The experience of being an advanced practice nurse within Australian acute care settings : a systematic review of qualitative evidence

Background There is a vast amount of international literature which, although agreeing on the need for advanced practice nurse roles, simultaneously debates and discusses the difficulties with nomenclature, definition and subsequent implementation of such roles. Due to this ambiguity it is difficult to equally compare evidence in this field across different countries. A context-specific systematic review on the qualitative evidence of the experience of being an advanced practice nurse in Australia has not been undertaken previously, however it is imperative for nursing managers and leaders to understand the complexities of advanced nursing roles in order to effectively utilise and retain these experienced and valuable nurses. With the creation of a national nursing regulating authority in 2010, it is timely to explore in-depth the experience of being an advanced practice nurse from a national perspective. Objective To identify the experience of being an advanced practice nurse working in Australian acute care settings. Inclusion criteria -Types of participants Registered nurses working in advanced practice roles in acute care settings throughout Australia. -Phenomena of interest The experience of being an advanced practice registered nurse working in an Australian acute care setting, as reported by the nurses themselves. -Types of studies Interpretive qualitative studies including designs such as phenomenology, grounded theory and ethnography. -Search strategy A three step search strategy was used to identify published and unpublished studies. The search process was conducted from August to October 2011 and considered published and unpublished studies from 1990 to October 2011. -Methodological quality Studies were appraised for methodological quality by two independent reviewers using the Joanna Briggs Qualitative Assessment and Review Instrument. -Data extraction Data was extracted from the papers included in the review using the standardised Joanna Briggs Institute Qualitative Assessment and Review Instrument data extraction tool. -Data synthesis Research findings were pooled using the Joanna Briggs Institute Qualitative Data and Review Instrument. Results Three published studies and one unpublished dissertation were included in the review. From these four studies, 216 findings were extracted, forming 18 categories which were then analysed to create six synthesised findings. Six meta-syntheses under the headings of expert knowledge, confidence, education, relationships, negative experiences and patient centred experience were formed from the findings. Conclusions The synthesised findings confirm that the experience of advanced practice nurses in Australian acute care settings is complex and greatly influenced personally and professionally by the organisation as well as the unpredictable nature of working with people.

Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : A modified Delphi study

Aim To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Background Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist presents means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances in which nurse-administered procedural sedation and analgesia is used in the cardiac catheterisation laboratory. Methods A sequential mixed methods design was utilised. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised in accordance with responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterisation laboratory nurses. All but one of the draft recommendations met the pre-determined cut-off point for inclusion. There were a total of 59 responses to the second round. Consensus was reached on all recommendations. Implications for nursing The guidelines that were derived from the Delphi study offer twenty four recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Post-procedural patient assessment and monitoring. Conclusion These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterisation laboratory setting.

Experience of being an advanced practice nurse within Australian acute care settings : a systematic review of qualitative evidence

Background Nationally and internationally, advanced practice nurses are working under various titles and in different contexts to address gaps within healthcare systems. Analysis of advanced practice roles in different countries has been undertaken, but due to variations in cultural, geographical and professional factors, it is difficult and perhaps ineffectual to compare roles between countries. Contextual factors may also affect the actual experience of being an advanced practice nurse. A systematic review was therefore undertaken of qualitative evidence on the experience of being an advanced practice nurse in Australia, to provide deeper understanding of the role in the defined context. Methods The review followed the method for qualitative synthesis as per the Joanna Briggs Institute. An extensive search was undertaken of databases and online resources to find published and unpublished studies. Papers from 1990 to October 2011 which met specified inclusion criteria were appraised using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Results Three published studies and one unpublished dissertation were included in the review. From these studies, 216 findings were extracted and these were formed into 18 categories. Six meta-syntheses grouped under the headings of expert knowledge, confidence, education, relationships, negative experiences and patient-centred experience were created. Organisational factors impact greatly on the experience, professionally and personally. Conclusions Heterogeneity of role titles makes synthesis a difficult process, but contextualising the population provides a pragmatic approach to informing the status of the advanced practice nurse discourse. The review identifies positive and negative experiences of being an advanced practice nurse in Australian acute care settings with overlapping and intertwining findings that reinforce the complexity of the role.

The role and contribution of the Queensland public sector employed nurse educator : a grounded theory study

This thesis applied a grounded theory methodology to generate a theoretical understanding of the challenging and ambiguous dimensions of the contemporary role of the public-sector nurse educator within Australia. New knowledge provides a useful structure to examine nurse educator support and mechanisms to foster constructive workplace learning, collaborative relationships and effective contributions to better health care.

School nurses and partnerships for health education : team teaching in the secondary school curricula

The purpose of this research is to examine School Based Youth Health Nurses experience of partnerships for health education and team teaching. The School Based Youth Health Nurse Program is a contemporary model of school nursing in Queensland, Australia. The role of the School Based Youth Health Nurse consists of individual health consultations and health promotion. This research analyses a subset of qualitative data collected for a larger project about the experience of school based youth health nursing. The Health Promoting Schools model is used as a deductive framework. The findings reveal five subthemes across the three areas of the Health Promoting Schools approach. There are two subthemes within the curriculum, teaching and learning area; We were on the same page so to speak and I can go and do my reports or whatever. There are two sub-themes within the partnerships and services area; I had a beautiful science teacher who was just delightful and really just wanted to do things in partnerships and It’s all airy fairy arty farty stuff that’s not important. There is one theme in the school organisation, ethos and environment area; I just don’t know how well the top of these organisations communicate with the bottom of those organisations. Successful partnerships for health education and team teaching between school nurses and teachers are based on personal relationships based on rapport which lead to trust and reciprocity. Partnerships are limited by teachers understanding of the role of the school nurse and engagement with school nurses in the classroom. Administrative support from the top down is fundamental.

The Nurse Practitioner Standards Project : Toolkit

"The aims of the project have been to conduct research that will inform a description of the core role of the nurse, core competency standards for the nurse and standards for education and program accreditation for nurse preparation leading to regsitration and authorisation. Includes Nurse Practitioner Standards Project: Toolkit, developed from the findings of the Nurse Practitioner standards research project. It presents standards related to Nurse Practitioner practice, education and authorisation/evaluation."--Libraries Australia

Clinical faculty : major contributors to the education of new CRNAs - Part 2

This study examines the important contributions of clinical faculty toward the education of the future workforce of Certified Registered Nurse Anesthetists (CRNAs). Differences in workload, work activities and income among clinical faculty, academic faculty and nonfaculty are examined. This is Part 2 of a 2-part column. Part 1, published in the April 2008 AANA Journal discussed salaries, recruitment, and retention of CRNA faculty.

The nurse's role in managing chemotherapy-induced nausea and vomiting

Background Nurses play a substantial role in the prevention and management of chemotherapy-induced nausea and vomiting (CINV). Objectives This study set out to describe nurses’ roles in the prevention and management of CINV and to identify any gaps that exist across countries. Methods A self-reported survey was completed by 458 registered nurses who administered chemotherapy to cancer patients in Australia, China, Hong Kong, and 9 Latin American countries. Results More than one-third of participants regarded their own knowledge of CINV as fair to poor. Most participants (>65%) agreed that chemotherapy-induced nausea and chemotherapy-induced vomiting should be considered separately (79%), but only 35% were confident in their ability to manage chemotherapy-induced nausea (53%) or chemotherapy-induced vomiting (59%). Only one-fifth reported frequent use of a standardized CINV assessment tool and only a quarter used international clinical guidelines to manage CINV. Conclusions Participants perceived their own knowledge of CINV management to be insufficient. They recognized the need to develop and use a standardized CINV assessment tool and the importance of adopting international guidelines to inform the management of CINV. Implications for Practice: Findings indicate that international guidelines should be made available to nurses in clinically relevant and easily accessible formats, that a review of chemotherapy assessment tools should be undertaken to identify reliable and valid measures amenable to use in a clinical settings, and that a CINV risk screening tool should be developed as a prompt for nurses to enable timely identification of and intervention for patients at high risk of CINV.

Degree of value alignment : a grounded theory of rural nurse resignations

INTRODUCTION: The shortage of nurses willing to work in rural Australian healthcare settings continues to worsen. Australian rural areas have a lower retention rate of nurses than metropolitan counterparts, with more remote communities experiencing an even higher turnover of nursing staff. When retention rates are lower, patient outcomes are known to be poorer. This article reports a study that sought to explore the reasons why registered nurses resign from rural hospitals in the state of New South Wales, Australia. METHODS: Using grounded theory methods, this study explored the reasons why registered nurses resigned from New South Wales rural hospitals. Data were collected from 12 participants using semi-structured interviews; each participant was a registered nurse who had resigned from a rural hospital. Nurses who had resigned due to retirement, relocation or maternity leave were excluded. Interviews were transcribed verbatim and imported into NVivo software. The constant comparative method of data collection and analysis was followed until a core category emerged. RESULTS: Nurses resigned from rural hospitals when their personal value of how nursing should occur conflicted with the hospital's organisational values driving the practice of nursing. These conflicting values led to a change in the degree of value alignment between the nurse and hospital. The degree of value alignment occurred in three dynamic stages that nurses moved through prior to resigning. The first stage, sharing values, was a time when a nurse and a hospital shared similar values. The second stage was conceding values where, due to perceived changes in a hospital's values, a nurse felt that patient care became compromised and this led to a divergence of values. The final stage was resigning, a stage where a nurse 'gave up' as they felt that their professional integrity was severely compromised. The findings revealed that when a nurse and organisational values were not aligned, conflict was created for a nurse about how they could perform nursing that aligned with their internalised professional values and integrity. Resignation occurred when nurses were unable to realign their personal values to changed organisational values - the organisational values changed due to rural area health service restructures, centralisation of budgets and resources, cumbersome hierarchies and management structures that inhibited communication and decision making, out-dated and ineffective operating systems, insufficient and inexperienced staff, bullying, and a lack of connectedness and shared vision. CONCLUSIONS: To fully comprehend rural nurse resignations, this study identified three stages that nurses move through prior to resignation. Effective retention strategies for the nursing workforce should address contributors to a decrease in value alignment and work towards encouraging the coalescence of nurses' and hospitals' values. It is imperative that strategies enable nurses to provide high quality patient care and promote a sense of connectedness and a shared vision between nurse and hospital. Senior managers need to have clear ways to articulate and imbue organisational values and be explicit in how these values accommodate nurses' values. Ward-level nurse managers have a significant responsibility to ensure that a hospital's values (both explicit and implicit) are incorporated into ward culture.

Profiling emergency nurse practitioner service

The aim of this study was to investigate the practice profile of emergency nurse practitioners across Australia. Nurse practitioners have been providing health service in the emergency setting internationally for more than 30 years, and evidence supports the value of this role in terms of patient satisfaction, effectiveness in improving service indicators, and acceptability of the role. The introduction of this service model has been instrumental in reducing waiting times for low-acuity patients and impacting positively on emergency department service delivery. Recent rapid uptake of this role internationally has outpaced development of the service model to inform education and ongoing service development. This was a national study that used interpretive research methods to identify the practice profile of emergency nurse practitioners. Data were collected from December 2012 to February 2013 through in-depth interviews. An inductive approach was used in data analysis to identify conceptual themes and develop an analysis framework. The study participants worked in a range of service models and managed patient presentations across all levels of acuity and complexity. The findings show that although there is no single definable model of the emergency nurse practitioner role in Australia, there are practice features that are common across all service models; these have been conceptualized as "modes of practice." This study has produced new knowledge about the practice profile of emergency nurse practitioners. The findings will inform development of practice standards for education and continuing professional development for emergency nurse practitioners and facilitate standardized operational definitions for ongoing research into this growing service model.

"Nursing is no place for men" ― A thematic analysis of male nursing students experiences of undergraduate nursing education

Background: Surprisingly, opinion about whether men are suitable within the profession continues to be a divided issue. Men enter the profession for a multitude of reasons, yet barriers whether emotional, verbal or sexual are still present. Aim: The aim of this study was to examine the experience of men “training” to be registered nurses within a regional New Zealand context. Design: A Narrative Analysis approach was used. Participants: Five New Zealand men currently undertaking their bachelor of nursing degree at a regional tertiary institute were interviewed as to their experiences of what it meant to be a man in “training”. Method: A thematic analysis was undertaken and guided by an understanding of the way personal narratives informs the human sciences especially within the context of nursing praxis. Four key themes were identified. Results: Four key themes were identified: A career with flexibility and promise; perceived gender inequality in providing care; developing professional boundaries with female colleagues and being unique has its advantages. Conclusion: The men in this study were attracted to the profession by career stability and advancement; the opportunities for travel also figured highly. At times they felt excluded and marginalised because of their minority status within their group and the feminine nature of the curriculum. The men attempted to dispel the myth around male nurse sexual stereotypes. Some of the students behaved in a manner to exert their heterosexualness. The students in this study sensed their vulnerability in choosing nursing as a career. However, all the participants saw nursing as viable and portable career in terms of advancement and travel.

Scoping study into wound management nurse practitioner models of practice

Objectives The primary objective of this research was to investigate wound management nurse practitioner (WMNP) models of service for the purposes of identifying parameters of practice and how patient outcomes are measured. Methods A scoping study was conducted with all authorised WMNPs in Australia from October to December 2012 using survey methodology. A questionnaire was developed to obtain data on the role and practice parameters of authorised WMNPs in Australia. The tool comprised seven sections and included a total of 59 questions. The questionnaire was distributed to all members of the WMNP Online Peer Review Group, to which it was anticipated the majority of WMNPs belonged. Results Twenty-one WMNPs responded (response rate 87%), with the results based on a subset of respondents who stated that, at the time of the questionnaire, they were employed as a WMNP, therefore yielding a response rate of 71% (n≤15). Most respondents (93%; n≤14) were employed in the public sector, with an average of 64 occasions of service per month. The typical length of a new case consultation was 60min, with 32min for follow ups. The most frequently performed activity was wound photography (83%; n≤12), patient, family or carer education (75%; n≤12), Doppler ankle-brachial pressure index assessment (58%; n≤12), conservative sharp wound debridement (58%; n≤12) and counselling (50%; n≤12). The most routinely prescribed medications were local anaesthetics (25%; n≤12) and oral antibiotics (25%; n≤12). Data were routinely collected by 91% of respondents on service-related and wound-related parameters to monitor patient outcomes, to justify and improve health services provided. Conclusion This study yielded important baseline information on this professional group, including data on patient problems managed, the types of interventions implemented, the resources used to accomplish outcomes and how outcomes are measured.

Education in stroke prevention: Efficacy of an educational counselling intervention to increase knowledge in stroke survivors

BACKGROUND Motivational interviewing and stages of change are approaches to increasing knowledge and effecting behavioural change. This study examined the application of this approach on stroke knowledge acquisition and changing individual lifestyle risk factors in an outpatient clinic. METHODS RCT in which 200 participants were allocated to an education-counselling interview (ECI) or a control group. ECI group participants mapped their individual risk factors on a stage of change model and received an appointment to the next group lifestyle class. Participants completed a stroke knowledge questionnaire at baseline (T1), post-appointment, and three months (T3) post-appointment. Passive to active changes in lifestyle behaviour were self-reported at three months. RESULTS There was a statistically significant difference between groups from T1 toT3 in stroke knowledge (p < 0.001). While there was a significant shift from a passive to active stage of change for the overall study sample (p < 0.000), there was no significant difference between groups on the identified risk factors. CONCLUSIONS Although contact with patients in ambulatory clinical settings is limited due to time constraints, it is still possible to improve knowledge and initiate lifestyle changes utilizing motivational interviewing and a stage of change model. Stroke nurses may wish to consider these techniques in their practice setting.

PW376 A pilot study of a post-discharge nurse-led, educational intervention on cardiac self-efficacy and anxiety in post-PCI patients

Introduction Hospitalisation for percutaneous coronary intervention (PCI) is often short, with limited nurse-teaching time and poor information absorption. Currently, patients are discharged home only to wait up to 4-8 weeks to commence a secondary prevention program and visit their cardiologist. This wait is an anxious time for patients and confidence or self-efficacy (SE) to self-manage may be low. Objectives To determine the effects of a nurse-led, educational intervention on participant SE and anxiety in the early post-discharge period. Methods A pilot study was undertaken as a randomised controlled clinical trial. Thirty-three participants were recruited, with n=13 randomised to the intervention group. A face-to-face, nurse-led, educational intervention was undertaken within the first 5-7 days post-discharge. Intervention group participants received standard post-discharge education, physical assessment, with a strong focus on the emotional impact of cardiovascular events and PCI. Early reiteration of post-discharge education was offered, along with health professional support with the aim to increase patients’ SE and to effectively manage their post-discharge health and well being, as well as anxieties. Self-efficacy to return to normal activities was measured to gauge participants’ abilities to manage post-PCI after attending the intervention using the cardiac self-efficacy (CSE) scale. State and trait anxiety was also measured using the State-Trait Anxiety Inventory (STAI) to determine if an increase in SE would influence participant anxiety. Results There were some increases in mean CSE scores in the intervention group participants over time. Areas of increase included return to normal social activities and confidence to change diet. Although reductions were observed in mean state and trait anxiety scores in both groups, an overall larger reduction in intervention group participants was observed over time. Conclusion It is essential that patients are given the education, support, and skills to self-manage in the early post-discharge period so that they have greater SE and are less anxious. This study provides some initial evidence that nurse-led support and education during this period, particularly the first week following PCI, is beneficial and could be trialled using alternate modes of communication to support remote and rural PCI patients and extend to other cardiovascular patients.