Nurses' perceptions of using an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury: A qualitative study

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Highlights

  • Care bundles are appropriate and feasible for use in emergency care in low resource environments.

  • Care bundles can be used to guide evidence-based emergency nursing care.

  • Strategies to support care bundle use must take into account local context.

  • Support from end-users is a major facilitator to care bundle use.

Abstract

Evidence to guide initial emergency nursing care of patients with severe traumatic brain injury (TBI) in Thailand is currently not available in a useable form. A care bundle was used to summarise an evidence-based approach to the initial emergency nursing management of patients with severe TBI and was implemented in one Thai emergency department. The aim of this study was to describe Thai emergency nurses' perceptions of care bundle use. A descriptive qualitative study was used to describe emergency nurses' perceptions of care bundle use during the implementation phase (Phase-One) and then post-implementation (Phase-Two). Ten emergency nurses participated in Phase-One, while 12 nurses participated in Phase-Two. In Phase-One, there were five important factors identified in relation to use of the care bundle including quality of care, competing priorities, inadequate equipment, agitated patients, and teamwork. In Phase Two, participants perceived that using the care bundle helped them to improve quality of care, increased nurses' knowledge, skills, and confidence. Care bundles are one strategy to increase integration of research evidence into clinical practice and facilitate healthcare providers to deliver optimal patient care in busy environments with limited resources.

Introduction

Care bundles are one solution to introduce evidence into clinical practice and optimise the care provided by healthcare providers (Resar et al., 2012). A care bundle is defined as “a small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually” (Resar et al., 2012, p. 2). The care bundle approach has been developed and used more widely in Western countries, particularly in intensive care units (Litch, 2007, Morris et al, 2011, Rello et al, 2010, Sedwick et al, 2012). Use of care bundles in intensive care not only improved clinical outcomes (Litch, 2007, Morris et al, 2011, Sedwick et al, 2012), decreased the length of hospital stay (Litch, 2007, Rello et al, 2010), and reduced the healthcare costs (Sedwick et al., 2012), but also increased knowledge among healthcare providers (Dumont, Wakeman, 2010, Subramanian et al, 2013).

Care bundles are being used in emergency care to improve the care of patients with stroke and transient ischaemic attack (National Institute of Clinical Studies [NICS], 2009, Weeraratne et al, 2010), sepsis (Kuan et al, 2013, Nguyen et al, 2011, Tromp et al, 2010), cardiac arrest (Nolan and Soar, 2008), chronic obstructive pulmonary disease (McCarthy et al., 2013), and acute asthma (McCreanor et al., 2012). Implementation of care bundles in emergency care has been shown to improve clinical outcomes (McCarthy et al, 2013, Tromp et al, 2010, Weeraratne et al, 2010). Although the development and implementation of care bundles in Western countries have been shown to improve patient outcomes and reduce healthcare costs, care bundle use in low-income and middle-income countries, where backgrounds, facilities, and resources are very different, is just beginning to occur (Apisarnthanarak et al, 2010, Liu et al, 2013, Subramanian et al, 2013, Unahalekhaka et al, 2007, Wu et al, 2012). In this paper, the particular focus will be on the use of a care bundle approach for management of patients with severe TBI in the Thai context.

Section snippets

Background

Severe TBI is a global problem (Crowe et al, 2010, Faul et al, 2010, Tagliaferri et al, 2006) and it is a major and increasing problem in Thailand (Bureau of Policy and Strategy [BOPS], Ministry of Public Health, Thailand, 2011, Ratanalert et al, 2007). Thai emergency nurses play a vital role in caring for patients with severe TBI, particularly during initial emergency care and resuscitation in the emergency department (ED). However, little is known about the evidence-based management of severe

Study design

A descriptive qualitative approach using interviews to collect study data was used. The interviews were conducted in two phases: during implementation of the care bundle (Phase-One) and two months after implementation of the care bundle (Phase-Two). In Phase-One, interviews were undertaken to understand emergency nurses' perspectives of the implementation of the care bundle as well as identify barriers and facilitators to care bundle use. In Phase-Two, interviews were conducted to establish a

Phase-one

Ten emergency nurses participated in the interviews in Phase-One. Of the ten emergency nurses who participated in this phase of the study, 80% were female, and the median age was 33 years. All ten nurses were Bachelor degree prepared, and the median years of emergency nursing experience was eight years. Eighty percent of the participants had undertaken specific training in trauma care.

Thematic analysis identified five major themes: (i) quality of care, (ii) competing priorities, (iii)

Discussion

The study highlighted that emergency nurses had positive perception of care bundle implementation and subsequent use in clinical practice. There are several reasons why use of an evidence-based care bundle was considered as positive by Thai emergency nurses. First, care bundles consist of a small group of evidence-based interventions (Resar et al., 2012), and as such, they make information easier for nursing staff to remember and prioritise the important elements of care. It is known that the

Conclusion

Thai emergency nurses perceived that using the care bundle helped them to improve quality of care as a result of increased knowledge, skills, and confidence. A care bundle approach is an acceptable strategy to increase integration of research evidence into the Thai ED context and facilitate Thai emergency nurses to deliver optimal care to patients with severe TBI in a resource poor environment.

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