Tensions and constraints for nurses in hospital-in-home programmes

Economic necessity constrains health-care expenditure and waiting lists for hospital treatments remain high. As a result, more care is delivered via alternative means, such as same-day surgery initiatives and home-care programmes. Acute care delivered in the home to patients who would otherwise require hospitalization is becoming an increasingly acceptable means of treatment. These Hospital-in-the-Home programmes offer increased comfort while delivering comparable outcomes to many patient groups. The purpose of this paper is to generate discussion concerning the tensions that exist for nurses who practice in the home under the auspices of acute-care institutions. Data drawn from field work that formed part of a critical ethnography is used to generate the discussion. The larger research project explored the constructions of the role of the nurse in four Hospital-in-the-Home programmes in Victoria, Australia. It will be argued that there is significant pressure exerted upon nurses to support the imperative to reduce bed days in acute hospitals by transferring people to their home. At times, this agenda clashes with the nurses’ professional commitment to provide holistic patient care yet the dilemmas are largely unacknowledged and/or unrecognized by the nurses despite the tension they generate.

Clinical research 5: quantitative data collection and analysis

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

A couple of points:

1. It is artificial to describe research as qualitative or quantitative. Studies often include both dimensions. However, for the purposes of this paper/series, this distinction is drawn for clarity of writing.

2. It is common practice for quantitative studies to refer to study ‘subjects’ and qualitative studies to refer to study ‘participants’. For ease of reading, the latter term will be used throughout this series.

Nurses' perceptions of discharge planning

The present paper investigates what the term discharge planning actually means to nurses working in the acute care environment. A qualitative approach was used for this study. Twelve volunteer registered nurses (RNs) working in a large metropolitan Victorian public hospital were interviewed. All participants stated emphatically that they were involved in the discharge planning process although differing levels of involvement existed. ‘Organizing’ and ‘planning’ were key words used by participants to define the term discharge planning. All but one participant considered the nurse to be the coordinator of the discharge planning process. How participants communicated with other nursing staff regarding the discharge planning needs of individual patients depended on the policy of each individual ward. Communication was perceived to be a major factor that either enhanced or impeded the discharge planning process.

Mismanagement of delerium places patients at risk

Objective: This paper discusses the problem of delirium and the challenges of accurately assessing, preventing and managing patients with delirium in an acute care setting.

Primary Argument: Acute confusion, also known as delirium, is misdiagnosed and under-treated in up to 94% of older patients in hospitals. With the ageing population, this problem will increase dramatically in the Australian setting. Managing patients with delirium is challenging not only for the management of their basic nursing care needs but also because they are prone to adverse events such as falls and medication problems. In order to address this issue it is vital that health care professionals routinely assess patients for signs of delirium. The current 'gold standard' for assessing delirium is the use of the Confusion Assessment Method (CAM) which has been developed based on the diagnostic criteria set by the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and can be used by non-psychiatrists. Further, increased attention should be given to the prevention and management of delirium and the use of orientation and validation therapy.

Conclusion: Research indicates that early identification and intervention can help to limit any negative effects or adverse events. Increasing knowledge and awareness of early detection and efficient management of delirium is the first step toward prevention.

The trials and tribulations of team-nursing

Aim: The aim of this study was to review the team-nursing approach to care adopted by two general medical wards in a large private hospital. The delivery model of care was reviewed to determine the factors that enhance and/or hinder the timely delivery, continuity and communication of care.
Method: All nursing and ancillary staff who worked on two medical wards at a private teaching hospital were invited to participate in the study. Thirty eight participants from the two wards took part in focus group discussions, individual interviews and completed the Staff Continuity of Care Questionnaire. Findings: Findings indicated that achieving functionally sound teamwork is a complex task that is affected by the interplay of a number of organisational, patient and staff factors. Its smooth application is further affected by the uncertain and changing conditions on the wards, which are difficult to control and impact on the smooth delivery of patient care. The findings revealed strengths and weaknesses in teamwork, communication of care, documentation and discharge planning. The results also highlighted factors that enhance and hinder the smooth delivery of care. This paper details the factors that influence the delivery of care from the perspectives of nursing staff and makes recommendations to enhance the delivery of patient care using a team-nursing approach.

Timed voiding for the management of urinary incontinence in adults (Review)

Background
Timed voiding is a fixed time interval toileting assistance program that has been promoted for the management of people with urinary incontinence who cannot participate in independent toileting. For this reason, it is commonly assumed to represent current practice in residential aged care settings.
Objectives
To assess the effects of timed voiding for the management of urinary incontinence in adults who cannot participate in independent toileting.
Search strategy
We searched the Cochrane Incontinence Group Specialised Register (28 February 2007), MEDLINE (January 1966 to November 2003), EMBASE (January 1980 to Week 18 2002), CINAHL (January 1982 to February 2001), PsycINFO (January 1972 to August 2002), Biological Abstracts (January 1980 to December 2000), Current Contents (January 1993 to December 2001) and the reference lists of relevant articles. We also contacted experts in the field, searched relevant websites and hand searched journals and conference proceedings.
Selection criteria
We selected all randomised and quasi-randomised trials that addressed timed voiding in an adult population and that had an alteration in continence status as a primary outcome. We included those trials that had assessed timed voiding delivered either alone or in combination with another intervention and compared it with either usual care, or no timed voiding, or another intervention.
Data collection and analysis
Data extraction and quality assessment were undertaken by at least two people working independently of each other. Any differences were resolved by discussion until agreement was reached. The relative risk for dichotomous data were calculated with 95% confidence intervals. Where data were insufficient to support a quantitative analysis, a narrative overview was undertaken.
Main results
Two trials with a total of 298 participants met the inclusion criteria. Both compared timed voiding plus additional intervention with usual care. In one of these timed voiding was combined with continence products, placement of a bedside commode for each participant, education to staff on transfer techniques, feedback and encouragement to staff, praise to participants for "successful responses" and administration of oxybutynin in small doses. The mean percentage who were incontinent when checked daily was 20% in the intervention group compared with 80% in the control group. No further between group analysis was possible from the data reported. The other trial combined timed voiding with a medical assessment and individualised medical management that was based on clinical data. Reduction in the number of participants with daytime and night-time incontinence was greater in the intervention group but this difference was statistically significant only for night-time wetting. There was no difference in the volume of urine lost as determined by pad weighing.
The methodological quality of these trials was not high based on the quality appraisal criteria of the Cochrane Incontinence Group. In particular, there was a lack of clarity regarding levels of blinding. It was not possible to combine data from trials. In both trials, the fixed schedule of toileting was combined with other interventions. The extent to which the results reflect the contribution of timed voiding is unknown because the trials' design did not allow assessment of the effects of the fixed schedule of toileting separately from other components of the interventions.
Authors' conclusions
The data were too few and of insufficient quality to provide empirical support for or against the intervention of timed voiding.

The language of subjective well-being

The Language of Depression project is a linguistic study of the language of Acute Care Hospital patients suffering depression with the ultimate aim of enabling medical and nursing staff to become more aware of their patients’ depression and immediately refer them for psychological or psychiatric help. As part of that larger project, and following recent developments in positive psychology (e.g. Seligman 2002) this paper will focus exclusively on the control group, that is, the language of those Acute Care Hospital patients deemed non-depressed. The data comprise 30 minute interviews between the patients and a Consultation-liaison psychiatrist. Prior to interview, the patients were screened using the Brief Case-find for Depression (Clarke et al. 1994). From the screening, patients were then deemed likely to be depressed and likely to be non-depressed. This paper reports on the analysis of 10 patients deemed as non-depressed. Using the linguistic theory of Systemic Functional Linguistics, the data were analysed for their Appraisal features (e.g. Martin and Rose 2003). Appraisal analysis provides a lexico-semantic analysis that is concerned with how speakers use language to evaluate as well as negotiate relationships. The Appraisal analysis has been used to identify in the language of non-depressed patients the types of attitudes that facilitate psychological well-being. This paper will present some analysed extracts from the interviews to show how key features of subjective well-being are realised in the language of non-depressed Acute Care Hospital patients.

Stories seldom told: paediatric nurses` experiences of caring for hospitalized children with special needs and their families.

Stories seldom told: paediatric nurses' experiences of caring for hospitalized children with special needs and their families

Aims of the study. This study explored paediatric nurses' experiences of caring for children with special needs and their families in an acute care setting. The aim of the study was to increase understanding of nurses' experiences of caring for these children and their families. The study was designed to reveal the caring practices embedded within these relationships through exploring nurses' stories.

Study design/methods. Gadamerian hermeneutic phenomenology and feminist research principles were the approaches used to guide the study. Interviews were held with experienced paediatric nurses and interpretation of interview transcripts using a Gadamerian hermeneutic phenomenological approach resulted in the identification of four themes.

Findings. The four themes revealed were: Special Relationships; Multiple Dimensions of Who is Expert; Development of Trust Between Nurses and Families; and Feelings of Frustration and Guilt.

Conclusions. The study emphasized the context-specific nature of relationships between nurses and children and their families. The nurses spoke about the difficulties they encountered in their practice and some of the ways that they dealt with these problems. They discussed the things that they valued and those that made them feel guilty and frustrated. In doing so, they revealed their warmth, strength, humanity and caring.

Dying in hospital: medical failure or nature outcome?

The purpose of this study was to describe patterns of medical and nursing practice in the care of patients dying of oncological and hematological malignancies in the acute care setting in Australia. A tool validated in a similar American study was used to study the medical records of 100 consecutive patients who died of oncological or hematological malignancies before August 1999 at The Canberra Hospital in the Australian Capital Territory. The three major indicators of patterns of end-of-life care were documentation of Do Not Resuscitate (DNR) orders, evidence that the patient was considered dying, and the presence of a palliative care intention. Findings were that 88 patients were documented DNR, 63 patients' records suggested that the patient was dying, and 74 patients had evidence of a palliative care plan. Forty-six patients were documented DNR 2 days or less prior to death and, of these, 12 were documented the day of death. Similar patterns emerged for days between considered dying and death, and between palliative care goals and death. Sixty patients had active treatment in progress at the time of death. The late implementation of end-of-life management plans and the lack of consistency within these plans suggested that patients were subjected to medical interventions and investigations up to the time of death. Implications for palliative care teams include the need to educate health care staff and to plan and implement policy regarding the management of dying patients in the acute care setting. Although the health care system in Australia has cultural differences when compared to the American context, this research suggests that the treatment imperative to prolong life is similar to that found in American-based studies.

Medication management by graduate nurses: before, during and following medication administration

The purpose of the present study was to explore graduate nurses' perceptions of their medication management activities in the acute care context. A qualitative research design with a semistructured interview schedule was used to elicit information from participants. The sampling population consisted of graduate nurses involved in direct patient care in medical and surgical wards of a Melbourne metropolitan teaching hospital, completing a graduate nurse program. Twelve graduate nurses participated in the interviews. Two major themes emerged: (i) monitoring medications and (ii) interventions for patient care. The findings indicate that graduate nurses are required to address several facets of the medication management role in their daily practice. It is pertinent to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals. Through collegial support, graduate nurses should also be encouraged to critically examine the different possibilities when making clinical judgments about monitoring patient medications.

Graduate nurses communication with health professionals when managing patients medications

Aim and objectives. The aim was to examine how graduate nurses communicated with other health professionals about their medication management activities in the acute care context. The objectives were to determine the types of information communicated about patients' medications and the communication processes used during interactions with other nurses, doctors and pharmacists.

Background. Graduate nurses are challenged with enormous responsibilities and their competence is constantly tested in an ever-changing arena. One of their responsibilities involves communicating with other health professionals about patients' medications.

Design. A qualitative exploratory research design was used for this study.

Methods. Participant observation and semi-structured interviews were conducted to elicit information from 12 graduate nurses with university degrees employed in a metropolitan public hospital, in Melbourne, Australia. Graduate nurses were observed once for two hours and interviewed on the same day of the observation at a mutually convenient time. The purpose of these interviews was to clarify activities observed and to obtain further information.

Results. The results highlighted how work dynamics of the clinical setting had an impact on the ability of graduate nurses to communicate effectively with other nurses, doctors and pharmacists. These work dynamics included the availability of doctors and the structure of ward rounds. The results also demonstrated the value graduate nurses placed on communicating particular information such as evaluating the effect of medication changes and organizing discharge medication.

Conclusions. Graduate nurses were effective in communicating about medication management activities when they initiated or were prepared for such interactions. When graduate nurses were not prepared, such as during impromptu ward rounds, they did not participate effectively and important information was not communicated.

Relevance to clinical practice. It is important to understand how collegial communication facilitates accurate exchange of information and effective decision-making to achieve optimal health care outcomes for patients.

The questioning skills of clinical teachers and preceptors: a comparative study

Aim of the study. The purpose of this study, conducted as partial requirement for a Master of Nursing Studies Degree, was to explore, describe and compare the level of questions asked by clinical teachers and preceptors.

Background. Questioning is one of many teaching/learning strategies thought to facilitate the development of critical thinking skills which are integral to nursing practice. As such the type and number of questions asked have implications for student learning. Currently in Melbourne, Australia, many undergraduate nursing degree courses utilize both clinical teachers and preceptors to facilitate student learning in the clinical setting.

Design. A comparative descriptive design was used. Participants were given three acute care patient scenarios involving an undergraduate nursing student, as part of a questionnaire, and asked to identify the questions they would ask the student in relation to the scenario.

Findings. Data revealed that the clinical teachers had considerably more years of experience in their role and higher academic qualifications than did the preceptors. The clinical teachers also asked a greater number of questions overall and more from the higher cognitive level. Despite this, the findings suggest that both clinical teachers and especially preceptors need to increase the number of higher level questions they ask.

Conclusions. Based on the findings of this study, it is evident that there is a need for further comparative studies into the questioning skills of clinical teachers and preceptors. Also, these two groups require education about the importance of higher level questioning for student learning as well as how to ask questions generally.

Stigmatization of AIDS patients : disentangling Thai nursing students' attitudes towards HIV/AIDS, drug use and commercial sex

This paper analyzes the interrelationships between the stigma of HIV/AIDS stigma and the co-stigmas of commercial sex (CS) and injecting drug use (IDU). Students of a Bangkok nursing college (N = 144) were presented with vignettes describing a person varying in the disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU, CS, blood transfusion, no co-characteristic). For each vignette, participants completed a social distance measure assessing their attitudes towards the hypothetical person portrayed. Multivariate analyses showed strong interactions between the stigmas of AIDS and IDU but not between AIDS and CS. Although AIDS was shown to be stigmatizing in and of itself, it was significantly less stigmatizing than IDU. The findings highlight the need to consider the non-disease-related stigmas associated with HIV as well as the actual stigma of HIV/AIDS in treatment and care settings. Methodological strengths and limitations were evaluated and implications for future research discussed.

Self-administration of medication in hospital: patients' perspectives

Background. Little information is available about patients' perspectives on self- or nurse-related administration of medication.

Aim. The aim of the study was to determine patients' perspectives about self-medication in the acute care setting.

Methods. A qualitative approach, using in-depth semi-structured interviews, was taken. Ten patients with a chronic medical illness who had experienced multiple hospital admissions for treatment were interviewed about their experiences of medication administration in the acute care setting. Participants were recruited from two cardiovascular wards in a private, not-for-profit hospital in Melbourne, Australia. Data collection occurred between August and September 2002.

Findings. Four major themes were identified from the interviews: benefits of self-administration, barriers to self-administration, assessing appropriateness of self-administration and timing of medication administration. Seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses' heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting.

Conclusions. In planning and implementing self-administration programmes, it is important to consider patients' views. Medication regimes should be simple and flexible enough to adapt to patients' lifestyles and usual routines. Nurses should also take advantage of opportunities to support and facilitate patient autonomy, to enable more effective management of health care needs when patients return home.

Out of pocket costs to stroke patients during the first year after stroke - results from the North East Melbourne stroke incidence study

Non-reimbursed ‘out of pocket’ costs to stroke patients have not been included in existing cost of illness studies. We aimed to determine the nature and magnitude of ‘out of pocket’ costs to stroke patients during the first year after stroke. ‘Out of pocket’ costs during the first year after stroke were documented for 165 persons registered in a community-based stroke incidence study during 1996/1997. Virtually all cases reported some ‘out of pocket’ costs. The average cost over 12 months was A$1110. The highest cost items were home modifications, aids and equipment. The most commonly incurred expense was for prescription medications. Total ‘out of pocket’ costs incurred by first-ever stroke patients in Australia in 1997 were estimated to be A$29 million or 5% of the total cost of stroke. The majority of ‘out of pocket’ costs relate to post-acute care aimed at minimising disability and handicap rather than to ‘acute’ healthcare.