Have you got what it takes? Nursing in a Psychiatric Intensive Care Unit

Purpose A Psychiatric Intensive Care Unit (PICU) and or High Dependency Unit (HDU) is a locked, intensive treatment facility available to people experiencing acute psychiatric distress. For many people who access public mental health services in Australia, the PICU/HDU is the primary point of admission, and should represent and facilitate timely assessment and an optimum treatment plan under a recovery framework. Nurses are the largest health discipline working in this specialty area of care. The paper aims to discuss these issues. Design/methodology/approach A qualitative study aimed to investigate the skills, experience, and practice, of nurses working in the PICU/HDU in relation to a recovery model of care. Identifying how nurses provide care in the PICU/HDU will inform a clinical practice guideline to further support this specialty area of care. Four focus groups were facilitated with 52 registered nurses attending. Findings The nurse participants identified specific skills under four distinct themes; Storytelling, Treatment and recovery, Taking responsibility, and Safeguarding. The skills highlight the expertise and clinical standard required to support a recovery model of care in the PICU. Research limitations/implications – The research findings highlight urgency for a National PICU/HDU clinical practice guideline. Practical implications A PICU/HDU practice guideline will promote the standard of nursing care required in the PICU/HDU. The PICU/HDU needs to be recognised as a patient centred, therapeutic opportunity as opposed to a restrictive and custodial clinical area. Social implications Providing transparency of practice in the PICU/HDU and educating nurses to this specialty area of care will improve client outcome and recovery. Originality/value Very few studies have explored the skills, experience, and practice, of nurses working in the PICU/HDU in relation to a recovery model of care. A dearth of research exists on what is required to work in this specialty area of care.

The experience of forging new emergency nursing curriculum development, through a course advisory network

Queensland University of Technology (QUT), School of Nursing (SoN), has offered a postgraduate Graduate Certificate in Emergency Nursing since 2003, for registered nurses practising in an emergency clinical area, who fulfil key entry criteria. Feedback from industry partners and students evidenced support for flexible and extended study pathways in emergency nursing. Therefore, in the context of a growing demand for emergency health services and the need for specialist qualified staff, it was timely to review and redevelop our emergency specialist nursing courses. The QUT postgraduate emergency nursing study area is supported by a course advisory group, whose aim is to provide input and focus development of current and future course planning. All members of the course advisory were invited to form an expert panel to review current emergency course documents. A half day “brainstorm session”, planning and development workshop was held to review the emergency courses to implement changes from 2009. Results from the expert panel planning day include: proposal for a new emergency specialty unit; incorporation of the College of Emergency Nurses (CENA) Standards for Emergency Nursing Specialist in clinical assessment; modification of the present core emergency unit; enhancing the focus of the two other units that emergency students undertake; and opening the emergency study area to the Graduate Diploma in Nursing (Emergency Nursing) and Master of Nursing (Emergency Nursing). The conclusion of the brainstorm session resulted in a clearer conceptualisation, of the study pathway for students. Overall, the expert panel group of enthusiastic emergency educators and clinicians provided viable options for extending the career progression opportunities for emergency nurses. In concluding, the opportunity for collaboration across university and clinical settings has resulted in the design of a course with exciting potential and strong clinical relevance.

Male nursing students in training: A comparative analysis of hidden advantage and discrimination

Aim The aim of this study was to examine the lived experience of men training to be registered nurses within a regional New Zealand context. Design This study draws upon the key principles of descriptive phenomenology. Sample Five male students enrolled from the 1st and 3rd year of the BN programme. Findings - A Career with Prospects - Gender inequality by superiors; - Developing professional boundaries with female colleagues; - Being unique has its advantages.

Nursing physical assessment for patient safety in general wards: Reaching consensus on core skills

Aims and objectives To determine consensus across acute care specialty areas on core physical assessment skills necessary for early recognition of changes in patient status in general wards. Background Current approaches to physical assessment are inconsistent and have not evolved to meet increased patient and system demands. New models of nursing assessment are needed in general wards that ensure a proactive and patient safety approach. Design A modified Delphi study. Methods Focus group interviews with 150 acute care registered nurses (RNs) at a large tertiary referral hospital generated a framework of core skills that were developed into a web-based survey. We then sought consensus with a panel of 35 senior acute care RNs following a classical Delphi approach over three rounds. Consensus was predefined as at least 80% agreement for each skill across specialty areas. Results Content analysis of focus group transcripts identified 40 discrete core physical assessment skills. In the Delphi rounds, 16 of these were consensus validated as core skills and were conceptually aligned with the primary survey: (Airway) Assess airway patency; (Breathing) Measure respiratory rate, Evaluate work of breathing, Measure oxygen saturation; (Circulation) Palpate pulse rate and rhythm, Measure blood pressure by auscultation, Assess urine output; (Disability) Assess level of consciousness, Evaluate speech, Assess for pain; (Exposure) Measure body temperature, Inspect skin integrity, Inspect and palpate skin for signs of pressure injury, Observe any wounds, dressings, drains and invasive lines, Observe ability to transfer and mobilise, Assess bowel movements. Conclusions Among a large and diverse group of experienced acute care RNs consensus was achieved on a structured core physical assessment to detect early changes in patient status. Relevance to clinical practice Although further research is needed to refine the model, clinical application should promote systematic assessment and clinical reasoning at the bedside.

Integration of clinical information systems in Saudi Arabian health care contexts: A grounded theory exploration

This research examined the implementation of clinical information system technology in a large Saudi Arabian health care organisation. The research was underpinned by symbolic interactionism and grounded theory methods informed data collection and analysis. Observations, a review of policy documents and 38 interviews with registered nurses produced in-depth data. Analysis generated three abstracted concepts that explained how imported technology increased practice and health care complexity rather than enhance quality patient care. The core category, Disseminating Change, also depicted a hierarchical and patriarchal culture that shaped the implementation process at the levels of government, organisation and the individual.

Identifying advanced practice: A national survey of a nursing workforce

Background The size and flexibility of the nursing workforce has positioned nursing as central to the goals of health service improvement. Nursing's response to meeting these goals has resulted in proliferation of advanced practice nursing with a confusing array of practice profiles, titles and roles. Whilst numerous models and definitions of advanced practice nursing have been developed there is scant published research of significant scope that supports these models. Consequently there is an ongoing call in the literature for clarity and stability in nomenclature, and confusion in the health industry on how to optimise the utility of advanced practice nursing. Objectives To identify and delineate advanced practice from other levels of nursing practice through examination of a national nursing workforce. Design A cross-sectional electronic survey of nurses using the validated Advanced Practice Role Delineation tool based on the Strong Model of Advanced Practice. Participants Study participants were registered nurses employed in a clinical service environment across all states and territories of Australia. Methods A sample of 5662 registered nurses participated in the study. Domain means for each participant were calculated then means for nursing position titles were calculated. Position titles were grouped by delineation and were compared with one-way analysis of variance on domain means. The alpha for all tests was set at 0.05. Significant effects were examined with Scheffe post hoc comparisons to control for Type 1 error. Results The survey tool was able to identify position titles where nurses were practicing at an advanced level and to delineate this cohort from other levels of nursing practice, including nurse practitioner. The results show that nurses who practice at an advanced level are characterised by high mean scores across all Domains of the Strong Model of Advanced Practice. The mean scores of advanced practice nurses were significantly different from nurse practitioners in the Direct Care Domain and significantly different from other levels of nurse across all domains. Conclusions The study results show that the nurse practitioner, advanced practice nurse and foundation level registered nurse have different patterns of practice and the Advanced Practice Role Delineation tool has the capacity to clearly delineate and define advanced practice nursing. These findings make a significant contribution to the international debate and show that the profession can now identify what is and what is not advanced practice in nursing.

Towards an understanding of the information dynamics of the handover process in aged care settings: A prerequisite for the safe and effective use of ICT

Background Poor clinical handover has been associated with inaccurate clinical assessment and diagnosis, delays in diagnosis and test ordering, medication errors and decreased patient satisfaction in the acute care setting. Research on the handover process in the residential aged care sector is very limited. Purpose The aims of this study were to: (i) Develop an in-depth understanding of the handover process in aged care by mapping all the key activities and their information dynamics, (ii) Identify gaps in information exchange in the handover process and analyze implications for resident safety, (iii) Develop practical recommendations on how information communication technology (ICT) can improve the process and resident safety. Methods The study was undertaken at a large metropolitan facility in NSW with more than 300 residents and a staff including 55 registered nurses (RNs) and 146 assistants in nursing (AINs). A total of 3 focus groups, 12 interviews and 3 observation sessions were conducted over a period from July to October 2010. Process mapping was undertaken by translating the qualitative data via a five-category code book that was developed prior to the analysis. Results Three major sub-processes were identified and mapped. The three major stages are Handover process (HOP) I “Information gathering by RN”, HOP II “Preparation of preliminary handover sheet” and HOP III “Execution of handover meeting”. Inefficient processes were identified in relation to the handover including duplication of information, utilization of multiple communication modes and information sources, and lack of standardization. Conclusion By providing a robust process model of handover this study has made two critical contributions to research in aged care: (i) a means to identify important, possibly suboptimal practices; and (ii) valuable evidence to plan and improve ICT implementation in residential aged care. The mapping of this process enabled analysis of gaps in information flow and potential impacts on resident safety. In addition it offers the basis for further studies into a process that, despite its importance for securing resident safety and continuity of care, lacks research.

Air evacuation in war : the role of RAAF nurses undertaking air evacuation of casualties between 1943-1953

Air transportation of Australian casualties in World War II was initially carried out in air ambulances with an accompanying male medical orderly. By late 1943 with the war effort concentrated in the Pacific, Allied military authorities realised that air transport was needed to move the increasing numbers of casualties over longer distances. The Royal Australian Air Force (RAAF) became responsible for air evacuation of Australian casualties and established a formal medical air evacuation system with trained flight teams early in 1944. Specialised Medical Air Evacuation Transport Units (MAETUs) were established whose sole responsibility was undertaking air evacuations of Australian casualties from the forward operational areas back to definitive medical care. Flight teams consisting of a RAAF nursing sister (registered nurse) and a medical orderly carried out the escort duties. These personnel had been specially trained in Australia for their role. Post-WWII, the RAAF Nursing Service was demobilised with a limited number of nurses being retained for the Interim Air Force. Subsequently, those nurses were offered commissions in the Permanent Air Force. Some of the nurses who remained were air evacuation trained and carried out air evacuations both in Australia and as part of the British Commonwealth Occupation Force in Japan. With the outbreak of the Korean War in June 1950, Australia became responsible for the air evacuation of British Commonwealth casualties from Korea to Japan. With a re-organisation of the Australian forces as part of the British Commonwealth forces, RAAF nurses were posted to undertake air evacuation from Korea and back to Australia from Iwakuni, Japan. By 1952, a specialised casualty staging section was established in Seoul and staffed by RAAF nurses from Iwakuni on a rotation basis. The development of the Australian air evacuation system and the role of the flight nurses are not well documented for the period 1943-1953. The aims of this research are three fold and include documenting the origins and development of the air evacuation system from 1943-1953; analysing and documenting the RAAF nurse’s role and exploring whether any influences or lessons remain valid today. A traditional historical methodology of narrative and then analysis was used to inform the flight nurse’s role within the totality of the social system. Evidence was based on primary data sources mainly held in Defence files, the Australian War Memorial or the National Archives of Australia. Interviews with 12 ex-RAAF nurses from both WWII and the Korean War were conducted to provide information where there were gaps in the primary data and to enable exploration of the flight nurses’ role and their contributions in war of the air evacuation of casualties. Finally, this thesis highlights two lessons that remain valid today. The first is that interoperability of air evacuation systems with other nations is a force multiplier when resources are scarce or limited. Second, the pre-flight assessment of patients was essential and ensured that there were no deaths in-flight.

Competency Standards and Educational Requirements for Specialist Breast Nurses in Australia

There is substantial evidence that Specialist Breast Nurses (SBNs) make an important contribution to improved outcomes for women with breast cancer, by providing information and support and promoting continuity of care. However, a recent study has identified significant variation in how the role functions across individual nurses and settings, which is likely to contribute to varied outcomes for women with breast cancer. The project reported in this paper illustrates how a set of competency standards for SBNs were developed by the National Breast Cancer Centre. The competency standards were developed through a review of published literature and consultation with key stakeholders. The resulting SBN Competency Standards reflect the core domains and elements of SBN practice seen as integral to achieving optimal outcomes for women with breast cancer. This project identifies the SBN as a registered nurse who applies advanced knowledge of the health needs, preferences and circumstances of women with breast cancer to optimise the individual's health and well-being at various phases across the continuum of care, including diagnosis, treatment, rehabilitation, follow-up and palliative care. The five core domains of practice identified are: Supportive care; Collaborative care; Coordinated care; Information provision and education; and Clinical leadership. A variety of education programs are currently available for nurses who wish to learn about breast cancer nursing. The majority of stakeholders consulted in this project agreed that a Graduate Diploma level of education is required at minimum in order for an SBN to develop the minimum level of competence required to perform the role. The evidence supports the view that as an advanced role, nurses practising as SBNs require high-quality programs of sufficient depth and scope to achieve the required level of competence

An investigation of foot and ankle problems experienced by nurses

Relatively little information has been reported about foot and ankle problems experienced by nurses, despite anecdotal evidence which suggests they are common ailments. The purpose of this study was to improve knowledge about the prevalence of foot and ankle musculoskeletal disorders (MSDs) and to explore relationships between these MSDs and proposed risk factors. A review of the literature relating to work-related MSDs, MSDs in nursing, foot and lower-limb MSDs, screening for work-related MSDs, foot discomfort, footwear and the prevalence of foot problems in the community was undertaken. Based on the review, theoretical risk factors were proposed that pertained to the individual characteristics of the nurses, their work activity or their work environment. Three studies were then undertaken. A cross-sectional survey of 304 nurses, working in a large tertiary paediatric hospital, established the prevalence of foot and ankle MSDs. The survey collected information about self-reported risk factors of interest. The second study involved the clinical examination of a subgroup of 40 nurses, to examine changes in body discomfort, foot discomfort and postural sway over the course of a single work shift. Objective measurements of additional risk factors, such as individual foot posture (arch index) and the hardness of shoe midsoles, were performed. A final study was used to confirm the test-retest reliability of important aspects of the survey and key clinical measurements. Foot and ankle problems were the most common MSDs experienced by nurses in the preceding seven days (42.7% of nurses). They were the second most common MSDs to cause disability in the last 12 months (17.4% of nurses), and the third most common MSDs experienced by nurses in the last 12 months (54% of nurses). Substantial foot discomfort (Visual Analogue Scale (VAS) score of 50mm or more) was experienced by 48.5% of nurses at sometime in the last 12 months. Individual risk factors, such as obesity and the number of self-reported foot conditions (e.g., callouses, curled toes, flat feet) were strongly associated with the likelihood of experiencing foot problems in the last seven days or during the last 12 months. These risk factors showed consistent associations with disabling foot conditions and substantial foot discomfort. Some of these associations were dependent upon work-related risk factors, such as the location within the hospital and the average hours worked per week. Working in the intensive care unit was associated with higher odds of experiencing foot problems within the last seven days, foot problems in the last 12 months and foot problems that impaired activity in the last 12 months. Changes in foot discomfort experienced within a day, showed large individual variability. Fifteen of the forty nurses experienced moderate/substantial foot discomfort at the end of their shift (VAS 25+mm). Analysis of the association between risk factors and moderate/substantial foot discomfort revealed that foot discomfort was less likely for nurses who were older, had greater BMI or had lower foot arches, as indicated by higher arch index scores. The nurses’ postural sway decreased over the course of the work shift, suggesting improved body balance by the end of the day. These findings were unexpected. Further clinical studies examining individual nurses on several work shifts are needed to confirm these results, particularly due to the small sample size and the single measurement occasion. There are more than 280,000 nurses registered to practice in Australia. The nursing workforce is ageing and the prevalence of foot problems will increase. If the prevalence estimates from this study are extrapolated to the profession generally, more than 70,000 hospital nurses have experienced substantial foot discomfort and 25-30,000 hospital nurses have been limited in their activity due to foot problems during the last 12 months. Nurses with underlying foot conditions were more likely to report having foot problems at work. Strategies to prevent or manage foot conditions exist and they should be disseminated to nurses. Obesity is a significant risk factor for foot and ankle MSDs and these nurses may need particular assistance to manage foot problems. The risk of foot problems for particular groups of nurses, e.g. obese nurses, may vary depending upon the location within the hospital. Further research is needed to confirm the findings of this study. Similar studies should be conducted in other occupational groups that require workers to stand for prolonged periods.

A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United Kingdom

Objective The aim of this study was to examine the prevalence of overweight and obesity and the association with demographic, reproductive work variables in a representative cohort of working nurses and midwives. Design A cross sectional study of self reported survey data. Settings Australia, New Zealand and the United Kingdom. Methods Measurement outcomes included BMI categories, demographic (age, gender, marital status, ethnicity), reproductive (parity, number of births, mother's age at first birth, birth type and menopausal status) and workforce (registration council, employment type and principal specialty) variables. Participants 4996 respondents to the Nurses and Midwives e-Cohort study who were currently registered and working in nursing or midwifery in Australia (n=3144), New Zealand (n=778) or the United Kingdom (n=1074). Results Amongst the sample 61.87% were outside the healthy weight range and across all three jurisdictions the prevalence of obesity in nurses and midwives exceeded rates in the source populations by 1.73% up to 3.74%. Being overweight or obese was significantly associated with increasing age (35–44 yrs aOR 1.71, 95% CI 1.41–2.08; 45–55 yrs aOR 1.90, 95%CI 1.56–2.31; 55–64 aOR 2.22, 95% CI 1.71–2.88), and male gender (aOR 1.46, 95% CI 1.15–1.87). Primiparous nurses and midwives were more likely to be overweight or obese (aOR 1.37, 95% CI 1.06–1.76) as were those who had reached menopause (aOR 1.37, 95% CI 1.11–1.69). Nurses and midwives in part-time or casual employment had significantly reduced risk of being overweight or obese, (aOR 0.81, 95% CI 0.70–0.94 and aOR 0.75, 95% CI 0.59–0.96 respectively), whilst working in aged carried increased risk (aOR 1.37, 95% CI 1.04–1.80). Conclusion Nurses and midwives in this study have higher prevalence of obesity and overweight than the general population and those who are older, male, or female primiparous and menopausal have significantly higher risk of overweight or obesity as do those working fulltime, or in aged care. The consequences of overweight and obesity in this occupational group may impact on their workforce participation, their management of overweight and obese patients in their care as well as influencing their individual health behaviours and risks of occupational injury and chronic disease.

The Levels of Job Satisfaction, Stress and Burnout In Australian and New Zealand Haemodialysis Nurses

Background: Job dissatisfaction, stress and burnout is linked to high rates of nurses leaving the profession, poor morale, poor patient outcomes and increased financial expenditure. Haemodialysis nurses find their work satisfying although it can be stressful. Little is known, however, about job satisfaction, stress or burnout levels of haemodialysis nurses in Australia and New Zealand. Aims: To assess the current levels of job satisfaction, stress, burnout and nurses’ perception of the haemodialysis work environment. Methods: An observational study involved a cross-sectional sample of 417 registered or enrolled nurses working in Australian or New Zealand haemodialysis units. Data was collected using an on-line questionnaire containing demographic and work characteristics as well as validated measures of job satisfaction, stress, burnout and the work environment Results: 74% of respondents were aged over 40 and 75% had more than six years of haemodialysis nursing experience. Job satisfaction levels were comparable to studies in other practice areas with higher satisfaction derived from professional status and interactions with colleagues. Despite nurses viewing their work environment favourably, moderate levels of burnout were noted with frequent stressors related to workload and patient death and dying. Interestingly there were no differences found between the type or location of dialysis unit. Conclusion: Despite acceptable levels of job satisfaction and burnout, stress with workloads and facets of patient care were found. Understanding the factors that contribute to job satisfaction, stress and burnout can impact the healthcare system through decreased costs by retaining valued staff and through improved patient care.

Australian nurses volunteering for the Sumatra-Andaman earthquake and tsunami of 2004 : a review of experience and analysis of data collected by the Tsunami Volunteer Hotline

This paper provides an outline of the work undertaken by nurses who participated in the relief effort as members of Australian medical teams during the Sumatra-Andaman earthquake and tsunami response. This profile is contrasted with the information provided by nurses who registered their interest in volunteering to help via the Australian Tsunami Hotline. The paper provides an overview of the skills and background of the nurses who provided information to the hotline and describes the range and extent of experience among this cohort of potential volunteers. This data is compared to nursing workforce data and internal rates of volunteering in Australia. The paper concludes that further research is necessary to examine the motivations of and disincentives for nurses to volunteer for overseas (disaster) work and, to develop an improved understanding within the discipline of the skills and experience required of volunteer responders. Further, it is argued that the development of standards for the collection of disaster health volunteer data would assist future responses and provide better tools for developing an improved understanding of disaster volunteering.