Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context

Background and Aims: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care.

Approach: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n = 30). Observations focused on nurses’ interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses.

Findings: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration.

Implications: Nurses’ abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error.

Conclusions: Nurses displayed behaviours that increased medication administration quality and safety; however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.

Can written nursing practice standards improve documentation of initial assessment of ED patients?

Introduction: There is wide variation in emergency nursing practice in terms of initial patient assessment and the interventions implemented in response to these patient assessment findings. It is hypothesised that written ED nursing practice standards will reduce variability in documentation standards related to initial patient assessment.

Aim: This study aimed to examine the effect of written ED nursing practice standards augmented by an in-service education programme on the documentation of the initial nursing assessment.

Method: A pre-test/post-test design was used. Initial patient assessment was assessed using the Emergency Department Observation Chart. All adult patients (>18 years) who presented with chest pain and who were triaged to the general adult cubicles were eligible for inclusion in the study. Random sampling was used to select the patients for the pre-test (n = 78) and post-test groups (n = 74).

Results: There was significant improvement in documentation of all aspects of symptom assessment except quality and historical variables: pre-hospital care, cardiac risk factors, and past medical history. Improvements in documentation of elements of primary survey assessment were variable. There were significant increases in documentation of respiratory effort, chest auscultation findings, capillary refill and conscious state. There was a significant 18.3% decrease in the frequency of documentation of respiratory rate and no significant changes in documentation of oxygen saturation, heart rate or blood pressure.

Conclusion: Written ED nursing practice standards were effective in improving the documentation of some elements of initial nursing assessment for patients with chest pain. Active implementation strategies are important to ensure effective uptake of written practice standards and the relationship between nursing documentation and actual clinical practice warrants further consideration using a naturalistic approach in real practice settings.

The need for best practice standards in electronic governance of patient medical records to facilitate innovation

Background : Optimising the use of electronic data offers many opportunities to health services, particularly in rural and remote areas. These include reducing the effect of distance on access to clinical information and sharing information where there are multiple service providers for a single patient. The increasing compilation of large electronic databases of patient information and the ease with which electronic information can be transferred has raised concerns about the privacy and confidentiality of such records.
Aims & rationale/Objectives : This review aims to identify legal and ethical standards for areas of electronic governance where a lack of clarity may currently impede innovation in health service delivery.
Methods : This paper describes best practices for storage and transfer of electronic patient data based on an examination of Australian legislative requirements and a review of a number of current models. This will firstly allow us to identify basic legal requirements of electronic governance as well as areas of ambiguity not fully addressed by legislation. An examination of current models will suggest recommendations for best practice in areas lacking sufficient legal guidance.
Principal findings : We have identified the following four areas of importance, and shall discuss relevant details:
1) Patients' right of ownership to electronic patient records. 2) Custodial issues with data stored in centralised health care institutions 3) IT Security, including hierarchical level access, data encryption, data transfer standards and physical security 4) Software applications usage.
Discussion : Our examination of several models of best practice for the transfer of electronic patient data, both in Australia and internationally, identifies and clarifies many unresolved issues of electronic governance. This paper will also inform future policy in this area.
Implications : Clarification will facilitate the future development of beneficial technology-based innovations by rural health services.
Presentation type : Poster

Nurses’ utilisation of complementary therapies : a pilot study exploring scope of practice

The increasing use of complementary therapies (CTs) by the public requires nurses to be fully informed about the use and safety of these modalities. In addition, nurses need to be aware of what constitutes complementary therapy practice, its overlap with nursing practice and how to respond appropriately to patients' requests for access to and information about CTs. A pilot study that aimed to describe nurses' knowledge about, and the use of CTs was conducted in four hospitals in southeast Queensland, Australia. One hundred and twenty-nine nurses (65% response rate) of varying levels of qualification and expertise completed a questionnaire. Over 80% of the participants indicated that they engaged in some form of complementary therapy (CT) activity. The entire sample worked in acute care hospitals but 5% engaged in CTs while employed in a second job. These nurses worked in either individual private practice or a multidisciplinary clinic setting. Only 2% of the sample had formal qualifications in a specific CT. Many nurses seemed unsure about what should be defined as a CT. The most common CTs engaged in by nurses were massage, music therapy and relaxation techniques but some nurses also participated in acupuncture, acupressure, hypnotherapy and osteopathy. Some nurses were confused about the difference between CT and usual nursing care. In addition, there were knowledge deficits relating to institutional policies and professional standards. Our findings suggest that nurses require more education about the scope of CT and how it differs from nursing practice. Nurses also require access to clear policies about the safe use of CTs in specific practice settings and about appropriate referral of clients to complementary therapists with accredited qualifications.

Adult learners in the workplace: online learning and communities of practice

Seven in-employment postgraduate Master's level students in an e-learning unit participated in this research, designed to identify tensions between participation in a community of learning that was part of their studies, and participation in the communities of practice that they were engaged in at their workplaces. It was hypothesised that participation in both these forms of community in their different contexts may enhance each other, or could potentially have a disrupting effect on each. The research employed an interviewing technique. The students' perceptions of the impact of participation in the one form of community on their participation in the other was mixed, with some suggesting that it was enhancing, and others suggesting the contrary, or that there was no impact. The findings indicate that the enhancing effect of participation in communities of learning relevant to a learner's workplace community of practice occur when the learning tasks are designed to enable negotiation of tasks and collaboration with learners who have similar workplace issues.

Empirical evidence from the corporate collapse literature suggesting re-examination of accounting standards in relation to valuation of assets

This paper examines the recent spectacular corporate collapses of Parmalat in Europe, Enron and WorldCom in the USA and HIH in Australia and argues for a re-examination of corporate governance regulations, particularly in relation to accounting standards regarding the valuation of assets. The recommendation that is put forward in this regard is based upon empirical evidence arising from further examination of the empirical results in (Hossari and Rahman, 2004). Specifically, the recommendation is based upon the realization that, among the 48 financial ratios across the 50-plus refereed studies, five financial ratios, all of which contained assets as one of the variables, were a relatively robust indicator of corporate collapse. The five ratios are: Net Income/Total Assets, Current Assets/Current Liabilities, Total Liabilities/Total Assets, Working Capital/Total Assets, and Earnings Before Interest and Taxes/Total Assets. This paper suggests that it's not the failure of the corporate collapse prediction models, rather it's the erosion of the reliability of some key input data, namely assets and the valuation thereof, that is largely responsible for the apparent failure of these models in capturing impending collapses, such as those that we witnessed in the recent past. Such empirical findings support the argument that assets are soft targets for misrepresentation, because of the leeway granted in accounting standards with regards to their valuation.

A trial of nurse practitioner scope of practice

Aims. The aim of this paper is to report a trial to investigate the feasibility of the nurse practitioner role in local health service delivery and to provide information about the educational and legislative requirements for nurse practitioner practice.

Background. Nurse practitioners have been shown to offer a beneficial service and fill a gap in health care provision. However, the lack of publications describing, critiquing, or defending the way that existing nurse practitioner roles have been developed may lead to a lack of clarity in comparing the nurse practitioner scope of practice internationally. In Australia, credible exploratory research is needed to realize the potential of nurse practitioners to bridge the divide of inequitable distribution of health services. A trial of nurse practitioner services in the Australian Capital Territory provided an excellent opportunity to investigate these scope and continuity issues.

Methods. This was an observational analytic study using multiple data sources. Four models of nurse practitioner service were chosen from a competitive field of applications that were evaluated according to efficacy, feasibility, and sustainability across specified selection criteria. Each model in the trial included a clinical support team, with the nurse practitioner candidate 'working-into-the-role' and collecting demographic, clinical practice, patient outcome, and health service and consumer survey data over a 10 month period.

Findings. The trial identified the broad potential of the nurse practitioner role, its breadth and limitations, and its impact on selected health services in the Australian Capital Territory. Data from individual models were compared highlighting generic elements, and formed the basis for the development of the scope of practice for the Australian Capital Territory nurse practitioner models.

Conclusions. This study has validated a research-based, iterative process for initial development of nurse practitioner scope of practice for any Australian specialization. Importantly, the study concluded with the scope of practice as a finding, rather than commencing with it a priori. Although general areas of health care need and under-servicing were identified at the outset, the process tested both the expansion and parameters of the roles.

Foucault's 'What is an author' : towards a critical discourse of practice as research

A vexed issue for many artistic researchers is related to the need for the artist/researcher to write about his or her own work in the research report or exegesis. In the creative arts, the outcomes that emerge from an alternative logic of practice are not easily quantifiable and it can be difficult to articulate conclusions objectively given the emotional and ideological investments and the intrinsically subjective dimension of the artistic process. How then, might the artist as researcher avoid on the one hand, what has been referred to as 'auto-connoisseurship', the undertaking of a thinly veiled labour of valorising what has been achieved in the creative work, or alternatively producing a research report that is mere description or history?

In this paper I suggest that a way of overcoming such a dilemma is for creative arts researchers to shift the critical focus away from the notion of the work as product, to an understanding of both studio enquiry and its outcomes as process. I’d like to draw on Michel Foucault’s essay ‘What is An Author ‘ to explore how we might move away from art criticism to the notion of a critical discourse of practice-led enquiry that involves viewing the artist as a researcher, and the artist/critic as a scholar who comments on the value of the artistic process as the production of knowledge.

Foucault’s essay provides artistic researchers with a template for more objective and distanced discourse on the practice-led research process and its writing. It allows researchers to locate themselves within contexts of theory and practice and provides an analytical framework though which researchers might locate themselves and their work within the broader social arena and field of research, As I will show with reference to the work of Donna Haraway and a number of commentaries on Pablo Picasso’s Demioselles d’Avignon, an application of Foucault’s ideas need not negate those subjective and situated aspects of practice as research.