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Sjuksköterskors kliniska beslutsfattande med fokus på perifera venkatetrar (PVK)
Malmö högskola, Faculty of Health and Society (HS), Department of Care Science (VV).
2007 (Swedish)Licentiate thesis, comprehensive summary (Other academic)
Abstract [sv]

För att kunna ge vård av säker och god kvalitet krävs att sjuksköterskor har kunskap inom många områden, eftersom de har ansvar för såväl bedömning, planering och genomförande, som utvärdering och dokumentation av omvårdnadsarbetet. Ett av flera ansvarsområden för sjuksköterskor i deras dagliga arbete är beslutsfattande om insättning och skötsel av perifera venkatetrar (PVK). En PVK är en tunn plastkateter som sätts in i ett blodkärl via en kanyl. PVK används vid intravenös behandling med till exempel antibiotika och andra läkemedel, blodkomponenter eller näringslösningar. En stor andel av alla patienter inom hälsooch sjukvård kommer någon gång i kontakt med en PVK och riskerar då också att utsättas för komplikationer. En vanlig komplikation i samband med PVK är tromboflebit. Tromboflebit förekommer i olika svårighetsgrader och innebär att inflammation har uppstått i blodkärlet i kombination med samtidig blodpropp. Symtom som kan uppstå är rodnad, svullnad, smärta, hårdhet i kärlet och varig infektion. Det finns kliniska riktlinjer om PVK framtagna både på nationell och på lokal nivå som fungerar som ett stöd i beslutsfattandet. Tidigare forskning har visat att kliniskt verksamma ibland inte följer riktlinjer. Anledningar till att inte riktlinjer följs kan till exempel vara att de kliniskt verksamma inte håller med om det som rekommenderas, inte känner till rekommendationerna, inte har tid eller möjlighet att påverka de beslut som fattas eller att det finns individuella faktorer att ta hänsyn till för den enskilda patienten. 52 Frågan kan ställas om sjuksköterskor använder sig av kliniska riktlinjer i sitt dagliga arbete eller om det är andra faktorer och aspekter som har betydelse och påverkar beslutsfattandet. Denna licentiatavhandling syftade till att beskriva sjuksköterskors kliniska beslutsfattande genom att fokusera på deras följsamhet till riktlinjer och beslutsresonemang om PVK. Två studier har genomförts inom ramen för denna licentiatavhandling. Studie I undersökte i vilken utsträckning sjuksköterskor följer nationella och lokala riktlinjer om PVK. PVKns placering och storlek, tiden som PVKn varit placerad i blodkärlet, dokumentation vid PVKns förband samt om det fanns tecken på tromboflebit vid PVKn var variabler som undersöktes i relation till de rekommendationer som fanns. Utifrån två protokoll samlades strukturerad data in och analyserades. Totalt 343 PVK ingick i analysen. I studie II undersöktes de tecken och påverkande faktorer som har betydelse när sjuksköterskor fattar beslut om skötsel av PVK. I studien observerades 43 sjuksköterskor i sitt dagliga arbete. Sjuksköterskorna intervjuades också dels om PVK-besluten som de fattade under observationerna, dels om deras beslutsfattande om PVK-skötsel i allmänhet. Studie I visade att sjuksköterskor delvis följer riktlinjer. Det fanns skillnader mellan de vårdavdelningar som hade nationella riktlinjer och de som hade lokala riktlinjer, i hur de olika avdelningarna valde placering, storlek och dokumenterade vid PVKns förband. PVKn hade suttit längre tid än rekommenderat i varierande utsträckning. Andelen tromboflebiter var låg (7.0%) och tromboflebiterna var milda. Det tyder på att sjuksköterskor är noga med att ta bort PVK vid tecken på komplikationer. Studie II visade att sjuksköterskor i sitt kliniska resonemang om PVK-skötsel tar hänsyn till den individuella patientsituationen, sjuksköterskans arbetssituation och erfarenhet av PVK-skötsel. Det framkom även att sjuksköterskor balanserar mellan att undvika eller minimera obehag och smärta för patienten och samtidigt förebygga komplikationer från PVKn. Resultaten från denna licentiatavhandling kan få betydelse för undervisning av sjuksköterskestudenter och även när kliniska riktlinjer ska införas på vårdavdelningar.

Abstract [en]

Every working shift nurses make several decisions, including decisions about management of peripheral venous catheters (PVC). Peripheral catheterisation is a common procedure, which affects numerous patients in health care today. PVC are for example used for intravenous infusions with antibiotics, nutrients and blood components. Having PVC in situ may lead to complications such as thrombophlebitis. Clinical guidelines have been developed within the area to assist nurses in their decision-making, but clinical guidelines are not always adhered to. There are several reasons why clinicians do not always adhere to clinical guidelines, although such adherence may lead to fewer complications. Choices for decisions regarding PVC management have been investigated in previous studies, but not in a naturalistic setting. The overall aim of this licentiate thesis was to describe nurses’ clinical decision-making through focusing on their adherence to clinical guidelines and their clinical reasoning concerning decisions of PVC. Two studies have been conducted and data were collected during a six-month period, from December 2004 to June 2005. Study I investigated nurses’ adherence to national and local PVC guidelines by focusing on time in situ, site, size and documentation at the dressing. The thrombophlebitis frequency associated with PVC in situ was also investigated. Structured observations through two protocols were carried out and data about 343 PVC were analysed. Study II investigated nurses’ clinical reasoning regarding PVC management and cues and factors of importance in the decision10 making process were analysed. Nurses were observed in their daily work with focus on PVC management. They were interviewed both about the PVC decisions made in the observed situations and about factors influencing their reasoning regarding PVC management in general. The observations facilitated the interviews. Transcribed interview texts were analysed with content analysis. The results in study I showed that thrombophlebitis frequency was 7.0% and the nurses seemed to replace or remove PVC before any severe complications arose in accordance with clinical guidelines. Nurses partly adhered to national and local guidelines concerning site, size, documentation at the dressing and time in situ. Differences in guideline adherence were observed for wards with local or national guidelines, as well as for wards with different specialities. The results indicate that local guidelines may have an impact on guideline adherence but these results need further exploration. Analysis of interview texts in study II resulted in a category system with three main categories describing cues and factors of importance in the nurses’ clinical reasoning about PVC: the individual patient situation, the nurse’s work situation, and experience of PVC management. An overall theme was also revealed in the interview texts and the nurses balance in their clinical reasoning between avoiding or minimizing discomfort and pain for the patient and preventing complications from the PVC. The results from this licentiate thesis have implications for the education of nurses as well as during implementation of clinical guidelines.

Place, publisher, year, edition, pages
Malmö university, Faculty of Health and Society , 2007. , p. 66
Series
FoU-rapport, ISSN 1650-2337 ; 3
Keywords [sv]
peripheral catheterization, decision making, clinical judgement, clinical reasoning, practice guidelines, guideline adherence, content analysis, interviews, observations
National Category
Nursing
Identifiers
URN: urn:nbn:se:mau:diva-7380Local ID: 5589ISBN: 978-91-7104-208-8 (print)OAI: oai:DiVA.org:mau-7380DiVA, id: diva2:1404296
Note

Note: The papers are not included in the fulltext online.

Paper I in thesis as accepted manuscript, paper II as manuscript.

Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-03-05Bibliographically approved
List of papers
1. Registered Nurses' Adherence to Clinical Guidelines Regarding Peripheral Venous Catheters: A Structured Observational Study
Open this publication in new window or tab >>Registered Nurses' Adherence to Clinical Guidelines Regarding Peripheral Venous Catheters: A Structured Observational Study
2008 (English)In: Worldviews on Evidence-Based Nursing, ISSN 1545-102X, E-ISSN 1741-6787, Vol. 5, no 3, p. 148-159Article in journal (Refereed)
National Category
Health Sciences
Identifiers
urn:nbn:se:mau:diva-4102 (URN)10.1111/j.1741-6787.2008.00105.x (DOI)18373638 (PubMedID)2-s2.0-51749100228 (Scopus ID)9423 (Local ID)9423 (Archive number)9423 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-02-05Bibliographically approved
2. Nurses’ clinical reasoning concerning management of peripheral venous cannulae
Open this publication in new window or tab >>Nurses’ clinical reasoning concerning management of peripheral venous cannulae
2009 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 18, no 23, p. 3366-3375Article in journal (Refereed)
Abstract [en]

AIM: The aim was to describe nurses' clinical reasoning regarding peripheral venous cannulae management by focusing on the clinical information and circumstances considered during the decision-making process. BACKGROUND: On every shift nurses make several decisions, among others concerning the management of peripheral venous cannulae. Thrombophlebitis is a common complication associated with its use, although more severe complications can arise. There are clinical practice guidelines within the area, but they are not always adhered to. Previous studies have examined decisions related to the management of peripheral venous cannulae, but did not include observations in a naturalistic setting. DESIGN: A qualitative study combining observations and interviews. METHODS: Participant observation facilitated open interviews about the clinical reasoning behind decision-making in observed situations, as well as semi-structured interviews regarding clinical reasoning about the general management of peripheral venous cannulae. Transcribed interview texts were analysed with content analysis. RESULTS: Three main categories describe clinical information and circumstances: the individual patient situation, the nurse's work situation and experience of peripheral venous cannulae management. The overall theme of the interview texts was that the clinical reasoning was a balancing act between minimising patient discomfort and preventing complications from the peripheral venous cannulae. CONCLUSIONS: At all times the patients' well-being was considered, but the ways the nurses approached this differed depending on how they considered clinical information in the individual patient situation, circumstances in their own work situation and their experience of peripheral venous cannulae management. RELEVANCE TO CLINICAL PRACTICE: Knowledge of the clinical information and circumstances considered in naturalistic settings, is valuable when implementing and adjusting clinical practice guidelines to local settings. This knowledge is also useful in nursing education as student nurses' and nurses' ability to balance between preventing complications and avoiding discomfort is important for enhancing patient care.

Place, publisher, year, edition, pages
Blackwell Publishing Ltd, 2009
National Category
Nursing
Identifiers
urn:nbn:se:mau:diva-5138 (URN)10.1111/j.1365-2702.2009.02973.x (DOI)000271637800019 ()19930090 (PubMedID)2-s2.0-70449478351 (Scopus ID)9422 (Local ID)9422 (Archive number)9422 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-02-05Bibliographically approved

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