Unlicensed personnel administering medications to older persons living at home : a challenge for social and care services

BACKGROUND: Administration of medication to care recipients is delegated to home-care assistants working in the municipal social care, alongside responsibility for providing personal assistance for older people. Home-care assistants have practical administration skills, but lack formal medical knowledge. AIM: The aim of this study was to explore how home-care assistants perceive administration of medication to older people living at home, as delegated to them in the context of social care. METHODS: Four focus groups consisting of 19 home-care assistants were conducted. Data were analysed using qualitative content analysis. RESULTS: According to home-care assistants, health and social care depends on delegation arrangements to function effectively, but in the first place it relieves a burden for district nurses. Even when the delegation had expired, administration of medication continued, placing the statutes of regulation in a subordinate position. There was low awareness among home-care assistants about the content of the statutes of delegation. Accepting delegation to administer medications has become an implicit prerequisite for social care work in the municipality. CONCLUSIONS: Accepting the delegation to administer medication was inevitable and routine. In practice, the regulating statute is made subordinate and consequently patient safety can be threatened. The organisation of health and social care relies on the delegation arrangement to meet the needs of a growing number of older home-care recipients. IMPLICATIONS FOR PRACTICE: This is a crucial task which management within both the healthcare professions and municipal social care needs to address, to bridge the gap between statutes and practice, to create arenas for mutual collaboration in the care recipients' best interest and to ensure patient safety.

Amalgamation of health services in South-West Victoria: reinvention or survival?

In Australia 'the hospital' has long been considered the cornerstone of small, rural health services. However, this premise has been altered significantly by the introduction of casemix loading and diagnostic-related groups that promote a rationalised output-based model of management. In the light of these changes, many rural health services have struggled to reinvent themselves by establishing a range of service models such as Multi-purpose Service (MPS) and Health Streams, while maintaining traditional models (i.e. bush nursing centres, nursing homes and aged-care facilities). These changes are about survival. This paper analyses one such case in south-west Victoria, the Macarthur and District Community Outreach Service, and compares the outcomes with other similar Victorian rural health research projects. Particular attention is paid to the nature of the health services, the management of change and the proposed health outcomes for the local rural communities. In conclusion, it is argued that this study adds to the body of knowledge surrounding the construction of models of community health and development programming, These models impact upon future rural and remote area initiatives throughout Australia.

Issues in the provision of nursing care to people undergoing cardiac surgery who also have type 2 diabetes

There has been little investigation of the issues associated with caring for patients presenting for cardiac surgery with a comorbid diagnosis of diabetes although there is some evidence that the diabetes management is suboptimal. This study aimed to identify issues that patients and cardiac specialist nurses experience with the provision of inpatient services for people undergoing cardiac surgery who also have type 2 diabetes. A qualitative interpretive design, using individual interviews with patients and nurses, provided data about some of these issues. The study found that nurses had high levels of confidence in their cardiac care but little confidence in diabetes management. Patients described concerns about their diabetes care and treatment regimens. A 'typical journey' for a person with diabetes undergoing cardiac surgery was identified. The findings support the need to build increased capacity in specialist nurses to support diabetes care as a secondary diagnosis.

ACCCN national nursing workforce survey of intensive care units

A descriptive study was designed and implemented by the Australian College of Critical Care Nurses (ACCCN) Workforce Planning Advisory Committee to capture data pertaining to workforce issues of intensive care nurses. All intensive care units (ICUs) within Australia were mailed a self reporting survey. Despite a low response rate (52 per cent) and difficulty reported by respondents in gaining the appropriate data requested, the results revealed an interesting snapshot of the intensive care nursing workforce.
Types of services offered by units varied considerably; paid overtime hours were low (<2 per cent of total hours worked) and use of both part-time and agency staff was also low (10 per cent of total hours worked). Private hospitals utilised a greater proportion of part-time and agency nursing staff than public hospitals (20:10 per cent). The turnover rate for registered nursing staff was estimated at 18 per cent, with education, skill acquisition and improved communication reported as the major incentives used by managers to attract and retain staff. This study demonstrated that valuable data are currently uncaptured and recommends a more refined process of a national database to record and manage this important information for future workforce planning.

Parenting a preterm infant: experiences in a regional neonatal health services programme

In an Australian regional health service, parents’ experiences of the neonatal intensive care (NICU), neonatal nurseries and a community discharge programme were investigated. Parents from 12 families participated in an in-depth interview. Three themes captured a partial, yet significant, view of these parents’ experiences as they strived to develop their identity and competence as parents. The findings are explored as they reveal issues associated with the provision of family centred, developmental care in neonatal services. Opportunities for nurses in this context to expand and clarify their role in ways that are responsive to parenting needs are discussed.

Nursing education and graduates in Victoria : profiles for 2000, 2001, and 2002 with projections for 2003

This project is the second of two projects commissioned by the Nurse Policy Branch, Victorian Department of Human Services (VDHS). The project investigated nursing education at the undergraduate and postgraduate levels in the university sector and in the VET sector. The data gathered from the project provided VDHS with a better understanding of nurse labour force issues.

Implementation of evidence into practice : Development of a tool to improve emergency nursing care of acute stroke

Background
Stroke is an increasing global health issue that places considerable burden on society and health care services. An important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24–48 hours. The current climate of prolonged time spent in the Emergency Department (ED) means that many aspects of stroke management are now the responsibility of emergency nurses.

Aims
The aims of this paper are to: i) examine the evidence related to nursing care of acute stroke, ii) identify evidence-based elements of stroke care with most applicability to emergency nursing and iii) use evidence-based stroke care recommendations to develop a guideline for the emergency nursing management of acute stroke.

Results
Emergency nursing care of acute stroke should focus on optimal triage decisions, physiological surveillance, fluid management, risk management, and early referral to specialists.

Conclusions
The role of emergency nurses in stroke care will increase and it is important that emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes. Guidelines and decision support tools for use in emergency nursing must be practical and have high levels of clinical utility for maximum uptake in a busy clinical environment.

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.

Population ageing and the politics of demographic alarmism : implications for the nursing profession

Objectives
This article provides a brief examination of the prejudices and politics framing current public debate on population ageing in Australia and the possible implications of this for the allocation of required health and social sector resources. The role and responsibility of nurses and professional nursing organisations to engage in and influence public policy debate concerning the health and social care of older people is highlighted.

Setting
Australia

Subjects
Australia's ageing population and succeeding generations over the next 40 years

Primary argument
According to the Australian government, population ageing in Australia is poised to cause unmanageable chaos for the nation's public services. The cost of meeting the future health and social care needs of older Australians is predicted to be unsustainable. Officials argue that government has a stringent responsibility to ration current and future resources in the health and social care sector, cautioning that if this is not done, the nation's public services will ultimately collapse under the strain of the ever increasing demands placed on these services by older people. This characterisation of population ageing and its consequences to the nation's social wellbeing may however be false and misleading and needs to be questioned.

Conclusion
The nursing profession has a fundamental role to play in ensuring responsible debate about population ageing and contributing to public policy agenda setting for the effective health and social care of Australia's ageing population.

Mental health triage : towards a model for nursing practice

Mental health triage/duty services play a pivotal role in the current framework for mental health service delivery in Victoria and other states of Australia. Australia is not alone in its increasing reliance on mental health triage as a model of psychiatric service provision; at a global level, there appears to be an emerging trend to utilize mental health triage services staffed by nurses as a cost-effective means of providing mental health care to large populations. At present, nurses comprise the greater proportion of the mental health triage workforce in Victoria and, as such, are performing the majority of point-of-entry mental health assessment across the state. Although mental health triage/duty services have been operational for nearly a decade in some regional healthcare sectors of Victoria, there is little local or international research on the topic, and therefore a paucity of established theory to inform and guide mental health triage practice and professional development. The discussion in this paper draws on the findings and recommendations of PhD research into mental health triage nursing in Victoria, to raise discussion on the need to develop theoretical models to inform and guide nursing practice. The paper concludes by presenting a provisional model for mental health triage nursing practice.

Grounded theory of nursing's contribution to inpatient rehabilitation

There is growing awareness of the benefits of rehabilitation both in Australia and overseas. While the provision of rehabilitation services is not new, recognition of this type of health service as an integral part of health care has been linked to changes in the provision of acute care services, advances in medical technology, improvements in the management of trauma and an ageing population. Despite this, little attention has been paid to nursing's contribution to patient rehabilitation in Australia. The aim of this grounded theory study, therefore, was to collect and analyse nurses' reports of their contributions to patient rehabilitation and to describe and analyse contextual factors influencing that contribution. Data were collected during interviews with registered and enrolled nurses working in five inpatient rehabilitation units in New South Wales and during observation of the nurses' everyday practice. A total of 53 nurses participated in the study, 35 registered nurses and 18 enrolled nurses. Grounded theory, informed by the theoretical perspective of symbolic interactionism, was used to guide data analysis, the ongoing collection of data and the generation of a substantive theory. The findings revealed six major categories. One was an everyday problem labelled incongruence between nurses' and patients' understandings and expectations of rehabilitation. Another category, labelled coaching patients to self-care, described how nurses independently negotiated the everyday problem of incongruence. The remaining four categories captured conditions in the inpatient context which influenced how nurses could contribute to patient rehabilitation. Two categories, labelled segregation: divided and dividing work practices between nursing and allied health and role ambiguity, were powerful in shaping nursing's contribution as they acted individually and synergistically to constrain nursing's contribution to patient rehabilitation. The other two categories, labelled distancing to manage systemic constraints and grasping the nettle to realise nursing's potential, represent the mutually exclusive strategies nurses used in response to segregation and role ambiguity. From exploration of the relationship between the six categories, the core category and an interactive grounded theory called opting in and opting out emerged. In turn, this grounded theory reveals nursing's contribution to inpatient rehabilitation as well as contextual conditions constraining that contribution. The significance of these findings is made manifest through their contribution to the advancement of nursing knowledge and through implications for nursing practice and education, rehabilitation service delivery and research.

Nursing work and nursing knowledge : exploring the work of women's health nurses, patterns of power and praxis

The majority of women's health nurses in this study work in generalist community health centres. They have developed their praxis within the philosophy and policies of the broader women's health movement and primary health care principles in Australia. The fundamental assumption underlying this study is that women's health nurses possess a unique body of knowledge and clinical wisdom that has not been previously documented and explored. The epistemological base from which these nurses' operate offers important insights into the substantive issues that create and continually shape the practice world of nurses and their clients. Whether this represents a (re)construction of the dominant forms of health care service delivery for women is examined in this study. The study specifically aims at exploring the practice issues and experience of women's health service provision by women's health nurses in the context of the provision of cervical cancer screening services. In mapping this particular group of nurses practice, it sets out to examine the professional and theoretical issues in contemporary nursing and women's health care. In critically analysing the powerful discourses that shape and reshape nursing work, the study raises the concern that previous analyses of pursing work tend to universalise the structural and social subordination of nurses and nursing knowledge. This universalism is most often based on examples of midwifery and nursing work in hospital settings, and subsequently, because of these conceptualisations, all of nursing is too often deemed as a dependent occupation, with little agency, and is analysed as always in relation to medicine, to hospitals, to other knowledge forms. Denoting certain discourses as dominant proposes a relationship of power and knowledge and the thesis argues that all work relations and practices in health are structured by certain power/knowledge relations. This analysis reveals that there IX are many competing and complimentary power/knowledge relations that structure nursing, but that nursing, and in particular women's health nurses, also challenge the power/knowledge relations around them. Through examining theories of power and knowledge the analysis, argues that theoretical eclecticism is necessary to address the complex and varied nature of nursing work. In particular it identifies that postmodern and radical feminist theorising provide the most appropriate framework to further analyse and interpret the work of women's health nurses. Fundamental to the position argued in this thesis is a feminist perspective. This position creates important theoretical and methodological links throughout the whole study. Feminist methodology was employed to guide the design, the collection and the analysis. Intrinsic to this process was the use of the 'voices' of women's health nurses as the basis for theorising. The 'voices' of these nurses are highlighted in the chapters as italicised bold script. A constant companion along the way in examining women's health nurses' work, was the reflexivity with feminist research processes, the theoretical discussions and their 'voices'. Capturing and analysing descriptive accounts of nursing praxis is seen in this thesis as providing a way to theorise about nursing work. This methodology is able to demonstrate the knowledge forms embedded in clinical nursing praxis. Three conceptual threads emerge throughout the discussions: one focuses on nursing praxis as a distinct process, with its own distinct epistemological base rather than in relation to 'other' knowledge forms; another describes the medical restriction and opposition as experienced by this group of nurses, but also of their resistance to medical opposition. The third theme apparent from the interviews, and which was conceptualised as beyond resistance, was the description of the alternative discourses evident in nursing work, and this focused on notions of being a professional and on autonomous nursing praxis. This study concludes that rather than accepting the totalising discourses about nursing there are examples within nursing of resistance—both ideologically and X in practice—to these dominant discourses. Women's health nurses represent an important model of women's health service delivery, an analysis of which can contribute to critically reflecting on the 'paradigm of oppression' cited in nursing and about nursing more generally. Reflecting on women's health service delivery also has relevance in today's policy environment, where structural shifts in Commonwealth/State funding arrangements in community based care, may undermine women's health programs. In summary this study identifies three important propositions for nursing: • nursing praxis can reconstruct traditional models of health care; • nursing praxis is powerful and able to 'resist' dominant discourses; and • nursing praxis can be transformative. Joining feminist perspectives and alternative analyses of power provides a pluralistic and emancipatory politics for viewing, describing and analysing 'other' nursing work. At the micro sites of power and knowledge relations—in the everyday practice worlds of nurses, of negotiation and renegotiation, of work on the margins and at the centre—women's health nurses' praxis operates as a positive, productive and reconstructive force in health care.

Public reporting of nursing home quality of care : Lessons from the United States experience for Canadian policy discussion

While the demand for continuing care services in Canada grows, the quality of such services has come under increasing scrutiny. Consideration has been given to the use of public reporting of quality data as a mechanism to stimulate quality improvement and promote public accountability for and transparency in service quality. The recent adoption of the Resident Assessment Instrument (RAI) throughout a number of Canadian jurisdictions means that standardized quality data are available for comparisons among facilities across regions, provinces and nationally. In this paper, we explore current knowledge on public reporting in nursing homes in the United States to identify what lessons may inform policy discussion regarding potential use of public reporting in Canada. Based on these findings, we make recommendations regarding how public reporting should be progressed and managed if Canadian jurisdictions were to implement this strategy.

Quality nephrology nursing care : beyond Kt/V

Ask nephrology nurses about the care in their hemodialysis units and they will probably say that high quality care is provided. This perception may reflect a genuine pride in their own and their colleagues' hemodialysis services, however, the meaning of high quality dialysis care remains unclear. Quality is often framed in terms of the high percentage of patients receiving a Kt/V of greater than 1.2 or 1.4. The unfortunate inference here is that high quality hemodialysis care is defined as the waste clearing service of the urea molecule. Defining quality in this narrow way conflicts with the caring and compassionate nursing ethic. Furthermore, it places a high value on a single mathematically derived formula that ignores many other indicators of quality dialysis care. In this article, the authors examine some historical, political, and technical features of Kt/V and use the metaphor of a hangover to illustrate the overuse of Kt/V, arguing that nurses have embraced Kt/V at the expense of other core elements of dialysis nursing care.