Can written nursing practice standards improve documentation of initial assessment of ED patients?

Introduction: There is wide variation in emergency nursing practice in terms of initial patient assessment and the interventions implemented in response to these patient assessment findings. It is hypothesised that written ED nursing practice standards will reduce variability in documentation standards related to initial patient assessment.

Aim: This study aimed to examine the effect of written ED nursing practice standards augmented by an in-service education programme on the documentation of the initial nursing assessment.

Method: A pre-test/post-test design was used. Initial patient assessment was assessed using the Emergency Department Observation Chart. All adult patients (>18 years) who presented with chest pain and who were triaged to the general adult cubicles were eligible for inclusion in the study. Random sampling was used to select the patients for the pre-test (n = 78) and post-test groups (n = 74).

Results: There was significant improvement in documentation of all aspects of symptom assessment except quality and historical variables: pre-hospital care, cardiac risk factors, and past medical history. Improvements in documentation of elements of primary survey assessment were variable. There were significant increases in documentation of respiratory effort, chest auscultation findings, capillary refill and conscious state. There was a significant 18.3% decrease in the frequency of documentation of respiratory rate and no significant changes in documentation of oxygen saturation, heart rate or blood pressure.

Conclusion: Written ED nursing practice standards were effective in improving the documentation of some elements of initial nursing assessment for patients with chest pain. Active implementation strategies are important to ensure effective uptake of written practice standards and the relationship between nursing documentation and actual clinical practice warrants further consideration using a naturalistic approach in real practice settings.

Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department

This study examined the emergency nurse practitioner candidate (ENPC) scope of practice in a Victorian emergency department (ED). The emergency nurse practitioner (ENP) role is relatively new in Victoria and the scope of the ENP(C) practice is yet to be defined. International research literature regarding the ENP role has focused on outcomes such as patient satisfaction, waiting times and/or ED length of stay, accuracy and adequacy of documentation, use of radiography, and patient education, health promotion and communication issues. A prospective exploratory design was used to conduct this cohort study. There were 476 ENPC-managed patients between 14 July 2004 and 31 March 2005 with an average age of 29 years. The majority (77.2%) of ENPC-managed patients were discharged from the ED. The majority of the ENPC time was devoted to clinical practice (55%) and development of clinical practice guidelines (25%). Of patients managed by the ENPC, 49.6% required medications, 51% required diagnostic imaging and 8.6% required pathology testing during their ED stay. The most common discharge referrals were made to local medical officers (73.5%) and the most common referrals made for patients requiring admission were made to the plastic surgery (37.3%) and orthopaedic (35.5%) units. Extensions to the current scope of emergency nursing practice are pivotal to effective management of specific patient groups by ENP. The ENP model of care is an important strategy for the management of increased service demands in Victoria; however, little is known about the scope of the ENPC practice and many outcomes of the ENP care are yet to be defined. Further research to better understand the relationships between ENP outcomes is required if the contribution that ENPs make to emergency care is to be accurately quantified.

Asymptomatic hypoechoic regions on patellar tendon ultrasound : a 4-year clinical and ultrasound followup of 46 tendons

Patellar tendon ultrasound appearance is commonly used in clinical practice to diagnose patellar tendinopathy and guide management. Using a longitudinal study design we examined whether or not the presence of a hypoechoic ultrasonographic lesion in an asymptomatic patellar tendon conferred a risk for developing jumper's knee compared with a tendon that was ultrasonographically normal. Ultrasonographic, symptomatic and anthropometric assessment was completed at baseline and followup. Magnetic resonance imaging was performed on four tendons that resolved ultrasonographically in the study period. Forty-six patellar tendons were followed over 47±11.8 months. Eighteen tendons were hypoechoic at baseline and 28 were ultrasonographically normal. Five tendons resolved ultrasonographically in the study period. Magnetic resonance imaging in four of these tendons was normal. Seven normal patellar tendons at baseline developed a hypoechoic area but only two became symptomatic. Analysis of ultrasonography at baseline and clinical outcome with Fisher's exact test shows there is no association between baseline ultrasound changes and symptoms at followup. In this study there is no statistically significant relationship between ultrasonographic patellar tendon abnormalities and clinical outcome in elite male athletes. Management of jumper's knee should not be solely based on ultrasonographic appearance; clinical assessment remains the cornerstone of appropriate management.

Evidence based practice: are critical care nurses ready for it?

In the emergence of the evidence based practice movement, critical care nurses have struggled to identify scientific evidence on which to base their clinical practice. While the lack of critical care nursing research is a major concern, other important issues have significantly stalled the implementation of evidence even when it is available. A descriptive study of 274 critical care nurses was undertaken to examine nursing research activity in Victorian critical care units. The study aimed to identify critical care nurses' research skills, the barriers encountered in participation and implementation and the current availability of resources.

Results revealed that 42 per cent of the nurses who participated in the study believed that they were not prepared adequately to evaluate research, and less than a third believed they were sufficiently skilled to conduct valid scientific studies. An association was found between nurses' ability to confidently perform research activities and higher academic qualifications. The study found that there is a lack of organisational support and management commitment for the development of evidence based nursing.

In order to facilitate the implementation of evidence based practice, clinicians must be made aware of the available resources, be educated and mentored when carrying out and using clinical research, and be supported in professional initiatives that promote evidence based practice. It is argued that this will have positive implications for patient outcomes in the critical care environment.

Integrating cost-effectiveness evidence into clincal practice guidelines in Australia for acute myocardial infarction

 A teaching hospital is working with the Victorian State Government and universities, integrating cost-effectiveness evidence into clinical practice guidelines (CPGs), protocols and pathways for respiratory and cardiology interventions. Acute myocardial infarction (AMI) findings are reported. Results will stimulate cost-effective practice and inform medical associations, federal and state governments and international organisations developing CPGs. Published CPGs by the American College of Cardiology/American Heart Foundation for AMI in 1999 are reviewed by a large interdis- ciplinary hospital-based committee given cost-effectiveness evidence. Levels of evi- dence criteria rating on methodological rigor for effectiveness and costs are applied. National Health and Medical Research Council (NHMRC) grades of recommendation criteria for combinations of relative effectiveness versus relative costs and cut-off points are used. Extrapolating results between countries was addressed by applying the OECD's health purchasing power parity series. Recommendations for revisions to United States guidelines and for local application are formulated. United States Guide- lines require updating: Regarding angioplasty, percutaneous transluminal coronary angioplasty (PTCA) is cost-effective for men aged 60 years relative to recombinant tissue plasminogen activator (tPA),with additional cost per life year saved of 274 ecu. PTCA with discharge after 3 days is cost-effective in low-risk AMI. Regarding GP llb/Illa drugs, Abciximab during intervention incurred equal mean hospital costs for placebabciximab bolus, and abciximab bolus+ infusion with incremental 6-month cost for the latter treatment costing US$ 293 per patient. Agent recouped almost all initial therapy costs with significant benefits. Incre- mental cost of abciximab per event prevent- ed is US$ 3,258.Tirofiban was compared to placebo after high-risk angioplasty for AMI or unstable angina.Tirofiban decreased the rate of hospital deaths, myocardial infarc- tion, revascularisation at 2 days by 36% relative to placebo (8% vs. 12%) without increased cost. Clinical benefits were similar at 30 days.Tirofiban+heparin+aspirin was compared to heparin+aspirin.Tirofiban arm resulted in net savings of 33,418 ecu per 100 patients for the first 7 days of treatment. Regarding thrombolytics,tPA is more cost- effective than streptokinase. Incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasmi- nogen are 31%,45%, 97% higher in Germa- ny, Italy and the United States than in the United Kingdom. Regarding anticoagulants, enoxaparin is a promising alternative to unfractionated heparin for hospitalised patients with non-Q-wave myocardiai infarc- tion or unstable angina, saving C$ 1,485 per patient over 12 months with 10% reduction in 1 year risk of death, myocardial infarction or recurrent angina. Regarding anti- arrhymics, the cost-effectiveness of no amiodarone, amiodarone for patients with depressed heart rate variability (DHRV),and amiodarone for patients with DHRV plus positive programmed ventricular stimula- tion (PPVS) for high-risk post-AMI was investigated. Amiodarone for DHRV+PPVS patients was dominated by a blend of the two alternatives. Compared to no amioda- rone, the incremental cost-effectiveness of amiodarone for DHRV patients was US$ 39,422 per quality adjusted life year gained. Amiodarone for DHRV is the most appropriate. Other CPG updates concern serum markers, for example, cardiac troponin I assay (c-Tnl), cost advantages of ad hoc angioplasty and secondary prevention through antioxidants and pravastatin. Australian costs are reported later in the paper.

Barriers to effective management of depression in general practice

Objective: The aim of this study was to investigate the effects of prior general practice training in mental health and practice location on general practitioner (GP) attitudes toward depression, self-confidence in assessing and treating depressed patients, identification of doctor, patient and practice barriers to the effective care of depressed patients in general medical practice and GP-reported current clinical practice.

Method: Fifty-two (out of 123) Divisions of General Practice that responded to an invitation to participate in the study distributed 608 anonymous surveys to a representative sample of GPs; 420 (69%) were returned. The questionnaire focused on current clinical practice, perceived barriers to care of depressed patients and doctors' self-efficacy for assessing and treating depressed patients. It also consisted of two scales, based upon previous research, designed to assess doctors' attitudes towards depression and depressed patients.

Results: General practitioners who had undertaken mental health education and training more often used non-pharmacological treatments (p = 0.00), as did female GPs (p = 0.00). Male GPs (p = 0.00) and those in rural settings (p = 0.01) more often prescribed medication for depression. Those without mental health training more often identified incomplete knowledge about depression as a barrier to its effective management (p = 0.00). Urban-based GPs (p = 0.04) and those with prior mental health training (p = 0.00) were more confident in the use of non-pharmacological treatments. Female GPs without mental health training were the least confident in the use of these methods (p = 0.01). Overall, GPs with mental health training were more positive in their attitudes toward depression and their treatment of these patients (p = 0.00). Female GPs appeared more positive in their attitudes toward depression than male GPs (p = 0.01), although the results were not entirely consistent.

Conclusions: Participation in mental health training by GPs appears to be related to their attitudes toward depressed patients and to their confidence and abilities to diagnose and manage the common mental disorders effectively.

Selecting the right integration of research into practice strategy

Healthcare professionals need to be cognizant of integration of research into practice literature to advance clinical practice. This article describes the strengths and limitations associated with 10 currently used integration of research into practice strategies and the issues that need to be considered when selecting an appropriate strategy. Selecting the right strategy that ensures the uptake of best available evidence is an essential component of developing evidence-based practice and ultimately improving patient care.

Generation of statements for the development of clinical indicators for mental heath nursing in New Zealand : achieving a bicultural focus

Aim : In this paper, the first of 4 stages of a large study aiming to develop culturally and clinically valid clinical indicators to flag the achievement of mental health nursing standards of practice in New Zealand are described.

Methods : A bicultural design was employed throughout the research project to ensure that nurses' views of practice and the cultural differences between New Zealand's indigenous Maori and non-Maori peoples could be identified. Accordingly, separate focus groups of Maori- and non-Maori-experienced mental health nurses were asked to develop lists of statementd reflective of the Australian and New Zealand College of Mental Health Nurses' Standards of Practice in New Zealand.

Results : The focus group participants produces 473 statements, which were synthesized into 190 clinical indicator statements. In keeping with the bicultural research design, Maori and non-Maori data were analysed separately until the data were merged to provide a single set of indicator statements. Although both Maori and non-Maori groups wrote statements relevant to clinical practice, there was a difference in the way the 2 groups addressed cultural issues. The Maori focus group wrote statements about cultural issues for 4 of the 6 Standards of Practice, whereas the non-Maori focus group participants wrote statements about cultural issues for only the Standard focusing on cultural safety.

Conclusion : The research design of this project in mental health nursing was unique in that it sought the perspectives of both indigenous and non-indigenous nurses about quality mental health nursing practice related to the professional standards of practice. The involvement of Maori and non-Maori mental health nurses enhanced the cultural and clinical validity of the study and the obtained from it. The bicultural approach adopted for the study highlights the need for more mental health nursing research involving indigenous partners.

Development of a professional practice audit questionnaire for mental health nursing in Aotearoa/New Zealand

This paper reports the three-stage development of a professional practice audit questionnaire for mental health nursing in Aotearoa/New Zealand. In Study 1, clinical indicator statements (n = 99) generated from focus group data, which were considered to be unobservable in the nursing documentation in consumer case notes, were included in a three-round Delphi process. Consensus of ratings occurred for the mental health nurse and academic participants (n = 7) on 83 clinical indicator statements. In Study 2, the clinical indicator statements (n = 67) that met importance and consensus criteria were incorporated into a questionnaire, which was piloted at a New Zealand mental health service. The questionnaire was then modified for use in a national field study. In Study 3, the national field study, registered mental health nurses (n = 422) from 11 New Zealand District Health Board mental health services completed the questionnaire. Five categories of nursing practice were identified: professional and evidence-based practice; consumer focus and reflective practice; professional development and integration; ethically and legally safe practice; and culturally safe practice. Analyses revealed little difference in the perceptions of nurses from different backgrounds regarding the regularity of the nursing practices. Further research is needed to calibrate the scores on each clinical indicator statement with behaviour in clinical practice.

New Zealand development and trial of mental health nursing clinical indicators - a bicultural study

This paper describes the development and validation of bicultural clinical indicators that measure achievement of mental health nursing practice standards in New Zealand (ANZMCHN, 1995, Standards of practice for mental health nursing in New Zealand. ANZCMHN, Greenacres). A four-stage research design was utilised including focus groups, Delphi surveys, a pilot, and a national field study, with mental health nurses and consumers as participants. During the national field study, consumer files (n=327) from 11 District Health Boards, and registered nurses (n=422) completed an attitude questionnaire regarding the regularity of specific nursing and service activities. Results revealed a variation in the mean occurrence of the clinical indicators in consumer case notes of 18.5–89.9%. Five factors with good internal consistency, encompassing domains of mental health nursing required for best practice, were derived from analysis of the questionnaire. This study presents a research framework for developing culturally and clinically valid, reliable measures of clinical practice.

Does an evidence-based sedation protocol improve practice and patient outcomes in critical care?

Learning Objective 1: compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care.

Learning Objective 2: explain the contrasting international research findings on sedation protocol implementation.
Minimization of sedation in critical care patients has recently received widespread support. Professional organizations internationally have published sedation management guidelines for critically ill patients to improve the use of research in practice, decrease practice variability and shorten mechanical ventilation duration. Innovations in practice have included the introduction of decision making protocols, daily sedation interruptions and new drugs and monitoring technologies. The aim of this study was to compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care setting.

A randomized, controlled trial design was used to study 312 mechanically ventilated adult patients in a general critical care unit at an Australian metropolitan teaching hospital. Patients were randomly assigned to receive protocol directed sedation management developed from evidence based guidelines (n=153) or usual clinical practice (n=159).

The median (95% CI) duration of ventilation was 58 hrs (44–78 hrs) for patients in the non-protocol group and 79 hrs (56–93) for those patients in the protocol group (p=0.20). Results were not significant for length of stay in critical care or hospital, the frequency of tracheostomies, and unplanned extubations. A Cox proportional hazards model estimated that protocol directed sedation management was associated with a 22% decrease (95% CI: 40% decrease to 2% increase, p=0.07) in the occurrence of successful weaning from mechanical ventilation.

Few randomized controlled trials have evaluated the effectiveness of protocol-directed sedation outside of North America. This study highlights the lack of transferability between different settings and different models of care. Qualified, high intensity nursing in the Australian critical care setting facilitates rapid, responsive decisions for sedation management and an increased success rate for weaning from mechanical ventilation.

Using meta-synthesis to facilitate evidence-based practice

In a previous column, Fineout-Overholt et al. (2008) discussed the use of systematic reviews in decision making for clinical practice, focusing primarily on the quantitative studies, such as randomised controlled trials. Narrative reviews were included but in less detail; this was intentional because the synthesis of qualitative evidence is a complex process and has evoked significant discussion over the past 5 years. Consequently, this column addresses some of the process issues surrounding qualitative evidence synthesis, or meta-synthesis as it is more commonly known, and offers ideas for how evidence arising from these can be used to inform education, teaching, and practice.

Implementing a journal club in a palliative care setting : a link in the chain of evidence-based practice

This paper describes the implementation and evaluation of a journal club in a privately funded palliative care unit. Journal club meetings were initiated as part of a quality improvement process to foster the uptake of evidence-based practice. Nurses were presented with research articles each month and discussions were conducted focussing on methodological considerations of the research and implications of the research for patient care. The maximum number of attendees at any one meeting was nine and the minimum number was four. Overall, evaluations were positive about all aspects of the meetings. Attendees found that the selected articles were relevant, providing new information, stimulated discussion and reflection on clinical practice and encouraged further reading. One of the positive aspects of the meetings identified by participants was the facilitation style that enabled discussion in a safe and supportive environment. An important outcome of the meetings is the potential to explore evidence-based practices relevant to palliative care and to implement new practices or revise existing ones. As part of this process practice changes and clinical guidelines have been implemented. A dedicated facilitator with university links and a supportive organisational culture promoted club meetings as a practical way to provide clinical nurses with the opportunity to explore evidence-based research in the area of palliative care.

An evidence-based practice approach to improving nursing care of acute stroke in an Australian emergency department

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications.
Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend considerable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in patient outcomes following stroke.
Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing management of acute stroke.
Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time, Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions.
Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure (p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area
interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1% (ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns).
Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke.

Practice into theory : working collaboratively with clinicians to articulate mental health triage practice

Learning objectives: To contribute to mental health nurses understanding and knowledge of mental health triage practice through the presentation of current research findings on the topic. A specific focus of the paper will be an overview of how mental health triage practice differs across the lifespan.

Mental health triage is a highly specialised area of clinical practice for mental health nursing that is in its infancy in terms of articulating practice and theory. This paper addresses the conference theme of mental health nursing practice: new roles, new challenges by presenting the findings of a qualitative research project that investigated mental health triage/duty/intake practices across the five community mental health agencies of The Alfred Hospital, Melbourne. The overall aim of the project was to work collaboratively with clinicians to further develop the quality and consistency of mental health triage, duty, and intake clinical practice across all arms of Alfred Psychiatry. The project was designed to facilitate the expansion of the mental health triage knowledge base, and thus contribute to the further development of triage clinical practice. One of the unique aspects of the project was its triangulation across the adult triage service (acute), the two Continuing Care Teams, and the specialist psychiatric services such as the Child and Adolescent Mental Health Service, the Homeless and Outreach Psychiatric Service, and the Mobile Aged Psychiatric Service. The project employed focus group method to collect in-depth, qualitative data. A series of nine focus groups were conducted at each site, which concentrated on eliciting data on the core areas of mental health triage practice such as telephone consultation skills, mental status examination, risk assessment, decision-making, negotiation, crisis assessment, secondary consultation, and documentation. The investigation produced a considerable amount of high quality, in-depth data that was analysed using content analysis methods. The project produced data that will make a significant contribution to the expanding body of knowledge on mental health triage practice.