Consensus statement on the investigation and management of non-radiographic axial spondyloarthritis (nr-axSpA)

Aim Non-radiographic axial spondyloarthritis (nr-axSpA) is axial inflammatory arthritis where plain radiographic damage is not evident. An unknown proportion of these patients will progress to ankylosing spondylitis (AS). The increasing recognition of nr-axSpA has been greatly assisted by the widespread use of magnetic resonance imaging. The aim of this article was to construct a set of consensus statements based on a literature review to guide investigation and promote best management of nr-axSpA. Methods A literature review using Medline was conducted covering the major investigation modalities and treatment options available. A group of rheumatologists and a radiologist with expertise in investigation and management of SpA reviewed the literature and formulated a set of consensus statements. The Grade system encompassing the level of evidence and strength of recommendation was used. The opinion of a patient with nr-axSpA and a nurse experienced in the care of SpA patients was also sought and included. Results The literature review found few studies specifically addressing nr-axSpA, or if these patients were included, their results were often not separately reported. Fourteen consensus statements covering investigation and management of nr-axSpA were formulated. The level of agreement was high and ranged from 8.1 to 9.8. Treatment recommendations vary little with established AS, but this is primarily due to the lack of available evidence on the specific treatment of nr-axSpA. Conclusion The consensus statements aim to improve the diagnosis and management of nr-axSpA. We aim to raise awareness of this condition by the public and doctors and promote appropriate investigation and management.

A qualitative study of the spouse's experience following coronary artery bypass surgery: Implications for Nursing Practice

Findings from numerous quantitative studies suggest that spouses of patients undergoing Coronary Artery Bypass (CAB) surgery experience both physical and emotional stress before and after their partner's surgery. Such studies have contributed to our understanding of the spouses' experiences, however they have largely failed to capture the qualitative experience of what it is like to be a spouse of a partner who has undergone CAB surgery. The objective of this study was to describe the experience of spouses of patients who had recently undergone CAB surgery. This study was guided by Husserl's phenomenological approach to qualitative research. In accordance with the nature of phenomenological research the number of participants necessarily needs to be small because phenomenology values the unique experience of individuals. Therefore this study gathered data from four participants utilising open ended indepth interviews. The method of analysis was adapted from Amedeo Giorgi's five step empirical phenomenological process which brackets preconceived notions, reducing participants' accounts to the essential essence or meanings. Numerous themes common to each of the spouses emerged. These included: seeking information; the necessity for rapid decision making; playing guardian; a desire to debrief with their partner and lastly, uncertainty of their future role. This study has attempted to understand the phenomena of the spouse's experience and in doing so, believe that we now have a better understanding and insight into the needs of spouses of CAB surgery patients. This has added another dimension to our existing body of knowledge and further facilitates holistic patient care.

Men in nursing: A thematic analysis of male nursing students experiences of nursing education in regional New Zealand

There is considerable debate about the effects the inclusion of men in nursing have on the quality of patient care and the profession itself. Whilst nursing is seen as a predominately female orientated career, it is often forgotten that the patron saint of nursing is actually a man – St Camillus of Lellis, a 16th century Italian Monk. However, evolution both politically and religiously had meant that the contemporary male figure within the nursing fraternity slowly gave way to women as men became more engaged with careers more befitting their social standing such as medicine, the church or the military 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. However, nursing is attractive because the variety of work enables an easy transition between specialties and the scope for career advancement is exciting both clinically and academically especially with the recent inception of nurse practitioner and nurse consultant roles.

The introduction of an Inter-professional learning unit: staff and student perspectives

Background The School of Clinical Sciences comprises a number of health disciplines including podiatry, paramedic science, pharmacy, medical imaging and radiation therapy. A new inter-professional unit was introduced in 2014, which covered key introductory learnings applicable for future health practitioners. This study examined teaching staff and student perspectives about their experience with the new unit for first year students. Methods Qualitative interviews with teaching staff (n=9) and focus group interviews with students (5 groups which ranged in size from 4-30) were conducted. Extensive notes were taken during the interviews Issues emerging from the interviews were identified and organised according to themes and subthemes. Results Four major themes were identified namely: Something new; To be or not to be that is the question; Advantages of the new unit; and Areas for improvement. Previous staff experience with inter-professional learning (IPL) had been ad-hoc, whereas the new unit brought together several disciplines in a planned and deliberate way. There was strong philosophical agreement about the value of IPL but some debate about the extent to which the unit provided IPL experience. The unit was seen as assisting students’ social and academic adjustment to university and provided opportunity for professional socialisation, exposure to macro and micro aspects of the Australian health care system and various types of communication. For podiatry students it was their first opportunity to formally meet and work with other podiatry students and moved their identity from ‘university student’ to ‘podiatry student’. Other positives included providing the opportunity for staff and students to interact at an early stage with the perceived benefit of reducing attrition. Areas for unit improvement included institutional arrangements, unit administration aspects and assessment. Conclusion The unit was seen as beneficial by staff and students however, students were more polarised in their views than staff. There was a tension between feeling apart of and learning about one's own profession and feeling apart of and learning about the roles of other health professionals in relation to patient care and the health care system.

Workplace acceptance and experiences of LGBTIQ health professionals: A systematic literature review

Background The purpose of this study was to explore the workplace acceptance and experiences of lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) paramedics. Methods A systematic search of academic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were research papers published in English, which focused on workplace acceptance and experiences of LGBTIQ health personnel. Results The initial focus of this systematic review was the workplace acceptance and experiences of LGBTIQ paramedics. However due to no published research specific to the paramedic profession the scope of the review was broadened to include of all LGBTIQ health personnel. Thirty-three papers were included in this review. Evidence indicated that LGBTIQ health professionals experienced discrimination from their patients, heterosexual colleagues and ‘closeted’ LGBTIQ peers. Positive contribution of LGBTIQ health professionals include improved patient care and role models for LGBTIQ peers. Inclusive policy is required for LGBTIQ health professional workforce retention. Conclusions The paramedic workforce is known to be a high risk occupational group for post-traumatic stress disorder and depression. Theoretically, LGBTIQ paramedics working in a heteronormative culture experience increased level of stress. While LGBTIQ health professionals receive legislative protection against discrimination, discrimination still exists in practice through lack of visibility. Effective and efficient integration of LGBTIQ health professionals could improve workplace satisfaction, workforce retention, and equity of access by marginalised groups. An inclusive workplace policy of LGBTIQ embraces and celebrates the value of diversity.

Do health inquiries lead to health system change? What have we learnt from recent health inquiries and will the same mistakes happen again?

Since 2001 there have been numerous Commissions of Inquiry into health system failures across the world. While the Inquiries were established to examine poor patient outcomes, each has identified a range of leadership and management shortcomings that have contributed to a poor standard of patient care. While there is an acknowledgement that different heath systems have different contexts, this paper highlights a number of themes that are common across Inquiries. It will discuss a number of common system failures in Inquiries spanning from 2001 to 2013 and pose questions as to why these types of failures are likely to re-occur, as well as possible learnings for health service management and leadership to address a number of these common themes.

Cytotoxic Effects and Biocompatibility of Antimicrobial Materials

The rising demand for medical implants for ageing populations and ongoing advancements in medical technology continue to drive the use of implantable devices. Higher implant usage has a consequent increased incidence of implant-related infections, and associated prolonged patient care, pain and loss of limb and other organ function. Numerous antibacterial surfaces have been designed that prevent the onset of biofilm formation, thus reducing or preventing implant-associated infections through inhibiting bacterial adhesion or by killing the organisms that successfully attach to the surface of the implant. Other surfaces have been designed to stimulate a local immune response, promoting the natural clearing of the invading pathogen. The desired antibacterial effects are typically achieved by modulating the surface chemistry and morphology of the implant material, by means of the controlled release of pharmacological agents and bioactive compounds from the surface of the material, or by a combination of both processes. An important issue for any type of antibacterial surface modification lies in balancing the non-fouling, bacteriostatic or bactericidal effects against local and systemic biocompatibility. In this chapter, we will first describe the concept of biocompatibility and its evolution, from devices that do not evoke a negative host response to those that actively drive host regeneration. We will then review the challenges associated with merging the need for an implant material to withstand a bacterial load with those associated with supporting function restoration and tissue healing.

Factors influencing sustainability of health service innovation, emergency nurse practitioner service

Escalating health care delivery costs and consumer expectations have led to a range of health service and workforce innovations in the provision of high quality cost effective patient care. This research has operationalised a theoretical framework to examine factors that influence sustainability of health service innovations, in particular, emergency nurse practitioner service. The results of this research will inform health service policy and practice for future implementation of innovative workforce models and add to the understanding of factors that influence sustainability.

Peripartum management of glycemia in women with type 1 diabetes

OBJECTIVE We aimed to 1) describe the peripartum management of type 1 diabetes at an Australian teaching hospital and 2) discuss factors influencing the apparent transient insulin independence postpartum. RESEARCH DESIGN AND METHODS We conducted a retrospective review of women with type 1 diabetes delivering singleton pregnancies from 2005 to 2010. Information was collected regarding demographics, medical history, peripartum management and outcome, and breast-feeding. To detect a difference in time to first postpartum blood glucose level (BGL) >8 mmol/L between women with an early (<4 h) and late (>12 h) requirement for insulin postpartum, with a power of 80% and a type 1 error of 0.05, at least 24 patients were required. RESULTS An intravenous insulin infusion was commenced in almost 95% of women. Univariate analysis showed that increased BMI at term, lower creatinine at term, longer duration from last dose of long- or intermediate-acting insulin, and discontinuation of an insulin infusion postpartum were associated with a shorter time to first requirement of insulin postpartum (P = 0.005, 0.026, 0.026, and <0.001, respectively). There was a correlation between higher doses of insulin commenced postpartum and number of out-of-range BGLs (r[36] = 0.358, P = 0.030) and hypoglycemia (r[36] = 0.434, P = 0.007). Almost 60% had at least one BGL <3.5 mmol/L between delivery and discharge. CONCLUSIONS Changes in the pharmacodynamic profile of insulin may contribute to the transient insulin independence sometimes observed postpartum in type 1 diabetes. A dose of 50–60% of the prepregnancy insulin requirement resulted in the lowest rate of hypoglycemia and glucose excursions. These results require validation in a larger, prospective study.

Perioperative Nursing

This chapter introduces the beginning perioperative nurse to the key concepts and principles informing perioperative practice within Australasia. It describes the patient care roles of the nurse as well as the perioperative context and culture that inform the delivery of care during the surgical patient's journey. Aspects of the regulatory environment are examined, such as advocacy, accountability, delegation and scope of practice. In addition, the chapter explores the role of professional associations and highlights the importance of practice standards for perioperative nursing. The role of evidence-based practice (EBP) is also acknowledged. As this dynamic nursing speciality continues to evolve, the chapter concludes with a discussion of emerging advanced-practice roles for perioperative nurses.

Discharge practices for the intensive care patient : a qualitative exploration in the general ward setting

OBJECTIVE: To explore how registered nurses (RNs) in the general ward perceive discharge processes and practices for patients recently discharged from the intensive care unit (ICU). BACKGROUND: Patients discharged from the ICU environment often require complicated and multifaceted care. The ward-based RN is at the forefront of the care of this fragile patient population, yet their views and perceptions have seldom been explored. DESIGN: A qualitative grounded theory design was used to guide focus group interviews with the RN participants. METHODS: Five semi-structured focus group interviews, including 27 RN participants, were conducted in an Australian metropolitan tertiary referral hospital in 2011. Data analyses of transcripts, field notes and memos used concurrent data generation, constant comparative analysis and theoretical sampling. RESULTS: Results yielded a core category of 'two worlds' stressing the disconnectedness between ICU and the ward setting. This category was divided into sub categories of 'communication disconnect' and 'remember the family'. Properties of 'what we say', 'what we write', 'transfer' and 'information needs' respectively were developed within those sub-categories. CONCLUSION: The discharge process for patients within the ICU setting is complicated and largely underappreciated. There are fundamental, misunderstood differences in prioritisation and care of patients between the areas, with a deep understanding of practice requirements of ward based RNs not being understood. The findings of this research may be used to facilitate inter departmental communications and progress practice development.

General practitioners’ experiences of the psychological aspects in the care of a dying patient

Objective: General practitioners (GPs) play an integral role in addressing the psychological needs of palliative care patients and their families. This qualitative study investigated psychosocial issues faced by GPs in the management of patients receiving palliative care and investigated the themes relevant to the psychosocial care of dying patients. Method: Fifteen general practitioners whose patient had been recently referred to the Mt. Olivet Palliative Home Care Services in Brisbane participated in an individual case review discussions guided by key questions within a semistructured format. These interviews focused on the psychosocial aspects of care and management of the referred patient, including aspects of the doctor/patient relationship, experience of delivering diagnosis and prognosis, addressing the psychological concerns of the patients' family, and the doctors' personal experiences, reactions, and responses. Qualitative analysis was conducted on the transcripts of these interviews. Results: The significant themes that emerged related to perceived barriers to exploration of emotional concerns, including spiritual issues, and the discussion of prognosis and dying, the perception of patients' responses/coping styles, and the GP's personal experience of the care (usually expressed in terms of identification with patient). Significance of results: The findings indicate the significant challenges facing clinicians in discussions with patients and families about death, to exploring the patient's emotional responses to terminal illness and spiritual concerns for the patient and family. These qualitative date indicate important tasks in the training and clinical support for doctors providing palliative care.

A robust reactive scheduling model for intensive care units

The ICU is an integral part of any hospital and is under great load from patient arrivals as well as resource limitations. Scheduling of patients in the ICU is complicated by the two general types; elective surgery and emergency arrivals. This complicated situation is handled by creating a tentative initial schedule and then reacting to uncertain arrivals as they occur. For most hospitals there is little or no flexibility in the number of beds that are available for use now or in the future. We propose an integer programming model to handle a parallel machine reacting system for scheduled and unscheduled arrivals.

Emergency department nurses' understanding and experiences of implementing discharge planning

Aim: This paper is a report of a study conducted to describe emergency department nurses' understanding and experiences of implementing discharge planning. ---------- Background: Discharge planning in the emergency department is an important issue because of increased healthcare costs and greater emphasis on continuity of care. When executed as a collaborative process involving a multi-disciplinary team with the patient and family, discharge planning provides continuity of care for patients, less demand on hospitals, improvement in community services and in the services of other healthcare organizations. ---------- Method: The qualitative approach of phenomenography was used in this study. Thirty-two emergency department nurses were recruited between July and September 2005. Semi-structured interviews were conducted. ---------- Findings: From interviewees' descriptions of implementing discharge planning, six categories were established: implementing discharge planning as 'getting rid of my patients', completing routines, being involved in patient education, professionally accountable practice, autonomous practice and demonstrating professional emergency department nursing care. The referential meaning of implementing discharge planning 'in the outcome space' was the professional commitment to emergency department provision of effective discharge services. ---------- Conclusion: The results of this research contribute to knowledge of emergency department nurses' experience in the implementation of the discharge planning process. Key requirements for the provision of manageable discharge services both in Taiwan and worldwide highlighted by this study include adequate workloads, sufficient time, clear policies and standards of discharge planning and enhancement of professional commitment.