YNEDT-02964; No of Pages 6 Nurse Education Today xxx (2015) xxx–xxx
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Use of technical skills and medical devices among new registered nurses: A questionnaire study Mona Ewertsson a,⁎, Margareta Gustafsson a, Karin Blomberg a, Inger K. Holmström b,c, Renée Allvin a,d a
Faculty of Health and Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden d Clinical Skills Centre, Örebro University Hospital, Örebro, Sweden b c
a r t i c l e
i n f o
Article history: Accepted 10 May 2015 Available online xxxx Keywords: Clinical competence Clinical laboratory Equipment and supplies Incident reports Medical devices New registered nurses Nursing skills Patient safety
s u m m a r y Background: One comprehensive part of nursing practice is performing technical skills and handling of medical equipment. This might be challenging for new registered nurses (RNs) to do in patient-safe way. Objectives: The aim of this study was to describe and compare the extent to which new RNs perform various technical skills and handle medical devices in different settings, and to investigate their possibility for continued learning in this respect. A further aim was to describe their perceptions of incident reporting related to technical skills and medical devices. Design: A cross-sectional study with descriptive and comparative design. Participants: RNs who recently graduated from a nursing programme at three Swedish universities and had worked as a RN for up to 1 year were included in the study (n = 113, response rate 57%). Method: Data were collected by means of a postal questionnaire. Results: Half of the RNs reported that they performed several of the listed tasks every day or every week, regardless of workplace. These tasks were most frequently performed in surgical departments. The majority of the participants (76%) stated a need of continued practical training. However, less than half of them (48%) had access to a training environment. Several participants (43%) had been involved in incidents related to technical skills or medical devices, which were not always reported. Nearly a third of the participants (31%) did not use the existing guidelines when performing technical skills, and reflection on performance was uncommon. Conclusions: This study highlights the importance of shared responsibilities between nurse educators and health care employers to provide learning opportunities for new RNs in technical skills, to maintain patient safety. To increase the safety culture where nursing students and new RNs understand the importance of using evidence-based guidelines and taking a reflective approach in the performance of technical tasks is needed. © 2015 Elsevier Ltd. All rights reserved.
Background One comprehensive part of nursing practice is the performance of technical skills and handling of medical equipment (Sandelowski, 2010). In order to provide adequate care and maintain patient safety, registered nurses (RNs) need to be equipped with proper skills in this respect (Norman, 2012). In this article, technical skills are defined as the portion of practical skills involving the use of equipment such as syringes, needles, catheters, probes, infusions, and masks. Technical skills in nursing are often described as simple and mechanical motor skills, but the performance of these skills is a complex action (Bjørk and Kirkevold, 2000; Reierson et al., 2013). A safe performance of technical skills requires both theoretical knowledge and the ability to take a ⁎ Corresponding author at: Faculty of Health and Medicine, School of Health and Medical Sciences, Örebro University S-701 82 Örebro, Sweden. Tel.: +46 19303708. E-mail address: [email protected] (M. Ewertsson).
critical approach in order to adapt the performance to a specific situation (Benner et al., 2008; Reierson et al., 2013). In clinical practice, problems often arise that cannot be solved with a clear-cut answer. Theory learned through professional preparation is not always useful in solving these real-life problems. In the process of learning practical skills it is important to reflect both in and on action. Unexpected events generate reflection in practice by using current and past experiences and reasoning about unfamiliar events while they are occurring, but also reflection on practice while thinking back on what happened in a past situation. Key issues to consider in the development of professional competence are what has to be done, why, and in what way (Schön, 1991). Today's increasingly technical and complex health care places high demands on new RNs. The transition from nursing student to RN is a challenging period. Experiences of a stressful work environment (Bisholt, 2012; Duchscher, 2009), feelings of not being able to meet workplace demands, and a fear of making mistakes (Higgins et al.,
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Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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M. Ewertsson et al. / Nurse Education Today xxx (2015) xxx–xxx
2010) can occur up to a year after graduation (Casey et al., 2004). It has been reported from both new RNs and their co-workers that new RNs are inadequately prepared and therefore lack competence in practical skills (Bisholt, 2012; Higgins et al., 2010; Wangensteen et al., 2008). This might lead to a risk of incidents related to the use of medical devices and performance of technical skills where patients are inadvertently harmed by errors in the care which was supposed to heal them (Keller, 2010). The process of learning technical skills is initiated during undergraduate nursing education. It is an important task for nursing education to provide nursing students with adequate and sufficient amount of training (Benner et al., 2010). The educators decide which technical skills to prioritize and integrate in nursing curricula. However, today there is no consensus about which technical skills and handling of medical devices should be included in the curriculum, nor about when during the nursing education these skills are actually taught (Bland et al., 2011). It is also important for nursing education to enhance the understanding of the importance of reflection and using safe and evidence-based methods and following national guidelines when performing various techniques (Rudman et al., 2012). There is also a need for continued learning of technical skills after graduation. Due to constant development and variation of medical and technical equipment, a life-long learning approach is required (Keller, 2010). Although employers have a responsibility to support new RNs, there are different prerequisites for learning technical skills in terms of both extent and structure (Bisholt, 2012; Jones et al., 2014). Access to a clinical skill laboratory (CSL) (Salminen et al., 2010), conscious discussions and evaluations regarding equipment and application principles (Mattox, 2012), and evaluations of incident reports (Vicente and Kern, 2005) can provide RNs with the opportunity to continue their learning and reduce the risk of incidents and errors in the clinical setting. To our knowledge, there is no current study that has explored the extent to which various technical skills and medical devices are used in the clinical settings where new RNs frequently work. Filling this knowledge gap can provide guidance for nursing education in the selection of which technical skills and medical devices should be included in the education. It can also guide the choice of training activities that employers need to provide to secure the quality of care and patient safety. The extent to which RNs use guidelines in their performance of technical skills, and how incidents are reported, also gives a picture of their work in relation to technical skills. Therefore, the aim of this study was to describe and compare the extent to which new RNs perform various technical skills and handle medical devices in different settings, and to investigate their possibility for continued learning in this respect. A further aim was to describe the new RNs' perceptions of incident reporting related to technical skills and medical devices.
2011. These nursing programmes were 3 years in duration, had similar content, led to a Bachelor's degree, and followed regulations from the Swedish government and the Swedish Higher Education Authority. Approximately half the time of the nursing programmes consisted of courses with clinical training in both CSLs and clinical settings. A total of 207 RNs graduated from the universities in the relevant time period; 200 of them were eligible for the study, and 113 (57%) answered a questionnaire (Fig. 1).
Data Collection Letters were sent to each RN's home address including information about the study, a request for written consent, and a questionnaire. The RNs were asked to return the questionnaire in an enclosed prepaid envelope. Those who did not answer within a month received a reminder letter, which increased the response rate.
Measurement The questionnaire contained study-specific questions developed in discussion between researchers in the research group who had experiences of teaching technical skills and medical devices in the nursing programme, and of teaching and training hospital staff. After this initial step, the questions were discussed by researchers outside the research group, nurse teachers, and clinical RNs in order to achieve face validity (Polit and Beck, 2012) and to obtain opinions of whether the questions were realistic ones to ask and whether the layout was easy to use. The questionnaire was then revised and its layout was refined. The final version of the questionnaire that contained 17 questions was divided into four sections (Table 1). In addition to the 17 questions, information was collected about demographic characteristics such as age, gender, workplace, months of employment as a graduated RN, employment status, and work time/months.
Students graduated from the universities, n = 207
Could not be located, n = 5
Methods
n = 202 surveys sent
Design This survey is a cross-sectional study with descriptive and comparative design carried out in Spring 2012, including RNs who had recently graduated from a nursing programme at three universities in Sweden. It is part of a comprehensive research programme in cooperation between the three universities investigating various aspects of clinical education within the nursing programme (Bisholt et al., 2014; Sundler et al., 2014) and aspects of work situation for new RNs (Blomberg et al., 2014). Sampling an Settings The participants had all worked as RNs for at most 1 year after graduation when the study took place, and were recruited from lists provided by the universities of those who had graduated in Spring
Did not work as a RN, n = 2
Not willing to participate n = 87
113 included in the analysis Response rate = 57%
Fig. 1. Flow chart of participant recruitment.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
M. Ewertsson et al. / Nurse Education Today xxx (2015) xxx–xxx Table 1 Questions and response alternatives in the study specific questionnaire. Questions PART 1. Technical skills To what extent do you perform the technical skills listed below in your current job? Do you want to add anything to the list of technical skills? How do you assess your own ability to perform technical skills? To what extent has the nurse education prepared you to perform technical skills? How do you act in new and unfamiliar situations related to technical skills? PART 2. Medical devices To what extent do you handle the medical devices listed below in your current job? Do you want to add anything to the list of medical devises? How do you assess your own ability to handle medical devices? To what extent has the nurse education prepared you to handle medical devices? How do you act in new and unfamiliar situations related to medical devices? PART 3. Needs and possibilities for continued training Do you need practical training in your workplace with regard to technical skills and/or medical devices? Are there teaching rooms for practical training in your workplace? To what extent do you discuss and evaluate how to perform technical skills and the use of medical devices? PART 4. Incidence reporting To what extent do you think that incidences related to performance of technical skills or handling medical devices are reported at your workplace? Are there procedures for incidence reporting in your workplace? Have you personally reported procedures for incidence reporting at your workplace? Have you refrained to report an incident related to technical skills and medical devices?
Response alternatives
3
terms of whether they considered that their nursing education had prepared them for using technical skills and medical devices. Version 20 of the IBM Statistical Package for Social Sciences Statistics for Windows was used for the statistical analyses, and the significance level was set to 0.05.
VDSa 1–5b
Ethical Considerations Open ended NRSc 1–10d NRS 1–10e Fixed alternatives VDS 1–5b Open ended NRS 1–10d NRS 1–10e Fixed alternatives Yes/No Fixed alternatives NRS 1–10e
VDS 1–5f
Yes/No/Don't know Yes/No/Don't know Yes/No
The RNs received written information about the study and were asked to return their informed consent in a sealed envelope. They were assured that participation was voluntary and that the data would be handled with confidentiality. The data were coded before being entered in the statistical file. The study had ethical approval from the Regional Ethical Review Board of Uppsala (reg. no. 2011/07). Results Sample Description The 113 new RNs participating in the study were between 23 and 51 years old, with a median age of 26. The majority were female. At the time of the survey, they had worked as RNs for between 1 and 11 months, with a median of 9 months. The majority of them worked full-time and most of them had temporary employment. The most common working situation was work in hospital departments for medical care, followed by work in surgical departments. Work outside the hospital was most unusual, but included work on pre-hospital wards and municipal wards (Table 2). Use of Technical Skills Half of the RNs in the study, regardless of workplace, reported giving injections and performing infusion treatment every day (md 5). Enteral
a
Verbal descriptive scale. VDS: 1 = Never, 2 = quarterly or more rarely, 3 = every month, 4 = every week, 5 = every day. c Numerical rating scale. d NRS: 1 = not good, to 10 = very good. e NRS: 1 = never, to 10 = large extent. f VDS: 1 = never, to 5 = always. b
Data Analysis Demographic data are reported by means of descriptive statistics. Observations of continuous variables (age and time of employment) had a skewed distribution and are therefore described with median (md), first and third quartiles (q1 and q3), and range. The RNs' ratings of the extent to which they used technical skills and medical devices were made on ordinal scales, and are described by means of median value and quartiles. In order to obtain sufficiently large groups for statistical analyses of differences between workplaces, workplaces with similar characteristics were grouped together. The Kruskal–Wallis test, which is used for analysis of differences in distributions when observations have a rank order and there are more than two groups, showed that there were significant differences between the workplace groups. They differed regarding the use of all technical skills and medical devices listed in the questionnaire. Therefore we decided to use the Mann–Whitney test to further examine which of the workplace groups differed from the others. The Mann–Whitney test is analogous to Kruskal–Wallis test but is used for analysis of differences when there are only two independent groups. In those analyses, the workplace group where the RNs most often used technical skills and medical devices was chosen as the reference group. Only the results of the Mann–Whitney test are reported. The Kruskal–Wallis test was also used to analyse differences between RNs in different workplaces in
Table 2 Description of the study participants (n = 113). Descriptive statistics Gender Female Male Age, years Time in employment as graduated nurse, months Form of employment, Temporary employment Permanent employment Working hours Full-time Part-time Workplace Hospital department for medical care General medicine Neurology Cardiology Infectious disease Lung medicine Psychiatry Nephrology Oncology/palliative care Others (haematology, rehabilitation, and geriatrics) Hospital department for surgical care General surgery Orthopaedic surgery Urological surgery Other (ears, nose, and throat, gastrointestinal, and gynaecological surgery) Workplace outside hospital Elderly care in the community Pre-hospital care
102 (90%) 11 (10%) md⁎ 26, q1⁎ 24, q3⁎ 31, range 23–51 md⁎ 9,, q1⁎ 9, q3⁎ 10 range 1–11 82 (73%) 31 (27%) 79 (70%) 34 (30%) 56 (50%) 13 9 6 5 5 5 4 3 6 36 (32%) 22 8 2 4 21 (18%) 13 8
⁎ md = Median, q1 = first quartile, q3 = third quartile.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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M. Ewertsson et al. / Nurse Education Today xxx (2015) xxx–xxx
tube insertion and suction of the respiratory system were performed more rarely (md 2), regardless of workplace (Table 3). In comparison between departments for surgical care and departments for medical care, there were significant differences in how often the RNs performed several skills. The RNs at the surgical departments performed most of the technical skills more often than RNs at departments for medical care; only suction of the respiratory system was more frequently performed in medical care. Giving injections, oxygen therapy, enteral nutrition, and urinary catheterization were equally common in surgical and medical care. In comparing the RNs working in departments for surgical care and the RNs working outside the hospital, all technical skills were used more often in the surgical departments except urinary catheterization and suction of the respiratory system, which were equally common in both workplaces (Table 3). The questionnaire included an open– ended alternative, which allowed the RNs to add technical skills which were missing from the list, but none of the respondents took this opportunity. The RNs generally considered that their ability to perform the technical skills that existed in their workplace was close to the “very good” endpoint, with median value of 8.0 (q1 7, q3 9, range 4–10). Concerning their estimations of how well their nursing education had prepared them to perform technical skills, about half of them scored 7–10 on the 10-point numeric rating scale (md 7, q1 6, q3 8, range 2–10). The workplaces did not differ in terms of whether the RNs considered that their education had prepared them to perform technical skills (p = 0.969). The RNs used different strategies to gain knowledge of technical skills in a new or unfamiliar situation; 78 of them (69%) always read national or local guidelines about how to perform technical skills, and the remaining 35 (31%) did not read any guidelines but instead asked colleagues or the ward manager how things should be done.
Table 4 Differences between workplaces in the extent to which nurses used medical devices, with departments for surgical care as reference.
Electronic thermometer Glucose metre Pulse oximeter Bladder scanner Infusion pump Electrocardiograph Electronic blood pressure device Patient-controlled analgesia (PCA) pump Nasogastric pump Haemoglobin metre Blood warming device Defibrillator Cryotherapy
Total
Hospital department for surgical care
Hospital department for medical care
(n = 113)
(n = 36)
(n = 56)
Workplace outside hospital (n = 21)
Md q1 q3 Md q1 q3 Md q1 q3
Md q1 q3
5
4
5
5
5
5
5
4
5*
4
3
5***
5 5 4 3 3 3
4 4 3 2 2 1
5 5 4 4 4 5
5 5 4 4 3 3
4 4 4 3 2 1
5 5 5 4 4 5
5 5 4 4 4 3
4 4 3 3 3 1
5 5 4*** 4 4 5
4 2 2 1 1 4
3 1 1 1 1 1
5 5** 3*** 2*** 4* 5
2
1
3
3
2
4
2
1
3*** 1
1
2***
2 1 1 1 1
1 1 1 1 1
3 3 2 2 1
2 3 1 1 1
1 2 1 1 1
3 4 3 2 1
2 1 1 2 1
2 1 1 1 1
3 2*** 2 2 1
1 1 1 1 1
2** 3** 2 3 1*
1 1 1 1 1
1 = Never, 2 = every quarter or more rarely, 3 = every month, 4 = every week, 5 = every day. Mann–Whitney U-test: * = p-value b 0.05, ** = p-value b 0.01, *** = p-value b 0.001.
listed. In comparison with RNs working outside the hospital, RNs working in hospital departments for surgical care made more frequent use of all medical devices except electronic blood pressure metres, blood warmers, defibrillators, and glucometers, which were equally used by both (Table 4). Most RNs rated their ability to use the medical devices that existed in their workplace close to the “very good” endpoint (md 8, q1 8, q3 9, range 3–10). On the question of whether their nursing education had prepared them for using medical devices, about half of the RNs scored 6–10 on the 10-point numeric rating scale (md 6, q1 5, q3 7, range 2– 10). There was no difference between the workplaces in terms of whether the RNs considered that their nursing education had prepared them to use medical devices (p = 0.157). In situations with new or unfamiliar medical devices, 71 RNs (63%) read national or local guidelines, 39 (35%) asked a colleague or the ward manger, and 3 (2%) said they had no experiences from an unfamiliar situation related to technical skills or medical devices.
Use of Medical Devices The most common medical devices used in all of the workplaces in the present study were electronic thermometers, glucometers, and pulse oximeters (md 5). About half of the RNs used these medical devices every day in their work. The use of haemoglobin metres, blood warming devices, defibrillators, and cryotherapy was less common (md 1) (Table 4). Six RNs from different clinical settings stated in the open–ended section of the questionnaire that they used a continuous positive airway pressure device every week. There were significant differences in the use of medical devices between different workplaces; the RNs who worked in hospital departments for surgical care used bladder scanners, patient-controlled analgesia pumps, haemoglobin metres, and electronic thermometers more often than RNs in medical care. There were no significant differences for the other medical devices
Table 3 Differences between workplaces in the extent to which nurses performed technical skills, with departments for surgical care as reference. Total (n = 113)
Giving injections Infusion treatment Peripheral venous catheter Venous sampling Oxygen therapy Capillary sampling Enteral nutrition Urinary catheterization CVC & Subc. venous port Blood transfusion Suction of respiratory system Enteral tube insertion
Hospital department for surgical care (n = 36)
Hospital department for medical care (n = 56)
Workplace outside hospital (n = 21)
Md
q1
q3
Md
q1
q3
Md
q1
q3
Md
q1
q3
5 5 4 4 4 4 3 3 3 3 2 2
4 4 4 4 4 3 2 2 2 2 2 1
5 5 5 5 5 5 4 4 4 4 3 2
5 5 5 5 5 5 3 3 4 4 2 2
5 5 4 4 4 4 2 3 3 3 1 2
5 5 5 5 5 5 3 4 5 4 2 3
5 5 4 4 5 4 3 3 3 3 3 2
4 4 4 4 4 2 2 2 2 3 2 1
5 5* 5** 5** 5 5*** 4 4 4* 4** 3*** 2*
5 3 2 4 2 4 2 3 2 1 2 1
4 2 1 3 2 2 1 3 1 1 1 1
5* 4*** 5** 5** 5** 5** 2*** 4 3*** 2*** 3 2***
1 = Never, 2 = every quarter or more rarely, 3 = every month, 4 = every week, 5 = every day. Mann–Whitney U-test: * = p-value b 0.05, ** = p-value b 0.01, *** = p-value b 0.001.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
M. Ewertsson et al. / Nurse Education Today xxx (2015) xxx–xxx
The RNs' Needs and Possibilities for Continued Training The majority, 86 RNs (76%), stated that they were in need of continued practical training in technical skills and the medical devices that were used at their workplace. On the question of whether there were special education rooms or CSLs where they had the opportunity for training, 59 RNs (52%) reported that there was no such place for training. The other 54 RNs (48%) had access to practical training rooms or CSLs, and 13 (11%) of them even had access to a high-tech CSL. The RNs' ratings of how often performance of technical skills and the use of medical devices that were discussed and evaluated at their workplace had a median value of 6 (q1 4, q3 8, range 1–10). Incident Reporting On the question of whether there were routines for incident reporting at their workplace, 101 RNs (89%) stated that their workplace had such routines while the remaining 12 (11%) stated that they did not know. Concerning how often the RNs thought that incidents related to technical skills and medical devices on their workplace were reported, 21 RNs (19%) stated that incidents were always or almost always reported, 26 (23%) that incidents were often reported, 57 (50%) that incidents were reported only sometimes, and 9 (8%) that incidents were never reported. Forty-nine RNs (43%) had personally been involved in an incident related to the use of technical skills and medical devices. Of these, 25 (22%) stated that they had not reported the incidents. On the open question about why they refrained from reporting incidents, 12 RNs reported time constraints and 13 reported forgetfulness, ignorance, or embarrassment as a reason to refrain. Discussion As far as we know, this is the only current survey exploring the extent to which new RNs perform technical skills and handle medical devices. Being prepared with knowledge about the technical skills commonly used in a wide variety of health care departments could be seen as a prerequisite to be able to work in the profession. Consequently, nursing education could emphasize those technical skills that are commonly used, to increase the possibility of preparation for the profession, while the employer could provide regular training opportunities for those technical skills that are used less frequently. Technical knowledge with no context and no regular exposure is easily forgotten (Danbjørg and Birkelund, 2011). Knowing the extent to which different skills are used can also provide both individual nursing students and RNs with an insight into which tasks are commonly performed, and they can then take responsibility for planning their learning process. An additional finding is that a majority of the RNs considered themselves in need of continued practical training, although they assessed their own ability at a high level. In the last decade, CSLs have been developed in clinical settings, providing an opportunity to practice technical skills in a secure environment (Salminen et al., 2010). However, less than half of the RNs had access to such a training environment; this indicates that the remainder trained their skills on patients in clinical practice, which may jeopardize patient safety. The wish for postgraduate training is a signal to employers to establish opportunities for a life-long learning approach. This finding is in line with previous studies describing the need for and benefits of training after graduation (Alsvåg, 2006; Clark and Holmes, 2007; Wangensteen et al., 2008; Bisholt, 2012). Learning can be stimulated through practical experiences in which the person integrates theory and practice (Kolb, 1984). Therefore, it is desirable that RNs have access to CSLs, which offer this opportunity without compromising the safety of patients. Another factor that might be seen to reduce the RNs' possibilities for future learning is that in this study they reported very little exchange of experiences between RNs on the ward regarding the use of technical skills and medical devices. According to Pennbrant et al. (2013), for
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the development of knowledge it is important that new RNs have the opportunity to discuss how to do things with their colleagues. Active discussions and evaluations regarding medical equipment and performing skills can also reduce the risk of incidents. RNs are in a unique position to do this, since RNs and technology are closely linked in several settings (Mattox, 2012). In terms of patient safety, some RNs in our study stated that they did not use existing guidelines when performing unfamiliar technical skills or handling unfamiliar medical devices. This can be seen as an additional threat to patient safety, as there are indications that performing technical skills based on evidence can improve the quality of care (PricewaterhouseCoopers' Health Research Institute, 2009). There is a mutual challenge for nursing education and employers in clinical settings to provide training opportunities; and in this connection, there is a balance between increasing the awareness about the importance of using available guidelines (Rudman et al., 2012) while at the same time emphasizing the need for reflection on the performance of different skills (Schön, 1991). A further finding is that the RNs estimated their ability to perform technical skills and handle medical devices at a high level, irrespective of workplace. This is contrary to other researchers' findings that new RNs expressed a lack of competence in this area (Bisholt, 2012; Danbjørg and Birkelund, 2011). The result might be interpreted as a positive development of RNs' knowledge regarding technical skills. It can also raise the question of whether their assessment focused exclusively on what, or included a reflection on how to perform a technical skill (Bisholt, 2012; Danbjørg and Birkelund, 2011; Schön, 1991). Although the RNs rated their technical ability highly, almost half of them had been involved in incidents relating to technical skills or medical devices. This can be seen as a risk for the patient, since errors leading to adverse events are more often caused by human relation to the system than by technical failure (The National Board of Health and Welfare, 2008; Chang et al., 2005; Reiman and Rollenhagen, 2011). The majority of the RNs were aware of department routines for reporting incidents, but compliance with these routines can be questioned, as a majority of the respondents believed that incidents were reported at a low level. It might be difficult for a less experienced person to take in the overall picture of what is happening, and these statements might have been based on the fact that about a quarter of the RNs reported their own experiences of not reporting incidents. However, earlier studies show that deviations and incidents are significantly under-reported (Mattox, 2012; Vicente, 2005). Consequently, the reported responses in the present study might be seen as a threat to patient safety, because incident reporting is a data-based register where deviations of various types shall be reported to qualifying the care of the patient (Dieckman et al., 2009). The RNs stated reasons such as time constraints, forgetfulness, ignorance, or embarrassment as a reason to refrain from reporting. One factor to be considered in the analysis of incident reporting is how the safety culture in the organization responds to problems and errors (Westrum, 2004). A limitation of this study was that we used a convenience sample of students. Non-random sampling involves a risk that the study group is atypical of the population under study (Polit and Beck, 2012). However, the three universities followed regulations from the Swedish government and were approved by the Swedish Higher Education Authority, which may be considered to strengthen the group's representativeness for RNs nationally. Furthermore, the RNs in the study worked in different clinical settings and different hospitals, and this can also be seen as representative of the national population of RNs. Another limitation in the study is that there was no previously-used and validated questionnaire suitable for the study purposes. However, the studyspecific questionnaire was scrutinized and discussed by different groups of researchers in order to achieve face validity. The RNs were given the opportunity to add any missing items to the lists of technical skills and medical devices in the questionnaire, but only one comment was added regarding medical devices. This can be taken to mean that the
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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questions were relevant and covered the relevant field. Finally, the results should be seen in light of the limitation of self-report data, which might contribute to underestimation and overestimation of the responses, and the risk of recall bias. Conclusion This study highlights the importance of shared responsibilities between nurse educators and health care employers to provide learning opportunities in technical skills, in order to maintain patient safety. RNs' work situations have a wide variation in the extent of performing different technical skills and handling medical devices. This means that RNs have limited opportunities to practice all skills during their clinical education, and so it is important that they have opportunities to repeat this knowledge in a safe learning environment, continuously in their work. Employers need to build up CSLs in any form for practical training in order to increase the patient safety related to the performance of technical skills. Though, the real challenge is to establish a culture where nurse students and RNs understand the importance of using evidencebased guidelines and taking a reflective approach in the performance of technical tasks. In order to create such a culture, it is important to systematically train the students' ability to reflect on the performance of technical skills during education, as well as create opportunities in the workplace for RNs to reflect together on their skills and if they follow evidence-based guidelines. Continuous reflection in and on action is of importance for development of practical skills in professions (Schön, 1991). Future research, preferably in the form of observation studies, is needed to investigate if and how these aspects are emphasized in learning situations where technical skills and medical devices are present. Conflict of Interest None declared. References Alsvåg, H., 2006. Nursing education in light of new RNS' professional experience. Vård Norden 81 (26), 34–38. Benner, P., Hughes, R.G., Stuthen, M., 2008. Clinical reasoning, decision making and action: thinking critically and clinically. In: Hughes, R.G. (Ed.), Patient Safety and Quality. An Evidence-Based Handbook for Nurses (AHRQ Publication No. 08-0043). Agency for Healthcare Research and Quality, Rockville, MD. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: A Call for Radical Transformation. Jossey-bass, San Francisco. Bisholt, B.K.M., 2012. The learning process of recently graduated nurses in professional situations — experiences of an introduction program. Nurse Educ. Today 32, 289–293. Bisholt, B.K.M., Ohlsson, U., Kullen Engström, A., Sundler Johansson, A., Gustafsson, M., 2014. Nursing students' assessment of the learning environment in different clinical settings. Nurse Educ. Pract. 14 (3), 304–310. Bjørk, I.T., Kirkevold, M., 2000. From simplicity to complexity: developing a model of practical skill performance in nursing. J. Clin. Nurs. 9 (4), 620–631. Bland, A.J., Topping, A., Wood, B., 2011. A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Educ. Today 31 (7), 664–670.
Blomberg, K., Bisholt, B., Kullén Engström, A., Ohlsson, U., Sundler Johansson, A., Gustafsson, M., 2014. Work stress among newly graduated nurses in relation to workplace and clinical group supervision. J. Nurs. Manag. http://dx.doi.org/10.1111/ jonm.12274 (E-pub ahead of print). Casey, K., Fink, R., Krugman, M., Propst, J., 2004. The graduate nurse experience. JONA 34 (6), 303–311. Chang, A., Schyve, P.M., Croteu, R.J., O'Leary, D.S., Loeb, J.M., 2005. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int. J. Qual. Health Care 17 (2), 95–105. Clark, S., Holmes, S., 2007. Fit for practice? An exploration of the development of newly qualified nursing using focus groups. Int. J. Nurs. Stud. 44, 1210–1220. Danbjørg, D.B., Birkelund, R., 2011. The practical skills of newly qualified nurses. Nurse Educ. Today 31 (7), 168–172. Dieckman, P., Rall, M., Ostergaard, D., 2009. The role of patient simulation and incident reporting in the development and evaluation of medical devices and the training of their users. J. Prev. Assess. Rehabil. 33 (2), 135–143. Duchscher, J.E., 2009. Transition shock: the initial stage of role adaption for newly graduated registered nurses. J. Adv. Nurs. 65 (5), 1103–1113. Higgins, G., Spencer, R.L., Kane, R., 2010. A systematic review of the experiences and perceptions of the newly qualified nurse in the United Kingdom. Nurse Educ. Today 30 (6), 499–508. Jones, A., Benbow, J., Gidman, R., 2014. Provision of training and support for newly qualified nurses. Nurs. Stand. 28 (19), 44–50. Keller, J.P., 2010. Instructions included? Make safety training part of medical device procurement process. Mater. Manag. Health Care 19 (4), 26–29. Kolb, D.A., 1984. Experiential Learning. Prentice Hall, Englewood Cliffs, NF. Mattox, E., 2012. Medical devices and patient safety. Crit. Care Nurse 32 (4), 60–68. Norman, J., 2012. Systematic review of the literature on simulation in nursing education. ABNF J. 23 (2), 24–28. Pennbrant, S., Skyvell Nilsson, M., Öhlèn, J., Rudman, A., 2013. Mastering the professional role as a newly graduated registered nurse. Nurse Educ. Today 33, 739–745. Polit, D., Beck, C., 2012. Nursing Research: Generating and Assessing Evidence for Nursing Practice. Wolter Kluwer Health/Lippincott Williams & Wilkins, Philadelphia. PricewaterhouseCoopers' Health Research Institute, 2009. The price of excess: identifying waste in healthcare spending. http://www.pwc.com/us/en/healthcare/publications/ the-price-of-excess.jhtml (Accessed 2014-11-14). Reierson, I.Å., Hvidsten, A., Wighus, M., Brungot, S., Björk, I.T., 2013. Key issues and challenges in developing a pedagogical intervention in the simulation skills centre — an action research study. Nurse Educ. Pract. 13, 294–300. Reiman, T., Rollenhagen, C., 2011. Human and organizational biases affecting the management of safety. Reliab. Eng. Syst. Saf. 96 (10), 1263–1274. Rudman, A., Gustavsson, P., Ehrenberg, A., Boström, A.-M., Wallin, L., 2012. Registered nurses' evidence-based practice: a longitudinal study of the first five years after graduation. Int. J. Nurs. Stud. 49, 1494–1504. Salminen, L., Stolt, M., Saarikoski, M., Suikkala, A., Vaartio, H., 2010. Future challenges for nurse education — a European perspective. Nurse Educ. Today 30 (3), 233–238. Sandelowski, M., 2010. Venous envy: The post-World War II debate over IV nursing. JAVA 15 (2), 75–81. Schön, D., 1991. The Reflective Practitioner: How Professionals Think in Action. Ashgate Publishing, Farnham. Sundler, A.J., Björk, M., Bisholt, B., Ohlsson, U., Kullén Engström, A., Gustafsson, M., 2014. Student nurses' experiences of the clinical learning environment in relation to the organization of supervision: a questionnaire survey. Nurse Educ. Today 34, 661–666. The National Board of Health and Welfare, 2008. Available at: http://www. Socialstyrelsen.se/publikationer2008/2008-109-16 (Accessed 2014-03-04). Vicente, K.J., Kern, S., 2005. Problems with medical devices may be severely underreported. Nurs. Leadersh. 18 (1), 82–88. Wangensteen, S., Johansson, I.S., Nordström, G., 2008. The first year as a graduate nurse — an experience of growth and development. J. Clin. Nurs. 17 (14), 1877–1885. Westrum, R., 2004. A typology of organizational cultures. Qual. Saf. Health Care 13, ii22–ii27. http://dx.doi.org/10.1136/qshc.2003.009522.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Use of technical skills and medical devices among new registered nurses: A questionnaire study Mona Ewertsson a,⁎, Margareta Gustafsson a, Karin Blomberg a, Inger K. Holmström b,c, Renée Allvin a,d a
Faculty of Health and Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden d Clinical Skills Centre, Örebro University Hospital, Örebro, Sweden b c
a r t i c l e
i n f o
Article history: Accepted 10 May 2015 Available online xxxx Keywords: Clinical competence Clinical laboratory Equipment and supplies Incident reports Medical devices New registered nurses Nursing skills Patient safety
s u m m a r y Background: One comprehensive part of nursing practice is performing technical skills and handling of medical equipment. This might be challenging for new registered nurses (RNs) to do in patient-safe way. Objectives: The aim of this study was to describe and compare the extent to which new RNs perform various technical skills and handle medical devices in different settings, and to investigate their possibility for continued learning in this respect. A further aim was to describe their perceptions of incident reporting related to technical skills and medical devices. Design: A cross-sectional study with descriptive and comparative design. Participants: RNs who recently graduated from a nursing programme at three Swedish universities and had worked as a RN for up to 1 year were included in the study (n = 113, response rate 57%). Method: Data were collected by means of a postal questionnaire. Results: Half of the RNs reported that they performed several of the listed tasks every day or every week, regardless of workplace. These tasks were most frequently performed in surgical departments. The majority of the participants (76%) stated a need of continued practical training. However, less than half of them (48%) had access to a training environment. Several participants (43%) had been involved in incidents related to technical skills or medical devices, which were not always reported. Nearly a third of the participants (31%) did not use the existing guidelines when performing technical skills, and reflection on performance was uncommon. Conclusions: This study highlights the importance of shared responsibilities between nurse educators and health care employers to provide learning opportunities for new RNs in technical skills, to maintain patient safety. To increase the safety culture where nursing students and new RNs understand the importance of using evidence-based guidelines and taking a reflective approach in the performance of technical tasks is needed. © 2015 Elsevier Ltd. All rights reserved.
Background One comprehensive part of nursing practice is the performance of technical skills and handling of medical equipment (Sandelowski, 2010). In order to provide adequate care and maintain patient safety, registered nurses (RNs) need to be equipped with proper skills in this respect (Norman, 2012). In this article, technical skills are defined as the portion of practical skills involving the use of equipment such as syringes, needles, catheters, probes, infusions, and masks. Technical skills in nursing are often described as simple and mechanical motor skills, but the performance of these skills is a complex action (Bjørk and Kirkevold, 2000; Reierson et al., 2013). A safe performance of technical skills requires both theoretical knowledge and the ability to take a ⁎ Corresponding author at: Faculty of Health and Medicine, School of Health and Medical Sciences, Örebro University S-701 82 Örebro, Sweden. Tel.: +46 19303708. E-mail address: [email protected] (M. Ewertsson).
critical approach in order to adapt the performance to a specific situation (Benner et al., 2008; Reierson et al., 2013). In clinical practice, problems often arise that cannot be solved with a clear-cut answer. Theory learned through professional preparation is not always useful in solving these real-life problems. In the process of learning practical skills it is important to reflect both in and on action. Unexpected events generate reflection in practice by using current and past experiences and reasoning about unfamiliar events while they are occurring, but also reflection on practice while thinking back on what happened in a past situation. Key issues to consider in the development of professional competence are what has to be done, why, and in what way (Schön, 1991). Today's increasingly technical and complex health care places high demands on new RNs. The transition from nursing student to RN is a challenging period. Experiences of a stressful work environment (Bisholt, 2012; Duchscher, 2009), feelings of not being able to meet workplace demands, and a fear of making mistakes (Higgins et al.,
http://dx.doi.org/10.1016/j.nedt.2015.05.006 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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2010) can occur up to a year after graduation (Casey et al., 2004). It has been reported from both new RNs and their co-workers that new RNs are inadequately prepared and therefore lack competence in practical skills (Bisholt, 2012; Higgins et al., 2010; Wangensteen et al., 2008). This might lead to a risk of incidents related to the use of medical devices and performance of technical skills where patients are inadvertently harmed by errors in the care which was supposed to heal them (Keller, 2010). The process of learning technical skills is initiated during undergraduate nursing education. It is an important task for nursing education to provide nursing students with adequate and sufficient amount of training (Benner et al., 2010). The educators decide which technical skills to prioritize and integrate in nursing curricula. However, today there is no consensus about which technical skills and handling of medical devices should be included in the curriculum, nor about when during the nursing education these skills are actually taught (Bland et al., 2011). It is also important for nursing education to enhance the understanding of the importance of reflection and using safe and evidence-based methods and following national guidelines when performing various techniques (Rudman et al., 2012). There is also a need for continued learning of technical skills after graduation. Due to constant development and variation of medical and technical equipment, a life-long learning approach is required (Keller, 2010). Although employers have a responsibility to support new RNs, there are different prerequisites for learning technical skills in terms of both extent and structure (Bisholt, 2012; Jones et al., 2014). Access to a clinical skill laboratory (CSL) (Salminen et al., 2010), conscious discussions and evaluations regarding equipment and application principles (Mattox, 2012), and evaluations of incident reports (Vicente and Kern, 2005) can provide RNs with the opportunity to continue their learning and reduce the risk of incidents and errors in the clinical setting. To our knowledge, there is no current study that has explored the extent to which various technical skills and medical devices are used in the clinical settings where new RNs frequently work. Filling this knowledge gap can provide guidance for nursing education in the selection of which technical skills and medical devices should be included in the education. It can also guide the choice of training activities that employers need to provide to secure the quality of care and patient safety. The extent to which RNs use guidelines in their performance of technical skills, and how incidents are reported, also gives a picture of their work in relation to technical skills. Therefore, the aim of this study was to describe and compare the extent to which new RNs perform various technical skills and handle medical devices in different settings, and to investigate their possibility for continued learning in this respect. A further aim was to describe the new RNs' perceptions of incident reporting related to technical skills and medical devices.
2011. These nursing programmes were 3 years in duration, had similar content, led to a Bachelor's degree, and followed regulations from the Swedish government and the Swedish Higher Education Authority. Approximately half the time of the nursing programmes consisted of courses with clinical training in both CSLs and clinical settings. A total of 207 RNs graduated from the universities in the relevant time period; 200 of them were eligible for the study, and 113 (57%) answered a questionnaire (Fig. 1).
Data Collection Letters were sent to each RN's home address including information about the study, a request for written consent, and a questionnaire. The RNs were asked to return the questionnaire in an enclosed prepaid envelope. Those who did not answer within a month received a reminder letter, which increased the response rate.
Measurement The questionnaire contained study-specific questions developed in discussion between researchers in the research group who had experiences of teaching technical skills and medical devices in the nursing programme, and of teaching and training hospital staff. After this initial step, the questions were discussed by researchers outside the research group, nurse teachers, and clinical RNs in order to achieve face validity (Polit and Beck, 2012) and to obtain opinions of whether the questions were realistic ones to ask and whether the layout was easy to use. The questionnaire was then revised and its layout was refined. The final version of the questionnaire that contained 17 questions was divided into four sections (Table 1). In addition to the 17 questions, information was collected about demographic characteristics such as age, gender, workplace, months of employment as a graduated RN, employment status, and work time/months.
Students graduated from the universities, n = 207
Could not be located, n = 5
Methods
n = 202 surveys sent
Design This survey is a cross-sectional study with descriptive and comparative design carried out in Spring 2012, including RNs who had recently graduated from a nursing programme at three universities in Sweden. It is part of a comprehensive research programme in cooperation between the three universities investigating various aspects of clinical education within the nursing programme (Bisholt et al., 2014; Sundler et al., 2014) and aspects of work situation for new RNs (Blomberg et al., 2014). Sampling an Settings The participants had all worked as RNs for at most 1 year after graduation when the study took place, and were recruited from lists provided by the universities of those who had graduated in Spring
Did not work as a RN, n = 2
Not willing to participate n = 87
113 included in the analysis Response rate = 57%
Fig. 1. Flow chart of participant recruitment.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
M. Ewertsson et al. / Nurse Education Today xxx (2015) xxx–xxx Table 1 Questions and response alternatives in the study specific questionnaire. Questions PART 1. Technical skills To what extent do you perform the technical skills listed below in your current job? Do you want to add anything to the list of technical skills? How do you assess your own ability to perform technical skills? To what extent has the nurse education prepared you to perform technical skills? How do you act in new and unfamiliar situations related to technical skills? PART 2. Medical devices To what extent do you handle the medical devices listed below in your current job? Do you want to add anything to the list of medical devises? How do you assess your own ability to handle medical devices? To what extent has the nurse education prepared you to handle medical devices? How do you act in new and unfamiliar situations related to medical devices? PART 3. Needs and possibilities for continued training Do you need practical training in your workplace with regard to technical skills and/or medical devices? Are there teaching rooms for practical training in your workplace? To what extent do you discuss and evaluate how to perform technical skills and the use of medical devices? PART 4. Incidence reporting To what extent do you think that incidences related to performance of technical skills or handling medical devices are reported at your workplace? Are there procedures for incidence reporting in your workplace? Have you personally reported procedures for incidence reporting at your workplace? Have you refrained to report an incident related to technical skills and medical devices?
Response alternatives
3
terms of whether they considered that their nursing education had prepared them for using technical skills and medical devices. Version 20 of the IBM Statistical Package for Social Sciences Statistics for Windows was used for the statistical analyses, and the significance level was set to 0.05.
VDSa 1–5b
Ethical Considerations Open ended NRSc 1–10d NRS 1–10e Fixed alternatives VDS 1–5b Open ended NRS 1–10d NRS 1–10e Fixed alternatives Yes/No Fixed alternatives NRS 1–10e
VDS 1–5f
Yes/No/Don't know Yes/No/Don't know Yes/No
The RNs received written information about the study and were asked to return their informed consent in a sealed envelope. They were assured that participation was voluntary and that the data would be handled with confidentiality. The data were coded before being entered in the statistical file. The study had ethical approval from the Regional Ethical Review Board of Uppsala (reg. no. 2011/07). Results Sample Description The 113 new RNs participating in the study were between 23 and 51 years old, with a median age of 26. The majority were female. At the time of the survey, they had worked as RNs for between 1 and 11 months, with a median of 9 months. The majority of them worked full-time and most of them had temporary employment. The most common working situation was work in hospital departments for medical care, followed by work in surgical departments. Work outside the hospital was most unusual, but included work on pre-hospital wards and municipal wards (Table 2). Use of Technical Skills Half of the RNs in the study, regardless of workplace, reported giving injections and performing infusion treatment every day (md 5). Enteral
a
Verbal descriptive scale. VDS: 1 = Never, 2 = quarterly or more rarely, 3 = every month, 4 = every week, 5 = every day. c Numerical rating scale. d NRS: 1 = not good, to 10 = very good. e NRS: 1 = never, to 10 = large extent. f VDS: 1 = never, to 5 = always. b
Data Analysis Demographic data are reported by means of descriptive statistics. Observations of continuous variables (age and time of employment) had a skewed distribution and are therefore described with median (md), first and third quartiles (q1 and q3), and range. The RNs' ratings of the extent to which they used technical skills and medical devices were made on ordinal scales, and are described by means of median value and quartiles. In order to obtain sufficiently large groups for statistical analyses of differences between workplaces, workplaces with similar characteristics were grouped together. The Kruskal–Wallis test, which is used for analysis of differences in distributions when observations have a rank order and there are more than two groups, showed that there were significant differences between the workplace groups. They differed regarding the use of all technical skills and medical devices listed in the questionnaire. Therefore we decided to use the Mann–Whitney test to further examine which of the workplace groups differed from the others. The Mann–Whitney test is analogous to Kruskal–Wallis test but is used for analysis of differences when there are only two independent groups. In those analyses, the workplace group where the RNs most often used technical skills and medical devices was chosen as the reference group. Only the results of the Mann–Whitney test are reported. The Kruskal–Wallis test was also used to analyse differences between RNs in different workplaces in
Table 2 Description of the study participants (n = 113). Descriptive statistics Gender Female Male Age, years Time in employment as graduated nurse, months Form of employment, Temporary employment Permanent employment Working hours Full-time Part-time Workplace Hospital department for medical care General medicine Neurology Cardiology Infectious disease Lung medicine Psychiatry Nephrology Oncology/palliative care Others (haematology, rehabilitation, and geriatrics) Hospital department for surgical care General surgery Orthopaedic surgery Urological surgery Other (ears, nose, and throat, gastrointestinal, and gynaecological surgery) Workplace outside hospital Elderly care in the community Pre-hospital care
102 (90%) 11 (10%) md⁎ 26, q1⁎ 24, q3⁎ 31, range 23–51 md⁎ 9,, q1⁎ 9, q3⁎ 10 range 1–11 82 (73%) 31 (27%) 79 (70%) 34 (30%) 56 (50%) 13 9 6 5 5 5 4 3 6 36 (32%) 22 8 2 4 21 (18%) 13 8
⁎ md = Median, q1 = first quartile, q3 = third quartile.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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tube insertion and suction of the respiratory system were performed more rarely (md 2), regardless of workplace (Table 3). In comparison between departments for surgical care and departments for medical care, there were significant differences in how often the RNs performed several skills. The RNs at the surgical departments performed most of the technical skills more often than RNs at departments for medical care; only suction of the respiratory system was more frequently performed in medical care. Giving injections, oxygen therapy, enteral nutrition, and urinary catheterization were equally common in surgical and medical care. In comparing the RNs working in departments for surgical care and the RNs working outside the hospital, all technical skills were used more often in the surgical departments except urinary catheterization and suction of the respiratory system, which were equally common in both workplaces (Table 3). The questionnaire included an open– ended alternative, which allowed the RNs to add technical skills which were missing from the list, but none of the respondents took this opportunity. The RNs generally considered that their ability to perform the technical skills that existed in their workplace was close to the “very good” endpoint, with median value of 8.0 (q1 7, q3 9, range 4–10). Concerning their estimations of how well their nursing education had prepared them to perform technical skills, about half of them scored 7–10 on the 10-point numeric rating scale (md 7, q1 6, q3 8, range 2–10). The workplaces did not differ in terms of whether the RNs considered that their education had prepared them to perform technical skills (p = 0.969). The RNs used different strategies to gain knowledge of technical skills in a new or unfamiliar situation; 78 of them (69%) always read national or local guidelines about how to perform technical skills, and the remaining 35 (31%) did not read any guidelines but instead asked colleagues or the ward manager how things should be done.
Table 4 Differences between workplaces in the extent to which nurses used medical devices, with departments for surgical care as reference.
Electronic thermometer Glucose metre Pulse oximeter Bladder scanner Infusion pump Electrocardiograph Electronic blood pressure device Patient-controlled analgesia (PCA) pump Nasogastric pump Haemoglobin metre Blood warming device Defibrillator Cryotherapy
Total
Hospital department for surgical care
Hospital department for medical care
(n = 113)
(n = 36)
(n = 56)
Workplace outside hospital (n = 21)
Md q1 q3 Md q1 q3 Md q1 q3
Md q1 q3
5
4
5
5
5
5
5
4
5*
4
3
5***
5 5 4 3 3 3
4 4 3 2 2 1
5 5 4 4 4 5
5 5 4 4 3 3
4 4 4 3 2 1
5 5 5 4 4 5
5 5 4 4 4 3
4 4 3 3 3 1
5 5 4*** 4 4 5
4 2 2 1 1 4
3 1 1 1 1 1
5 5** 3*** 2*** 4* 5
2
1
3
3
2
4
2
1
3*** 1
1
2***
2 1 1 1 1
1 1 1 1 1
3 3 2 2 1
2 3 1 1 1
1 2 1 1 1
3 4 3 2 1
2 1 1 2 1
2 1 1 1 1
3 2*** 2 2 1
1 1 1 1 1
2** 3** 2 3 1*
1 1 1 1 1
1 = Never, 2 = every quarter or more rarely, 3 = every month, 4 = every week, 5 = every day. Mann–Whitney U-test: * = p-value b 0.05, ** = p-value b 0.01, *** = p-value b 0.001.
listed. In comparison with RNs working outside the hospital, RNs working in hospital departments for surgical care made more frequent use of all medical devices except electronic blood pressure metres, blood warmers, defibrillators, and glucometers, which were equally used by both (Table 4). Most RNs rated their ability to use the medical devices that existed in their workplace close to the “very good” endpoint (md 8, q1 8, q3 9, range 3–10). On the question of whether their nursing education had prepared them for using medical devices, about half of the RNs scored 6–10 on the 10-point numeric rating scale (md 6, q1 5, q3 7, range 2– 10). There was no difference between the workplaces in terms of whether the RNs considered that their nursing education had prepared them to use medical devices (p = 0.157). In situations with new or unfamiliar medical devices, 71 RNs (63%) read national or local guidelines, 39 (35%) asked a colleague or the ward manger, and 3 (2%) said they had no experiences from an unfamiliar situation related to technical skills or medical devices.
Use of Medical Devices The most common medical devices used in all of the workplaces in the present study were electronic thermometers, glucometers, and pulse oximeters (md 5). About half of the RNs used these medical devices every day in their work. The use of haemoglobin metres, blood warming devices, defibrillators, and cryotherapy was less common (md 1) (Table 4). Six RNs from different clinical settings stated in the open–ended section of the questionnaire that they used a continuous positive airway pressure device every week. There were significant differences in the use of medical devices between different workplaces; the RNs who worked in hospital departments for surgical care used bladder scanners, patient-controlled analgesia pumps, haemoglobin metres, and electronic thermometers more often than RNs in medical care. There were no significant differences for the other medical devices
Table 3 Differences between workplaces in the extent to which nurses performed technical skills, with departments for surgical care as reference. Total (n = 113)
Giving injections Infusion treatment Peripheral venous catheter Venous sampling Oxygen therapy Capillary sampling Enteral nutrition Urinary catheterization CVC & Subc. venous port Blood transfusion Suction of respiratory system Enteral tube insertion
Hospital department for surgical care (n = 36)
Hospital department for medical care (n = 56)
Workplace outside hospital (n = 21)
Md
q1
q3
Md
q1
q3
Md
q1
q3
Md
q1
q3
5 5 4 4 4 4 3 3 3 3 2 2
4 4 4 4 4 3 2 2 2 2 2 1
5 5 5 5 5 5 4 4 4 4 3 2
5 5 5 5 5 5 3 3 4 4 2 2
5 5 4 4 4 4 2 3 3 3 1 2
5 5 5 5 5 5 3 4 5 4 2 3
5 5 4 4 5 4 3 3 3 3 3 2
4 4 4 4 4 2 2 2 2 3 2 1
5 5* 5** 5** 5 5*** 4 4 4* 4** 3*** 2*
5 3 2 4 2 4 2 3 2 1 2 1
4 2 1 3 2 2 1 3 1 1 1 1
5* 4*** 5** 5** 5** 5** 2*** 4 3*** 2*** 3 2***
1 = Never, 2 = every quarter or more rarely, 3 = every month, 4 = every week, 5 = every day. Mann–Whitney U-test: * = p-value b 0.05, ** = p-value b 0.01, *** = p-value b 0.001.
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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The RNs' Needs and Possibilities for Continued Training The majority, 86 RNs (76%), stated that they were in need of continued practical training in technical skills and the medical devices that were used at their workplace. On the question of whether there were special education rooms or CSLs where they had the opportunity for training, 59 RNs (52%) reported that there was no such place for training. The other 54 RNs (48%) had access to practical training rooms or CSLs, and 13 (11%) of them even had access to a high-tech CSL. The RNs' ratings of how often performance of technical skills and the use of medical devices that were discussed and evaluated at their workplace had a median value of 6 (q1 4, q3 8, range 1–10). Incident Reporting On the question of whether there were routines for incident reporting at their workplace, 101 RNs (89%) stated that their workplace had such routines while the remaining 12 (11%) stated that they did not know. Concerning how often the RNs thought that incidents related to technical skills and medical devices on their workplace were reported, 21 RNs (19%) stated that incidents were always or almost always reported, 26 (23%) that incidents were often reported, 57 (50%) that incidents were reported only sometimes, and 9 (8%) that incidents were never reported. Forty-nine RNs (43%) had personally been involved in an incident related to the use of technical skills and medical devices. Of these, 25 (22%) stated that they had not reported the incidents. On the open question about why they refrained from reporting incidents, 12 RNs reported time constraints and 13 reported forgetfulness, ignorance, or embarrassment as a reason to refrain. Discussion As far as we know, this is the only current survey exploring the extent to which new RNs perform technical skills and handle medical devices. Being prepared with knowledge about the technical skills commonly used in a wide variety of health care departments could be seen as a prerequisite to be able to work in the profession. Consequently, nursing education could emphasize those technical skills that are commonly used, to increase the possibility of preparation for the profession, while the employer could provide regular training opportunities for those technical skills that are used less frequently. Technical knowledge with no context and no regular exposure is easily forgotten (Danbjørg and Birkelund, 2011). Knowing the extent to which different skills are used can also provide both individual nursing students and RNs with an insight into which tasks are commonly performed, and they can then take responsibility for planning their learning process. An additional finding is that a majority of the RNs considered themselves in need of continued practical training, although they assessed their own ability at a high level. In the last decade, CSLs have been developed in clinical settings, providing an opportunity to practice technical skills in a secure environment (Salminen et al., 2010). However, less than half of the RNs had access to such a training environment; this indicates that the remainder trained their skills on patients in clinical practice, which may jeopardize patient safety. The wish for postgraduate training is a signal to employers to establish opportunities for a life-long learning approach. This finding is in line with previous studies describing the need for and benefits of training after graduation (Alsvåg, 2006; Clark and Holmes, 2007; Wangensteen et al., 2008; Bisholt, 2012). Learning can be stimulated through practical experiences in which the person integrates theory and practice (Kolb, 1984). Therefore, it is desirable that RNs have access to CSLs, which offer this opportunity without compromising the safety of patients. Another factor that might be seen to reduce the RNs' possibilities for future learning is that in this study they reported very little exchange of experiences between RNs on the ward regarding the use of technical skills and medical devices. According to Pennbrant et al. (2013), for
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the development of knowledge it is important that new RNs have the opportunity to discuss how to do things with their colleagues. Active discussions and evaluations regarding medical equipment and performing skills can also reduce the risk of incidents. RNs are in a unique position to do this, since RNs and technology are closely linked in several settings (Mattox, 2012). In terms of patient safety, some RNs in our study stated that they did not use existing guidelines when performing unfamiliar technical skills or handling unfamiliar medical devices. This can be seen as an additional threat to patient safety, as there are indications that performing technical skills based on evidence can improve the quality of care (PricewaterhouseCoopers' Health Research Institute, 2009). There is a mutual challenge for nursing education and employers in clinical settings to provide training opportunities; and in this connection, there is a balance between increasing the awareness about the importance of using available guidelines (Rudman et al., 2012) while at the same time emphasizing the need for reflection on the performance of different skills (Schön, 1991). A further finding is that the RNs estimated their ability to perform technical skills and handle medical devices at a high level, irrespective of workplace. This is contrary to other researchers' findings that new RNs expressed a lack of competence in this area (Bisholt, 2012; Danbjørg and Birkelund, 2011). The result might be interpreted as a positive development of RNs' knowledge regarding technical skills. It can also raise the question of whether their assessment focused exclusively on what, or included a reflection on how to perform a technical skill (Bisholt, 2012; Danbjørg and Birkelund, 2011; Schön, 1991). Although the RNs rated their technical ability highly, almost half of them had been involved in incidents relating to technical skills or medical devices. This can be seen as a risk for the patient, since errors leading to adverse events are more often caused by human relation to the system than by technical failure (The National Board of Health and Welfare, 2008; Chang et al., 2005; Reiman and Rollenhagen, 2011). The majority of the RNs were aware of department routines for reporting incidents, but compliance with these routines can be questioned, as a majority of the respondents believed that incidents were reported at a low level. It might be difficult for a less experienced person to take in the overall picture of what is happening, and these statements might have been based on the fact that about a quarter of the RNs reported their own experiences of not reporting incidents. However, earlier studies show that deviations and incidents are significantly under-reported (Mattox, 2012; Vicente, 2005). Consequently, the reported responses in the present study might be seen as a threat to patient safety, because incident reporting is a data-based register where deviations of various types shall be reported to qualifying the care of the patient (Dieckman et al., 2009). The RNs stated reasons such as time constraints, forgetfulness, ignorance, or embarrassment as a reason to refrain from reporting. One factor to be considered in the analysis of incident reporting is how the safety culture in the organization responds to problems and errors (Westrum, 2004). A limitation of this study was that we used a convenience sample of students. Non-random sampling involves a risk that the study group is atypical of the population under study (Polit and Beck, 2012). However, the three universities followed regulations from the Swedish government and were approved by the Swedish Higher Education Authority, which may be considered to strengthen the group's representativeness for RNs nationally. Furthermore, the RNs in the study worked in different clinical settings and different hospitals, and this can also be seen as representative of the national population of RNs. Another limitation in the study is that there was no previously-used and validated questionnaire suitable for the study purposes. However, the studyspecific questionnaire was scrutinized and discussed by different groups of researchers in order to achieve face validity. The RNs were given the opportunity to add any missing items to the lists of technical skills and medical devices in the questionnaire, but only one comment was added regarding medical devices. This can be taken to mean that the
Please cite this article as: Ewertsson, M., et al., Use of technical skills and medical devices among new registered nurses: A questionnaire study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.006
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questions were relevant and covered the relevant field. Finally, the results should be seen in light of the limitation of self-report data, which might contribute to underestimation and overestimation of the responses, and the risk of recall bias. Conclusion This study highlights the importance of shared responsibilities between nurse educators and health care employers to provide learning opportunities in technical skills, in order to maintain patient safety. RNs' work situations have a wide variation in the extent of performing different technical skills and handling medical devices. This means that RNs have limited opportunities to practice all skills during their clinical education, and so it is important that they have opportunities to repeat this knowledge in a safe learning environment, continuously in their work. Employers need to build up CSLs in any form for practical training in order to increase the patient safety related to the performance of technical skills. Though, the real challenge is to establish a culture where nurse students and RNs understand the importance of using evidencebased guidelines and taking a reflective approach in the performance of technical tasks. In order to create such a culture, it is important to systematically train the students' ability to reflect on the performance of technical skills during education, as well as create opportunities in the workplace for RNs to reflect together on their skills and if they follow evidence-based guidelines. Continuous reflection in and on action is of importance for development of practical skills in professions (Schön, 1991). Future research, preferably in the form of observation studies, is needed to investigate if and how these aspects are emphasized in learning situations where technical skills and medical devices are present. Conflict of Interest None declared. References Alsvåg, H., 2006. Nursing education in light of new RNS' professional experience. Vård Norden 81 (26), 34–38. Benner, P., Hughes, R.G., Stuthen, M., 2008. Clinical reasoning, decision making and action: thinking critically and clinically. In: Hughes, R.G. (Ed.), Patient Safety and Quality. An Evidence-Based Handbook for Nurses (AHRQ Publication No. 08-0043). Agency for Healthcare Research and Quality, Rockville, MD. Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: A Call for Radical Transformation. Jossey-bass, San Francisco. Bisholt, B.K.M., 2012. The learning process of recently graduated nurses in professional situations — experiences of an introduction program. Nurse Educ. Today 32, 289–293. Bisholt, B.K.M., Ohlsson, U., Kullen Engström, A., Sundler Johansson, A., Gustafsson, M., 2014. Nursing students' assessment of the learning environment in different clinical settings. Nurse Educ. Pract. 14 (3), 304–310. Bjørk, I.T., Kirkevold, M., 2000. From simplicity to complexity: developing a model of practical skill performance in nursing. J. Clin. Nurs. 9 (4), 620–631. Bland, A.J., Topping, A., Wood, B., 2011. A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Educ. Today 31 (7), 664–670.
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