Empowering partnerships: nurses and those they care for

This chapter:
• explores the traditional roles of nurses and those they care for;
• discusses the concepts of empowerment and partnerships as they apply
   to the provision of health care;
•examines the key concepts of a partnership model:
  a) non-patronising empowerment;
  b) collaborative decision making;
  c)  valuing diversity and individuality; and
  d) mutually beneficial relationship; and
•  identifies the threat to each characteristic of the partnership model.

Risky business: stories from the field of rural community nurses' work in domestic violence.

This paper reports on a descriptive study into family violence in rural Victoria. Focus groups were held in a number of areas across rural Victoria with a total of 24 community nurse participants. The focus groups were audio-taped and the tapes transcribed to enable the clustering of themes. The dominant themes were: picking up cues, helping and helplessness, holding secrets and quiet resistance. Underpinning all these themes however, was the notion of 'risky business'. All nurses in the study gave examples of situations that they encountered; their ways of helping; of working sensitively; of working around a system that is unhelpful; and the ways in which their work while skilled, thoughtful and wise, is also costly in terms of the emotional wounds they carry. Rural nurses work with considerable risk and courage as they engage in the care and support of women experiencing family violence.

Work context, personal control, and burnout amongst nurses

While situational factors such as high workloads have been found to be predictive of burnout, not all people in the same work context develop burnout. This suggests that individual factors are implicated in susceptibility to burnout. We investigated the relationships between care type (acute/chronic), neuroticism, control (primary/secondary), and symptoms of burnout (exhaustion, cynicism, and reduced professional efficacy) amongst 21 chronic care nurses and 83 acute care nurses working in a public hospital in regional Australia. Similar levels of burnout symptomatology and neuroticism were found in each group of nurses, and neuroticism was found to be associated with exhaustion, cynicism, and reduced professional efficacy in the total sample of nurses. Our prediction that primary control would protect against burnout symptoms in acute care nurses was supported only for professional efficacy, and the prediction that secondary control would protect against burnout in chronic care nurses was not supported.

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.

Intensive care nurses' perceptions of brain death

Research during the last 2 decades has revealed significant confusion or lack of acceptance and inconsistent application of the brain death concept within the medical and nursing professions. The aim of this naturalistic and descriptive study was to investigate the extent to which a sample of 40 Australian intensive care nurses regarded brain death as a meaningful conception of death. In contrast with the majority of the literature pertaining to health care professionals' perceptions of brain death which has focused upon clinical knowledge, the study elicited the expression of personal beliefs. The study utilised a structured interview method with nurses from seven metropolitan intensive care units (ICUs). Transcript analysis revealed five categories of perception constituting a spectrum ranging from complete acceptance to complete rejection, with almost half (48%, n=19) the sample regarding the brain dead patient as less than completely meaningfully dead.

Rather than supporting the literature's suggestion that non-acceptance of the medico-legally recognised brain death notion is, necessarily, evidence of professional ignorance, the findings suggest the participants holding these perceptions were generally well-informed about brain stem function and brain death diagnosis. The study affirms the importance of supportive workplace environments which facilitate the expression of dissonant perceptions and proposes that educators and managers must acknowledge these dissonances.

Clinical nurses` response to an environment of health care reform and organizational restructuring

The aim of this paper is to provide an explanation for clinicians' undisputed acceptance of change. This will be performed by examining the process of organizational restructuring across three analytical levels – the macro, meso and micro; identifying the consequences of restructuring for clinical nurses' performance; and evaluating organizational restructuring using a micro-political theoretical framework.

Role of knowledge and ability in student nurses` clinical decision-making

Little is known about the acquisition of decision-making skills in nursing students as a function of experience and academic ability. Knowing how experience and academic skills interact may help inform clinical education programs and formulate ways of assessing students' progress. The aims of the present study were to develop a problem-solving task capable of measuring clinical decision-making skills in novice nurses at different levels of domain-specific knowledge; and to establish the relative impact on decision-making of domain-specific knowledge and general ability as determinants of the acquisition of decision-making skills. Three types of clinical problems of increasing complexity were developed. Sixty second-year and third-year student nurses with high and low academic scores were studied in terms of their ability to generate hypotheses for a hypothetical case, recognize disconfirming information and the need to access additional information, and diagnostic accuracy. The results showed that general academic ability and knowledge function partly independently in the acquisition of expertise in nursing. Academic ability affects decision-making in low complexity tasks, but as case complexity increases, domain-specific knowledge and experience determines decision-making skills. There are important differences in the way novices with different levels of knowledge and ability make clinical decisions and these can be studied by systematically increasing the complexity of the decision task. These results have implications for the way in which clinical education is structured and evaluated.

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.

The role of management consultation, support, and coping on nurses` health during the stress of restructuring

This study examined the impact of hospital restructuring moves on a sample of Australian nurses' health. The role of organizational support, assessed via levels of consultation with staff, social support, and nurses coping were examined as further contributors or mediators of the relationship between the impact of restructuring and nurses' health. Data from 201 hospital nurses indicated that the factors in the model explained 41% of the variance in nurses' health. “Top-down” communication style by management contributed negatively to nurses' health and increased their perceptions of the impact of restructuring. Support from peers, supervisors, and family together with seeing the demands of impact of restructuring as a challenge, contributed positively to nurses' health and reduced the level of avoidance strategies used. The implications of these findings are discussed.

The early detection of postpartum depression: midwives and nurses trial a checklist

Objective: To evaluate the use of a standard pen-and-paper test versus the use of a checklist for the early identification of women at risk of postpartum depression and to investigate the experiences of nurses in using the checklist.

Design: A prospective cohort design using repeated measures.

Setting: The booking-in prenatal clinic at a regional hospital in Victoria, Australia, and the community-based postpartum maternal and child health service.

Participants: 107 pregnant women over 20 years of age.

Main Measures: Postpartum Depression Prediction Inventory (PDPI), Postpartum Depression Screening Scale (PDSS), Edinburgh Postnatal Depression Scale (EPDS), demographic questionnaire, and data on the outcome from the midwives and nurses.

Results: The PDPI identified 45% of the women at risk of depression during pregnancy and 30% postpartum. The PDSS and EPDS both identified the same 8 women (10%), who scored highly for depression at the 8-week postpartum health visit. Nurses provided 80% of the women with anticipatory guidance on postpartum depression in the prenatal period and 46% of women at the 8-week postpartum health visit. Nurse counseling or anticipatory guidance was provided for 60% of the women in the prenatal period.

Conclusion: The PDPI was found to be a valuable checklist by many nurses involved in this research, particularly as a way of initiating open discussion with women about postpartum depression. It correlated strongly with both the PDSS and the EPDS, suggesting that it is useful as an inventory to identify women at risk of postpartum depression.

Ten Australian ICU nurses` perceptions of organisational restructuring

The Australian healthcare system underwent radical reform in the 1990s as economic rationalist policies were embraced. As a result, there was significant organisational restructuring within hospitals. Traditional indicators, such as nursing absenteeism and attrition, increase during times of organisational change. Despite this, nurses' views of healthcare reform are under-represented in the literature and little is known about the impact of organisational restructuring on perceived performance. This study investigated the perceived impact of organisational restructuring on a group of intensive care unit (ICU) nurses' workplace performance. It employed a qualitative approach to collect data from a purposive sample of clinical nurses. The primary method of data collection was semi-structured interviews. Content analysis generated three categories of data. Participants identified constant pressure, inadequate communication and organisational components of restructuring within the hospital as issues that had a significant impact on their workplace performance. They perceived organisational restructuring was poorly communicated, and this resulted in an environment of constant pressure. Organisational components of restructuring included the subcategories of specialised service provision and an alternative administrative structure that had both positive and negative ramifications for performance.
To date, there has been little investigation of nurses' perceptions of organisational restructure or the impact this type of change has in the clinical domain. Participants in this study believed reorganisation was detrimental to quality care delivery in intensive care, as a result of fiscal constraint, inadequate communication and pressure that influenced their workplace performance.

The role of nurses in preventing adverse events related to respiratory dysfunction: literature review

Aims. This paper reports a literature review examining the relationship between specific clinical indicators of respiratory dysfunction and adverse events, and exploring the role of nurses in preventing adverse events related to respiratory dysfunction.

Background. Adverse events in hospital are associated with poor patient outcomes such as increased mortality and permanent disability. Many of these adverse events are preventable and are preceded by a period during which the patient exhibits clearly abnormal physiological signs. The role of nurses in preserving physiological safety by early recognition and correction of physiological abnormality is a key factor in preventing adverse events.

Methods. A search of the Medline and CINAHL databases was conducted using the following terms: predictors of poor outcome, adverse events, mortality, cardiac arrest, emergency, oxygen, supplemental oxygen, oxygen therapy, oxygen saturation, oxygen delivery, assessment, patient assessment, physical assessment, dyspnoea, hypoxia, hypoxaemia, respiratory assessment, respiratory dysfunction, shortness of breath and pulse oximetry. The papers reviewed were research papers that demonstrated a relationship between adverse events and various clinical indicators of respiratory dysfunction.

Results. Respiratory dysfunction is a known clinical antecedent of adverse events such as cardiac arrest, need for medical emergency team activation and unplanned intensive care unit admission. The presence of respiratory dysfunction prior to an adverse event is associated with increased mortality. The specific clinical indicators involved are alterations in respiratory rate, and the presence of dyspnoea, hypoxaemia and acidosis.

Conclusions. The way in which nurses assess, document and use clinical indicators of respiratory dysfunction is influential in identifying patients at risk of an adverse event and preventing adverse events related to respiratory dysfunction. If such adverse events are to be prevented, nurses must not only be able to recognise and interpret signs of respiratory dysfunction, but must also take responsibility for initiating and evaluating interventions aimed at correcting respiratory dysfunction.

Tensions and constraints for nurses in hospital-in-home programmes

Economic necessity constrains health-care expenditure and waiting lists for hospital treatments remain high. As a result, more care is delivered via alternative means, such as same-day surgery initiatives and home-care programmes. Acute care delivered in the home to patients who would otherwise require hospitalization is becoming an increasingly acceptable means of treatment. These Hospital-in-the-Home programmes offer increased comfort while delivering comparable outcomes to many patient groups. The purpose of this paper is to generate discussion concerning the tensions that exist for nurses who practice in the home under the auspices of acute-care institutions. Data drawn from field work that formed part of a critical ethnography is used to generate the discussion. The larger research project explored the constructions of the role of the nurse in four Hospital-in-the-Home programmes in Victoria, Australia. It will be argued that there is significant pressure exerted upon nurses to support the imperative to reduce bed days in acute hospitals by transferring people to their home. At times, this agenda clashes with the nurses’ professional commitment to provide holistic patient care yet the dilemmas are largely unacknowledged and/or unrecognized by the nurses despite the tension they generate.

Effect of a self-directed learning package on emergency nurses` knowledge of assessment of oxygenation and use of supplemental oxygen

Abstract Emergency nurses frequently and independently make decisions regarding supplemental oxygen. The importance of these decisions for patients is highlighted by the well documented association between respiratory dysfunction and adverse events. This study aimed to: (i) examine the effect of educational preparation on emergency nurses' knowledge of assessment of oxygenation, and the use of supplemental oxygen; (ii) explore the impact of existing knowledge on decisions related to the implementation of supplemental oxygen; and (iii) explore nurses' characteristics that were associated with effectiveness of the educational preparation. A pretest/post-test, controlled, quasi-experimental design was used in this study. Educational preparation was effective in increasing emergency nurses' knowledge. Baseline level of knowledge was predictive of reports of independent decisions regarding the implementation of oxygen. There was a significant positive relationship between postgraduate qualification in emergency nursing and the effect of education, and significant negative relationships between effect of education and baseline level of knowledge and daily decisions to implement supplemental oxygen.