Generic rehabilitation assistants : will rehabilitation nurses take up the challenge?

This paper provides an overview of some of the issues that need to be considered in the context of a declining health workforce. It outlines some of the arguments for and against the introduction of generic health workers and more specifically, for the role of generic rehabilitation - assistant. It is argued that rehabilitation nurses, amongst others, are well placed to take an active role in the development of innovative interdisciplinary models of care that enhance patient outcomes as they transect the continuum of care. Failure to do so will be at the peril of rehabilitation nursing.

Do clinicians know how to use pulse oximetry? A literature review and clinical implications

Pulse oximerry has become one of the most commonly used tools in the clinical environment for assessing patients' oxygenation status. It is employed almost continuously in critical care areas and frequently in the general ward environment. Although it is a much better tool for determining hypoxia than the human eye, its use is limited if clinicians do not understand relevant physiological principles, such as the oxyhaemoglobin dissociation curve and the inherent limitations of the device. Furthermore, the risk for compromised patient safety is significant if clinicians fail to recognise the potential for false or erroneous readings. This paper explores the research which has examined clinicians' comprehension of pulse oximetry. Fourteen studies examining clinicians' knowledge of pulse oximerry were reviewed. These studies revealed significant knowledge deficits about pulse oximerry amongst nurses, doctors and allied health professionals, all of whom used this technology frequently. Alarmingly, those lacking an adequate understanding of pulse oximerry included senior, experienced clinicians. The studies were limited by their use of convenience sampling and small sample sizes. Further research is needed to better understand the significance of this problem and to examine how principles of pulse oximerry are taught to nurses and other health professionals at the undergraduate and postgraduate levels. Educators and clinicians alike must ensure that a safe level of knowledge for the use of pulse oximerry is maintained in order to ensure that patient outcomes are not compromised.

The effects of specific educational preparation on emergency nurses` clinical decisions regarding supplemental oxygen administration

Abstract The use of supplemental oxygen by emergency nurses has important implications for patient outcomes, yet there is significant variability in oxygen administration practises. Specific education related to oxygen administration increases factual knowledge in this domain; however, the impact of knowledge acquisition on nurses' clinical decisions is poorly understood. This study aimed to examine the effect of educational preparation on 20 emergency nurses' decisions regarding the assessment of oxygenation and the use of supplemental oxygen. A pre-test/post-test, quasi-experimental design was used. The intervention was a written, self-directed learning package. The major effects of the completion of the learning package included no change in the number or types of parameters used by nurses to assess oxygenation, a significant decrease in the selection of simple masks, a significant increase in the selection of air entrainment masks, fewer hypothetical outcomes of unresolved respiratory distress and more hypothetical outcomes of decreased respiratory distress. As many nursing education programs are aimed at increasing factual knowledge, while experience remains relatively constant, a greater understanding of the relationship between factual knowledge and clinical decisions is needed if educational interventions are to improve patient outcomes.

Barriers in providing psychosocial support for patients with cancer

There is sound evidence to support the notion that the provision of effective psychosocial care improves the outcomes of patients with cancer. Central to the implementation of this care is that health professionals have the necessary communication and assessment skills. This study aimed to identify key issues related to providing effective psychosocial care for adult patients admitted with hematological cancer, as perceived by registered nurses with 3 or more years of clinical experience. An exploratory qualitative design was used for this study. Two focus group interviews were conducted with 15 experienced cancer nurses. The provision of psychosocial care for patients with cancer is a dynamic process that has a professional and personal impact on the nurse. The 5 analytic themes to emerge from the data were as follows: When is it a good time to talk? Building relationships; Being drawn into the emotional world; Providing support throughout the patient's journey; and Breakdown in communication processes. The findings from this study indicate an urgent need to develop a framework to provide nurses with both skill development and ongoing support in order to improve nurses' ability to integrate psychosocial aspects of care and optimize patient outcomes.

Rationale and design of the national benchmarking and evidence-based national clinical guidelines for chronic heart failure management programs study

OBJECTIVES: The National Benchmarks and Evidence-Based National Clinical Guidelines for Heart Failure Management Programs Study is a national, multicenter study designed to determine the nature, range, and effect of interventions applied by chronic heart failure management programs (CHF-MPs) throughout Australia on patient outcomes. Its primary objective is to use these data to develop national benchmarks and evidence-based clinical guidelines and optimize their cost-effective application by reducing quality and outcome variability. DATA SOURCES/STUDY SETTING: Primary data will be collected from CHF-MP coordinators and CHF patients enrolled in these programs on a national basis. Secondary outcome data will be collected from a national morbidity record and from patients' medical records. STUDY DESIGN: Stage I of the study involves a prospective clinical audit of all CHF-MPs throughout Australia (n = 45) to determine the extent of variability in programs currently. Stage II is a prospective cross-sectional survey design enrolling 1,500 patients (average of 40 patients per program) to firstly determine the typical profile of patients being managed via a CHF-MP in Australia and, secondly, the subsequent morbidity and mortality during the 6-month follow-up. Outcome data will be subject to multivariate analysis to determine the key components of care in this regard. All study data will be then examined in the final stage of the study (III) to develop national benchmarks for the application and auditing of CHF-MPs in Australia. CONCLUSION: Variability in patient outcomes is a product of heterogeneity among CHF-MPs. The development of national benchmarks will minimize such heterogeneity and will provide a greater level of evidence for their cost-effective application.

Making decisions: nursing practices in critical care

This article reports the types and complexity level of decisions made in everyday clinical practice by critical care nurses. It also reports factors that influence the complexity of those decisions. A combination of methods were chosen for the two phase study. In the first phase, 12 qualified critical care nurses documented decisions (over a 2 hour period) on a clinical decision recording form designed by the researcher. In the second phase, participants attended a semi-structured focus group.

From the analysis, five types of decisions were identified; assessment, intervention, organisation, communication and education. In addition to these documented decisions, three factors that influenced decision complexity were identified from a thematic analysis of the transcribed interviews; communication, patient related and properties of the decision. Nurses reported that communication decisions were the most difficult to make. However, the concept of nurses knowing the patient reduced the level of decision complexity. It is suggested that this has important implications for decision making practices of nurses working in the area of critical care and potentially for patient outcomes.

Evidence based practice: are critical care nurses ready for it?

In the emergence of the evidence based practice movement, critical care nurses have struggled to identify scientific evidence on which to base their clinical practice. While the lack of critical care nursing research is a major concern, other important issues have significantly stalled the implementation of evidence even when it is available. A descriptive study of 274 critical care nurses was undertaken to examine nursing research activity in Victorian critical care units. The study aimed to identify critical care nurses' research skills, the barriers encountered in participation and implementation and the current availability of resources.

Results revealed that 42 per cent of the nurses who participated in the study believed that they were not prepared adequately to evaluate research, and less than a third believed they were sufficiently skilled to conduct valid scientific studies. An association was found between nurses' ability to confidently perform research activities and higher academic qualifications. The study found that there is a lack of organisational support and management commitment for the development of evidence based nursing.

In order to facilitate the implementation of evidence based practice, clinicians must be made aware of the available resources, be educated and mentored when carrying out and using clinical research, and be supported in professional initiatives that promote evidence based practice. It is argued that this will have positive implications for patient outcomes in the critical care environment.

Do knowledge and experience have specific roles in triage decision-making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.

Responding to self-harm in borderline personality disorder : from clinician frustration to therapeutic enquiry

Pessimistic attitudes and reactive behavioural management strategies act as a major barrier to effective service provision for patients with borderline personality disorder. This paper reviews research on countertransference reactions (negative professional attitudes) towards these patients and the professional response to the common presentation of self harm in this particular client group. The psychotherapeutic treatment of patients with borderline personality disorder is complex and both professionally and personally demanding. A clinical framework is proposed that enables clinicians to develop a more nuanced and empathic understanding of self harm within the context of personality disorder in order to facilitate enhanced therapeutic engagement with these challenging patients. A clinical case study illustrates the use of this framework and the potential for enhanced therapeutic management in conjunction with the recognition and reduction of clinician indifference and rejection, thus improving patient outcomes. (editor abstract)Pessimistic attitudes and reactive behavioural management strategies act as a major barrier to effective service provision for patients with borderline personality disorder. This paper reviews research on countertransference reactions (negative professional attitudes) towards these patients and the professional response to the common presentation of self harm in this particular client group. The psychotherapeutic treatment of patients with borderline personality disorder is complex and both professionally and personally demanding. A clinical framework is proposed that enables clinicians to develop a more nuanced and empathic understanding of self harm within the context of personality disorder in order to facilitate enhanced therapeutic engagement with these challenging patients. A clinical case study illustrates the use of this framework and the potential for enhanced therapeutic management in conjunction with the recognition and reduction of clinician indifference and rejection, thus improving patient outcomes.

Long-term risk factor control after a cardiac rehabilitation programme

This study examined the hypothesis that Phase II cardiac rehabilitation participants (CRP) had better long-term risk factor control, self-rated perception of health and return to work rates than non-participants (NP) between 18 and 36 months post myocardial infarction (MI). It was a comparative study in a 550 bed hospital.

Approximately half of both groups did not achieve a total cholesterol (TC) of 5.5mmol/L or less. Compared with NP, CRP were significantly more likely to have a TC<=6.5mmol/L (7% vs. 28%) (p=0.006). NP with TC>6.5mmol/L were significantly less likely to be on treatment (p=0.002). CRP were more likely to regularly exercise than NP (79% vs. 61%) (p=0.038). The success rate for blood pressure targets, return to work rates and self-rated perception of health were similar in both groups.

In conclusion, CRP had better long-term control of some risk factors than NP. The study provides comparative longer term patient outcomes after an Australian cardiac rehabilitation (CR) programme and forms the basis for further outcome measurement.

Staff perceptions on the use of a sedation protocol in the intensive care setting

Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data.

The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay.

Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.

Effectiveness of pain management in hospital in the home programs

Alternative health care delivery models such as HITH facilitate the care of patients requiring acute treatments in their own homes. There are over 570 Diagnostic Related Groups managed in HITH programs and many of these are known to have associated physical pain. The impact of the home environment on patients’ experience of pain or how pain is managed is poorly understood. The purpose of this presentation is to
present the background and preliminary findings of a study that aims to increase our understanding of the issues related to providing optimal pain management for acute care patients who are transferred to Hospital in the Home. This knowledge will enable the development of effective practice guidelines to improve patient outcomes. More specifically, the aims are:
• To identify whether patients are transferred to HITH in pain or develop
   significant pain while in the program
• To identify the frequency and intensity of pain experienced by patients in 3      HITH programs.
• To describe patients’ experience of pain in the home environment.
• To investigate whether patients receive adequate pain relief once                      transferred to HITH.
• To explore the strategies patients use to manage pain at home.

The study will be carried out over 12 months in three HITH units in Victoria: Box Hill Hospital, Alfred Hospital and Epworth Hospital. The design is a descriptive survey of patients’ experience of pain and pain management using a modified version of The American Pain Society’s Patient Outcome Questionnaire. 360 consecutive surgical patients transferred to HITH care in the three participating programs will be interviewed by telephone between 48 and 72 hours of admission to the program.

The findings of this study will identify issues in providing optimum pain management for patients receiving acute care in non-traditional treatment environments.

Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

A controlled trial of internet-based cognitive-behavioural therapy for panic disorder with face-to-face support from a general practitioner or email support from a psychologist

Background: Panic disorder (PD) is one of the most common anxiety disorders seen in general practice, but provision of evidence-based cognitive-behavioural treatment (CBT) is rare. Many Australian GPs are now trained to deliver focused psychological strategies, but in practice this is time consuming and costly.

Objective: To evaluate the efficacy of an internet-based CBT intervention (Panic Online) for the treatment of PD supported by general practitioner (GP)-delivered therapeutic assistance.

Design: Panic Online supported by GP-delivered face-to-face therapy was compared to Panic Online supported by psychologist-delivered email therapy.

Methods: Sixty-five people with a primary diagnosis of PD (78% of whom also had agoraphobia) completed 12 weeks of therapy using Panic Online and therapeutic assistance with his/her GP (n = 34) or a clinical psychologist (n = 31). The mean duration of PD for participants allocated to these groups was 59 months and 58 months, respectively. Participants completed a clinical diagnostic interview delivered by a psychologist via telephone and questionnaires to assess panic-related symptoms, before and after treatment.

Results: The total attrition rate was 20%, with no group differences in attrition frequency. Both treatments led to significant improvements in panic attack frequency, depression, anxiety, stress, anxiety sensitivity and quality of life. There were no statistically significant differences in the two treatments on any of these measures, or in the frequency of participants with clinically significant PD at post assessment.

Conclusions: When provided with accessible online treatment protocols, GPs trained to deliver focused psychological strategies can achieve patient outcomes comparable to efficacious treatments delivered by clinical psychologists. The findings of this research provide a model for how GPs may be assisted to provide evidence-based mental healthcare successfully.

Implementation of evidence into practice : Development of a tool to improve emergency nursing care of acute stroke

Background
Stroke is an increasing global health issue that places considerable burden on society and health care services. An important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24–48 hours. The current climate of prolonged time spent in the Emergency Department (ED) means that many aspects of stroke management are now the responsibility of emergency nurses.

Aims
The aims of this paper are to: i) examine the evidence related to nursing care of acute stroke, ii) identify evidence-based elements of stroke care with most applicability to emergency nursing and iii) use evidence-based stroke care recommendations to develop a guideline for the emergency nursing management of acute stroke.

Results
Emergency nursing care of acute stroke should focus on optimal triage decisions, physiological surveillance, fluid management, risk management, and early referral to specialists.

Conclusions
The role of emergency nurses in stroke care will increase and it is important that emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes. Guidelines and decision support tools for use in emergency nursing must be practical and have high levels of clinical utility for maximum uptake in a busy clinical environment.