The initiation and administration of drugs for advanced life support by critical care nurses in the absence of a medical practitioner

Current legislation does not permit the administration of first line resuscitation medications by suitably qualified Division 1 registered nurses (RNs) in the absence of a medical officer. This omission by the Drugs, Poisons and Controlled Substances Act 1981 (Vic) and the Drugs, Poisons and The Controlled Substances Regulations 1995 (Vic) leaves many critical care nurses in a vulnerable legal position. The primary aim of this study was to gauge the view of critical care nurses with respect to lobbying for change to the current legislation. In addition, the study aimed to explore and describe the educational preparation, practice perceptions and experiences of RNs working in critical care regarding cardiopulmonary resuscitation and the administration of first line advanced life support (ALS) medications in the absence of a medical officer. It was anticipated that data collected would demonstrate some of the dilemmas associated with the initiation and administration of ALS medications for practising critical care nurses and could be used to inform controlling bodies in order for them to gain an appreciation of the issues facing critical care nurses during resuscitation. A mailout survey was sent to all members of the Victorian Branch of the Australian College of Critical Care Nurses (ACCCN). The results showed that the majority of nurses underwent an annual ALS assessment and had current ALS accreditation. Nurses indicated that they felt educationally prepared and were confident to manage cardiopulmonary resuscitation without a medical officer; indeed, the majority had done so. The differences in practice issues for metropolitan, regional and rural nurses were highlighted. There is therefore clear evidence to suggest that legislative amendments are appropriate and necessary, given the time critical nature of cardiopulmonary arrest. There was overwhelming support for ACCCN Vic. Ltd to lobby the Victorian government for changes to the law.

Efficacy of continuous versus intermittent morphine administration after major surgery in 0-3-year-old infants; a double-blind randomized controlled trial

A randomized double-blind clinical trial compared the efficacy of 10 microg/kg/h morphine continuous intravenous infusion (CM) with that of 30 microg/kg morphine (IM) every 3h after major abdominal or thoracic surgery, in 181 infants aged 0-3 years. Efficacy was assessed by the caregiving nurses with the COMFORT 'behavior' and a visual analogue scale (VAS) for pain, every 3h in the first 24h after surgery. Random regression modeling was used to simultaneously estimate the effect of randomized group assignment, actual morphine dose (protocol dosage plus extra morphine when required), age category, surgical stress, and the time-varying covariate mechanical ventilation on COMFORT 'behavior' and the observational VAS rated pain, respectively. Overall, no statistical differences were found between CM and IM morphine administration in reducing postoperative pain. A significant interaction effect of condition with age category showed that the CM assignment was favorable for the oldest age category (1-3 years old). The greatest differences in pain response and actual morphine dose were between neonates and infants aged 1-6 months, with lower pain response in neonates who were on average satisfied with the protocol dosage of 10 microg/kg/h. Surgical stress and mechanical ventilation were not related to postoperative pain or morphine doses, leaving the inter-individual differences in pain response and morphine requirement largely unexplained.

Career paths beyond nursing and the contribution of nursing experience and skills in attaining these positions

This paper reports on an exploratory study undertaken in New South Wales, Australia which sought to identify the positions nurses go on to when they leave nursing and the skills and experience they gained from nursing which they believe enabled them to obtain employment outside the profession. In addition, the reasons why they left nursing were also ascertained. A network sampling technique was used to recruit 17 participants. A tape-recorded semi-structured interview of approximately 1h was conducted with each participant. Interviews were conducted until no new information emerged (14) and the remaining three interviews were used for validation. While many participants were employed in health-related fields, others were in diverse areas such as business, landscape coordination and market research, to name a few. All participants reported positively on the range of skills they had acquired as a nurse. Reasons provided for leaving the nursing workforce included reaching a ceiling in nursing or wishing to develop themselves in another direction. Respondents had also undertaken a wide range of additional qualifications.

Two-dimensional mapping of impedance magnetocardiograms

A new method for measuring two-dimensional (2-D) impedance magnetocardiograms (I-MCGs) and magnetocardiograms (MCGs) above the heart simultaneously, has been developed. The I-MCG's and MCG's signals are recorded by using a superconducting interference device (SQUID) system. To measure the I-MCG and MCG signals, four first-order gradiometers with an 18-mm diameter and a 50-mm baseline were used. The SQUIDs are driven by a flux-locked-loop circuit with a frequency range higher than that of an ac-current (40 kHz) with constant amplitude passed through a subject. The output of the circuit is filtered through two circuits: one for measuring the I-MCG signals and one for measuring the MCG signals. The I-MCG signals are obtained by demodulating the magnetic field, which is detected by the gradiometers, at the frequency of the ac current. As a result, the I-MCG signal reflects the change in spatial distribution of conductivity caused by the movement of the heart muscle and blood volume. A contour map of the 2-D I-MCG signals showed the largest signals occur above the right ventricle and right atrium. In a corresponding current-arrow map, it was found that the large current arrows occurred above the right side of the right ventricle. Furthermore, it was found that the systole and diastole timings obtained from the first-derivative I-MCG signal and the phonocardiogram were different. These results show that primitive 2-D I-MCG signal can provide much physiological information on the circulatory movement of the heart.

Recovering From Cardiac Surgery: What Patients Want You To Know

• Background Care of cardiac surgery patients has changed substantially in the past decade, with an emphasis on streamlined procedures and shortened hospital stays. The few qualitative reports of patients’ perspectives of this experience focus primarily on physical complications and discomforts during the immediate postoperative period.

• Objective To examine patients’ perceptions of the quality of the nursing and medical care they received during their hospital stay after cardiac surgery.

• Methods Data were collected from a consecutive sample of 89 cardiac surgical patients who consented to participate in 2 telephone interviews at 1 week and 6 weeks after hospitalization. Patients responded to a single open-ended question: “What do you want your nurses and doctors to know to help them do a better job?” Thematic extraction analysis of patients’ responses was conducted by using commercially available statistical software. Extracted themes were applied to the structure-process-outcome framework of quality of care.

• Results Four major themes (and 12 subthemes) were identified: (1) being satisfied (having a positive experience, getting information), (2) not being cared for (feeling depersonalized, having expectations that did not match recovery experiences, not being listened to, experiencing unprofessional behavior by care providers, experiencing continued care needs after going home), (3) physical needs unmet (sleep, pain, complications, physical environment), and (4) informational needs unmet (needing more or different information).

• Conclusions Patients want nurses and doctors to provide a smooth transition to home, recognize the patients as individuals, prepare them honestly for their experiences with specific information, and manage pain and sleep.

How does an implantable cardioverter defibrillator (ICD) affect the lives of patients and their families?

This study aimed to identify the lived experience of patients with implantable cardioverter defibrillators (ICD) and their families. The methodology used was interpretative phenomenology. Unstructured interviews were conducted with three family members and three ICD recipients. Using a methodological approach outlined by van Manen, the participants transcribed texts were analysed looking for similar concepts and ideas that developed into themes that explicated the meaning of this phenomena. The themes that emerged were: dependence, which encompassed their perceptions about the life-saving device; the memory of their first defibrillation experience; lifestyle changes, which incorporated modification techniques; lack of control, which highlighted feelings such as fear, anxiety and powerlessness; mind game, which illustrated psychological challenges; and the issue of security, demonstrating how 'being there' and not 'being there' impacted on their everyday lives. The long-term outcomes of living with an ICD are important considerations for all health-care providers. This research highlights the everyday activities of recipients, the lifestyle changes they have made, the emotional significance of the device and the psychological coping strategies that the participants have adopted. The findings of this research will allow health-care professionals to be better prepared to provide education and support for ICD recipients and their families in regards to issues related to insertion of the device during the postinsertion recovery period and for long-term management after hospital discharge.

Exploring family needs during withdrawal of life support in critically ill patients

Withdrawal of life support is a process where medical interventions are taken away from the patient with the expectation that the patient will die. This deliberate decision occurs when it is determined that medical options are exhausted and the prognosis is terminal. With this study, the primary family member of twenty adult patients who had undergone withdrawal of life support was contacted and interviewed by the research team 3-5 weeks after the patients' death. Interview questions related to their experience with the withdrawal of life support process. Specifically, whether or not the situation was anticipated, a description of the events surrounding withdrawal, events that made the process easier, and what they would like to see changed. This information was used to determine if and to what extent family needs are met and to determine if further interventions are required.

Cancer nursing research in Queensland, Australia: barriers, priorities, and strategies for progress

Nursing research is an integral component of improving the care of people with cancer; however, the literature suggests that many organizational, resource, and attitudinal barriers to research remain. The aim of the present study was to systematically describe the research experience, attitudes, and opinions of nurses in Queensland, Australia, about priorities and strategies for developing cancer nursing research. A mail survey was sent to all 589 members of the Oncology Nurses Group of Queensland to assess their research knowledge, experience, and attitudes. A response rate of 54.2% (319 nurses) was obtained. Results suggest that many nurses in this study have access to and are reading available research regularly. However, many nurses reported only limited education and skills in research, scarce resources, and limited time to participate in research. Few nurses were involved in developing research proposals, were presenting at conferences, or were writing for publication. Despite these constraints, most of the sample indicated high levels of interest in participating in conducting research. Furthermore, most nurses in this study viewed research as important to patient care and as being an important role for clinical nurses. The top 3 priority areas for cancer nursing research were identified as psychosocial support, pain management, and symptom management. Specific strategies identified for developing nursing research included providing information, support, mentorship, and resources. Professional groups were viewed as having an important role in the development of nursing research in education, lobbying, and facilitating networking among researchers.

Will he get back to normal? Survival and functional status after intensive care therapy

The study aim was to address healthcare workers' and patients' questions about the likely level of recovery at 6 months of patients admitted to an Australian intensive care unit (ICU). Ninety-three consecutive, eligible adults were identified and followed prospectively. Severity of illness on admission was assessed using Acute Physiological and Chronic Health Evaluation (APACHE II), while functional status at 6 months was evaluated using the Sickness Impact Profile (SIP). Cumulative mortality was 25%. Admission severity of illness was associated with survival at 6 months (P < or = 0.001). Fifty-one (78%) of the 70 survivors were interviewed. Admission severity of illness scores correlated with functional status at 6 months (r = 0.34, P = 0.01), a finding reported in only one other study. More than half of those interviewed had returned to near pre-admission functional status. Those with poor functional status included high proportions of people with chronic illness and head injury. Overall, physical recovery was more complete than psychosocial recovery. The findings provide useful information for addressing questions relating to physical and psychosocial recovery, appetite, sleep patterns and return to work post discharge.

From ward-based critical care to educational curriculum 1: a literature review

There has been recent recognition in the literature, and a longer standing awareness amongst clinicians, that critically ill patients are to be found outside of intensive care units. These patients are not always well managed and some have concluded that their care is 'suboptimal' [Br. Med. J. 316 (1998) 1853] and that they die of preventable clinical problems [Extremes of Age: the 1999 Report of the National Confidential Enquiry into Perioperative Deaths (1999) NCEPOD]. Whilst the cause of this situation in the NHS probably involves a complex interplay of factors including failures in management, policy and the evidence/information base for practice, education failures have also been blamed. In response the government has mandated formal critical care education for ward nurses [Comprehensive Critical Care: a Review of Adult Critical Care Services (2000) Department of Health]. In this two-part paper, the literature around education for ward-based critical care is examined (Part 1) prior to a report of the findings (Part 2) of a case study exploring the everyday practices, context and culture of an acute surgical ward where seriously ill patients were cared for prior to the introduction of a critical care outreach service (Part 2). Implications for practice, education and future research are discussed.

Critical care nurses: professional development in the private sector

The purpose of this study was to gain a greater understanding of the experiences and perceptions of private hospital critical care nurses regarding critical care education delivery. It addressed the question of whether rural private hospital critical care nurses have different experiences and perceptions of critical care education delivery than metropolitan private hospital critical care nurses, and the implication these differences may have for the providers of continuing professional education for critical care nurses. The study used a phenomenographic approach to identify participants' common sense conceptions of their experiences and perceptions of critical care education delivery. A focus group session was held at a rural private hospital and a metropolitan private hospital, where interviewees were encouraged to reflect on previously unthematised aspects of the phenomenon in question. In addition, questionnaires were distributed to critical care staff in each unit and interviews were held with key stakeholders. Nineteen nurses participated in the study, providing a cross section of the experiences and qualifications present within these units. A number of issues were identified from the data, namely the need for clinical educators within critical care units to support students undertaking critical care courses and the desire for a move back to hospital based courses supported by the tertiary system. Education providers need to look closely at the issues of access, cost and organisation of courses to make them more appealing and relevant for both rural and metropolitan critical care nurses.

Synergizing acute care and palliative care to optimise nursing care in end-stage cardiorespiratory disease

Advances in the practice of medicine and nursing science have increased survival for patients with chronic cardiorespiratory disease. Parallel to this positive outcome is a societal expectation of longevity and cure of disease. Chronic disease and the inevitability of death creates a dilemma, more than ever before, for the health care professional, who is committed to the delivery of quality care to patients and their families. The appropriate time for broaching the issue of dying and determining when palliative care is required is problematic. Dilemmas occur with a perceived dissonance between acute and palliative care and difficulties in determining prognosis. Palliative care must be integrated within the health care continuum, rather than being a discrete entity at the end of life, in order to achieve optimal patient outcomes. Anecdotally, acute and critical care nurses experience frustration from the tensions that arise between acute and palliative care philosophies. Many clinicians are concerned that patients are denied a good death and yet the moment when care should be oriented toward palliation rather than aggressive management is usually unclear. Clearly this has implications for the type and quality of care that patients receive. This paper provides a review of the extant literature and identifies issues in the end of life care for patients with chronic cardiorespiratory diseases within acute and critical care environments. Issues for refinement of acute and critical care nursing practice and research priorities are identified to create a synergy between these philosophical perspectives.

Searching the health care literature efficiently: from clinical decision-making to continuing education

Searching the health care literature is an activity in which infection control professionals must routinely engage to seek evidence-based answers to specific practice questions and to stay abreast of developments in the field. Without the appropriate tools, the tremendous volume of clinical literature makes both of these daunting tasks. In this article, we illustrate techniques for searching MEDLINE efficiently, both as a means of answering particular clinical questions and for generating periodic updates on topics of general interest. With use of a specific example relevant to infection control, we demonstrate the identification of appropriate Medical Subject Headings terms that capture a given question or topic and the development of effective searches with use of these terms. We also touch on the advantages of targeting systematic reviews and meta-analyses in searching for evidence and staying abreast of the literature in general.

What makes a good intensive care unit: a nursing perspective

With the high prevalence of nursing shortages and low staff retention rates in many Australian intensive care units (ICUs), we aimed to determine what factors were important to nurses working in an ICU. Of all the nursing specialties in New South Wales, intensive care was reported to have had the fifth highest vacancy rate from June 2000-January 2001. A questionnaire was distributed to 36 nurses in a major metropolitan ICU. The response rate was 32 (89 per cent). The ICU has had high staff retention rates and low vacancy rates for a number of years. We were interested to document what factors made this unit a popular one to work in. Factors that were of greatest importance to most nurses were those that dealt with nursing unit management and medical staff. Other factors that rated highly included the ability to self-roster, some aspects of working relationships and having an active role in patient care issues. The survey informed us that nurses at this study site were mostly satisfied with these aspects. Previous studies have demonstrated a strong correlation between job satisfaction and turnover rates amongst nurses. The results of this study highlight the importance of good nursing management and various aspects of the nursing role in attaining job satisfaction in the workplace. These key factors play an important role in achieving high staff retention and low vacancy rates.

Evidence-based Education and the Evaluation of a Critical Care Course

A critical care nursing course was designed to enhance knowledge attainment for RNs new to critical care, and to prepare seasoned critical care nurses for specialty certification. The convenience sample of nurses (N = 57) was either enrolled in the 16-session course (n = 27) or assigned to a control group (n = 30). A repeated measures design allowed data collection at three time points: precourse, course completion, and 6 months after course completion. Mean scores on the Basic Knowledge Assessment Tool were significantly higher for course participants at the time of course completion, and scores continued to remain high 6 months later, demonstrating important retention of critical care knowledge.

Online learning: enhancing nurse education?

BACKGROUND

The need to integrate information technology into nursing education has been recognized and well documented. In spite of this, information technology remains a neglected subject in many nursing programmes. Strategies have been considered for increasing the integration of information technology in nursing education. One of the key issues identified is the need for research into the factors that contribute to optimal learning with information technology, specifically the need to explore issues that contribute to student frustration and satisfaction with learning. Within Australia, the incorporation of information technology as a core subject in nursing education is still relatively new. This article describes how one university used 'online' learning to expose students to conceptual and experiential opportunities that enabled them to develop skills in the management of information technology.

METHODS

Twenty-one students participated in this qualitative study. Individual interviews were used to develop insights into student perceptions. Thematic analysis enabled refined themes to emerge. These themes formed the basis of focus group discussions. Focus groups were used to enhance and validate the information from one-to-one interviews by using group dynamics to add experiential richness to the data.

FINDINGS

Four major themes emerged: computer confidence, flexibility, active learning and practicalities of teaching.

CONCLUSIONS

The integration of information technology into nursing education requires a dramatic change in thinking. The 'learning curve' is steep for both student and educator and there are many issues that need to be considered. This research does not aim to provide solutions to the issues highlighted but rather offers recommendations for enhancing the teaching and learning experience.

Paediatric high dependency provision: a case for urgent review in the United Kingdom

The issues surrounding paediatric high dependency provision require attention. The field of adult high dependency has revealed some useful studies, which promote the benefits of designated care. These relate to improved quality of care and reduced pressure on the availability of intensive care beds. This review outlines recent initiatives made in the development of paediatric intensive care units in Britain and demonstrates how practical lessons learnt in the adult critical care sector may be used to establish appropriate Level 1 care in paediatrics. Two paediatric clinical issues are reviewed that support the need for high dependency provision, these being: paediatric respiratory management and the management of sedation withdrawal. The options available to district general hospitals, specialist hospitals, as well as lead paediatric hospitals are discussed, and include quality issues, where education, training and clinical audit are integral to structural and staffing HDU considerations.

ICU nurses' perceptions of discharge planning: a preliminary study

The role that intensive care unit (ICU) nurses could play in hospital discharge planning remains relatively unexplored. Using a case study, all ICU nurses in one hospital were surveyed about their perceptions of their role in the discharge process. Over 70% of the 58 nurses who responded thought that discharge planning was both appropriate in the ICU and not premature. However, several obstacles including patient acuity, time constraints and limited experience with this process were evident. While ICU nurses are aptly placed to manage discharge planning, they cannot be expected to undertake this important role without a systematic approach to its implementation.

Vulnerability and security in seriously ill patients in intensive care

The purpose of this research was to gain an understanding of the experience of being a seriously ill patient in an intensive care unit (ICU). Fourteen former patients, aged 17-71 years old, who had been in ICU 3-53 days, participated in focus group interviews 3-6 months after discharge. The focus groups met 3 times each for 1.5 hours, resulting in 13-14 hours of audiotaped discussions. The transcribed data were qualitatively analysed to identify themes representing participants' experiences. Vulnerability emerged as a central concept that captured the identified themes. The data reveal that patient vulnerability while in ICU was related to extreme physical and emotional dependency. Lack of information and depersonalizing care were associated with fear, anxiety and increased vulnerability. Lack of sleep and rest also contributed to patient fear and anxiety. Vulnerability decreased when patients were kept informed of what was occurring while in ICU, received care that was personalized to their individual needs, and when their families were present. The results of this study suggest that ICU patients' vulnerability may be decreased by the security that they experience when they are adequately informed about what is happening, and when nursing and medical care is personalized to their individual needs.

Benefits and barriers for registered nurses undertaking post-graduate diplomas in paediatric nursing

This paper presents one aspect of a larger study identifying key influences on curriculum redesign and development of a post-graduate diploma in advanced clinical nursing. The focus is on paediatric intensive care and general paediatric streams. Data presented here relate to registered nurses' perceptions of benefits and barriers when undertaking this post-graduate diploma. As well as interviews and focus group discussions with a number of nurses, data were collected through a self-administered questionnaire, A total of 885 surveys were distributed to nurses working in paediatric areas in five hospitals in Victoria, Australia. Of these, 391 were completed (response rate 44%). One hundred and thirty (33%) had post-registration or post-graduate paediatric qualifications. Perceived benefits of undertaking the post-graduate diploma mainly related to an increase in knowledge and experience and improvement of employment opportunities. Perceived barriers mainly related to financial and professional issues such as cost of the course, loss of salary, the lack of direct remuneration on completion of the course and a lack of promotional opportunities. It was of concern that several nurses expressed a belief that paediatric qualifications were unnecessary and that many believed their employers did not value the qualification. Several recommendations are suggested to address the main barriers. These include more flexibility in the provision of such courses and opportunities for financial assistance.

Health status of ICU survivors: a pilot study

This paper reports on a pilot study that focused on the feasibility of conducting longitudinal research on the health status of intensive care unit (ICU) survivors. Twenty patients completed a short ICU specific health status survey while in ICU and then were invited to complete the same survey--with the addition of the Medical Outcome Study Short Form-36 (SF-36) health status survey--at 6 and 12 months after their hospital discharge. While the patients were in the ICU, 20 family members completed the same survey on the patients' behalf as proxy respondents. Most patients were willing to be in the study for its duration. There was a wide variation in patients' responses to the ICU specific instrument at all data collection points. Patient and proxy responses were very similar for almost all of the physical items but there was a lack of agreement for the more subjective psychosocial items. The SF-36 was found to be more reliable and easier to score and analyse in this small study than the ICU specific health status instrument. The three SF-36 scales ranked lowest at 6 months were physical functioning, role-physical and role-emotional, while at 12 months the three lowest were role-physical, role-emotional and vitality. Total attrition at 12 months was 40 per cent. Using the results of the SF-36, sample size estimates were conducted in preparation for a larger study. It was concluded that it is feasible to conduct longitudinal research on ICU survivors but proxy responses should not be used indiscriminately.

Nurses’ Accuracy in Estimating Backrest Elevation

• Background Positioning patients is a key component of nursing care and can affect their morbidity and mortality. The Centers for Disease Control and Prevention recommend that patients receiving mechanical ventilation have the head of the bed elevated 30°to 45°to prevent nosocomial pneumonia. However, use of higher backrest positions for critically ill patients is not common nursing practice. Backrest elevation may be affected by the accuracy of nurses’ estimates of patients’ positions.

• Objectives To determine the difference between nurses’ estimates of bed angles and measured bed angles and to describe the relationship between nurses’ characteristics and the accuracy of their estimates.

• Methods A convenience sample of 67 nurses attending the 1999 American Association of Critical-Care Nurses National Teaching Institute and Critical Care Exposition in New Orleans, La. Each subject provided demographic information and estimated 3 bed angles. The angles were preselected by using a random number table. Summary statistics were used and were categorized according to the demographic information provided by participants. Estimated angles were correlated with measured angles, and accuracies in estimating angles were correlated with demographic characteristics.

• Results Nurses were accurate in estimating bed angles (correlation, 0.8488). Demographic information, including sex, age, years of practice, years of critical care practice, basic education, highest educational level, and present position had no relationship to accuracy.

• Conclusions Nurses are able to estimate backrest elevation accurately. Other explanations are needed to understand why recommendations for backrest elevation are not used in practice.

The relationship between maternal needs and priorities in a neonatal intensive care environment

AIM

The aim of this study was to investigate the nature and organization of maternal needs and priorities in a neonatal unit.

BACKGROUND

The relationship between maternal needs and priorities appears to be an under studied area in neonatal nursing.

METHODS

A quantitative survey was carried out based on 209 mothers with premature infants. Two self-assessment schedules were used: critical care maternal needs inventory (J. Leske, Heart and Lung 15, 27-42) and a ranking scale. The data were analysed with multivariate analysis.

FINDINGS

Data analysis revealed clear priorities in maternal needs. In particular the need for accurate infant related information was a priority for 93% of the mothers. Good communication practices with professionals were also valued. The mothers displayed altruistic behaviour, and self-related needs took second place. It is proposed that maternal needs demonstrate a hierarchical organization.

CONCLUSION

It is important for nurses to consider the individual needs of the mothers, simply because the satisfaction of these needs is essential for maternal well-being.

Gender influences handwashing rates in the critical care unit

BACKGROUND

Nurses tend to wash their hands more often than physicians, and among nonhealth care workers, women tend to wash their hands more often than men. This study examined the influence of gender on the handwashing rates of health care workers (HCWs). The null hypotheses were that there would be no intergender difference in (a) handwashing rates in HCWs across professions and (b) within professional groups.

METHODS

Handwashing by nurses, physicians, wardspersons, x-ray technicians, and physiotherapists after patient contact in a critical care unit (CCU) was determined through covert observation. The gender and profession of the subjects were recorded, but their identity was not.

RESULTS

Female CCU staff washed their hands significantly more often than did their male counterparts after patient contact (P =.0001). When the results were examined for the influence of profession on handwashing, significant intergender differences remained for physicians (P =.0468) and wardspersons (P =.0001). There was also a nonsignificant trend (P =.07) toward higher rates of handwashing among female x-ray technicians. There were no statistically significant intergender differences in handwashing rates among nurses (P =.7588) and physiotherapists.

CONCLUSIONS

It appears that gender may influence handwashing rates in HCWs in the CCU, although this difference appears to be modified in particular professional groups. Further research should examine factors that modify handwashing rates within professional groups and in settings other than the CCU.

Undergraduate student nurses' expectations and their self-reported preparedness for the graduate year role

AIMS OF THE STUDY

The study identifies third-year nurses' expectations of the graduate nurse role and ascertains how prepared they feel to fulfil this role.

BACKGROUND

The literature substantiates that the university-workplace transition is marked by differences between students' expectations of the graduate year and the realities of practice they encounter in the workforce setting. Nursing professionals and health service employers continue to debate the expectations required of the new nurse graduate. Yet there is little assessment of graduate nurses' expectations of the workplace. This study describes student nurses' expectations of the graduate year and the extent to which they regard themselves as well- or ill-prepared.

DESIGN

Third-year student nurses (n=105) from a 3-year Bachelor of Nursing (BN) course at a large Metropolitan University in Australia were surveyed. A group of nursing academics and their senior colleagues in the clinical setting designed a questionnaire in light of common themes derived from literature on the graduate year role. Responses were examined and analysed using descriptive statistics.

RESULTS

Responses revealed that student nurses tended to favour large public hospitals, and sought a good graduate programme with associated opportunities for guidance and support. Most expected to achieve good working relationships with both professional colleagues and patients. Final year students expressed some apprehension about meeting the performance expectations of the workplace, given their self-perceived lack of clinical experience.

CONCLUSION

When asked about their initial expectations of the workplace, third year student nurses expressed little apprehension and reported high levels on scales of organizational commitment and professionalism. The research literature suggests that divisions exist between students' expectations of the graduate year and the actual work experience. The expectations of the graduate year described in this study offer a student-centred perspective that contributes to future planning and policy directions of undergraduate curricula, graduate year programmes and nurse retention.

Worldwide overview of critical care nursing organizations and their activities

While critical care has been a specialty within nursing for almost 50 years, with many countries having professional organizations representing these nurses, it is only recently that the formation of an international society has been considered. A three-phased study was planned: the aim of the first phase was to identify critical care organizations worldwide; the aim of the second was to describe the characteristics of these organizations, including their issues and activities; and the aim of the third was to plan for an international society, if international support was evident. In the first phase, contacts in 44 countries were identified using a number of strategies. In the second phase, 24 (55%) countries responded to a survey about their organizations. Common issues for critical care nurses were identified, including concerns over staffing levels, working conditions, educational programme standards and wages. Critical care nursing organizations were generally favourable towards the notion of establishing a World Federation of their respective societies. Some of the important issues that will need to be addressed in the lead up to the formation of such a federation are now being considered.

Propofol or midazolam--which is best for the sedation of adult ventilated patients in intensive care units? A systematic review

Intensive care patients are commonly sedated to maintain comfort and to facilitate life saving therapy. Although sedation is ordered by medical staff, nurses are usually responsible for its administration and titration and thus the question of which drug regime should be chosen is an important practice issue for nurses (1,2). This paper is a report on a systematic review that was conducted to compare the effectiveness of two of the most common drugs used for the sedation of adult ventilated patients in Australian intensive care units (ICUs)--propofol and midazolam (3). All randomised controlled trials (RCTs) which compared propofol with midazolam for the sedation of adult ventilated patients in ICUs were included in the study. The outcome measures evaluated were the quality of sedation achieved, the length of time from cessation of sedation till extubation, recovery time, duration of admission to the ICU and the incidence of haemodynamic complications. Meta-analysis was used to compare results of studies where subjects had the same characteristics and the outcome criteria were measured in the same manner. The review found that infusions of both midazolam and propofol appear to provide similar quality sedation, that extubation time and recovery time is shorter in patients sedated with propofol and that haemodynamic complications related to either drug regime are not usually clinically significant.

Critical care education: an examination of students' perspectives

Specialist nursing education at the tertiary level is a relatively recent occurrence in Australia. With this move to higher education a variety of issues such as course duration, award level and clinical versus theoretical outcomes provided the impetus for this study. This study examined critical care nursing students' perceptions of undertaking post-graduate education within the higher education sector. Four themes arose from analysis of eight focus group interviews with a total of 42 students from 35 courses offered in eight universities across Australia. The first theme, student burden, included subthemes of financial, heavy workload and student-work conflicts. Student benefits, the second theme, encompassed financial and other benefits. The third theme, clinical experience, incorporated clinical capability, synthesizing, support required and clinical learning. The final theme of student attitude included the subthemes of individual, technology and course. Without student evaluations, curricular improvements including assessment and clinical experience will not evolve to the best of their potential.

Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin

AIM

The research evaluated two subcutaneous heparin injection techniques to determine the effects of different injection duration (10- and 30-seconds) on site-pain intensity and bruising.

BACKGROUND

The research was instigated because nurses and patients in the hospital under investigation reported a high incidence of site-pain and bruising associated with subcutaneous heparin therapy. This research was conducted over a period of 7 months between September 1998 and April 1999. The Ethic Committees of the University and the hospital approved the research.

METHODS

The research used a within-subjects, quasiexperiment, which would yield more convincing causal inferences, owing to the assumption that pain perception and physiological factors affecting coagulation varied less in the same subject than in two comparable subjects. The research involved 34 stroke patients receiving low-molecular weight heparin. For each subject, one of the two injection techniques was used as the first injection and 12 hours later the other injection technique as the second injection. Subjects rated the level of perceived site-pain intensity using the vertical visual analogue scale (VAS). Injection-site bruising were measured at 48 and 60 hours after each injection. Digital planimetry was used to measure the surface-area of bruise tracings. The final data set for analysis consisted of 68 VAS pain scores and 136 bruise sizes. As normality of the data could not met after transformations, Wilcoxon Signed-Rank tests were used to determine the effects caused by injection duration on site-pain and bruise size. The level of significance was determined at P < 0.05.

RESULTS

Results indicated that the 30-second duration injection technique resulted in significantly less intense site-pain and fewer and smaller bruises.

CONCLUSIONS

It was concluded that administering a subcutaneous heparin injection over longer duration reduces injection site-pain and bruising. However, the convenience, relatively small sample may limit the generalisability of the research findings.

Sedative and analgesic practice in the intensive care unit: the results of a European survey

Sedation and analgesia are important aspects of patient care on the intensive care unit (ICU), yet relatively little information is available on common sedative and analgesic practice. We sought to assess international differences in the prescription of sedative and analgesic drugs in western European ICUs by means of a short, self-administered questionnaire. Six hundred and forty-seven intensive care physicians from 16 western European countries replied to the questionnaire. Midazolam was used as a sedative often or always by 63% of respondents and propofol by 35%. There were considerable international variations, with midazolam being preferred over propofol in France, Germany, the Netherlands, Norway and Austria. For analgesia, the drugs most commonly used were morphine (33%), fentanyl (33%) and sufentanil (24%). Morphine was preferred over fentanyl and sufentanil in Norway, UK and Ireland, Sweden, Switzerland, the Netherlands, and Spain and Portugal. Fentanyl was preferred in France, Germany and Italy. Sufentanil was preferred in Belgium and Luxemburg and in Austria. Multivariate analysis showed that the combination of midazolam with fentanyl was most often used in France; propofol with morphine in Sweden, the UK and Ireland, and Switzerland; midazolam with morphine in Norway; and propofol with sufentanil in Belgium and Luxemburg, Germany and Italy. The use of a sedation scale varied from 72% in the UK and Ireland to 18% in Austria. When used, the most common sedation scale was the Ramsay scale. This study demonstrates substantial international differences in sedative and analgesic practices in western European ICUs.

Clarification of conceptualizations of empathy

BACKGROUND

If understanding our clients needs, emotions, and circumstances is fundamental to nursing practice, and empathy is the foundation of that understanding, then a conceptualization of empathy that can be used by nurses is of utmost importance to the profession. In 1992, Morse, Anderson, Bottorff, Yonge, O'Brien, Solberg and McIlveen analysed the concept of empathy in the psychological and nursing literature, and suggested the conceptualization of empathy was incomplete. Since that time, nurse authors have continued to publish conceptualizations and research on empathy.

PURPOSE

The purpose of our analysis was to describe empathy as presented in the nursing literature between 1992 and 2000.

METHOD

A concept clarification methodology of concept analysis was used because of the many definitions, the rich descriptions, and the application of empathy as a research variable in the reviewed literature.

FINDINGS

Five conceptualizations of empathy were revealed: empathy as human trait, empathy as a professional state, empathy as a communication process, empathy as caring, and empathy as a special relationship.

CONCLUSIONS

The literature reviewed contained evidence that the concept is developing more depth and breadth. Nurse authors are approaching empathy from a variety of perspectives, time frames, measurements, and outcomes. While all are important to the development of the concept, further enrichment of the conceptual work on empathy is needed before a fully mature concept emerges that is fully useful in nursing practice, research, and education.

A consensus driven method to measure the required number of intensive care nurses in Australia

This paper describes a methodology for determining the number of nurses required to staff Australia's intensive care unit (ICU) beds. The evidence used is level IV, that is the use of expert panel opinion, and it is the strongest and most accurate attempt yet to describe how Australia's ICU beds should be staffed with nurses. The researchers provide ratios of staffing applicable to a variety of situations that should be of use to ICU managers and hospital administrators. Equally, the broader calculations explaining the national supply and demand needs provide an easy to use approach and explanation suitable to health professionals, health administrators, policy advisors, governments, politicians and the broader community. Limitations of the approach and further recommendations are made to encourage future work in this area. Finally, a strong correlation between the number of available 'open' ICU beds in Australia and the number of nurses actually working in ICU at any given time is well demonstrated using the methodology outlined in this paper. Clarification of scope and terminology: This paper focuses on the nursing requirements of ICUs only; occasionally we use the word critical care nurse--this generally refers to those nurses who have completed a generic critical care nursing course but who, for the purposes of our study, are working in ICUs. Critical care units encompass ICUs but may also encompass recovery room, cardiothoracic units, coronary care, emergency departments and many other environments where critically ill patients are cared for and treated. This paper does not cover the broader scope of critical care units, only ICUs.

The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs

Although many studies have attempted to define levels of staff experience appropriate for the care of critically ill patients, minimal data is available on the effect of nursing staff inexperience (NSI) on the occurrence of incidents in the intensive care environment. The Australian Incident Monitoring Study in Intensive Care Units (AIMS-ICU), an anonymous, voluntary incident reporting system, can help to identify problems in which NSI may be implicated. NSI may be an incident in itself or contribute to the occurrence of other incidents. The objective of this paper was to identify incidents associated with NSI and estimate their effect on the quality of patient care. Incidents related to NSI were extracted from the AIMS-ICU database and analysed using descriptive methodology. Seven hundred and thirty five reports covering 1,472 incidents were identified as relating to NSI. Of these, 282 were described in the narrative section and 453 were selected as a contributing factor by the reporter. Major categories for the 1,472 incidents included airway and ventilation (317) drugs and therapeutics (468), procedures, lines and equipment (219), patient environment (234) and unit management (234). An undesirable major adverse patient outcome was selected in 20 per cent of reports. NSI associated incidents reported to AIMS-ICU suggest that NSI can have a negative impact on the quality of care delivered to critically ill patients as shown by the occurrence and outcome of incidents related to such inexperience. Errors are more likely to occur when NSI is combined with staff shortage, inadequate supervision and high unit activity. When rostering or employing staff, nurse managers and educators must consider the special requirements of inexperienced nurses. Safe patient care requires these issues be included in discussions about ICU resource allocation.

Quality use of medicines (QUM) in critical care: an imperative for best practice

Quality use of medicines (QUM) as a discrete concept is gaining increasing importance in Australia and is supported by a policy platform which has federal government and health professional support. The QUM movement is also supported by a strong consumer base and this lobby group has been responsible for endorsement as a major health initiative. However, the importance of QUM to achievement of optimal patient outcomes has not achieved sufficient recognition in the critical care literature. Implicit in the discussion of QUM is the rational, ethical, safe and effective use of drugs within a best practice framework. Successful implementation of QUM requires appropriate infrastructure and the commitment and cooperation of medical, nursing and pharmacy staff. Support, education and training provide the prerequisites of knowledge, skills and awareness for quality use of medicines for all groups. An emphasis upon evidence based practice and the prevalence of polypharmacy in contemporary health care systems requires examination of factors that are barriers to best practice. QUM in critical care areas requires appropriately skilled staff who are competent to manage patients with a wide range of selected drugs, often in highly stressful situations. In many situations in critical care, the role of the critical care nurse is one of patient advocate. It is important to note that the delivery of critical care is not limited to a discrete setting and is inclusive of management at the trauma scene, assessment and delivery of care in the emergency department, through to intensive, coronary care and high dependency units. This paper presents a discussion of the concept of QUM and its relevance in the critical care context. Key theoretical, policy and research considerations for establishment of QUM in critical care are reviewed and discussed. This paper seeks to describe key issues in QUM and endorse the need for a research agenda in critical care.

Are auditory warnings in the intensive care unit properly adjusted?

The purpose of this study was to determine whether auditory warnings in the intensive care unit (ICU) were properly adjusted. An intervention study (before- and-after assessment) was conducted in a 12-bed medical-surgical ICU of an acute-care teaching hospital in Barcelona, Spain. A total of 100 patients with stable haemodynamic and respiratory parameters were included. In the first 3-month phase of the study, minimum and maximum alarm parameters of breathing rate, expired volume/min, airway pressure, SaO(2), arterial blood pressure and heart rate were recorded. In the second 12-month phase of the study, the same alarm parameters were recorded every 4 hours in the patient's medical record. In the third 3-month phase of the study, alarm readings were recorded again as in the first phase. The change throughout coefficient of variation (CV) and the 95% confidence interval (CI) for each alarm were calculated. Following the intervention, there was a statistically significant improvement in alarm readings for expired volume, heart rate and systolic blood pressure, so that alarms had been more properly adjusted to the patient's real value. Nursing staff should be aware that auditory warnings in ICU stable patients are frequently set very far from suitable values. Recording of alarm parameters in the patient's medical record as a routine daily activity was an effective intervention for improving adjustment of auditory warnings.

[Organizational culture in health and nursing studies]

This study aims at presenting a literature review on the theme concerning organizational culture and at pointing out the subjacent assumptions to some theoretical and methodological conceptions. It focuses on health care and nursing studies.

Predictors of cardiac patients' psychophysiological responses to caregiving

Patients who are hospitalized for treatment of cardiac problems are at risk from life-threatening cardiovascular changes related to autonomic nervous system (ANS) arousal. Physical care during hospitalization can increase ANS arousal, yet caregiving is an essential feature of patient treatment. The purpose of this study was to identify the degree to which a patient's vulnerability to sensory stimuli, perceptions of previous caregiving and stressful events during hospitalization may contribute to ANS arousal during caregiving. Fifty-nine patients, who were hospitalized for treatment of coronary artery or valvular disease, received a standardized protocol designed to simulate aspects of physical caregiving. Heart rate, incidence of arrhythmias, blood pressure and state anxiety were measured during the protocol to determine ANS arousal. Regression analyses provided evidence that sensory vulnerability was the most consistent predictor across all indices of arousal during caregiving. Previous caregiving experiences that were perceived as 'negative' by the patient also contributed to higher blood pressure and anxiety. Stressful hospital events involving the family predicted higher blood pressure during caregiving.

[Ethnography: methodologic strategy used to conceptualize the cultural scenario in an intensive care center at a university hospital]

This work is a part of an ethnographic study accomplished in a university hospital ICC that had as objective to describe the intensive care workers' culture. It is presented cultural domains a taxonomies developed from the workers' narration The results here presented show that ethnography is a methodological strategy appropriate for a cultural background contexture from a viewpoint of those who experiment the everyday intensive care work.

Neonatal intensive care: communication and attachment

Birth has traditionally been recognized as a family-centred event where immediate exposure to the infant occurs and where the family begins, through direct contact, touch and voice, to form an attachment to the infant. In high-risk pregnancy and delivery, medical and technological advances distance the family from the birth event. This article describes some aspects of a research project with identified factors that facilitate and hinder family and mother attachment to the infant during periods of separation subsequent to premature delivery or other problems which require management in a neonatal intensive care unit (NICU). The project was exploratory. It involved observation of care, participation in care, individual unstructured interviews, focus group interviews and also use of Leske's (1986, 1991a,b) critical care family needs inventory, which was modified and responded to by family members (n = 109) in an attempt to quantify and validate their needs. Six constructs were derived from the inventory and then ranked by mothers (n = 100). The findings from this process were triangulated to observation and interview data in order to confirm factors that facilitate and hinder the process of attachment during family and mother-infant separation. The results of the study imply that when the family and mother are supported by an individualized approach to care and appropriate communication is used, attachment can be facilitated.

ACCCN national nursing workforce survey of intensive care units

A descriptive study was designed and implemented by the Australian College of Critical Care Nurses (ACCCN) Workforce Planning Advisory Committee to capture data pertaining to workforce issues of intensive care nurses. All intensive care units (ICUs) within Australia were mailed a self reporting survey. Despite a low response rate (52 per cent) and difficulty reported by respondents in gaining the appropriate data requested, the results revealed an interesting snapshot of the intensive care nursing workforce. Types of services offered by units varied considerably; paid overtime hours were low (< 2 per cent of total hours worked) and use of both part-time and agency staff was also low (10 per cent of total hours worked). Private hospitals utilised a greater proportion of part-time and agency nursing staff than public hospitals (20:10 per cent). The turnover rate for registered nursing staff was estimated at 18 per cent, with education, skill acquisition and improved communication reported as the major incentives used by managers to attract and retain staff. This study demonstrated that valuable data are currently uncaptured and recommends a more refined process of a national database to record and manage this important information for future workforce planning.

Staff rostering in the operating department

The smooth running of the operating department is often facilitated by the goodwill of the staff who agree to stay behind when cases overrun, or work through lunch and coffee breaks. Many perioperative staff also cover on-calls and stand-bys, causing disruption to their social and family lives. These demands may make working in the operating department harder for some staff. With reference to current shortages of perioperative staff and staff retention, Judith Tanner and Gloria Bailey discuss some suggestions for being flexible with the off duty rota which may give staff more control and more choices over when they work.

The evolutionary process of Medical Emergency Team (MET) implementation: reduction in unanticipated ICU transfers

OBJECTIVE

To determine whether the introduction of the Medical Emergency Team (MET) system designed to provide immediate help for seriously ill patients: (i) changed the pattern of ICU patient transfers from the wards; and (ii) improved hospital survival rates.

METHODS

Prospective information on MET calls and unanticipated ICU transfers was collected for 3 years in a suburban metropolitan hospital.

RESULTS

A 3-year review of MET showed the number of MET calls doubled in the second and third year and the team was activated for more than just the most extremely ill patients. Whilst the frequency of calls for cardiopulmonary arrest remained constant (n = 16), increased use of the MET resulted in the proportion of calls for cardiopulmonary arrest dropping from 30% in year 1 to 13% in year 3. A slight decrease in the percentage of in-hospital deaths (0.74% in year 1 to 0.65% in year 3) was also demonstrated. The incidence of cardiopulmonary arrest per hospital admission also decreased slightly (0.08-0.07%). Although the overall number of ICU transfers remained constant, more seriously ill patients were transferred to ICU via the MET system. This was accompanied by a significant fall in unanticipated ICU transfers. Whilst the reduction in hospital deaths was encouraging, this study could not demonstrate whether the slight improvement in hospital survival rate over the 3 years was due to the MET system.

CONCLUSION

More information is needed to demonstrate that the MET system improves patient survival. The study also highlights the importance of taking proactive measures, which should include providing in-service education on the benefits of early identification and treatment of patients who are at risk of acute deterioration, raising awareness and changing attitudes in hospitals when introducing system such as the MET.