Experience of Novice Nurses with NIV in General Wards Essay

Experience of novice nurses caring patients with non-invasive ventilation in general wards.

ORDER  HERE A PLAGIARISM-FREE PAPER HERE

Non invasive ventilation (NIV) is used to provide respiratory pressure support to upper airway by using external masks without the insertion of endotracheal tube. It is mostly used for the early management of acute respiratory failure (ARF) (Rose and Gerdtz, 2009) and chronic obstructive pulmonary diseases (COPD) ( Penuelas, Frutos-Vivar & Esteban, 2007). NIV is considering less intensive than mechanical ventilation, therefore some clinicians manage these patients outside the intensive care unit (ICU), particularly in hospitals where ICU beds are unavailable (Farha et al., 2006, Hill, 2009). One audit report revealed that inappropriate use of NIV outside the ICU is associated with higher mortality (Sumner and Yadegafar, 2011). Its increasingly usage outside the ICU, lead less experienced nurses to care for these patients’ results in quality care compromised. Previous studies have identified the following factors that contribute towards treatment failure with NIV is lack of knowledge and experience about the regulation of NIV (Kallet, 2009, Lopez et al., 2006, Lopez-Campos et al., 2006, Elliott et al., 2011), inappropriate guideline (Sinuff et al., 2007), patient-ventilator asynchrony, poor judgment about the appropriate mask selection, patient intolerance (Hess, 2011) and delay in patient care at ward level (Elliott et al., 2011).Experience of Novice Nurses with NIV in General Wards Essay

Safe delivery of NIV can be assured when the patient received care from experienced, educated and well trained staff (Rose and Gerdtz, 2009). Previous studies had explored the experiences of experienced nurses worked in ICU and identified that experienced nurses are using their practical knowledge to select the appropriate mask to patient face. They are using their communication skills to gain control on patient breathing and using their clinical experiences to solve the problems and avoiding delays in adjusting the ventilation (Sørensen et al., 2013) and providing reassurance to immobilized patients and protect them from errors (Acebedo-Urdiales et al., 2014). There is another study that covers the perspectives of general ward nurses about the NIV, is not generalizable study because it was conducted only in one hospital. However, data revealed that 67% nurses didn’t get involved in the decision making process and were inadequately informed. Even they did not received adequate consultation from physicians and medical emergency team and mostly, all nurses in medical wards state that training was inadequate about the NIV (Cabrini et al., 2009). Most of the studies have viewed the experiences of competent nurses in ICU or general ward; however no study has explored the experiences of novice nurses caring the patient with NIV in general ward.Experience of Novice Nurses with NIV in General Wards Essay

Therefore, the purpose of my study is to explore the experiences of novice nurses caring the patient with NIV in medical ward. The one of the reason for selecting this topic is my own area of practice and my experience of being a novice nurse in medical ward in Pakistan. I remembered that when I was assigned with NIV patient, I really felt very anxious and worried. Because, I didn’t have any idea about the BIPAP machine like how it is operated, what assessment I need to do in patient condition to monitor the effectiveness of treatment. Sometime, I felt hesitate to consult with physician about the patient’s condition, because of my lack of knowledge, skills and training about the NIV. Therefore, some time I had a fear of harming to patient. My colleagues also had shared the same experiences and feeling with me.Experience of Novice Nurses with NIV in General Wards Essay

For literature search, I have used these electronic databases: CINAHL (15), PubMed (45), Embase (32) and Scopus (35). I have developed the keywords from Medical Subject Headings (MeSH) from each database. I have used these keywords for literature search: work experience; job experience; experience; experiential learning; nursing knowledge; nursing role; nurse-patient relations; job satisfaction, nursing practice; critical care nursing; education, nursing; staff nurses; nurse attitudes; decision making; nurse-physician relations evaluation; new graduates nurse; staff development, nursing care; nurses; novice nurses; respiration, artificial; noninvasive ventilation; noninvasive ventilation; non-invasive ventilation. Reference lists of relevant papers were also checked to identify other potentially relevant literature and take the assistance from nursing librarian. The inclusion criteria for each database were paper published in the English and between the periods of 1 January 2005 to 31 March 2015. I have also used the Boolean operators to limit my search results. The reason for such limitation is to get the relevant literature about my area of interest. Total number of paper which I get from each database is 127 documents. Once, I done with literature search, I started to read the abstract of each article and select the relevant and near relevant article to my research purpose and eliminate those which I found irrelevant. Out of 127, 26 articles were selected, review critically and develop themes like factors for NIV failure, lack of knowledge and skills etc .The difficulty which I faced during literature search was I cannot be able to remove the duplicate articles from each databases.Experience of Novice Nurses with NIV in General Wards Essay

As, no study has viewed the experience of novice nurses, therefore I would like to conduct the research build on this research question that “what are the experiences of novice nurses, while caring the NIV patients in general wards?” This study will explore the experiences of novice nurses and uncover the challenges which novice nurses are facing at intrapersonal, interpersonal or organizational level while caring the patient with NIV. Moreover, this study will highlight the need for staff training. Because, through proper training of staff, it’s eliminates those factors which contributed towards NIV failure in ARF patients and provides quality patient care. In these studies, novice nurse is defined as “nurses who are new graduates or have limited experience in nursing care particularly with NIV patients” (CINAHL). The reason for selecting the general wards setting is as my area of specialty in medical ward and most of the time, general wards staffs are less experienced and untrained comparatively to ICU staff.Experience of Novice Nurses with NIV in General Wards Essay

Non-invasive ventilation (NIV) has proven to be effective in acute respiratory illness of various etiologies in Intensive Care Units (ICU) and general ward/Unit settings. It is viewed as complementary to invasive ventilation and primarily a means of preventing some patients from deteriorating to the point at which intubation is needed. Benefits include the avoidance of endotracheal-tube-associated infections, reduction of morbidity and mortality, improvement in patient outcomes and a gross reduction in health care costs. Nurse staffing levels will continue to vary in ICUs, high dependency units or general wards but the intensity of nursing input will be much lower in the general wards than on the ICU, particularly at night. In developing countries with scarce technology and less ICU beds, NIV will be an asset in general wards for nurses who have adequate experience in caring for acutely ill patients. The most important ingredient for an acute NIV nurse led service is a welltrained enthusiastic ward team. This article highlights the factors that should be considered in providing an acute NIV nurse led service in general or acute care settings. Utilizing the Roper, Logan and Tierney nursing model, which focuses on patients as individuals, recommendations are made for best nursing practices based on 12 activities of living, promoting independence with quality of life and essential functions of living. Keywords: Non-invasive Ventilation, Non-invasive Positive Pressure Ventilation, Holistic Nursing Practice, Nurse’s Role, Roper, Logan and Tierney Model, Evidence Based Practice.

Limited intensive care beds have caused an increasing incidence of non-invasively ventilated patients in general wards, which require trainings on care of non-invasively ventilated patients. The objectives of study were to assess the nurses’ competence in caring for non-invasively ventilated patients before and after intervention, to identify the patient outcomes before and after intervention related to care of NIV patients and to identify the effect of intervention related to care of non-invasively ventilated patients on nurses’ knowledge, skills and attitude. A pretest, posttest design tested the effect of onsite trainings related to care of non-invasively ventilated patients on nurses’ competence (i.e., nurses’ knowledge, skills and attitude) and the patient outcomes, incidence of Hospital Associated Infection (HAI). Experience of Novice Nurses with NIV in General Wards Essay Following onsite trainings on care of non-invasively ventilated patients for 65 nurses from general wards, their knowledge, skills and attitude were assessed using questionnaires and Competency assessment tool. The hospital-associated infections in these patients were compared before and after training. The McNemar’s Test was used to find the association between the Pretest and Post test in areas of knowledge, skill and attitude. Chi Square method was used for analysis. The p value remained statistically significant (p=0.00 to 0.014), indicating a significant improvement in the nurses’ competency post intervention. There was an overall decreasing trend in the hospital associated infection rates over the posttests period. Regular trainings for general ward nurses may help them to become more competent in caring for the non-invasively ventilated patients, improving patient outcomes.Experience of Novice Nurses with NIV in General Wards Essay

Non-Invasive Ventilation (NIV) was an effective treatment for acute hypercapnic respiratory failure1. It is now increasingly used in the treatment of acute hypoxemic respiratory failure. A study done in a tertiary care centre, from Jan 2009 to Sept 2010, on medical ward patients (for whom the Rapid Response Team was activated for anoxygen saturation ≤90% and an respiratory rate ≥28), compared the patients on Bipap (Bilevel positive airway pressure) with those not on Bipap. Only 3% of the Bipappatients were intubated compared to the 18% of the non-Bipap patients. They concluded that the acute use of Bipap in medical wards will prevent intubation and does not adversely affect mortality2. Bipap is a beneficial therapy for children presenting with severe asthma exacerbation3.Experience of Novice Nurses with NIV in General Wards Essay

NIV is a therapeutic procedure for acute and chronic respiratory failure. There was a need to provide set standards and practical advice to nurses for caring for patients on non-invasive ventilation in the general wards. Facilities for NIV should be available 24 h per day in hospitals admitting such patients. A designated ward area with supervision by the respiratory team, trained staff and on-going teaching for medical and nursing staff was needed4. The unavailability of acute NIV services is an important issue, as this prevents the availability of facilities for invasive ventilation of deteriorating patients leading to increased mortality in ward settings especially when there were less intensive care beds5.Experience of Novice Nurses with NIV in General Wards Essay

Another benefit with noninvasive ventilation may be a reduction in nosocomial infections associated with its application. This was because averting endotracheal intubation also avoids a major risk factor for ventilator-associated pneumonia (i.e., the endotracheal tube). Experience in a case-control study suggested a reduction in nosocomial pneumonia from 22 to 8%, with fewer days in the ICU (Intensive Care Unit) and lower mortality (26% down to >4%) in those treated with noninvasive ventilation as opposed to those who received endotracheal intubation6. NIV has been shown to decrease the rate of Intubation/Intrathoracic unit admission by 66%, decrease mortality from 29 to 9%, decrease in Intrathoracic unit length of stay from 32 to 13 days and decrease in hospital length of stay from 35 to 23 days. Efficacy was also seen in patients with stable, although deteriorating, chronic hypercapnic respiratory failure secondary to respiratory pump dysfunction7. The concept that critical care is a service rather than a location has been increasingly highlighted in the same study.Experience of Novice Nurses with NIV in General Wards Essay

ORDER  HERE NOW

All over the world, the nurses lead intervention protocols that are evaluated through their impacts on patient outcomes. However, the studies have ignored the related nurses’ perceptions and views7. NIV facilities should be available 24 h per day in all hospitals to admit such patients. The unavailability of acute NIV services would mean less or no facilities available to invasively ventilate patients leading to the sure death of some patients especially during a shortage of intensive care beds4. Provision of ward based acute respiratory care improves patient outcomes and reduces hospital length of stay.Experience of Novice Nurses with NIV in General Wards Essay

A recent study in 2017 stressed that in order to enhance the feeling of safety among ‘home mechanically ventilated’ patients, nurses needed to work towards developing a trusting relationship with patients with their presence and attentiveness (in form of attitude); stay updated on current standards (knowledge) and provide competent, continuous nursing care (skill)8.

Despite numerous benefits of NIV, it is important that the nurses should be made aware that patients might start to deteriorate while on NIV. Progressive respiratory decompensation, cardio respiratory arrest and hypotension related to positive intrathoracic pressure (support with fluids) are few of the risks that may go unnoticed by the ward nurses, thinking that they were being safely managed by NIV6.Experience of Novice Nurses with NIV in General Wards Essay

A study that explored the factors that influenced the experience of competent nurses that cared for critical patients located in general wards, found that nurses felt panicky and nervous. The nurses admitted their lack of awareness of own training needs and that education needs to be ongoing. Nurses may feel they lack the skills and knowledge required to wean patients from ventilation and this needs to be addressed in formal education programs and in-service training9.

NIV, within both the ICU and the ward environment, has been shown in RCTs and systematic reviews to reduce intubation rate and mortality in COPD (Chronic Obstructive Pulmonary Disorder) patients with decompensated respiratory acidosis (pH<7.35 and PaCO2 >6 kPa) following immediate medical therapy. Ward studies have also shown a reduction in the need for ICU and reduced hospital costs compared to standard medical therapy. Mortality rates were reduced by approximately 50% (Mortality Relative Risk 0.52; 95% CI 0.35 to 0.76) 34, equating in usual clinical practice for a need to treat approximately 10 patients to save one life10.Experience of Novice Nurses with NIV in General Wards Essay

Besides, the high cost and limited resource environment such as ICU has resulted in the higher need for NIV interventions outside the intensive care. Wards with trained nurses and resources that provide NIV are an effective alternative to ICU admission. The lack of sufficiently trained nurses to provide 24 h cover, the seasonal disuse that causes down-skilling, particularly during the summer months when lesser patients were admitted and inevitable staff turnover are other issues that prevent competent care of NIV patients. The principles behind the practice of NIV are relatively simple and can be mastered quickly. The real problems relate to service delivery. The service needs to available 24 h per day. Nursing work practices, however, are based around shift work and therefore a sufficient cohort of interested staff needs to be trained in order to have a constant skill mix available7.Experience of Novice Nurses with NIV in General Wards Essay

Study variables: This includes Dependent and Independent variables:

Dependent variable

Nurses’ competence (This includes nurses’ knowledge, skill and attitude)
Patient outcomes (Measured by monthly incidence of HAI, Hospital Acquired Infections)
Independent variable

Onsite trainings related to care of non-invasive ventilation (NIV) patients
Study hypotheses

The nurses’ knowledge, skills and attitude after intervention related to care of NIV patients would be higher than their knowledge, skills and attitude before intervention
The NIV patient outcomes related to care of NIV patients will improve after intervention
Therefore the objective of study was:Experience of Novice Nurses with NIV in General Wards Essay

To assess the nurses’ competence in caring for NIV patients before and after intervention
To identify the patient outcomes before and after intervention related to care of NIV patients
To identify the effect of intervention related to care of NIV patients on nurses’ knowledge, skills and attitude
MATERIALS AND METHODS

The study was carried out in general wards of Dubai Hospital.Experience of Novice Nurses with NIV in General Wards Essay

Existing gaps in general wards of Dubai Hospital: The researchers assessed the existing gaps by observation, open-ended interview with the Nursing supervisors, Charge nurses (of concerned wards), intensivists (who cover the NIV patients in wards) and biomedical technicians. The gaps identified were:

Nurses’ knowledge on clinical signs of deterioration in the patients on NIV needs to be improved in general wards
Nurses in general wards needed to become competent in caring for NIV patients
Nurses did not understand the basic troubleshooting of the ventilating machine
Nurses in general wards were unable to do the basic blood gas analysis
Nurses lacked confidence in preparing for inter departmental patient transfer or power shutdown in general wards
Improper infection control practices related to care of NIV patients, machine and its accessories were followed in the general wards
Improper documentation in the nursing care plans
Existing supports in Dubai Hospital

The ventilator accessories and the consumable equipments are stored in the general wards and a portable ventilator placed in the hospital’s “Equipment Library”, which was easily accessible
Other available portable ventilators kept standby in MICU (Medical Intensive Care unit), SICU (Surgical intensive Care Unit) and Emergency Department
Ongoing training sessions on ‘Care of patients on BIPAP” for the nurses in general wards that included the principles of respiratory failure, the evolution and role of NIV and arterial blood gas analysis
An existing nursing policy on “Ventilated Patient Care” in the hospital intra-site
Locally, the researcher monitored the frequency of NIV use in all the general wards of Dubai hospital from November 2013 until March 2014 (Table 1).Experience of Novice Nurses with NIV in General Wards Essay

Data presented in Table 1 depicts that the wards with the highest frequency of NIV use include the male and female medical, nephrology and oncology wards. These wards were selected for the study. It is a common practice in this hospital, that patients are quickly put on the NIV and transferred from the Accident and Emergency department to the general wards. At other times, patients who deteriorate in the wards are referred to the intensivist who decides to connect them tonurses on the care of NIV patients, basic blood gas analysis and troubleshooting of ventilators.Experience of Novice Nurses with NIV in General Wards Essay

The design of this study was pre-experimental. A pretest, posttest design tested the effect of intervention related to care of NIV patients on nurses’ competence (i.e., nurses’ knowledge, skills and attitude) and the patient outcomes i.e., incidence of Hospital Associated Infection (HAI). The study was conducted in the general wards (medical, nephrology and oncology) in Dubai Hospital. The sample included 65 nurses selected using purposive sampling technique. The tools used for the data collection were List of Expectations, Questionnaire A and Questionnaire B, Highlights of Onsite Trainings, Policy on care of patients on non-invasive ventilation and NIV Competency Assessment Form. The researcher used the existing hospital policy and the competency forms that were available in the hospital intrasite for the study. List of expectations included the areas that the nurses need to prepare on, before being tested for their competencies. Important areas on nursing competence and documentation in nursing care plan were stressed on11.Experience of Novice Nurses with NIV in General Wards Essay

During the month of March 2014, the researcher inspected the routines in the selected general wards (during her rounds) and identified the existing gaps in care of NIV patients. A random discussion with the supervisors, charge nurses and nurses of the selected general wards helped the researcher to understand the needs of the nurses. In addition, suggestions were taken from the intensivists, physiotherapists and biomedical staffs. Then the researcher started the study with pretests on the existing nurses’ knowledge, skills and attitude and the patient outcomes (HAI rate). This was completed on March 28, 2014. Based on the pretests, onsite training was planned during the period between 1 to 30th May, 2014. Acritical care nurse with an extensive critical care background provided the nurses working in general ward with first-hand onsite training; expert also assessed their competencies. This teaching included topics on knowledge aspects, skill related topics (like the basic troubleshooting of the machine, recognizing signs of deterioration and preparing for power shutdown) and attitude areas like patient/family teaching. The monthly HAI incidence rates were procured. Post-tests were done on day 7 (from 8th June to 5th August 2014) and the HAI incidence was monitored for the following 4 months.Experience of Novice Nurses with NIV in General Wards Essay

Statistical analysis: The McNemar’s Test was used to find the association between the Pretest and Posttest in all the above areas of knowledge, skill and attitude. The effect of intervention on nurses’ knowledge, skill and attitude was analyzed by Chi Square method. The p value remained statistically significant (p=0.00 to 0.014).Experience of Novice Nurses with NIV in General Wards Essay