The provision of patient personal hygiene in the intensive care unit : a descriptive exploratory study of bed-bathing practice

Background/objectives The provision of the patient bed-bath is a fundamental nursing care activity yet few quantitative data and no qualitative data are available on registered nurses’ (RNs) clinical practice in this domain in the intensive care unit (ICU). The aim of this study was to describe ICU RNs current practice with respect to the timing, frequency and duration of the patient bed-bath and the cleansing and emollient agents used. Methods The study utilised a two-phase sequential explanatory mixed method design. Phase one used a questionnaire to survey RNs and phase two employed semi-structured focus group (FG) interviews with RNs. Data was collected over 28 days across four Australian metropolitan ICUs. Ethical approval was granted from the relevant hospital and university human research ethics committees. RNs were asked to complete a questionnaire following each episode of care (i.e. bed-bath) and then to attend one of three FG interviews: RNs with less than 2 years ICU experience; RNs with 2–5 years ICU experience; and RNs with greater than 5 years ICU experience. Results During the 28-day study period the four ICUs had 77.25 beds open. In phase one a total of 539 questionnaires were returned, representing 30.5% of episodes of patient bed-baths (based on 1767 bed occupancy and one bed-bath per patient per day). In 349 bed-bath episodes 54.7% patients were mechanically ventilated. The bed-bath was given between 02.00 and 06.00 h in 161 episodes (30%), took 15–30 min to complete (n = 195, 36.2%) and was completed within the last 8 h in 304 episodes (56.8%). Cleansing agents used were predominantly pH balanced soap or liquid soap and water (n = 379, 71%) in comparison to chlorhexidine impregnated sponges/cloths (n = 86, 16.1%) or other agents such as pre-packaged washcloths (n = 65, 12.2%). In 347 episodes (64.4%) emollients were not applied after the bed-bath. In phase two 12 FGs were conducted (three FGs at each ICU) with a total of 42 RN participants. Thematic analysis of FG transcripts across the three levels of RN ICU experience highlighted a transition of patient hygiene practice philosophy from shades of grey – falling in line for inexperienced clinicians to experienced clinicians concrete beliefs about patient bed-bath needs. Conclusions This study identified variation in process and products used in patient hygiene practices in four ICUs. Further study to improve patient outcomes is required to determine the appropriate timing of patient hygiene activities and cleansing agents used to improve skin integrity.

Changing academic practice to prepare nursing undergraduates for an evidence-based approach

Evidence based practice (EBP) has been accepted as a process to assist health professionals in clinical decision making to improve patient outcomes. It requires applying skills in a prescribed sequence to critique existing practices. Many countries, including Australia, require nurses to demonstrate competencies in EBP skills to be registered. In the last ten years, this has lead to universities incorporating EBP in undergraduate nursing degree courses. The literature reports many challenges including students’ difficulties in critically appraising research evidence, and their need for both simplification of the process and extensive support. The purpose of our study was to investigate the effectiveness of a standalone introductory EBP subject for a diverse group of third-year undergraduates, based on a novel but challenging approach to assessment. Despite many changes made in the second iteration of the subject, most students’ perceptions of the subject’s difficulty remained unchanged. This research aligns with the issues identified in the literature and has wider applicability to the teaching of rapidly changing disciplines, where evidence-driven consumers have easy access to information and expect up-to-date practices.

A national roll out of an insufficiently evaluated practice : how evidence based are our end-of-life care policies?

There has been increasing international efforts to ensure that health care policies are evidence based. One area where there is a lack of ‘effectiveness’ evidence is in the use of end-of-life care pathways (EOLCP) (1). Despite the lack of evidence supporting the efficacy of the EOCLP, their use has been endorsed in the recent national palliative care strategy document in the UK (2). In addition, a publication endorsed by the Australian Government (titled: Supporting Australians to live well at the End of Life- National Palliative Care Strategy 2010) (3), recommended a national roll out of EOLCP across all sectors (primary, acute and aged care) in Australia. According to this document, it is a measure of “appropriateness” and “effectiveness” for promoting quality end-of-life care.

Policy into practice : adoption of hazard mitigation measures by local government in Queensland : a collaborative research project between Queensland University of Technology and Emergency Management Queensland in association with Local Government of Queensland Disaster Management Alliance

The focus of the present research was to investigate how Local Governments in Queensland were progressing with the adoption of delineated DM policies and supporting guidelines. The study consulted Local Government representatives and hence, the results reflect their views on these issues. Is adoption occurring? To what degree? Are policies and guidelines being effectively implemented so that the objective of a safer, more resilient community is being achieved? If not, what are the current barriers to achieving this, and can recommendations be made to overcome these barriers? These questions defined the basis on which the present study was designed and the survey tools developed. While it was recognised that LGAQ and Emergency Management Queensland (EMQ) may have differing views on some reported issues, it was beyond the scope of the present study to canvass those views. The study resolved to document and analyse these questions under the broad themes of: • Building community capacity (notably via community awareness). • Council operationalisation of DM. • Regional partnerships (in mitigation/adaptation). Data was collected via a survey tool comprising two components: • An online questionnaire survey distributed via the LGAQ Disaster Management Alliance (hereafter referred to as the “Alliance”) to DM sections of all Queensland Local Government Councils; and • a series of focus groups with selected Queensland Councils

Focusing on patients : differences between the practice of expert and non-expert nephrology nurses

Specialisation in nursing enables a nurse to focus, in much greater depth, on the requisite knowledge and skills for providing patients with the best possible care. Nephrology nursing is one such area where specialisation has evolved. The characteristic focus of practice emerged as an important feature during a study into the process of expertise acquisition in nephrology nursing practice. Using grounded theory methodology, this study involved 6 non-expert and 11 expert nurses and took place in one renal unit in New South Wales. Nephrology nursing practice was observed for 103 hours, and this was immediately followed by semi-structured interviews. The characteristic of focus was conceptualised as the nurses' centre of attention or concentration while they were undertaking nursing activities. Focus ranged from inexperienced non-expert nurses concentrating predominantly on the immediate task at hand, experienced non-expert nurses who focussed on the medium term to expert nurses who viewed actions (and their possible consequences) more broadly and in the longer term. Of significance to nursing, is how nephrology nurses alter their focus of practice as they acquire and exercise their developing expertise in this specialty.

What information counts at the moment of practice? Information practices of renal nurses

Aims. This article is a report of a study done to identify how renal nurses experience information about renal care and the information practices that they used to support everyday practice. Background. What counts as nursing knowledge remains a contested area in the discipline yet little research has been undertaken. Information practice encompasses a range of activities such as seeking, evaluation and sharing of information. The ability to make informed judgement is dependent on nurses being able to identify relevant sources of information that inform their practice and those sources of information may enable the identification of what knowledge is important to nursing practice. Method. The study was philosophically framed from a practice perspective and informed by Habermas and Schatzki; it employed qualitative research techniques. Using purposive sampling six registered nurses working in two regional renal units were interviewed during 2009 and data was thematically analysed. Findings. The information practices of renal nurses involved mapping an information landscape in which they drew on information obtained from epistemic, social and corporeal sources. They also used coupling, a process of drawing together information from a range of sources, to enable them to practice. Conclusion. Exploring how nurses engage with information, and the role the information plays in situating and enacting epistemic, social and corporeal knowledge into everyday nursing practice is instructive because it indicates that nurses must engage with all three modalities in order to perform effectively, efficiently and holistically in the context of patient care. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

Understanding the role of knowledge in the practice of expert nephrology nurses in Australia

This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the role of knowledge in expert practice. Using grounded theory methodology, the study involved 17 registered nurses who were practicing in a metropolitan renal unit in New South Wales, Australia. Concurrent data collection and analysis was undertaken, incorporating participants' observations and interviews. Having extensive nephrology nursing knowledge was a striking characteristic of a nursing expert. Expert nurses clearly relied on and utilized extensive nephrology nursing knowledge to practice. Of importance for nursing, the results of this study indicate that domain-specific knowledge is a crucial feature of expert practice.

Recognition of expertise : an important concept in the acquisition of nephrology nursing expertise

The present article, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept of recognition of expertise. The study used grounded theory methodology and involved 17 registered nurses who were practising in a metropolitan renal unit in New South Wales, Australia. Concurrent data collection and analysis was undertaken, incorporating participant observations and interviews. According to nurses in this study, patients, doctors and other nurses recognized that some nurses were experts while others were not. In addition, being trusted, being a role model and teaching others were important components of being recognized as an expert nephrology nurse. Of importance for nursing, the results of the present study indicate that knowledge and experience are not sufficient to ensure expert practice; recognition of expertise by others is an important function of expertise acquisition.

The acquisition and exercise of nephrology nursing expertise : A grounded theory study

Aims and objectives. This purpose of this study was to describe the process of expertise acquisition in nephrology nursing practice. Background. It has been recognized for a number of decades that experts, compared with other practitioners in a number of professions and occupations, are the most knowledgeable and effective, in terms of both the quantity and quality of output. Studies relating to expertise have been undertaken in a range of nursing contexts and specialties; to date, however, none have been undertaken which focus on nephrology nursing. Design. This study, using grounded theory methodology, took place in one renal unit in New South Wales, Australia and involved six non-expert and 11 expert nurses. Methods. Simultaneous data collection and analysis took place using participant observation, semi-structured interviews and review of nursing documentation. Findings. The study revealed a three-stage skills-acquisitive process that was identified as non-expert, experienced non-expert and expert stages. Each stage was typified by four characteristics, which altered during the acquisitive process; these were knowledge, experience, skill and focus. Conclusion. This was the first study to explore nephrology nursing expertise and uncovered new aspects of expertise not documented in the literature and it also made explicit other areas, which had only been previously implied. Relevance to clinical practice. Of significance to nursing, the exercise of expertise is a function of the recognition of expertise by others and it includes the blurring of the normal boundaries of professional practice. © 2006 Blackwell Publishing Ltd.

ICU nurses' experiences and perspectives of caring for obstetric patients in intensive care: A qualitative study

Aims and objectives.  The aim of this study was to gain an understanding of the experiences and perspectives of intensive care nurses caring for critically ill obstetric patients. Background.  Current literature suggests critically ill obstetric patients need specialised, technically appropriate care to meet their specific needs with which many intensive care nurses are unfamiliar. Furthermore, there is little research and evidence to guide the care of this distinct patient group. Design.  This study used a descriptive qualitative design. Methods.  Two focus groups were used to collect data from 10 Australian intensive care units nurses in May 2007. Open-ended questions were used to guide the discussion. Latent content analysis was used to analyse the data set. Each interview lasted no longer than 60 minutes and was recorded using audio tape. The full interviews were transcribed prior to in-depth analysis to identify major themes. Results.  The themes identified from the focus group interviews were competence with knowledge and skills for managing obstetric patients in the intensive care unit, confidence in caring for obstetric patients admitted to the intensive care unit and acceptance of an expanded scope of practice perceived to include fundamental midwifery knowledge and skills. Conclusion.  The expressed lack of confidence and competence in meeting the obstetric and support needs of critically ill obstetric women indicates a clear need for greater assistance and education of intensive care nurses. This in turn may encourage critical care nurses to accept an expanded role of clinical practice in caring for critically ill obstetric patients. Relevance to clinical practice.  Recognition of the issues for nurses in successfully caring for obstetric patients admitted to an adult intensive care setting provides direction for designing education packages, ensuring specific carepaths and guidelines are in place and that support from a multidisciplinary team is available including midwifery staff.

Using the Precede-Proceed Model of Health Program Planning in breast cancer nursing research

Aim: In this paper we discuss the use of the Precede-Proceed model when investigating health promotion options for breast cancer survivors. Background: Adherence to recommended health behaviors can optimize well-being after cancer treatment. Guided by the Precede-Proceed approach, we studied the behaviors of breast cancer survivors in our health service area. Data sources: The interview data from the cohort of breast cancer survivors are used in this paper to illustrate the use of Precede-Proceed in this nursing research context. Interview data were collected from June to December 2009. We also searched Medline, CINAHL, PsychInfo and PsychExtra up to 2010 for relevant literature in English to interrogate the data from other theoretical perspectives. Discussion: The Precede-Proceed model is theoretically-complex. The deductive analytic process guided by the model usefully explained some of the health behaviors of cancer survivors, although it could not explicate many other findings. A complementary inductive approach to the analysis and subsequent interpretation by way of Uncertainty in Illness Theory and other psychosocial perspectives provided a comprehensive account of the qualitative data that resulted in contextually-relevant recommendations for nursing practice. Implications for nursing: Nursing researchers using Precede-Proceed should maintain theoretical flexibility when interpreting qualitative data. Perspectives not embedded in the model might need to be considered to ensure that the data are analyzed in a contextually-relevant way. Conclusion: Precede-Proceed provides a robust framework for nursing researchers investigating health promotion in cancer survivors; however additional theoretical lenses to those embedded in the model can enhance data interpretation.

Developing a model of embedding academic numeracy in university programs : a case study from nursing

This is a study of the academic numeracy of nursing students. This study develops a theoretical model for the design and delivery of university courses in academic numeracy. The following objectives are addressed: 1. To investigate nursing students' current knowledge of academic numeracy; 2. To investigate how nursing students’ knowledge and skills in academic numeracy can be enhanced using a developmental psychology framework; and 3. To utilise data derived from meeting objectives 1 and 2 to develop a theoretical model to embed academic numeracy in university programs. This study draws from Valsiner’s Human Development Theory (Valsiner, 1997, 2007). It is a quasi-experimental intervention case study (Faltis, 1997) and takes a multimethod approach using pre- and post-tests; observation notes; and semi-structured teaching sessions to document a series of microgenetic studies of student numeracy. Each microgenetic study is centered on the lived experience of students becoming more numerate. The method for this section is based on Vygotsky’s double stimulation (Valsiner, 2000a; 2007). Data collection includes interviews on students’ past experience with mathematics; their present feelings and experiences and how these present feelings and experiences are transformed. The findings from this study have provided evidence that the course developed for nursing students, underpinned by an appropriate framework, does improve academic numeracy. More specifically, students improved their content knowledge of and confidence in mathematics in areas that were directly related to their degree. The study used Valsiner’s microgenetic approach to development to trace the course as it was being taught and two students’ personal academic numeracy journeys. It highlighted particularly troublesome concepts, then outlined scaffolding and pathways used to develop understanding. This approach to academic numeracy development was summarised into a four-faceted model at the university, program, course and individual level. This model can be applied successfully to similar contexts. Thus the thesis advances both theory and practice in this under-researched and under-theorised area.

A case study examination of the influence of cultural diversity in the multicultural nursing workforce on the quality of care and patient safety in a Saudi Arabian hospital

The purpose of the study: The purpose of this study is to investigate the influence of cultural diversity, in a multicultural nursing workforce, on the quality and safety of patient care and the work environment at King Abdul-Aziz Medical City, Riyadh region. Study background: Due to global migration and workforce mobility, to varying degrees, cultural diversity exists in most health services around the world, particularly occurring where the health care workforce is multicultural or where the domestic population comprises minority groups from different cultures speaking different languages. Further complexities occur when countries have a multicultural workforce which is different from the population for whom they care, in addition to the workers being from culturally diverse countries and with different languages. In Saudi Arabia the health system is mainly staffed by expatriate nurses who comprise 67.7% of the total number of nurses. Study design: This research utilised a case study design which incorporated multiple methods including survey, qualitative interviews and document review. Methods: The participant nurses were selected for the survey via a population sampling strategy; 319 nurses returned their completed Safety Climate Survey questionnaires. Descriptive and inferential statistics (Kruskal–Wallis test) were used to analyse survey data. For the qualitative component of the study, a purposive sampling strategy was used; 24 nurses were interviewed using a semi-structured interview technique. The documentary review included KAMC-R policy documents that met the inclusion criteria using a predetermined data abstraction instrument. Content analysis was used to analyse the policy documents data. Results: The data revealed the nurses‘ perceptions of the clinical climate in this multicultural environment is that it was unsafe, with a mean score of 3.9 out of 5. No significant difference was detected between the age groups or years of experience of the nurses and the perception of safety climate in this context; the study did reveal a statistically significant difference between the cultural background categories and the perception of safety climate. The qualitative phase indicated that the nurses within this environment were struggling to achieve cultural competence; consequently, they were having difficulties in meeting the patients‘ cultural and spiritual needs as well as maintaining a high standard of care. The results also indicated that nurses were disempowered in this context. Importantly, there was inadequate support by the organisation to manage the cultural diversity issue and to protect patients from any associated risks, as demonstrated by the policy documents and supported by the nurses‘ experiences. The study also illustrated the limitations of the conceptual framework of cultural competence when tested in this multicultural workforce context. Therefore, this study generated amendments to the model that is suitable to be used in the context of a multicultural nursing workforce. Conclusion: The multicultural nature of this nursing work environment is inherently risky due to the conflicts that arise from the different cultural norms, beliefs, behaviours and languages. Further, there was uncertainty within the multicultural nursing workforce about the clinical and cultural safety of the patient care environment and about the cultural safety of the nursing workforce. The findings of the study contribute important new knowledge to the area of patient and nurse safety in a multicultural environment and contribute theoretical development to the field of cultural competence. Specifically, the findings will inform policy and practice related to patient care in the context of cultural diversity.

Examination of relationships and mediating effects of self-efficacy, locus of control, coping and the practice environment on caring efficacy and job satisfaction in Australian registered nurses

Background to the Problem: Improving nurses' self-efficacy and job satisfaction may improve the quality of nursing care to patients. Moreover, to work effectively and consistently with professional nursing standards, nurses have to believe they are able to make decisions about their practice. In order to identify what strategies and professional development programmes should be developed and implemented for registered nurses in the Australian context, a comprehensive profile of registered nurses and factors that affect nursing care in Australia needs to be available. However, at present, there is limited information available on a) the perceived caring efficacy and job satisfaction of registered nurses in Australia, and b) the relationships between the demographic variables general self-efficacy, work locus of control, coping styles, the professional nursing practice environment and caring efficacy and job satisfaction of registered nurses in Australia. This is the first study to 1) investigate relationships between caring efficacy and job satisfaction with factors such as general self-efficacy, locus of control and coping, 2) the nursing practice environment in the Australian context and 3) conceptualise a model of caring efficacy and job satisfaction in the Australian context. Research Design and Methods: This study used a two-phase cross-sectional survey design. A pilot study was conducted in order to determine the validity and reliability of the survey instruments and to assess the effectiveness of the participant recruitment process. The second study of the research involved investigating the relationships between the socio-demographic, dependent and independent variables. Socio-demographic variables included age, gender, level of education, years of experience, years in current job, employment status, geographical location, specialty area, health sector, state and marital status. Other independent variables in this study included general self-efficacy, work locus of control, coping styles and the professional nursing practice environment. The dependent variables were job satisfaction and caring efficacy. Results: A confirmatory factor analysis of the Brisbane Practice Environment Measure (B-PEM) was conducted. A five-factor structure of the B-PEM was confirmed. Relationships between socio-demographic variables, caring efficacy and job satisfaction, were identified at the bivariate and multivariable levels. Further, examination using structural equation modelling revealed general self-efficacy, work locus of control, coping style and the professional nursing practice environment contributed to caring efficacy and job satisfaction of registered nurses in Australia. Conclusion: This research contributes to the literature on how socio-demographic, personal and environmental variables (work locus of control, general self-efficacy and the nursing practice environment) influence caring efficacy and job satisfaction in registered nurses in Australia. Caring efficacy and job satisfaction may be improved if general self-efficacy is high in those that have an internal work locus of control. The study has also shown that practice environments that provide the necessary resources improve job satisfaction in nurses. The results have identified that the development and implementation of strategies for professional development and orientation programmes that enhance self-efficacy and work locus of control may contribute to better quality nursing practice and job satisfaction. This may further assist registered nurses towards focusing on improving their practice abilities. These strategies along with practice environments that provide the necessary resources for nurses to practice effectively may lead to better job satisfaction. This information is important for nursing leaders, healthcare organisations and policymakers, as the development and implementation of these strategies may lead to better recruitment and retention of nurses. The study results will contribute to the national and international literature on self-efficacy, job satisfaction and nursing practice.

Perceptions of clinical safety climate of the multicultural nursing workforce in Saudi Arabia : a cross-sectional survey

Purpose The purpose of this study is to explore the safety climate perceptions of the multicultural nursing workforce, and to investigate the influence of diversity of the multicultural nursing workforce on clinical safety in a large tertiary hospital in Saudi Arabia. Background Working in a multicultural environment is challenging. Each culture has its own unique characteristics and dimensions that shape the language, lifestyle, beliefs, values, customs, traditions, and patterns of behaviour, which expatriate nurses must come to terms with. However, cultural diversity in the health care environment can potentially affect the quality of care and patient safety. Method A mixed-method case study (survey, interview and document analysis) was employed. A primary study phase entailed the administration of the Safety Climate Survey (SCS). A population sampling strategy was used and 319 nurses participated, yielding a 76.8% response rate. Descriptive and inferential statistics (Kruskal–Wallis test) were used to analyse survey data. Results The data revealed the nurses’ perceptions of the clinical safety climate in this multicultural environment was unsafe, with a mean score of 3.9 out of 5. No significant difference was found between the age groups, years of nursing experience and their perceptions of the safety climate in this context. A significant difference was observed between the national background categories of nurses and perceptions of safety climate. Conclusion Cultural diversity within the nursing workforce could have a significant influence on perceptions of clinical safety. These findings have the potential to inform policy and practice related to cultural diversity in Saudi Arabia.