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.

Social Media Sites as Online Information Grounds : An exploratory study of the ways in which Information Technology (IT) professionals experience social media

Social media tools are often the result of innovations in Information Technology and developed by IT professionals and innovators. Nevertheless, IT professionals, many of whom are responsible for designing and building social media technologies, have not been investigated on how they themselves use or experience social media for professional purposes. This study will use Information Grounds Theory (Pettigrew, 1998) as a framework to study IT professionals’ experience in using social media for professional purposes. Information grounds facilitates the opportunistic discovery of information within social settings created temporarily at a place where people gather for a specific purpose (e.g., doctors’ waiting rooms, office tea rooms etc.), but the social atmosphere stimulates spontaneous sharing of information (Pettigrew, 1999). This study proposes that social media has the qualities that make it a rich information grounds; people participate from separate “places” in cyberspace in a synchronous manner in real-time, making it almost as dynamic and unplanned as physical information grounds. There is limited research on how social media platforms are perceived as a “place,” (a place to go to, a place to gather, or a place to be seen in) that is comparable to physical spaces. There is also no empirical study on how IT professionals use or “experience” social media. The data for this study is being collected through a study of IT professionals who currently use Twitter. A digital ethnography approach is being taken wherein the researcher uses online observations and “follows” the participants online and observes their behaviours and interactions on social media. Next, a sub-set of participants will be interviewed on their experiences with and within social media and how social media compares with traditional methods of information grounds, information communication, and collaborative environments. An Evolved Grounded Theory (Glaser, 1992) approach will be used to analyse tweets data and interviews and to map the findings against the Information Ground Theory. Findings from this study will provide foundational understanding of IT professionals’ experiences within social media, and can help both professionals and researchers understand this fast-evolving method of communications.

Unnatural selection : curricular conversations in TIP 1962–2012

Our task is to consider the evolving perspectives around curriculum documented in the Theory Into Practice (TIP) corpus to date. The 50 years in question, 1962–2012, account for approximately half the history of mass institutionalized schooling. Over this time, the upper age of compulsory schooling has crept up, stretching the school curriculum's reach, purpose, and clientele. These years also span remarkable changes in the social fabric, challenging deep senses of the nature and shelf-life of knowledge, whose knowledge counts, what science can and cannot deliver, and the very purpose of education. The school curriculum is a key social site where these challenges have to be addressed in a very practical sense, through a design on the future implemented within the resources and politics of the present. The task's metaphor of ‘evolution’ may invoke a sense of gradual cumulative improvement, but equally connotes mutation, hybridization, extinction, survival of the fittest, and environmental pressures. Viewed in this way, curriculum theory and practice cannot be isolated and studied in laboratory conditions—there is nothing natural, neutral, or self-evident about what knowledge gets selected into the curriculum. Rather, the process of selection unfolds as a series of messy, politically contaminated, lived experiments; thus curriculum studies require field work in dynamic open systems. We subscribe to Raymond Williams' approach to social change, which he argues is not absolute and abrupt, one set of ideas neatly replacing the other. For Williams, newly emergent ideas have to compete against the dominant mindset and residual ideas “still active in the cultural process'” (Williams, 1977, p. 122). This means ongoing debates. For these reasons, we join Schubert (1992) in advocating “continuous reconceptualising of the flow of experience” (p. 238) by both researchers and practitioners.

40 years of cancer nursing in Australia : the emergence of a specialty

Over the past 40 years, the nature and scope of cancer nursing practice has been shaped to a large extent by scientific and medical advances, as well as by social, economic and political factors. Nurses’ role in cancer care has evolved from being predominantly functional and dependent in its approach to being a specialty with clearly defined standards of practice underpinned by a growing evidence base and an agreed set of professional performance capabilities. The unique contribution that nurses make to minimising the effects of cancer on a person’s life and improving the patient experience is now well established and Australian cancer nurses are recognised as leaders in the field internationally. Nurses have achieved improved outcomes for people affected by cancer as part of a multidisciplinary team. By being active participants in the Clinical Oncological Society of Australia for at least 30 of the organisation’s 40 year history, Australian cancer nurses have been provided unique opportunities for professional development and inter-professional collaboration. To meet future challenges in delivering quality cancer care, cancer nurses will need to be full partners with consumers and with other health professionals in redesigning health care systems that are more responsive to changes in social, demographic, scientific and technological contexts.

Differences in the symptom experience of older versus younger oncology outpatients : a cross-sectional study

Background: Mortality rates for cancer are decreasing in patients under 60 and increasing in those over 60 years of age. The reasons for these differences in mortality rates remain poorly understood. One explanation may be that older patients received substandard treatment because of concerns about adverse effects. Given the paucity of research on the multiple dimensions of the symptom experience in older oncology patients, the purpose of this study was to evaluate for differences in ratings of symptom occurrence, severity, frequency, and distress between younger (< 60 years) and older ( ≥ 60 years) adults undergoing cancer treatment. We hypothesized that older patients would have significantly lower ratings on four symptom dimensions. Methods: Data from two studies in the United States and one study in Australia were combined to conduct this analysis. All three studies used the MSAS to evaluate the occurrence, severity, frequency, and distress of 32 symptoms. Results: Data from 593 oncology outpatients receiving active treatment for their cancer (i.e., 44.4% were < 60 years and 55.6% were ≥ 60 years of age) were evaluated. Of the 32 MSAS symptoms, after controlling for significant covariates, older patients reported significantly lower occurrence rates for 15 (46.9%) symptoms, lower severity ratings for 6 (18.9%) symptoms, lower frequency ratings for 4 (12.5%) symptoms, and lower distress ratings for 14 (43.8%) symptoms. Conclusions: This study is the first to evaluate for differences in multiple dimensions of symptom experience in older oncology patients. For almost 50% of the MSAS symptoms, older patients reported significantly lower occurrence rates. While fewer age-related differences were found in ratings of symptom severity, frequency, and distress, a similar pattern was found across all three dimensions. Future research needs to focus on a detailed evaluation of patient and clinical characteristics (i.e., type and dose of treatment) that explain the differences in symptom experience identified in this study.

Approaches to creativity : how adolescents engage in the creative process

Despite growing recognition of creativity's importance for young people, the creativity of adolescents remains a neglected field of study. Hence, grounded theory research was conducted with 20 adolescents from two Australian schools regarding their self-reported experiences of creativity in diverse domains. Four approaches to the creative process – adaptation, transfer, synthesis, and genesis – emerged from the research. These approaches used by students across a range of domains contribute to the literature in two key ways: (a) explaining how adolescents engage in the creative process, theorised from adolescent creators’ self-reports of their experiences and (b) confirms hybrid theories that recognise that creativity has elements of both domain-generality and domain-specificity. The findings have educational implications for both students and teachers. For students, enhancing metacognitive awareness of their preferred approaches to creativity was reported as a valuable experience in itself, and might also enable adolescents to expand their creativity through experimenting with other ways of engaging in the creative process. For teachers, using these understandings to underpin their pedagogies can promote metacognitive awareness and experimentation, and also provide teachers with a framework for assessing students’ creative processes.

Untangling the evidence : teacher librarians and evidence based practice

The research was a qualitative study investigating the lived experiences of teacher librarians as evidence based practitioners in Australian school libraries. It addressed how teacher librarians understood, applied and implemented evidence based practice, and investigated what these teacher librarians considered to constitute evidence. Two key critical findings of this research are that evidence based practice for teacher librarians is a holistic experience and evidence for teacher librarians can take many forms, including professional knowledge, observations, statistics, informal feedback and personal reflections. The study is significant to teacher librarians, library and information professionals, schools and school administrators, and the research field.

A method for predicting rain-induced instability of an individual slope

Awareness to avoid losses and casualties due to rain-induced landslide is increasing in regions that routinely experience heavy rainfall. Improvements in early warning systems against rain-induced landslide such as prediction modelling using rainfall records, is urgently needed in vulnerable regions. The existing warning systems have been applied using stability chart development and real-time displacement measurement on slope surfaces. However, there are still some drawbacks such as: ignorance of rain-induced instability mechanism, mislead prediction due to the probabilistic prediction and short time for evacuation. In this research, a real-time predictive method was proposed to alleviate the drawbacks mentioned above. A case-study soil slope in Indonesia that failed in 2010 during rainfall was used to verify the proposed predictive method. Using the results from the field and laboratory characterizations, numerical analyses can be applied to develop a model of unsaturated residual soils slope with deep cracks and subject to rainwater infiltration. Real-time rainfall measurement in the slope and the prediction of future rainfall are needed. By coupling transient seepage and stability analysis, the variation of safety factor of the slope with time were provided as a basis to develop method for the real-time prediction of the rain-induced instability of slopes. This study shows the proposed prediction method has the potential to be used in an early warning system against landslide hazard, since the FOS value and the timing of the end-result of the prediction can be provided before the actual failure of the case study slope.

Partnerships to promote school to work transitions : evidence from the field

Internationally, vocational education and training (VET) is challenged by increasing skills shortages in certain industries and rapidly changing skill requirements. Rigid and centralised state bureaucracies have proven inadequate to adapt to these challenges. Increasingly, partnerships between schools and industry have been established as a potential strategy to address local labour market demand and to provide school to work transition programs. Drawing on experiences in Australia, this paper reports on a case study of government-let partnerships between schools and industry. The Queensland Gateway schools initiative currently involves over 120 schools. The study aimed to understand how partnerships were constructed in this initiative. Selected partnerships were analysed in terms of the following principles of public-private partnerships – efficiency, effectiveness, sustainability, and beneficiaries. Although there are some benefits of partnership activities reported by both school and industry stakeholders, little evidence was found that the above underlying principles had been addressed to a significant extent in the Gateway school initiative. Further, these partnerships are often tenuously facilitated by individuals who have limited infrastructure or strategic support. Implications are that project stakeholders have not sufficiently accommodated theoretical perspectives on implementation and management of partnerships. Similar initiatives may be improved if stakeholders are cognisant of the underlying principles supporting successful public-private partnerships.

An investigation into painting's transformation and regeneration through post-photographic intervention in the digital archive

This PhD practice-led research inquiry sets out to examine and describe how the fluid interactions between memory and time can be rendered via the remediation of my painting and the construction of a digital image archive. My abstract digital art and handcrafted practice is informed by Deleuze and Guattari’s rhizomics of becoming. I aim to show that the technological mobility of my creative strategies produce new conditions of artistic possibility through the mobile principles of rhizomic interconnection, multiplicity and diversity. Subsequently through the ongoing modification of past painting I map how emergent forms and ideas open up new and incisive engagements with the experience of a ‘continual present’. The deployment of new media and cross media processes in my art also deterritorialises the modernist notion of painting as a static and two dimensional spatial object. Instead, it shows painting in a postmodern field of dynamic and transformative intermediality through digital formats of still and moving images that re-imagines the relationship between memory, time and creative practice.

Factors influencing research engagement : research interest, confidence and experience in an Australian speech-language pathology workforce

Background Recent initiatives within an Australia public healthcare service have seen a focus on increasing the research capacity of their workforce. One of the key initiatives involves encouraging clinicians to be research generators rather than solely research consumers. As a result, baseline data of current research capacity are essential to determine whether initiatives encouraging clinicians to undertake research have been effective. Speech pathologists have previously been shown to be interested in conducting research within their clinical role; therefore they are well positioned to benefit from such initiatives. The present study examined the current research interest, confidence and experience of speech language pathologists (SLPs) in a public healthcare workforce, as well as factors that predicted clinician research engagement. Methods Data were collected via an online survey emailed to an estimated 330 SLPs working within Queensland, Australia. The survey consisted of 30 questions relating to current levels of interest, confidence and experience performing specific research tasks, as well as how frequently SLPs had performed these tasks in the last 5 years. Results Although 158 SLPs responded to the survey, complete data were available for only 137. Respondents were more confident and experienced with basic research tasks (e.g., finding literature) and less confident and experienced with complex research tasks (e.g., analysing and interpreting results, publishing results). For most tasks, SLPs displayed higher levels of interest in the task than confidence and experience. Research engagement was predicted by highest qualification obtained, current job classification level and overall interest in research. Conclusions Respondents generally reported levels of interest in research higher than their confidence and experience, with many respondents reporting limited experience in most research tasks. Therefore SLPs have potential to benefit from research capacity building activities to increase their research skills in order to meet organisational research engagement objectives. However, these findings must be interpreted with the caveats that a relatively low response rate occurred and participants were recruited from a single state-wide health service, and therefore may not be representative of the wider SLP workforce.

Hybrid placemaking in the library : designing digital technology to enhance users’ on-site experience

This paper presents research findings and design strategies that illustrate how digital technology can be applied as a tool for hybrid placemaking in ways that would not be possible in purely digital or physical space. Digital technology has revolutionised the way people learn and gather new information. This trend has challenged the role of the library as a physical place, as well as the interplay of digital and physical aspects of the library. The paper provides an overview of how the penetration of digital technology into everyday life has affected the library as a place, both as designed by place makers, and, as perceived by library users. It then identifies a gap in current library research about the use of digital technology as a tool for placemaking, and reports results from a study of Gelatine – a custom built user check-in system that displays real-time user information on a set of public screens. Gelatine and its evaluation at The Edge, at State Library of Queensland illustrates how combining affordances of social, spatial and digital space can improve the connected learning experience among on-site visitors. Future design strategies involving gamifying the user experience in libraries are described based on Gelatine’s infrastructure. The presented design ideas and concepts are relevant for managers and designers of libraries as well as other informal, social learning environments.

Segmentation of cone-beam CT using a hidden Markov random field with informative priors

Purpose: Flat-detector, cone-beam computed tomography (CBCT) has enormous potential to improve the accuracy of treatment delivery in image-guided radiotherapy (IGRT). To assist radiotherapists in interpreting these images, we use a Bayesian statistical model to label each voxel according to its tissue type. Methods: The rich sources of prior information in IGRT are incorporated into a hidden Markov random field (MRF) model of the 3D image lattice. Tissue densities in the reference CT scan are estimated using inverse regression and then rescaled to approximate the corresponding CBCT intensity values. The treatment planning contours are combined with published studies of physiological variability to produce a spatial prior distribution for changes in the size, shape and position of the tumour volume and organs at risk (OAR). The voxel labels are estimated using the iterated conditional modes (ICM) algorithm. Results: The accuracy of the method has been evaluated using 27 CBCT scans of an electron density phantom (CIRS, Inc. model 062). The mean voxel-wise misclassification rate was 6.2%, with Dice similarity coefficient of 0.73 for liver, muscle, breast and adipose tissue. Conclusions: By incorporating prior information, we are able to successfully segment CBCT images. This could be a viable approach for automated, online image analysis in radiotherapy.

Driver perceptions of the benefits of reducing their driving speed on safety, emissions, and stress and road rage

The existing literature shows driving speed significantly affects levels of safety, emissions, and stress in driving. In addition, drivers who feel tense when driving have been found to drive more slowly than others. These findings were mostly obtained from crash data analyses or field studies, and less is known regarding driver perceptions of the extent to which reducing their driving speed would improve road safety, reduce their car’s emissions, and reduce stress and road rage. This paper uses ordered probit regression models to analyse responses from 3538 Queensland drivers who completed an online RACQ survey. Drivers most strongly agreed that reducing their driving speed would improve road safety, less strongly agreed that reducing their driving speed would reduce their car’s emissions and least strongly agreed that reducing their driving speed would reduce stress and road rage. Younger drivers less strongly agreed that these benefits would occur than older drivers. Drivers of automatic cars and those who are bicycle commuters agreed more to these benefits than other drivers. Female drivers agreed more strongly than males on improving safety and reducing stress and road rage. Type of fuel used, engine size, driving experience, and distance driven per week were also found to be associated with driver perceptions, although these were not found to be significant in all of the regression models. The findings from this study may help in developing targeted training or educational measures to improve drivers’ willingness to reduce their driving speed.