Future of medical engagement

Although it has long been recognised that doctors play a crucial role in the effectiveness and efficiency of health organisations, patient experience and clinical outcomes, over the past 20 years the topic of medical engagement has started to garner significant international attention. Australia currently lags behind other countries in its heedfulness to, and evidence base for, medical engagement. This Perspective piece explores the link between medical engagement and health system performance and identifies some key questions that need to be addressed in Australia if we are to drive more effective engagement.

The influence of patient complexity and nurses` experience on haemodynamic decision-making following cardiac surgery

Critical care nurses’ haemodynamic decision-making in the immediate postoperative cardiac surgical context is complex. To optimise patient outcomes, nurses of varying levels of experience are required to make complex decisions rapidly and accurately. In a dynamic clinical context such as critical care, the quality of such decision-making is likely to vary considerably. The aim of this study was to describe variability of nurses’ haemodynamic decision-making in the 2-hour period after cardiac surgery as a function of interplay between decision complexity, nurses’ levels of experience, and the support provided. A descriptive study based on naturalistic decision-making was used. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses’ decision-making was influenced by interplay between the complexity of patients’ haemodynamic presentations, nurses’ levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. Two factors specifically influenced decision-making quality: nurses’ utilisation of evidence for practice and the experience levels of both nurses and their colleagues. The findings have implications for staff resourcing decisions and postoperative patient management, and may be used to inform nurses’ professional development and education.

Communication at the bedside to enhance patient care : a survey of nurses’ experience and perspective of handover

Strategies to support continuity of care and improve patient safety during clinical handover have been developed. The aims of this study were to identify the strengths and limitations in current practice of nursing clinical handover and implement a new bedside handover process. A total of 259 nurses completed a cross-sectional survey at change of shift on 1 day, which was followed by an audit of the pilot implementation of bedside handover. The survey results showed great variation in the duration, location and method of handover with significant differences in the experience of nurses employed part-time compared with full-time. Following implementation of standardized bedside handover on two wards, the audit revealed significant improvement in the involvement of patients, use of Situation-Background-Assessment-Recommendation, active patient checks and checking of documentation. These findings suggest the use of standardized protocols and communication tools for bedside handover improve continuity of patient care

Understanding the experience of inpatient rehabilitation: insights into patient-centred care from patients and family members

The aim of the study was describe the experiences, needs and preferences of recent inpatients of a rehabilitation centre, and the needs of their families. Data were collected in four focus groups, two with patients (n = 13) who had recently completed inpatient rehabilitation following an illness, injury or elective surgery, and two with family members (n = 11). During the focus groups, two researchers facilitated discussion on any topic that participants considered important to the experience of inpatient rehabilitation; participants were encouraged to describe their care, needs and preferences. The focus group discussions were audio-taped and transcribed verbatim. Field notes were hand recorded. Data were analysed and collated into themes. Six key themes emerged. Participants wanted: interactions with friendly, empathetic staff; regular contact with senior staff and all staff to introduce themselves by name and profession; timely communication of accurate information; and rehabilitation services seven days a week. The physical environment had both positive and negative effects on patient well-being. Patients with complex or atypical circumstances required special attention to ensure their needs were met. In conclusion, patients and families identified six important issues that need to be considered during inpatient rehabilitation.

How new graduate nurses experience patient death : a systematic review and qualitative meta-synthesis

Background

Patient death is an emotional and demanding experience for nurses, especially for new graduate nurses who are unprepared to deliver end-of-life care. Understanding new graduate nurses’ experience of death and dying will inform the design of training programs and interventions for improvements in the quality of care and support of new graduates.

Objective

To summarize new graduate nurses’ experience with patient death by examining the findings of existing qualitative studies.

Design

Systematic review methods incorporating meta-synthesis were used.

Methods

A comprehensive search was conducted in 12 databases from January 1990 to December 2014. All qualitative and mixed-method studies in English and Chinese that explored new graduate nurses’ experience of patient death were included. Two independent reviewers selected the studies for inclusion and assessed each study quality. Meta-aggregation was performed to synthesize the findings of the included studies.

Results

Five primary qualitative studies and one mix-method study met inclusion and quality criteria. Six key themes were identified from the original findings: emotional experiences, facilitating a good death, support for family, inadequacy on end-of-life care issues, personal and professional growth and coping strategies. New graduate nurses expressed a variety of feelings when faced with patient death, but still they tried to facilitate a good death for dying patients and provide support for their families. The nurses benefited from this challenging encounter though they lacked of coping strategies.

Experience with and attitudes toward psychotherapy and antidepressants among patients with inflammatory bowel disease and functional gastrointestinal disorders: an online patient survey to inform system design

This study aimed to explore and compare experiences with and attitudes toward psychotherapy and antidepressants of patients with inflammatory bowel disease (IBD) and functional gastrointestinal disorders (FGiDs). Patients from gastroenterology clinic databases were invited to an online survey. Student's t test, Mann-Whitney U test, chi-square test, and Fisher's test were used to compare patients with IBD and FGiD on demographics and variables of interest. Of 86 participants, 56 (65%) had IBD and 30 (35%) had FGiDs. Mean levels of anxiety, depressive, and stress symptoms were within the moderate to severe range. Psychological care and antidepressants were offered to significantly more FGiD than to IBD respondents (37% vs. 9%; p = .009). Although the symptoms were generally reduced after the prescription of antidepressants, only 30% of IBD respondents and 21% of FGiD respondents using antidepressants would recommend them to others. In contrast, 53% of IBD respondents and 69% of FGiD respondents who used psychotherapy would recommend it to others. Both these therapies were valued by recipients; however, neither was reported to improve gastrointestinal (GI) symptoms. Given the high desire for and positive experiences of psychological care for these 2 common GI conditions, access to formal psychological support services within GI clinics would appear to be the most efficient model.

An Australian experience of managing pressure ulcers in persons with SCI

Pressure ulcers are a difficult and complex problem, frequently resulting in poor patient outcomes ,and significantly increased cost of care. This project evolved from a desire to improve the management and subsequent outcomes for persons with spinal cord injury (SCI) who experience pressure ulcers acquired in the community. The vast body of work related to pressure ulcers has focused on risk assessment and prevention. However, there has been little interest in the management of prevailing pressure ulcers. Using a retrospective case history audit and interviews with patients and health care workers from an Australian spinal services unit, current practices associated with the care of pressure ulcers are described. A number of issues are identified that relate to funding, diet, attitudes, consistency of care, and low levels of staff interest in pressure ulcer management. This work provides baseline data from which current management practices can be reviewed, revised, and empirically evaluated.

Direct patient contacts of dietetic students during their final clinical placement

Direct student-patient contacts, during the professional clinical placement of a Master of Nutrition and Dietetics course, were collected and analysed for the first time using a computerised method. In the final eight-week hospital placement, 26 dietetic students submitted data on direct patient contacts which included: dietetic activities (e.g. assessing, counselling and reviewing); the primary nutritional condition of the patient (e.g. type 2 diabetes and liver disease); and the time spent in contact with patients. The most common dietetic activities were reviews, followed by collection of dietary information and counselling. The most common nutritional condition encountered by students was an inadequate nutrient intake, followed by patients receiving enteral nutrition. Contact time with patients increased over the placement, with proportionately more time spent by students seeing patients independently than when being observed by supervising dietitians. The data collected provided valuable informa tion on the amount of time spent by students in direct patient contacts, the range of dietetic activities undertaken and the amount of time student activities were directly observed. This information will be useful in the development of benchmarks for clinical skill development, hospital and university staff planning and the assessment of the impact of any changes to the format of student placement experience in the clinical setting.

Do knowledge and experience have specific roles in triage decision-making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.

Registered nurses` lived experience of advocacy within a critical care nuit: a phenomenological study

Anecdotally, it has often been expressed by registered nurses (RNs) working within critical care environments that they are patient advocates. However, to date, little systematic research has been undertaken to validate this assertion. Thus this project, which explored the lived experience of RNs working within a critical care unit in a country area of Australia, was conceived.

The five participants of this study were all Division 1 RNs possessing a critical care certificate and a minimum of 4 years' nursing experience. Through their participation in an in-depth audiotaped interview they revealed a wealth of experiences and ideas about their involvement as patient advocates. The results of this research indicate that the phenomenon of nurse advocacy is a multi-faceted process and embraces many kinds of activities that nurses engage in on behalf of their clients.

The findings of this study indicate that some of the participants' experiences are congruent with elements of advocacy contained within the nursing literature and statements of professional nursing bodies. However, there are some findings in this study that are not consistent with available literature. For instance, these participants markedly reject the notion that advocacy is an inappropriate concept for nurses, despite suggestions in the literature that this is an inappropriate role. Instead they wholeheartedly embrace this role, asserting it as central to their practice. Further, although the literature identifies potential controversies regarding enactment of the role of advocacy, the participants of this study are silent on these matters. It is not known what this silence implies and, in light of the study findings, it is recommended that nursing organisations, theorists and clinicians consider whether it is worthwhile to more clearly confirm the nature and role of advocacy within Australian nursing.

Integrating partners into erectile dysfunction treatment: improving the sexual experience for the couple

Introduction: Erectile dysfunction (ED) is a common condition estimated to affect more than 150 million men worldwide. ED should be regarded as a shared sexual problem which has significant detrimental effects both on the men who experience this condition and on their partners.
Evidence to support partner involvement in ED therapy: Evidence shows that the partner plays a key supportive role in the man's ED treatment and in successful long-term ED therapy. Including the partner in consultations may highlight discordant attitudes and communication problems between couple members which may indicate treatment acceptance or rejection, or realistic or unrealistic treatment expectations.
Options for partner involvement in ED therapy: Most patients with ED consult their physician in the absence of their partner. Therefore, involving the partner in therapy can be challenging. Two options which physicians should consider are: encouraging the patient to bring the partner into the office and, often more realistically, seeking information about, and providing information to, the partner, via the patient.
Objectives: The objective of these recommendations is to provide practical guidance on treating couples affected by ED, and suggest techniques that may be helpful in integrating the partner into the process of ED treatment.

Do mass media campaigns capture and describe the experience of stroke symptoms?

Introduction: In 2006, the National Stroke Foundation of Australia launched the FAST (Face, Arm, Speech)/ Signs of Stroke (SOS) (5 symptom categories) campaigns designed to improve public awareness of stroke symptoms and the sense of urgency to present to hospital. However, there is little published review of how well such campaigns capture and describe the experience of stroke. This study aims to examine the awareness, content and language of the FAST/SOS campaigns by those experiencing stroke symptoms.
Methods: Interviews were conducted with either the stroke patient or a witness (incapacitated patients) whilst an inpatient at Box Hill or Maroondah Hospitals between August 2006 through April 2008. They were asked to describe awareness of campaigns, symptoms experienced (recorded verbatim and coded into campaign symptom categories) and to evaluate the descriptions of “Signs of Stroke” against their own experience (exact, somewhat, or not at all).
Results: Of 239 eligible stroke cases, 167 (70%) were interviewed (100 patients and 67 witnesses). Few (n= 20, 12%) were aware of the FAST campaign and only 16% recalled all three symptoms. Most recalled that it was “something” to do with the face, however facial droop (n=6) was less commonly experienced compared to speech impairments (n=16) and arm drift (n=13). FAST symptoms detected 84% (patients 77% and witnesses 94%) and SOS symptoms 100% of stroke patients. Patients not describing a FAST symptom (n=27) described: arm or hand numbness; hand incoordination; leg impairments; vision disturbances; or collapse. Approximately, half of patients and witnesses thought the SOS descriptions of the most commonly detected symptoms (arm/leg/face weakness or paralysis or numbness and speech impairments) exactly described the experience. Common language used to describe symptoms were: incoordination of hands or limbs; sudden difficulty walking; drooped/dropped face or mouth; slurred or loss of speech; pins and needles or tingling.
Conclusion: Both campaigns identified symptoms most commonly detected in those experiencing and reacting to symptoms. Both campaigns could portray symptoms more realistically using common descriptors without impacting on the simplicity of the messages

Reflexivity in nursing : where is the Patient? Where is the Nurse?

Drawing upon forty years of nursing experience, in this paper we are reflexive about four issues relative to nursing clinical practices: seeking technological solutions to health and ill-health; moving from the nurse-patient relationship to the patient-healer relationship; utilising critical pathways; and, supporting evidence-based nursing. We examine current nursing practices and ask probing questions to generate debate. Most of all, we encourage nurses to engage in reflexivity and not to lose sight of their selves (knowledge, expertise and skills), and their patients' voices and subjectivity, in their contribution to health care.