Clinical risk management and patient safety education for nurses : a critique

Nurses have a pivotal role to play in clinical risk management (CRM) and promoting patient safety in health care domains. Accordingly, nurses need to be prepared educationally to manage clinical risk effectively when delivering patient care. Just what form the CRM and safety education of nurses should take, however, remains an open question. A recent search of the literature has revealed a surprising lack of evidence substantiating models of effective CRM and safety education for nurses. In this paper, a critical discussion is advanced on the question of CRM and safety education for nurses and the need for nurse education in this area to be reviewed and systematically researched as a strategic priority, nationally and internationally. It is a key contention of this paper that without ‘good’ safety education research it will not be possible to ensure that the educational programs that are being offered to nurses in this area are evidence-based and designed in a manner that will enable nurses to develop the capabilities they need to respond effectively to the multifaceted and complex demands that are inherent in their ethical and professional responsibilities to promote and protect patient safety and quality care in health care domains.

Agency nursing work in acute care settings: perceptions of hospital nursing managers and agency nurse providers

• There is a paucity of research in investigating agency nursing work from the perspectives of hospital nursing managers and agency nurse providers.

• This exploratory paper examines the hospital nursing managers' and agency nurse providers' perceptions and experiences of agency nursing work.

• Individual, in-depth interviews were conducted with three agency nurse providers and eight hospital nursing managers. Because of the lack of previous research in this area, an exploratory, semi-structured interviewing technique was deemed appropriate.

• Three major themes emerged from interview data: planning for ward allocation, communication and professionalism.

• In planning for ward allocation, hospital managers were primarily concerned with maintaining adequate numbers of nursing staff in the ward settings. A major concern for agency nurse providers was inappropriate allocation of temporary staff.

• Communication was valued in different ways. While hospital managers focused on communication between the agency nurse and other permanent members of the health care team, agency providers were concerned with exchanges between agencies and hospital organizations, and between the agencies and agency nurses.

• For both groups, responsibility for professional development and the status of agency nursing as a career choice for graduate and experienced nurses were the focal aspects for consideration.

• A limitation of this study is the small number of individual interviews conducted with hospital nursing managers and agency nurse providers. Nevertheless, the findings represent the views of 11 individuals in senior managerial roles.

• The findings reinforce the need to enhance collaboration between hospitals and nursing agencies, and to examine how divergent views of agency nursing work could be reconciled – with the aim of providing quality patient care.

The TrueBlue study : is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes?

Background: In the presence of type 2 diabetes (T2DM) or coronary heart disease (CHD), depression is under diagnosed and under treated despite being associated with worse clinical outcomes. Our earlier pilot study demonstrated that it was feasible, acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors. The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD.

Methods: This is a cluster-randomised intervention trial. Eighteen general practices from regional and metropolitan areas agreed to join this study, and were allocated randomly to an intervention or control group. We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practices. In the intervention group, practice nurses (PNs) will be trained for their enhanced roles in this nurse-led collaborative care study. Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner. The PN will assess psychological, physiological and lifestyle parameters then work with the patient to set management goals. The outcome of this assessment will form the basis of a GP Management Plan document. In the control group, the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol. The primary clinical outcome will be a reduction in the depression score. The study will also measure the impact on physiological measures, quality of life and on patient attitude to health care delivered by practice nurses.

Conclusion: The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological, lifestyle and psychological risk factors for high-risk patients with co-morbid depression, diabetes or heart disease. The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care.

The personal meaning of being a diabetes nurse educator

This phenomenological study explores the lived experiences of four diabetes nurse educators, as they describe their roles and focus on what it is like to be a diabetes nurse educator, from their unique perspectives.

Sustainable workforce reform : case study of Victorian nurse practitioner roles

Nurse practitioner (NP) roles have been identified as a key strategy in the development of a sustainable and responsive health workforce. To date, the focus of research related to NP roles has been on implementation and short-term evaluation of aspects of NP care; however, little is known about the sustainability of NP roles. A major challenge for the
healthcare sector is to demonstrate long-term outcomes of NP care and shift the research focus from individual NPs to the effectiveness of healthcare teams that incorporate NPs. This paper draws on a framework of the following domains of sustainability in primary care: political, institutional, financial–economic, workforce and client (or patient) and applies these domains to NP planning in the Victorian context.

Nurse stress in hospital and satellite haemodialysis units

Focus groups of nurses from both in-centre and satellite dialysis units were undertaken followed by questionnaires. The In-centre nursing staff rated the busy-ness of the unit as the maximum stress. The mostly notable stressor for the staff at the satellite unit related to patient behaviour and the perceived unrealistic expectations of the patient followed by patients arriving unwell at the unit.

Nurses suffer stress on a daily basis in both in-centre and satellite dialysis units. The major stressors differ from in-centre to satellite dialysis units.

Horizons revealed : post anaesthetic nurse care for prisoner-patients

This qualitative study revealed the experiences of registered nurses who cared for prisoner-patients in a major public hospital setting. The study found that caring for prisoner-patients is an emotionally draining experience where knowing or imagining the prisoner-patient's crime subtly provokes registered nurses to give reactive and perfunctory care that straddles real and ideal perspectives.

Vascular access surveillance : the role of the access nurse in the renal dialysis unit.

Introduction
In January 2006, the Renal Dialysis Unit at Geelong Hospital appointed a Vascular Access Nurse. A Transonic Flow Qc HDO2 Ultrasound Dilution Monitor was purchased to monitor access flow and recirculation in arteriovenous fistulae in an attempt to predict AVF stenoses requiring early surgical correction.

Methods
A bi-monthly monitoring program tested all facility-based patients. 82 patients were assessed for access flow and recirculation between February and December 2006.

Results
18 (22%) had poor AVF function; 13 with access flows <500ml/minute on initial testing and 5 with an access flow decreasing >25% over a four month period. Of the 18 patients shown to have poor access flow, 2 died within one month of measurement while 5 were too frail to attempt corrective surgery. The remaining 11 proceeded to ultrasound or fistulography. A >50% stenosis was detected in all 11 cases. Of these, 4 had successful vein patch surgery and one had PTFE grafting, each with marked improvement in access flow. One had failed vein patch surgery requiring creation of a femoral AVF, one patient required cvc insertion to await AVF creation, and one had failed stenting requiring a permanent cvc. 3 died before planned surgery.

Conclusion
5 of the 82 patients that had access flow assessment, and needed further evaluation, proceeded to successful pre-emptive surgical intervention. We believe the Transonic is a useful adjunct to routine clinical AVF surveillance, in providing early evidence of AVF failure that can be avoided by pre-emptive surgery.

The impact of nurse-led education on haemodialysis patients' phosphate binder medication adherence

Background Phosphate binder medication adherence is required to maintain optimal phosphate levels and minimise bone disease in people with end stage kidney disease.

Objectives To examine the impact of a nurse-led education intervention on bone disorder markers, adherence to phosphate binder medication and medication knowledge.

Design Descriptive study with a paired pre–post intervention survey.

Participants Adults receiving haemodialysis.

Methods Twelve-week intervention where patients self-administered their phosphate binder medication at each dialysis treatment. Nurses provided individualised education. Patients completed a pre- and post-intervention survey designed to explore their knowledge of phosphate binders.

Results There were no statistically significant changes in clinical markers but a significant improvement in the proportion of patients who took their phosphate binder correctly, increasing from 44 to 72% (p = 0.016). There were moderate to large effect size changes for improved knowledge.

Conclusions A nurse-led intervention education programme can increase patients' phosphate binder adherence. However, this does not necessarily manifest into improved serum phosphate levels.

A nurse managed kidney disease program in regional and remote Australia

Health services that aim to prevent and manage chronic kidney disease (CKD) in rural and remote Aboriginal communities in Australia, including the Goldfields region of Western Australia (WA), require innovative approaches. Nursing roles can significantly improve access to renal services in rural and remote areas as they are able to address a range of renal health promotion and prevention activities, and provide renal clinical education and support to Aboriginal people. The Goldfields Kidney Disease Nursing Management Program (GKDNMP), funded through the Council of Australian Governments (COAG) National Partnership Agreements, was developed to provide a comprehensive approach to primary health care that incorporates a range of health promotion and disease management activities. In the first year, the program increased home dialysis rates and decreased patient travel due to expanded access to renal care within the region. Context-specific health programs generated in response to local needs can be successful in addressing specific health care challenges in rural and remote health.

Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents and angiotensin receptor blockers for patients with left ventricular systolic dysfunction

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effects of nurse-led titration of ACEIs, beta-adrenergic blocking agents and ARBs in patients with left ventricular systolic dysfunction in terms of safety and patient outcomes.

Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach

Aim.  To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. Background.  Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management. Design.  Systematic review. Method.  The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage). Results.  Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase. Conclusions.  Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design. Relevance to clinical practice.  To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family.

Risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a matched case-control study

Background
Side effects of the medications used for procedural sedation and analgesia in the cardiac catheterisation laboratory are known to cause impaired respiratory function. Impaired respiratory function poses considerable risk to patient safety as it can lead to inadequate oxygenation. Having knowledge about the conditions that predict impaired respiratory function prior to the procedure would enable nurses to identify at-risk patients and selectively implement intensive respiratory monitoring. This would reduce the possibility of inadequate oxygenation occurring.

Aim
To identify pre-procedure risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Design
Retrospective matched case–control.

Methods
21 cases of impaired respiratory function were identified and matched to 113 controls from a consecutive cohort of patients over 18 years of age. Conditional logistic regression was used to identify risk factors for impaired respiratory function.

Results
With each additional indicator of acute illness, case patients were nearly two times more likely than their controls to experience impaired respiratory function (OR 1.78; 95% CI 1.19–2.67; p = 0.005). Indicators of acute illness included emergency admission, being transferred from a critical care unit for the procedure or requiring respiratory or haemodynamic support in the lead up to the procedure.

Conclusion
Several factors that predict the likelihood of impaired respiratory function were identified. The results from this study could be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory: a qualitative study

Aims and objectives
To explore issues and challenges associated with nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory from the perspectives of senior nurses.

Background
Nurses play an important part in managing sedation because the prescription is usually given verbally directly from the cardiologist who is performing the procedure and typically, an anaesthetist is not present.

Design
A qualitative exploratory design was employed.

Methods
Semi-structured interviews with 23 nurses from 16 cardiac catheterisation laboratories across four states in Australia and also New Zealand were conducted. Data analysis followed the guide developed by Braun and Clark to identify the main themes.

Results
Major themes emerged from analysis regarding the lack of access to anaesthetists, the limitations of sedative medications, the barriers to effective patient monitoring and the impact that the increasing complexity of procedures has on patients' sedation requirements.

Conclusions
The most critical issue identified in this study is that current guidelines, which are meant to apply regardless of the clinical setting, are not practical for the cardiac catheterisation laboratory due to a lack of access to anaesthetists. Furthermore, this study has demonstrated that nurses hold concerns about the legitimacy of their practice in situations when they are required to perform tasks outside of clinical practice guidelines. To address nurses' concerns, it is proposed that new guidelines could be developed, which address the unique circumstances in which sedation is used in the cardiac catheterisation laboratory.

Relevance to clinical practice
Nurses need to possess advanced knowledge and skills in monitoring for the adverse effects of sedation. Several challenges impact on nurses' ability to monitor patients during procedural sedation and analgesia. Preprocedural patient education about what to expect from sedation is essential.