Advanced Clinical Assessment Skills for Critical Care Outreach Nurses - Dissertation Example

CHAPTER TWO Literature review 2.0: Introduction: This Chapter provides evidence that supports the relevance of assessment of advanced competency skills for critical care nurses, as a vital part of their effectiveness in a clinical situation. In a changing modern environment where clinical needs and definitions are constantly changing and greater accountability is expected in health care, the relevance of adequate competency frameworks is a vital issue to address. 2.1: Professional literature: A comprehensive review of available literature on the subject of critical care competency was undertaken, with a view to extract relevant information concerning advanced skills which may be relevant in critical care nurses. The evolution of competency frameworks was examined, together with recent changes that have mandated the development of such frameworks 2.1.1: Literature search strategy: I began my literature search by first identifying the appropriate electronic bibliographic databases using the Gale Directory of Databases[Marcaccio, 1995] as well as consulting with experts in information retrieval. Then I took up a search on the Internet using the MEDLINE, MEDSCAPE and PUBMED databases, in order to locate articles/ studies on advanced assessment skills for competency. The latest editions of American Journal of Critical care were also searched using the Findarticles search engine. A facet analysis search was undertaken and each facet searched in turn with the “map term to subject heading” switched off. Phrases such as “advanced critical care skills” and “competency assessment” were input at the initial stage of the search. However, several Papers were pulled up, which were in relation to critical nursing in general and also nursing education but not answering the specific quest for advanced critical skills. Then the search was refined with the index term selected to “focus”, which pulled up those articles which were relevant to the specific search that was taken up. Additionally key words such as “critical$” “nursing$ “ “care$” “competency$, “effectiveness$” were also searched. However, searching for literature on effectiveness using electronized databases was a problem, because the term “effectiveness” rarely appears in the abstracts of the papers. The most relevant articles were found form the search on the key word “competency”. Results of the search: The most relevant article that was useful from the FindArticles quest that searched the Journal of Critical Care was an article by Ruth Klienpell published in May 2005 on the results of a longitudinal study. The search of MEDLINE however, revealed several articles that were relevant from the point of view of this study and they are set out in Table 1, appended to this Literature review. Many of these articles were also available through PUBMED and MEDSCAPE and on this basis, this literature review will examine generally, the relevant articles in order to arrived at the framework for advanced assessment of critical competency skills. Advanced skills: The Department has recently commenced a review to try and evaluate nursing competencies. NHS Hospitals are devising standards against which performance of nurses are to be measured in order improve lives [DH press Release, 2001]. The National Health Services has outlined objectives to achieve team competencies for patient centered health care services, including the combined accessibility to technological facilities such as endoscopy that are available at diverse hospitals. The thrust of the NHS objective is to improve the quality of patient care by developing a detailed framework to evaluate critical care review of the existing literature on the subject and the assessment of current critical care competency. By employing a thematic analysis of this framework, the NHS aims to map the results of desired competencies vis a vis the existing ones and develop a realistic thematic framework for team competency, which will then be subject to continuous evaluation, including the constant monitoring of concerns, claims and results [www.dh.gov.uk, n.d.]. A clinical nurse specialist needs to be an expert clinician, consultant, educator and researcher [Kimmith 2005]. But contemporary nursing has evolved beyond these skills and incorporates more features, such as skilled interaction with three groups: patients and families care providers and the organization. In the context of cancer for example, extended hospital stay followed by the trauma and stress in adjustments can be eased through the services of a skilled nurse who is able to interact well with patients and their families. Acute care Nurse Practitioners have evolved in their roles, which are no longer confined merely to ICUs; nowadays they need to be able to function in both traditional settings such as ICUs where they provide inpatient emergency care and also have to work in a non traditional setting such as specialty clinics and private practice groups [Kleinpell, 2005]. Their role as nurses encompasses a wide variety of functions that involve interaction with patients from the diagnosis level to other therapeutic procedures such as follow up measures and discharge of patients. All of these involve a high level of interaction with patients, their relatives, physicians and other personnel. Critical care nurses also have to maintain a high level of personal hygiene that is mandated by the surgical environment that they work in every day, where risk of infection is high and may be worsened even by the practice of growing nails [McNeil, Foster, Hedderwick, et al., 2001]. Additionally, providing information to patients of terminal, life threatening illness during their illness and after discharge has been found to be a vital function of nurses (Miaskowski & Rostad, 1990) and this assessment of nurse competency is best made by patients. Modern health care organizations are re-developing their organizational framework in order to support a patient centered care and support system. There is increasing collaboration between medical personnel and hospital administrations in order to educate nurses to become more skilled in the specialty area of critical area. The need for education of critical care nurses is increasingly being felt. For example, in the Edmonton region, partnership between two public institutions has led to the development of innovative educational programs to prepare nurses to function in the critical care setting and supplement their skills, which are periodically assessed. [Pooler et al, 2005]. Nurses have to provide holistic care to patients, especially in the case of surgical procedures that involve post operative care for some categories of patients who undergo surgical procedures.[Colwell et al, 2001] Critical care nurses often have to be specialists in WOC – wound, ostomy and continence, and this involves a degree of advanced skills that are a direct result of improvements in technology that have produced specialized surgical procedures. The pediatric Oncology unit of the King Fahad National center has identified several levels of competencies that are required in nurses, such as initial competencies, annual competencies and unit specific competency skills[www.kfshrc.edu.sa, n.d.]. Initial competencies are those that are basic to critical care nurses and are developed in ICU, while annual competencies are tested on other categories such as infection control, skin integrity, wound care and POCT (urinalysis and blood glucose). Unit specific competencies relate to specific areas that may extend beyond the ICU setting and are centered on patient care. Critical care nurses need to be well acquainted with end of life competencies and it is difficult to assess these skills in critical care nurses. Critical care nursing textbooks were evaluated in a study, to assess whether they provided an adequate fund of knowledge for nurses to learn end of life skills and were found to be lacking. Thus it is difficult to assess end of life competency skills, however it forms an essential component of critical care competency skills.[Kirchoff et al, 2003]. The competency framework that has been developed by the London Standing Conference is the result of intensive collaboration and consultation between expert nurses[Bench et al, 2003]. These nurses advocate the development of a competency framework for critical care nurses that are tailored to meet patient needs. The patient is the central focus of the framework and an assessment of their competency skills depends upon the extent to which it reflects patient needs at the critical care level. Accordingly, a competency framework was developed using functional analysis. The basic focus of this approach was intended to develop consistency in the field of critical care education and practice. The development of a uniform standard of assessment for critical care nurses may be seen to be advantageous in terms of reducing redundancies, which place a strain on limited resources that are available for critical care.[Bench et al, 2003]. This study envisages the development of a standard competency framework that can be uniformly implemented across the nation through collaboration with Trusts and higher educational institutions. It also includes the development of a manual that will serve as the standard for assessing and supporting the competency framework. This study identifies four main drivers in the development of this competency framework, among which the patient is the central focus of the framework and thus, through collaboration with agencies and groups, many of the redundancies can be eliminated and a consistent pan-London approach to critical care education can be developed. [Bench et al, 2003]. According to this framework, needs assessment of the patients is one of the principal drivers and therefore assessment of critical competency would be determined by how effectively nurses are able to cater to the patient’s needs. Applying this principle to the assessment of critical care nursing, it may be noted that this corroborates the literature mentioned earlier that critical care competency would encompass functions and skills that are not limited to ICU, but would include extended patient care, even after their discharge from the emergency ward. Hospital stays are shorter and there is a greater emphasis on outpatient treatment, where the nurse’s skills and competencies are continually required, even after discharge of the patient. One of the most relevant studies in this area were the multi level critical care competency statements as detailed in a report by Bourgault and Smith, on the development of competency frameworks in order to facilitate the evolution from novice nurse to expert. In addition, what is particularly relevant in this study was the fact that the development of an appropriate framework is based upon a multi leveled assessment of skills.[Borgault and Smith, 2004]. This corroborates the multi level competency framework established at King Fahad National center and also the multi level model of nurse competencies which has been suggested by the study conducted by Kimmith et al and Bench et al. These studies serve to establish fairly conclusively that the modern role of the nurse is changing rapidly and any assessment tools must incorporate the necessity for evaluation at various different levels, in different specialties and through step up training from novice to expert nurse. In today’s age of technology, most nurses need to be computer savvy and well acquainted with technology, in order to perform well in an ICU setting where sophistical devices are increasingly been used. These studies identified the need for changes in the existing assessment frameworks, such as Lenburg’s Competency Outcomes and Performance Assessment (COPA) Model. According to this Model, the basic competencies which are deemed to be essential for nursing practice and assessment of competency are: psychomotor, cognitive, and affective domains, in all the relevant areas of specialty education of nurses, which is an integral part of critical care.[Lenburg, 1991]. However, in a report by Redman et al (1999), basic skills are stated to be inadequate in a clinical setting and certain qualities are found to be necessary to distinguish advanced skills in critical care nurses. Some of these competencies which are essential for advanced critical care are critical thinking, problem solving, communication and effective assertiveness.[Redman et al, 1999]. One of the most notable features that needs to be assessed in today’s clinical setting is the possession of computer skills, since working in a critical clinical setting mandates the use of several sophistical electronic machines and gadgets and information systems are a vital part of any public hospital/clinic setting. Redman et al also state that critical care nurses must be assessed on their ability to work with data and to develop cost effective alternatives for practicing in a clinical environment. Therefore, basic accounting and technological skills are mandatory advanced skills that critical care nurses need to possess, in order to make the transition from novice to expert nurse. On the basis of their assessment of the deficiencies in current methods of assessment, Redman et al proposed ten competency based tests, which focus on education and the ability of a nurse to adapt to social change. Included in the ten point competency list is the vital area of reflection. The importance of the need for reflection in a nursing graduate has been stressed by many professionals [Stockhausen 1994; Glaze 1998; Greenwood 1998; 2001]. Additional competencies that have been identified are leadership and social change in order to bring about improved health for individuals and communities. Therefore, as per the criteria identified by Redman et al, the assessment of competency must include the ability of the nurse to effectively integrate technology and information systems, in order to derive more cost effective methods of operation, while communicating more effectively and with increased efficiency in operations that facilitate effective decision making in the modern environment. With increasing accountability becoming the norm in today’s well-connected, technologically powered world environment, health professionals are also being held accountable in that their standard of performance is assessed through the levels of satisfaction they provide to patients. Therefore Redman et al advocate advanced competency skills as being those that include effective nurse interaction with the environment and effective networking with patients and others. Increased self reflection and self awareness are considered essential to communicate effectively and develop meaningful relationships. Critical thinking and reflective practice are among the most essential qualities a nurse must possess and assessment of competency must include these aspects as a part of a common framework. The University of Colorado School of Nursing has implemented these recommendations for assessment of advanced skills for critical competency [Redman et al, 1999] through the allocation of a series of modules, each of which tests competency in one specialized area, such as adult, geriatric, pediatric assessment, etc. While entry level competencies are determined theoretically, advanced competency requirements may be met by completing the necessary clinical performance examination. Therefore, assessment of competency takes place on two levels – the basis entry level which is adequate to demonstrate basic level competency and the advanced health module which demonstrates advanced competency in a particular area through the assessment made on an actual clinical test. This system of assessment is under review and is constantly being reviewed in order to make it more compatible with the overall mission and goals, philosophy and conceptual framework of the organization. This is also similar to what is being implemented on a pan London basis as discussed before through coordination between various organizations in order to develop a common vision, goal and standard for assessment of critical care competency.[Bench et al, 2003]. New clinical roles for nurses have also developed largely as a result of external policy drives, such as those sponsored by the National Health Service and the need to contain costs and make quality health care accessible to a wider base of patients. [Glen, 2003]. The role and requirements from nursing services has been in a state of flux and nurses are now active in clinical specialist practice and associated areas with innovation at many levels in prescribing, critical care, post operative care as well as community empowerment and care of terminally ill patients. From 1996, the Government has empowered nurses to fill the gaps that have resulted as a result of reduction of hours for junior doctors, which has called for additional skills from nurses in carrying out in part, those functions and skills ascribed to the physician [Glen, 2003]. The role of nurses has now expanded and they function in the role of “intermediate professionals” who need to be equipped with a wider variety of skills in diagnoses and treatment of diseases, which also need to form a part of the assessment of competency, in order to enable them to function in a modern environment. Increased technological advances have also introduced the concept of physician intervention through video conferencing, which enables a physician to attend to several of his patients at various stages of recovery at one time. This has necessarily imposed greater responsibility on nurses who now make triage decisions, perform minor surgical procedures, administer drugs and manage treatments [Glen, 2003]. Therefore, a competency framework that is implemented also needs to assess the nurse’s ability to perform in part, the role of a physician and this entails a much wider knowledge base, with critical thinking ability, reflection and the intelligence to make the right decisions on diagnoses and treatment of patients. Nursing is now evolving into a field that is not as specialized as it once was. The role of the nurse has widened and transferability of skills has become an important factor in assessing competency [Glen, 2003]. Competency frameworks have been designed by the National Health Service for use with all kinds of patient services [Department of health, 2001]. The primary areas of focus identified by the National Health Service that contribute towards the assessment of critical care competency are the ability to work together with a team, the achievement of transferability of skills and communication skills, clinical audit, the practice of reflection and critical thinking and the development of technological and information skills to ensure efficiency in operations and the assumption of a partial physician role. Summary of the literature: From the above review, it becomes clear that the role of the nurse has changed in modern times because of the changing scenario in technology and the introduction of sophisticated medical equipment that requires knowledge of computer and information technology. This has also contributed to video conferencing by surgeons and an expansion of the nurse’s role to partly fill the physician’s shoes. Additionally, the recent policy initiatives in the NHS are also a contributing factor. With increasing accountability demanded from the health care sector, the field of nursing and adequate nursing skills to cope in the modern clinical setting have widened to encompass a much more holistic role. Several competency frameworks have been identified in order to assess nurse competency in critical care, where factors such as critical thinking, emotional intelligence and knowledge of technology may be seen to be vital in nurses, in order to render them effective. Competency frameworks have been devised at different levels, to test not only the performance in a clinical setting from a medical or treatment point of view, but also from the point of view of interpersonal skills and the ability to interact well with patients. Advanced competency assessments are being implemented in various specialties, in order to ensure that nurses are better equipped to cope in a modern clinical setting. In view of the revised policy directives from the National Health Services, the patient has now become the central focus of the competency framework and team work has become a vital part of ensuring successful nursing, therefore assessment of competency of nurses will be effective only if the nurse’s contribution to patient well being and satisfaction are also taken into account. References cited: Bench, Suzanne, Crowe, Dot , Day, Tina, Jones, Michaela and Wilebore, Suzanne. (2003): Developing a competency framework for critical care to match patient need, Intensive and Critical care Nursing, 2003, 19(3), pp 136-142 Colwell, Janice, Goldberg, Janice and Carmel, Jane. (2001). Ostomy care: The state of the standard diversion. Journal of WOC Nursing, 2001, 28 (1): 6-17 Department of health, Press release Notice (2001). First ever cancer standards central to sweeping reform in cancer care. Publication of the Department of health, retrieved 7/26/2005 from: http://www.dh.gov.uk/PublicationsAndStatistics/ PressReleases/PressReleasesNotices/fs/en?CONTENT_ID= 4009916&chk=04vW2k Department of Health. Working together—learning together: a framework for Lifelong learning for the NHS. London: DoH, 2001 Developing team competencies for patient centered critical care services. Retrieved July 19, 2005 from URL: http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/EmergencyCare/ModernisingEmergencyCare/ModernisingEmergencyCareArticle/fs/en?CONTENT_ID=4081971&chk=mUGSGn Glaze, J. 1998, Developing nursing practice through reflection: part 1, British Journal of Theatre Nursing, Vol. 8, No. 7, pp. 9-24 Glen, S. (2003). Healthcare reforms: Implications for the education and training of acute and critical care nurses. Postgraduate Medical Journal 2004;80:706-710 Greenwood, J. 1998, The role of reflection in single and double loop learning, Journal of Advanced Nursing, Vol. 27, No. 5, pp. 1048-53. Kathleen Y. Marcaccio, ed., Gale Directory of Databases (Detroit: Gale Research, 1995). Kimmith, Jones (2004). Contemporary Clinical Nurse Specialist Practice: Living the Synergy Model Excellence in nursing knowledge, August-Sept 2004. retrieved July 26, 2005 from URL: http://www.nursingknowledge.org/Portal/main.aspx?pageid=3507&ContentID=56439 Kirchhoff, Karin T, Beckstrand, Renea L and Anumandla, Prashant Reddy. (2003). Analysis of end-of-life content in critical care nursing textbooks. Journal of Professional Nursing, 2003, Volume 19, Issue 6, pp 372-381 Lenburg, C.B. (1991). Assessing the goals of nursing education: Issues and approaches to evaluation outcomes. In M. Garbin, M. (ed.), Assessing educational outcomes. (pp.25-52). New York: National League for Nursing. Miaskowski, C., & Rostad, M. (1990). Standards of advanced practice in oncology nursing. Pittsburgh, PA: Oncology Nursing Society Press. McNeil, S.A., Foster, C.L., Hedderwick, S.A., et al. (2001). Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clinical Infectious Diseases, 32(3), 367-372. Pooler C; Slater-MacLean L; Simpson N; Giblin C. (2005). Knowledge and skill acquisition for critical care nursing practice. Advanced Studies in Critical Care Nursing Program, Mount Royal College, Calgary, AB Dynamics 2005 Spring;16(1):20-3   Redman, R.W., Lenburg, C.B., Hinton Walker, P. (Sept. 30, 1999): Competency Assessment: Methods for Development and Implementation in Nursing Education. Online Journal of Issues in Nursing. Available http://www.nursingworld.org/ojin/topic10/tpc10_3.htm Stockhausen, L. 1994, The clinical learning spiral: a model to develop reflective practitioners, Nurse Education Today, Vol. 14, No. 5, pp. 363-71.    TABLE 1 96% Pooler C, Slater-MacLean L, Simpson N, et al. Knowledge and skill acquisition for critical care nursing practice. Dynamics (Canada), Spring 2005, 16(1) p20-3 89% Hravnak M, Tuite P, Baldisseri M Expanding acute care nurse practitioner and clinical nurse specialist education: invasive procedure training and human simulation in critical care. AACN Clin Issues (United States), Jan-Mar 2005, 16(1) p89-104 89% Bourgault AM, Smith S The development of multi-level critical care competency statements for self-assessment by ICU nurses. Dynamics (Canada), Winter 2004, 15(4) p15-8 87% Mayo PH, Hackney JE, Mueck JT, et al. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med (United States), Dec 2004, 32(12) p2422-7 87% Verger J, Trimarchi T, Barnsteiner JH Challenges of advanced practice nursing in pediatric acute and critical care: education to practice. Crit Care Nurs Clin North Am (United States), Sep 2002, 14(3) p315-26 87% Dunn SV, Lawson D, Robertson S, et al. The development of competency standards for specialist critical care nurses. J Adv Nurs (England), Feb 2000, 31(2) p339-46 85% Saggs P Developing postgraduate awards for critical care. Nurse Educ Today (Scotland), May 2003, 23(4) p307-14 85% Dorman T, Angood PB, Angus DC, et al. Guidelines for critical care medicine training and continuing medical education. Crit Care Med (United States), Jan 2004, 32(1) p263-72 83% Peterson MJ, Bechtel GA Combining the arts: an applied critical thinking approach in the skills laboratory. Nursingconnections (United States), Summer 2000, 13(2) p43-9 81% Hammond F, Saba M, Simes T, et al. Advanced life support: retention of registered nurses knowledge 18 months after initial training. Aust Crit Care (Australia), Aug 2000, 13(3) p99-104 80% Carley S, Driscoll P Trauma education. Resuscitation (Ireland), Jan 2001, 48(1) p47-56 79% Wheeldon A Exploring nursing roles: using physical assessment in the respiratory unit. Br J Nurs (England), May 26-Jun 8 2005, 14(10) p571-4 78% Thorne L, Hackwood H Developing critical care skills for nurses in the ward environment: a work-based learning approach. Nurs Crit Care (England), May-Jun 2002, 7(3) p121-5 77% Ballard P, Trowbridge C Critical care clinical experience for novice students: reinforcing basic nursing skills. Nurse Educ (United States), May-Jun 2004, 29(3) p103-6 77% Abner CM Increasing critical care skills of noncritical care nurses. J Nurses Staff Dev (United States), May-Jun 2000, 16(3) p124-30 76% Hulme J, Perkins GD, Baldock C, et al. Use of advanced life support skills. Resuscitation (Ireland), Jul 2003, 58(1) p59-63 76% Hulme J, Perkins GD, Baldock C, et al. Use of advanced life support skills. Resuscitation (Ireland), Jul 2003, 58(1) p59-63 76% Scholes J The skills escalator: implications for critical care nursing. Nurs Crit Care (England), May-Jun 2003, 8(3) p93-5 76% Murray D, Boulet J, Ziv A, et al. An acute care skills evaluation for graduating medical students: a pilot study using clinical simulation. Med Educ (England), Sep 2002, 36(9) p833-41 76% Curtis JR, Wenrich MD, Carline JD, et al. Patients perspectives on physician skill in end-of-life care: differences between patients with COPD, cancer, and AIDS. Chest (United States), Jul 2002, 122(1) p356-62 75% Wueste DE A philosophical yet user-friendly framework for ethical decision making in critical care nursing. Dimens Crit Care Nurs (United States), Mar-Apr 2005, 24(2) p70-9 Author Keywords: Competency; Critical care Read More