland (Turtiainen et al 2000)
• Sweden, Brazil, Thailand,
• European (Mortensen, 1997)
• International (Goossen, Delaney, Coenen, 2003)

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Belgium NMDS

• Used by the Ministry of Health from 1988 for
  mandatory registration of nursing data by nursing
  staff in all Belgian hospitals
• Leading to a database of gt13 million inpatient
  days referring to 4 million patients in 2,500
  units
• Interventions predominately referred to physical
  care.
• The data inputs to workforce planning and the
  assignment of institutions nursing budget
• Data is presented in the form of a statistical
  fingerprint of the unit , comparing the unit
  with a baseline norm from the institution as a
  whole or comparable units elsewhere.

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The Irish Research Approach
development of INMDS

• 1. Focus Groups
• From both mental health and general nursing
  groups
• 2. Examination of Nursing Documentation
• From both mental health and general nursing
  records
• 3. Delphi Technique
• Series of questionnaires to rank the core nursing
  elements

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Focus Groups (Mental Health
Nursing)

• 10 focus groups
• Sites chosen from two health boards
• - Acute admissions
• - High Dependency Community Hostels
• Sample
• - N 59 Nurses
• Staff nurses (n30)
• Clinical Nurse Managers (n18)
• Clinical Nurse Specialists (n11)

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Focus Group Probes

• Perceptions of the nursing contribution to
  patient care
• Types of patient problems nurses deal with
• How nurses assess patients
• Frameworks used by nurses
• How nurses organise and deliver their care

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Findings (focus groups)

• Difficulty in articulating contribution
• Conceptualisation of contribution
• Patient assessment
• Patient problems
• Nursing interventions
• Patient outcomes
• Issues in/aspects of nursing

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Unique to mental health nursing

• Promotion of patient independence
• underpinned all nursinginterventions
• Communication a large factor in mental health
  nursing practice
• Transient nature of nursing practice
• Knowing the patient
• Non-threatening approach

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Examination of nursing documentation

• Aimed to investigate how mental health nurses
  document their contribution to patient care

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Documentary analysis Approach

• Data
• - three mental health settings
• - 43 patient records selected by staff
• (28 in-patient acute units
• 15 records from community)

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Patient Problems

• Mental Health
• Psychological 26
• Physical 12
• Social 18

• General
• Psychological 8
• Physical 30
• Social 5

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Sub categories divide into
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Co-ordinaton of care contd
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Other Findings

• Roper, Logan, Tierney Model used in most general
  and mental health hospitals and mental health
  community settings.
• Roy adaptation model used in one community mental
  health unit.
• Orem is used in one mental health hospital and in
  their community setting (high support hostel).
• Most hospitals organised their nursing care using
  a combination of the Primary Team Nursing
  approaches
• Nurses do not document all care activities
  danger of capturing only limited view of what
  nurses do through examining their nursing records

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Development of Delphi Survey

• Findings informed the development of the Delphi
  questionnaire and subsequent research

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Delphi Questionnaire Structure

• 1. Demographic profile 2. Patient Problems
  (38) 3. Nursing Interventions (27) 4.
  Co-ordination/Organisation of Care (10) 5.
  Outcomes of nursing care (11) 6. Qualitative
  response sections

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• Pre-testing the Delphi Survey
• Cognitive interviews
• 4 mental health and 3 general nurses
• One participant at a time
• Notes were taken by the researcher ease of
  completion, time take, questions skipped etc.
• Pilot study of nurses representing the sample
• 15 mental health nurses and 15 general nurses
• The nurses were asked to complete the survey to
  the best of their ability and they were given a
  sheet on which they could make comments on the
  usability and ability of the survey to capture
  the required data

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Sample 650 mental health and general nurses
working in a number of pre-selected sites in both
rural and urban healthcare settings in Ireland
The sample used for Round 1 of the study
consisted of 304 mental health nurses and 346
general nurses 279 mental health nurses and
290 general nurses were available to complete the
survey i.e. they were not on leave at the time of
data collection.
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Sites
Mental Health Nursing - acute and community
mental health services offered by three hospitals
operating in the Greater Dublin Area and four
hospitals operating in rural locations in
Ireland General Nursing the sites included
three large teaching hospitals in an urban
location and one district hospital in a rural
location. Within each of the hospitals staff were
sampled from a combination of cardiology,
oncology, medical, surgical, orthopedic and ear,
nose and throat units
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Rating Method

• Items rated using a 7 point Likert scale
• - Round One Importance and Frequency
• - Round Two Relevance
• - Round Three Agreement
• Response Rates
• - Round One 58
• - Round Two 72
• - Round Three 64

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• Delphi Analysis
• Items that were strongly endorsed in Rounds One
  and Two of the Delphi were grouped together as
  core to nursing activity i.e. that they were
  occurring frequently, that they were important
  and relevant to nursing care
• Items that were not so strongly endorsed in
  Rounds One and Two of the Delphi were grouped
  together to illustrated that there was agreement
  among nurses that those items were not core to
  nursing activity
• Newly proposed items were included based on
  feedback given through the qualitative section of
  the survey

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Consensus achieved on items identified as core to
both geeneral and mental health nursing include

• Physical Problems
• Nutrition
• Negative physical side effects from treatments
  /medications
• Psychological problems
• Mood (e.g. low mood, low self esteem, low self
  worth, mania)
• Anxiety or fear in response to current stressors
  (e.g. illness, bereavement, fear of dying)
• Social problems
• Level of social support received from significant
  others (e.g. shortfall in support, caregiver
  stress, social isolation, loneliness)
• Physical Intervention
• Administration of medication, fluids and/or blood
  products (e.g. IV, Oral, IM, SC, NG, PR
• Hygiene

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Consensus achieved on items identified as core to
both geeneral and mental health nursing include

• Psych Interventions
• Developing and maintaining trust
• Providing client with information about illness
  or treatment
• Coordination activities
• Acting as a facilitator for family or significant
  other and multidisciplinary team
• Client support activities (e.g. facilitating
  treatment outside the hospital or unit and/or
  arranging appointments, weekend pass)
• Outcomes of care
• Key social indicators of the quality of care
  provided
• General indicators of the quality of care

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• Core items endorsed by Mental Health Nurses only
• Non-adherence to a treatment or medication
• Negative psychological side effects of
  medications
• Substance dependence or misuse
• Work in relation to social skills
• Core items endorsed by General Nurses only
• Administration of medication, fluids and/or blood
  products (e.g. IV, Oral, IM, SC, NG, PR)
• Monitoring, observing, and evaluating physical
  condition (e.g. vital signs, specimen collection,
  judgements of physical state)
• Controlling pain
• Insertion, monitoring and care of medical devices
  and equipment
• Hygiene (e.g. changing, washing, bathing, mouth
  care, eye care)

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Comments on Delphi findings to date

• Mental health nurses report a diverse set of
  clinical concerns and roles
• Physical problems and interventions were rated
  fairly low across mental health nursing
  respondents
• More similarities were noted between hospital
  based mental health nurses and general nurses
  across physical items than were noted between
  community based mental health nurses and general
  nurses

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Development of the INMDS
instrument
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Next steps in the development of the
INMDS

• Refinement of tool and preparation for testing
• Commencement of piloting and validation of tool

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Research Team

• DCU Team UCD Team
• Professor Anne Scott Professor Pearl
  Treacy
• Co-Director
  Co-Director
• Principal Investigator
• Dr. Padraig Mac Neela Dr. Abbey Hyde
• Mr. Gerard Clinton Dr. Michelle
  Butler
• Ms. Melissa Corbally Ms. Anne Byrne
• Ms. Pam Henry Mr. Jonathon
  Drennan
• Ms. Roisin Morris Dr. Kate Irving
• Dr. Anne Walsh Ms. Niamh
  Frawley
• -Daneshmandi