Proactivity in VTE prevention: a concept analysis Averil Adams
Abstract
Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience. Key words: Venous thromboembolism ■ Nursing assessment ■ Leadership ■ Nurse’s role ■ Pulmonary embolism
C
oncept analysis involves forming and clarifying a mental construct, and appraising it to both advance theory and guide practice (Weaver and Mitcham, 2008). Risjord (2008) states that concepts get their content from the context they are set in, and that concept analyses must be related to context to make the process more robust. This was the aim of this concept analysis of proactivity set in the context of venous thromboembolism (VTE) prevention, and specifically aimed at nurses. The term ‘proactive’ is defined as ‘actively instigating changes in anticipation of future developments, as opposed to merely reacting to events as they occur’ and ‘ready to take the initiative: acting without being prompted by others’ (Manser and Thomson, 1995). Parker et al (2010: 1), add ‘being proactive is about anticipating and preventing problems and seizing opportunities’. VTE prevention is an international patient safety issue. The incidence of VTE is around 1-2 per 1000, with the risk
increasing with age. It is thought that 1 in 20 people will suffer with VTE at some point and around half of these cases are linked with recent hospitalisation (NHS England, 2013).VTE is the umbrella term used for two related conditions: thrombosis of the ‘deep veins’, known as deep vein thrombosis (DVT), and pulmonary embolism (PE), which is when a clot dislodges and travels through the heart to the lungs (Welch, 2010). Since 2010, assessing adults on admission to hospital for risk of VTE has become mandatory (Welch, 2010).
Background VTE is often asymptomatic, but may cause pain and swelling in the leg. It can cause long-term morbidity owing to chronic venous insufficiency (National Institute for Health and Care Excellence (NICE), 2010).VTE prophylaxis is either mechanical—e.g. anti-embolism stockings—pharmacological— e.g. anticoagulants such as heparin—or both, and this is dependent on individual patient risk assessment. Anti-embolism stockings reduce venous stasis, whereas anticoagulants attempt to alter components in the blood responsible for clotting (Welch, 2010). Through implementation of these measures, nurses play a central role in VTE prevention (Bonner et al, 2008; Worel, 2009). The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive, with treatment taking place after VTE has occurred rather than preventing the occurrence. There is a wealth of literature on how to prevent VTE and how to increase concordance in VTE prevention (Tooher et al, 2005; Geerts, 2009; Li et al, 2010); however defining proactivity in VTE prevention and exploring how staff can be encouraged to behave proactively could potentially increase the prescription, and, crucially, provision of prophylaxis, thereby improving patient care. The model used to analyse the concept of proactivity in VTE prevention is based on that of Walker and Avant (2010). It consists of: choosing a concept, identifying all current uses of the concept, identifying defining attributes, developing model, borderline and contrary cases, identifying antecedents and consequences, and demonstrating empirical referents.
Averil Adams, Junior Sister and Clinical Educator, Clayton Ward, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust Accepted for publication: October 2014
20
The following ten databases were searched in March 2012: Applied Social Sciences Index and Abstracts (ASSIA), CINAHL, Cochrane, Medline, NICE database, PAIS International, PsycINFO, Scopus, Sociological Abstracts, and Web of Science.The following keywords were used: proactive, proactivity, nurse/nursing, VTE/venous thromboembolism,
© 2015 MA Healthcare Ltd
Methods
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
CONCEPT ANALYSIS prevent/prevention/preventing, behaviour (this was included to identify literature on employee behaviour) and DVT/ PE. It was decided to use two different search strategies, one focusing on proactivity and one on VTE prevention. An initial literature search (2005-2012, in line with recent VTE literature) did not yield any results directly linking proactivity and VTE prevention. This was a significant finding, suggesting it had not been explored before. This meant there were no current uses of the concept to compare/ explore, as per the second stage of the Walker and Avant model of concept analysis (2010). Therefore it was necessary to identify all relevant proactivity sources and apply them to the VTE prevention sources. Proactivity research began in 1993 with seminal work by Bateman and Crant. However, research on VTE prevention needed to be current, as additional emphasis was placed on this following publication of the report by the House of Commons Select Committee in 2005 (Welch, 2010). Hence, a date limit of 20 years was applied to the proactivity keyword search, and 7 years to the VTE search. The results were refined by excluding non-English language, research on non-human subjects, conference papers, news reports, editorials, comments, reviews, abstracts, dissertations, theses, studies on children, articles using ‘proactive’ as an adverb with no definition, articles on proactivity linked with ageing, coaching, advancement potential, newcomers, social capital, leadership of teams and mood. This left 24 articles on proactivity for inclusion in the study. Articles on treating or recognising VTE, comparing/testing the efficacy of prophylaxis, and on developing protocols and guidelines were excluded, as the focus of the concept analysis is prevention.Articles focusing on increasing staff concordance were excluded, as proactive behaviour means acting without being prompted by others (Manser and Thomson, 1995). The remaining 10 articles focused on promoting VTE prevention, particularly the nurse’s role. It was deemed important to obtain a local viewpoint. Kay Sumner is the VTE specialist nurse at United Lincolnshire Hospitals NHS Trust. She directed the author to the Safety and Quality Dashboard, a reliability tool that assesses what doctors and nurses do that affects patient care. It is part of the Safety Express Plus programme that measures data in four key areas: falls, pressure ulcers, catheter-acquired urinary tract infections and VTE (Department of Health (DH), 2010). Sumner suggests that good practice in VTE prevention can be identified through the monthly results. She also directed the author to the ‘CQUIN’ for VTE prevention—the Commissioning for Quality and Innovation payment framework (Arya and Hunt, 2010), which gave a financial incentive for NHS trusts to achieve 90% VTE risk assessment on admission. From April 2014 this incentive ceased to exist (NHS England, 2014).
© 2015 MA Healthcare Ltd
Defining attributes Reviewing the proactivity sources and linking them to the VTE sources identified the defining attributes of proactivity in VTE prevention. Wilson (1963) states that defining attributes facilitate understanding of the concept when explaining it to colleagues; they enable us to decide what is a good example of the concept, illustrated later within the model case.
British Journal of Nursing, 2015, Vol 24, No 1
Personal initiative Parker et al (2010), state that personal initiative (n=17 of 24 articles) is one of the most important concepts introduced into the literature on proactivity. Crant (2000) states personal initiative is persistent, self-starting and proactive. Thomas et al (2010) conducted a meta-analysis of literature on four proactive constructs, including personal initiative (n=103 articles, 32 967 participants). Personal initiative was studied in 21% of the articles analysed. Findlay et al (2010) observed, from working as junior doctors, countless instances of being prompted by nurses to prescribe thromboprophylaxis. This could be identified as nurses demonstrating personal initiative in VTE prevention. However, while anecdotal evidence may serve to illustrate a point, it is subjective in nature and should be used with caution (Polit et al, 2001). Patients’ needs are constantly changing and nurses are well positioned to recognise this and instigate prompt changes to their treatment (Beck, 2006; Bonner et al, 2008). Anecdotally, Bonner provides her own example of personal initiative: nurses must consider whether the measures prescribed are relevant and applicable to the patient’s needs. For example, they may have a drain in situ that has drained an excessive amount, which may make pharmacological prophylaxis inappropriate. Bonner et al (2008) add that risk assessment is only the first stage of a process. It does not protect the patient unless measures are implemented following the assessment; ensuring they are relevant and implementing these measures would demonstrate personal initiative. For a nurse to function as an effective advocate for patients, he or she needs to demonstrate personal initiative on a daily basis. Personal initiative is therefore an essential attribute for a nurse to possess. Each patient is an individual, and each will have differing requirements in VTE prevention.
Taking charge Taking charge (n=15 of 24 articles) can be defined as a constructive effort to change how work is executed (Crant, 2000). It is important to differentiate between the nurse taking charge of the ward/group of patients, and taking charge in the proactive sense. Taking charge was one of the proactive constructs included in the meta-analysis by Thomas et al (2010), included in 7% of the studies analysed. Bonner et al (2008) comment that provision of VTE prophylaxis generates an increased workload for nurses. This may be a reason why prophylaxis is not always fully implemented; ensuring the patient has been risk assessed, measuring for and applying anti-embolism stockings, giving verbal and written information to patients and completing documentation takes a significant amount of time. Taking charge is an important attribute for nurses to ensure they see the process through, with all necessary steps taken. Labarere et al (2007) studied the effectiveness of an intervention targeting doctors and nurses in improving VTE prophylaxis provision. Compared with the intervention aimed at doctors only (n=497 patients), the intervention aimed at doctors and nurses (n=315) found the rate of antiembolism stocking usage increased, but not significantly
21
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Feedback-seeking behaviour Feedback-seeking behaviour (n=12 of 24 sources) is viewed as a proactive behaviour (Crant, 2000; Grant and Ashford, 2008; Belschak et al, 2010). Kim et al (2009) state that seeking feedback improves an employee’s performance, as he or she can understand the organisation’s needs and his or her supervisor’s expectations, and, as a result, prioritise appropriately. At the King’s Thrombosis Centre, Lynda Bonner, Consultant Nurse for Thrombosis and Anticoagulation at King’s College Hospital, says nurses are involved in audits so they can feed back where improvement is needed. This can be directly compared with the Safety and Quality Dashboard (DH, 2010). NHS England (2013) advises that a root cause analysis be performed for all hospital-acquired thrombosis. Root cause analysis could be described as the ‘ultimate’ in feedback-seeking behaviour, looking into the cause of VTE in detail to try and prevent it recurring in the future. These initiatives can be effective in improving VTE prevention strategies, but the onus is on nurses demonstrating proactivity by accessing the information and learning from it to shape practice. Without this, they would not be able to direct their efforts appropriately or effectively.
Cases The following fictitious cases aim to illustrate the concept of proactivity in VTE prevention by providing examples of a model case (that displays all defining attributes), a borderline
22
case (displaying some of the defining attributes) and a contrary case (illustrating what is not the concept.This section seeks to situate the concept firmly within the clinical context.
Model case Mrs Fuller is admitted with abdominal pain. The staff nurse, Sally, knows that Mrs Fuller will need a VTE assessment and appropriate prophylaxis. Sally sees that the risk assessment has not been completed, but heparin and anti-embolism stockings have been prescribed. Sally contacts the doctor and asks her to complete the risk assessment. Once this has been done, Sally notes that Mrs Fuller suffers with peripheral vascular disease and that anti-embolism stockings are contraindicated. She therefore does not apply stockings, explaining why to Mrs Fuller, documenting the reason for the omission in the notes, and informing the doctor. Sally completes the nursing assessment and gives Mrs Fuller the patient information leaflet on VTE prevention. Sally accesses the Safety and Quality Dashboard on a monthly basis to establish where the team are doing well and where further input is needed. Within this example, Sally demonstrates all three defining attributes. She takes charge when she asks the doctor to complete the risk assessment. Sally uses personal initiative when not applying anti-embolism stockings, despite these being prescribed. Accessing the Safety and Quality Dashboard demonstrates regular feedback-seeking behaviour.
Borderline case Mrs Fuller is admitted with abdominal pain. Sally notes that heparin and anti-embolism stockings are prescribed. She does not apply stockings, as she sees that Mrs Fuller has peripheral vascular disease. Sally does not check to see if the VTE risk assessment has been completed. She completes the nursing assessment and provides Mrs Fuller with the patient information leaflet, but does not document her actions in the notes. She is aware of the Safety and Quality Dashboard, but does not access the results to improve her practice. In this example, Sally demonstrates personal initiative when not applying anti-embolism stockings, as they are contraindicated. Completing the nursing assessment and providing the patient information leaflet shows she is taking charge, but only to a limited extent. Sally does not demonstrate feedback-seeking behaviour.
Contrary case Mrs Fuller is admitted to the ward with abdominal pain. The VTE risk assessment is not completed on admission, however heparin and anti-embolism stockings are prescribed. Sally administers both, but the stockings have to be removed the following day as Mrs Fuller suffers from peripheral vascular disease and complains of leg pain caused by the inappropriate application of anti-embolism stockings. Sally is not aware of the Safety and Quality Dashboard. This case clearly demonstrates what is not the concept. Sally does not use personal initiative as she applies antiembolism stockings even though they are contraindicated. She does not take charge to ensure the risk assessment is completed. She is reactive rather than proactive when the
© 2015 MA Healthcare Ltd
(p=0.74). By educating nurses, the authors expected provision of anti-embolism stockings to increase. Similarly, Findlay and Keogh (2011) studied the effect of 10-minute educational sessions for doctors and nurses in VTE prevention. They found prescription of anti-embolism stockings improved significantly (p=0.015) but provision (i.e. application of anti-embolism stockings by nursing staff) improved non-significantly (p=0.167). These studies suggest effective VTE prevention involves more than education about its importance. Nurses need to make a conscious decision to ‘take charge’ of VTE prevention. Collins et al (2010) studied rates of VTE prophylaxis before and after nursing educational sessions. They carried out a longitudinal audit on 2063 patients and found prophylaxis increased from 27% to 85% (p=0.0001). The reason their intervention may have succeeded is that it focused on empowering nurses to take ownership of VTE prevention. They concluded nurses must adopt a ‘can do’ attitude in actively promoting VTE prevention. In addition to this, Bonner (2010) said that successful implementation of VTE prevention requires strong leadership, courage, ownership and project-management skills. Individuals do not have to wait to be told what to do, or act only when a problem occurs. They can choose to take charge, anticipate opportunities and problems and shape themselves or the situation to change the future (Parker et al, 2010). Nurses can receive inordinate amounts of training in VTE prevention, but without making the conscious decision to take charge this training is worthless—they are the key to successful implementation.
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
CONCEPT ANALYSIS stockings have to be removed the following day. She does not demonstrate feedback-seeking behaviour.
Discussion The borderline and contrary cases are a potential breach of the Nursing and Midwifery (NMC) Code (2008), which states that nurses must have the knowledge and skills for safe and effective practice when working without supervision. This emphasises the importance of proactivity in nursing, rather than reacting to events after they have occurred. It also emphasises the importance of ensuring the antecedents to proactivity in VTE prevention are present.
Antecedents Autonomy Grant and Ashford (2008), state that autonomy fosters proactivity. Parker et al (2010) add that jobs enriched with autonomy and complexity are key in influencing perceptions of control over the work environment. Professional autonomy is an essential antecedent; nurses need to have the freedom to take charge and use their initiative to ensure each patient is treated as an individual and receives the prophylaxis they require.
Leadership Bindl and Parker (2010) suggest leaders have a role to play in proactivity through motivation; a good relationship between leader and employee should promote a climate of trust, where employees engage in change-oriented, self-initiated behaviours. Supporting this, Parker et al (2006) state that supportive leadership such as encouraging high expectations, self-observation and goal-setting will foster proactive behaviours in employees. Bonner (2010) places a high emphasis on strong leadership skills to get doctors and nurses involved with audits and feedback for ongoing improvement. Worel (2009) states the VTE specialist nurse plays an important part in leadership, developing and using monitoring systems including audits and result reporting. Bindl and Parker (2010) add employees may require support from managers to feel confident enough to engage in proactive behaviours. Bolino et al (2010) caution that if proactivity is discouraged by supervisors, this may lead to employee withdrawal.
© 2015 MA Healthcare Ltd
Knowledge, education and training In a review of performance measures, Worel (2009) identified that one of the barriers to implementing VTE prevention guidelines was a lack of knowledge of risk assessment and prophylaxis strategies. Bonner et al (2008) states that nurses need to be aware of the indications, correct administration, modes of action, contraindications, side effects and ongoing monitoring needed when implementing VTE prophylaxis. A significant part of the successful initiative to improve VTE prophylaxis described by Collins et al (2010) focused on developing nurses’ knowledge and skills. They concluded that this undoubtedly led to an improvement in patient care.
Responsibility and accountability Lack of individual responsibility was found to be a barrier to effective VTE prevention (Worel, 2009). Nurses are responsible
British Journal of Nursing, 2015, Vol 24, No 1
and accountable for the administration of VTE prophylaxis (Morrison, 2006). Collins et al (2010) concluded it is vital nurses accept responsibility for VTE prevention. Anecdotally, Bonner feels VTE prevention measures should focus on protecting the patient, and the nurse’s accountability.The NMC (2008) states that nurses must maintain the safety of those in their care, and that they are personally accountable for their actions and omissions. One way of ensuring nurses are aware of their responsibility and accountability around VTE prevention is to use a specific nursing care plan (Bonner, 2010).
Role-based self efficacy Role-based self efficacy is a self-perception of the confidence an individual has in his or her own ability to perform in ways that increase responsibility and complexity in his or her role (Hornung and Rousseau, 2007). Parker et al (2006) found rolebased self efficacy was an important predictor of proactivity. Similarly, in a longitudinal study of hospital employees (n=373) Hornung and Rousseau (2007) found role-based self efficacy was related to commitment to changes that broaden the employee’s role. Role-based self efficacy is an important antecedent; without confidence in their abilities, nurses may not be able to take charge of VTE prevention effectively. The yearly appraisal should reinforce role-based self efficacy.
Ethics and duty of care The NMC (2008) states that nurses must provide a high standard of care at all times. Keogh (BBC Radio 4, 2011) adds that tackling VTE is a professional, moral and social responsibility for health professionals. The nurses’ own personal beliefs and ethics may affect their viewpoint on the importance of VTE prevention, and how proactive they are. Anecdotally, Sumner suggests coagulation link nurses who have a personal interest in VTE prevention are often more motivated or dedicated to the role and Bonner recommends two coagulation link nurses per clinical area, recruited for their attributes and keenness. The National Patient Safety Agency (NPSA) advocate that trusts or clinical areas select coagulation link nurses with an interest in VTE prevention (NPSA, 2011).
Consequences Findlay et al (2010) state that nurses have the ability to prevent a huge amount of morbidity and mortality by providing routine prophylaxis and can promote a culture change to ensure prophylaxis is considered for all patients automatically. In addition, Morrison (2006) suggests that nurses meeting quality assurance standards can directly translate into improvements in patient care. Therefore, the consequence of proactivity in VTE prevention should be a fall in hospital-acquired thrombosis, as suggested by the empirical referents. Additional beneficial consequences of proactivity in VTE prevention include nurses feeling empowered, thus increasing their job satisfaction; and patients being well-informed of the risk factors and what is being done to minimise them, reassuring them that patient safety is a priority. Proactivity may lead to increased use of mental and physical resources, leading to increased stress for the employee
23
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Empirical referents Empirical referents are behaviours or conditions that prove the existence of the concept (Weaver and Mitcham, 2008). Since undertaking this work, recent studies have been published that demonstrated a drop in hospital-acquired thrombosis since the CQUIN target was introduced (Lester et al, 2013; Roberts et al, 2013; Catterick and Hunt, 2014). These prove the existence of the concept as they strongly suggest that prophylaxis was implemented as a result of risk assessment. Colchester Hospital University NHS Foundation Trust devised a ‘nurse-led-doctors-complete’ VTE risk assessment system (Arya and Hunt, 2010). This allowed senior nurses to demonstrate proactivity by taking charge, proving the existence of the taking charge element of proactivity in VTE prevention. Conducting root cause analyses after incidences of hospitalacquired thrombosis and conducting audits such as the Safety and Quality Dashboard prove the existence of the feedbackseeking behaviour element of proactivity in VTE prevention.
KEY POINTS n The
author has observed gaps in prescription and provision of venous thromboembolism (VTE) prophylaxis, and that the attitude to VTE is often reactive rather than proactive
n A
key finding in itself is that this is an original concept, which has never been defined before
n Defining
attributes are identified as personal initiative, feedback-seeking behaviour and taking charge
n The
antecedents are identified as autonomy, leadership, knowledge, education and training, responsibility and accountability, role-based self efficacy and ethics/duty of care
n Defining
the concept and identifying its antecedents should allow organisations to foster and develop these to demonstrate a measurable reduction in hospital-acquired thrombosis
24
Assessment, prescription and provision of VTE prophylaxis is more stream-lined when suitably trained nurses apply anti-embolism stockings without prescription (unless contraindicated) and carry out the risk assessment on admission, as advocated by the DH (Arya, 2009). Proactivity in VTE prevention is demonstrated at trusts where this occurs. As encouraging proactivity inVTE prevention is so important (and it must be acknowledged that it can be time-consuming and challenging at times), Bonner suggests two coagulation link nurses per clinical area is sound advice. This demonstrates the taking charge and personal initiative elements of proactivity in VTE prevention. It is important that the role is developed in order for it to be effective. For this to happen, the coagulation link nurse must be supported by his or her line manager, be given the autonomy to develop the role and be supported through the yearly appraisal. The VTE specialist nurse should be a regular visible presence in clinical areas. Link nurse meetings give coagulation link nurses the opportunity to meet and share ideas and best practice. An effective link nurse network demonstrates the feedback-seeking behaviour element of proactivity in VTE prevention.
Conclusion This concept analysis has identified the defining attributes of proactivity in VTE prevention, personal initiative, taking charge and feedback-seeking behaviour. It also identified antecedents, which are essential as these are factors that need to be present to allow nurses to be proactive in VTE prevention. Nurses have a pivotal role in VTE prevention, and proactivity is central to this. As each patient is an individual, nurses must use their personal initiative and take charge to ensure patients are protected from avoidable VTE. Seeking feedback is central to effective nursing practice, reflecting on measures that are working and areas that need improvement, both at an individual and organisational level, to ensure that patients receive the best care possible. Defining proactivity in VTE prevention and exploring how nurses can be encouraged to behave proactively could potentially increase the prescription and, crucially, provision of prophylaxis, thereby reducing avoidable BJN harm and improving the patient experience. Conflict of interest: none Acknowledgements: the author would like to thank Lynda Bonner, Consultant Nurse for Thrombosis and Anticoagulation at King’s College Hospital and Dave Wilson, Assistant Professor (Mental Health) from the University of Nottingham. The full article is available online at http://tinyurl.com/ conceptanalysisvte Arya R (ed) (2009) Venous Thromboembolism Prevention: A Patient Safety Priority http://tinyurl.com/psswk3u (accessed 8 November 2014) Arya R, Hunt B (eds) (2010) Venous Thromboembolism Prevention: A Guide for Delivering the CQUIN Goal http://tinyurl.com/q6wuz6g (accessed 8 December 2014) Bateman TS, Crant JM (1993) The proactive component of organizational behavior: A measure and correlates. J Organiz Behav 14(2): 103–18. doi: 10.1002/job.4030140202 BBC Radio 4 (2011) Face the Facts: Saving Lives in Seconds (Broadcast date 17 July 2011) http://tinyurl.com/nx3k4lv (accessed 10 December 2014)
© 2015 MA Healthcare Ltd
(Belschak and Den Hartog, 2010; Bolino et al, 2010). Proactive employees may be seen as ‘doing too much’ or ingratiating themselves with their supervisors (Belschak and Den Hartog, 2010). Bolino et al (2010) add they may be seen as overzealous or impulsive; and that it is important to consider that individuals may all perceive proactivity differently. Bolino et al (2010) also state proactive behaviours may take up more of the employee’s time. This is supported by studies by Fritz and Sonnentag (2007) and Ohly et al (2006) who also found too much time pressure constrained proactivity; suggesting it is by nature time-consuming. Grant and Ashford (2008) state further research into the costs and benefits of proactivity may reveal mixed effects and unintended consequences for organisations and employees. Spychala and Sonnentag (2011) add that the consequences of proactivity may be more complex than previously acknowledged. However, Belschak and Den Hartog (2010) and Bolino et al (2010) both conclude that overall proactivity does more good than harm. Bindl and Parker (2010) add that the price of passivity may be greater than occasional misguided proactivity.
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
CONCEPT ANALYSIS Beck DM (2006) Venous thromboembolism (VTE) prophylaxis: implications for medical-surgical nurses. Medsurg Nurs 15(5): 282–7 Belschak FD, Den Hartog DN (2010) Pro-self, prosocial, and pro-organizational foci of proactive behaviour: differential antecedents and consequences. J Occup Organ Psych 83(2): 475–98. doi: 10.1348/096317909X439208 Belschak FD, Den Hartog DN, Fay D (2010) Exploring positive, negative and context-dependent aspects of proactive behaviours at work. J Occup Organ Psych 83(2): 267–73. doi: 10.1348/096317910X501143 Bindl U, Parker S (2010) Proactive work behaviour: Forward-thinking and change-oriented action in organizations In: Zedeck S (ed) APA Handbook of Industrial and Organizational Psychology.Vol 2: Selecting and developing members for the organization 567-98 American Psychological Association, Washington DC Bolino M,Valcea S, Harvey J (2010) Employee, manage thyself: The potentially negative implications of expecting employees to behave proactively. J Occup Organ Psych 83(2): 325–45. doi: 10.1348/096317910X493134 Bonner L (2010) Chapter 8: Nursing Interventions In: Welch E (ed) Venous thromboembolism: A Nurse’s Guide to Prevention and Management. WileyBlackwell, Chichester Bonner L, Coker E, Wood L (2008) Preventing venous thromboembolism through risk assessment approaches. Br J Nurs 17(12): 778–82 Catterick D, Hunt BJ (2014) Impact of the national venous thromboembolism risk assessment tool in secondary care in England: retrospective populationbased database study. Blood Coagul Fibrinolysis 25(6): 571–6. doi: 10.1097/ MBC.0000000000000100 Collins R, MacLellan L, Gibbs, MacLellan D, Fletcher J (2010) Venous thromboembolism prophylaxis: the role of the nurse in changing practice and saving lives. Aust J Adv Nurs 27(3): 83-89 Crant J (2000) Proactive behavior in organizations. J Manage 26(3): 435-62. doi: 10.1177/014920630002600304 Department of Health (2010) Equity and Excellence: Liberating the NHS. http:// tinyurl.com/mk4m6hd (accessed 8 December 2014) Findlay J, Keogh M (2011) Simple multidisciplinary education of junior doctors and nurses improves prescription of venous thromboembolism prophylaxis. J Perioper Pract 21(1): 28–32 Findlay J, Keogh M, Cooper L (2010) Venous thromboembolism prophylaxis: the role of the nurse. Br J Nurs 19(16): 1028–32 Fritz C, Sonnentag S (2007) Antecedents of day-level proactive behavior: a look at job stressors and positive affect during the workday. J Manage 35(1): 94–111. doi: 10.1177/0149206307308911 Geerts W (2009) Prevention of venous thromboembolism: a key patient safety priority. J Thromb Haemost 7(Suppl 1): 1–8. doi: 10.1111/j.15387836.2009.03384.x Grant AM, Ashford SJ (2008) The dynamics of proactivity at work. Res Organ Behav 28: 3–34. doi: 10.1016/j.riob.2008.04.002 Hornung S, Rousseau DM (2007) Active on the job—proactive in change how autonomy at work contributes to employee support for organizational change. Journal of Applied Behavioral Science 43(4): 401–26. doi: 10.1177/0021886307307555 Kim T, Cable, DM, Kim, S, Wang, J (2009) Emotional competence and work performance: The mediating effect of proactivity and the moderating effect of job autonomy. Journal of Organ Behav 30(7): 983-1000 Labarere J, Bosson J-L, Sevestre M-A, Sellier E, Richaud C, Legagneux A(2007) Intervention targeted at nurses to improve venous thromboprophylaxis. Int J Qual Health Care 19(5): 301–8 Lester W, Freemantle N, Begaj I, Ray D, Wood J, Pagano D (2013) Fatal venous thromboembolism associated with hospital admission: a cohort study to assess the impact of a national risk assessment target. Heart 99(23): 1734–9. doi: 10.1136/heartjnl-2013-304479 Li F, Walker K, McInnes E, Duff J (2010) Testing the effect of a targeted intervention on nurses’ compliance with ‘best practice’ mechanical venous
thromboembolism prevention. J Vasc Nurs 28(3): 92–6. doi: 10.1016/j. jvn.2010.06.002 Manser M, Thomson M (eds) (1995) Chambers Combined Dictionary Thesaurus. Chambers Harrap, Edinburgh Morrison R (2006) Venous thromboembolism: scope of the problem and the nurse’s role in risk assessment and prevention. J Vasc Nurs 24(3): 82–90. doi: 10.1016/j.jvn.2006.05.002 NHS England (2013) Commissioning services that deliver high quality VTE prevention: Guidance for Commissioners. http://tinyurl.com/n5gyrjb (accessed 10 December 2014) NHS England (2014) Letter to CCGs regarding venous thromboembolism (VTE) CQUIN Bulletin for CCGs. 6 March. http://tinyurl.com/mmnyb8f (accessed 11 December 2014) National Institute for Health and Care Excellence (2010) Venous thromboembolism: Reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital, NICE Clinical Guideline 92. http://www. nice.org.uk/guidance/CG92 (accessed 11 December 2014) National Patient Safety Agency (2011) How to guide:Venous Thromboembolism Risk Assessment. http://tinyurl.com/kquapcb (accessed 11 December 2014) Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. http://tinyurl.com/737we4y (accessed 11 December 2014) Ohly S, Sonnentag S, Pluntke F (2006) Routinization, work characteristics and their relationships with creative and proactive behaviors. J Organiz Behav 27(3): 257–79. doi: 10.1002/job.376 Parker SK, Turner N, Williams HM (2006) Modeling the antecedents of proactive behavior at work. J Appl Psychol 91(3): 636-52 Parker SK, Bindl UK, Strauss K (2010) Making things happen: A model of proactive motivation. J Manage 36(4): 827-56 Polit DF, Beck CT, Hungler B (2001) Essentials of Nursing Research: Methods, Appraisal and Utilization 5th edn. Lippincott Williams & Wilkins Philadelphia Risjord M (2008) Rethinking concept analysis. J Adv Nurs 65:(3) 684-91 Roberts LN, Porter G, Barker RD et al (2013) Comprehensive VTE prevention program incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis. Chest 144(4): 1276–81. doi: 10.1378/chest.13-0267 Spychala A, Sonnentag S (2011) The dark and the bright sides of proactive work behaviour and situational constraints: Longitudinal relationships with task conflicts. European Journal of Work and Organizational Psychology 20(5): 654–80. doi: 10.1080/1359432X.2010.487646 Thomas JP, Whitman DS,Viswesvaran C (2010) Employee proactivity in organizations: a comparative meta-analysis of emergent proactive constructs J Occup Organ Psychol 83(2): 275-300 Tooher R, Middleton P, Pham C, Fitridge R, Rowe S, Babidge W (2005) A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg 241(3): 397–415 Walker L, Avant KC (2010) Strategies for Theory Construction in Nursing 5th edn. Prentice Hall International, London Weaver K, Mitcham C (2008) Nursing concept analysis in North America: state of the art. Nurs Philos 9(3): 180–94. doi: 10.1111/j.1466769X.2008.00359.x Welch E (2010) Venous thromboembolism: A Nurse’s Guide to Prevention and Management. Wiley-Blackwell, Chichester Wilson J (1963) Thinking with Concepts. Cambridge University Press, Cambridge Worel JN (2009) Venous thromboembolism: What is preventing achievement of performance measures and consensus guidelines? J Cardiovasc Nurs 24(6): S14-19
Support and care for patients with long-term conditions Helen McVeigh
About the book
§ Each chapter presents learning points, using a reflective approach
Like other books in this series, Fundamental Aspects of Long-Term Conditions provides a succinct, useful basis from which both student nurses and adult nurses can extend their knowledge and skills.
§ Essential guide to long-term conditions, exploring the key principles of About the author
practice, skills and policy
Helen McVeigh is a Senior Lecturer in Primary Care at De Montfort University Leicester. She is a qualified District Nurse. She has over 20 years experience of working in Primary Care working in both rural and inner city practices.
Other titles in the Fundamental Aspects of Nursing series: Children & Young Peoples Nursing Procedures Community Nursing Complementary therapies Finding Information Mental Health Nursing
§ Case history examples included to illustrate issues discussed
Nursing Adults with Respiratory Disorders Nursing the Acutely Ill Adult Pain Assessment & Management Palliative Care Nursing 2nd edition Research for Nurses
Order your copies by visiting
www.quaybooks.co.uk
Long-Term Conditions Edited by Helen McVeigh
or call our Hotline
+44(0)1722 716 935 ISBN 1-85642-392-1
9
British Journal of Nursing, 2015, Vol 24, No 1
www.quaybooks.co.uk
781856 423922
Edited by Helen McVeigh
© 2015 MA Healthcare Ltd
Editor: John Fowler ISBN-13: 978-1-85642-392-2; 234 x 156 mm; paperback; 280Seriespages; publication 2010; £24.99
Fundamental Aspects of
Fundamental Aspects of Long-Term Conditions
Providing support and care for individuals with a long-term condition is an essential feature of modern health care. Over 15 million people in England currently have a long-term condition, and it is predicted that these numbers will continue to rise. Treating the range of long-term conditions that affect the population will therefore play an important role for health professionals. This book is an essential guide to long-term conditions, exploring the key principles of practice, skills and policy. The chapters in this book can be read as stand-alone chapters, or the book can be read in sequence. Full references are provided.
Fundamental Aspects of Nursing series
25
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved. FA LTCs cover.indd 1
Abstract
Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience. Key words: Venous thromboembolism ■ Nursing assessment ■ Leadership ■ Nurse’s role ■ Pulmonary embolism
C
oncept analysis involves forming and clarifying a mental construct, and appraising it to both advance theory and guide practice (Weaver and Mitcham, 2008). Risjord (2008) states that concepts get their content from the context they are set in, and that concept analyses must be related to context to make the process more robust. This was the aim of this concept analysis of proactivity set in the context of venous thromboembolism (VTE) prevention, and specifically aimed at nurses. The term ‘proactive’ is defined as ‘actively instigating changes in anticipation of future developments, as opposed to merely reacting to events as they occur’ and ‘ready to take the initiative: acting without being prompted by others’ (Manser and Thomson, 1995). Parker et al (2010: 1), add ‘being proactive is about anticipating and preventing problems and seizing opportunities’. VTE prevention is an international patient safety issue. The incidence of VTE is around 1-2 per 1000, with the risk
increasing with age. It is thought that 1 in 20 people will suffer with VTE at some point and around half of these cases are linked with recent hospitalisation (NHS England, 2013).VTE is the umbrella term used for two related conditions: thrombosis of the ‘deep veins’, known as deep vein thrombosis (DVT), and pulmonary embolism (PE), which is when a clot dislodges and travels through the heart to the lungs (Welch, 2010). Since 2010, assessing adults on admission to hospital for risk of VTE has become mandatory (Welch, 2010).
Background VTE is often asymptomatic, but may cause pain and swelling in the leg. It can cause long-term morbidity owing to chronic venous insufficiency (National Institute for Health and Care Excellence (NICE), 2010).VTE prophylaxis is either mechanical—e.g. anti-embolism stockings—pharmacological— e.g. anticoagulants such as heparin—or both, and this is dependent on individual patient risk assessment. Anti-embolism stockings reduce venous stasis, whereas anticoagulants attempt to alter components in the blood responsible for clotting (Welch, 2010). Through implementation of these measures, nurses play a central role in VTE prevention (Bonner et al, 2008; Worel, 2009). The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive, with treatment taking place after VTE has occurred rather than preventing the occurrence. There is a wealth of literature on how to prevent VTE and how to increase concordance in VTE prevention (Tooher et al, 2005; Geerts, 2009; Li et al, 2010); however defining proactivity in VTE prevention and exploring how staff can be encouraged to behave proactively could potentially increase the prescription, and, crucially, provision of prophylaxis, thereby improving patient care. The model used to analyse the concept of proactivity in VTE prevention is based on that of Walker and Avant (2010). It consists of: choosing a concept, identifying all current uses of the concept, identifying defining attributes, developing model, borderline and contrary cases, identifying antecedents and consequences, and demonstrating empirical referents.
Averil Adams, Junior Sister and Clinical Educator, Clayton Ward, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust Accepted for publication: October 2014
20
The following ten databases were searched in March 2012: Applied Social Sciences Index and Abstracts (ASSIA), CINAHL, Cochrane, Medline, NICE database, PAIS International, PsycINFO, Scopus, Sociological Abstracts, and Web of Science.The following keywords were used: proactive, proactivity, nurse/nursing, VTE/venous thromboembolism,
© 2015 MA Healthcare Ltd
Methods
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
CONCEPT ANALYSIS prevent/prevention/preventing, behaviour (this was included to identify literature on employee behaviour) and DVT/ PE. It was decided to use two different search strategies, one focusing on proactivity and one on VTE prevention. An initial literature search (2005-2012, in line with recent VTE literature) did not yield any results directly linking proactivity and VTE prevention. This was a significant finding, suggesting it had not been explored before. This meant there were no current uses of the concept to compare/ explore, as per the second stage of the Walker and Avant model of concept analysis (2010). Therefore it was necessary to identify all relevant proactivity sources and apply them to the VTE prevention sources. Proactivity research began in 1993 with seminal work by Bateman and Crant. However, research on VTE prevention needed to be current, as additional emphasis was placed on this following publication of the report by the House of Commons Select Committee in 2005 (Welch, 2010). Hence, a date limit of 20 years was applied to the proactivity keyword search, and 7 years to the VTE search. The results were refined by excluding non-English language, research on non-human subjects, conference papers, news reports, editorials, comments, reviews, abstracts, dissertations, theses, studies on children, articles using ‘proactive’ as an adverb with no definition, articles on proactivity linked with ageing, coaching, advancement potential, newcomers, social capital, leadership of teams and mood. This left 24 articles on proactivity for inclusion in the study. Articles on treating or recognising VTE, comparing/testing the efficacy of prophylaxis, and on developing protocols and guidelines were excluded, as the focus of the concept analysis is prevention.Articles focusing on increasing staff concordance were excluded, as proactive behaviour means acting without being prompted by others (Manser and Thomson, 1995). The remaining 10 articles focused on promoting VTE prevention, particularly the nurse’s role. It was deemed important to obtain a local viewpoint. Kay Sumner is the VTE specialist nurse at United Lincolnshire Hospitals NHS Trust. She directed the author to the Safety and Quality Dashboard, a reliability tool that assesses what doctors and nurses do that affects patient care. It is part of the Safety Express Plus programme that measures data in four key areas: falls, pressure ulcers, catheter-acquired urinary tract infections and VTE (Department of Health (DH), 2010). Sumner suggests that good practice in VTE prevention can be identified through the monthly results. She also directed the author to the ‘CQUIN’ for VTE prevention—the Commissioning for Quality and Innovation payment framework (Arya and Hunt, 2010), which gave a financial incentive for NHS trusts to achieve 90% VTE risk assessment on admission. From April 2014 this incentive ceased to exist (NHS England, 2014).
© 2015 MA Healthcare Ltd
Defining attributes Reviewing the proactivity sources and linking them to the VTE sources identified the defining attributes of proactivity in VTE prevention. Wilson (1963) states that defining attributes facilitate understanding of the concept when explaining it to colleagues; they enable us to decide what is a good example of the concept, illustrated later within the model case.
British Journal of Nursing, 2015, Vol 24, No 1
Personal initiative Parker et al (2010), state that personal initiative (n=17 of 24 articles) is one of the most important concepts introduced into the literature on proactivity. Crant (2000) states personal initiative is persistent, self-starting and proactive. Thomas et al (2010) conducted a meta-analysis of literature on four proactive constructs, including personal initiative (n=103 articles, 32 967 participants). Personal initiative was studied in 21% of the articles analysed. Findlay et al (2010) observed, from working as junior doctors, countless instances of being prompted by nurses to prescribe thromboprophylaxis. This could be identified as nurses demonstrating personal initiative in VTE prevention. However, while anecdotal evidence may serve to illustrate a point, it is subjective in nature and should be used with caution (Polit et al, 2001). Patients’ needs are constantly changing and nurses are well positioned to recognise this and instigate prompt changes to their treatment (Beck, 2006; Bonner et al, 2008). Anecdotally, Bonner provides her own example of personal initiative: nurses must consider whether the measures prescribed are relevant and applicable to the patient’s needs. For example, they may have a drain in situ that has drained an excessive amount, which may make pharmacological prophylaxis inappropriate. Bonner et al (2008) add that risk assessment is only the first stage of a process. It does not protect the patient unless measures are implemented following the assessment; ensuring they are relevant and implementing these measures would demonstrate personal initiative. For a nurse to function as an effective advocate for patients, he or she needs to demonstrate personal initiative on a daily basis. Personal initiative is therefore an essential attribute for a nurse to possess. Each patient is an individual, and each will have differing requirements in VTE prevention.
Taking charge Taking charge (n=15 of 24 articles) can be defined as a constructive effort to change how work is executed (Crant, 2000). It is important to differentiate between the nurse taking charge of the ward/group of patients, and taking charge in the proactive sense. Taking charge was one of the proactive constructs included in the meta-analysis by Thomas et al (2010), included in 7% of the studies analysed. Bonner et al (2008) comment that provision of VTE prophylaxis generates an increased workload for nurses. This may be a reason why prophylaxis is not always fully implemented; ensuring the patient has been risk assessed, measuring for and applying anti-embolism stockings, giving verbal and written information to patients and completing documentation takes a significant amount of time. Taking charge is an important attribute for nurses to ensure they see the process through, with all necessary steps taken. Labarere et al (2007) studied the effectiveness of an intervention targeting doctors and nurses in improving VTE prophylaxis provision. Compared with the intervention aimed at doctors only (n=497 patients), the intervention aimed at doctors and nurses (n=315) found the rate of antiembolism stocking usage increased, but not significantly
21
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Feedback-seeking behaviour Feedback-seeking behaviour (n=12 of 24 sources) is viewed as a proactive behaviour (Crant, 2000; Grant and Ashford, 2008; Belschak et al, 2010). Kim et al (2009) state that seeking feedback improves an employee’s performance, as he or she can understand the organisation’s needs and his or her supervisor’s expectations, and, as a result, prioritise appropriately. At the King’s Thrombosis Centre, Lynda Bonner, Consultant Nurse for Thrombosis and Anticoagulation at King’s College Hospital, says nurses are involved in audits so they can feed back where improvement is needed. This can be directly compared with the Safety and Quality Dashboard (DH, 2010). NHS England (2013) advises that a root cause analysis be performed for all hospital-acquired thrombosis. Root cause analysis could be described as the ‘ultimate’ in feedback-seeking behaviour, looking into the cause of VTE in detail to try and prevent it recurring in the future. These initiatives can be effective in improving VTE prevention strategies, but the onus is on nurses demonstrating proactivity by accessing the information and learning from it to shape practice. Without this, they would not be able to direct their efforts appropriately or effectively.
Cases The following fictitious cases aim to illustrate the concept of proactivity in VTE prevention by providing examples of a model case (that displays all defining attributes), a borderline
22
case (displaying some of the defining attributes) and a contrary case (illustrating what is not the concept.This section seeks to situate the concept firmly within the clinical context.
Model case Mrs Fuller is admitted with abdominal pain. The staff nurse, Sally, knows that Mrs Fuller will need a VTE assessment and appropriate prophylaxis. Sally sees that the risk assessment has not been completed, but heparin and anti-embolism stockings have been prescribed. Sally contacts the doctor and asks her to complete the risk assessment. Once this has been done, Sally notes that Mrs Fuller suffers with peripheral vascular disease and that anti-embolism stockings are contraindicated. She therefore does not apply stockings, explaining why to Mrs Fuller, documenting the reason for the omission in the notes, and informing the doctor. Sally completes the nursing assessment and gives Mrs Fuller the patient information leaflet on VTE prevention. Sally accesses the Safety and Quality Dashboard on a monthly basis to establish where the team are doing well and where further input is needed. Within this example, Sally demonstrates all three defining attributes. She takes charge when she asks the doctor to complete the risk assessment. Sally uses personal initiative when not applying anti-embolism stockings, despite these being prescribed. Accessing the Safety and Quality Dashboard demonstrates regular feedback-seeking behaviour.
Borderline case Mrs Fuller is admitted with abdominal pain. Sally notes that heparin and anti-embolism stockings are prescribed. She does not apply stockings, as she sees that Mrs Fuller has peripheral vascular disease. Sally does not check to see if the VTE risk assessment has been completed. She completes the nursing assessment and provides Mrs Fuller with the patient information leaflet, but does not document her actions in the notes. She is aware of the Safety and Quality Dashboard, but does not access the results to improve her practice. In this example, Sally demonstrates personal initiative when not applying anti-embolism stockings, as they are contraindicated. Completing the nursing assessment and providing the patient information leaflet shows she is taking charge, but only to a limited extent. Sally does not demonstrate feedback-seeking behaviour.
Contrary case Mrs Fuller is admitted to the ward with abdominal pain. The VTE risk assessment is not completed on admission, however heparin and anti-embolism stockings are prescribed. Sally administers both, but the stockings have to be removed the following day as Mrs Fuller suffers from peripheral vascular disease and complains of leg pain caused by the inappropriate application of anti-embolism stockings. Sally is not aware of the Safety and Quality Dashboard. This case clearly demonstrates what is not the concept. Sally does not use personal initiative as she applies antiembolism stockings even though they are contraindicated. She does not take charge to ensure the risk assessment is completed. She is reactive rather than proactive when the
© 2015 MA Healthcare Ltd
(p=0.74). By educating nurses, the authors expected provision of anti-embolism stockings to increase. Similarly, Findlay and Keogh (2011) studied the effect of 10-minute educational sessions for doctors and nurses in VTE prevention. They found prescription of anti-embolism stockings improved significantly (p=0.015) but provision (i.e. application of anti-embolism stockings by nursing staff) improved non-significantly (p=0.167). These studies suggest effective VTE prevention involves more than education about its importance. Nurses need to make a conscious decision to ‘take charge’ of VTE prevention. Collins et al (2010) studied rates of VTE prophylaxis before and after nursing educational sessions. They carried out a longitudinal audit on 2063 patients and found prophylaxis increased from 27% to 85% (p=0.0001). The reason their intervention may have succeeded is that it focused on empowering nurses to take ownership of VTE prevention. They concluded nurses must adopt a ‘can do’ attitude in actively promoting VTE prevention. In addition to this, Bonner (2010) said that successful implementation of VTE prevention requires strong leadership, courage, ownership and project-management skills. Individuals do not have to wait to be told what to do, or act only when a problem occurs. They can choose to take charge, anticipate opportunities and problems and shape themselves or the situation to change the future (Parker et al, 2010). Nurses can receive inordinate amounts of training in VTE prevention, but without making the conscious decision to take charge this training is worthless—they are the key to successful implementation.
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
CONCEPT ANALYSIS stockings have to be removed the following day. She does not demonstrate feedback-seeking behaviour.
Discussion The borderline and contrary cases are a potential breach of the Nursing and Midwifery (NMC) Code (2008), which states that nurses must have the knowledge and skills for safe and effective practice when working without supervision. This emphasises the importance of proactivity in nursing, rather than reacting to events after they have occurred. It also emphasises the importance of ensuring the antecedents to proactivity in VTE prevention are present.
Antecedents Autonomy Grant and Ashford (2008), state that autonomy fosters proactivity. Parker et al (2010) add that jobs enriched with autonomy and complexity are key in influencing perceptions of control over the work environment. Professional autonomy is an essential antecedent; nurses need to have the freedom to take charge and use their initiative to ensure each patient is treated as an individual and receives the prophylaxis they require.
Leadership Bindl and Parker (2010) suggest leaders have a role to play in proactivity through motivation; a good relationship between leader and employee should promote a climate of trust, where employees engage in change-oriented, self-initiated behaviours. Supporting this, Parker et al (2006) state that supportive leadership such as encouraging high expectations, self-observation and goal-setting will foster proactive behaviours in employees. Bonner (2010) places a high emphasis on strong leadership skills to get doctors and nurses involved with audits and feedback for ongoing improvement. Worel (2009) states the VTE specialist nurse plays an important part in leadership, developing and using monitoring systems including audits and result reporting. Bindl and Parker (2010) add employees may require support from managers to feel confident enough to engage in proactive behaviours. Bolino et al (2010) caution that if proactivity is discouraged by supervisors, this may lead to employee withdrawal.
© 2015 MA Healthcare Ltd
Knowledge, education and training In a review of performance measures, Worel (2009) identified that one of the barriers to implementing VTE prevention guidelines was a lack of knowledge of risk assessment and prophylaxis strategies. Bonner et al (2008) states that nurses need to be aware of the indications, correct administration, modes of action, contraindications, side effects and ongoing monitoring needed when implementing VTE prophylaxis. A significant part of the successful initiative to improve VTE prophylaxis described by Collins et al (2010) focused on developing nurses’ knowledge and skills. They concluded that this undoubtedly led to an improvement in patient care.
Responsibility and accountability Lack of individual responsibility was found to be a barrier to effective VTE prevention (Worel, 2009). Nurses are responsible
British Journal of Nursing, 2015, Vol 24, No 1
and accountable for the administration of VTE prophylaxis (Morrison, 2006). Collins et al (2010) concluded it is vital nurses accept responsibility for VTE prevention. Anecdotally, Bonner feels VTE prevention measures should focus on protecting the patient, and the nurse’s accountability.The NMC (2008) states that nurses must maintain the safety of those in their care, and that they are personally accountable for their actions and omissions. One way of ensuring nurses are aware of their responsibility and accountability around VTE prevention is to use a specific nursing care plan (Bonner, 2010).
Role-based self efficacy Role-based self efficacy is a self-perception of the confidence an individual has in his or her own ability to perform in ways that increase responsibility and complexity in his or her role (Hornung and Rousseau, 2007). Parker et al (2006) found rolebased self efficacy was an important predictor of proactivity. Similarly, in a longitudinal study of hospital employees (n=373) Hornung and Rousseau (2007) found role-based self efficacy was related to commitment to changes that broaden the employee’s role. Role-based self efficacy is an important antecedent; without confidence in their abilities, nurses may not be able to take charge of VTE prevention effectively. The yearly appraisal should reinforce role-based self efficacy.
Ethics and duty of care The NMC (2008) states that nurses must provide a high standard of care at all times. Keogh (BBC Radio 4, 2011) adds that tackling VTE is a professional, moral and social responsibility for health professionals. The nurses’ own personal beliefs and ethics may affect their viewpoint on the importance of VTE prevention, and how proactive they are. Anecdotally, Sumner suggests coagulation link nurses who have a personal interest in VTE prevention are often more motivated or dedicated to the role and Bonner recommends two coagulation link nurses per clinical area, recruited for their attributes and keenness. The National Patient Safety Agency (NPSA) advocate that trusts or clinical areas select coagulation link nurses with an interest in VTE prevention (NPSA, 2011).
Consequences Findlay et al (2010) state that nurses have the ability to prevent a huge amount of morbidity and mortality by providing routine prophylaxis and can promote a culture change to ensure prophylaxis is considered for all patients automatically. In addition, Morrison (2006) suggests that nurses meeting quality assurance standards can directly translate into improvements in patient care. Therefore, the consequence of proactivity in VTE prevention should be a fall in hospital-acquired thrombosis, as suggested by the empirical referents. Additional beneficial consequences of proactivity in VTE prevention include nurses feeling empowered, thus increasing their job satisfaction; and patients being well-informed of the risk factors and what is being done to minimise them, reassuring them that patient safety is a priority. Proactivity may lead to increased use of mental and physical resources, leading to increased stress for the employee
23
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Empirical referents Empirical referents are behaviours or conditions that prove the existence of the concept (Weaver and Mitcham, 2008). Since undertaking this work, recent studies have been published that demonstrated a drop in hospital-acquired thrombosis since the CQUIN target was introduced (Lester et al, 2013; Roberts et al, 2013; Catterick and Hunt, 2014). These prove the existence of the concept as they strongly suggest that prophylaxis was implemented as a result of risk assessment. Colchester Hospital University NHS Foundation Trust devised a ‘nurse-led-doctors-complete’ VTE risk assessment system (Arya and Hunt, 2010). This allowed senior nurses to demonstrate proactivity by taking charge, proving the existence of the taking charge element of proactivity in VTE prevention. Conducting root cause analyses after incidences of hospitalacquired thrombosis and conducting audits such as the Safety and Quality Dashboard prove the existence of the feedbackseeking behaviour element of proactivity in VTE prevention.
KEY POINTS n The
author has observed gaps in prescription and provision of venous thromboembolism (VTE) prophylaxis, and that the attitude to VTE is often reactive rather than proactive
n A
key finding in itself is that this is an original concept, which has never been defined before
n Defining
attributes are identified as personal initiative, feedback-seeking behaviour and taking charge
n The
antecedents are identified as autonomy, leadership, knowledge, education and training, responsibility and accountability, role-based self efficacy and ethics/duty of care
n Defining
the concept and identifying its antecedents should allow organisations to foster and develop these to demonstrate a measurable reduction in hospital-acquired thrombosis
24
Assessment, prescription and provision of VTE prophylaxis is more stream-lined when suitably trained nurses apply anti-embolism stockings without prescription (unless contraindicated) and carry out the risk assessment on admission, as advocated by the DH (Arya, 2009). Proactivity in VTE prevention is demonstrated at trusts where this occurs. As encouraging proactivity inVTE prevention is so important (and it must be acknowledged that it can be time-consuming and challenging at times), Bonner suggests two coagulation link nurses per clinical area is sound advice. This demonstrates the taking charge and personal initiative elements of proactivity in VTE prevention. It is important that the role is developed in order for it to be effective. For this to happen, the coagulation link nurse must be supported by his or her line manager, be given the autonomy to develop the role and be supported through the yearly appraisal. The VTE specialist nurse should be a regular visible presence in clinical areas. Link nurse meetings give coagulation link nurses the opportunity to meet and share ideas and best practice. An effective link nurse network demonstrates the feedback-seeking behaviour element of proactivity in VTE prevention.
Conclusion This concept analysis has identified the defining attributes of proactivity in VTE prevention, personal initiative, taking charge and feedback-seeking behaviour. It also identified antecedents, which are essential as these are factors that need to be present to allow nurses to be proactive in VTE prevention. Nurses have a pivotal role in VTE prevention, and proactivity is central to this. As each patient is an individual, nurses must use their personal initiative and take charge to ensure patients are protected from avoidable VTE. Seeking feedback is central to effective nursing practice, reflecting on measures that are working and areas that need improvement, both at an individual and organisational level, to ensure that patients receive the best care possible. Defining proactivity in VTE prevention and exploring how nurses can be encouraged to behave proactively could potentially increase the prescription and, crucially, provision of prophylaxis, thereby reducing avoidable BJN harm and improving the patient experience. Conflict of interest: none Acknowledgements: the author would like to thank Lynda Bonner, Consultant Nurse for Thrombosis and Anticoagulation at King’s College Hospital and Dave Wilson, Assistant Professor (Mental Health) from the University of Nottingham. The full article is available online at http://tinyurl.com/ conceptanalysisvte Arya R (ed) (2009) Venous Thromboembolism Prevention: A Patient Safety Priority http://tinyurl.com/psswk3u (accessed 8 November 2014) Arya R, Hunt B (eds) (2010) Venous Thromboembolism Prevention: A Guide for Delivering the CQUIN Goal http://tinyurl.com/q6wuz6g (accessed 8 December 2014) Bateman TS, Crant JM (1993) The proactive component of organizational behavior: A measure and correlates. J Organiz Behav 14(2): 103–18. doi: 10.1002/job.4030140202 BBC Radio 4 (2011) Face the Facts: Saving Lives in Seconds (Broadcast date 17 July 2011) http://tinyurl.com/nx3k4lv (accessed 10 December 2014)
© 2015 MA Healthcare Ltd
(Belschak and Den Hartog, 2010; Bolino et al, 2010). Proactive employees may be seen as ‘doing too much’ or ingratiating themselves with their supervisors (Belschak and Den Hartog, 2010). Bolino et al (2010) add they may be seen as overzealous or impulsive; and that it is important to consider that individuals may all perceive proactivity differently. Bolino et al (2010) also state proactive behaviours may take up more of the employee’s time. This is supported by studies by Fritz and Sonnentag (2007) and Ohly et al (2006) who also found too much time pressure constrained proactivity; suggesting it is by nature time-consuming. Grant and Ashford (2008) state further research into the costs and benefits of proactivity may reveal mixed effects and unintended consequences for organisations and employees. Spychala and Sonnentag (2011) add that the consequences of proactivity may be more complex than previously acknowledged. However, Belschak and Den Hartog (2010) and Bolino et al (2010) both conclude that overall proactivity does more good than harm. Bindl and Parker (2010) add that the price of passivity may be greater than occasional misguided proactivity.
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
CONCEPT ANALYSIS Beck DM (2006) Venous thromboembolism (VTE) prophylaxis: implications for medical-surgical nurses. Medsurg Nurs 15(5): 282–7 Belschak FD, Den Hartog DN (2010) Pro-self, prosocial, and pro-organizational foci of proactive behaviour: differential antecedents and consequences. J Occup Organ Psych 83(2): 475–98. doi: 10.1348/096317909X439208 Belschak FD, Den Hartog DN, Fay D (2010) Exploring positive, negative and context-dependent aspects of proactive behaviours at work. J Occup Organ Psych 83(2): 267–73. doi: 10.1348/096317910X501143 Bindl U, Parker S (2010) Proactive work behaviour: Forward-thinking and change-oriented action in organizations In: Zedeck S (ed) APA Handbook of Industrial and Organizational Psychology.Vol 2: Selecting and developing members for the organization 567-98 American Psychological Association, Washington DC Bolino M,Valcea S, Harvey J (2010) Employee, manage thyself: The potentially negative implications of expecting employees to behave proactively. J Occup Organ Psych 83(2): 325–45. doi: 10.1348/096317910X493134 Bonner L (2010) Chapter 8: Nursing Interventions In: Welch E (ed) Venous thromboembolism: A Nurse’s Guide to Prevention and Management. WileyBlackwell, Chichester Bonner L, Coker E, Wood L (2008) Preventing venous thromboembolism through risk assessment approaches. Br J Nurs 17(12): 778–82 Catterick D, Hunt BJ (2014) Impact of the national venous thromboembolism risk assessment tool in secondary care in England: retrospective populationbased database study. Blood Coagul Fibrinolysis 25(6): 571–6. doi: 10.1097/ MBC.0000000000000100 Collins R, MacLellan L, Gibbs, MacLellan D, Fletcher J (2010) Venous thromboembolism prophylaxis: the role of the nurse in changing practice and saving lives. Aust J Adv Nurs 27(3): 83-89 Crant J (2000) Proactive behavior in organizations. J Manage 26(3): 435-62. doi: 10.1177/014920630002600304 Department of Health (2010) Equity and Excellence: Liberating the NHS. http:// tinyurl.com/mk4m6hd (accessed 8 December 2014) Findlay J, Keogh M (2011) Simple multidisciplinary education of junior doctors and nurses improves prescription of venous thromboembolism prophylaxis. J Perioper Pract 21(1): 28–32 Findlay J, Keogh M, Cooper L (2010) Venous thromboembolism prophylaxis: the role of the nurse. Br J Nurs 19(16): 1028–32 Fritz C, Sonnentag S (2007) Antecedents of day-level proactive behavior: a look at job stressors and positive affect during the workday. J Manage 35(1): 94–111. doi: 10.1177/0149206307308911 Geerts W (2009) Prevention of venous thromboembolism: a key patient safety priority. J Thromb Haemost 7(Suppl 1): 1–8. doi: 10.1111/j.15387836.2009.03384.x Grant AM, Ashford SJ (2008) The dynamics of proactivity at work. Res Organ Behav 28: 3–34. doi: 10.1016/j.riob.2008.04.002 Hornung S, Rousseau DM (2007) Active on the job—proactive in change how autonomy at work contributes to employee support for organizational change. Journal of Applied Behavioral Science 43(4): 401–26. doi: 10.1177/0021886307307555 Kim T, Cable, DM, Kim, S, Wang, J (2009) Emotional competence and work performance: The mediating effect of proactivity and the moderating effect of job autonomy. Journal of Organ Behav 30(7): 983-1000 Labarere J, Bosson J-L, Sevestre M-A, Sellier E, Richaud C, Legagneux A(2007) Intervention targeted at nurses to improve venous thromboprophylaxis. Int J Qual Health Care 19(5): 301–8 Lester W, Freemantle N, Begaj I, Ray D, Wood J, Pagano D (2013) Fatal venous thromboembolism associated with hospital admission: a cohort study to assess the impact of a national risk assessment target. Heart 99(23): 1734–9. doi: 10.1136/heartjnl-2013-304479 Li F, Walker K, McInnes E, Duff J (2010) Testing the effect of a targeted intervention on nurses’ compliance with ‘best practice’ mechanical venous
thromboembolism prevention. J Vasc Nurs 28(3): 92–6. doi: 10.1016/j. jvn.2010.06.002 Manser M, Thomson M (eds) (1995) Chambers Combined Dictionary Thesaurus. Chambers Harrap, Edinburgh Morrison R (2006) Venous thromboembolism: scope of the problem and the nurse’s role in risk assessment and prevention. J Vasc Nurs 24(3): 82–90. doi: 10.1016/j.jvn.2006.05.002 NHS England (2013) Commissioning services that deliver high quality VTE prevention: Guidance for Commissioners. http://tinyurl.com/n5gyrjb (accessed 10 December 2014) NHS England (2014) Letter to CCGs regarding venous thromboembolism (VTE) CQUIN Bulletin for CCGs. 6 March. http://tinyurl.com/mmnyb8f (accessed 11 December 2014) National Institute for Health and Care Excellence (2010) Venous thromboembolism: Reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital, NICE Clinical Guideline 92. http://www. nice.org.uk/guidance/CG92 (accessed 11 December 2014) National Patient Safety Agency (2011) How to guide:Venous Thromboembolism Risk Assessment. http://tinyurl.com/kquapcb (accessed 11 December 2014) Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. http://tinyurl.com/737we4y (accessed 11 December 2014) Ohly S, Sonnentag S, Pluntke F (2006) Routinization, work characteristics and their relationships with creative and proactive behaviors. J Organiz Behav 27(3): 257–79. doi: 10.1002/job.376 Parker SK, Turner N, Williams HM (2006) Modeling the antecedents of proactive behavior at work. J Appl Psychol 91(3): 636-52 Parker SK, Bindl UK, Strauss K (2010) Making things happen: A model of proactive motivation. J Manage 36(4): 827-56 Polit DF, Beck CT, Hungler B (2001) Essentials of Nursing Research: Methods, Appraisal and Utilization 5th edn. Lippincott Williams & Wilkins Philadelphia Risjord M (2008) Rethinking concept analysis. J Adv Nurs 65:(3) 684-91 Roberts LN, Porter G, Barker RD et al (2013) Comprehensive VTE prevention program incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis. Chest 144(4): 1276–81. doi: 10.1378/chest.13-0267 Spychala A, Sonnentag S (2011) The dark and the bright sides of proactive work behaviour and situational constraints: Longitudinal relationships with task conflicts. European Journal of Work and Organizational Psychology 20(5): 654–80. doi: 10.1080/1359432X.2010.487646 Thomas JP, Whitman DS,Viswesvaran C (2010) Employee proactivity in organizations: a comparative meta-analysis of emergent proactive constructs J Occup Organ Psychol 83(2): 275-300 Tooher R, Middleton P, Pham C, Fitridge R, Rowe S, Babidge W (2005) A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg 241(3): 397–415 Walker L, Avant KC (2010) Strategies for Theory Construction in Nursing 5th edn. Prentice Hall International, London Weaver K, Mitcham C (2008) Nursing concept analysis in North America: state of the art. Nurs Philos 9(3): 180–94. doi: 10.1111/j.1466769X.2008.00359.x Welch E (2010) Venous thromboembolism: A Nurse’s Guide to Prevention and Management. Wiley-Blackwell, Chichester Wilson J (1963) Thinking with Concepts. Cambridge University Press, Cambridge Worel JN (2009) Venous thromboembolism: What is preventing achievement of performance measures and consensus guidelines? J Cardiovasc Nurs 24(6): S14-19
Support and care for patients with long-term conditions Helen McVeigh
About the book
§ Each chapter presents learning points, using a reflective approach
Like other books in this series, Fundamental Aspects of Long-Term Conditions provides a succinct, useful basis from which both student nurses and adult nurses can extend their knowledge and skills.
§ Essential guide to long-term conditions, exploring the key principles of About the author
practice, skills and policy
Helen McVeigh is a Senior Lecturer in Primary Care at De Montfort University Leicester. She is a qualified District Nurse. She has over 20 years experience of working in Primary Care working in both rural and inner city practices.
Other titles in the Fundamental Aspects of Nursing series: Children & Young Peoples Nursing Procedures Community Nursing Complementary therapies Finding Information Mental Health Nursing
§ Case history examples included to illustrate issues discussed
Nursing Adults with Respiratory Disorders Nursing the Acutely Ill Adult Pain Assessment & Management Palliative Care Nursing 2nd edition Research for Nurses
Order your copies by visiting
www.quaybooks.co.uk
Long-Term Conditions Edited by Helen McVeigh
or call our Hotline
+44(0)1722 716 935 ISBN 1-85642-392-1
9
British Journal of Nursing, 2015, Vol 24, No 1
www.quaybooks.co.uk
781856 423922
Edited by Helen McVeigh
© 2015 MA Healthcare Ltd
Editor: John Fowler ISBN-13: 978-1-85642-392-2; 234 x 156 mm; paperback; 280Seriespages; publication 2010; £24.99
Fundamental Aspects of
Fundamental Aspects of Long-Term Conditions
Providing support and care for individuals with a long-term condition is an essential feature of modern health care. Over 15 million people in England currently have a long-term condition, and it is predicted that these numbers will continue to rise. Treating the range of long-term conditions that affect the population will therefore play an important role for health professionals. This book is an essential guide to long-term conditions, exploring the key principles of practice, skills and policy. The chapters in this book can be read as stand-alone chapters, or the book can be read in sequence. Full references are provided.
Fundamental Aspects of Nursing series
25
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved. FA LTCs cover.indd 1
