Wednesday, March 04, 2015

Clinical Inquiry Series

The RNs at St. Joseph Hospital are curious and inquisitive when it comes to best nursing practice.  Our nurses are encouraged to submit their clinical practice questions to our Research Department for review of the best evidence to guide patient care.  Here is the first of our series entitled "Clinical Inquiry".

Question:  Why does St. Joseph RTs and RNs still lavage ET tubes with normal saline when evidence-based practice research shows this is not helpful and potentially harmful?

Answer: According to Lippincott’s Nursing Procedures, the use of normal saline is not included in the guidelines for suctioning. Current research is not clear.  A recent study indicates that not using normal saline before endotracheal suction decreases the incidence of ventilator-associated pneumonia and associated medical costs (Mei-Yu, Shu-Hua,  & Yi-Hui, 2012). This is contradicted by findings from another recent study which found that instillation of normal saline decreased incidence of pneumonia in intubated and ventilated patients (Caruso, Denari, Ruiz, Demarzo, & Deheinzelin, 2009).  One possible explanation for the discrepancy in results is from variations in the administration of the normal saline, time to suctioning, patient position, and dosages of saline. 

Response written by Kathleen Pentecost, SRN CBU, BA Sociology & Carla I. Morales, SRN CBU, BS Psychobiology

Caruso,P. Denari,s., Ruiz, S. A. L., Demarzo, S. E., Deheinzelin, D. (2009). Instillation of normal saline before suctioning reduces the incidence of pneumonia in intubated and ventilated adults.  Critical Care Medicine, 37, 32-38.
Lippincott Williams & Wilkins. (2009). Lippincott's nursing procedures. Philadelphia: Lippincott
Williams & Wilkins.
Mei-Yu, L., Shu-Hua, C., & Yi-Hui, S. (2012). Reducing Ventilator-Associated Pneumonia (VAP) by not using instillation saline before suctioning [Chinese]. Journal of Nursing & Healthcare Research, 8(4), 325-331.

Wednesday, February 11, 2015

Danielle's Picks from the Literature - February 2015

Here are my picks from the nursing literature for February. SJO and CHOC staff have access to the articles by contacting Burlew Medical Library.

What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review.
Williams, Brett; Perillo, Samuel; Brown, Ted;
Nurse Education Today, 2015 Feb; 35 (2): e34-41.
Abstract: Summary Background The responsibility to implement evidence-based practice (EBP) in a health care workplace does not fall solely on the individual health care professional. Organisational barriers relate to the workplace setting, administrational support, infrastructure, and facilities available for the retrieval, critique, summation, utilisation, and integration of research findings in health care practices and settings. Objective Using a scoping review approach, the organisational barriers to the implementation of EBP in health care settings were sought. Method This scoping review used the first five of the six stage methodology developed by Levac et al. (2010). The five stages used are: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The following databases were searched from January 2004 until February 2014: Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library and CINAHL. Results Of the 49 articles included in this study, there were 29 cross-sectional surveys, six descriptions of specific interventions, seven literature reviews, four narrative reviews, nine qualitative studies, one ethnographic study and one systematic review. The articles were analysed and five broad organisational barriers were identified. Conclusions This scoping review sought to map the breadth of information available on the organisational barriers to the use of EBP in health care settings. Even for a health care professional who is motivated and competent in the use of EBP; all of these barriers will impact on their ability to increase and maintain their use of EBP in the workplace.

Back to Basics: Implementing Evidence-Based Practice.
Spruce, Lisa;
AORN Journal, 2015; 101 (1): 106-12.
Abstract: As health care transitions from volume-based care to value-based care, it is imperative that perioperative nurses implement evidence-based practices that support effective care. Implementing evidence-based practice is a challenge but improves patient outcomes, standardizes care, and decreases patient care costs. Understanding how care interventions work and how to implement them is important to compete in today's health care market. This "Back to Basics" article discusses how to identify, review, and appraise research; make recommendations to implement new practices; evaluate the outcomes of the implementations; and make necessary changes to facilitate evidence-based practice.

Development of Evidence-Based Remote Telemetry Policy Guidelines for a Multifacility Hospital System.
George, Karen J.; Walsh-Irwin, Colleen; Queen, Caleb; Vander Heuvel, Kimberly; Hawkins, Carrie; Roberts, Susan;
Dimensions of Critical Care Nursing, 2015 Jan-Feb; 34 (1): 10-8.
Abstract: Over 10 years ago, the standards for cardiac monitoring were set forth by the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young. The standards were endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. The American Heart Association printed the standards as an American Heart Association Scientific Statement. The standards provided direction related to remote telemetry monitoring to acute care hospitals. Since the standards were published, remote monitoring of cardiac patients has increased dramatically prompting research and literature related to appropriate utilization. Appropriate and safe telemetry monitoring requires clearly written evidence-based facility policies. This article describes the process whereby a team of Veterans Hospital Administration nurses from across the country reviewed 70 remote telemetry policies representing 75 Veterans Hospital Administration hospitals for clarity, consistency, and congruency to existing levels of evidence found in the literature. This article describes the processes, successes, and challenges of compiling an evidence-based remote telemetry policy guideline.
Evidence-Based Practice to Improve Outcomes for Late Preterm Infants.
Baker, Brenda;
JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 2015 Jan; 44 (1): 127-34
Abstract: Infants born between 34 weeks 0 days to 36 weeks 6 days gestation have been identified as late preterm infants (LPIs) and account for 70% of preterm births and 9% of all births. The rise in elective deliveries in the past decade is believed to have contributed to the number of late preterm births. An interprofessional team including labor and delivery, neonatal intensive care, and postpartum care providers collaborated to address this issue at an urban academic medical center.
Evidence-based nursing. Harnessing technology to promote patient-centered care.
Fisher, Cheryl A.; Feigenbaum, Kathryn;
Nursing Management, 2015 Jan; 46 (1): 14-5.
Implementing evidence-based care for patients with obstructive sleep apnea.
Bourdon, Leslie;
AORN Journal, 2014; 100 (6): C5-7.
Nursing Journal Clubs: A Literature Review on the Effective Teaching Strategy for Continuing Education and Evidence-Based Practice.
Lachance, Carly;
Journal of Continuing Education in Nursing, 2014 Dec; 45 (12): 559-65.
Abstract: Background: This literature review on nursing journal clubs evaluates the efficacy of the teaching strategy within the clinical setting. Method: Peer-reviewed articles were retrieved using an online journal database. Inclusion criteria incorporated information on efficacy of the teaching strategy, evidence-based practices, and continuing education as they related to nursing journal club initiatives. Results: The literature cited numerous benefits and proved to be in favor of nursing journal clubs. The most common benefits found were nurses remaining abreast of current research, skill development in reading and critically appraising research, and incorporation of evidence-based practices to patient care. Due to the self-motivated and voluntary nature of this teaching strategy, a limitation commonly identified was lack of participation, and further research on this limitation often was suggested. Conclusion: Nursing journal clubs proved to be an effective teaching strategy, a finding that remains consistent with the medical pioneers of the movement. J Contin Educ Nurs. 2014;45(12):559-565.
Evidence Synthesis and Its Role in Evidence-Based Health Care.
Pearson, Alan;
Nursing Clinics of North America, 2014 Dec; 49 (4): 453-60.
Promoting patient safety with evidence-based management.
Hastings, Clare;
Nursing Management, 2014 Dec; 45 (12): 11-3.

Implementing Evidence-Based Medication Safety Interventions on a Progressive Care Unit.
Williams, Tyeasha; King, Melissa W.; Thompson, Julie A.; Champagne, Mary T.;
American Journal of Nursing, 2014 Nov; 114 (11): 53-62.
Abstract: While preparing medications in complex health care environments, nurses are frequently distracted or interrupted, which can lead to medication errors that may adversely affect patient outcomes. This pilot quality improvement project, which took place in a 32-bed surgical progressive care unit in an academic medical center, implemented five medication safety interventions designed to decrease distractions and interruptions during medication preparation: nursing staff education, use o f a medication safety vest, delineation of a no-interruption zone, signage, and a card instructing nurses how to respond to interruptions. Four types of distractions and interruptions decreased significantly between the two-month preimplementation and two-month postimplementation periods: those caused by a physician, NR o r physician assistant; those caused by other personnel; phone calls and pages placed or received by the nurse during medication administration; and conversation unrelated to medication administration that involved the nurse or loud nearby conversation that distracted the nurse. The total number of reported adverse drug events also decreased from 10 to four, or by 60%. Thus, medication safety interventions may help decrease distractions and interruptions in high-acuity settings.
Improving the Culture of Evidence-Based Practice at a Magnet® Hospital.
Kaplan, Louise; Zeller, Edna; Damitio, Diane; Culbert, Sarah; Bayley, K. Bruce;
Journal for Nurses in Professional Development, 2014 Nov-Dec; 30 (6): 274-80.

Role of the Acute Care Nurse in Managing Patients With Heart Failure Using Evidence-Based Care.
Paul, Sara; Hice, Amber;
Critical Care Nursing Quarterly, 2014 Oct-Dec; 37 (4): 357-76.
Abstract: Acute heart failure is a major US public health problem, accounting for more than 1 million hospitalizations each year. As part of the health care team, nurses play an important role in the evaluation and management of patients presenting to the emergency department with acute decompensated heart failure. Once acute decompensation is controlled, nurses also play a critical role in preparing patients for hospital discharge and educating patients and caregivers about strategies to improve long-term outcomes and prevent future decompensation and rehospitalization. Nurses’ assessment skills and comprehensive knowledge of acute and chronic heart failure are important to optimize patient care and improve outcomes from initial emergency department presentation through discharge and follow-up. This review presents an overview of current heart failure guidelines, with the goal of providing acute care cardiac nurses with information that will allow them to better use their knowledge of heart failure to facilitate diagnosis, management, and education of patients with acute heart failure.
Preventing Ventilator-Associated Events: Complying With Evidence-Based Practice.
Munaco, Sandra S.; Dumas, Bonnie; Edlund, Barbara J.;
Critical Care Nursing Quarterly, 2014 Oct-Dec; 37 (4): 384-92.
Abstract: The leading cause of death due to health care-associated infections is ventilator-associated pneumonia (VAP). The lack of clarity in the definition of VAP has made it difficult to execute and evaluate the effectiveness of prevention strategies. Beginning in 2013, hospitals were expected to implement a new surveillance definition algorithm to identify ventilator-associated events (VAEs). The Institute for Healthcare Improvement recommended the use of the Ventilator Care Bundle as part of an initiative to decrease the incidence of VAP. This article outlines the results of a quality improvement project that was conducted to address this recommendation, improve current staff knowledge, identify gaps in practice, and determine the rate of compliance with prevention strategies. The major findings of this project also exposed limitations of the electronic medical record system, and suggested enhancements, which would promote the VAP Bundle initiatives, facilitate documentation, and permit straightforward data collection.

Systematic review of instruments for measuring nurses' knowledge, skills and attitudes for evidence-based practice.
Leung, Kat; Trevena, Lyndal; Waters, Donna;
Journal of Advanced Nursing, 2014 Oct; 70 (10): 2181-95.
Abstract: Aim To identify, appraise and describe the characteristics of instruments for measuring evidence-based knowledge, skills and/or attitudes in nursing practice. Background Evidence-based practice has been proposed for optimal patient care for more than three decades, yet competence in evidence-based practice knowledge and skills among nurse clinicians remains difficult to measure. There is a need to identify well-validated and reliable instruments for assessing competence for evidence-based practice in nursing. Design Psychometric systematic review. Data Sources The MEDLINE, EMBASE, CINAHL, ERIC, CDSR, All EBM reviews and PsycInfo databases were searched from 1960-April 2013; with no language restrictions applied. Review Methods Using pre-determined inclusion criteria, three reviewers independently identified studies for full-text review, extracting data and grading instrument validity using a Psychometric Grading Framework. Results Of 91 studies identified for full-text review, 59 met the inclusion criteria representing 24 different instruments. The Psychometric Grading Framework determined that only two instruments had adequate validity - the Evidence Based Practice Questionnaire measuring knowledge, skills and attitudes and another un-named instrument measuring only EBP knowledge and attitudes. Instruments used in another nine studies were graded as having 'weak' validity and instruments in the remaining 24 studies were graded as 'very weak'. Conclusion The Evidence Based Practice Questionnaire was assessed as having the highest validity and was the most practical instrument to use. However, the Evidence Based Practice Questionnaire relies totally on self-report rather than direct measurement of competence suggesting a need for a performance-based instrument for measuring evidence-based knowledge, skills and attitudes in nursing.
$trategies for Searching and Managing Evidence-Based Practice Resources.
Robb, Meigan; Shellenbarger, Teresa;
Journal of Continuing Education in Nursing, 2014 Oct; 45 (10): 461-6.
Abstract: Evidence-based nursing practice requires the use of effective search strategies to locate relevant resources to guide practice change. Continuing education and staff development professionals can assist nurses to conduct effective literature searches. This article provides suggestions for strategies to aid in identifying search terms. Strategies also are recommended for refining searches by using controlled vocabulary, truncation, Boolean operators, PICOT (Population/Patient Problem, Intervention. Comparison, Outcome, Time) searching, and search limits. Suggestions for methods of managing resources also are identified. Using these approaches will assist in more effective literature searches and may help evidence-based practice decisions.

Wednesday, August 06, 2014

Clinical Inquiry - first of a series

The RNs at St. Joseph Hospital are curious and inquisitive when it comes to best nursing practice.  Our nurses are encouraged to submit their clinical practice questions to our Research Department for review of the best evidence to guide patient care.  Here is the first of our series entitled "Clinical Inquiry".

Q: Why do we use sterile water to flush NG tubes? Why can't we use bottled or tap water?
A: Bottled or tap water is only indicated for hydration in healthy patients who are not immunocompromised.  Acutely ill patients or those with chronic conditions that have any alterations to the GI tract are vulnerable to nosocomial infections from non-sterile products including water.  This also holds true for patients who are immunocompromised but not acutely ill.  Because tap water contains metals, medications should only be diluted in sterile water to prevent reduction of bioavailability.  Tap water also has the potential to be a source of contamination when reconstituting formula.  Filtration of water may be beneficial but still poses a risk for contamination.  Sterile water is solute-free and free of chemical or microbial contaminants; therefore, it is the only type of water that should be used to flush NG tubes, dilute medications and reconstitute formula.

response written by Kathleen Pentecost, SRN CBU, BA Sociology & Carla I. Morales, SRN CBU, BS Psychobiology

Bankhead, R., Boullata, B.S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B., et al. (2009) A.S.P.E.N. Enteral nutrition    practice recommendations. Journal of Enteral and Parenteral Nutrition, 33, 122-69.

Monday, August 04, 2014

St. Joseph Hospital Staff Publishes Article

Congratulations to the following St. Joseph Hospital staff for their newly published article on blood culture accuracy: Beth Winokur, RN, PhD, CEN, Debra Pai, RN, BSN, CEN, Dana Rutledge, RN, PhD, Kate Vogel, MA, CLS, MT, Sadeeka Al-Majid, RN, PhD, Christine Marshall, RN, MSN, CEN, CPEN and Paul Sheikewitz, MD!  SJO employees have access to the full article through Burlew Medical Library.  Contact library staff for more details.

J Emerg Nurs. 2014 Jul;40(4):323-9. doi: 10.1016/j.jen.2013.04.007. Epub 2013 Jun 29.
Blood culture accuracy: discards from central venous catheters in pediatric oncology patients in the emergency department.
Winokur EJ1, Pai D2, Rutledge DN2, Vogel K2, Al-Majid S2, Marshall C2, Sheikewitz P2.

Lack of specific guidelines regarding collection of blood for culture from central venous catheters (CVCs) has led to inconsistencies in policies among hospitals. Currently, no specific professional or regulatory recommendations exist in relation to using, reinfusing, or discarding blood drawn from CVCs before drawing blood for a culture. Repeated wasting of blood may harm immunocompromised pediatric oncology patients. The purpose of this comparative study was to determine whether differences exist between blood cultures obtained from the first 5 mL of blood drawn from a CVC line when compared with the second 5 mL drawn.
During 2009-2011, 62 pediatric oncology patients with CVCs and orders for blood cultures to determine potential sepsis were enrolled during ED visits. Trained study nurses aseptically drew blood and injected the normally discarded first 5 mL and the second specimen (usual care) into separate culture bottles. Specimens were processed in the microbiology laboratory per hospital policy.
Positive cultures were evaluated to assess agreement between specimen results and to determine that the identified pathogen was not a contaminant. Out of 186 blood culture pairs, 4.8% demonstrated positive results. In all positive-positive matches, the normal discard specimen contained the same organism as the usual care specimen. In 4 matches, the normally discarded specimen demonstrated notably earlier time to positivity (4 to 31 hours) compared with the usual care specimen, which resulted in earlier initiation of definitive antibiotics.
These findings support the accuracy of the specimen that is normally discarded and suggest the need to reconsider its use for blood culture testing.

Monday, July 14, 2014

St. Joseph Hospital Nurse Publishes Article

Congratulations to St. Joseph Hospital RN Lupe Ramos, MSN, NP-C, ACNP for her newly published article on cardiac diagnostic testing!  SJO employees have access to the full article through Burlew Medical Library.  Contact library staff for more details.

Critical Care Nurse.
2014 Jun;34(3):16-27; quiz 28. doi: 10.4037/ccn2014361.
Cardiac diagnostic testing: what bedside nurses need to know.
Ramos LM.
Abstract: Coronary artery disease affects more than 385000 persons annually and continues to be a leading cause of death in the United States. Recently, the number of available noninvasive cardiac diagnostic tests has increased substantially. Nurses should be knowledgeable about available noninvasive cardiac diagnostic testing. The common noninvasive cardiac diagnostic testing procedures used to diagnose coronary heart disease are transthoracic echocardiography, stress testing (exercise, pharmacological, and nuclear), multidetector computed tomography, coronary artery calcium scoring (with electron beam computed tomography or computed tomographic angiography), and cardiac magnetic resonance imaging. Objectives include (1) describing available methods for noninvasive assessment of coronary artery disease, (2) identifying which populations each test is most appropriate for, (3) discussing advantages and limitations of each method of testing, (4) identifying nursing considerations when caring for patients undergoing various methods of testing, and (5) describing outcome findings of various methods.

Wednesday, April 02, 2014

Danielle's Picks from the Literature - April 2014

Here are my picks from the nursing literature for April. SJO and CHOC staff have access to the articles by contacting Burlew Medical Library.

1. Ruptured thought: rupture as a critical attitude to nursing research.
Beedholm, Kirsten; Lomborg, Kirsten; Frederiksen, Kirsten; 
Nursing Philosophy, 2014 Apr; 15 (2): 102-11.
Abstract: In this paper, we introduce the notion of 'rupture' from the French philosopher Michel Foucault, whose studies of discourse and governmentality have become prominent within nursing research during the last 25 years. We argue that a rupture perspective can be helpful for identifying and maintaining a critical potential within nursing research. The paper begins by introducing rupture as an inheritance from the French epistemological tradition. It then describes how rupture appears in Foucault's works, as both an overall philosophical approach and as an analytic tool in his historical studies. Two examples of analytical applications of rupture are elaborated. In the first example, rupture has inspired us to make an effort to seek alternatives to mainstream conceptions of the phenomenon under study. In the second example, inspired by Foucault's work on discontinuity, we construct a framework for historical epochs in nursing history. The paper concludes by discussing the potential of the notion of rupture as a response to the methodological concerns regarding the use of Foucault-inspired discourse analysis within nursing research. We agree with the critique of Cheek that the critical potential of discourse analysis is at risk of being undermined by research that tends to convert the approach into a fixed method.

2. Pursuing a career in nursing research. 
Fawcett, Tonks (Josephine) Nicola; McCulloch, Corrienne; 
Nursing Standard, 2014 Mar 12; 28 (28): 54-8.
Abstract: Nursing is an evidence-based profession that uses the latest and best research to improve nursing practice and patient outcomes. Nursing research is needed to generate knowledge and develop nursing care. Despite this, the role of the research nurse is poorly understood and appreciated. This article discusses the importance of the nurses' role in clinical research and provides information on how to pursue a career in research.

3.  Analysis and Use of Different Research Review Approaches in Nursing.
Cope, Diane G.; 
Oncology Nursing Forum, 2014 Mar; 41 (2): 207-8.
Abstract: Asignificant increase in nursing research is being conducted as the nursing profession shifts from "ritual" clinical decisions to practice based on research evidence. Evidence-based practice is now an accepted, essential foundation for high-quality patient care. Initially, best practice was based on a few randomized, controlled trials that reflected similar clinical problems. However, with the plethora of nursing research to date, evidence-based nursing practice currently is grounded in summaries of research or research reviews, resulting in robust findings used in the development of clinical guidelines. Several terms exist for reviews, such as literature, integrative, systematic, meta-analysis, and metasynthesis. Similarities can be noted among the types of reviews; however, the objectives and goals of each method differ and the terms should not be used synonymously. This article will define each of the literature and research reviews and discuss methodologic procedures for conducting each method. 

4.  Creating a Culture of Caring.
Letcher, Deborah C.; Nelson, Margot L.; 
Journal of Nursing Administration, 2014 Mar; 44 (3): 175-86.  

5.  The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing.
Brown, Carlton G.; 
Clinical Journal of Oncology Nursing, Apr2014; 18 (2): 157-159.  

6.  Evidence to Change Practice: Creating a Restful Hospital Environment for Nurses and Patients.
Hinkulow, Maricel B.; 
Archives of Psychiatric Nursing, 2014 Feb; 28 (1): 74-5.  

7.  Evidence-based nursing explained.
Smith, Joanna; Cappleman, Julia; 
Nursing Children & Young People, 2014 Feb; 26 (1): 12.  

8.  The Establishment of Evidence-Based Practice Competencies for Practicing Registered Nurses and Advanced Practice Nurses in Real-World Clinical Settings: Proficiencies to Improve Healthcare Quality, Reliability, Patient Outcomes, and Costs. 
Melnyk, Bernadette Mazurek; Gallagher-Ford, Lynn; Long, Lisa English; Fineout-Overholt, Ellen; 
Worldviews on Evidence-Based Nursing, 2014; 11 (1): 1st Quarter: 5-15.  
Abstract: Background Although it is widely known that evidence-based practice (EBP) improves healthcare quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still not the standard of care delivered by practicing clinicians across the globe. Adoption of specific EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health care. Aim The aim of this study was to develop a set of clear EBP competencies for both practicing registered nurses and APNs in clinical settings that can be used by healthcare institutions in their quest to achieve high performing systems that consistently implement and sustain EBP. Methods Seven national EBP leaders developed an initial set of competencies for practicing registered nurses and APNs through a consensus building process. Next, a Delphi survey was conducted with 80 EBP mentors across the United States to determine consensus and clarity around the competencies. Findings Two rounds of the Delphi survey resulted in total consensus by the EBP mentors, resulting in a final set of 13 competencies for practicing registered nurses and 11 additional competencies for APNs. Linking Evidence to Action Incorporation of these competencies into healthcare system expectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion processes could drive higher quality, reliability, and consistency of healthcare as well as reduce costs. Research is now needed to develop valid and reliable tools for assessing these competencies as well as linking them to clinician and patient outcomes.

9.  Advancing advanced practice — Clarifying the conceptual confusion.
Stasa, Helen; Cashin, Andrew; Buckley, Thomas; Donoghue, Judith; 
Nurse Education Today, 2014 Mar; 34 (3): 356-61.  
Abstract: Summary: Background: In recent years, there has been a substantial increase in the number of nurses holding advanced practice nursing positions. However, the lack of clarity regarding key terms such as ‘advanced practice nursing’, ‘advanced nursing practice’, ‘scope of practice’ and ‘extended practice’, and international variability in how these terms are used has created significant confusion. This lack of clarity is problematic for nurses, other health professionals, health service consumers, educators and policy makers, particularly given the global mobility of the nursing workforce. Objectives: 1) To highlight the significant international variability in how advanced practice nursing, and associated terms such as extended and expanded practice, are defined and regulated across a variety of different English speaking countries, including the US, UK, New Zealand, Canada and Australia. 2) To propose innovative formulations for how the nursing profession may attempt to ensure greater precision and agreement around advanced practice terminology. Design: Discursive paper. Results: It was found that there is a considerable lack of clarity regarding the precise definitions of key terms surrounding the discussion of advanced practice. Additionally, there are large disparities in how the five chosen countries regulate advanced practice nursing, and roles such as that of the nurse practitioner. Conclusions: It is suggested that the confusion regarding advanced practice terminology can be reduced definitionally by minimising the use of the term ‘expanded practice’; defining advanced practice nursing to refer to the type of practice in defined and regulated advanced practice nursing scopes; and defining advanced nursing practice as expert practice within a regulated nursing scope. 

10. Understanding the Role of the Professional Practice Environment on Quality of Care in Magnet® and Non-Magnet Hospitals.
Stimpfel, Amy Witkoski; Rosen, Jennifer E.; McHugh, Matthew D.; 
Journal of Nursing Administration, 2014 Jan; 44 (1): 10-6.
Abstract: OBJECTIVE: The aim of this study was to explore the relationship between Magnet Recognition® and nurse-reported quality of care. BACKGROUND: Magnet® hospitals are recognized for nursing excellence and quality patient outcomes; however, few studies have explored contributing fac-tors for these superior outcomes. METHODS: This was a secondary analysis of linked nurse survey data, hospital administrative data, and a listing of American Nurses Credentialing Center Magnet hospitals. Multivariate regressions were modeled before and after propensity score matching to assess the relationship between Magnet status and quality of care. A mediation model assessed the indirect effect of the professional practice environ-ment on quality of care. RESULTS: Nurse-reported quality of care was sig-nificantly associated with Magnet Recognition after matching. The professional practice environment me-diates the relationship between Magnet status and quality of care. CONCLUSION: A prominent feature of Magnet hospitals, a professional practice environment that is supportive of nursing, plays a role in explaining why Magnet hospitals have better nurse-reported quality of care.