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.

Valuing student and community voices in the university : action research as a framework for community service-learning

The Community Service-learning Lab (the Lab) was initiated as a university-wide service-learning experience at an Australian university. The Lab engages students, academics, and key community organisations in interdisciplinary action research projects to support student learning and to explore complex and ongoing problems nominated by the community partners. The current study uses feedback from the first offering of the Lab and focuses on exploring student experiences of the service learning project using an action research framework. Student reflections on this experience have revealed some positive outcomes of the Lab such as an appreciation for positive and strengths-based change. These outcomes are corroborated by collected reflections from community partners and academics. The students also identified challenges balancing the requirements for assessment and their goals to serve the community partner’s needs. This feedback has provided vital information for the academic team, highlighting the difficulties in balancing the agenda of the academic framework and the desire to give students authentic experiences.

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.

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.

The voices of the exegesis : Composing the speech genres of the practitioner-researcher into a connective thesis

Postgraduate candidates in the creative arts encounter unique challenges when writing an exegesis (the written document that accompanies creative work as a thesis). As a practitioner-researcher, they must adopt a dual perspective–looking out towards an established field of research, exemplars and theories, as well as inwards towards their experiential creative processes and practice. This dual orientation provides clear benefits, for it enables them to situate the research within its field and make objective claims for the research methodologies and outcomes while maintaining an intimate, voiced relationship with the practice. However, a dual orientation introduces considerable complexities in the writing. It requires a reconciliation of multi-perspectival subject positions: the disinterested academic posture of the observer/ethnographer/analyst/theorist at times; and the invested, subjective stance the practitioner/producer at others. It requires the author to negotiate a range of writing styles and speech genres–from the formal, polemical style of the theorist to the personal, questioning and emotive voice of reflexivity. Moreover, these multi-variant orientations, subject positions, styles and voices must be integrated into a unified and coherent text. In this chapter I offer a conceptual framework and strategies for approaching this relatively new genre of thesis. I begin by summarizing the characteristics of what has begun to emerge as the predominant model of exegesis (the dual-oriented ‘Connective’ exegesis). Framing it against theoretical and philosophical understandings of polyvocality and matrixicality, I go on to point to recent textual models that provide precedents for connecting differently oriented perspectives, subjectivities and voices. I then turn to emergent archives of practice-led research to explain how the challenge of writing a ‘Connective’ exegesis has so far been resolved by higher degree research (HDR) candidates. Exemplars illustrate a range of strategies they have used to compose a multi-perspectival text, reconcile the divergent subject positions of the practitioner researcher, and harmonize the speech genres of a ployvocal text.

Cultural inhibitors to hearing the voices of child sexual abuse by church personnel

It is increasingly recognised that Christian Churches and their Institutions have historically been sites where the voices of survivors of child sexual abuse (csa) by Church personnel have not been effectively heard. This paper draws on data from a research project which sought the voices of Church Leaders who were identified as being pro-active in addressing csa within their individual denominations. From this research several key inhibitors to hearing survivor’s voices, within Churches of Australia, were identified. These key inhibitors include the culture of Churches themselves, gendered ideologies, constructions of leadership and the deployment of forgiveness. The identification of such factors creates space to learn more effective strategies for hearing the voices of survivors both within Churches and their organisations and externally. This paper goes beyond considering these factors to report on a collaborative project initiated, between Survivors Australia and Dr Death. This project specifically targets the voices of Australian Survivors of csa by Church leaders. It is hoped that this project will not only achieve the primary objective of hearing and valuing the voices of survivors of csa by Church leaders, but will also provide impetus for the creation of alternative ways of managing complaints of csa by Church leaders in Australia. Such complaints processes will be increasingly survivor focussed and include the creation of spaces where the voices of survivors are valued.

Carrot red leaf and carrot mottle viruses : observations on the composition of the particles in single and mixed infections

Particles of carrot red leaf virus (CRLV; luteovirus group) purified from chervil (Anthriscus cerefolium) contain a single ssRNA species of mol. wt. about 1.8 x 106 and a major protein of mol. wt. about 25000. CRLV acts as a helper for aphid transmission of carrot mottle virus (CMotV; ungrouped) from mixedly infected plants. Virus preparations purified from such plants possess the infectivity of both viruses but contain particles indistinguishable from those of CRLV; some of the particles are therefore thought to consist of CMotV RNA packaged in CRLV coat protein. When RNA from such preparations was electrophoresed in agarose/polyacrylamide gels, CMotV infectivity was associated with an RNA band that migrated ahead of the CRLV RNA band and had an estimated mol. wt. of about 1.5 x 106, similar to that previously found for the infective ssRNA extracted directly from Nicotiana clevelandii leaves infected with CMotV alone. Preparations of dsRNA from CMotV-infected N. clevelandii leaves contained two species: one of mol. wt. about 3.2 x 106, presumably the replicative form of the infective ssRNA, and the other, mol. wt. about 0.9 x 106, of unknown origin and function. The infective agent in buffer extracts of CMotV-infected N. clevelandii was resistant to RNase (although the enzyme acted as a reversible inhibitor of infection at high concentrations) and is therefore not unprotected RNA. It may be protected within the approximately 52 nm enveloped structures previously reported.

Control strategies to prevent total hip replacement-related infections : a systematic review and mixed treatment comparison

OBJECTIVE: To synthesise the available evidence and estimate the comparative efficacy of control strategies to prevent total hip replacement (THR)-related surgical site infections (SSIs) using a mixed treatment comparison. DESIGN: Systematic review and mixed treatment comparison. SETTING: Hospital and other healthcare settings. PARTICIPANTS: Patients undergoing THR. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of THR-related SSIs occurring following the surgical operation. RESULTS: 12 studies involving 123 788 THRs and 9 infection control strategies were identified. The strategy of 'systemic antibiotics+antibiotic-impregnated cement+conventional ventilation' significantly reduced the risk of THR-related SSI compared with the referent strategy (no systemic antibiotics+plain cement+conventional ventilation), OR 0.13 (95% credible interval (CrI) 0.03-0.35), and had the highest probability (47-64%) and highest median rank of being the most effective strategy. There was some evidence to suggest that 'systemic antibiotics+antibiotic-impregnated cement+laminar airflow' could potentially increase infection risk compared with 'systemic antibiotics+antibiotic-impregnated cement+conventional ventilation', 1.96 (95% CrI 0.52-5.37). There was no high-quality evidence that antibiotic-impregnated cement without systemic antibiotic prophylaxis was effective in reducing infection compared with plain cement with systemic antibiotics, 1.28 (95% CrI 0.38-3.38). CONCLUSIONS: We found no convincing evidence in favour of the use of laminar airflow over conventional ventilation for prevention of THR-related SSIs, yet laminar airflow is costly and widely used. Antibiotic-impregnated cement without systemic antibiotics may not be effective in reducing THR-related SSIs. The combination with the highest confidence for reducing SSIs was 'systemic antibiotics+antibiotic-impregnated cement+conventional ventilation'. Our evidence synthesis underscores the need to review current guidelines based on the available evidence, and to conduct further high-quality double-blind randomised controlled trials to better inform the current clinical guidelines and practice for prevention of THR-related SSIs.

Mixed venous oxygen saturation monitoring revisited : thoughts for critical care nursing practice

Background Less invasive methods of determining cardiac output are now readily available. Using indicator dilution technique, for example has made it easier to continuously measure cardiac output because it uses the existing intra-arterial line. Therefore gone is the need for a pulmonary artery floatation catheter and with it the ability to measure left atrial and left ventricular work indices as well the ability to monitor and measure a mixed venous saturation (SvO2). Purpose The aim of this paper is to put forward the notion that SvO2 provides valuable information about oxygen consumption and venous reserve; important measures in the critically ill to ensure oxygen supply meets cellular demand. In an attempt to portray this, a simplified example of the septic patient is offered to highlight the changing pathophysiological sequelae of the inflammatory process and its importance for monitoring SvO2. Relevance to clinical practice SvO2 monitoring, it could be argued, provides the gold standard for assessing arterial and venous oxygen indices in the critically ill. For the bedside ICU nurse the plethora of information inherent in SvO2 monitoring could provide them with important data that will assist in averting potential problems with oxygen delivery and consumption. However, it has been suggested that central venous saturation (ScvO2) might be an attractive alternative to SvO2 because of its less invasiveness and ease of obtaining a sample for analysis. There are problems with this approach and these are to do with where the catheter tip is sited and the nature of the venous admixture at this site. Studies have shown that ScvO2 is less accurate than SvO2 and should not be used as a sole guiding variable for decision-making. These studies have demonstrated that there is an unacceptably wide range in variance between ScvO2 and SvO2 and this is dependent on the presenting disease, in some cases SvO2 will be significantly lower than ScvO2. Conclusion Whilst newer technologies have been developed to continuously measure cardiac output, SvO2 monitoring is still an important adjunct to clinical decision-making in the ICU. Given the information that it provides, seeking alternatives such as ScvO2 or blood samples obtained from femorally placed central venous lines, can unnecessarily lead to inappropriate treatment being given or withheld. Instead when using ScvO2, trending of this variable should provide clinical determinates that are useable for the bedside ICU nurse, remembering that in most conditions SvO2 will be approximately 16% lower.

Paper-based mixed reality sketch augmentation as a conceptual design support tool

This undergraduate student paper explores usage of mixed reality techniques as support tools for conceptual design. A proof-of-concept was developed to illustrate this principle. Using this as an example, a small group of designers was interviewed to determine their views on the use of this technology. These interviews are the main contribution of this paper. Several interesting applications were determined, suggesting possible usage in a wide range of domains. Paper-based sketching, mixed reality and sketch augmentation techniques complement each other, and the combination results in a highly intuitive interface.

Culture makes you stronger : Aboriginal women’s voices from the South Coast of NSW

This paper will describe a community based research project examining the health and wellbeing of a sample of Aboriginal women in Australia, and present preliminary findings of a community needs analysis. The Shoalhaven Koori Women’s Study (SKWS) is being led by an Aboriginal woman based within Waminda, an Aboriginal women’s community controlled service located on the South Coast of NSW. The community needs analysis is the first stage of the SKWS, and aims to explore Aboriginal women’s perceptions and experiences of wellness and wellbeing, including issues related to their personal strengths, health and social priorities, support needs and that of their families. Thirty Aboriginal women were interviewed using a survey that included closed and open ended questions. Methods used to administer the survey included yarning and Dadirri (deep listening), two valid and culturally safe approaches for data collection with Aboriginal people. Adopting these approaches ensured Aboriginal protocols were maintained and upheld throughout the research process. This enabled scientific rigour while also ensuring activities were culturally safe. Key findings of the survey will be presented, and how Waminda is modifying service delivery to better respond to the health and social priorities of Aboriginal women in the Shoalhaven region will be discussed. Community feedback of survey results will occur to validate the analysis from the community perspective.