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.

Alternative models of cardiac rehabilitation : a systematic review

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

The Convergence Review and the principle of Australians' access to and opportunities for participation

The recent Australian Convergence Review’s second principle states: “Australians should have access to and opportunities for participation in a diverse mix of services, voices, views and information”. However, in failing to define its own use and understanding of the terms ‘access’ and ‘participation’ the Convergence Review exposes itself to criticism. These terms would no doubt be made unambiguously clear should the Review’s recommendations move towards policy, and this paper contributes to this discussion by framing access and participation, from the perspective of the ‘produser’ (Bruns, 2008), around three separate but related issues: the failure to frame the discussion that will be undertaken by the Australian Law Reform Commission’s 2012 2013 Copyright Inquiry; the prioritising of the market over and above media accountability and the health of the public sphere; and the missed opportunity to develop a national framework for digital literacy and advanced digital citizenry.

Review : "Networking : commercial television in Australia : a history" -- Nick Herd

Nick Herd begins his institutional history of Australian commercial television in the early 1890s, when an amateur inventor named Henry Sutton designed the ‘telephane’ with the intent of watching the Melbourne Cup in his home town of Ballarat. The ‘race that stops a nation’ was not broadcast live on television until 1960, but Sutton’s initiative indicates how closely sport and television were aligned in Australia even before the medium existed. The first licensed commercial stations to begin regular broadcasting went on air in Sydney and Melbourne shortly before the 1956 Melbourne Olympic Games, although Herd claims that this was ‘almost accidental’ rather than planned. (49) Only Melbourne viewers were able to see some events live, many via television sets in Ampol service stations following the company’s last minute sponsorship of coverage on Melbourne station GTV-9...

Review : "Birthday Boy" -- Sejong Park

Synopsis and review of Sejong Park's film Birthday Boy. Includes credits. Birthday Boy has won over 40 awards at film festivals around the world including Best Animated Short at the prestigious SIGGRAPH Computer Animation Festival in 2004 which qualified the film for the 2005 Academy Awards even before Park and fellow students had graduated from the Australian Film, Television and Radio School (AFTRS). It was subsequently nominated for the Oscar for Best Animated Short Film, losing to another extraordinary short, Chris Landreth’s tribute to pioneering Canadian animator Ryan Larkin, Ryan. Other awards include the Prix Jean-Luc Xiberras at the Annecy International Animated Film Festival in 2005 (which had a special focus on Korea) and Best Short Animation at the 2005 BAFTA awards. It has screened at over 100 film festivals around the world, and is the most awarded film in the almost forty year history of the AFTRS...

Review : "Everynight...Everynight" -- Alkinos Tsilimidos

Synopsis and review of the Australian prison film Everynight...Everynight (Alkinos Tsilimidos, 1994). Includes cast and credits. An opening title states that Everynight… Everynight is a true story, but due to “legal implications”, the characters have been fictionalised. Another title dedicates the film to the memory of Christopher Dale Flannery, an infamous underworld figure known as ‘Mr Rent-a-Kill’ who spent time in H Division in the 1970s and 1980s. Originally from Melbourne, Flannery was a major figure in the Sydney ‘gang wars’ of 1984-85, dramatised in the television series Underbelly: A Tale of Two Cities (2009). He disappeared in mid-1985; there are several conflicting stories about his fate. The character of Bryant appears to have been based on Stan Taylor who had spent time in H Division with Flannery. Taylor was sentenced to life imprisonment without parole in 1988 for the 1986 bombing of police headquarters in Melbourne...

Review : "For the Term of His Natural Life" -- Norman Dawn

Synopsis and review of For the Term of His Natural Life (Norman Dawn, 1927). Includes cast and credits. For the Term of His Natural Life was one of the last Australian silent films, and also one of the most significant in the history of Australian cinema. At the time of its production, controversy raged over its depiction of convict life, its scale and cost (which was reported to be around 50,000 pounds at a time when most Australian films had budgets of less than 2,000 pounds1) and the fact that the director, several of the crew and the leading cast members were American. Australasian Films launched a publicity campaign of unprecedented scale to counter opposition to the film’s subject matter and the charge that they were “seeking to make capital out of the drab and sordid days of Australia”.2 The film’s expense was turned into a virtue: hundreds of unemployed men were used as extras, while the film also provided work for many within the Australian film industry and, according to Australasian, enabled the establishment of new production companies. The American imports who earlier had been accused of being “party to the slaughtering” of the Australian film industry, were feted for their artistic contributions, and the concerns raised in federal parliament about an American “invasion” were deflected by claims about what the local industry could learn from those with Hollywood experience.3 The publicity campaign was successful, as the film proved enormously popular at the Australian box office in its initial run. But the coming of sound film in 1928 had a considerable impact on audiences for silent films like For the Term, and its early local success was not repeated in subsequent seasons or in overseas markets...

Review : "Ghosts...of the Civil Dead" -- John Hillcoat

Synopsis and review of the Australian prison film Ghosts...of the Civil Dead (John Hillcoat, 1988). Drawing heavily from the book In the Belly of the Beast by American author and long-term prisoner Jack Henry Abbott, as well as from the historical and philosophical work of Michel Foucault (the credits include ‘Foucault Authority – Simon During’), Ghosts… Of the Civil Dead is a searing critique of the so-called ‘new generation’ prison system developed in the United States and recently introduced in Australia. Director John Hillcoat and producer Evan English conducted extensive research for the film, including spending time at the National Institute of Corrections, a think tank in Colorado, and visiting numerous institutions like the ‘new Alcatraz’ at Marion Illinois and other maximum security prisons across the United States. Using a mix of professionals and non-actors, including former prisoners and prison guards, the ‘story’ was workshopped during a lengthy rehearsal period with many actual events and experiences of participants incorporated into the film. The end result deliberately blurs the line between American and Australian prison experience to make the political point that what had happened in the US – from where many events and characters, and much of the architecture and design of the prison are drawn – was beginning to happen in Australia. The film emphasises the vicious cycle of institutionalisation, and highlights the role state authorities play in manufacturing, provoking and manipulating violence and fear both in prisons and in wider society as a means to augment policing and surveillance of the population, to oppress the working classes, and to maintain the political status quo...

Review: "Stir" -- Stephen Wallace

Synopsis and review of the Australian prison film Stir (Stephen Wallace, 1980). Includes cast and credits. Stir was written by a former prisoner, Bob Jewson, who had witnessed first hand a notorious riot at Bathurst Gaol in New South Wales in February 1974, the second serious disturbance at the prison in four years. In 1979, prisoners at Parramatta Gaol staged a peaceful sit-in to protest against the New South Wales’ government’s decision not to pursue criminal charges against prison officers for their actions during the 1974 Bathurst riot. The bashing of China Jackson and his cellmate in the first scene of Stir follows a sit-in, with the rest of the film drawing heavily on events around the 1974 Bathurst riot. The director later claimed that he wanted to call the film ‘The Riot at Bathurst Prison’, but was persuaded by nervous bureaucrats to apply the veneer of fiction. The film was retitled Stir, and set in the fictional Gatunga Gaol. Like other films in this genre, Stir draws heavily on the experiences of former prisoners and warders. The Prisoners’ Action Group played a leading role in the planning and preparation of the film, and many former inmates and guards were employed as extras. And in common with many films in this genre, Stir is concerned to humanise the plight of prisoners. Through the depiction of the routines of punishment, violence and retribution by which order in the institution is maintained, and through careful evocation of the atmosphere of fear and intimidation that prisoners (and warders) live with every day, Stir, again like other films in this genre blames the authorities and the system itself for events like those portrayed here. As producer Richard Brennan says in an interview on the 2005 DVD release of the film, “prisons create monsters”...

Review : "The Square" -- Nash Edgerton

Synopsis and review of the Australian crime film The Square (Nash Edgerton, 2009). Includes cast and credits. The Square is the feature film debut of director Nash Edgerton, well-known in Australian film circles not only for his award-winning music videos and short films Deadline (first prize winner at Tropfest in 1997) and Spider, but also for his work as an actor, editor, producer, writer and stuntman on countless Australian films and television programs. The film was co-written by Edgerton’s regular partner and brother Joel, who also plays the arsonist Billy. Joel is familiar to Australian and international audiences for his television work in The Secret Life of Us as well as numerous film roles...

Review : "The Jammed" -- Dee McLachlan

Synopsis and review of Australian crime film The Jammed (Dee McLachlan, 2007). Includes cast and credits. One of the strengths of Dee McLachlan’s shocking and moving film is the extensive research undertaken in pre-production, which grounds the film in a reality of which many Australians are unaware. The film opens with a caption stating that it was inspired by court transcripts, and closes with an intertitle stating that in 2001 and 2002, two sex trafficked victims died in Villawood Detention Centre. The film makes it clear that human trafficking and the coercion of women into prostitution are as much problems in Australia as anywhere; Project Respect, an organisation that acts on behalf of trafficked sex workers, has estimated that about 1000 women are illegally brought to Australia to work as prostitutes each year. The film’s title is taken from the term used by support workers to describe how the women are ‘jammed’ between their captors and the authorities; their illegal status and often heavy endebtedness, coupled with their innate fear of authority figures and the captors threats to their families back home, deter them from escaping or going to the police. The latter course of action may only lead to incarceration and deportation, as it does for Crystal in The Jammed. They are also deterred from speaking out by the implied (and often real) collusion between the traffickers and the authorities. While she is held in an apartment shortly after she arrives in Australia, Crystal threatens to call the police, only to be told by her captor ‘My best friend is the police’...

Review : "The Man from Hong Kong" -- Brian Trenchard Smith

Synopsis and review of the Australian action film The Man from Hong Kong (Brian Trenchard Smith, 1975). Includes cast and credits. Australia’s first martial arts action film was a coproduction between Hong Kong production company Golden Harvest and director Brian Trenchard Smith’s Movie Company, with significant investment from BEF Distributors, a subsidiary of the Australian exhibition chain Greater Union. Two years previously, Golden Harvest had coproduced the Bruce Lee smash hit Enter the Dragon, with Warner Bros. The Man from Hong Kong was its first partnership with an Australian producer, and the first coproduction between Hong Kong and Australian based companies. Although the film was almost entirely set in Sydney, much of the production was shot in a Hong Kong studio, where sets including Wilton’s gloriously decorated apartment were built...

Review : "The Adventures of Barry McKenzie" -- Bruce Beresford

Synopsis and review of the Australian ocker comedy The Adventures of Barry McKenzie (Bruce Beresford, 1972). Includes cast and credits. The Adventures of Barry McKenzie, adapted from a comic strip written by Barry Humphries, is a landmark film in the revival of Australian cinema. It was the first film to be fully funded by the new federal agency, the Australian Film Development Corporation (AFDC), and its unexpected success (in Britain as well as in Australia) both demonstrated that Australian films could be popular, and helped establish the ‘ocker comedy’ as the first indigenous (sub)genre of the Australian ‘new wave’. In common with other ocker comedies including Stork (Tim Burstall, 1971), and Alvin Purple (Tim Burstall, 1973), The Adventures of Barry McKenzie was derided by critics despite its popular success. But as Tom O’Regan has argued, these films were vitally important in developing a public profile for Australian films, for encouraging private investment in production, and for convincing exhibitors to screen Australian films...