The experiences of families of critically ill patients in Greece: A social constructionist grounded theory study

Background: The experiences of patients’ families in intensive care units (ICUs) are of international concern. In Greece however, adequate attention has not been paid to this issue.

Objective: To explore the experiences of critical care patients’ families in Greece.

Setting: The intensive care units of 3 general district hospitals in the area of Athens, Greece.

Methodology: The social constructionist version of grounded theory was used. In-depth interviews with 25 relatives of critically ill patients were carried out, and participant and non-participant observation was used to cross-validate the data obtained.

Results: Seven major categories were identified, with 32 components across all categories. The experiences of families revolved around the two core categories of “Intense Emotions” and “Vigilant Attendance”. The study conceptualised two new categories in this field, “Religiosity” and “Loss of Intimacy” and enhanced the category “Vigilant Attendance”. Three further categories were identified, namely “Caring”, “Dignity” and “Information”. The various interrelationships between the categories were also examined.

Conclusions: The study has examined the experience of Greek patients’ families from a qualitative perspective and suggests that major changes need to be made in terms of management and support.

The effects of time pressure and experience on nurses' risk assessment decisions : a signal detection analysis

Background: Time pressure and, occasionally, suboptimal assessment decisions are features of nursing in acute care.

Objectives: To explore the effect of generic and specialist clinical experience on the ability to detect the need to take action in acute care and the impact of time pressure on nurses' decision-making performance.

Methods: Experienced acute care registered nurses (n = 241) were presented with 50 vignettes of real clinical risk assessments. Each vignette contained seven information cues. In response to these vignettes, nurses had to decide whether to intervene or not. The 26 vignettes were time limited and mixed randomly into the 50 cases. Signal detection analysis was used to establish nurses' performance, personal decision thresholds ([beta]), and their abilities (d') to distinguish a signal of clinical risk from the clinical noise of noncontributory information.

Results: Nurses had significantly lower d' and were significantly less likely to indicate intervening under time pressure. For ability-but not threshold-there was a significant interaction of time pressure and years of experience in acute care. With no time pressure, d' increased in line with years of experience. Under time pressure, there was no effect.

Discussion: Time pressure reduced nurses' ability to detect the need and the tendency to report intervening. Thus, there were more failures to report appropriate intervention under time pressure, and the positive effects of clinical experience were negated under time pressure. More and larger scale research on the effect on clinical outcomes of time pressured nursing choices is required.

Assessing advanced life support (ALS) competence: Victorian practices

Advanced life support (ALS) assessments are performed to assess nurses’ abilities to recognize cardiac arrest events, and appropriately manage patients according to resuscitation guidelines. Although there is evidence for conducting assessments after initial ALS education, there is little evidence to guide educators about ongoing assessments in terms of methods, format and frequency.

The aim of this study was to determine methods used by educators to assess ALS skills and knowledge for nurses in Victorian intensive care units. This descriptive study used telephone interviews to collect data. Data were analysed using content analysis. Twenty intensive care educators participated in this study. Thirteen educators (65%) were employed in public hospitals, and 7 educators (35%) worked in private hospitals across 12 Level 3 (60%) and 8 Level 2 (40%) intensive care units.

Results showed all educators used scenarios to assess ALS skills, with 12 educators (60%) including an additional theoretical test. There was variability in ALS assessment frequency, assessment timing in relation to initial/ongoing education, person performing the assessment, and the assessor/participant ratio. Nineteen educators (95%) reported ALS skill competency assessments occurred annually; 1 educator (5%) reported assessments occurred every 2 years. Assessments were conducted during a designated month (n = 10), numerous times throughout the year (n = 8), or on nurses’ employment anniversaries (n = 2). All educators reported many nurses avoided undertaking assessments.

Variability in ongoing ALS assessment methods was evident in Victorian intensive care units with some units applying evidence-based practices. Consideration should be given to the purposes and methods of conducting annual ALS assessments to ensure resources and strategies are directed appropriately. To encourage nurses to retain ALS skills and knowledge, regular practices are recommended as an alternative to assessments. However, further research is required to support this notion.

The role of religiosity as a coping resource for relatives of critically ill patients in Greece

Critical care hospitalisation is emotionally overwhelming for the relatives of patients. Research has shown that religiosity is an effective coping resource for people with health related problems and has been correlated with better health outcomes. However the processes by which religiosity is utilized and its ejfocts on relatives of critically ill patients have not been adequately explored. This article presents relatives' experiences and processes of religiosity; it is part of a wider grounded theory study on the experiences of critically ill patients'relatives in Greece. T wenty-jive relatives of patients in the intensive care units of three public general district hospitals in Athens, Greece, participated in 19 interviews. Religiosity was found tv be the main source of hope, strength and courage for relatives and was expressed with church/monastery attendance, belief in God, praying. and performing religious rituals. Health care professionals should pay attention and understand these aspects of coping.

Transition from clinical manager to university lecturer : a self-reflective case study

This paper is a case study exploring the author’s use of reflective practice to facilitate the transition in role from a clinical manager with teaching responsibilities in a critical care unit to university lecturer. The similarities and differences in the roles with respect to learner characteristics, teaching contexts and effective teaching strategies are discussed. Brookfield’s model provides the methodological framework for the process of critically reflective practice undertaken to support and inform the transition. This case study describes a novice academic’s reflection through the four lenses of autobiography, the theoretical literature, student feedback and the perspectives of colleagues as she seeks to optimise student engagement and learning using the large lecture as the teaching and learning activity. The author suggests that the use of a framework such as Brookfield’s model that supports critical reflection may be of significant benefit to accelerate the personal and professional growth of new academic staff in their teaching practice.

Insulin sensitivity not modulated 24 to 78 h after acute resistance exercise in type 2 diabetes patients

Background
The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).
Methods
This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.
Results
Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.
Conclusions
This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a matched case-control study

Background
Side effects of the medications used for procedural sedation and analgesia in the cardiac catheterisation laboratory are known to cause impaired respiratory function. Impaired respiratory function poses considerable risk to patient safety as it can lead to inadequate oxygenation. Having knowledge about the conditions that predict impaired respiratory function prior to the procedure would enable nurses to identify at-risk patients and selectively implement intensive respiratory monitoring. This would reduce the possibility of inadequate oxygenation occurring.

Aim
To identify pre-procedure risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Design
Retrospective matched case–control.

Methods
21 cases of impaired respiratory function were identified and matched to 113 controls from a consecutive cohort of patients over 18 years of age. Conditional logistic regression was used to identify risk factors for impaired respiratory function.

Results
With each additional indicator of acute illness, case patients were nearly two times more likely than their controls to experience impaired respiratory function (OR 1.78; 95% CI 1.19–2.67; p = 0.005). Indicators of acute illness included emergency admission, being transferred from a critical care unit for the procedure or requiring respiratory or haemodynamic support in the lead up to the procedure.

Conclusion
Several factors that predict the likelihood of impaired respiratory function were identified. The results from this study could be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Characteristics and outcomes of patients requiring rapid response system activation within 24 hours of emergency admission

Objectives: 

Evaluating objective structured clinical assessment (OSCA) in undergraduate nursing

The aims of this mixed methods study were to gain insight into how individual assessors determine an Objective Structured Clinical Assessment (OSCA) result for undergraduate nursing students and identify whether individual assessor perceptions and professional characteristics have an impact on students' results. Results from 25 participants showed that although less than half (44%) of the participants were teaching in the course that they were assessing, the participants were highly experienced clinicians and nearly three-quarters (72%) had completed formal teaching qualifications. There were wide variations in pass rates (16.7–90%) between assessors. The widest disparity was observed between assessors with and those without critical care experience (66% versus 39%), as well as assessors who were teaching the course and those who were not (68% versus 49%). Qualitative analysis revealed three dominant themes within participants' transcripts. The themes focused on determining student safety, and the use of personal perceptions and clinical experience to determine competency. Findings indicate that assessors' individual perceptions and clinical experience have the potential to influence and determine undergraduate nursing students OSCA results. Development of criteria standards and objective assessment may be enhanced by greater involvement of assessors and thorough education and training within the context of student assessments.

Self-reported access to and quality of healthcare for diabetes : Do the severely obese experience equal access?

Background: Given reported pejorative views that health professionals have about patients who are severely obese, we examined the self-reported views of the quality and availability of diabetes care from the perspective of adults with type 2 diabetes (T2DM), stratified by body mass index (BMI). Methods: 1795 respondents to the Diabetes MILES - Australia national survey had T2DM. Of these, 530 (30%) were severely obese (BMI ≥35 kg/m2) and these participants were matched with 530 controls (BMI <35 kg/m2). Data regarding participants' self-reported interactions with health practitioners and services were compared. Results: Over 70% of participants reported that their general practitioner was the professional they relied on most for diabetes care. There were no betweengroup differences in patient-reported availability of health services, quality of interaction with health practitioners, resources and support for selfmanagement, or access to almost all diabetes services. Discussion: Participants who were severely obese did not generally report greater difficulty in accessing diabetes care.

Development of a postgraduate interventional cardiac nursing curriculum

Interventional cardiology practices have advanced immensely in the last two decades, but the educational preparation of the workforce in cardiac catheter laboratories has not seen commensurate changes. Although on-the-job training has sufficed in the past, recognition of this workforce as a specialty practice domain now demands specialist educational preparation. The aim of this paper is to present the development of an interventional cardiac nursing curriculum nested within a Master of Nursing Practice in Australia. International and national health educational principles, teaching and learning theories and professional frameworks and philosophies are foundational to the program designed for interventional cardiac specialist nurses. These broader health, educational and professional underpinnings will be described to illustrate their application to the program's theoretical and clinical components. Situating interventional cardiac nursing within a Master's degree program at University provides nurses with the opportunities to develop high level critical thinking and problem solving knowledge and skills.

Patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery.

BACKGROUND: Clinical interventions aimed at reducing the incidence of postoperative pulmonary complications necessitate patient engagement and participation in care. Patients' ability and willingness to participate in care to reduce postoperative complications is unclear. Further, nurses' facilitation of patient participation in pulmonary interventions has not been explored. OBJECTIVE: To explore patients' ability and willingness to participate in pulmonary interventions and nurses' facilitation of pulmonary interventions. DESIGN: Single institution, case study design. Multiple methods of data collection were used including preadmission (n=130) and pre-discharge (n=98) patient interviews, naturalistic observations (n=48) and nursing focus group interviews (n=2). SETTING: A cardiac surgical ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. PARTICIPANTS: One hundred and thirty patients admitted for cardiac surgery via the preadmission clinic during a 1-year period and 40 registered nurses who were part of the permanent workforce on the cardiac surgical ward. OUTCOME MEASURES: Patients' understanding of their role in pulmonary interventions and patients' preference for and reported involvement in pulmonary management. Nurses' facilitation of patients to participate in pulmonary interventions. RESULTS: Patients displayed a greater understanding of their role in pulmonary interventions after their surgical admission than they did at preadmission. While 55% of patients preferred to make decisions about deep breathing and coughing exercises, three-quarters of patients (75%) reported they made decisions about deep breathing and coughing during their surgical admission. Nurses missed opportunities to engage patients in this aspect of pulmonary management. CONCLUSIONS: Patients appear willing to take responsibility for pulmonary management in the postoperative period. Nurses could enhance patient participation in pulmonary interventions by ensuring adequate information and education is provided. Facilitation of patients' participation in their recovery is a fundamental aspect of care delivery in this context.