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.

Engaging undergraduate nursing students in face-to-face tutorials

Chronic nursing shortages have placed increasing pressure on many nursing schools to recruit greater numbers of students with the consequence of larger class sizes. Larger class sizes have the potential to lead to student disengagement. This paper describes a case study that examined the strategies used by a group of nursing lecturers to engage students and to overcome passivity in a Bachelor of Nursing programme. A non-participant observer attended 20 tutorials to observe five academics deliver four tutorials each. Academics were interviewed both individually and as a group following the completion of all tutorial observations. All observations, field notes, interviews and focus groups were coded separately and major themes identified. From this analysis two broad categories emerged: getting students involved; and engagement as a struggle. Academics used a wide variety of techniques to interest and involve students. Additionally, academics desired an equal relationship with students. They believed that both they and the students had some power to influence the dynamics of tutorials and that neither party had ultimate power. The findings of this study serve to re-emphasise past literature which suggests that to engage students, the academics must also engage.

Is language a barrier for quality care in hospitals? A case series from an Emergency Department of a teaching hospital in Brisbane

Aim: The aim of this pilot study is to describe the use of an Emergency Department (ED) at a large metropolitan teaching hospital by patients who speak English or other languages at home. Methods: All data were retrieved from the Emergency Department Information System (EDIS) of this tertiary teaching hospital in Brisbane. Patients were divided into two groups based on the language spoken at home: patients who speak English only at home (SEO) and patients who do not speak English only or speak other language at home (NSEO). Modes of arrival, length of ED stay and the proportion of hospital admission were compared among the two groups of patients by using SPSS V18 software. Results: A total of 69,494 patients visited this hospital ED in 2009 with 67,727 (97.5%) being in the SEO group and 1,281 (1.80%) in the NSEO group. The proportion of ambulance utilisation in arrival mode was significantly higher among SEO 23,172 (34.2%) than NSEO 397 (31.0%), p <0.05. The NSEO patients had longer length of stay in the ED (M = 337.21, SD = 285.9) compared to SEO patients (M= 290.9, SD = 266.8), with 46.3 minutes (95%CI 62.1, 30.5, p <0.001) difference. The admission to the hospital among NSEO was 402 (31.9%) higher than SEO 17,652 (26.6%), p <0.001. Conclusion: The lower utilisation rates of ambulance services, longer length of ED stay and higher hospital admission rates in NSEO patients compared to SEO patients are consistent with other international studies and may be due to the language barriers.

Transition to intensive care nursing: A state-wide, workplace centred program-12 years on

In November 1999, the Queensland Health (QH) Transition to Practice Nurse Education Program - Intensive Care (TPNEP-IC) was initiated in QH Intensive Care Units (ICUs) across Queensland. This 12-month, state-wide, workplace based education program has set minimum standards for intensive care nursing education and therefore minimum standards for intensive care nursing practice in QH. In the 12 years of operation, 824 nurses have completed TPNEP-IC, 761 achieving academic credit status and 453 utilising this academic credit status to undertake postgraduate study in critical/intensive care nursing at three Queensland universities. These outcomes were achieved through the appointment of nurse educators within ICUs who, through a united and strong commitment to this state-wide approach formed collaborative professional networks, which resulted in the development, implementation and maintenance of the program. Furthermore, these networks enabled a framework of support for discussion and dissemination of evidence based practice, to endorse quality processes for TPNEP-IC and to nurture leadership potential among educators. Challenges to overcome included obtaining adequate resources to support all aspects of the program, gaining local management and administrative support, and embedding TPNEP-IC within ICU culture. The 12 years of operation of the program have demonstrated its long term sustainability. The program is being launched through a new blended learning approach utilising e-learning strategies. To capitalise on the current success, a strong commitment by all stakeholders will be required to ensure the ongoing sustainability of the program.

What health problems overcrowd hospital emergency departments in Queensland and has this changed over time? A case study of two hospitals in Queensland 2001 - 2009

Aim: to describe what health problems patients attending emergency department with and whether this changed over time. Methods: Electronic data was retrieved from EDIS (Emergency Department Information System) and HBCIS (Hospital Based Clinical Information System) in two hospitals in Queensland in the period 2001-2009. The ICD-10 code of patient's diagnosis was then extrapolated and then group into ICD-10 chapters, such that the health problem can be presented. Results: Among the specific health problems, Chapter XIX 'Injury and poisoning' ranked number one consistently (ranging from 22.1% to 31.2% of the total presentations) in both the urban and remote hospitals in Queensland. The top ten specific presenting health problems in both the urban and remote hospital include Chapter XI 'Digestive system', Chapter XIV 'Genitourinary system', Chapter IX 'Circulatory system', and Chapter XIII 'Musculoskeletal system and connective tissue'. Chapter X 'Respiratory system' made the top ten presenting Chapters in both hospitals, but ranked much higher (number four consistently for the eight years, ranging from 6.8% to 8.3%) in the remote hospital. Chapter XV 'Pregnancy childbirth and puerperium' made to the top ten in the urban hospital only while Chapter XII 'Skin and subcutaneous tissue', Chapter I 'Infectious and parasitic diseases' made the top ten in the remote hospital only. Conclusion: The number one health problem presenting to both the urban and remote hospitals in Queensland is Chapter XIX 'Injury and poisoning', and it did not change in the period 211 - 2009.

Impact of opening a new emergency department on healthcare service and patient outcomes : analyses based on linking ambulance, emergency and hospital databases

Background Emergency department (ED) crowding caused by access block is an increasing public health issue and has been associated with impaired healthcare delivery, negative patient outcomes and increased staff workload. Aim To investigate the impact of opening a new ED on patient and healthcare service outcomes. Methods A 24-month time series analysis was employed using deterministically linked data from the ambulance service and three ED and hospital admission databases in Queensland, Australia. Results Total volume of ED presentations increased 18%, while local population growth increased by 3%. Healthcare service and patient outcomes at the two pre-existing hospitals did not improve. These outcomes included ambulance offload time: (Hospital A PRE: 10 min, POST: 10 min, P < 0.001; Hospital B PRE: 10 min, POST: 15 min, P < 0.001); ED length of stay: (Hospital A PRE: 242 min, POST: 246 min, P < 0.001; Hospital B PRE: 182 min, POST: 210 min, P < 0.001); and access block: (Hospital A PRE: 41%, POST: 46%, P < 0.001; Hospital B PRE: 23%, POST: 40%, P < 0.001). Time series modelling indicated that the effect was worst at the hospital furthest away from the new ED. Conclusions An additional ED within the region saw an increase in the total volume of presentations at a rate far greater than local population growth, suggesting it either provided an unmet need or a shifting of activity from one sector to another. Future studies should examine patient decision making regarding reasons for presenting to a new or pre-existing ED. There is an inherent need to take a ‘whole of health service area’ approach to solve crowding issues.

Queensland Emergency Medicine Research Foundation: Special report

The development of any new profession is dependent on the development of a special body of knowledge which is the domain of the profession and key to this is the conduct of research. In 2007, as part of the settlement of an Enterprise Bargaining Agreement and following sustained lobbying by Emergency Physicians, the Queensland Government agreed to establish an Emergency Medicine Research Fund to foster the development of research activities in Emergency Medicine in Queensland. That fund is now managed by the Queensland Emergency Medicine Research Foundation. The aims of this article are to describe the strategic approaches taken by the Foundation and its first three years of experience, to describe the application of research funds and to foreshadow an evaluative framework for determining the strategic value of this community investment. The Foundation has developed a range of personnel and project support funding programs and competition for funding has increased. Ongoing evaluation will seek to determine the effectiveness of this funding strategy on improving the effectiveness of research performance and the clinical and organisational outcomes that may derive from that initiative.

Pandemic (H1N1) Influenza 2009 and Australian emergency departments : implications for policy, practice and pandemic preparedness

Objective: To describe the reported impact of Pandemic (H1N1) 2009 on EDs, so as to inform future pandemic policy, planning and response management. Methods: This study comprised an issue and theme analysis of publicly accessible literature, data from jurisdictional health departments, and data obtained from two electronic surveys of ED directors and ED staff. The issues identified formed the basis of policy analysis and evaluation. Results: Pandemic (H1N1) 2009 had a significant impact on EDs with presentation for patients with ‘influenza-like illness’ up to three times that of the same time in previous years. Staff reported a range of issues, including poor awareness of pandemic plans, patient and family aggression, chaotic information flow to themselves and the public, heightened stress related to increased workloads and lower levels of staffing due to illness, family care duties and redeployment of staff to flu clinics. Staff identified considerable discomfort associated with prolonged times wearing personal protective equipment. Staff believed that the care of non-flu patients was compromised during the pandemic as a result of overwork, distraction from core business and the difficulties associated with accommodating infectious patients in an environment that was not conducive. Conclusions: This paper describes the breadth of the impact of pandemics on ED operations. It identifies a need to address a range of industrial, management and procedural issues. In particular, there is a need for a single authoritative source of information, the re-engineering of EDs to accommodate infectious patients and organizational changes to enable rapid deployment of alternative sources of care.

Controlled emergency landing of an unpowered unmanned aerial system

The ability to perform autonomous emergency (forced) landings is one of the key technology enablers identified for UAS. This paper presents the flight test results of forced landings involving a UAS, in a controlled environment, and which was conducted to ascertain the performances of previously developed (and published) path planning and guidance algorithms. These novel 3-D nonlinear algorithms have been designed to control the vehicle in both the lateral and longitudinal planes of motion. These algorithms have hitherto been verified in simulation. A modified Boomerang 60 RC aircraft is used as the flight test platform, with associated onboard and ground support equipment sourced Off-the-Shelf or developed in-house at the Australian Research Centre for Aerospace Automation (ARCAA). HITL simulations were conducted prior to the flight tests and displayed good landing performance, however, due to certain identified interfacing errors, the flight results differed from that obtained in simulation. This paper details the lessons learnt and presents a plausible solution for the way forward.

Flight guardian: a common avionics architecture for collision avoidance and safe emergency landing for unmanned aerial systems

This paper presents an approach to derive requirements for an avionics architecture that provides onboard sense-and-avoid and autonomous emergency forced landing capabilities to a UAS. The approach is based on two design paradigms that (1) derive requirements analyzing the common functionality between these two functions to then derive requirements for sensors, computing capability, interfaces, etc. (2) consider the risk and safety mitigation associated with these functions to derive certification requirements for the system design. We propose to use the Aircraft Certification Matrix (ACM) approach to tailor the system Development Assurance Levels (DAL) and architecture requirements in accordance with acceptable risk criteria. This architecture is developed under the name “Flight Guardian”. Flight Guardian is an avionics architecture that integrates common sensory elements that are essential components of any UAS that is required to be dependable. The Flight Guardian concept is also applicable to conventionally piloted aircraft, where it will serve to reduce cockpit workload.

Context-aware multicast protocol for emergency message dissemination in vehicular networks

Road traffic accidents can be reduced by providing early warning to drivers through wireless ad hoc networks. When a vehicle detects an event that may lead to an imminent accident, the vehicle disseminates emergency messages to alert other vehicles that may be endangered by the accident. In many existing broadcast-based dissemination schemes, emergency messages may be sent to a large number of vehicles in the area and can be propagated to only one direction. This paper presents a more efficient context aware multicast protocol that disseminates messages only to endangered vehicles that may be affected by the emergency event. The endangered vehicles can be identified by calculating the interaction among vehicles based on their motion properties. To ensure fast delivery, the dissemination follows a routing path obtained by computing a minimum delay tree. The multicast protocol uses a generalized approach that can support any arbitrary road topology. The performance of the multicast protocol is compared with existing broadcast protocols by simulating chain collision accidents on a typical highway. Simulation results show that the multicast protocol outperforms the other protocols in terms of reliability, efficiency, and latency.