Critical care nurses' decision-making activities in the natural clinical setting

• This article reports on observation of 18 nurses in urban and rural based critical care settings.

• The purpose of the study was to observe and describe the decision-making activities of critical care nurses within natural clinical settings.

• During the 2-hour observation, the researcher dictated a detailed commentary on to audio-tape of each nurse's actions. Tapes were transcribed and subjected to content analysis.

• Findings indicated three main categories of decisions. Decision frequencies were linked to nurses' critical care experience, appointment level, and location, as well as nursing shifts.

• The findings are discussed in relation to previous empirical evidence and the implications for practice.

• The author concludes that future research should be directed towards measuring the contextual influences on nurses' decision-making on the outcome of patient care.

Being a palliative care volunteer

In this research volunteers' experiences in the field of palliative care were explored from the perspective of volunteers. The study made visible the skills, values and wisdom inherent in enactment of the volunteer role and provided new insights into the nature of relatedness between clients / families and volunteers.

The validity of the 21-item version of the depression anxiety stress scales as a routine outcome measure

Objective: This study aimed to test the validity of the 21-item Depression Anxiety Stress Scales (DASS-21) as a routine clinical outcome measure in the private in-patient setting. We hypothesized that it would be a suitable routine outcome instrument in this setting.

Method: All in-patients treated at a private psychiatric hospital over a period of 24 months were included in the study. Data were collected on demographics, service utilization, diagnosis and a set of four routine measures both at admission and discharge. These measures consisted of the Clinical Global Impressions (CGI) scales, Health of the Nation Outcome Scales (HoNOS), the Mental Health Questionnaire (MHQ-14) and DASS-21. The results of these measures were compared.

Results: Of 786 admissions in total, the number of fully completed (ie paired admission and discharge) data sets for the DASS-21 depression, anxiety and stress subscales were 337, 328 and 347, respectively. All subscales showed statistically significant reductions in mean scores from admission to discharge (P < 0.001) and were significantly correlated with all MHQ-14 subscales and significantly related to CGI scale categories. The total DASS-21 and total HoNOS scores were also significantly correlated.

Conclusions: The findings from the present study support the validity of DASS-21 as a routine clinical outcome measure in the private in-patient setting.

Horizons revealed : post anaesthetic nurse care for prisoner-patients

This qualitative study revealed the experiences of registered nurses who cared for prisoner-patients in a major public hospital setting. The study found that caring for prisoner-patients is an emotionally draining experience where knowing or imagining the prisoner-patient's crime subtly provokes registered nurses to give reactive and perfunctory care that straddles real and ideal perspectives.

The uptake of an early warning system in an Australian emergency department : a pilot study

Objectives: To evaluate the uptake of an emergency department early warning system (ED EWS) for recognition of, and response to, clinical deterioration.

Design, setting and participants: A descriptive exploratory study conducted in an urban district hospital in Melbourne, Australia. Systematic sampling was used to identify every 10th patient for whom the ED EWS was activated from May 2009 to May 2011.

Main outcome measures: Patient characteristics, ED system data and ED EWS activation characteristics.

Results: ED EWS activation occurred in 1.5% of ED patients; 204 patients were included in this pilot study. The median age was 65.1 years (interquartile range [IQR], 47.8-77.5 years), 89.2% of patients were classified as triage category 2 or 3, and 82.4% of patients were seen by medical staff before ED EWS activation. Hypotension (27.7%) and tachycardia (23.7%) were the most common reasons for ED EWS activation. Median duration of clinical instability was 39 minutes (IQR, 5- 129 minutes). Nurses made 93.1% of ED EWS activations. Median time between documenting physiological abnormalities and ED EWS activation was 5 minutes (IQR, 0- 20). Most patients (57.8%) required hospital admission: 4.4% of patients required intensive care unit admission.

Conclusions: The ED EWS resulted in at least two formal reports of clinical deterioration in ED patients per day, indicating reasonable uptake by clinicians. A greater understanding of clinical deterioration in ED patients is warranted to inform an evidence-based approach to recognition of, and response to, clinical deterioration in ED patients.

Improving outcomes of preschool language delay in the community : protocol for the Language for Learning randomised controlled trial

Background

Early language delay is a high-prevalence condition of concern to parents and professionals. It may result in lifelong deficits not only in language function, but also in social, emotional/behavioural, academic and economic well-being. Such delays can lead to considerable costs to the individual, the family and to society more widely. The Language for Learning trial tests a population-based intervention in 4 year olds with measured language delay, to determine (1) if it improves language and associated outcomes at ages 5 and 6 years and (2) its cost-effectiveness for families and the health care system.

Methods/Design

A large-scale randomised trial of a year-long intervention targeting preschoolers with language delay, nested within a well-documented, prospective, population-based cohort of 1464 children in Melbourne, Australia. All children received a 1.25-1.5 hour formal language assessment at their 4th birthday. The 200 children with expressive and/or receptive language scores more than 1.25 standard deviations below the mean were randomised into intervention or ‘usual care’ control arms. The 20-session intervention program comprises 18 one-hour home-based therapeutic sessions in three 6-week blocks, an outcome assessment, and a final feed-back/forward planning session. The therapy utilises a ‘step up-step down’ therapeutic approach depending on the child’s language profile, severity and progress, with standardised, manualised activities covering the four language development domains of: vocabulary and grammar; narrative skills; comprehension monitoring; and phonological awareness/pre-literacy skills. Blinded follow-up assessments at ages 5 and 6 years measure the primary outcome of receptive and expressive language, and secondary outcomes of vocabulary, narrative, and phonological skills.

Discussion

A key strength of this robust study is the implementation of a therapeutic framework that provides a standardised yet tailored approach for each child, with a focus on specific language domains known to be associated with later language and literacy. The trial responds to identified evidence gaps, has outcomes of direct relevance to families and the community, includes a well-developed economic analysis, and has the potential to improve long-term consequences of early language delay within a public health framework.

A randomised, feasibility trial of a tele-health intervention for acute coronary syndrome patients with depression (‘MoodCare’): study protocol

Background Coronary heart disease (CHD) and depression are leading causes of disease burden globally and the two often co-exist. Depression is common after Myocardial Infarction (MI) and it has been estimated that 15-35% of patients experience depressive symptoms. Co-morbid depression can impair health related quality of life (HRQOL), decrease medication adherence and appropriate utilisation of health services, lead to increased morbidity and suicide risk, and is associated with poorer CHD risk factor profiles and reduced survival. We aim to determine the feasibility of conducting a randomised, multi-centre trial designed to compare a tele-health program (MoodCare) for depression and CHD secondary prevention, with Usual Care (UC).

Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome (ACS) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensland. Consenting participants are then contacted at two weeks post-discharge for baseline assessment. One hundred eligible participants are to be randomised to an intervention or a usual medical care control group (50 per group). The intervention consists of up to 10 × 30-40 minute structured telephone sessions, delivered by registered psychologists, commencing within two weeks of baseline screening. The intervention focuses on depression management, lifestyle factors (physical activity, healthy eating, smoking cessation, alcohol intake), medication adherence and managing co-morbidities. Data collection occurs at baseline (Time 1), 6 months (post-intervention) (Time 2), 12 months (Time 3) and 24 months follow-up for longer term effects (Time 4). We are comparing depression (Cardiac Depression Scale [CDS]) and HRQOL (Short Form-12 [SF-12]) scores between treatment and UC groups, assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects. A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government.

Discussion This manuscript presents the protocol for a randomised, multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients. The results of this trial will provide valuable new information about potential psychological and wellbeing benefits, cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression.

Nursing care practices following a percutaneous coronary intervention : results of a survey of Australian and New Zealand cardiovascular nurses

Background: Although there is high-level evidence to guide optimal medical care for percutaneous coronary interventions, there are less explicit guidelines to support nurses in providing care. Aim: This study describes the practice standards and priorities of care of cardiovascular nurses in Australia and New Zealand. Method: Item generation for the survey was informed by an integrative literature review and existing clinical guidelines. A 116-item Web-based survey was administered to cardiovascular nurses, via electronic mail lists of professional cardiovascular nursing organizations, using a secure online data collection system. Results: Data were collected from March 2008 to March 2009. A total of 148 respondents attempted the survey, with 110 (74.3%) completing all items. All respondents were registered nurses with an average of 12.3 (SD, 7.61) years of clinical experience in the cardiovascular setting. A range of practice patterns was evident in ambulation time after percutaneous coronary intervention, methods of sheath removal, pain relief, and patient positioning. Respondents consistently rated psychosocial care a lower priority than other tasks and also identified a knowledge deficit in this area. Conclusion: This survey identified diversity of practice patterns and a range of educational needs. Increasing evidence to support evidence-based practice and guideline development is necessary to promote high-quality care and improved patient outcomes.

Performance of the assessment of quality of life measure in people with hip and knee joint disease and implications for research and clinical use

Objective
To comprehensively evaluate the performance of the Assessment of Quality of Life (AQoL) instrument for measuring health-related quality of life (HRQOL) in people with hip and knee joint disease (arthritis or osteoarthritis).

Methods
Data from 237 individuals were available for analysis from a national cross-sectional, population-based study of hip and knee joint disease in Australia. AQoL-4D data were evaluated using Rasch analysis. A range of measurement properties was explored, including model and item fit, threshold ordering, differential item functioning, and targeting.

Results
Good overall fit of the AQoL with the Rasch model was demonstrated across a range of tests, supporting internal validity. Only 1 item (relating to hearing) showed evidence of misfit. Most AQoL items showed logical sequencing of response option categories, with threshold disordering evident for only 2 of the 12 items (items 4 and 9). Minor issues with potential clinical and research implications include limited options for reporting pain and some evidence of measurement bias between demographic subgroups (including age and sex). Participants' HRQOL was generally better than that represented by the AQoL items (mean ± SD for person abilities −2.15 ± 1.39, mean ± SD for item difficulties 0.00 ± 0.67), indicating ceiling effects that could impact the instrument's ability to detect HRQOL improvement in population-based studies.

Conclusion
The AQoL is a competent tool for assessing HRQOL in people with hip and knee joint disease, although researchers and clinicians should consider the caveats identified when selecting appropriate HRQOL measures for future outcome assessment involving this patient group.

Genetic research in Aboriginal and Torres Strait Islander communities : continuing the conversation

Genetics is at the forefront of medical research, but it is rarely used in Indigenous health research projects. This discussion paper is the outcome of the first ever national discussion of the conduct of genetic research in Indigenous communities in Australia convened by the Lowitja Institute in 2010. It reviews the ethical issues relevant to genetic research in an Australian Indigenous context; existing guidelines for genetic research in indigenous communities internationally; and literature on genetic literacy in Indigenous contexts. Finally, the discussion paper presents a summary of the productive and challenging conversations at the round table.

Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities

The purpose of this retrospective, cross-sectional study was to determine the prevalence of advance care planning (ACP) among older people presenting to an Emergency Department (ED) from the community or a residential aged care facility. The study sample comprised 300 older people (aged 65+ years) presenting to three Victorian EDs in 2011. A total of 150 patients transferred from residential aged care to ED were randomly selected and then matched to 150 people who lived in the community and attended the ED by age, gender, reason for ED attendance and triage category on arrival. Overall prevalence of ACP was 13.3% (n = 40/300); over one-quarter (26.6%, n = 40/150) of those presenting to the ED from residential aged care had a documented Advance Care Plan, compared to none (0%, n = 0/150) of the people from the community. There were no significant differences in the median ED length of stay, number of investigations and interventions undertaken in ED, time seen by a doctor or rate of hospital admission for those with an Advance Care Plan compared to those without. Those with a comorbidity of cerebrovascular disease or dementia and those assessed with impaired brain function were more likely to have a documented Advance Care Plan on arrival at ED. Length of hospital stay was shorter for those with an Advance Care Plan [median (IQR) = 3 days (2–6) vs. 6 days (2–10), P = 0.027] and readmission lower (0% vs. 13.7%). In conclusion, older people from the community transferred to ED were unlikely to have a documented Advance Care Plan. Those from residential aged care who were cognitively impaired more frequently had an Advance Care Plan. In the ED, decisions of care did not appear to be influenced by the presence or absence of Advance Care Plans, but length of hospital admission was shorter for those with an Advance Care Plan.

Emergency department mental health triage scales improve outcomes.

The assessment and management of clients with mental illness is an important facet of providing emergency care. In Australian emergency departments, it is usually the generalist registered nurses* without adequate preparation in the assessment and care for clients with mental illness who conduct the initial assessment at triage. A search of the literature revealed a limited number of publications addressing the provision of triage and management guidelines to assist nurses to make objective clinical decisions to ensure appropriate care for clients with mental illness. This paper examines the need for such guidelines and reviews a number of mental health triage scales that have been evaluated for use in emergency departments. Findings show that these triage scales have led to improvements in staff confidence and attitudes when dealing with clients with mental health problems, resulting in improved outcomes for clients. Strengths and limitations of the evaluations have also been explored. Highlighted is the need for consideration of the inclusion of clients' reactions to the impact of this change to service delivery in future evaluations.

The influence of social disadvantage on children's emotional and behavioral difficulties at age 4-7 years

Objective To examine associations between indicators of social disadvantage and emotional and behavioral difficulties in children aged 4-7 years. Study design This cross-sectional study was based on data collected in a questionnaire completed by parents of children enrolled in their first year of school in Victoria, Australia, in 2010. Just over 57 000 children participated (86% of children enrolled), of whom complete data were available for 38 955 (68% of the dataset); these children formed the analysis sample. The outcome measure was emotional and behavioral difficulties, assessed by the Strengths and Difficulties Questionnaire Total Difficulties score. Logistic regression analyses were undertaken. Results Having a concession card (a government-issued card enabling access to subsidized goods and services, particularly in relation to medical care, primarily for economically vulnerable households) was the strongest predictor of emotional and behavioral difficulties (OR, 2.71; 95% CI, 2.39-3.07), followed by living with 1 parent and the parent's partner or not living with either parent (OR, 1.93; 95% CI, 1.58-2.37) and having a mother who did not complete high school (OR, 1.27; 95% CI, 1.11-1.45). Conclusion These findings may assist schools and early childhood practitioners in identifying young children who are at increased risk of emotional and behavioral difficulties, to provide these children, together with their parents and families, with support from appropriate preventive interventions.