Nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a mixed methods study

The cardiac catheterisation laboratory (CCL) is a specialised medical radiology facility where both chronic-stable and life-threatening cardiovascular illness is evaluated and treated. Although there are many potential sources of discomfort and distress associated with procedures performed in the CCL, a general anaesthetic is not usually required. For this reason, an anaesthetist is not routinely assigned to the CCL. Instead, to manage pain, discomfort and anxiety during the procedure, nurses administer a combination of sedative and analgesic medications according to direction from the cardiologist performing the procedure. This practice is referred to as nurse-administered procedural sedation and analgesia (PSA). While anecdotal evidence suggested that nurse-administered PSA was commonly used in the CCL, it was clear from the limited information available that current nurse-led PSA administration and monitoring practices varied and that there was contention around some aspects of practice including the type of medications that were suitable to be used and the depth of sedation that could be safely induced without an anaesthetist present. The overall aim of the program of research presented in this thesis was to establish an evidence base for nurse-led sedation practices in the CCL context. A sequential mixed methods design was used over three phases. The objective of the first phase was to appraise the existing evidence for nurse-administered PSA in the CCL. Two studies were conducted. The first study was an integrative review of empirical research studies and clinical practice guidelines focused on nurse-administered PSA in the CCL as well as in other similar procedural settings. This was the first review to systematically appraise the available evidence supporting the use of nurse-administered PSA in the CCL. A major finding was that, overall, nurse-administered PSA in the CCL was generally deemed to be safe. However, it was concluded from the analysis of the studies and the guidelines that were included in the review, that the management of sedation in the CCL was impacted by a variety of contextual factors including local hospital policy, workforce constraints and cardiologists’ preferences for the type of sedation used. The second study in the first phase was conducted to identify a sedation scale that could be used to monitor level of sedation during nurse-administered PSA in the CCL. It involved a structured literature review and psychometric analysis of scale properties. However, only one scale was found that was developed specifically for the CCL, which had not undergone psychometric testing. Several weaknesses were identified in its item structure. Other sedation scales that were identified were developed for the ICU. Although these scales have demonstrated validity and reliability in the ICU, weaknesses in their item structure precluded their use in the CCL. As findings indicated that no existing sedation scale should be applied to practice in the CCL, recommendations for the development and psychometric testing of a new sedation scale were developed. The objective of the second phase of the program of research was to explore current practice. Three studies were conducted in this phase using both quantitative and qualitative research methods. The first was a qualitative explorative study of nurses’ perceptions of the issues and challenges associated with nurse-administered PSA in the CCL. Major themes emerged from analysis of the qualitative data regarding the lack of access to anaesthetists, the limitations of sedative medications, the barriers to effective patient monitoring and the impact that the increasing complexity of procedures has on patients' sedation requirements. The second study in Phase Two was a cross-sectional survey of nurse-administered PSA practice in Australian and New Zealand CCLs. This was the first study to quantify the frequency that nurse-administered PSA was used in the CCL setting and to characterise associated nursing practices. It was found that nearly all CCLs utilise nurse-administered PSA (94%). Of note, by characterising nurse-administered PSA in Australian and New Zealand CCLs, several strategies to improve practice, such as setting up protocols for patient monitoring and establishing comprehensive PSA education for CCL nurses, were identified. The third study in Phase Two was a matched case-control study of risk factors for impaired respiratory function during nurse-administered PSA in the CCL setting. Patients with acute illness were found to be nearly twice as likely to experience impaired respiratory function during nurse-administered PSA (OR=1.78; 95%CI=1.19-2.67; p=0.005). These significant findings can now be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered PSA in the CCL. The objective of the third and final phase of the program of research was to develop recommendations for practice. To achieve this objective, a synthesis of findings from the previous phases of the program of research informed a modified Delphi study, which was conducted to develop a set of clinical practice guidelines for nurse-administered PSA in the CCL. The clinical practice guidelines that were developed set current best practice standards for pre-procedural patient assessment and risk screening practices as well as the intra and post-procedural patient monitoring practices that nurses who administer PSA in the CCL should undertake in order to deliver safe, evidence-based and consistent care to the many patients who undergo procedures in this setting. In summary, the mixed methods approach that was used clearly enabled the research objectives to be comprehensively addressed in an informed sequential manner, and, as a consequence, this thesis has generated a substantial amount of new knowledge to inform and support nurse-led sedation practice in the CCL context. However, a limitation of the research to note is that the comprehensive appraisal of the evidence conducted, combined with the guideline development process, highlighted that there were numerous deficiencies in the evidence base. As such, rather than being based on high-level evidence, many of the recommendations for practice were produced by consensus. For this reason, further research is required in order to ascertain which specific practices result in the most optimal patient and health service outcomes. Therefore, along with necessary guideline implementation and evaluation projects, post-doctoral research is planned to follow up on the research gaps identified, which are planned to form part of a continuing program of research in this field.

Prolegomenon to the study of the concepts of maturity and maturity model : from Black Horse to White Knight?

This paper takes its root in a trivial observation: management approaches are unable to provide relevant guidelines to cope with uncertainty, and trust of our modern worlds. Thus, managers are looking for reducing uncertainty through information’s supported decision-making, sustained by ex-ante rationalization. They strive to achieve best possible solution, stability, predictability, and control of “future”. Hence, they turn to a plethora of “prescriptive panaceas”, and “management fads” to bring simple solutions through best practices. However, these solutions are ineffective. They address only one part of a system (e.g. an organization) instead of the whole. They miss the interactions and interdependencies with other parts leading to “suboptimization”. Further classical cause-effects investigations and researches are not very helpful to this regard. Where do we go from there? In this conversation, we want to challenge the assumptions supporting the traditional management approaches and shed some lights on the problem of management discourse fad using the concept of maturity and maturity models in the context of temporary organizations as support for reflexion. Global economy is characterized by use and development of standards and compliance to standards as a practice is said to enable better decision-making by managers in uncertainty, control complexity, and higher performance. Amongst the plethora of standards, organizational maturity and maturity models hold a specific place due to general belief in organizational performance as dependent variable of (business) processes continuous improvement, grounded on a kind of evolutionary metaphor. Our intention is neither to offer a new “evidence based management fad” for practitioners, nor to suggest research gap to scholars. Rather, we want to open an assumption-challenging conversation with regards to main stream approaches (neo-classical economics and organization theory), turning “our eyes away from the blinding light of eternal certitude towards the refracted world of turbid finitude” (Long, 2002, p. 44) generating what Bernstein has named “Cartesian Anxiety” (Bernstein, 1983, p. 18), and revisit the conceptualization of maturity and maturity models. We rely on conventions theory and a systemic-discursive perspective. These two lenses have both information & communication and self-producing systems as common threads. Furthermore the narrative approach is well suited to explore complex way of thinking about organizational phenomena as complex systems. This approach is relevant with our object of curiosity, i.e. the concept of maturity and maturity models, as maturity models (as standards) are discourses and systems of regulations. The main contribution of this conversation is that we suggest moving from a neo-classical “theory of the game” aiming at making the complex world simpler in playing the game, to a “theory of the rules of the game”, aiming at influencing and challenging the rules of the game constitutive of maturity models – conventions, governing systems – making compatible individual calculation and social context, and possible the coordination of relationships and cooperation between agents with or potentially divergent interests and values. A second contribution is the reconceptualization of maturity as structural coupling between conventions, rather than as an independent variable leading to organizational performance.

Generalized-positioning for mixed-frequency of mixed-GNSS and its preliminary applications

Modernized GPS and GLONASS, together with new GNSS systems, BeiDou and Galileo, offer code and phase ranging signals in three or more carriers. Traditionally, dual-frequency code and/or phase GPS measurements are linearly combined to eliminate effects of ionosphere delays in various positioning and analysis. This typical treatment method has imitations in processing signals at three or more frequencies from more than one system and can be hardly adapted itself to cope with the booming of various receivers with a broad variety of singles. In this contribution, a generalized-positioning model that the navigation system independent and the carrier number unrelated is promoted, which is suitable for both single- and multi-sites data processing. For the synchronization of different signals, uncalibrated signal delays (USD) are more generally defined to compensate the signal specific offsets in code and phase signals respectively. In addition, the ionospheric delays are included in the parameterization with an elaborate consideration. Based on the analysis of the algebraic structures, this generalized-positioning model is further refined with a set of proper constrains to regularize the datum deficiency of the observation equation system. With this new model, uncalibrated signal delays (USD) and ionospheric delays are derived for both GPS and BeiDou with a large dada set. Numerical results demonstrate that, with a limited number of stations, the uncalibrated code delays (UCD) are determinate to a precision of about 0.1 ns for GPS and 0.4 ns for BeiDou signals, while the uncalibrated phase delays (UPD) for L1 and L2 are generated with 37 stations evenly distributed in China for GPS with a consistency of about 0.3 cycle. Extra experiments concerning the performance of this novel model in point positioning with mixed-frequencies of mixed-constellations is analyzed, in which the USD parameters are fixed with our generated values. The results are evaluated in terms of both positioning accuracy and convergence time.

Limbal mesenchymal stromal cells (L-MSC) display immunosuppressive properties across donor and species boundaries

Purpose: We have evaluated the immunosuppressive properties of L-MSC with the view to using these cells in allogeneic cell therapies for corneal disorders. We hypothesized that L-MSC cultures would suppress T-cell activation, in a similar way to those established from human bone marrow (BM-MSC). Methods: MSC cultures were established from the limbal stroma of cadaveric donor eye tissue (up to 1 week postmortem) using either conventional serum-supplemented growth medium or a commercial serum-free medium optimized for bone marrow derived MSC (MesenCult-XF system). The MSC phenotype was examined by flow cytometry according to current and emerging markers for human MSC. Immunosuppressive properties were assessed using a mixed lymphocyte reaction (MLR) assay, whereby the white cell fraction from two immunologically incompatible blood donors are cultured together in direct contact with growth arrested MSC. T-cell activation (proliferation) was measured by uptake of tritiated thymidine. Human L-MSC were tested in parallel with human BM-MSC and rabbit L-MSC. Human and rabbit L-MSC were also tested for their ability to stimulate the growth of limbal epithelial (LE) cells in colony formation assays (for both human as well as rabbit LE cells). Results: L-MSC cultures were >95% negative for CD34, CD45 and HLA-DR and positive for CD73, CD90, CD105 and HLA-ABC. Modest levels (30%) of CD146 expression were observed for L-MSC cultures grown in serum-supplemented growth medium, but not those grown in MesenCult-XF. All MSC cultures derived from both human and rabbit tissue suppressed T-cell activation to varying degrees according to culture technique and species (MesenCult-XF >> serum-fed cultures, rabbit L-MSC >> human L-MSC). All L-MSC stimulated colony formation by LE cells irrespectively of the combination of cell species used. Conclusions: L-MSC display immunosuppressive qualities, in addition to their established non-immunogenic cell surface marker profile, and stimulate LE cell growth in vitro across species boundaries. These results support the potential use of allogeneic or even xenogeneic L-MSC in the treatment of corneal disorders.

Vision, Viability and Value: Three perspectives on the performing arts across cultures, context and nations

How can we reach out to institutions, artists and audiences with sometimes radically different agendas to encourage them to see, participate in and support the development of new practices and programs in the performing arts? In this paper, based on a plenary panel at PSi#18 Performance Culture Industry at the University of Leeds, Clarissa Ruiz (Columbia), AnuradhaKapur (India) and Sheena Wrigley (England) together with interloctorBree Hadley (Australia) speak about their work in as policy-makers, managers and producers in the performing arts in Europe, Asia and America over the past several decades. Acknowledged trailblazers in their fields, Ruiz, Kapur and Wrigley all have a commitment to creating a vital, viable and sustainable performing arts ecologies. Each has extensive experience in performance, politics, and the challenging process of managing histories, visions, stakeholders, and sometimes scarce resources to generate lasting benefits for the various communities have worked for, with and within. Their work, cultivating new initiatives, programs or policy has made them expert at brokering relationships in and in between private, public and political spheres to elevate the status of and support for performing arts as a socially and economically beneficial activity everyone can participate in. Each gives examples from their own practice to provide insight into how to negotiate the interests of artistic, government, corporate, community and education partners, and the interests of audiences, to create aesthetic, cultural and / or economic value. Together, their views offer a compelling set of perspectives on the changing meanings of the ‘value of the arts’ and the effects this has had for the artists that make and arts organisations that produce and present work in a range of different regional, national and cross-national contexts.

Feeding attitudes, practices and traditional dietary beliefs of Chinese mothers with young children in Australia : a mixed methods study

Background and Objectives Obesity and some dietary related diseases are emerging health problems among Chinese immigrants and their children in developed countries. These health problems are closely linked to eating habits, which are established in the early years of life. Young children’s eating habits are likely to persist into later childhood and youth. Family environment and parental feeding practices have a strong effect on young children’s eating habits. Little information is available on the early feeding practices of Chinese mothers in Australia. The aim of this study was to understand the dietary beliefs, feeding attitudes and practices of Chinese mothers with young children who were recent immigrants to Australia. Methods Using a sequential explanatory design, this mixed methods study consisted of two distinct phases. Phase 1 (quantitative): 254 Chinese immigrant mothers of children aged 12 to 59 months completed a cross-sectional survey. The psychometric properties and factor structure of a Chinese version of the Child Feeding Questionnaire (CFQ, by Birch et al. 2001) were assessed and used to measure specific maternal feeding attitudes and controlling feeding practices. Other questions were developed from the literature and used to explore maternal traditional dietary beliefs and feeding practices related to their beliefs, perceptions of picky eating in children and a range of socioeconomic and acculturation factors. Phase 2 (qualitative): 21 mothers took part in a follow-up telephone interview to assist in explaining and interpreting some significant findings obtained in the first phase. Results Chinese mothers held strong traditional dietary beliefs and fed their children according to these beliefs. However, children’s consumption of non-core foods was high. Both traditional Chinese and Australian style foods were consumed by their children. Confirmatory factor analysis revealed that the original 7-factor model of the CFQ provided an acceptable fit to the data with minor modification. However, an alternative model with eight constructs in which two items related to using food rewards were separated from the original restriction construct, not only provided an acceptable fit to the data, but also improved the conceptual clarity of the constructs. The latter model included 24 items loading onto the following eight constructs: restriction, pressure to eat, monitoring, use of food rewards, perceived responsibility, perception of own weight, perception of child’s weight, and concern about child becoming overweight. The internal consistency of the constructs was acceptable or desirable (Cronbach’s α = .60 - .93). Mothers reported low levels of concern about their child overeating or becoming overweight, but high levels of controlling feeding practices: restriction, monitoring, pressure to eat and use of food rewards. More than one quarter of mothers misinterpreted their child’s weight status (based on mothers’ self-reported data). In addition, mothers’ controlling feeding practices independently predicted half of the variance and explained 16% of the variance in child weight status: pressuring the child to eat was negatively associated with child weight status (β = -0.30, p < .01) and using food rewards was positively associated with child weight status (β = 0.20, p < .05) after adjusting for maternal and child covariates. Monitoring and restriction were not associated with child weight status. Mothers’ perceptions of their child’s weight were positively associated with child weight status (β = 0.33, p < .01). Moreover, mothers reported that they mostly decided what (65%) and how much (80%) food their child ate. Mothers who decided what food their child ate were more likely to monitor (β = -0.17, p < .05) and restrict (β = -0.17, p < .05) their child’s food consumption. Mothers who let their child decide how much food their child ate were less likely to pressure their child to eat (β = -0.38, p < .01) and use food rewards (β = -0.24, p < .01). Mothers’ perceptions of picky eating behaviour were positively associated with their use of pressure (β = 0.21, p < .01) and negatively associated with monitoring (β = -0.16, p < .05) and perceptions of their child’s weight status (β = -0.13, p < .05). Qualitative data showed that pressuring to eat, monitoring and restriction of the child’s food consumption were common practices among these mothers. However, mothers stated that their motivation for monitoring and restricting was to ensure the child’s general health. Mothers’ understandings of picky eating behaviour in their children were consistent with the literature and they reported multiple feeding strategies to deal with it. Conclusion Chinese immigrant mothers demonstrated strong traditional dietary beliefs, a low level of concern for child weight, misperceptions of child weight status, and a high overall level of control in child feeding in this study. The Chinese version of the CFQ, which consists of eight constructs and distinguishes between the constructs using food rewards and restriction, is an appropriate instrument to assess feeding attitudes and controlling feeding practices among Chinese immigrant mothers of young children in Australia. Mothers’ feeding attitudes and practices were associated with children’s weight status and mothers’ perceptions of picky eating behaviour in children after adjusting for a range of socio-demographic maternal and child characteristics. Monitoring and restriction of children’s food consumption according to food selection may be positive feeding practices, whereas pressuring to eat and using food rewards appeared to be negative feeding practices in this study. In addition, the results suggest that these young children have high exposure to energy-dense, nutrient-poor food. There is a need to develop and implement nutrition interventions to improve maternal feeding practices and the dietary quality among children of Chinese immigrant mothers in Australia.

Outdoor Worker Sun Protection Project : a mixed methods intervention to improve sun safety among outdoor workers

Queensland, Australia has one of the highest rates of skin cancer in the world. Outdoor workers are regularly exposed to high doses of ultraviolet radiation, and are at increased risk to develop non-melanoma and melanoma skin cancers. In 2010, a health promotion intervention to improve sun protection among outdoor workers in Queensland commenced. The intervention employed a mixed methods approach and a participatory action research framework. Fourteen workplaces were recruited from building and construction, rural and farming, local government, and public sector organisations. Management and workers were engaged in cycles of assessment, reflection and discussion, planning, implementation and reassessing, over a 14-month intervention period. Overall, at least one workplace representative from each workplace (range 1-3) and in depth focus groups were held with a subset of workers (range 3-16) to assess sun safe behaviours pre and post intervention. Workers’ attitudes, beliefs, knowledge and willingness to engage in sun protection differed depending on workplace characteristics and support. A familiar theme among workers spoke of sun safety as being “common sense” and the “workers individual responsibility”. Often there was a discrepancy in the perceptions of the workers, compared to the view of workplace representatives and the workplaces position or policy on sun safety. In larger workplaces, especially Government Departments, workers were more aware and followed sun safe practices compared to smaller workplaces where sun safety was not a high priority. These results indicate that a workplace culture which places high values on safety and polices more broadly may also have a positive effect on sun safety among outdoor workers as well. In addition, the specific characteristics of the workplace and the outdoor work tasks influence workers willingness to engage in sun safety measures.

Integrating Intangible Cultural Heritage elements and learning strategy : a case study

Tanzania has a rich and diverse cultural history based on community cultural life. However, at present, young people have limited opportunity to exploit this richness of creative expressions and engage in creative jobs as their future career. Hence, the significant challenge remains: how to integrate Intangible cultural heritage elements and learning strategy as a means of promoting creative jobs for youth. This paper presents a case study on 'Strategies for youth employment in Tanzania: A creative industries approach'. The case study employed mixed methods incorporating questionnaires, interviews and focus groups and was held in Dar-Es-Salaam, Mwanza, Dodoma, Lindi and Morogoro from July to October, 2012. This paper discusses some of the issues and argues that there is no virtual utilization of the intangible cultural heritage knowledge and skills in 'putting education to work' (UNESCO, 2012) for the better prospects of youth. Although the discussion is specific to Tanzania, the case may also apply to other developing countries.

Re-orientations : East Asian popular cultures in contemporary Vietnam

Vietnamese-Australians live in Australia, a large island continent. The physical contrast between Vietnam and Australia is remarked upon by many Vietnamese in their migration stories. Whereas Vietnam is remembered as an interlinked sensual and social world, Australia is often viewed as a harsh, spacious, empty, dry continent. Australia is located in a regional Asian context, but this location has always been culturally and politically problematic, as it historically attempted to define itself as a "white" European nation in the Southern Hemisphere (Ang, 2000, p. xiii; McNamara & Coughlan, 1997, p. 1). During the Gold Rush period in the late 1800s, when there was widespread opposition to Chinese labor, Australia implemented a "White Australia" policy, although there were historically a significant number of Australians of Asian background. This exclusionary immigration policy was effectively overturned in the 1970s with the acceptance of a large number of refugees from Vietnam, Cambodia, and Laos in 1975. Vietnamese-Australians live predominantly in urban areas with over three quarters living in Sydney and Melbourne, the two largest cities. Within these two cities they are also highly concentrated in ethnically diverse suburbs, most living in areas with more than 1,000 residents born in Vietnam (Viviani, 1996, p. 49). However, Jupp (Jupp et al., 1990; Jupp, 1993) has argued that these areas are also zones of transition, with much movement in and out.

Development and validation of an instrument to measure organizational cultures' support of business process management

The purpose of Business Process Management (BPM) is to increase the efficiency and effectiveness of organizational processes through improvement and innovation. Despite a common understanding that culture is an important element in these efforts, there is a dearth of theoretical and empirical research on culture as a facilitator of successful BPM. We develop the BPM culture construct and propose a validated instrument with which to measure organizational cultures’ support of BPM. The operationalization of the BPM culture concept provides a theoretical foundation for future research and a tool to assist organizations in developing a cultural environment that supports successful BPM.

Continuous monitoring of reservoir water quality: The Wivenhoe Project

The Lake Wivenhoe Integrated Wireless Sensor Network is conceptually similar to traditional SCADA monitoring and control approaches. However, it is applied in an open system using wireless devices to monitor processes that affect water quality at both a high spatial and temporal frequency. This monitoring assists scientists to better understand drivers of key processes that influence water quality and provide the operators with an early warning system if below standard water enters the reservoir. Both of these aspects improve the safety and efficient delivery of drinking water to the end users.

Continuous production of Bi-2212 thick film on silver tape

Bi-2212 thick film on silver tapes are seen as a simple and low cost alternative to high temperature superconducting wires produced by the Powder In Thbe (PIT) technique, particularly in react and wind applications. A rig for the continuous production of Bi-2212 tapes for use in react and wind component manufacture has been developed and commissioned. The rig consists of several sections, each fully automatic, for task specific duties in the production of HTS tape. The major sections are: tape coating, sintering and annealing. High temperature superconducting tapes with engineering critical current densities of 10 kA/cm2 (77 K, self field), and lengths of up to 100 m have been produced using the rig. Properties of the finished tape are discussed and results are presented for current density versus bend radius and applied strain. Depending on tape content and thickness, irreversible strain tirrm varies between 0.04 and 0.1 %. Cyclic bending tests when applied strain does not exceed Eirrm showed negligible reduction in J c along the length of the tape.

Continuous remote emissions monitoring – the lynchpin for air quality management

Diesel particulate matter (DPM), in particular, has been likened in a somewhat inflammatory manner to be the ‘next asbestos’. From the business change perspective, there are three areas holding the industry back from fully engaging with the issue: 1. There is no real feedback loop in any operational sense to assess the impact of investment or application of controls to manage diesel emissions. 2. DPM are getting ever smaller and more numerous, but there is no practical way of measuring them to regulate them in the field. Mass, the current basis of regulation, is becoming less and less relevant. 3. Diesel emissions management is generally wholly viewed as a cost, yet there are significant areas of benefit available from good management. This paper discusses a feedback approach to address these three areas to move the industry forward. The six main areas of benefit from providing a feedback loop by continuously monitoring diesel emissions have been identified: 1. Condition-based maintenance. Emissions change instantaneously if engine condition changes. 2. Operator performance. An operator can use a lot more fuel for little incremental work output through poor technique or discipline. 3. Vehicle utilisation. Operating hours achieved and ratios of idling to under power affect the proportion of emissions produced with no economic value. 4. Fuel efficiency. This allows visibility into other contributing configuration and environmental factors for the vehicle. 5. Emission rates. This allows scope to directly address the required ratio of ventilation to diesel emissions. 6. Total carbon emissions - for NGER-type reporting requirements, calculating the emissions individually from each vehicle rather than just reporting on fuel delivered to a site.