Improving the quality of life for patients' with co-morbidities requiring acute care

Reduced mortality rates in the Western world have created an increase in people with co-morbidities who have the potential to require acute care hospital services. These patients' chronic conditions often require complex needs that may not always be met by an acute care focus. This has created a precedent for nurses concerned with the holistic care and quality of life for these patients. This paper aims to describe the experiences of patients with co-morbidities who were admitted to hospital with an acute illness. This exploratory descriptive design selected patients in acute care who had more than one co-morbidity for approximately five years. Data was obtained from a purposive sample of twelve patients within two weeks of being discharged home using a semi-structured interview approach. Data analysis was conducted utilising Nvivo software to process the Colaizzi [1978] method. The theme clusters revealed a lack of continuity and co-ordinated care of the patients' co-morbidities during the acute admission and in discharge planning. It was seen that combinations of chronic conditions and treatments affected these patients' experience of acute care and thereafter, where conceptualisations of co-morbidity failed to accurately capture the underlying health care needs of these patients. These findings have implications for a comprehensive and considered approach to these patients' health care needs and quality of life whilst developing an improved understanding of co-morbidity for nursing. Recommendations for further research conclude this paper.

Nursing administration of medication via enteral tubes in adults : a systematic review

Background Enteral tubes are frequently inserted as part of medical treatment in a wide range of patient situations. Patients with an enteral tube are cared for by nurses in a variety of settings, including general and specialised acute care areas, aged care facilities and at home. Regardless of the setting, nurses have the primary responsibility for administering medication through enteral tubes. Medication administration via an enteral tube is a reasonably common nursing intervention that entails a number of skills, including preparing the medication, verifying the tube position, flushing the tube and assessing for potential complications. If medications are not given effectively through an enteral tube, harmful consequences may result leading to increased morbidity, for example, tube occlusion, diarrhoea and aspiration pneumonia. There are resultant costs for the health-care system related to possible increased length of stay and increased use of equipment. Presently what is considered to be best practice to give medications through enteral tubes is unknown.

Objectives The objective of this systematic review was to determine the best available evidence on which nursing interventions are effective in minimising the complications associated with the administration of medications via enteral tubes in adults. Nursing interventions and considerations related to medication administration included form of medication, verifying tube placement before administration, methods used to give medication, methods used to flush tubes, maintenance of tube patency and specific practices to prevent possible complications related to the administration of enteral medications.

Search strategy The following databases were searched for literature reported in English only: CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO. There was no date restriction applied. In addition, the reference lists of all included studies were scrutinised for other potentially relevant studies.

Selection criteria Systematic reviews of randomised controlled trials (RCTs) and RCTs that compared the effectiveness of nursing interventions and considerations used in the administration of medications via enteral tubes. Other research methods, such as non-randomised controlled trials, longitudinal studies, cohort and case control studies, were also included. Exclusion criteria included studies investigating drug–nutrient interactions or the bioavailability of specific medications.

Data collection and analysis Initial consideration of potential relevance to the review was carried out by the primary author (NP). Two reviewers independently assessed study eligibility for inclusion. A meta-analysis could not be undertaken, as there were no comparable RCTs identified. All data were presented in a narrative summary.

Results There is very limited evidence regarding the effectiveness of nursing interventions in minimising the complications associated with enteral tube medication administration in adults. The review highlights a lack of high quality research on many important nursing issues relating to enteral medication administration. There is huge scope for further research. Some of the evidence that was identified included that nurses should consider the use of liquid form medications as there may be fewer tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastronomy tubes. Nurses may need to consider the sorbitol content of some liquid medications, for example, elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. In addition, the use of 30 mL of water for irrigation when administering medications or flushing small-diameter nasoenteral tubes may reduce the number of tube occlusions.

Assessment of indigenous older peoples ’ needs for home and community care in remote central Australia

The Home and Community Care (HACC) program in Australia provides services which supports older people to live at home. Individual HACC organisations are generally responsible for initial assessment of eligibility and need of clients presenting for services. This paper reports on a project which aimed to develop an understanding of the various approaches to assessment of client needs in Central Australia. The majority of clients in this geographical area are indigenous. The project was initiated in recognition of the primary importance of assessment in determining service access and service delivery and of the particular challenges faced by service providers in remote areas. This paper discusses key project findings including the client group and services provided, initial needs assessment and care planning processes. Evident inconsistencies in practice reflect a variety of complex contextual factors. Staff in remote areas have an inadequate knowledge base to draw upon to assist them with assessment and care planning decisions, and further research and professional development is required.

Implementation of evidence into practice : Development of a tool to improve emergency nursing care of acute stroke

Background
Stroke is an increasing global health issue that places considerable burden on society and health care services. An important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24–48 hours. The current climate of prolonged time spent in the Emergency Department (ED) means that many aspects of stroke management are now the responsibility of emergency nurses.

Aims
The aims of this paper are to: i) examine the evidence related to nursing care of acute stroke, ii) identify evidence-based elements of stroke care with most applicability to emergency nursing and iii) use evidence-based stroke care recommendations to develop a guideline for the emergency nursing management of acute stroke.

Results
Emergency nursing care of acute stroke should focus on optimal triage decisions, physiological surveillance, fluid management, risk management, and early referral to specialists.

Conclusions
The role of emergency nurses in stroke care will increase and it is important that emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes. Guidelines and decision support tools for use in emergency nursing must be practical and have high levels of clinical utility for maximum uptake in a busy clinical environment.

An evidence-based practice approach to improving nursing care of acute stroke in an Australian emergency department

Aims. The aim of this study was to improve the emergency nursing care of acute stroke by enhancing the use of evidence regarding prevention of early complications.
Background. Preventing complications in the first 24–48 hours decreases stroke-related mortality. Many patients spend considerable part of the first 24 hours following stroke in the Emergency Department therefore emergency nurses play a key role in patient outcomes following stroke.
Design. A pre-test/post-test design was used and the study intervention was a guideline for Emergency Department nursing management of acute stroke.
Methods. The following outcomes were measured before and after guideline implementation: triage category, waiting time, Emergency Department length of stay, time to specialist assessment, assessment and monitoring of vital signs, temperature and blood glucose and venous-thromboembolism and pressure injury risk assessment and interventions.
Results. There was significant improvement in triage decisions (21Æ4% increase in triage category 2, p = 0Æ009; 15Æ6% decrease in triage category 4, p = 0Æ048). Frequency of assessments of respiratory rate (p = 0Æ009), heart rate (p = 0Æ022), blood pressure (p = 0Æ032) and oxygen saturation (p = 0Æ001) increased. In terms of risk management, documentation of pressure area
interventions increased by 28Æ8% (p = 0Æ006), documentation of nil orally status increased by 13Æ8% (ns), swallow assessment prior to oral intake increased by 41Æ3% (p = 0Æ003), speech pathology assessment in Emergency Department increased by 6Æ1% (ns) and there was 93Æ5 minute decrease in time to speech pathology assessment for admitted patients (ns).
Relevance to clinical practice. An evidence-based guideline can improve emergency nursing care of acute stroke and optimise patient outcomes following stroke. As the continuum of stroke care begins in the Emergency Department, detailed recommendations for evidence-based emergency nursing care should be included in all multidisciplinary guidelines for the management of acute stroke.

The moral imperative of designating patient safety and quality care as a national nursing research priority

Since the early 1990s, research studies conducted respectively in the USA, UK and Australia have found that between 4 and 16.6 per cent of patients suffer from some kind of harm (including permanent disability and death) as a result of human errors and adverse events while in hospital. It has been further estimated that approximately 50 per cent of these human errors/adverse events resulting in harm could have been prevented. In response to the significant financial, social, and political implications of these figures, a range of processes have been put in place in an attempt to improve patient safety and quality care in Australia. Nonetheless, it is evident that more can be done to improve the status quo. One process that warrants consideration is that of peak health professional groups and organisations providing active leadership in the promotion of patient safety, such as by making a visible and recognisable commitment to patient safety as a strategic research priority area. In this paper it is contended that, given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focussed public attention to patient safety and quality care as a national research priority.

Agency nursing work in acute care settings: perceptions of hospital nursing managers and agency nurse providers

• There is a paucity of research in investigating agency nursing work from the perspectives of hospital nursing managers and agency nurse providers.

• This exploratory paper examines the hospital nursing managers' and agency nurse providers' perceptions and experiences of agency nursing work.

• Individual, in-depth interviews were conducted with three agency nurse providers and eight hospital nursing managers. Because of the lack of previous research in this area, an exploratory, semi-structured interviewing technique was deemed appropriate.

• Three major themes emerged from interview data: planning for ward allocation, communication and professionalism.

• In planning for ward allocation, hospital managers were primarily concerned with maintaining adequate numbers of nursing staff in the ward settings. A major concern for agency nurse providers was inappropriate allocation of temporary staff.

• Communication was valued in different ways. While hospital managers focused on communication between the agency nurse and other permanent members of the health care team, agency providers were concerned with exchanges between agencies and hospital organizations, and between the agencies and agency nurses.

• For both groups, responsibility for professional development and the status of agency nursing as a career choice for graduate and experienced nurses were the focal aspects for consideration.

• A limitation of this study is the small number of individual interviews conducted with hospital nursing managers and agency nurse providers. Nevertheless, the findings represent the views of 11 individuals in senior managerial roles.

• The findings reinforce the need to enhance collaboration between hospitals and nursing agencies, and to examine how divergent views of agency nursing work could be reconciled – with the aim of providing quality patient care.

Nursing care of clients treated with atypical antipsychotics who have a risk of developing metabolic instability and/or type 2 diabetes

Objective : The aim of this article is to present a current discussion related to the nursing care of clients treated with atypical antipsychotic medicines and who have a risk of developing metabolic instability and/or Type 2 diabetes. The importance of such a discussion is to provide both the novice and the experienced nurse with additional knowledge of this current health issue with which to inform their nursing practice.

Discussion : The potential for psychosis to be a chronic condition is very high, and often people require antipsychotic medicine for lengthy periods throughout their lives. Sometimes, treatment is for life. The second generation of antipsychotic medicines was greeted with much enthusiasm since it was better tolerated than the first generation. However, each medication has desired and adverse effects and, when taken for lengthy periods, these effects may produce physical illness. Studies show that the prevalence of Type 2 diabetes and the metabolic syndrome was significantly higher in clients with a chronic psychiatric disorder, particularly schizophrenia.

Conclusions : Metabolic instability, especially weight gain, is associated with some psychotropic medicines. Nursing interventions need to include care assessment, planning, intervention, and evaluation for clients treated with antipsychotic medicines in terms of risk minimization strategies in routine nursing care.

An evaluation of a mental health screening and referral pathway for community nursing care : nurses' and general practitioners' perspectives

Aims and objectives. To evaluate a feasible, best practice mental health screening and referral clinical pathway for generalist community nursing care of war veterans and war widow(er)s in Australia.
Background. War veterans commonly experience mental health difficulties and do not always receive required treatment, as can also occur for war widow(er)s. Whenever opportunity arises, such as during community nursing care, it is vital to identify mental health problems in a health promotion framework.
Design. A clinical pathway was developed by literature review and consultation and then trialled and evaluated using mixed methods – quantitative and qualitative.
Methods. Community nurses who trialled the pathway completed an evaluation survey and attended focus groups. General practitioners responded to an evaluation survey.
Results. Most nurses found the pathway clear and easy to understand but not always easy to use. They emphasised the need to establish trust and rapport with clients prior to implementing the pathway. It was sometimes difficult to ensure effective referral to general practitioners for clients who screened positive for a mental health problem. When referral was accomplished, general practitioners reported adequate and useful information was provided. Some general practitioners also commented on the difficulty of achieving effective communication between general practitioners and nurses.
Conclusions. Nurses and some general practitioners found the pathway useful for their practice. They offered several suggestions for improvement by simplifying the trialled pathway and accompanying guidelines and strategies to improve communication between nurses and general practitioners. This study adds understanding of how community nurses might productively screen for mental health difficulties.
Relevance to clinical practice. The trialled pathway, which was modified and refined following the study, is an evidence-based
resource for community nurses in Australia and similar contexts to guide practise and maximise holistic care for war veterans and war widow(er)s and possibly other client groups.

Quality nephrology nursing care : beyond Kt/V

Ask nephrology nurses about the care in their hemodialysis units and they will probably say that high quality care is provided. This perception may reflect a genuine pride in their own and their colleagues' hemodialysis services, however, the meaning of high quality dialysis care remains unclear. Quality is often framed in terms of the high percentage of patients receiving a Kt/V of greater than 1.2 or 1.4. The unfortunate inference here is that high quality hemodialysis care is defined as the waste clearing service of the urea molecule. Defining quality in this narrow way conflicts with the caring and compassionate nursing ethic. Furthermore, it places a high value on a single mathematically derived formula that ignores many other indicators of quality dialysis care. In this article, the authors examine some historical, political, and technical features of Kt/V and use the metaphor of a hangover to illustrate the overuse of Kt/V, arguing that nurses have embraced Kt/V at the expense of other core elements of dialysis nursing care.

A pilot program of physical activity promotion among clients receiving home and community care

Three Victorian local governments cooperated in a pilot study of physical activity promotion as part of home and community care (HACC) service delivery. Thirty-one people receiving HACC volunteered to participate, including completing the Transtheoretical Stages of Change Exercise Questionnaire and the short-form Stanford Health Assessment Questionnaire (HAQ) just before and at 3 months and 6 months after starting regular self-selected physical activity. Twenty-one participants returned questionnaires at 3 months, and 17 participants returned questionnaires at 6 months. Data were analysed using paired t tests and effect sizes were calculated as mean differences. At 3 months, mean improvements were identified on 6 of the 8 HAQDI (disability index) subscales, and in the overall HAQ-DI score. Improvement in dressing and grooming was preserved at 6 months. At either 3 or 6 months, improvements in dressing and grooming, reach, hygiene, and daily activities, and overall HAQ-DI score exceeded the minimum clinically important difference. No improvements were statistically significant, as is likely in a pilot study with a small sample, however, these results suggest that even very small increases in physical activity may afford clinically meaningful improvements in some areas of physical function required for independent living.