Nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a mixed methods study

The cardiac catheterisation laboratory (CCL) is a specialised medical radiology facility where both chronic-stable and life-threatening cardiovascular illness is evaluated and treated. Although there are many potential sources of discomfort and distress associated with procedures performed in the CCL, a general anaesthetic is not usually required. For this reason, an anaesthetist is not routinely assigned to the CCL. Instead, to manage pain, discomfort and anxiety during the procedure, nurses administer a combination of sedative and analgesic medications according to direction from the cardiologist performing the procedure. This practice is referred to as nurse-administered procedural sedation and analgesia (PSA). While anecdotal evidence suggested that nurse-administered PSA was commonly used in the CCL, it was clear from the limited information available that current nurse-led PSA administration and monitoring practices varied and that there was contention around some aspects of practice including the type of medications that were suitable to be used and the depth of sedation that could be safely induced without an anaesthetist present. The overall aim of the program of research presented in this thesis was to establish an evidence base for nurse-led sedation practices in the CCL context. A sequential mixed methods design was used over three phases. The objective of the first phase was to appraise the existing evidence for nurse-administered PSA in the CCL. Two studies were conducted. The first study was an integrative review of empirical research studies and clinical practice guidelines focused on nurse-administered PSA in the CCL as well as in other similar procedural settings. This was the first review to systematically appraise the available evidence supporting the use of nurse-administered PSA in the CCL. A major finding was that, overall, nurse-administered PSA in the CCL was generally deemed to be safe. However, it was concluded from the analysis of the studies and the guidelines that were included in the review, that the management of sedation in the CCL was impacted by a variety of contextual factors including local hospital policy, workforce constraints and cardiologists’ preferences for the type of sedation used. The second study in the first phase was conducted to identify a sedation scale that could be used to monitor level of sedation during nurse-administered PSA in the CCL. It involved a structured literature review and psychometric analysis of scale properties. However, only one scale was found that was developed specifically for the CCL, which had not undergone psychometric testing. Several weaknesses were identified in its item structure. Other sedation scales that were identified were developed for the ICU. Although these scales have demonstrated validity and reliability in the ICU, weaknesses in their item structure precluded their use in the CCL. As findings indicated that no existing sedation scale should be applied to practice in the CCL, recommendations for the development and psychometric testing of a new sedation scale were developed. The objective of the second phase of the program of research was to explore current practice. Three studies were conducted in this phase using both quantitative and qualitative research methods. The first was a qualitative explorative study of nurses’ perceptions of the issues and challenges associated with nurse-administered PSA in the CCL. Major themes emerged from analysis of the qualitative data 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. The second study in Phase Two was a cross-sectional survey of nurse-administered PSA practice in Australian and New Zealand CCLs. This was the first study to quantify the frequency that nurse-administered PSA was used in the CCL setting and to characterise associated nursing practices. It was found that nearly all CCLs utilise nurse-administered PSA (94%). Of note, by characterising nurse-administered PSA in Australian and New Zealand CCLs, several strategies to improve practice, such as setting up protocols for patient monitoring and establishing comprehensive PSA education for CCL nurses, were identified. The third study in Phase Two was a matched case-control study of risk factors for impaired respiratory function during nurse-administered PSA in the CCL setting. Patients with acute illness were found to be nearly twice as likely to experience impaired respiratory function during nurse-administered PSA (OR=1.78; 95%CI=1.19-2.67; p=0.005). These significant findings can now be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered PSA in the CCL. The objective of the third and final phase of the program of research was to develop recommendations for practice. To achieve this objective, a synthesis of findings from the previous phases of the program of research informed a modified Delphi study, which was conducted to develop a set of clinical practice guidelines for nurse-administered PSA in the CCL. The clinical practice guidelines that were developed set current best practice standards for pre-procedural patient assessment and risk screening practices as well as the intra and post-procedural patient monitoring practices that nurses who administer PSA in the CCL should undertake in order to deliver safe, evidence-based and consistent care to the many patients who undergo procedures in this setting. In summary, the mixed methods approach that was used clearly enabled the research objectives to be comprehensively addressed in an informed sequential manner, and, as a consequence, this thesis has generated a substantial amount of new knowledge to inform and support nurse-led sedation practice in the CCL context. However, a limitation of the research to note is that the comprehensive appraisal of the evidence conducted, combined with the guideline development process, highlighted that there were numerous deficiencies in the evidence base. As such, rather than being based on high-level evidence, many of the recommendations for practice were produced by consensus. For this reason, further research is required in order to ascertain which specific practices result in the most optimal patient and health service outcomes. Therefore, along with necessary guideline implementation and evaluation projects, post-doctoral research is planned to follow up on the research gaps identified, which are planned to form part of a continuing program of research in this field.

Supporting context-aware process design : learnings from a design science study

Recent studies have started to explore context-awareness as a driver in the design of adaptable business processes. The emerging challenge of identifying and considering contextual drivers in the environment of a business process are well understood, however, typical methods and models for business process design do not yet consider this context. In this paper, we describe our work on the design of a method framework and appropriate models to enable a context-aware process design approach. We report on our ongoing work with an Australian insurance provider and describe the design science we employed to develop innovative and useful artifacts as part of a context-aware method framework. We discuss the utility of these artifacts in an application in the claims handling process at the case organization.

Conceptualising the learning organisation : creating a maturity framework to develop a shared understanding of the library's role in literacy and learning

Although they sit outside the formal education sector, libraries are intrinsically centres of learning where people can engage with knowledge and ideas and acquire the literacy skills that are essential for active participation in an increasingly digital society. In Australia, National and State Libraries Australasia (NSLA) has acknowledged the need to not only better understand the general concept of the library as a learning institution, but also to help the individual NSLA libraries specifically identify their capabilities in this arena. The NSLA Literacy and Learning project aimed to improve the members' organisational comprehension and practice as learning institutions and to help them conceptualise their ability to deliver literacy and learning programmes that will benefit their staff and their communities. The NSLA concept of learning institution encompassed two discrete lenses: the internal lens of the library's own organisational understanding and practice, and the external lens of the clients who engage in the literacy and learning programmes delivered by the library. The ultimate goal was to develop a matrix which could enable libraries to assess their perceived levels of maturity as learning institutions along a continuum of emerging to active capabilities. The matrix should also serve as a tool for shared understanding about the NSLA's own strategic directions in the literacy and learning space. This case study documents the evolving process of developing a learning institution maturity framework for libraries that considers individual, team and organisational learning, as well as clients' interactions with the organisation, with the goal of producing a framework that has the potential to measure the value of learning and growth in both the library's staff and the library's communities

Importance of knowledge management processes in a project-based organization : a case study of research enterprise

Knowledge Management (KM) is vital factor to successfully undertake projects. The temporary nature of projects necessitates employing useful KM practices for tackling issues such as knowledge leakiness and rework. The Project Management Office (PMO) is a unit within organizations to facilitate and oversee organizational projects. Project Management Maturity Models (PMMM) shows the development of PMOs from immature to mature levels. The existing PMMMs have focused on discussing Project Management (PM) practices, however, the management of project knowledge is yet to be addressed, at various levels of maturity. This research project was undertaken to investigate the mentioned gap for addressing KM practices at the existing PMMMs. Due to the exploratory and inductive nature of this research, qualitative methods were chosen as the research methodology. In total, three cases selected from different industries: research; mining and government organizations, to provide broad categories for research and research questions were examined using the developed framework. This paper presents the partial findings of undertaken investigation of the research organisation with the lowest level of maturity. The result shows that knowledge creation and capturing are the most important processes, while knowledge transferring and reusing are not as important as the other two processes. In addition, it was revealed that provision of “knowledge about client” and “project management knowledge” are the most important types of knowledge that are required at this level of maturity. In conclusion, the outcomes of this paper shall provide powerful guidance to PMOs at lowest level of maturity from KM point of view.

Virtual business role-play : leveraging familiar environments to prime stakeholder memory during process elicitation

Business process models have traditionally been an effective way of examining business practices to identify areas for improvement. While common information gathering approaches are generally efficacious, they can be quite time consuming and have the risk of developing inaccuracies when information is forgotten or incorrectly interpreted by analysts. In this study, the potential of a role-playing approach for process elicitation and specification has been examined. This method allows stakeholders to enter a virtual world and role-play actions as they would in reality. As actions are completed, a model is automatically developed, removing the need for stakeholders to learn and understand a modelling grammar. Empirical data obtained in this study suggests that this approach may not only improve both the number of individual process task steps remembered and the correctness of task ordering, but also provide a reduction in the time required for stakeholders to model a process view.

Process visualization techniques for multi-perspective process comparisons

Organizations executing similar business processes need to understand the differences and similarities in activities performed across work environments. Presently, research interest is directed towards the potential of visualization for the display of process models, to support users in their analysis tasks. Although recent literature in process mining and comparison provide several methods and algorithms to perform process and log comparison, few contributions explore novel visualization approaches. This paper analyses process comparison from a design perspective, providing some practical visualization techniques as anal- ysis solutions (/to support process analysis). The design of the visual comparison has been tackled through three different points of view: the general model, the projected model and the side-by-side comparison in order to support the needs of business analysts. A case study is presented showing the application of process mining and visualization techniques to patient treatment across two Australian hospitals.

Liquid Business Process Model Collections

Many organizations realize that increasing amounts of data (“Big Data”) need to be dealt with intelligently in order to compete with other organizations in terms of efficiency, speed and services. The goal is not to collect as much data as possible, but to turn event data into valuable insights that can be used to improve business processes. However, data-oriented analysis approaches fail to relate event data to process models. At the same time, large organizations are generating piles of process models that are disconnected from the real processes and information systems. In this chapter we propose to manage large collections of process models and event data in an integrated manner. Observed and modeled behavior need to be continuously compared and aligned. This results in a “liquid” business process model collection, i.e. a collection of process models that is in sync with the actual organizational behavior. The collection should self-adapt to evolving organizational behavior and incorporate relevant execution data (e.g. process performance and resource utilization) extracted from the logs, thereby allowing insightful reports to be produced from factual organizational data.

Chirp-spread-spectrum-based real time location system for construction safety management: A case study

Observing the working procedure of construction workers is an effective means of maintaining the safety performance of a construction project. It is also difficult to achieve due to a high worker-to-safety-officer ratio. There is an imminent need for the development of a tool to assist in the real-time monitoring of workers, in order to reduce the number of construction accidents. The development and application of a real time locating system (RTLS) based on the Chirp Spread Spectrum (CSS) technique is described in this paper for tracking the real-time position of workers on construction sites. Experiments and tests were carried out both on- and off-site to verify the accuracy of static and dynamic targets by the system, indicating an average error of within one metre. Experiments were also carried out to verify the ability of the system to identify workers’ unsafe behaviours. Wireless data transfer was used to simplify the deployment of the system. The system was deployed in a public residential construction project and proved to be quick and simple to use. The cost of the developed system is also reported to be reasonable (around 1800USD) in this study and is much cheaper than the cost of other RTLS. In addition, the CCS technique is shown to provide an economical solution with reasonable accuracy compared with other positioning systems, such as ultra wideband. The study verifies the potential of the CCS technique to provide an effective and economical aid in the improvement of safety management in the construction industry.

Towards an understanding of the information dynamics of the handover process in aged care settings: A prerequisite for the safe and effective use of ICT

Background Poor clinical handover has been associated with inaccurate clinical assessment and diagnosis, delays in diagnosis and test ordering, medication errors and decreased patient satisfaction in the acute care setting. Research on the handover process in the residential aged care sector is very limited. Purpose The aims of this study were to: (i) Develop an in-depth understanding of the handover process in aged care by mapping all the key activities and their information dynamics, (ii) Identify gaps in information exchange in the handover process and analyze implications for resident safety, (iii) Develop practical recommendations on how information communication technology (ICT) can improve the process and resident safety. Methods The study was undertaken at a large metropolitan facility in NSW with more than 300 residents and a staff including 55 registered nurses (RNs) and 146 assistants in nursing (AINs). A total of 3 focus groups, 12 interviews and 3 observation sessions were conducted over a period from July to October 2010. Process mapping was undertaken by translating the qualitative data via a five-category code book that was developed prior to the analysis. Results Three major sub-processes were identified and mapped. The three major stages are Handover process (HOP) I “Information gathering by RN”, HOP II “Preparation of preliminary handover sheet” and HOP III “Execution of handover meeting”. Inefficient processes were identified in relation to the handover including duplication of information, utilization of multiple communication modes and information sources, and lack of standardization. Conclusion By providing a robust process model of handover this study has made two critical contributions to research in aged care: (i) a means to identify important, possibly suboptimal practices; and (ii) valuable evidence to plan and improve ICT implementation in residential aged care. The mapping of this process enabled analysis of gaps in information flow and potential impacts on resident safety. In addition it offers the basis for further studies into a process that, despite its importance for securing resident safety and continuity of care, lacks research.

Augmenting process elicitation with visual priming: An empirical exploration of user behaviour and modelling outcomes

Business process models have become an effective way of examining business practices to identify areas for improvement. While common information gathering approaches are generally efficacious, they can be quite time consuming and have the risk of developing inaccuracies when information is forgotten or incorrectly interpreted by analysts. In this study, the potential of a role-playing approach to process elicitation and specification has been examined. This method allows stakeholders to enter a virtual world and role-play actions similarly to how they would in reality. As actions are completed, a model is automatically developed, removing the need for stakeholders to learn and understand a modelling grammar. An empirical investigation comparing both the modelling outputs and participant behaviour of this virtual world role-play elicitor with an S-BPM process modelling tool found that while the modelling approaches of the two groups varied greatly, the virtual world elicitor may not only improve both the number of individual process task steps remembered and the correctness of task ordering, but also provide a reduction in the time required for stakeholders to model a process view.

Tutorial on NK model

NK model, proposed by Kauffman (1993), is a strong simulation framework to study competing dynamics. It has been applied in some social science fields, for instance, organization science. However, like many other simulation methods, NK model has not received much attention from Management Information Systems (MIS) discipline. This tutorial, thus, is trying to introduce NK model in a simple way and encourage related studies. To demonstrate how NK model works, this tutorial reproduces several Levinthal’s (1997) experiments. Besides, this tutorial attempts to make clear the relevance between NK model and agent-based modeling (ABM). The relevance can be a theoretical basis to further develop NK model framework for other research scenarios. For example, this tutorial provides an NK model solution to study IT value cocreation process by extending network structure and agent interactions.

Optimal management of beaver population using a reduced-order distributed parameter model and single network adaptive critics

Beavers are often found to be in conflict with human interests by creating nuisances like building dams on flowing water (leading to flooding), blocking irrigation canals, cutting down timbers, etc. At the same time they contribute to raising water tables, increased vegetation, etc. Consequently, maintaining an optimal beaver population is beneficial. Because of their diffusion externality (due to migratory nature), strategies based on lumped parameter models are often ineffective. Using a distributed parameter model for beaver population that accounts for their spatial and temporal behavior, an optimal control (trapping) strategy is presented in this paper that leads to a desired distribution of the animal density in a region in the long run. The optimal control solution presented, imbeds the solution for a large number of initial conditions (i.e., it has a feedback form), which is otherwise nontrivial to obtain. The solution obtained can be used in real-time by a nonexpert in control theory since it involves only using the neural networks trained offline. Proper orthogonal decomposition-based basis function design followed by their use in a Galerkin projection has been incorporated in the solution process as a model reduction technique. Optimal solutions are obtained through a "single network adaptive critic" (SNAC) neural-network architecture.

A rational fraction polynomials model to study vertical dynamic wheel-rail interaction

This paper presents a model designed to study vertical interactions between wheel and rail when the wheel moves over a rail welding. The model focuses on the spatial domain, and is drawn up in a simple fashion from track receptances. The paper obtains the receptances from a full track model in the frequency domain already developed by the authors, which includes deformation of the rail section and propagation of bending, elongation and torsional waves along an infinite track. Transformation between domains was secured by applying a modified rational fraction polynomials method. This obtains a track model with very few degrees of freedom, and thus with minimum time consumption for integration, with a good match to the original model over a sufficiently broad range of frequencies. Wheel-rail interaction is modelled on a non-linear Hertzian spring, and consideration is given to parametric excitation caused by the wheel moving over a sleeper, since this is a moving wheel model and not a moving irregularity model. The model is used to study the dynamic loads and displacements emerging at the wheel-rail contact passing over a welding defect at different speeds.