Career development year in emergency nursing: using specific educational preparation and clinical support to facilitate the transition to specialist practice

This article outlines the development, implementation and evaluation of the Career Development Year (CDY) in the Emergency Department (ED) at Dandenong Hospital in Victoria, Australia. As a consequence of a shortage of emergency nurses, hospitals have recruited inadequately prepared nurses to staff their EDs. The resultant increase in stress of qualified and experienced emergency nurses has had a major impact on the retention of emergency nurses. The CDY aims to provide nurses with little or no experience in emergency nursing with supported entry into this area of specialist practice. The CDY is based on three factors identified as important in the transition to emergency nursing; knowledge, clinical support and professional development. By providing beginning emergency nurses with supported entry to a new and challenging clinical environment, the CDY has been an effective recruitment and retention strategy. In addition it has demonstrated that a committed ED team has the capability to teach and nurture the emergency nurses of the future.

Australian consumers expectations for expanded nursing roles in general practice - choice not gatekeeping

While research has focussed on the current and potential role of the practice nurse (PN) in Australia, the acceptability of this role by consumers has not been investigated. In 2002, two independent studies were carried out into consumer perceptions of PNs. A discussion between the two groups of researchers at the inaugural National Practice Nurse Conference in 2003, identified significant similarities in the findings of these studies. This article reports the combined findings as they relate to consumers' desire for access to the health practitioner of their choice, and their concern that PNs may assume a gatekeeping role. These perceptions may have significant impact on the acceptance of PNs across Australia.

Simulation to practice: developing nursing skills in mental health: an Australian perspective

A variety of developments in nursing education in Australia including some innovative and exciting models, educational enterprises between education and industry, and evidence of developing strengths in research and professional alliances on a national level have been discussed recently. This paper presents Simulation to Practice as an example of an educational program that can maximise skill mastery for nurses in mental health fields as practised by Deakin University in Victoria, Australia. The program is multimodal and is under-pinned by a problem-solving approach and has an online presentation. The extension of nursing skills through this approach encourages nurses to take theoretical skills to practice during these scenarios which help student nurses to gain experience through simulated real life characters. These sessions, while challenging at the time, were highly valued by students and seen as a beneficial part of their learning as a beginning nurse and often instrumental in moving comprehensively trained students into mental health careers.

Designing the future in wound care: the role of the nurse practitioner

The nurse practitioner is emerging as a new level and type of health care. Increasing specialisation and advanced educational opportunities in nursing and the inequality in access to health care for sectors of the community have established the conditions under which the nurse practitioner movement has strengthened both nationally and internationally. The boundaries of responsibility for nurses are changing, not only because of increased demands but also because nurses have demonstrated their competence in varied extended and expanded practice roles. The nurse practitioner role reflects the continuing development of the nursing profession and substantially extends the career path for clinical nurses.

This paper describes an aspect of a large-scale investigation into the feasibility of the role of the nurse practitioner in the Australian Capital Territory (ACT) health care system. The paper reports on the trial of practice for a wound care nurse practitioner model in a tertiary institution. In the trial the wound care nurse practitioner worked in an extended practice role for 10 months. The nurse practitioner practice was supported, monitored and mentored by a clinical support team. Data were collected relating to a range of outcomes including definition of the scope of practice for the model, description of patient demographics and outcomes and the efficacy of the nurse practitioner service.

The findings informed the development of clinical protocols that define the scope of practice and the parameters of the wound care nurse practitioner model and provided information on the efficacy of this model of health care for the tertiary care environment. The findings further suggest that this model brings expert wound care and case management to an at-risk patient population. Recommendations are made relating to ongoing research into the role of the wound care nurse practitioner model in the ACT health care system.

Clinical education : a challenging component of undergraduate nursing education

Clinical education is an essential part of every undergraduate nursing curriculum. The main benefits are that it allows students to put theory into practice and experience the realities of the practice- based nursing profession. Limitations include the unstable nature of the clinical area as a learning environment and the challenges this produces with students' assessments. This article reviews the literature and concludes there is room for significant improvement in the area of clinical education and numerous strategies can be implemented to do so.

Generation of statements for the development of clinical indicators for mental heath nursing in New Zealand : achieving a bicultural focus

Aim : In this paper, the first of 4 stages of a large study aiming to develop culturally and clinically valid clinical indicators to flag the achievement of mental health nursing standards of practice in New Zealand are described.

Methods : A bicultural design was employed throughout the research project to ensure that nurses' views of practice and the cultural differences between New Zealand's indigenous Maori and non-Maori peoples could be identified. Accordingly, separate focus groups of Maori- and non-Maori-experienced mental health nurses were asked to develop lists of statementd reflective of the Australian and New Zealand College of Mental Health Nurses' Standards of Practice in New Zealand.

Results : The focus group participants produces 473 statements, which were synthesized into 190 clinical indicator statements. In keeping with the bicultural research design, Maori and non-Maori data were analysed separately until the data were merged to provide a single set of indicator statements. Although both Maori and non-Maori groups wrote statements relevant to clinical practice, there was a difference in the way the 2 groups addressed cultural issues. The Maori focus group wrote statements about cultural issues for 4 of the 6 Standards of Practice, whereas the non-Maori focus group participants wrote statements about cultural issues for only the Standard focusing on cultural safety.

Conclusion : The research design of this project in mental health nursing was unique in that it sought the perspectives of both indigenous and non-indigenous nurses about quality mental health nursing practice related to the professional standards of practice. The involvement of Maori and non-Maori mental health nurses enhanced the cultural and clinical validity of the study and the obtained from it. The bicultural approach adopted for the study highlights the need for more mental health nursing research involving indigenous partners.

Practical application of the Delphi technique in a bicultural mental health nursing study in New Zealand

Background. Numerous studies have employed the Delphi technique to seek expert opinion about aspects of clinical practice. When researching literature on the Delphi technique, however, we discovered discrepancies in its application, and a lack of detail when reporting design, administration, and analysis methods. Such lack of specificity hinders the replicability and assessment of the clinical and cultural validity and reliability of Delphi studies.

Aim. The aim of this paper is to detail the practical application of the Delphi technique as a culturally and clinically valid means of accessing expert opinion on the importance of clinical criteria.

Methods. Reference is made to a bicultural New Zealand mental health nursing clinical indicator study that employed a three-round reactive Delphi survey. Equal proportions of Maori and non-Maori nurses (n = 20) and consumers (n = 10) rated the importance of 91 clinical indicator statements for the achievement of professional practice standards. Additional statements (n = 21) suggested by Delphi participants in round 1 were included in subsequent rounds. In round 2, participants explained the rating they applied to statements that had not reached consensus in round 1, and summarized responses were provided to participants in round 3. Consensus was considered to have been achieved if 85% of round 3 ratings lay within a 2-point bracket on the 5-point Likert-scale overall, or in one of the Maori nurse, non-Maori nurse, or consumer groups. A mean rating of 4·5 after round 3 was set as the importance threshold.

Findings. Consensus occurred overall on 75 statements, and within groups on another 24. Most statements (n = 86) reached the importance benchmark.

Conclusions. When rigorous methods of participant selection, group composition, participant feedback, and determination of consensus and importance are employed, the Delphi technique is a reliable, cost-effective means of obtaining and prioritizing experts judgements.

New Zealand development and trial of mental health nursing clinical indicators - a bicultural study

This paper describes the development and validation of bicultural clinical indicators that measure achievement of mental health nursing practice standards in New Zealand (ANZMCHN, 1995, Standards of practice for mental health nursing in New Zealand. ANZCMHN, Greenacres). A four-stage research design was utilised including focus groups, Delphi surveys, a pilot, and a national field study, with mental health nurses and consumers as participants. During the national field study, consumer files (n=327) from 11 District Health Boards, and registered nurses (n=422) completed an attitude questionnaire regarding the regularity of specific nursing and service activities. Results revealed a variation in the mean occurrence of the clinical indicators in consumer case notes of 18.5–89.9%. Five factors with good internal consistency, encompassing domains of mental health nursing required for best practice, were derived from analysis of the questionnaire. This study presents a research framework for developing culturally and clinically valid, reliable measures of clinical practice.

An exploration of clinical decision-making in mental health triage

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

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.

Metaphysics of love as moral responsibility in nursing and midwifery

This study used a qualitative research design incorporating principles of social constructionism, hermeneutic dialectic method, Neo-Socratic dialogue and philosophy for reporting the tacit and social knowledge constructions underlying particular ways of knowing that inform the experiential reality of love in the practice of nursing and midwifery. The philosophy of Emmanuel Levinas, that culminated in his magnum opus of the ‘metaphysics of otherness’, provided the theoretical underpinning for the interpretation of the experiences nurses and midwives believed were examples of love in their clinical practice in Australia, Singapore and Bhutan. What is love in nursing and midwifery? The answer is moral responsibility. The relational context has a nurse and midwife constantly exposed to patient situations that give rise to expressions of love as moral responsibility. It is a form of love that centres on the ability of our being, or at least the possibility of our being, to transcend its everyday form to a metaphysical state of being moral. It enables a nurse and midwife to transcend the isolation associated with their personal being as a self-project, to be ‘for’ the patient as a first priority. But while the ‘Goodness’ of the ‘Good’ assigns the nurse and midwife responsible and is expressed to their personal being in the form of the ‘urge to do’, ‘what to do’ in caring for the patient is a matter of living out the command to be responsible and will be different for each nurse and midwife. However, no matter the outcome, love as moral responsibility will always leave a nurse and midwife feeling there is still more to be done in being responsible.

Phenomenon of ordinariness in nursing

This phenomenological research aimed to illuminate the nature and effects of ordinariness in nursing and to discover whether the phenomenon enhanced the nursing encounter. The researcher worked as a participant observer with six registered nurses in a Professorial Nursing Unit. Following each interaction, the researcher wrote her impressions in a personal-professional journal and audiotaped conversations with the respective nurses and patients to gain their impressions. Using a theoretical framework of the phenomenological concepts of lived experience, Dasein, Being-in-the-world and fusion of horizons as an underpinning methodology, an initial hermeneutical analysis and interpretation of the impressions generated qualities and activities indicative of the aspects of the phenomenon of ordinariness in nursing. The second phase of the analysis and interpretation sought to illuminate the nature of the phenomenon itself. Eight actualities of the nature of the phenomenon emerged: 'allowingness,' 'straightforwardness,' 'self-likeness,' 'homeliness,' 'favourableness,' 'intuneness,' 'lightheartedness' and 'connectedness.' These actualities were described in relation to the phenomenon of interest. The effects of the phenomenon were the creative potential to enhance the nursing encounter and included many and various effects of facilitation, fair play, familiarity, family, favouring, feelings, fun and friendship. The research found that nurses and patients shared a common sense of humanity, which enhanced the nursing encounter. Within the context of caring, the nurses were ordinary people, perceived as being extraordinarily effective, by the very ways in which their humanness shone through their knowledge and skills, to make their whole being with patients something more than just professional helping. The shared sense of ordinariness between nurses and patients made them as one in then- humanness and created a special place, in which the relative strangeness of the experience of being in a health care setting, could be made familiar and manageable.

Nursing work and nursing knowledge : exploring the work of women's health nurses, patterns of power and praxis

The majority of women's health nurses in this study work in generalist community health centres. They have developed their praxis within the philosophy and policies of the broader women's health movement and primary health care principles in Australia. The fundamental assumption underlying this study is that women's health nurses possess a unique body of knowledge and clinical wisdom that has not been previously documented and explored. The epistemological base from which these nurses' operate offers important insights into the substantive issues that create and continually shape the practice world of nurses and their clients. Whether this represents a (re)construction of the dominant forms of health care service delivery for women is examined in this study. The study specifically aims at exploring the practice issues and experience of women's health service provision by women's health nurses in the context of the provision of cervical cancer screening services. In mapping this particular group of nurses practice, it sets out to examine the professional and theoretical issues in contemporary nursing and women's health care. In critically analysing the powerful discourses that shape and reshape nursing work, the study raises the concern that previous analyses of pursing work tend to universalise the structural and social subordination of nurses and nursing knowledge. This universalism is most often based on examples of midwifery and nursing work in hospital settings, and subsequently, because of these conceptualisations, all of nursing is too often deemed as a dependent occupation, with little agency, and is analysed as always in relation to medicine, to hospitals, to other knowledge forms. Denoting certain discourses as dominant proposes a relationship of power and knowledge and the thesis argues that all work relations and practices in health are structured by certain power/knowledge relations. This analysis reveals that there IX are many competing and complimentary power/knowledge relations that structure nursing, but that nursing, and in particular women's health nurses, also challenge the power/knowledge relations around them. Through examining theories of power and knowledge the analysis, argues that theoretical eclecticism is necessary to address the complex and varied nature of nursing work. In particular it identifies that postmodern and radical feminist theorising provide the most appropriate framework to further analyse and interpret the work of women's health nurses. Fundamental to the position argued in this thesis is a feminist perspective. This position creates important theoretical and methodological links throughout the whole study. Feminist methodology was employed to guide the design, the collection and the analysis. Intrinsic to this process was the use of the 'voices' of women's health nurses as the basis for theorising. The 'voices' of these nurses are highlighted in the chapters as italicised bold script. A constant companion along the way in examining women's health nurses' work, was the reflexivity with feminist research processes, the theoretical discussions and their 'voices'. Capturing and analysing descriptive accounts of nursing praxis is seen in this thesis as providing a way to theorise about nursing work. This methodology is able to demonstrate the knowledge forms embedded in clinical nursing praxis. Three conceptual threads emerge throughout the discussions: one focuses on nursing praxis as a distinct process, with its own distinct epistemological base rather than in relation to 'other' knowledge forms; another describes the medical restriction and opposition as experienced by this group of nurses, but also of their resistance to medical opposition. The third theme apparent from the interviews, and which was conceptualised as beyond resistance, was the description of the alternative discourses evident in nursing work, and this focused on notions of being a professional and on autonomous nursing praxis. This study concludes that rather than accepting the totalising discourses about nursing there are examples within nursing of resistance—both ideologically and X in practice—to these dominant discourses. Women's health nurses represent an important model of women's health service delivery, an analysis of which can contribute to critically reflecting on the 'paradigm of oppression' cited in nursing and about nursing more generally. Reflecting on women's health service delivery also has relevance in today's policy environment, where structural shifts in Commonwealth/State funding arrangements in community based care, may undermine women's health programs. In summary this study identifies three important propositions for nursing: • nursing praxis can reconstruct traditional models of health care; • nursing praxis is powerful and able to 'resist' dominant discourses; and • nursing praxis can be transformative. Joining feminist perspectives and alternative analyses of power provides a pluralistic and emancipatory politics for viewing, describing and analysing 'other' nursing work. At the micro sites of power and knowledge relations—in the everyday practice worlds of nurses, of negotiation and renegotiation, of work on the margins and at the centre—women's health nurses' praxis operates as a positive, productive and reconstructive force in health care.

The story of fable : a narrative analysis of the experience of four registered nurses in their first year of practice

This research explores the transition from student to registered nurse from the perspective of the new graduate. This interpretive study uses narrative analysis as the methodology. Individual stories were collected and processed using the method of core story creation and emplotment (Emden 1998). Four newly registered nurses were invited to share stories related to how they were experiencing their role. Participants were encouraged to tell their stories in response to the open question 'what is it like to be a registered nurse?' In the final step of the analysis one honest and critical story has been crafted (Barone 1992) using a process termed emplotment thus disclosing the themes that allow the stories to be grasped together as a single story (Polkinghorne 1988, Emden 1998). The final story of 'Fable' gives insight into the ways in which newly registered nurses experience their role. Becoming a registered nurse is not easy however, Fable finds that nursing is more than just a job and describes many rewarding experiences. It is hoped that the outcomes of this research will be valuable to students, graduates, nurse academics and the profession of nursing generally by enhancing understandings of the relationship between the graduate and the actual employment experience.