A Critical Review of the Harm Minimization Ideology in Australia

Harm minimization as a drug-policy approach represents a major step forward in Australian society's method of dealing with the myriad problems associated with illicit drug use. However, harm minimization lacks a substantial theoretical underpinning and there has been little debate about harm minimization at the sociological level. This article investigates a number of the assertions made within the harm minimization literature and the assumptions on which they are based. These assumptions are critically deconstructed from a number of points of view, including a Foucauldian perspective. Areas investigated include: the use of epidemiological data as a foundation for many harm-reduction strategies, the failure of harm minimization theories to deal adequately with the role of discourse in the drug policy arena, the harm minimization claim to amorality, the use of a utilitarian set of values, the supposed popularity of harm reduction and the idea that the current harm-reduction paradigm clearly acts as an extension of 'surveillance medicine' through the vehicle of governmentality. It is concluded that, whilst harm minimization represents the most promising advance in drug policy in the past, the lack of theoretical rigour in the development of these initiatives results in many of the claims made by proponents of harm-reduction strategies being either overly optimistic or fundamentally flawed.

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.

Security management : modelling critical infrastructure

Secure management of Australia's commercial critical infrastructure presents ongoing challenges to owners and the government. Currently a high-level iriformation sharing collaboration between the government and business manages complex security issues, but critical irifrastructure protection also lacks a scalable model exhibiting the overall structure of critical infrastructure at various levels, sectors and sub-sectors. This research builds on the work of Marasea and Warren (2003) to establish a representative model of Australia's critical irifrastructure; discusses the boundaries between critical infrastructures, and considers the existence andpotential irifluence ofcritical irifrastructure relationships.

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.

Australian commercial-critical infrastructure management protection

Secure management of Australia's commercial critical infrastructure presents ongoing challenges to owners and the government. Although managed via a high-level information sharing collaboration of government and business, critical infrastructure protection is further complicated by the lack of a lower-level scalable model exhibiting its various levels, sectors and sub-sectors. This research builds on the work of Marasea (2003) to establish a descriptive critical infrastructure model and also considers the influence and proposed modelling of critical infrastructure dependency inter-relationships.

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.

Democracy, global transitions, and education : using speculative fictions as thought experiments in anticipatory critical inquiry

The purpose of a thought experiment, as the term was used by quantum and relativity physicists in the early part of the twentieth century, was not prediction (as is the goal of classical experimental science), but more defensible representations of present 'realities'. Indeed, one of the best-known examples of a thought experiment ('Schrodinger's cat') demonstrates the impossibility of prediction at the quantum level. Speculative fictions, from Mary Shelley's Frankenstein to the Star Wars saga, can be read as socio-technical thought experiments that can help us to apprehend and comprehend present 'realities' and uncertainties, and to anticipate and critique possible futures. In this paper I will demonstrate how two examples of popular speculative fictions, Frank Herbert's Dune (1965) and Ursula Le Guin's The Telling (2000), can be read as thought experiments that describe problematic aspects of contemporary social and cultural transformations. I will argue that critical and deconstructive readings of these novels can help us to produce anticipatory critiques of possible ways in which democratic institutions are being transformed by globalisation. I will conclude by considering the implications of such anticipatory critiques for generating questions, problems and issues in educational inquiry and for choosing appropriate methodologies for investigating them.

Effects of human activities on rocky shores of the Surf Coast Shire: scientific basis for management at the regional level

The Surf Coast Shire in regional Victoria contains some of the most spectacular coastline in Australia, running from Point Impossible in the east to just west of the resort town of Lorne. The Surf Coast Shire council is committed to ecologically sustainable tourism based on its coastal assets, including the important intertidal environments. The challenge for the Shire is to protect and enhance the biodiversity of its intertidal areas whilst allowing for their sustainable use as a critical component of the local economy. In order to do this the Council needed to identify the conservation values of intertidal areas within the shire and assess the impacts that current human use has on these values. The impacts of shellfish collecting on rocky shores were identified as an issue of particular concern. We have conducted a research project with the Shire to provide a scientific basis for management decisions. The principal aims of this project were to: (1) determine the patterns of human use of intertidal habitats; (2) measure the impacts of human usage on biological communities and species populations; and (3) to identify intertidal sites of regional conservation significance for the Surf Coast Shire. Surveys of human usage identified reef walking, looking in rock pools and fossicking as major uses of rocky shores within the Surf Coast. This poster reports the effects of this usage on gastropod populations of rocky shores within the Surf Coast Shire. A small proportion of visitors collected intertidal organisms. Shores were categorized as high or low use based on total numbers of people observed at each shore over the first year of the project. Mean size and catch per unit effort were compared for several gastropod species between high use and low use shores. The results presented here show that the populations of some gastropod species are of smaller mean size and less abundant on high use shores than on low use shores. There was also a noticeable difference in degree of effect detected between sandstone and mudstone shores. The implications of these results are briefly discussed in terms of management options available to the Shire.

Commercial critical systems and critical infrastructure protection : a future research agenda

Secure management of Australia’s commercial critical infrastructure presents ongoing challenges to owners and the government. Although it is currently managed through high-level information sharing via collaboration, but does this suit the commercial sector. One of the issues facing Australia is that the majority of critical infrastructure resides under the control of the business sector and certain aspects such of the critical infrastructure such as Supply Chain Management (SCM) systems are distributed entities and not a single entity. The paper focuses upon the security issues associated with SCM systems and critical infrastructure protection.

Predictors of critical care admission in emergency department patients triaged as low to moderate urgency

Aim. This paper is a report of a study to identify predictors of critical care admission in emergency department patients triaged as low to moderate urgency that may be apparent early in the emergency department episode of care.

Background. Observations of clinical practice show that a number of emergency department patients triaged as low to moderate urgency require critical care admission, raising questions about the relationship between illness severity and physiological status early in the emergency department episode of care.

Methods. A retrospective case control design was used. All participants were aged over 18 years, triaged to Australasian Triage Scale categories 3, 4 or 5, and attended emergency department between 1 July 2004 and 30 June 2005. Cases were admitted to intensive care unit or coronary care unit and controls were admitted to general medical or surgical units. Cases (n = 193) and controls (n = 193) were matched by age, gender, emergency department discharge diagnosis and triage category.

Results. Critical care admission associated with: (i) a presenting complaint of nausea, vomiting and diarrhoea (OR = 3·40, 95%CI:1·22–9·47, P = 0·019), (ii) heart rate abnormalities at triage (OR = 2·10, 95%CI:1·19–3·71, P = 0·011), (iii) temperature abnormalities at triage (OR = 2·87 95%CI:1·05–7·89, P = 0·041), (iv) respiratory rate at first nursing assessment (OR = 1·66, 95%CI:1·05–2·06, P = 0·31) or (v) heart rate abnormalities at first nursing assessment (OR = 1·57, 95%CI = 1·04−2·39, P = 0·033).

Conclusion. Derangements in temperature, respiratory rate and heart appear to increase risk of critical care admission. Further work using a prospective approach is needed to establish which physiological parameters have the highest predictive validity, the level(s) of physiological abnormality with highest clinical utility, and the optimal timing for collection of physiological data.

Critical care nurses' decision-making activities in the natural clinical setting

• This article reports on observation of 18 nurses in urban and rural based critical care settings.

• The purpose of the study was to observe and describe the decision-making activities of critical care nurses within natural clinical settings.

• During the 2-hour observation, the researcher dictated a detailed commentary on to audio-tape of each nurse's actions. Tapes were transcribed and subjected to content analysis.

• Findings indicated three main categories of decisions. Decision frequencies were linked to nurses' critical care experience, appointment level, and location, as well as nursing shifts.

• The findings are discussed in relation to previous empirical evidence and the implications for practice.

• The author concludes that future research should be directed towards measuring the contextual influences on nurses' decision-making on the outcome of patient care.

Towards a cyclical framework for the investigation and management of elite level sponsorships

Sponsorship is a growing marketing communications tool which can produce unmatched results when used effectively. As such, rigid and applicable management frameworks are of critical importance as the discipline continues to develop. A conceptual review of existing sponsorship management frameworks and their common components are presented before an alternate cyclical management framework is derived. A series of case studies with organizations investing in elite level, million dollar sport sponsorship was used as the research strategy. Data was collected through qualitative interviews with within and cross case analysis used to identify trends. Five pillars of evidence supported the view that sponsorships were viewed and managed by corporate sponsors under a cyclical framework. The cyclical framework allows for interrelations between sponsorship management components to be better identified and investigated, and demonstrate how a cyclical view of management can aid the ongoing creation of value in long term sponsorships.