The initiation and administration of drugs for advanced life support by critical care nurses in the absence of a medical practitioner

Current legislation does not permit the administration of first line resuscitation medications by suitably qualified Division 1 registered nurses (RNs) in the absence of a medical officer. This omission by the Drugs,  Poisons and Controlled Substances Act 1981 (Vic) and the Drugs, Poisons and The Controlled Substances Regulations 1995 (Vic) leaves many critical care nurses in a vulnerable legal position.

The primary aim of this study was to gauge the view of critical care nurses with respect to lobbying for change to the current legislation. In addition, the study aimed to explore and describe the educational preparation, practice perceptions and experiences of RNs working in critical care regarding cardiopulmonary resuscitation and the administration of first line advanced life support (ALS) medications in the absence of a medical officer. It was anticipated that data collected would demonstrate some of the dilemmas associated with the initiation and administration of ALS medications for practising critical care nurses and could be used to inform controlling bodies in order for them to gain an appreciation of the issues facing critical care nurses during resuscitation.

A mailout survey was sent to all members of the Victorian Branch of the Australian College of Critical Care Nurses (ACCCN). The results showed that the majority of nurses underwent an annual ALS assessment and had current ALS accreditation. Nurses indicated that they felt educationally prepared and were confident to manage cardiopulmonary resuscitation without a medical officer; indeed, the majority had done so. The differences in practice issues for metropolitan, regional and rural nurses were highlighted. There is therefore clear evidence to suggest that legislative amendments are appropriate and necessary, given the time critical nature of cardiopulmonary arrest. There was overwhelming support for ACCCN Vic. Ltd to lobby the Victorian government for changes to the law.

Naturalistic decision making: a model to overcome methodological challenges in the study of critical care nurses` decision making about patients` hemodynamic status

The quality of critical care nurses' decision making about patients' hemodynamic status in the immediate period after cardiac surgery is important for the patients' well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses' skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.

Factors that enhance or impede critical care nurses' discharge planning practices

Introduction:
Any illness that is serious enough to require admission to the critical care unit will intensify the physical and psychological effects that the patient and their significant others experience. Hence, the discharge needs of patients admitted to critical care are unquestionably complex, diverse and dynamic.

Methods:
Utilising an exploratory descriptive approach 502 critical care nurses, identified from the Australian College of Critical Care Nursing (ACCCN) (Victoria) database were invited to participate in this study. A 31-item questionnaire was developed and distributed. A total of 218 eligible participants completed the survey. One-to-one semi-structured interviews with 13 Victorian critical care nurses were also conducted.

Results:
Participants reported that a lack of time was a barrier to discharge planning. Communication however, could enhance or impede the discharge planning process in critical care. Participants considered that the critical pathway, used in the care of cardiothoracic patients, did assist with communication of discharge planning processes, hence enhancing the process.

Conclusions:
While these findings provide some understanding of the factors that enhanced or impeded critical care nurses’ discharge planning practices further research is indicated. The findings reported here may, however, provide a starting point for improving the discharge planning process in critical care.

How do critical care nurses define the discharge planning process?

Background: Professional, political and organisational factors have focused attention on the discharge planning process in the Victorian health care sector. Discharge planning for patients, as part of continuity of care, is seen as a key concept in the delivery of nursing care. However, there is no question that discharge planning has emerged as a complex area of practice, and is, perhaps, most complex in the critical care area.

Aim: The study reported here is part of a larger thesis exploring critical care nurses’ perceptions and understanding of the discharge planning process in the health care system in the state of Victoria, Australia. As part of the survey participants were asked to define discharge planning as it related to the critical care environment in which they worked.

Methods: Utilising an exploratory descriptive approach, 502 Victorian critical care nurses were approached to take part in the study. The resultant net total of 218 participants completed the survey, which represented a net response rate of 43.4%. The data were analysed using quantitative and qualitative methodologies.

Findings: Three common themes emerged. A significant number of participants did not believe that discharge planning occurred in critical care, and therefore, thought that they could not provide a definition. There was uncertainty as to what the discharge planning process actually referred to in terms of discharge from critical care to the general ward or discharge from the hospital. There was an emphasis on movement of the patient to the general ward, which was considered in three main ways by first, getting the patient ready for transfer; second, ensuring a smooth transition to the ward and third, transfer of the patient to the ward often occurred because the critical care bed was needed for another patient.

Conclusion: The findings presented here suggest at a nursing level, the discharge planning process is not well understood and some degree of mutual exclusivity still remains. There is a need for further education of critical care nurses with regard to the underlying principles of the discharge planning process.

Critical care nurses' beliefs about discharge planning process: a questionnaire survey

Aim: To report on the beliefs of critical care nurses with regard to the discharge planning process, in Victoria, Australia.

Methods: An exploratory descriptive design was used. A total of 502 Victorian critical care nurses were approached to take part in the study. A total of 218 eligible participants completed the survey, which represented a nett response rate of 43.4%. The data were analysed using descriptive statistics.

Results: The current discharge planning processes are ad hoc and influenced by patient acuity. Critical care nurses believe that workload issues, unplanned discharges and inadequate communication contribute to difficulties implementing the discharge plan.

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.

The clinical landscape of critical care: nurses' decision-making

Background. Many studies have tended to explore individual characteristics that impact on nurses' decision-making, despite significant acknowledgement that context is a major determinant in decision-making. The few studies that have examined environmental influences have tended not to study real decisions in the dynamic and complex clinical environment.

Aims. To investigate environmental influences on nurses' real decisions in the critical care setting.

Method. Naturalistic observations and semi-structured interviews were conducted with 18 critical care nurses in private, public and rural hospitals. Observations and interviews were recorded, transcribed verbatim and coded for themes using content analysis.

Results. All clinical decisions were strongly influenced by the context in which the decision was made. Three main environmental influences were identified: the patient situation, resource availability and interpersonal relationships. Time and risk guided all clinical decisions. Nurses established the state of the situation, the time constraints on decisions and the level of risk involved for both patient and nurse.

Conclusions. Decision-making is a manifestation of the landscape and although an increased understanding of the landscape is required, more important is the need to measure the impact of contextual variables on nurses' decision-making in order to improve health care 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.

Revising the critical care family needs inventory for the emergency department

Background: The Critical Care Family Needs Inventory (CCFNI) has been used widely over the last two decades for analysing the needs of family members in the intensive care unit. However, it has significant limitations as a needs assessment tool for use with families in the Emergency Department (ED). This paper discusses the methodological challenges encountered during the process of reviewing and adapting this tool for use in the ED. Aims: The purpose of this study was to revise and adapt the CCFNI for use with a population of family members of critically ill patients in an Australian Emergency Department. Instrument: The process of tool revision, adaptation and reconstruction included: critique of the CCFNI; concept definition; item review; content and structure revision; scale revision; and testing with a sample of the target population. Methods: Data collection methods were aimed at accessing a vulnerable population, while enhancing response rate and data quality. A sample of 84 relatives of critically ill patients from one Melbourne Metropolitan Emergency Department was used, 73% of whom returned questionnaires. Results: Pilot data were examined with the specific purpose of identifying elements of the tool that required refinement or modification. Methods used for establishing reliability and validity of the revised tool provided satisfactory results. Limitations: Limitations of this study include inadequate sample size for exploratory factor analysis, and an incomplete response set for some items, which influenced item analysis. Conclusion: The process used for addressing the identified methodological issues in reviewing and adapting the CCFNI for use in the ED provides a framework for adapting an established tool for a specific purpose.

The diversity of critical care nursing education in Australian universities

A range of critical care nursing educational courses exist throughout Australia. These courses vary in level of award, integration of clinical and academic competence and desired educational outcomes; this variability potentially leads to confuson by stakeholders regarding educational and clinical outcomes. The study objective was to describe the range of critical care nursing courses in Australia. Following institutional ethics approval, all relevant higher education providers (n=18) were invited to complete a questionnaire about course structure, content and nomenclature. Information about desired professional and general graduate characteristics and clinical competency was also sought.

A total of 89% of providers (n=16) responded to the questionnaire. There was little consistency in course structure in regard to the proportion of each programme devoted to core, speciality or generic subjects. In general, graduate certificate courses concentrated on core aspects of critical care, graduate diploma courses provided similar amounts of critical care core and speciality content, while master's level courses concentrated on generic nursing issues. The majority of courses had employment requirements, although only a small proportion specified the minimum level of critical care unit required for clinical experience. The competency standards developed by the Australian College of Critical Care Nurses (ACCCN) were used by 83% of providers, albeit in an adapted form, to assess competency. However, only 60% of programmes used personnel with a combined clinical and educational role to assess such competence.

In conclusion, stakeholders should not assume consistency in educational and clinical outcomes from critical care nursing education programmes, despite similar nomenclature or level of programme. However, consistency in the framework for speciality nurse education has the potential to prove beneficial for all stakeholders.

Key stakeholders' expectations of educational outcomes from Australian critical care nursing courses: a Delphi study

Background
Educational preparation for critical care nursing in Australia varies considerably in terms of the level of qualification resulting in a lack of clarity for key stakeholders about student outcomes.

Objectives
The study aim was to identify and reach consensus regarding the desired learning outcomes from Australian post-registration critical care education programs as demonstrated through the graduate's knowledge, skills and attitudes.

Design
A Delphi technique was used to establish consensus between educators, managers, clinicians and students regarding learning outcomes expected of graduates with a Graduate Certificate, Graduate Diploma and Master level qualification in critical care nursing.

Participants
A total of 164 critical care nurses (66 clinicians, 48 educators, 32 managers and 18 students) participated and 99 questionnaires were returned in the first round (response rate 60%). Fifty-seven questionnaires were returned for Round 2 (response rate 58%).

Methods
Learning outcomes were obtained from the Australian College of Critical Care Nurses Competency Standards for Specialist Critical Care Nurses. Some statements included more than one characteristic, and these were split to create learning outcomes with one characteristic per item. A survey of Australian higher education providers of critical care education provided additional learning outcomes, for a total of 73 learning outcomes for the first Delphi round.

Results
Findings suggest that patient comfort, safety, professional responsibility and ethical conduct are deemed most important for all three levels of educational preparation. There was a lack of emphasis on clinical practice issues for all levels. Participants placed higher emphasis on learning outcomes related to complex decision-making, leadership, supervision, policy development and research for Graduate Diploma and Master level programs.

Conclusion
The findings have implications for curriculum development and the profession with regards to the level of educational preparation required of critical care nurses and suggest that further work is required before clear recommendations can be made for desired educational outcomes from critical care nursing programs in Australia.

Co-ordination of the discharge planning process in critical care

Aim and objectives: This article reports on the current discharge planning beliefs in relation to the co-ordination of the discharge planning process in the critical care environment in the health care system in the state of Victoria, Australia. As there is a paucity of previous studies examining discharge planning in critical care nursing knowledge about the phenomena is consequently limited. Background: The study reported here is part of a larger study exploring critical care nurses' perceptions and understanding of the discharge planning process in the health care system in the state of Victoria, Australia. While a number of different discharge planning models are reported in the literature there is no agreement on the most effective or the most efficient model. Design: An exploratory descriptive research design was used for this study. Methods: A total of 502 Victorian critical care nurses were approached to take part in the study. A total of 218 participants completed the survey, which represented a nett response rate of 43·4%. The data from the questionnaire were entered into the Statistical Package for Social Sciences (SPSS) Base 10.0. This allowed calculation of descriptive statistics and statistical analysis using chi-square test for goodness-of-fit.  Results: While just over half the participants reported that the discharge planning process in their unit was co-ordinated by a combination of personnel that included a nurse, just under half the participants believed that this was an appropriate model. Another key finding was of those participants who worked in critical care units using primary nursing, just over half responded that the bedside nurse/primary nurse co-ordinated the discharge planning process while just under half responded that a combination of health care team members, including a nurse, co-ordinated the process. Overall there was little support for the designated discharge planning nurse to co-ordinate the process. Conclusions: The findings presented here suggest critical care nurses need to examine who has the ultimate responsibility of co-ordinating the critical care patient's discharge plan irrespective of the nursing model employed within the critical care ward. There is the need to ensure that when discharge planning becomes everybody's responsibility it ultimately does not become no-one's responsibility. Relevance to clinical practice: If discharge planning practices are to be changed with the introduction of new discharge planning models in the critical care environment then it is important not only to know current practice but also the perceptions of critical care nurses in terms of who they believe should co-ordinate the discharge planning process.

Registered nurses` lived experience of advocacy within a critical care nuit: a phenomenological study

Anecdotally, it has often been expressed by registered nurses (RNs) working within critical care environments that they are patient advocates. However, to date, little systematic research has been undertaken to validate this assertion. Thus this project, which explored the lived experience of RNs working within a critical care unit in a country area of Australia, was conceived.

The five participants of this study were all Division 1 RNs possessing a critical care certificate and a minimum of 4 years' nursing experience. Through their participation in an in-depth audiotaped interview they revealed a wealth of experiences and ideas about their involvement as patient advocates. The results of this research indicate that the phenomenon of nurse advocacy is a multi-faceted process and embraces many kinds of activities that nurses engage in on behalf of their clients.

The findings of this study indicate that some of the participants' experiences are congruent with elements of advocacy contained within the nursing literature and statements of professional nursing bodies. However, there are some findings in this study that are not consistent with available literature. For instance, these participants markedly reject the notion that advocacy is an inappropriate concept for nurses, despite suggestions in the literature that this is an inappropriate role. Instead they wholeheartedly embrace this role, asserting it as central to their practice. Further, although the literature identifies potential controversies regarding enactment of the role of advocacy, the participants of this study are silent on these matters. It is not known what this silence implies and, in light of the study findings, it is recommended that nursing organisations, theorists and clinicians consider whether it is worthwhile to more clearly confirm the nature and role of advocacy within Australian nursing.

Pain assessment in critical care: what have we learnt from research

Despite an ongoing acknowledgement in the literature that pain is a significant problem within the critical care environment, this issue has not been adequately addressed by critical care nurses. This paper examines strategies for changing pain management practices in critical care, including reviewing documentation practices, the utilisation of guidelines and algorithms to augment clinical decision making, and increasing educational opportunities available to critical care nurses. It is recommended that pain assessment be given a higher priority within the clinical context, particularly as inadequate pain assessment and management has been linked to increased morbidity and mortality within critical care. Importantly, critical care nurses need to not only be aware of research-based pain management practices, but also lead the way in implementation and continuous evaluation as a measure of decreasing patient pain in the future.