Evaluation of a simplified therapeutic intervention scoring system (TISS-28) and the modified early warning score (MEWS) in predicting physiological deterioration during inter-facility transport

INTRODUCTION: There is an emerging demand for inter-facility transport (IFT) of patients in recent years following changes in the healthcare framework in Hong Kong but this carries certain risks. Anticipation of possible deterioration of patients is important for patient safety and therefore risk stratification of patients before transport is important. OBJECTIVE: This study evaluated the simplified therapeutic intervention scoring system (TISS-28) and modified early warning score (MEWS) in predicting physiological deterioration en route. METHODS: This is a prospective single centre study of all emergency IFT for adult patients, excluding patients with obstetric conditions, occurring between 1 January 2005 and 30 June 2006. The severity of illness was quantified in terms of TISS-28 and MEWS. Mann-Whitney test and receiver operator characteristic (ROC) curves were used to illustrate and compare their performance. RESULTS: Among 102 patients requiring IFT, 28 had physiological deterioration en route (27%). The TISS-28 scores upon dispatch ranged from 5 to 34 with a mean of 16.5+/-5.71 whereas MEWS ranged from 0 to 11 with a mean of 2.82+/-2.01. The incidence of physiological deterioration en route was significantly greater with a higher MEWS score (P=0.001) but this was not seen with the TISS-28 score. The area under the ROC curve for the predictive value of MEWS was 0.71 which performed better than TISS-28 (area under the curve=0.53). CONCLUSION: IFT represents a group of patients with vast heterogeneity. TISS-28 is not a useful tool for risk stratification prior to transport. MEWS was able to identify patients at risk but was not ideal.     

Risk stratification in providing inter-facility transport: Experience from a specialized transport team

BACKGROUND:

The role of Inter-facility transport (IFT) of patients is an emerging specialty requiring service reorganization, diversion of major trauma to trauma center. This study aimed to determine the patients who are more prone to en route adverse event during the period of 22:00 to 07:00, based on critical in-patient needs provided by the Emergency Department (ED) nursing staff at Alice Ho Miu Ling Nethersole Hospital (AHNH).

METHODS:

This study included all 22:00 to 07:00 IFTs accompanied by ED nurses at AHNH for a period of 28 months from August 2006 until December 2008. The transports were reviewed for: (1) age, (2) gender, (3) transport configuration, (4) clinical category, and (5) physiological instability before transport.

RESULTS:

A total of 79 patients were transported during the 22:00 to 07:00 timeframe within the study period. The types of patients were mainly neurosurgical emergencies (n=32; 40.5%), surgical emergencies (n=28; 35.4%), and upper gastrointestinal bleeding (UGIB) (n=11; 13.9%). En route adverse events were encountered by the accompanying nurses in 16 transports (20.3%) with a higher incidence of adverse events during transport of surgical emergencies, UGIB and patients who were physiological unstable before transport (P< 0.05).

CONCLUSION:

A specialized transport team from the ED can assist other clinical departments by providing expert care during IFT. In spite of the high quality of care, adverse events do commonly occur.KEY WORDS: Inter-facility transport, Specialized transport team, Hong Kong     

Evolving towards professionalism in emergency nursing in Hong Kong

This paper aims to share with the readers about the experience of emergency nursing development and related roles in Hong Kong. The roles of emergency nurses are evolving and triggered by three major historical milestones. The three milestones consist of: (1) Transition of nursing education from hospital training to nursing degree program at universities in 1990; (2) The re-evolution after the establishment of Hospital Authority in 1993; (3) Hong Kong's return to China in 1997. These milestones have contributed immensely to the development of quality nursing education, nursing professionalism with emphasis on specialty knowledge and skill training in Accident and Emergency departments (AED) in Hong Kong. Since 1991, the emergency nursing role has been expanded and extended. Wound management remains one of the major extending roles for emergency nurses, who confine themselves to manage simple wounds. Nurse initiated tetanus immunization, intravenous access; investigations such as electrocardiogram, blood glucose, and urinalysis are well implemented in all AEDs under the governance of guidelines and protocols. Initial triage analgesic for the minor musculoskeletal injury and fever are also part of the triage care in some AEDs in Hong Kong now. To meet the demand and challenge, innovative role development such as lecturer practitioners and emergency nurse practitioners have been piloted and implemented recently. Besides the normal duty, emergency nurses also participate in the work outside the hospitals such as involvement in emergency medical teams to assist in various rescue missions or volunteer for Flight Nursing (Government Flying Services). However, the nursing shortage is another common problem faced by the Hong Kong health care body. With the help of advanced technology, better pre-graduate and specialty-training programs, Hong Kong health care strives to achieve the highest standards of quality care. Emergency nursing role development in Hong Kong is evolving and starts to chart its way to meet the demand.     

粤港两地部分急诊科医护人员对哀伤关顾认识的调查分析

目的 调查粤港两地部分急诊科医护人员对哀伤关顾的认识情况,为国内开展哀伤关顾护理提供理论依据.方法 自行设计对哀伤关顾的认识调查问卷,对香港各大联网医院的急诊科医护人员、本省各地区赴港学习的急诊科专科护士和本院急诊科医护人员进行调查,了解他们对哀伤关顾的认识情况.结果 香港急诊科医护人员对哀伤关顾的认识(100.0％)、参加过哀伤关顾培训(100.0％)、实施过哀伤关顾(100.0％)以及具备的哀伤关顾技能(100.0％)都比较好,并认为有必要开展哀伤关顾(98.8％)和愿意加入哀伤关顾小组(86.3％);而赴港学习的本省急诊科专科护士和本院急诊科医护人员对哀伤关顾的认识、参加过哀伤关顾培训、实施哀伤关顾以及所具备的哀伤关顾技能基本处于较少或无的状态,对于是否有必要开展哀伤关顾和愿意加入哀伤关顾小组,赴港学习的本省急诊科专科护士有92.6％认为有必要,85.2％愿意加入;而本院急诊科医护人员84.1％认为有必要,63.2％愿意加入.结论 国内医护人员对哀伤关顾的认识以及对病人实施哀伤关顾较少,学习并引进香港以及国外关于哀伤关顾的知识,结合本国国情发展和完善本土哀伤关顾文化非常重要.     

Chronic obstructive pulmonary disease and engagement in occupation.

The goal of this study was to gain an understanding of participants' experiences with chronic obstructive pulmonary disease (COPD) and their perceptions of an occupational therapy intervention as it related to occupational behaviors. The researcher conducted semistructured interviews with three participants recruited from a pulmonary rehabilitation program in Hong Kong. Using thematic analysis, five themes related to the disease experience were identified: (1) uncertainty during the course of the disease, (2) external attribution, (3) activity restriction and isolation, (4) anxiety and depression, and (5) passive fortitude. Regarding the participants' perceptions of the effects of the occupational therapy intervention on occupation engagement, four themes were identified: (1) increased knowledge of COPD, (2) taking control of the disease and reengagement in activities, (3) alleviation of mental burden, and (4) social support from peers and therapists. The study suggests a temporal framework for better understanding participants' experiences of COPD as well as for developing more appropriate occupational therapy interventions.     

A pilot study on nurses' attitudes toward perinatal bereavement support: a cluster analysis

AIM: Nurses' attitudes towards perinatal bereavement care are explored by identifying profiles of nurses working in a Hong Kong Obstetrics and Gynaecology (OAG) unit. Relationships between nurses' attitudes towards bereavement support, need for bereavement training and hospital policy are explored. RESEARCH METHOD: 110 nurses recruited from the OAG unit of a large Hong Kong public hospital completed a structured questionnaire. OUTCOME MEASURES: Attitudes towards perinatal bereavement support; required support and training needs for nurses on bereavement care. RESULTS: Two-step cluster analysis yielded two clusters. Cluster A consisted of 55.5% (n = 49) and cluster B consisted of 44.5% (n = 61) of nurses. Cluster A nurses were younger, had less OAG experience, more junior ranking and less education than cluster B nurses. Cluster B nurses had additional midwifery and bereavement care training, personal grieving experiences and experience handling grieving clients. The majority held positive bereavement care attitudes. Significant differences towards perinatal bereavement support were found. Only 25.5% (n = 28) had bereavement related training. Attitudes towards bereavement care were positively correlated with training needs (rs = 0.59) and hospital policy support (rs = 0.60). CONCLUSION: Hong Kong nurses emphasized need for increased bereavement care knowledge and experience, improved communication skills, and greater hospital and team members' support. Findings may be used to improve support of nurses, to ensure sensitive bereavement care in perinatal settings, and to enhance nursing curricula.     

Nurses' attitudes towards perinatal bereavement support in Hong Kong: a pilot study

The purpose of this study is to explore nurses' attitudes towards perinatal bereavement care and to identify required support and training needs for nurses on bereavement care in Hong Kong. Data were collected through a structured questionnaire, and 110 nurses were recruited from the obstetrics and gynaecology unit in one of the largest public hospitals in Hong Kong. The majority of nurses held a positive attitude towards bereavement care. A significant difference in nurses' attitudes towards bereavement support was found in terms of demographics, practical experiences and training factors. The results showed that only 25.5% (n = 28) of nurses had bereavement-related training. In contrast, 90.9% of nurses showed a positive response to grief training and 90.0% would share experiences with colleagues and seek support when feeling under stress. The findings also suggest that nurses' attitudes towards bereavement care are positively correlated with bereavement care training needs (r = 0.53) and hospital policy support (r = 0.55). Hong Kong nurses' attitudes towards perinatal care emphasized their need for increased knowledge and experience, improved communication skills, and greater support from team members and the hospital. These findings may be used for Hong Kong health care professionals to improve support of nurses, to ensure delivery of sensitive bereavement care in perinatal settings and to enhance nursing school curricula.     

Critical care nursing research priorities in Hong Kong

BACKGROUND: Research is vital to nursing practice especially in an area such as critical care, where nursing practice continues to increase in complexity and nurses assume greater responsibility and accountability for patient care. However, without knowledge of what are the most significant problems or questions affecting the welfare of critically ill patients in Hong Kong, nurses' research efforts may be directed to areas that are not of highest priority in today's climate of decreasing health care resources and changing health care provision. AIM: To identify and prioritize research questions of importance to Hong Kong critical care nurses. METHOD: A three-round Delphi technique was used to solicit, identify and prioritize problems for critical care nursing research. RESULTS: Respondents who completed the third round had a mean of 6.25 years of critical care nursing experience. Ninety-one research topics were ranked important or extremely important. Twenty-seven research priorities ranked as extremely important included topics relating to patient care, family care, nursing, technology, alternative interventions, and illness prevention/health promotion research domains. Thirteen research topics were ranked as least important. None of the participants ranked research topics as not important. STUDY LIMITATIONS: Only full-time active members of the Hong Kong Association of Critical Care Nurses participated in this study and they may not necessarily represent the views of all critical care nurses in Hong Kong. In addition, no attempts were made to compare research priorities between specialty groups of nurses. CONCLUSION: With the re-structuring of Hong Kong's health care system, critical care nurses are expected to take an active role in advancing the profession, and to be accountable for improving patient outcomes by use of effective, evidence-based interventions. The research priorities identified in this study may provide impetus and direction for critical care nursing research initiatives.     

Evaluation of a simulation-based workshop on clinical performance for emergency physicians and nurses

BACKGROUND: Simulation-based medical education has been growing rapidly and becomes one of the most popular teaching methods for improving patient safety and patient care. The Simulation Subcommittee of the Hong Kong College of Emergency Medicine organized an educational program emphasizing the team training, clinical decision-making and communication skills. This study aimed to evaluate the attitude of the participants toward a new training program and the change in the knowledge on clinical performance in emergency physicians and nurses after attending the educational program.METHODS: A course evaluation form was filled in by the participants at the end of the workshop. An assessment of 20 multiple-choice questions with 5 options was administered to the participants before and after the 2-day simulation-based training workshop.RESULTS: A total of 72 doctors and nurses working in the Accident and Emergency Department were enrolled. The average pretest and posttest scores were 12 and 14.3 respectively. The percentage improvement in the mean score of the pretest and posttest was 11.5%. The Chi-square test showed signifi cant improvement in the pretest and posttest score grading(P=0.00). Paired t-test revealed signifi cant difference between the mean scores of the pretest and posttest(P=0.00).CONCLUSIONS: Participants had positive attitude toward this new training program. Significant improvement of the knowledge on clinical performance in healthcare professionals in the Accident and Emergency Department was observed after the participation in this simulation-based educational program.     

Nurses’ knowledge and self-assessment of their clinical experiences of intraosseous access: A multicentre cross-sectional study

BackgroundIntraosseous access is an effective and safe option when difficult vascular access occurs. The knowledge, competence, and clinical experience of nurses are collectively essential for the successful implementation of this approach in clinical practice. Education and clinical learning are the main pillars supporting this new practice to ensure patient safety. The aim of this study was to identify the nurses’ knowledge and clinical experience of intraosseous access and the factors associated with the adoption of this procedure.MethodsA cross-sectional study was carried out from October to December 2020. A convenience sample of 432 nurses from four Italian hospitals were involved. A structured questionnaire was used to assess the nurses’ knowledge of the intraosseous access guidelines and their clinical experience.ResultsMost participants were female (71.5%) with more than 10 years of experience (63.7%) working in an emergency (38.9%) and medical (37.7%) setting. Most of the participants demonstrated their knowledge of the use of a device e.g., it is used if vascular access is not rapidly achieved in a child (83.1%) and the boluses of liquids required in the intraosseous procedure (72.7%). A few participants reported having placed intraosseous access (3.5%). A higher level of educational preparation and working in emergency and paediatric settings were associated with increased knowledge.ConclusionsOur findings highlighted a sub-optimal level of knowledge of the IO procedure, little experience of this practice in clinical contexts, also associated with a lack of adequate protocols and devices available to nurses. Nurses need to develop their knowledge and practice the skill clinically to embed this practice. University and nurse educators should emphasise the relevance of this practice in nursing education and training, so as to improve the nursing care practice and level of patient safety.     

Therapeutic communication strategies used by Hong Kong mental health nurses with their Chinese clients.

Therapeutic communication is central to mental health nursing and through this process nurse-client relationships can be enhanced. In Hong Kong, mental health nurses are educated in 'western' theories and strategies in using therapeutic communication and the field of communication is predominantly Eurocentric. However, the majority of people in Hong Kong are Chinese and little research has been conducted into how Hong Kong nurses communicate with their Chinese clients. This qualitative study focused on identifying the therapeutic communication strategies used by mental health nurses with Chinese clients in Hong Kong. Three case study vignettes with some of the characteristics of Chinese culture were developed to elicit information about the strategies that respondents used in therapeutic communication. The purposive sample of 20 comprised 10 admission ward nurses and 10 community nurses from two psychiatric hospitals. All participants had at least five years post-registration experience. Content analysis revealed categories of communication and theme clusters for the nurses' response to the vignettes. The result showed a unique cultural influence emerged in communication patterns. In view of the scant nature of existing literature and studies in this area, this research provided some valuable data for further studies. Implications for mental health nursing education and practice in Hong Kong are raised, as are implications for nurses working in multicultural countries such as Australia, the UK and the USA, where there are significant numbers of Chinese clients who would benefit from nurses practising with a deeper understanding of communication strategies which are culturally bound.     

Intuition in emergency nursing: a phenomenological study

The evidence of experience of intuitive knowing in the clinical setting has to this point only been informal and anecdotal. Reported experiences thus need to be either validated or refuted so that its place in emergency nursing can be determined. The history, nature and component themes captured within the intuitive practice of emergency nursing are described. This study was informed by the philosophy and method of phenomenology. Participants were 14 experienced emergency nurses. Through their narrative accounts and recall of events their experience of knowing was captured. Through a Van Manen process and a Gadamerian analysis, six themes associated with the ways in which the participants experienced intuition in clinical practice, were identified. This paper reveals the six emerging themes as knowledge, experience, connection, feeling, syncretism and trust.     

SARS (severe acute respiratory syndrome): reflective practice of a nurse manager

Aims and objectives. This paper describes the reflective practice of a nurse manager in Hong Kong in supporting frontline nurses to overcome the crisis of SARS. Background. SARS infection was a crisis for everyone in endemic areas because of its threat to physical and emotional health. Hong Kong was the second leading endemic area in the world. Inadequate supplies of protective devices and the death of a nurse infected with SARS triggered nurses’ negative emotions. Methods. A model of structured reflection was adopted to examine one's practice. A problem‐solving model for crisis intervention was integrated into the reflective stage of structured reflection. Results. Promotion of nurses’ safety and emotional stability were the major goals in handling the crisis. Strategies were employed including self‐awareness, empowerment and team building, information sharing, provision of personal protective equipment and emotional support for frontline nurses. Conclusions. SARS infection threatens the physical and emotional health of nurses. From a positive perspective, such a crisis created an opportunity to learn and grow in terms of ethical, personal and aesthetic arenas. Relevance to clinical practice. SARS epidemic raised worldwide attention and challenged the Hong Kong's health care system. Reflective practice is useful to guide and examine nurses’ professional action during the crisis, and to put the experience into a learning perspective.     

SARS: caring for patients in Hong Kong

Aim and objective. To explore in depth the experiences of nurses' caring for SARS patients in Hong Kong. Background. Severe Acute Respiratory Syndrome (SARS) dramatically demonstrates the global havoc that can be wreaked by a newly emerging infectious disease. The current literature either has a predominantly biomedical focus or deals with the psychological impact on healthcare workers. Published studies on the lived experience of nurses caring for SARS patients are currently lacking. Design. A phenomenological design. Methods. Using methods consistent with Husserl's philosophy, eight Registered Nurses working in three regional hospitals in Hong Kong were invited to participate in sharing their lived experience of caring for SARS patients and data were analysed using Colaizzi's approach. Results. The three major themes explicated were: the various emotions experienced in caring for SARS patients, the concept of uncertainty and revisiting the ‘taken for granted’ features of nursing. Conclusion. These themes, when taken together, describe the essence of the voyage undertaken by nurses who cared for SARS patients during the outbreak. The findings of this study indicate that extensive and ongoing support is needed to prepare and enable nurses to care for SARS patients during a crisis and make it easier for nurses to deal with the various uncertainties. Relevance to clinical practice. The essence of caring for SARS patients is highlighted in this study. The experience of caring for SARS patients prompts nurses to find meaning in their experience(s), and to develop knowledge and attitudes on how best to care for patients and prepare for a new crisis in the future. This paper considers a more in‐depth understanding of the lived experience of nurses during the crisis and the relevance of this perspective for education and support of nurses.     

Psychiatric nurses' attitudes to antipsychotic depots in Hong Kong and comparison with London

Psychiatric nurses' attitudes to depots have only been explored in the UK. We conducted a cross-sectional attitudinal study for Hong Kong psychiatric nurses and also conducted international comparisons for nurses' views about depots. A pre-existing UK questionnaire on clinicians' attitudes and knowledge regarding depots was updated for the present study. Participants were 98 psychiatric nurses who attended an academic meeting. The majority of respondents had positive views regarding their role in depot administration; most reported that they had sufficient training (84%). However, many did not feel involved in treatment decision making (60%) and other negative views were expressed including: (1) most patients always prefer to have oral (vs. depot) (80%); and (2) force is sometimes required when administering a depot (40%). Interestingly, most reported that patients' friends and family were more accepting of depot (vs. oral) (69%). When compared with a former sample of London community psychiatric nurses, Hong Kong nurses had less favourable patient-focussed attitudes (mean 56% vs. 60%, P = 0.051) and depot-specific attitudes regarding depots (mean 63% vs. 69%, P < 0.001). In conclusion, therefore, international variation exists and encompasses clinical practice aspects for both the patient and the depot formulation per se. Our participants wanted more involvement in treatment decision making.     

Knowledge and attitudes in pain management: Hong Kong nurses' perspective

Effective pain management requires accurate knowledge, attitudes and assessment skills. To determine the current knowledge level and attitudes of nurses in pain management, 1,604 registered nurses working in three different hospitals in Hong Kong were invited to participate in this study. The sample consisted of 601 registered nurses, 63 nursing officers, and 14 nursing specialists (N = 678). The response rate was 43%. The Nurses' Knowledge and Attitudes Survey Instrument questionnaire developed by McCaffery and Ferrell was translated into Chinese and used with permission. To ensure the contextual relevancy and consistency of the questionnaire, content validity and test-retest reliability tests were performed. The content validity index was 0.87 and the test-retest reliability (Spearman's p coefficient) was 0.812. The percentage of correctly answered questions was 44%. There was statistical significant in educational preparation and clinical experiences with correct scores. The findings of our study support the concern of inadequate knowledge and attitudes in relation to pain management. Further intensive continuing education and staff development is highly indicated for nurses in Hong Kong.