Demand for hospital emergency departments : a conceptual understanding

BACKGROUND: Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to infl uence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs. DATA SOURCES: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand. RESULTS: Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship. CONCLUSION: This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

The role of physical activity in the lives of people with lymphoedema following cancer treatment : a social constructionist study

Lymphoedema is a chronic condition predominantly affecting the limbs, although it can involve the trunk and other areas of the body. It is characterised by swelling due to excess accumulation of fluid in body tissues. Secondary lymphoedema, which arises following cancer treatment, is the more common form of lymphoedema in developed countries. At least 20% of those diagnosed with the most common cancers will develop lymphoedema. This is a concern in Australia as incidence of these cancers is increasing. Cancer survival rates are also increasing. Currently, this equates to 9 300 new cases of secondary lymphoedema diagnosed each year. Considerable physical and psychosocial impacts of lymphoedema have been reported and its subsequent impact on health-related quality of life can exacerbate other side effects of cancer treatment. Exercise following cancer treatment has been shown to significantly reduce the impact of treatment side effects, improve quality of life and physical status. While participating in exercise does not increase risk nor exacerbate existing lymphoedema, reductions in incidence of lymphoedema exacerbations and associated symptoms have been observed in women participating in regular weight lifting following breast cancer treatment. Despite these benefits, lymphoedema prevention and management advice cautions people with lymphoedema against „repetitive use. or „overuse. of their affected arm. It is possible that this advice creates a barrier to participation in physical activity; however, little is known about the relationship between physical activity and lymphoedema. In addition, the majority of studies examining the experiences of people living with lymphoedema and the impact of the condition have been predominantly conducted internationally and have focused on women following breast cancer. This study sought to explore firstly, how men and women construct their experience of living with lymphoedema following treatment for a range of cancers in the context of everyday life in Australia; and secondly, to analyse the role of physical activity in the lives of those living with lymphoedema following cancer treatment. A social constructivist grounded theory approach was taken to explore these objectives as it is acknowledged that human actions and the meanings associated with these actions are influenced by the interaction between the self and the social world. It is also acknowledged that the research process itself is a social construction between the researcher and participant. Purposive sampling techniques were used to recruit a total of 29 participants from a variety of sources. Telephone interviews and focus groups were conducted to collect data. Data were concurrently collected and analysed and analysis was conducted using the constant comparative method. The core category that developed in objective one was „sense of self‟. The self was defined by perceptions participants held of themselves and their identity prior to a lymphoedema diagnosis and changes to their perceptions and identity since diagnosis. Three conceptual categories which related to each other and to „sense of self‟ were developed through the process of coding that represented the process of how participants constructed their experiences living with secondary lymphoedema in the context of everyday life. Firstly, altered normalcy reflected the physical and psychosocial changes experienced and the effect it had on their lives. Secondly, „accidental journey‟ reflected participants‟ journey with the heath care system prior to diagnosis through to longer term management. Thirdly, renegotiating control revealed participants perceived control over lymphoedema and their ability to participate in daily activities previously enjoyed. These findings revealed the failure of the broader health system to recognise the significant and chronic nature of a lymphoedema diagnosis following cancer treatment with greater understanding, knowledge and support from health professionals being needed. The findings also reveal access to health professionals trained in lymphoedema management, a comprehensive approach encompassing both physical and psychosocial needs and provision of practical and meaningful guidelines supported by scientific evidence would contribute to improved treatment and management of the condition. The key findings for objective two were that people with lymphoedema define physical activity in different ways. Physical activity post-diagnosis was perceived as important by most for a variety of reasons ranging from everyday functioning, to physical and psychosocial health benefits. Issues relating to the impact of lymphoedema on physical activity related to the impact on peoples‟ ability to be physically active, confusion about acceptable forms of physical activity and barriers that lymphoedema presented to being physically active. A relationship between how people construct their experiences with lymphoedema and the role of physical activity was also established. The contribution of physical activity to the lives of people living with lymphoedema following cancer treatment appeared to be influenced by their sense of self as socially constructed through their experiences prior to diagnosis and following diagnosis with lymphoedema. The influence of pre-lymphoedema habits, norms and beliefs suggests the importance of effective health promotion messages to encourage physical activity among the general population and specific messages and guidelines particular to the needs of those diagnosed with lymphoedema following cancer treatment. The influence of participant.s social constructions on the lymphoedema experience highlights the importance of improving interactions between the overall health care system and patients, providing a clear treatment plan, providing evidence-based and clear advice about participation in appropriate physical activity, which in doing so will limit the physical and psychosocial effect of lymphoedema and providing comprehensive physical and psychosocial support to those living with the condition and their families. This study has contributed to a deep understanding of people.s experiences with lymphoedema following cancer treatment and the role of physical activity in the context of daily life in Australia. Findings from this study lead to recommendations for advocacy, a comprehensive approach to diagnosis, treatment and management, and specific areas for future research.

Emergency medicine in China

With the world’s largest population of 1.3 billion, China is a rapidly developing country. In line with this development, China’s enormous health system is experiencing an unprecedented series of reforms. According to a recent official government report, China has 300, 000 health organizations, which include 60, 000 hospitals and a total number of 3.07 million beds (China NBoSoP 2006). To provide health services for the national population, as well as the substantial number of visitors, China has 1.93 million doctors and 1.34 million registered nurses (China NBoSoP 2006). From 1984 to 2004, the number of inpatients grew from about 25 to 50 million, with outpatient figures increasing from 1.1 to 1.3 billion (China MoH 2006). The scale of the health system is likely bigger than in any other countries in the world, but the quality of medical services is still among the levels of developing countries. In 2005, approximately 3.8% of inpatients (about 1.5 million)(China NBoSoP 2006) were admitted because of injury and poisoning, which created significant load for the acute health system. These increased figures are at least partly because of the development of the health system and technological health-care advances but, even with such advances, this rapid change in emergency health-care demand has created a very significant burden on existing systems...

Assessing the effectiveness of the child safety net : linkage of hospital and child protection services data on ‘maltreated’ and ‘unintentionally injured' children

-International recognition of need for public health response to child maltreatment -Need for early intervention at health system level -Important role of health professionals in identifying, reporting, documenting suspician of maltreatment -Up to 10% of all children presenting at ED’s are victims and without identification, 35% reinjured and 5% die -In Qld, mandatory reporting requirement for doctors and nurses for suspected abuse or neglect

A case study examination of the influence of cultural diversity in the multicultural nursing workforce on the quality of care and patient safety in a Saudi Arabian hospital

The purpose of the study: The purpose of this study is to investigate the influence of cultural diversity, in a multicultural nursing workforce, on the quality and safety of patient care and the work environment at King Abdul-Aziz Medical City, Riyadh region. Study background: Due to global migration and workforce mobility, to varying degrees, cultural diversity exists in most health services around the world, particularly occurring where the health care workforce is multicultural or where the domestic population comprises minority groups from different cultures speaking different languages. Further complexities occur when countries have a multicultural workforce which is different from the population for whom they care, in addition to the workers being from culturally diverse countries and with different languages. In Saudi Arabia the health system is mainly staffed by expatriate nurses who comprise 67.7% of the total number of nurses. Study design: This research utilised a case study design which incorporated multiple methods including survey, qualitative interviews and document review. Methods: The participant nurses were selected for the survey via a population sampling strategy; 319 nurses returned their completed Safety Climate Survey questionnaires. Descriptive and inferential statistics (Kruskal–Wallis test) were used to analyse survey data. For the qualitative component of the study, a purposive sampling strategy was used; 24 nurses were interviewed using a semi-structured interview technique. The documentary review included KAMC-R policy documents that met the inclusion criteria using a predetermined data abstraction instrument. Content analysis was used to analyse the policy documents data. Results: The data revealed the nurses‘ perceptions of the clinical climate in this multicultural environment is that it was unsafe, with a mean score of 3.9 out of 5. No significant difference was detected between the age groups or years of experience of the nurses and the perception of safety climate in this context; the study did reveal a statistically significant difference between the cultural background categories and the perception of safety climate. The qualitative phase indicated that the nurses within this environment were struggling to achieve cultural competence; consequently, they were having difficulties in meeting the patients‘ cultural and spiritual needs as well as maintaining a high standard of care. The results also indicated that nurses were disempowered in this context. Importantly, there was inadequate support by the organisation to manage the cultural diversity issue and to protect patients from any associated risks, as demonstrated by the policy documents and supported by the nurses‘ experiences. The study also illustrated the limitations of the conceptual framework of cultural competence when tested in this multicultural workforce context. Therefore, this study generated amendments to the model that is suitable to be used in the context of a multicultural nursing workforce. Conclusion: The multicultural nature of this nursing work environment is inherently risky due to the conflicts that arise from the different cultural norms, beliefs, behaviours and languages. Further, there was uncertainty within the multicultural nursing workforce about the clinical and cultural safety of the patient care environment and about the cultural safety of the nursing workforce. The findings of the study contribute important new knowledge to the area of patient and nurse safety in a multicultural environment and contribute theoretical development to the field of cultural competence. Specifically, the findings will inform policy and practice related to patient care in the context of cultural diversity.

Factors affecting antihypertensive treatment adherence : a Saudi Arabian perspective

Hypertension is a global health issue among the adult population. Adherence to antihypertensive medications is an effective step for better control of blood pressure and preventing the risk of complications. Several factors support or hinder hypertensive patients’ adherence. Objectives: This article reviews the factors affecting adherence to antihypertensive treatments, and reflects on these factors from a Saudi Arabian perspective. Methods: Papers and studies about antihypertensive medication adherence were reviewed from different databases including MEDLINE, PubMed, ScienceDirect and Google scholar. Results: Factors affecting antihypertensive treatments adherence are classified into three domains: Patient (e.g. sociodemographic, individual knowledge and skills), Health System, and Provider related factors.

The current workforce status of prehospital care in China

Abstract The Chinese Emergency Medicine System is primarily composed of three sectors; prehospital care, emergency department in a city hospital, and intensive care unit ward. While all sectors are integral to the system, the prehospital care system is less developed than the others. There are many possible contributors to the under-development of the prehospital care system, however, workforce issues may play a significant role. Firstly, there is no officially recognised paramedic profession in China. The staff members working in the prehospital care system are medical doctors, registered nurses, patient-carriers, and drivers. Secondly, these doctors and nurses are either over-qualified or under-qualified for practicing in the prehospital care system. Lastly, Chinese health professionals have taken actions to improve the current workforce status with initiatives such as short-term training workshops for doctors and nurses, implementation of a trial unit in a university, and development of a Major Degree of Emergency Medicine in a medical university. All of these actions are important steps toward improving the current workforce status in the prehospital care system. However, a long term workforce development plan is still essential for the Chinese system, and implementation of a professional paramedic education system in a medical university/college in China, may provide the solution. Keywords: China; emergency medicine system; health services; prehospital care system; workforce; service delivery

Review of statistical methods for disease mapping

Cancer poses an undeniable burden to the health and wellbeing of the Australian community. In a recent report commissioned by the Australian Institute for Health and Welfare(AIHW, 2010), one in every two Australians on average will be diagnosed with cancer by the age of 85, making cancer the second leading cause of death in 2007, preceded only by cardiovascular disease. Despite modest decreases in standardised combined cancer mortality over the past few decades, in part due to increased funding and access to screening programs, cancer remains a significant economic burden. In 2010, all cancers accounted for an estimated 19% of the country's total burden of disease, equating to approximately $3:8 billion in direct health system costs (Cancer Council Australia, 2011). Furthermore, there remains established socio-economic and other demographic inequalities in cancer incidence and survival, for example, by indigenous status and rurality. Therefore, in the interests of the nation's health and economic management, there is an immediate need to devise data-driven strategies to not only understand the socio-economic drivers of cancer but also facilitate the implementation of cost-effective resource allocation for cancer management...

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010 : a systematic analysis for the Global Burden of Disease Study 2010

Background Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). Methods Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. Findings Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350 000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient −0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. Interpretation Rates of YLDs per 100 000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. Funding Bill & Melinda Gates Foundation.

What relationships exist between general self efficacy, locus of control and the nursing practice environment and caring efficacy and job satisfaction?

Research Question: What relationships exist between general self efficacy, locus of control and the nursing practice environment and caring efficacy and job satisfaction? Background: Important characteristics of current nursing practice include nurses having the ability to develop and continue therapeutic relationships with patients, nurses having autonomy and control over the practice environment and nurses having more involvement in decision making. In addition, employee satisfaction is enhanced when organisations offer access to authority. Despite this, nurses continue to complain of feeling powerless in their ability to make decisions. Sample: The study population and criteria for selection included Registered Nurses in Australia who were at the time members of an Australian professional and industrial organisation. Methods: A cross-sectional survey was undertaken. Data analysis was conducted using descriptive and bivariate statistics, and structural equation modeling. Results: The model fit the data well (χ² = 2.3594, χ²/df = 2.3594 and CFI = 0.9987). Twenty four percent of variation in caring efficacy (CE) can be accounted for by general self-efficacy (GSE); work locus of control (WLC) and practice environment (PE) and 62% of the variation in job satisfaction (JS) can be accounted for by GSE, WLC and PE. All pathways were found to be significant except PE to CE. GSE positively explained CE (β = 0.38). WLC was negatively related to CE i.e., as CE scores increased WLC scores decreased (β = -0.23). Further testing of the model found CE was positively related to GSE (βZ = 0.38, p < 0.001) and negatively related to WLC (βZ = - 0.23, p = 0.001). PE was not significantly associated with CE (βZ = - 0.01, p = 0.85). JS was explained by PE, which was positively related (βZ = 0.69, p = < 0.001); GSE which was negatively related (βZ - 0 .09, p < 0.001) and WLC, which was also negatively related (βZ = - 0.20, p < 0.001). Implications for Practice Nursing and organisational leaders should ensure the development of strategies for professional development and orientation programmes which may enhance nurses’ ability to develop caring relationships and express caring behaviours to their patients and as a result improve organisational and patient outcomes. Nursing shortages and turnover rates are associated with job satisfaction and the nursing practice environment. Improving the nursing environment can produce benefits to the health system such as better job satisfaction, improved workforce retention and better patient outcomes.

Examination of factors affecting caring efficacy, job satisfaction in Australian registered nurses

Research Question: What relationships exist between general self efficacy, locus of control and the nursing practice environment and caring efficacy and job satisfaction? Background: Important characteristics of current nursing practice include nurses having the ability to develop and continue therapeutic relationships with patients, nurses having autonomy and control over the practice environment and nurses having more involvement in decision making. In addition, employee satisfaction is enhanced when organisations offer access to authority. Despite this, nurses continue to complain of feeling powerless in their ability to make decisions. Sample: The study population and criteria for selection included Registered Nurses in Australia who were at the time members of an Australian professional and industrial organisation. Methods: A cross-sectional survey was undertaken. Data analysis was conducted using descriptive and bivariate statistics, and structural equation modelling. Results: The model fit the data well (χ² = 2.3594, χ²/df = 2.3594 and CFI = 0.9987). Twenty four percent of variation in caring efficacy (CE) can be accounted for by general self-efficacy (GSE); work locus of control (WLC) and practice environment (PE) and 62% of the variation in job satisfaction (JS) can be accounted for by GSE, WLC and PE. All pathways were found to be significant except PE to CE. GSE positively explained CE (β = 0.38). WLC was negatively related to CE i.e., as CE scores increased WLC scores decreased (β = -0.23). Further testing of the model found CE was positively related to GSE (βZ = 0.38, p < 0.001) and negatively related to WLC (βZ = - 0.23, p = 0.001). PE was not significantly associated with CE (βZ = - 0.01, p = 0.85). JS was explained by PE, which was positively related (βZ = 0.69, p = < 0.001); GSE which was negatively related (βZ - 0 .09, p < 0.001) and WLC, which was also negatively related (βZ = - 0.20, p < 0.001). Implications for Practice Nursing and organisational leaders should ensure the development of strategies for professional development and orientation programmes which may enhance nurses’ ability to develop caring relationships and express caring behaviours to their patients and as a result improve organisational and patient outcomes. Nursing shortages and turnover rates are associated with job satisfaction and the nursing practice environment. Improving the nursing environment can produce benefits to the health system such as better job satisfaction, improved workforce retention and better patient outcomes.

Older drivers' crashes in Queensland, Australia

Background: The growing proportion of older adults in Australia is predicted to comprise 23% of the population by 2030. Accordingly, an increasing number of older drivers and fatal crashes of these drivers could also be expected. While the cognitive and physiological limitations of ageing and their road safety implications have been widely documented, research has generally considered older drivers as a homogeneous group. Knowledge of age-related crash trends within the older driver group itself is currently limited. Objective: The aim of this research was to identify age-related differences in serious road crashes of older drivers. This was achieved by comparing crash characteristics between older and younger drivers and between sub-groups of older drivers. Particular attention was paid to serious crashes (crashes resulting in hospitalisation and fatalities) as they place the greatest burden on the Australian health system. Method: Using Queensland Crash data, a total of 191,709 crashes of all-aged drivers (17–80+) over a 9-year period were analysed. Crash patterns of drivers’ aged 17–24, 25–39, 40–49, 50–59, 60–69, 70–79 and 80+ were compared in terms of crash severity (e.g., fatal), at fault levels, traffic control measures (e.g., stop signs) and road features (e.g., intersections). Crashes of older driver sub-groups (60–69, 70–79, 80+) were also compared to those of middle-aged drivers (40–49 and 50–59 combined, who were identified as the safest driving cohort) with respect to crash-related traffic control features and other factors (e.g., speed). Confounding factors including speed and crash nature (e.g., sideswipe) were controlled for. Results and discussion: Results indicated that patterns of serious crashes, as a function of crash severity, at-fault levels, road conditions and traffic control measures, differed significantly between age groups. As a group, older drivers (60+) represented the greatest proportion of crashes resulting in fatalities and hospitalisation, as well as those involving uncontrolled intersections and failure to give way. The opposite was found for middle-aged drivers, although they had the highest proportion of alcohol and speed-related crashes when compared to older drivers. Among all older drivers, those aged 60–69 were least likely to be involved in or the cause of crashes, but most likely to crash at interchanges and as a result of driving while fatigued or after consuming alcohol. Drivers aged 70–79 represented a mid-range level of crash involvement and culpability, and were most likely to crash at stop and give way signs. Drivers aged 80 years and beyond were most likely to be seriously injured or killed in, and at-fault for, crashes, and had the greatest number of crashes at both conventional and circular intersections. Overall, our findings highlight the heterogeneity of older drivers’ crash patterns and suggest that age-related differences must be considered in measures designed to improve older driver safety.

Deformation with coupled chemical diffusion

The deformation of rocks is commonly intimately associated with metamorphic reactions. This paper is a step towards understanding the behaviour of fully coupled, deforming, chemically reacting systems by considering a simple example of the problem comprising a single layer system with elastic-power law viscous constitutive behaviour where the deformation is controlled by the diffusion of a single chemical component that is produced during a metamorphic reaction. Analysis of the problem using the principles of non-equilibrium thermodynamics allows the energy dissipated by the chemical reaction-diffusion processes to be coupled with the energy dissipated during deformation of the layers. This leads to strain-rate softening behaviour and the resultant development of localised deformation which in turn nucleates buckles in the layer. All such diffusion processes, in leading to Herring-Nabarro, Coble or “pressure solution” behaviour, are capable of producing mechanical weakening through the development of a “chemical viscosity”, with the potential for instability in the deformation. For geologically realistic strain rates these chemical feed-back instabilities occur at the centimetre to micron scales, and so produce structures at these scales, as opposed to thermal feed-back instabilities that become important at the 100–1000 m scales.

Integrated multi-professional teams in primary care : rhetoric or reality?

Integrated multi-professional teams are crucial to ongoing health system development and need to be responsive to the increasing demands of health care such as the burgeoning rate of chronic diseases. Integrated multi-professional teams also constitute a fundamental pillar of health service delivery in primary care worldwide. The aim of these teams is to deliver care beyond simple co-location of healthcare providers, through implementing integrated practice together, rather than as a group of independent disciplines. The challenges of developing and implementing integrated multi-professional teams in busy primary care clinical environments is addressed in this paper through a conceptual framework specifically designed for primary care and a case study analysis of examples of teamwork in Australian primary care.

Understanding cultural competence in a multicultural nursing workforce : registered nurses’ experience in Saudi Arabia

Purpose In Saudi Arabia, the health system is mainly staffed by expatriate nurses from different cultural and linguistic backgrounds. Given the potential risks this situation poses for patient care, it is important to understand how cultural diversity can be effectively managed in this multicultural environment. The purpose of this study was to explore notions of cultural competence with non-Saudi Arabian nurses working in a major hospital in Saudi Arabia. Design Face-to-face, audio-recorded, semistructured interviews were conducted with 24 non-Saudi Arabian nurses. Deductive data collection and analysis were undertaken drawing on Campinha-Bacote’s cultural competence model. The data that could not be explained by this model were coded and analyzed inductively. Findings Nurses within this culturally diverse environment struggled with the notion of cultural competence in terms of each other’s cultural expectations and those of the dominant Saudi culture. Discussion The study also addressed the limitations of Campinha-Bacote’s model, which did not account for all of the nurses’ experiences. Subsequent inductive analysis yielded important themes that more fully explained the nurses’ experiences in this environment. Implications for Practice The findings can inform policy, professional education, and practice in the multicultural Saudi setting.