The status of Australian nurse practitioners : the first national census

A five-section questionnaire was mailed to all 234 authorised Australian nurse practitioners in late 2007. An 85% response rate was achieved (202 responses). Respondents had a mean age of 47.0 years and 84.2% were women. Only 145 nurse practitioners (72% of respondents) reported being employed in Australia at the time of the census. Emergency nurse practitioners were the most commonly employed nationally (26.9%). Nearly one third of employed nurse practitioners reported that they were still awaiting approval to prescribe medications despite this being a core legislated skill. Over 70% stated that lack of Medicare provider numbers and lack of authority to prescribe through the Pharmaceut ical Benef its Scheme was extremely limiting to their practice. These findings are consistent with the international literature describing establishment of reformative

Queensland Emergency Medical System : a structural and organizational model for the emergency medical system in Australia

Objective: The emergency medical system (EMS) can be defined as a comprehensive, coordinated and integrated system of care for patients suffering acute illness and injury. The aim of the present paper is to describe the evolution of the Queensland Emergency Medical System (QEMS) and to recommend a strategic national approach to EMS development. Methods: Following the formation of the Queensland Ambulance Service in 1991, a state EMS committee was formed. This committee led the development and approval of the cross portfolio QEMS policy framework that has resulted in dynamic policy development, system monitoring and evaluation. This framework is led by the Queensland Emergency Medical Services Advisory Committee. Results: There has been considerable progress in the development of all aspects of the EMS in Queensland. These developments have derived from the improved coordination and leadership that QEMS provides and has resulted in widespread satisfaction by both patients and stakeholders. Conclusions: The strategic approach outlined in the present paper offers a model for EMS arrangements throughout Australia. We propose that the Council of Australian Governments should require each state and Territory to maintain an EMS committee. These state EMS committees should have a broad portfolio of responsibilities. They should provide leadership and direction to the development of the EMS and ensure coordination and quality of outcomes. A national EMS committee with broad representation and broad scope should be established to coordinate the national development of Australia's EMS.

How does ambulance service utilisation impact demand for Emergency Departments in Queensland, Australia?

Background: There are indications that pre-hospital emergency care and management of patients can help reduce the demand for hospital emergency departments (EDs). Ambulance services play a significant role at this stage of care. In 2003, the Queensland Government introduced a Community Ambulance Cover (CAC) levy in return for a free ambulance service at the point of access to all Queenslanders. This may have led to the impression in consumers of an entitlement to free ambulance services under any circumstances regardless of the urgency of the matter which may have in turn contributed to the crowding of EDs in Queensland. Objectives: This paper aims to answer the following questions: - How many patients arrive at hospital EDs by ambulance in Queensland, compared to other modes of arrival? - How has this changed over time, particularly after the CAC introduction in 2003? What percentage of ambulance arrivals are urgent ED patients? - Has the perceived free ambulance services created extra demand for EDs in Queensland, compared with other Australian jurisdictions that charge patients for ambulance services? Methods: We will secondary analyse the data from sources such as Queensland Ambulance Services, Department of Health and Australian Bureau of Statistics to answer the research questions. Findings and Conclusions Queensland has the highest utilization rate of ambulance services (about 18% in 2007-08) and the highest annual growth rate in demand for these services (7.7% on average since 2000-01), well above the population growth. On the other hand, the proportion of ED patients arriving by ambulance in Queensland has increased by about 4% annually. However, when compared with other states and territories with charge at the point of access, it seems that the growth in demand for EDs cannot be explained solely or mainly by CAC or ambulance utilisation in Queensland.

Emergency department triage revisited

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

Conceptions of school based youth health nursing : a phenomenographic study

The School Based Youth Health Nurse Program was established in 1999 by the Queensland Government to fund school nurse positions in Queensland state high schools. Schools were required to apply for a School Based Youth Health Nurse during a five-phase recruitment process, managed by the health districts, and rolled out over four years. The only mandatory selection criterion for the position of School Based Youth Health Nurse was registration as a General Nurse and most School Based Youth Health Nurses are allocated to two state high schools. Currently, there are approximately 115 Full Time Equivalent School Based Youth Health Nurse positions across all Queensland state high schools. The literature review revealed an abundance of information about school nursing. Most of the literature came from the United Kingdom and the United States, who have a different model of school nursing to school based youth health nursing. However, there is literature to suggest school nursing is gradually moving from a disease-focused approach to a social view of health. The noticeable number of articles about, for example, drug and alcohol, mental health, and contemporary sexual health issues, is evidence of this change. Additionally, there is a significant the volume of literature about partnerships and collaboration, much of which is about health education, team teaching and how school nurses and schools do health business together. The surfacing of this literature is a good indication that school nursing is aligning with the broader national health priority areas. More particularly, the literature exposed a small but relevant and current body of research, predominantly from Queensland, about school based youth health nursing. However, there remain significant gaps in the knowledge about school based youth health nursing. In particular, there is a deficit about how School Based Youth Heath Nurses understand the experience of school based youth health nursing. This research aimed to reveal the meaning of the experience of school based youth health nursing. The research question was How do School Based Youth Health Nurses’ understand the experience of school based youth health nursing? This enquiry was instigated because the researcher, who had a positive experience of school based youth health nursing, considered it important to validate other School Based Youth Health Nurses’ experiences. Consequently, a comprehensive use of qualitative research was considered the most appropriate manner to explore this research question. Within this qualitative paradigm, the research framework consists of the epistemology of social constructionism, the theoretical perspective of interpretivism and the approach of phenomenography. After ethical approval was gained, purposeful and snowball sampling was used to recruit a sample of 16 participants. In-depth interviews, which were voluntary, confidential and anonymous, were mostly conducted in public venues and lasted from 40-75 minutes. The researcher also kept a researchers journal as another form of data collection. Data analysis was guided by Dahlgren and Fallsbergs’ (1991, p. 152) seven phases of data analysis which includes familiarization, condensation, comparison, grouping, articulating, labelling and contrasting. The most important finding in this research is the outcome space, which represents the entirety of the experience of school based youth health nursing. The outcome space consists of two components: inside the school environment and outside the school environment. Metaphorically and considered as whole-in-themselves, these two components are not discreet but intertwined with each other. The outcome space consists of eight categories. Each category of description is comprised of several sub-categories of description but as a whole, is a conception of school based youth health nursing. The eight conceptions of school based youth health nursing are: 1. The conception of school based youth health nursing as out there all by yourself. 2. The conception of school based youth health nursing as no real backup. 3. The conception of school based youth health nursing as confronted by many barriers. 4. The conception of school based youth health nursing as hectic and full-on. 5. The conception of school based youth health nursing as working together. 6. The conception of school based youth health nursing as belonging to school. 7. The conception of school based youth health nursing as treated the same as others. 8. The conception of school based youth health nursing as the reason it’s all worthwhile. These eight conceptions of school based youth health nursing are logically related and form a staged hierarchical relationship because they are not equally dependent on each other. The conceptions of school based youth health nursing are grouped according to negative, negative and positive and positive conceptions of school based youth health nursing. The conceptions of school based youth health nursing build on each other, from the bottom upwards, to reach the authorized, or the most desired, conception of school based youth health nursing. This research adds to the knowledge about school nursing in general but especially about school based youth health nursing specifically. Furthermore, this research has operational and strategic implications, highlighted in the negative conceptions of school based youth health nursing, for the School Based Youth Health Nurse Program. The researcher suggests the School Based Youth Health Nurse Program, as a priority, address the operational issues The researcher recommends a range of actions to tackle issues and problems associated with accommodation and information, consultations and referral pathways, confidentiality, health promotion and education, professional development, line management and School Based Youth Health Nurse Program support and school management and community. Strategically, the researcher proposes a variety of actions to address strategic issues, such as the School Based Youth Health Nurse Program vision, model and policy and practice framework, recruitment and retention rates and evaluation. Additionally, the researcher believes the findings of this research have the capacity to spawn a myriad of future research projects. The researcher has identified the most important areas for future research as confidentiality, information, qualifications and health outcomes.

Emergency department surge capacity : Recommendations of the Australasian surge strategy working group

Background For more than a decade emergency medicine organizations have produced guidelines, training and leadership for disaster management. However to date, there have been limited guidelines for emergency physicians needing to provide a rapid response to a surge in demand. The aim of this study is to identify strategies which may guide surge management in the Emergency Department. Method A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations. The Working Group identified underlying assumptions from epidemiological and empirical understanding and then identified remedial strategies from literature and from personal experience and collated these within domains of space, staff, supplies, and system operation. Findings These recommendations detail 22 potential actions available to an emergency physician working in the context of surge. The Working Group also provides detailed guidance on surge recognition, triage, patient flow through the emergency department and clinical goals and practices. Discussion These strategies provide guidance to emergency physicians confronting the challenges of a surge in demand. The paper also identifies areas that merit future research including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies and measurement of strategy impacts on throughput, cost, and quality of care.

Temperature variation and emergency hospital admissions for stroke in Brisbane, Australia, 1996-2005

Stroke is a leading cause of disability and death. This study evaluated the association between temperature variation and emergency admissions for stroke in Brisbane, Australia. Daily emergency admissions for stroke, meteorologic and air pollution data were obtained for the period of January 1996 to December 2005. The relative risk of emergency admissions for stroke was estimated with a generalized estimating equations (GEE) model. For primary intracerebral hemorrhage (PIH) emergency admissions, the average daily PIH for the group aged < 65 increased by 15% (95% Confidence Interval (CI): 5, 26%) and 12% (95% CI: 2, 22%) for a 1°C increase in daily maximum temperature and minimum temperature in summer, respectively, after controlling for potential confounding effects of humidity and air pollutants. For ischemic stroke (IS) emergency admissions, the average daily IS for the group aged ≥ 65 decreased by 3% (95% CI: -6, 0%) for a 1°C increase in daily maximum temperature in winter after adjustment for confounding factors. Temperature variation was significantly associated with emergency admissions for stroke, and its impact varied with different type of stroke. Health authorities should pay greater attention to possible increasing emergency care for strokes when temperature changes, in both summer and winter.

A grounded theory study of nursing students’ experiences in the off-campus clinical setting

Poor workplace relations are an issue of concern in many workplaces and this phenomenon is not restricted to the nursing profession. The issue of workplace violence in nursing is well documented and there are an increasing number of studies which have investigated the notion of horizontal violence amongst graduate nurses. The impact that poor workplace relations has on the development of a professional identity by nursing students in the off-campus clinical setting is significant in light of the current global shortage of nurses. There is a dearth of knowledge in understanding how Australian undergraduate nursing students experience the off-campus clinical setting and subsequently develop a professional identity as a nurse. Therefore the aim of this study was to discover and describe the phenomena in order to develop a substantive theory that explains the experiences of the undergraduate nursing students in a regional setting. Constructivist grounded theory methods were utilised in the conduct of the study. A sample of 29 participants was recruited permitting the formulation of a substantive theory regarding the development of a professional identity in nursing students. This substantive theory contributes knowledge relevant to the undergraduate nursing students, nurse educators, nursing workforce planners, and the tertiary educational institutions offering nursing. This is achieved through discovering, describing and explaining the phenomenon of ‘anxiety’ which the nursing students experience as a result of the interrelationship and interactions of tradition bearing, staff and student performance. These interactions intersect to form expectations of where the student fits within the hierarchy of the facility and the nursing profession in general. An understanding of the issues associated with tradition bearing, staff performance, and student performance and the impact that the interaction of these conditions has upon the student’s developing professional identity as a nurse is necessary to allow for the implementation of corrective strategies.

University and workplace culture : lifelong learning in nursing students

Lifelong learning in nursing is an essential if the individual is to remain a competent professional. It becomes apparent that whilst the university culture is supportive of the concept or lifelong learning, the workplace culture is not. Students are discouraged from challenging the norms despite a collaborative partnership that promotes lifelong learning.

The development and evaluation of an innovative nursing practice model to improve undergraduate nursing students' competence in paediatric physical assessment

Introduction The purpose of this study was to develop, implement and evaluate the impact of an educational intervention, comprising an innovative model of clinical decisionmaking and educational delivery strategy for facilitating nursing students‘ learning and development of competence in paediatric physical assessment practices. Background of the study Nursing students have an undergraduate education that aims to produce graduates of a generalist nature who demonstrate entry level competence for providing nursing care in a variety of health settings. Consistent with population morbidity and health care roles, paediatric nursing concepts typically form a comparatively small part of undergraduate curricula and students‘ exposure to paediatric physical assessment concepts and principles are brief. However, the nursing shortage has changed traditional nursing employment patterns and new graduates form the majority of the recruitment pool for paediatric nursing speciality staff. Paediatric nursing is a popular career choice for graduates and anecdotal evidence suggests that nursing students who select a clinical placement in their final year intend to seek employment in paediatrics upon graduation. Although concepts of paediatric nursing are included within undergraduate curriculum, students‘ ability to develop the required habits of mind to practice in what is still regarded as a speciality area of practice is somewhat limited. One of the areas of practice where this particularly impacts is in paediatric nursing physical assessment. Physical assessment is a fundamental component of nursing practice and competence in this area of practice is central to nursing students‘ development of clinical capability for practice as a registered nurse. Timely recognition of physiologic deterioration of patients is a key outcome of nurses‘ competent use of physical assessment strategies, regardless of the practice context. In paediatric nursing contexts children‘s physical assessment practices must specifically accommodate the child‘s different physiological composition, function and pattern of clinical deterioration (Hockenberry & Barrera, 2007). Thus, to effectively manage physical assessment of patients within the paediatric practice setting nursing students need to integrate paediatric nursing theory into their practice. This requires significant information processing and it is in this process where students are frequently challenged. The provision of rules or models can guide practice and assist novice-level nurses to develop their capabilities (Benner, 1984; Benner, Hooper-Kyriakidis & Stannard, 1999). Nursing practice models are cognitive tools that represent simplified patterns of expert analysis employing concepts that suit the limited reasoning of the inexperienced, and can represent the =rules‘ referred to by Benner (1984). Without a practice model of physical assessment students are likely to be uncertain about how to proceed with data collection, the interpretation of paediatric clinical findings and the appraisal of findings. These circumstances can result in ad hoc and unreliable nursing physical assessment that forms a poor basis for nursing decisions. The educational intervention developed as part of this study sought to resolve this problem and support nursing students‘ development of competence in paediatric physical assessment. Methods This study utilised the Context Input Process Product (CIPP) Model by Stufflebeam (2004) as the theoretical framework that underpinned the research design and evaluation methodology. Each of the four elements in the CIPP model were utilised to guide discrete stages of this study. The Context element informed design of the clinical decision-making process, the Paediatric Nursing Physical Assessment model. The Input element was utilised in appraising relevant literature, identifying an appropriate instructional methodology to facilitate learning and educational intervention delivery to undergraduate nursing students, and development of program content (the CD-ROM kit). Study One employed the Process element and used expert panel approaches to review and refine instructional methods, identifying potential barriers to obtaining an effective evaluation outcome. The Product element guided design and implementation of Study Two, which was conducted in two phases. Phase One employed a quasiexperimental between-subjects methodology to evaluate the impact of the educational intervention on nursing students‘ clinical performance and selfappraisal of practices in paediatric physical assessment. Phase Two employed a thematic analysis and explored the experiences and perspectives of a sample subgroup of nursing students who used the PNPA CD-ROM kit as preparation for paediatric clinical placement. Results Results from the Process review in Study One indicated that the prototype CDROM kit containing the PNPA model met the predetermined benchmarks for face validity and the impact evaluation instrumentation had adequate content validity in comparison with predetermined benchmarks. In the first phase of Study Two the educational intervention did not result in statistically significant differences in measures of student performance or self-appraisal of practice. However, in Phase Two qualitative commentary from students, and from the expert panel who reviewed the prototype CD-ROM kit (Study One, Phase One), strongly endorsed the quality of the intervention and its potential for supporting learning. This raises questions regarding transfer of learning and it is likely that, within this study, several factors have influenced students‘ transfer of learning from the educational intervention to the clinical practice environment, where outcomes were measured. Conclusion In summary, the educational intervention employed in this study provides insights into the potential e-learning approaches offer for delivering authentic learning experiences to undergraduate nursing students. Findings in this study raise important questions regarding possible pedagogical influences on learning outcomes, issues within the transfer of theory to practice and factors that may have influenced findings within the context of this study. This study makes a unique contribution to nursing education, specifically with respect to progressing an understanding of the challenges faced in employing instructive methods to impact upon nursing students‘ development of competence. The important contribution transfer of learning processes make to students‘ transition into the professional practice context and to their development of competence within the context of speciality practice is also highlighted. This study contributes to a greater awareness of the complexity of translating theoretical learning at undergraduate level into clinical practice, particularly within speciality contexts.

The intra-aortic balloon pump in heart failure management : implications for nursing practice

Management of acute heart failure is an important consideration in critical care. Mechanical support of the failing heart is crucial for improving health outcomes. The most common Australasian application of intraaortic balloon counterpulsation (IABP) is in the setting of cardiogenic shock. High end users of IABP (>37/annum) demonstrate significantly lower mortality for cardiogenic shock managed with IABP (p <0.001) in contrast to hospitals which employ limited IABP (<4/annum). This underscores the importance of proficiency in managing patient receiving IABP support. Nurses play a crucial role in carding for patients with acute heart failure. This paper summarises care considerations for management of the IABP.

Evaluation of contextual influences on the medication administration practice of paediatric nurses

Aim. This paper is a report of a study conducted to explore the impact of preidentified contextual themes (related to work environment and socialization) on nursing medication practice. Background. Medication administration is a complex aspect of paediatric nursing and an important component of day-to-day nursing practice. Many attempts are being made to improve patient safety, but many errors remain. Identifying and understanding factors that influence medication administration errors are of utmost importance. Method. A cross-sectional survey was conducted with a sample of 278 paediatric nurses from the emergency department, intensive care unit and medical and surgical wards of an Australian tertiary paediatric hospital in 2004. The response rate was 67%. Result. Contextual influences were important in determining how closely medication policy was followed. Completed questionnaires were returned by 185 nurses (67%). Younger nurses aged <34 years thought that their medication administration practice could be influenced by the person with whom they checked the drugs (P = 0·001), and that there were daily circumstances when it was acceptable not to adhere strictly to medication policy (P < 0·001), including choosing between following policy and acting in the best interests of the child (P = 0·002). Senior nurses agreed that senior staff dictate acceptable levels of medication policy adherence through role modelling (P = 0·01). Less experienced nurses reported greater confidence with computer literacy (P < 0·001). Conclusions. Organizations need to employ multidisciplinary education programmes to promote universal understanding of, and adherence to, medication policies. Skill mix should be closely monitored to ensure adequate support for new and junior staff.