Post-anaesthetic discharge scoring criteria: key findings from a systematic review

Background
Patient safety depends on nurses' clinical judgment. In post-anaesthetic care, objective scoring systems are commonly used to help nurses assess when a patient is ready to go back to the ward or be discharged home after day surgery. Although there are several criteria used to assess patient readiness for discharge from the post-anaesthetic care unit, evaluation of the validity and reliability of these criteria is scarce.

Aims
This article presents key findings from a systematic review conducted to identify the essential components of an effective and feasible scoring system to assess patients following surgical anaesthesia for discharge from the post-anaesthetic care unit.

Methods
The protocol for the systematic review of quantitative studies investigating assessment criteria for discharge of adult patients from the post-anaesthetic care unit was approved by the Joanna Briggs Institute and conducted consistent with the methodology of the Institute. Twelve databases and grey literature, such as conference proceedings, were searched for published studies between 1970 and 2010. Two reviewers independently assessed study eligibility for inclusion. Reference lists of included studies were appraised.

Results
Eight studies met the inclusion criteria; only one was a randomised controlled trial. Variables identified as essential when assessing a patient's readiness for discharge from the post-anaesthetic care unit were conscious state, blood pressure, nausea and vomiting, and pain. Assessment of psychomotor and cognitive recovery and other vital signs were also identified as relevant variables to consider.

Conclusions
There was limited high-quality research regarding criteria to assess patient readiness for discharge from the post-anaesthetic unit. The key recommendations, with moderate to high risk of bias, include that assessment of specific variables (pain, conscious state, blood pressure, and nausea and vomiting) should be made before patient discharge. These key findings have informed a subsequent study to reach international consensus on effective assessment criteria and a project to test the clinical reliability of a tool for use by nurses in assessing patient readiness for discharge from post-anaesthetic care.

Determining criteria to assess patient readiness for discharge from postanaesthetic care: an international Delphi study

Aims and objectives
To obtain expert consensus on essential criteria required to assess patient readiness for discharge from the postanaesthetic care unit.

Background
A patient's condition can deteriorate after surgery, and the immediate postoperative period is recognised internationally as a time of increased risk to patient safety. A recent systematic review identified evidence-based assessment criteria for the safe discharge of patients from the postanaesthetic care unit and identified gaps in the evidence.

Design
Descriptive consensus study using the Delphi method.

Methods
Members of international clinical specialist groups with expertise in anaesthesia or postanaesthetic care participated in three consultation rounds. Online surveys were used to determine expert consensus with regard to aspects of postanaesthetic care and specific criteria for assessing patient readiness for discharge. Three rounds of surveys were conducted from May 2011–September 2012.

Results
Twenty-three experts contributed to the panel. Consensus, that is, at least 75% agreement, was reached in regard to 24 criteria considered essential (e.g. respiratory rate 100%; pain 100%; heart rate 95%; temperature 91%). Consensus was also reached for 15 criteria not considered essential (e.g. appetite 96%; headache 76%). Consensus was not obtained for a further 10 criteria. Participants (95%) agreed that a discharge tool was important to ensure safe patient discharge.

Conclusion
Consensus was achieved by a panel of international experts on the use of a tool to assess patient readiness for discharge from postanaesthesia care unit and specific variables to be included or excluded from the tool. Further work is required to develop a tool and test its reliability and validity.

Relevance to clinical practice
The findings of this study have informed the development of an evidence-based tool to be piloted in a subsequent funded study of nursing assessment of patient readiness for discharge from the postanaesthetic care unit.

Integrating theory and practice in the pre-service teacher education practicum

This article reports on a study into student teachers’ perceptions about their professional development during practicum. Framed within a symbolic interactionist perspective, the study examined to what extent, and how effectively, one group of student teachers was able to integrate theory and practice during a three-week practicum in the first year of their degree. The context for this mixed methods study was a Master of Teaching, graduate-level entry programme in the Faculty of Education at an urban Australian university. Although there is a strong field of literature around the practicum in pre-service teacher education, there has been a limited focus on how student teachers themselves perceive their development during this learning period. Further, despite widespread and longstanding acknowledgement of the ‘gap’ between theory and practice in teacher education, there is still more to learn about how well the practicum enables an integration of these two dimensions of teacher preparation. In presenting three major findings of the study, this paper goes some way in addressing these shortcomings in the literature. First, participants in this study largely valued both the theoretical and practical components of their programme, which stands in contrast to the commonly identified tendency of the student teacher to privilege practice over theory. Second, opportunities to integrate theory and practice were varied, with many participants reporting the detrimental impact of an apparent lack of clarity around stakeholders’ roles and responsibilities. Third, participants overwhelmingly supported the notion of linking university coursework assessment to the practicum as a means of bridging the gap between, on the one hand, the university and the school and, on the other hand, theory and practice.

Stakeholders’ perspectives of the nature and role of assessment during practicum

This paper focuses on the assessment of student teachers during practicum. The study is contextualised in an Australian pre-service teacher education program in which practicum has been reconceptualised to help bridge the theory–practice gap commonly associated with “front-end loading” programs. Survey and interview data collected from student teachers and supervising teachers point to what participants perceive as disparate understandings between university and school staff about the nature and role of assessment and suggest that this lack of common understanding adversely affects students’ experiences of assessment.

Assessing for work integrated learning experiences : a pre-service teacher perspective

A critical aspect of the debate about work integrated learning in the university context is the blurring of boundaries and responsibilities in terms of student learning. In an Australian pre-service teacher education program this blurring of boundaries is apparent in stakeholder tensions about the nature and role of assessment during the practicum. In the study reported in this paper students responded positively to the content of assessment tasks but maintained that their efforts to implement the associated planning in the workplace were stymied because of disparate understandings between university and school staff about the purpose of the task.

Building academic resilience: A longitudinal study of Master of Teaching students’ perceptions of written feedback on high stakes assessment

This paper reports on a two-year study of tertiary education students’ perceptions of written feedback on assessment. Contextualised in a regional Australian university and drawing on a cohort of Master of Teaching pre-service teachers, a survey approach was used to collect data from participants in both years of their graduate-level entry program. The paper contributes to the emerging body of literature on students’ perceptions of written feedback on assessment by discussing four themes that emerged from the study. It concludes with a number of recommendations for teacher educators to enhance current feedback practices.

The nature and role of assessment during practicum : stakeholders’ perspectives

This paper focuses on the assessment of student teachers during practicum. The study is contextualised in an Australian pre-service teacher education program in which practicum has been reconceptualised to help bridge the theory-practice gap commonly associated with “front-end loading” programs. Survey and interview data collected from student teachers and supervising teachers point to what participants perceive as disparate understandings between university and school staff about the nature and role of assessment and suggest that this lack of common understanding adversely affects students’ experiences of assessment. While contextualised in teacher education, these findings have applicability to other tertiary programs for the professions. The study’s conclusions are threefold: the importance of establishing and sustaining effective university-school partnerships is paramount; there is a clearly identified need for shared stakeholder understandings about practicum assessment; and disregarding failed or diminished partnerships jeopardises student learning.

Authentically assessing graduate teaching: outside and beyond neo-liberal constructs

In this paper, we challenge the current focus on ‘best practice’, graduate teacher tests, and student test scores as the panacea for ensuring teaching quality and argue for ways of thinking about evidence of quality beginning teaching outside and beyond the current neoliberal accountability discourses circulating in Australia and other countries. We suggest that teacher educators need to reinsert themselves as key players in the debates around quality beginning teaching, rather than being viewed as a source of the problem. To enable teacher educators to assume accountability for quality beginning teachers, we propose the framework of a capstone teacher performance assessment—a structured portfolio called the Authentic Teacher Assessment (ATA)— and examine examples of these assessments through the lens of critical discourse analysis. As a measure of ‘readiness to teach’, the ATA is compared with supervising teachers’ assessments of preservice teachers. We argue that structured portfolios that include artefacts derived from preservice teachers’ practice in classrooms along with graduate teacher self assessments provide a stronger accountability measure of effec- tive beginning teaching and demonstrably address the current anxiety regarding ‘evi- dence’. We suggest that such an approach should be reliable enough to be ‘read’ by external assessors (and moderated across other teacher education institutions). Rigor- ous research on a national basis is called for in order to develop and implement a structured portfolio as rich evidence of graduates’ quality and readiness to teach.

Australian pre-service secondary teacher education courses : challenges and Dilemmas

Pre-service visual art teachers’ perceptions of assessment in online learning

This paper reports on a study conducted into how one cohort of Master of Teaching pre-service visual art teachers perceived their learning in a fully online learning environment. Located in an Australian urban university, this qualitative study provided insights into a number of areas associated with higher education online learning, including that of assessment, the focus of this paper. Authentic assessment tasks were designed within the University’s learning and teaching framework of constructive alignment and were sequenced across the three semesters of the visual art program. Analysis of data collected through a questionnaire and semi-structured interviews revealed that participants largely held very positive attitudes about the suite of online assessment tasks, particularly in light of (a) the collaborative learning that took place, (b) the nature, structure and sequence of the tasks, and (c) the ways in which the tasks contributed to their workplace readiness.

Ensuring a proactive, evidence-based, patient safety approach to patient assessment

Aims and objectives: To argue that if all nurses were to adopt the primary survey approach (assessment of airway, breathing, circulation and disability) as the first element of patient assessment, they would be more focused on active detection of clinical deterioration rather than passive collection of patient data. Background: Nurses are the professional group that carry the highest level of responsibility for patient assessment, accurate data collection and interpretation. The timely recognition of, and response to deteriorating patients, is dependent on the measurement and interpretation of pertinent physiological data by nurses. Design: Discursive paper. Methods: Traditionally taught and commonly used approaches to patient assessment such as 'vital signs' and 'body systems' are not evidence-based nor framed in patient safety. The primary survey approach as the first element in patient assessment has three major advantages: (1) data are collected according to clinical importance; (2) data are collected using the same framework as most organisation's rapid response system activation criteria; and (3) the primary survey acts as a patient safety checklist, thereby decreasing the risk of failure to recognise, and therefore respond to, deteriorating patients. Conclusion: The vital signs and body systems approaches to patient assessment have significant limitations in identifying clinical deterioration. The primary survey approach provides nurses with a consistent, evidence-based and sequenced approach to patient assessment in every clinical setting. Relevance to clinical practice: All nurses should use a primary survey approach as the first element of patient assessment in every patient encounter as a patient safety strategy. © 2014 John Wiley & Sons Ltd.

The National Safety and Quality Health Service Standards requirements for orientation and induction within Australian healthcare: a review of the literature

Introduction: A workplace orientation program is a core requirement of the National Safety and Quality Health Service (NSQHS) Standards in Australia. This is particularly important within healthcare as patient safety and the patient experience are at risk if the healthcare workforce is not supported with an effective orientation and induction program. Aim: This study aimed to review the literature and map the requirements of the NSQHS Standards in relation to orientation and induction. Method: This study utilised online databases to search for literature pertaining to orientation and induction within healthcare. Inclusion criteria included relevance to research questions, and originating in a country with a comparative health system to Australia. Results: The search identified a total of 202 articles of potential relevance with 42 articles meeting the inclusion criteria. Articles were ranked according to hierarchy of evidence criteria for both qualitative and quantitative studies. The importance of using orientation to detail safety and quality roles, the organisations' risk management system, governance structure, operational processes and procedures was highlighted. Patient-centred care, antimicrobial stewardship, clinical handover and mechanisms for escalation of care and emergency assistance should also be covered within the orientation process. Conclusion: There is a dearth of studies in relation to orientation and induction in the healthcare literature. Orientation content is now clearly prescribed, what is lacking within healthcare is a standardised framework. Concept mapping, educational theory and adult learning methods have been shown to enhance workforce problem solving and engagement with orientation, however further research is needed to enhance practice

Student self-assessment in higher education: a meta-analysis

Quantitative self-assessment studies that compared self- and teacher marks were subjected to a meta-analysis. Predictions stemming from the results of an earlier critical review of the literature (Boud & Falchikov, 1989) were tested, and salient variables were identified. Factors that seem to be important with regard to the closeness of correspondence between self- and teacher marks were found to include the following: the quality of design of the study (with better designed studies having closer correspondence between student and teacher than poorly designed ones); the level of the course of which the assessment was a part (with students in advanced courses appearing to be more accurate assessors than those in introductory courses); and the broad area of study (with studies within the area of science appearing to produce more accurate self-assessment generally than did those from other areas of study). Results of the analysis are discussed and differences signaled by the results of the three common metrics examined. The distinction between relative and absolute judgment of performance is drawn. It is recommended that researchers give attention to both good design and to adequate reporting of self-assessment studies.

Determining criteria to assess patient readiness for discharge from postanaesthetic care: An international Delphi study

Aims and objectives: To obtain expert consensus on essential criteria required to assess patient readiness for discharge from the postanaesthetic care unit. Background: A patient's condition can deteriorate after surgery, and the immediate postoperative period is recognised internationally as a time of increased risk to patient safety. A recent systematic review identified evidence-based assessment criteria for the safe discharge of patients from the postanaesthetic care unit and identified gaps in the evidence. Design: Descriptive consensus study using the Delphi method. Methods: Members of international clinical specialist groups with expertise in anaesthesia or postanaesthetic care participated in three consultation rounds. Online surveys were used to determine expert consensus with regard to aspects of postanaesthetic care and specific criteria for assessing patient readiness for discharge. Three rounds of surveys were conducted from May 2011-September 2012. Results: Twenty-three experts contributed to the panel. Consensus, that is, at least 75% agreement, was reached in regard to 24 criteria considered essential (e.g. respiratory rate 100%; pain 100%; heart rate 95%; temperature 91%). Consensus was also reached for 15 criteria not considered essential (e.g. appetite 96%; headache 76%). Consensus was not obtained for a further 10 criteria. Participants (95%) agreed that a discharge tool was important to ensure safe patient discharge. Conclusion: Consensus was achieved by a panel of international experts on the use of a tool to assess patient readiness for discharge from postanaesthesia care unit and specific variables to be included or excluded from the tool. Further work is required to develop a tool and test its reliability and validity. Relevance to clinical practice: The findings of this study have informed the development of an evidence-based tool to be piloted in a subsequent funded study of nursing assessment of patient readiness for discharge from the postanaesthetic care unit.