The impact of nurse practitioner services on cost, quality of care, satisfaction and wait times in the emergency department: A systematic review

Aims To provide the best available evidence to determine the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department for adult patients. Background The delivery of quality care in the emergency department is one of the most important service indicators in health delivery. Increasing service pressures in the emergency department have resulted in the adoption of service innovation models: the most common and rapidly expanding of these is emergency nurse practitioner services. The rapid uptake of emergency nurse practitioner service in Australia has outpaced the capacity to evaluate this service model in terms of outcomes related to safety and quality of patient care. Previous research is now outdated and not commensurate with the changing domain of delivering emergency care with nurse practitioner services. Data A comprehensive search of four electronic databases from 2006-­‐2013 was conducted to identify research evaluating nurse practitioner service impact in the emergency department. English language articles were sought using MEDLINE, CINAHL, Embase and Cochrane and included two previous systematic reviews completed five and seven years ago. Methods A three step approach was used. Following a comprehensive search, two reviewers assessed identified studies against the inclusion criteria. From the original 1013 studies, 14 papers were retained for critical appraisal on methodological quality by two independent reviewers and data extracted using standardised tools. Results Narrative synthesis was conducted to summarise and report the findings as insufficient data was available for meta-­‐analysis of results. This systematic review has shown that emergency nurse practitioner service has a positive impact on quality of care, patient satisfaction and waiting times. There was insufficient evidence to draw conclusions regarding impact on costs. Conclusion Synthesis of the available research attempts to provide an evidence base for emergency nurse practitioner service to guide healthcare leaders, policy makers and clinicians in reforming emergency department service provision. The findings suggest that further quality research is required for comparative measures of clinical and service effectiveness of emergency nurse practitioner service. In the context of increased health service demand and the need to provide timely and effective care to patients, such measures will assist in delivering quality patient care.

What parents value from formal support services in the context of identified child abuse

Parents whose children are identified as having experienced or being at risk of experiencing significant harm potentially provide an invaluable dimension to our understanding of the circumstances that result in child abuse or neglect and how best to respond to these invariably complex situations. This paper reports findings from a study of the experiences of six parents. In-depth interviews were conducted with four mothers and two fathers who had been referred to an intensive family support services by the Queensland statutory child protection authority. Using a critical ecological perspective, the study focused on identifying and understanding the experiences of the parents in using formal family support services, including aspects of service delivery that were helpful or unhelpful. Parents also commented on their experiences of statutory child protection services. Service components and worker qualities that parents identified as being helpful included being accessible, targeted and integrated and being able to meet a continuum of needs, from a micro to a broader level. Their reports provide invaluable insight into how formal family support services, including child protection services, can better meet the needs of parents in addressing the recurring problem of child maltreatment.

Profiling emergency nurse practitioner service

The aim of this study was to investigate the practice profile of emergency nurse practitioners across Australia. Nurse practitioners have been providing health service in the emergency setting internationally for more than 30 years, and evidence supports the value of this role in terms of patient satisfaction, effectiveness in improving service indicators, and acceptability of the role. The introduction of this service model has been instrumental in reducing waiting times for low-acuity patients and impacting positively on emergency department service delivery. Recent rapid uptake of this role internationally has outpaced development of the service model to inform education and ongoing service development. This was a national study that used interpretive research methods to identify the practice profile of emergency nurse practitioners. Data were collected from December 2012 to February 2013 through in-depth interviews. An inductive approach was used in data analysis to identify conceptual themes and develop an analysis framework. The study participants worked in a range of service models and managed patient presentations across all levels of acuity and complexity. The findings show that although there is no single definable model of the emergency nurse practitioner role in Australia, there are practice features that are common across all service models; these have been conceptualized as "modes of practice." This study has produced new knowledge about the practice profile of emergency nurse practitioners. The findings will inform development of practice standards for education and continuing professional development for emergency nurse practitioners and facilitate standardized operational definitions for ongoing research into this growing service model.

Recognising emotional expressions of complaining customers : A cross-cultural study

Purpose This study aims to test service providers’ ability to recognise non-verbal emotions in complaining customers of same and different cultures. Design/methodology/approach In a laboratory study, using a between-subjects experimental design (n = 153), we tested the accuracy of service providers’ perceptions of the emotional expressions of anger, fear, shame and happiness of customers from varying cultural backgrounds. After viewing video vignettes of customers complaining (with the audio removed), participants (in the role of service providers) assessed the emotional state of the customers portrayed in the video. Findings Service providers in culturally mismatched dyads were prone to misreading anger, happiness and shame expressed by dissatisfied customers. Happiness was misread in the displayed emotions of both dyads. Anger was recognisable in the Anglo customers but not Confucian Asian, while Anglo service providers misread both shame and happiness in Confucian Asian customers. Research limitations/implications The study was conducted in the laboratory and was based solely on participant’s perceptions of actors’ non-verbal facial expressions in a single encounter. Practical implications Given the level of ethnic differences in developed nations, a culturally sensitive workplace is needed to foster effective functioning of service employee teams. Ability to understand cultural display rules and to recognise and interpret emotions is an important skill for people working in direct contact with customers. Originality/value This research addresses the lack of empirical evidence for the recognition of customer emotions by service providers and the impact of cross-cultural differences.

Government grants - an abrogation or management of risks?

New public management (NPFM), with its hands-on, private sector-style performance measurement, output control, parsimonious use of resources, disaggreation of public sector units and greater competition in the public sector, has significantly affected charitable and nonprofit organisations delivering community services (Hood, 1991; Dunleavy, 1994; George & Wilding, 2002). The literature indicates that nonprofit organisations under NPM believe they are doing more for less: while administration is increasing, core costs are not being met; their dependence on government funding comes at the expense of other funding strategies; and there are concerns about proportionality and power asymmetries in the relationship (Kerr & Savelsberg, 2001; Powell & Dalton, 2011; Smith, 2002, p. 175; Morris, 1999, 2000a). Government agencies are under increased pressure to do more with less, demonstrate value for money, measure social outcomes, not merely outputs and minimise political risk (Grant, 2008; McGreogor-Lowndes, 2008). Government-community service organisation relationships are often viewed as 'uneasy alliances' characterised by the pressures that come with the parties' differing roles and expectations and the pressures that come with the parties' differing roles and expectations and the pressurs of funding and security (Productivity Commission, 2010, p. 308; McGregor-Lowndes, 2008, p. 45; Morris, 200a). Significant community services are now delivered to citizens through such relationships, often to the most disadvantaged in the community, and it is important for this to be achieved with equity, efficiently and effectively. On one level, the welfare state was seen as a 'risk management system' for the poor, with the state mitigating the risks of sickness, job loss and old age (Giddens, 1999) with the subsequent neoliberalist outlook shifting this risk back to households (Hacker, 2006). At the core of this risk shift are written contracts. Vincent-Jones (1999,2006) has mapped how NPM is characterised by the use of written contracts for all manner of relations; e.g., relgulation of dealings between government agencies, between individual citizens and the state, and the creation of quais-markets of service providers and infrastructure partners. We take this lens of contracts to examine where risk falls in relation to the outsourcing of community services. First we examine the concept of risk. We consider how risk might be managed and apportioned between governments and community serivce organisations (CSOs) in grant agreements, which are quasiy-market transactions at best. This is informed by insights from the law and economics literature. Then, standard grant agreements covering several years in two jurisdictions - Australia and the United Kingdom - are analysed, to establish the risk allocation between government and CSOs. This is placed in the context of the reform agenda in both jurisdictions. In Australia this context is th enonprofit reforms built around the creation of a national charities regulator, and red tape reduction. In the United Kingdom, the backdrop is the THird Way agenda with its compacts, succeed by Big Society in a climate of austerity. These 'case studies' inform a discussion about who is best placed to bear and manage the risks of community service provision on behalf of government. We conclude by identifying the lessons to be learned from our analysis and possible pathways for further scholarship.

Patient group directions : the application and integration of knowledge in advancing nursing practice

Background: The introduction of Patient Group Directions (PGD) has changed significantly the way in which nurses can now administer prescription only medicines as a one-off for patients requiring this level of service. PGD’s are a written authority to administer drugs to patients that are not identified at the time of treatment. Aim: The aim of this project was to develop a PGD for use within an Outreach team to administer colloid boluses to patients presenting with hypovolemia. Method: Using a case exemplar this paper will discuss the development of a PGD using aspects of transitional change theory to highlight the potential barriers that were encountered. Implications for Practice: The implications for this PGD are wide reaching. First it now enables members from the nursing Outreach team to administer colloid fluid boluses to a prescribed patient cohort without the need for prescription. Second, it ensures the deteriorating patient has interventions initiated in a timely and appropriate manner to reduce inadvertent admission to high care areas. Last, it will improve inter-professional team-working and communication so much so that collaborative patient care reduces health costs and identifies earlier those patients requiring substantially greater nursing and medical input. Conclusion: The experience of developing a working PGD for fluid administration has meant that the Outreach team is able to respond to patients in a more effective way. In addition, it is the experience of developing this PGD that has enabled the team to contemplate other PGD’s in the execution of Outreach work.

Explicit finite element modelling of bridge girder bearing pedestals

Bridge girder bearings rest on pedestals to transfer the loading safely to the pier headstock. In spite of the existence of industry guidelines, due to construction complexities, such guidelines are often overlooked. Further, there is paucity of research on the performance of pedestals, although their failure could cause exorbitant maintenance costs. Although reinforced concrete pedestals are recommended in the industry design guidelines, unreinforced concrete and/ or epoxy glue pedestals are provided due to construction issues; such pedestals fail within a very short period of service. With a view to understanding the response of pedestals subject to monotonic loading, a three-dimensional nonlinear explicit finite element micro-model of unreinforced and reinforced concrete pedestals has been developed. Contact and material nonlinearity have been accounted for in the model. It is shown that the unreinforced concrete pedestals suffer from localised edge stress singularities, the failure of which was comparable to those in the field. The reinforced concrete pedestals, on the other hand, distribute the loading without edge stress singularity, again conforming to the field experience.

A data mining based method for discovery of web services and their compositions

Due to the availability of huge number of web services, finding an appropriate Web service according to the requirements of a service consumer is still a challenge. Moreover, sometimes a single web service is unable to fully satisfy the requirements of the service consumer. In such cases, combinations of multiple inter-related web services can be utilised. This paper proposes a method that first utilises a semantic kernel model to find related services and then models these related Web services as nodes of a graph. An all-pair shortest-path algorithm is applied to find the best compositions of Web services that are semantically related to the service consumer requirement. The recommendation of individual and composite Web services composition for a service request is finally made. Empirical evaluation confirms that the proposed method significantly improves the accuracy of service discovery in comparison to traditional keyword-based discovery methods.

Are Australia’s universities in deficit? A tale of generic managers, audit culture, and casualisation

Managerial changes to Australian universities have had considerable impact on employees. In this paper we consider some of these changes and apply a theory known as the democratic deficit to them. This theory was developed from the democratic critique of managerialism, as it has been applied in the public sector in countries with Westminster-type political systems. This deficit covers the weakening of accountability through politicisation, the denial of public values through the use of private sector performance practices, and the hollowing out of the state through the contracting out and privatisation of public goods and services, and the redefinition of citizens as customers and clients. We suggest that the increased power of managers, expansion of the audit culture, and the extensive use of contract employment seem to be weakening the democratic culture and role of universities in part by replacing accountability as responsibility with accountability as responsiveness.

Child and youth sport in rurally remote regions of Australia: the views of a north Queensland community

This study addresses the under-researched area of community sport in rurally isolated contexts. Data were gathered using semi-structured interviews with teachers, children, parents, and local community members from a small township in an isolated North Queensland region. The data indicate that community sport for young people is circumstantially difficult in some regional centres, but is none-the-less viewed differently by different sectors of the community. There is much value ascribed to sport as part of the social and cultural capital of the area however, it appears that community opinion is divided on the quality of sport experiences available with the young people of the community being particularly critical of the facilities, equipment, and the level of service from sports organisations in larger towns and cities.

Refactoring Service Interface to Support Artefact-centric Service interaction

The growth of APIs and Web services on the Internet, especially through larger enterprise systems increasingly being leveraged for Cloud and software-as-a-service opportunities, poses challenges for improving the efficiency of integration with these services. Interfaces of enterprise systems are typically larger, more complex and overloaded, with single operations having multiple data entities and parameter sets, supporting varying requests, and reflecting versioning across different system releases, compared to fine-grained operations of contemporary interfaces. We propose a technique to support the refactoring of service interfaces by deriving business entities and their relationships. In this paper, we focus on the behavioural aspects of service interfaces, aiming to discover the sequential dependencies of operations (otherwise known as protocol extraction) based on the entities and relationships derived. Specifically, we propose heuristics according to these relationships, and in turn, deriving permissible orders in which operations are invoked. As a result of this, service operations can be refactored on business entity CRUD lines, with explicit behavioural protocols as part of an interface definition. This supports flexible service discovery, composition and integration. A prototypical implementation and analysis of existing Web services, including those of commercial logistic systems (Fedex), are used to validate the algorithms proposed through the paper.

Emergency department models of care in the context of care quality and cost: A systematic review

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Rubbing shoulders with mobile service robots

This paper is not about the details of yet another robot control system, but rather the issues surrounding realworld robotic implementation. It is a fact that in order to realise a future where robots co-exist with people in everyday places, we have to pass through a developmental phase that involves some risk. Putting a “Keep Out, Experiment in Progress” sign on the door is no longer possible since we are now at a level of capability that requires testing over long periods of time in complex realistic environments that contain people. We all know that controlling the risk is important – a serious accident could set the field back globally – but just as important is convincing others that the risks are known and controlled. In this article, we describe our experience going down this path and we show that mobile robotics research health and safety assessment is still unexplored territory in universities and is often ignored. We hope that the article will make robotics research labs in universities around the world take note of these issues rather than operating under the radar to prevent any catastrophic accidents.

Service Interface Synthesis in Business Networks

Mismatches between services needing to interoperate have been addressed through the adaptation of structural and behavioural interfaces of services, which in practice incur long lead time through manual, coding effort. We propose a framework, complementary to con- ventional service adaptation, to synthesise service interfaces in the open setting of business networks, allowing consumers to introspect service interfaces and formulate service invocations. The framework also allows evolved service requests, as new features of service capabilities are discov- ered, through interactions with other, similar services. Finally the frame- work fosters reuse of adaptation efforts through normalisation of struc- tural and behavioural interfaces of similar services. This paper provides a first exposition of the service interface synthesis framework, describing patterns containing novel requirements for unilateral service adaptation and detailing the interface synthesis technique. Complex examples of ser- vices drawn from commercial logistic systems are then used to validate the synthesis technique and identify open challenges and future research directions.

Principles of experience design for airport terminals

In this thesis, the issue of airport terminal design is examined from a novel perspective: that of the passenger rather than the airport operator. A qualitative approach, based on interviews with 199 passengers at Brisbane International Terminal was adopted. The outcomes of this research make the following three key contributions to existing knowledge: (i) identification of a paradox in the Level of Service metrics, (ii) development of a conceptual model of passenger experience and six design principles and (iii) contribution towards advancing the theoretical knowledge about passengers and their experience in airport terminals.