When all else has failed: Nurses' perception of factors influencing palliative care for patients with end-stage heart failure

The purpose of this study was to describe registered nurses' (RNs') perceptions of factors influencing care for patients in the palliative phase of end-stage heart failure (ESHF). Seventeen senior RNs across 3 acute care and 5 community centres in metropolitan Adelaide, Australia, participated in the study. In this descriptive, exploratory research project, we analyzed audiotaped indepth, semistructured interviews, using a computer-assisted (NVIVO) thematic procedure. According to participants, the care of patients with ESHF is dominated by a focus on symptom management and optimal pharmacologic therapies, with a perceived deficit in other aspects of palliative management. Key mitigating factors against quality palliative care for this population included the difficulty in recognising ESHF and reluctance by physicians to negotiate end-of-life decisions. In the acute care sector, nurses believed ESHF was medicalized and characterized by paternalistic care, with treatment generally curative to the last breath. Nursing care and patient advocacy were also negatively influenced by a lack of awareness in patients and families concerning the inevitability of death in ESHF until the last few days or hours before death. Involvement of the palliative care team was often an afterthought rather than an integral component of care. Nurses in acute care settings embraced the concept of a multidisciplinary team approach, but stressed the need for the cardiac team to be the overall coordinator of care for the ESHF population. Care of patients with ESHF should promote the amalgamation of technological and pharmaceutical advances in the treatment of heart failure with more timely end-of-life care. All involved parties must work toward advancing a common middle ground for appropriate end-of-life care for patients with ESHF. Recommendations for practice include the need for greater education for patients and their families and greater collaboration between the members of the multidisciplinary healthcare team to assist patients with ESHF and their families prepare more timely for the final trajectory of the illness.

Malodour in denture wearers: an ill-defined problem

Denture plaque has not been studied to the same extent as dental plaque, and although there are many similarities in microbial composition, there are some significant differences. Denture-induced stomatitis is associated with poor denture hygiene, a more acidogenic plaque and the presence of Candida albicans. Obligate Gram-negative anaerobic micro-organisms, although present in denture plaque, have rarely been specifically investigated. Opportunist pathogens including coliforms and staphylococci have been isolated from dentures. Teeth adjacent to partial dentures are more susceptible to caries and periodontal diseases, perhaps due to an increased plaque buildup at the prosthesis/tooth interface. Little work has been published on malodour associated with dentures. The inert material provides a substratum for the plaque biofilm, which encompasses a range of odour-producing species. The microbiology of the tongue in denture wearers has not been specifically studied. Thus the nature, origin and extent of malodour in denture wearers is ill-defined, but many species capable of producing malodorous compounds are present. The wide age and health range presented by denture wearers further confounds investigation. There is a need for further work in the area, both for cosmetic- and health-associated reasons in the increasing elderly population.

The role of nurses in preventing adverse events related to respiratory dysfunction: literature review

AIMS

This paper reports a literature review examining the relationship between specific clinical indicators of respiratory dysfunction and adverse events, and exploring the role of nurses in preventing adverse events related to respiratory dysfunction.

BACKGROUND

Adverse events in hospital are associated with poor patient outcomes such as increased mortality and permanent disability. Many of these adverse events are preventable and are preceded by a period during which the patient exhibits clearly abnormal physiological signs. The role of nurses in preserving physiological safety by early recognition and correction of physiological abnormality is a key factor in preventing adverse events.

METHODS

A search of the Medline and CINAHL databases was conducted using the following terms: predictors of poor outcome, adverse events, mortality, cardiac arrest, emergency, oxygen, supplemental oxygen, oxygen therapy, oxygen saturation, oxygen delivery, assessment, patient assessment, physical assessment, dyspnoea, hypoxia, hypoxaemia, respiratory assessment, respiratory dysfunction, shortness of breath and pulse oximetry. The papers reviewed were research papers that demonstrated a relationship between adverse events and various clinical indicators of respiratory dysfunction.

RESULTS

Respiratory dysfunction is a known clinical antecedent of adverse events such as cardiac arrest, need for medical emergency team activation and unplanned intensive care unit admission. The presence of respiratory dysfunction prior to an adverse event is associated with increased mortality. The specific clinical indicators involved are alterations in respiratory rate, and the presence of dyspnoea, hypoxaemia and acidosis.

CONCLUSIONS

The way in which nurses assess, document and use clinical indicators of respiratory dysfunction is influential in identifying patients at risk of an adverse event and preventing adverse events related to respiratory dysfunction. If such adverse events are to be prevented, nurses must not only be able to recognise and interpret signs of respiratory dysfunction, but must also take responsibility for initiating and evaluating interventions aimed at correcting respiratory dysfunction.

Infrared ear thermometry in the critically ill patient

OBJECTIVE

The purpose of this clinical study was to determine the accuracy of infrared tympanic membrane thermometry compared to axillary temperature (tempAx) for detecting body temperature reliably in critically ill patients in the daily practice.

MATERIALS AND METHODS

Fifty adult patients admitted to a medical-surgical intensive care unit of an acute-care teaching hospital in Seville, Spain, during a 2-month period underwent prospective and simultaneous measurements of body temperature using a mercury-in-glass thermometer placed at the axilla of the dominant arm for at least 3 minutes and an infrared thermometer (ThermoScan 07, Braun Corporation, Kronberg, Germany) in both ears.

RESULTS

A total of 429 simultaneous measurements of axillary temperature (tempAx) and tympanic temperature (tempTT) were made. The mean +/- SD tempAx was 36.90 degrees C +/- 1.06 degrees C and the mean tempTT was 36.94 degrees C +/- 0.97 degrees C ( P = NS; 95% CI, -0.18 to 0.10), with a difference between tempTT and tempAx means of 0.04 degrees C. There was a statistically significant correlation between tempAx and tempTT ( r = 0.813, P < .0005). When 20 extreme readings of both methods (<34.2 degrees C and >39.8 degrees C) were excluded, the mean tempAx was 36.91 degrees C +/- 0.86 degrees C and the mean tempTT was 36.9 degrees C +/- 0.89 degrees C ( P = NS; 95% CI, -0.05 to 0.06), with a difference of 0.01 degrees C and a statistically significant correlation between both measurements ( r = 0.80, P < .0005). The sensitivity and specificity of tempTT for different thresholds were 74% and 85% for 37 degrees C, 70% and 95% for 38 degrees C, and 25% and 99.8% for 39 degrees C, respectively. The negative predictive value for 39 degrees C was 99%.

CONCLUSIONS

In adult intensive care unit patients, the infrared tympanic thermometer (ThermoScan 07) produced highly reliable measurements when compared to tempAx measured using a conventional mercury-in-glass thermometer. Both methods correlated positively and significantly.

Use of Physical Restraints in Adult Critical Care: A Bicultural Study

• Background Although controversial, physical restraints are commonly used in adult critical care units in the United States to prevent treatment interference and self-inflicted harm. Use of physical restraints in Norwegian hospitals is very limited. In the United States, an experimental design for research on use of restraints has not seemed feasible. However, international research provides an opportunity to compare and contrast practices.

• Objectives To describe the relationship between patients’ characteristics, environment, and use of physical restraints in the United States and Norway.

• Methods Observations of patients and chart data were collected from 2 intensive care units (n = 50 patients) in Norway and 3 (n = 50 patients) in the United States. Sedation was measured by using the Sedation-Agitation Scale. The Nine Equivalents of Nursing Manpower Use Score was used to indicate patients’ acuity level.

• Results Restraints were in use in 39 of 100 observations in the United States and not at all in Norway (P = .001). Categories of patients were balanced. In the Norwegian sample, the median Nine Equivalents of Nursing Manpower Use Score was higher (37 vs 27 points, P &lt; .001), patients were more sedated (P &lt; .001), and nurse-to-patient ratios were higher (1.05:1 vs 0.65:1, P &lt; .001). Seven incidents of unplanned device removal were reported in the US sample.

• Conclusions Critical care units with similar technology and characteristics of patients vary between nations in restraint practices, levels of sedation, and nurse-to-patient ratios. Restraint-free care was, in this sample, safe in terms of treatment interference.

Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers*

OBJECTIVE

The aging baby boomers are expected to have a significant impact on the healthcare system. Mechanical ventilation is an age-dependent, costly, and relatively nondiscretionary medical service that may be particularly affected by the aging population. We forecast the future incidence of mechanical ventilation to the year 2026 to understand the impact of aging baby boomers on critical care resources.

DESIGN

Population-based, sex-specific, and age-specific mechanical ventilation incidences for adults for the year 2000 were directly standardized to population projections to estimate the incidence of mechanical ventilation, in 5-yr intervals, from 2006 to 2026. Sensitivity analyses were performed by varying population projections and mechanical ventilation incidence for the elderly.

SETTING

Province of Ontario, Canada.

PATIENTS

Noncardiac surgery, mechanically ventilated adults.

INTERVENTIONS

None.

MAIN RESULTS

The projected number of ventilated patients in 2026 was 34,478, representing an 80% increase from 2000. The crude incidence increased 31%, from 222 to 291 per 100,000 adults. The annually compounded projected growth rate during this 26-yr period was 2.3%, similar to the actual growth rate experienced in the 1990s. The projected incidence was relatively insensitive to changes in assumptions, with estimates for 2026 ranging from 31,473 to 36,313 ventilated adults.

CONCLUSIONS

The incidence of mechanical ventilation projected to the year 2026 will steadily increase and outpace population growth as occurred in the 1990s. In the current environment in which intensive care unit resources are limited and ventilated patients already use a significant proportion of acute care resources, planning for this continued growth is necessary. Existing evidence-based strategies that improve both the efficiency and efficacy of critical care services should be carefully evaluated for widespread implementation.

The teleo-affective limits of end-of-life care in the intensive care unit

This paper explores the relevance of a specific kind of sensed connectedness or 'teleo-affectivity' to the organisation and enactment of end-of-life care. Referred to as heedful inter-relating, this teleo-affective connectedness has been found to occur among employees as they carry out their highly complex and dangerous work. This paper focuses on the proposals put in the literature for confronting the complexity of end-of-life care in the intensive care unit (ICU), and inquires into the positionings incurred in and around end-of-life care in one specific unit, with the aim of gauging the pertinence of heedful inter-relating to end-of-life care in ICU. The paper argues that while several commentators appear to be calling for enhanced heedful conduct in end-of-life care, ICU practices may not admit the kind of heedful inter-relating that is evident in high-reliability organisations such as nuclear aircraft carriers. We suggest it may be unwise to gauge intensive care units' complexity purely against the brief of realising cultural scripts of the dying, and that ICU in fact manifests a broader societal concern necessitating a more variegated composition: to devise multiple ways to contain the impression and impact of (the meaning) death for society (societies) generally.

Actigraphy in the Critically Ill: Correlation With Activity, Agitation, and Sedation

Objectives To determine the feasibility of continuous measurement of limb movement via wrist and ankle actigraphy (an activity measure) in critically ill patients and to compare actigraphy measurements with observed activity, subjective scores on sedation-agitation scales, and heart rate and blood pressure of patients.

• Methods In a prospective, descriptive, correlational study, all activity of 20 adult patients in medical and coronary care units in a university medical center were observed for 2 hours and documented. Wrist and ankle actigraphy, heart rate, and systolic and diastolic blood pressure data were collected every minute. The Comfort Scale and the Richmond Agitation-Sedation Scale were completed at the beginning of the observation period and 1 and 2 hours later.

•Results Wrist actigraphy data correlated with scores on the Richmond Agitation-Sedation Scale (r = 0.58) and the Comfort Scale (r = 0.62) and with observed stimulation and activity events of patients (r = 0.45). Correlations with systolic, diastolic, and mean arterial pressures were weaker. Wrist and ankle actigraphy data were significantly correlated (r = 0.69; P &lt; .001); however, their mean values (wrist, 418; ankle, 147) were significantly different (t = 5.77; P &lt; .001).

• Conclusions Actigraphy provides a continuous recording of patients’ limb movement. Actigraphy measurements correlate well with patients’ observed activity and with subjective scores on agitation and sedation scales. Actigraphy may become particularly important as a continuous measurement of activity for use in behavioral research and may enhance early recognition and management of the excessive activity that characterizes agitation.

Poor knowledge and faulty thinking regarding hemolysis and potassium elevation

A questionnaire to assess knowledge of the expected elevation in serum K measurement with different grades of hemolysis was administered to medical technologists working in biochemistry laboratories, hospital physicians and nurses. The questions involved different grades of hemolysis (mild, 1.0, moderate, 2.5 and severe, 5.0g/L) and different final K measurements (2.9, 4.0, 5.2 and 8.2mmol/L). Subjects estimated the K concentration in a non-hemolyzed sample for each scenario. Adjustment values (difference between final hemolyzed K concentration and subject's response) were calculated. For the 132 respondees, the mean correct score was 1.7/12. Mean adjustment values were: mild, 0.43mmol/L (K 2.9), 0.55 (4.0), 0.88 (5.2) and 1.53 (8.2); moderate, 0.85 (2.9), 0.92 (4.0), 1.33 (5.2) and 2.50 (8.2); and severe, 0.93 (2.9), 1.48 (4.0), 1.96 (5.2), 2.96 (8.2). Correct adjustments were: mild, 0.28; moderate, 0.70; and severe, 1.40mmol/L. Healthcare staff overestimated the effect of hemolysis on potassium measurement and used an incorrect proportional adjustment approach to the problem. Such poor knowledge and faulty thinking could lead to diagnostic delays or misdiagnoses. There is potential for such faulty thinking in all areas of laboratory medicine, and laboratories should review their educational responsibilities and reporting practices in light of this.

Examining discharge outcomes and health status of critically ill patients: some practical considerations

This prospective observational study examined the outcomes of 200 consecutive admissions to an adult tertiary level Intensive Care Unit (ICU). Eligible and consenting participants were also involved in a sub-study that examined health status at four measurement points from pre-illness to 6 months post-discharge. Of the 189 individual patients admitted, 23% died in ICU and 57% were discharged home. The health status sub-study enrolled 34 participants (39% of eligible patients) who were representative of the ICU population for demographic and clinical variables. Surviving participants returned to a similar, though not identical state of health at 6 months post-discharge, when compared to their pre-ICU health-state using the 15D and SF-36 instruments. Health status at ICU discharge was significantly impaired when compared to other measurement points, particularly for mobility, breathing, eating, usual activities and vitality. A number of methodological challenges were evident, particularly for the health status sub-study, including prospective subject recruitment and retention, losses to follow-up and instrument responsiveness. Despite the limitations noted, the study provided useful findings and recommendations for the continued development of methods to examine the health status of critically ill patients.

A review of the nursing care of enteral feeding tubes in critically ill adults: part I

Enteral tubes are frequently used in critically ill patients for feeding and gastric decompression. Many of the nursing guidelines to facilitate the care of patients with enteral tubes have not been based on current research, but on ritual and opinion. Using a computerised literature search and an evidence-based classification system as described by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tube management. Several nursing practices related to enteral tube management are described. Evidence to support alternate methods of tube placement assessment other than abdominal X-ray was inconclusive. Enteral feeding should continue if gastric residual volumes are not considered excessive, as feeding is often withheld unnecessarily. Frequency of checking gastric residual volumes is largely opinion based and varies considerably, but prokinetics that aid gastric emptying should be used if absorption of feeds is problematic. Other recommendations include continuous rather than intermittent feeding, semi-recumbent positioning to reduce the risk of airway aspiration and diligent artificial airway cuff management. Contamination of feeds can be minimised by minimal, meticulous handling and the use of closed rather than open systems. Generally, there was little high quality evidence to support practice recommendations leaving significant scope for further research by nurses in the management of patients with enteral tubes.

Medical errors: impact on clinical laboratories and other critical areas

The Institute of Medicine (IOM) report (1999) stated that the prevalence of medical errors is high in today's health care system. Some specialties in health care are more risky than others. A varying blunder/error rate of 0.1-9.3% in clinical diagnostic laboratories has been reported in the literature. Many of these errors occur in the preanalytical and postanalytical phases of testing. It has been suggested that the errors occurring in clinical diagnostic laboratories are smaller in number than those occurring elsewhere in a hospital setting. However, given the quantum of laboratory tests used in health care, even this small rate may reflect a large number of errors. The surgical specialties, emergency rooms, and intensive care units have been previously identified as areas of risk for patient safety. Though the nature of work in these specialties and their interdependence on clinical diagnostic laboratories presents abundant opportunities for error-generating behavior, many of these errors may be preventable. Appropriate attention to system factors involved in these errors and designing intelligent system approaches may help control and eliminate many of these errors in health care.

The meaning of effective education for critical care nursing practice: a thematic analysis

Continuing education and practice development are integral components of specialist nursing practice in environments such as intensive and critical care. Previous studies have examined the 'effectiveness' of various approaches to teaching and learning in critical care, yet few have considered how effective education affects the relationship between education and practice development. Using thematic analysis, this study explored the phenomenon of effective education (for critical care nursing practice) by asking: What does effective education for critical care nursing practice mean to nurses currently practising in the specialty? Eighty eight critical care nurses from the South Island of New Zealand provided written descriptions of what effective education for critical care nursing practice meant to them. Descriptive statements were analysed to reveal constituents, themes and essences of meaning. Four core themes of personal quality, practice quality, the learning process and learning needs emerged. Appropriateness or relevance for individual learning needs is further identified as an essential theme within the meaning of effective education for critical care nursing practice. Shared experiences of the phenomenon are made explicit and discussed with reference to education and practice development in the specialty. The study results lend support to education that focuses on individual learning needs, and identifies work based learning as a potential strategy for learning and practice development in critical care nursing.

A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS)*

OBJECTIVE

To evaluate the contributing and limiting factors for airway events reported in the Intensive Care Unit Safety Reporting System (ICUSRS) developed in partnership with the Society of Critical Care Medicine.

DESIGN

Analysis of system factors in airway vs. nonairway events reported to a voluntary, anonymous, Web-based patient safety reporting system (the ICUSRS).

SETTING

Sixteen adult and two pediatric intensive care units (ICU) across the United States.

PATIENTS

Incidents reported during the 12-month period ending June 30, 2003.

INTERVENTIONS

None

MEASUREMENTS

Descriptive characteristics of incidents (defined as events that could have, or did, cause harm), patients, and patient harm; separate multivariable logistic regression analyses of contributing and limiting factors for airway vs. nonairway events.

MAIN RESULTS

There were 78 airway and 763 nonairway events reported. More than half of airway events were considered preventable. One patient death was attributed to an airway event. Physical injury, increased hospital length of stay, and family dissatisfaction occurred in at least 20% of airway events. Important factors contributing to reported airway events (odds ratio (OR), 95% confidence interval (CI)) included patients' medical condition (5.24, 3.07-8.95) and age <1 yr old (4.15, 1.79-9.59). Factors limiting the impact of airway events (OR, 95% CI) included adequate ICU staffing (3.60, 1.71-7.56) and use of skilled assistants (3.20, 1.62-6.32).

CONCLUSIONS

Patients are harmed by unintended and preventable incidents involving airway management. Prevention efforts should focus on critically ill infants and patients with complex medical conditions. Managers should ensure appropriate ICU staffing to limit the impact of airway events when they occur.

Bench-to-bedside review: Resuscitation in the emergency department

Over the past decade the practice of acute resuscitation and its monitoring have undergone significant changes. Utilization of noninvasive mechanical ventilation, goal-directed therapy, restricted fluid volume, blood transfusion and minimally invasive technology for monitoring tissue oxygenation have changed the practice of acute resuscitation. Early diagnosis and definitive treatment of the underlying cause of shock remains the mainstay for survival after successful resuscitation. Patient-centered outcome end-points, in addition to survival, are being utilized to appraise the effectiveness of treatment. Application of medical ethics to the ever changing practice of acute resuscitation has also become a societal expectation.

Truth-telling in clinical practice and the arguments for and against: a review of the literature

In general, most, but not necessarily all, patients want truthfulness about their health. Available evidence indicates that truth-telling practices and preferences are, to an extent, a cultural artefact. It is the case that practices among nurses and doctors have moved towards more honest and truthful disclosure to their patients. It is interesting that arguments both for and against truth-telling are established in terms of autonomy and physical and psychological harm. In the literature reviewed here, there is also the view that truth-telling is essential because it is an intrinsic good, while it is argued against on the grounds of the uncertainty principle. Based on this review, it is recommended that practitioners ought to ask patients and patients' families what informational requirements are preferred, and research should continue into truth-telling in clinical practice, particularly to discover its very nature as a cultural artefact, and the other conditions and contexts in which truth-telling may not be preferred.

A systematic review of the content of critical appraisal tools

Background

Consumers of research (researchers, administrators, educators and clinicians) frequently use standard critical appraisal tools to evaluate the quality of published research reports. However, there is no consensus regarding the most appropriate critical appraisal tool for allied health research. We summarized the content, intent, construction and psychometric properties of published, currently available critical appraisal tools to identify common elements and their relevance to allied health research.

Methods

A systematic review was undertaken of 121 published critical appraisal tools sourced from 108 papers located on electronic databases and the Internet. The tools were classified according to the study design for which they were intended. Their items were then classified into one of 12 criteria based on their intent. Commonly occurring items were identified. The empirical basis for construction of the tool, the method by which overall quality of the study was established, the psychometric properties of the critical appraisal tools and whether guidelines were provided for their use were also recorded.

Results

Eighty-seven percent of critical appraisal tools were specific to a research design, with most tools having been developed for experimental studies. There was considerable variability in items contained in the critical appraisal tools. Twelve percent of available tools were developed using specified empirical research. Forty-nine percent of the critical appraisal tools summarized the quality appraisal into a numeric summary score. Few critical appraisal tools had documented evidence of validity of their items, or reliability of use. Guidelines regarding administration of the tools were provided in 43% of cases.

Conclusions

There was considerable variability in intent, components, construction and psychometric properties of published critical appraisal tools for research reports. There is no "gold standard' critical appraisal tool for any study design, nor is there any widely accepted generic tool that can be applied equally well across study types. No tool was specific to allied health research requirements. Thus interpretation of critical appraisal of research reports currently needs to be considered in light of the properties and intent of the critical appraisal tool chosen for the task.

Wolff-Parkinson-White Syndrome: Essentials for the Primary Care Nurse Practitioner

PURPOSE

To provide nurse practitioners with a basic understanding of the pathophysiology, clinical characteristics, diagnostic methods, and management of Wolff-Parkinson-White (WPW) syndrome.

DATA SOURCES

Selected research and clinical articles.

CONCLUSIONS

WPW syndrome is the most common form of ventricular preexcitation. The ventricular myocardium is activated earlier than expected by an accessory conduction pathway that allows a direct electrical connection between the atria and ventricles. Although many patients remain asymptomatic throughout their lives, approximately half of the patients with WPW syndrome experience symptoms secondary to tachyarrhythmias, such as paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter, and, rarely, ventricular fibrillation and sudden death. Symptoms include palpitations, dizziness, syncope, and dyspnea. Diagnosis is usually made by electrocardiogram findings, but further testing may be warranted to confirm the diagnosis.

IMPLICATIONS FOR PRACTICE

A thorough patient history and physical examination can aid the practitioner in identifying patients who may have WPW syndrome. With appropriate referral, treatment, and patient education, patients with WPW syndrome can expect to have a normal life expectancy and good quality of life.

Nursing Outcomes

Percutaneous coronary interventional (PCI) procedures are commonly performed in the United States. The process of caring for this patient population has changed dramatically over the last 10 years, with many of the changes being driven by an evolution in the knowledge base underlying nursing practice. The purpose of this article is to provide a summary and critique of nurse-sensitive outcomes related to patients undergoing PCI procedures and to identify gaps in the literature to provide recommendations for future research. Nursing research on indicators related to costs of care, morbidity, symptom management, functional status, patient/family knowledge, patient responses, behavior, and home/occupational function following PCI are discussed in this review.

Decision-making models used by 'graduate nurses' managing patients' medications

BACKGROUND

Nurses in a graduate programme in Australia are those who are in the first year of clinical practice following completion of a 3-year undergraduate nursing degree. When working in an acute care setting, they need to make complex and ever-changing decisions about patients' medications in a clinical environment affected by multifaceted, contextual issues. It is important that comprehensive information about graduate nurses' decision-making processes and the contextual influences affecting these processes are obtained in order to prepare them to meet patients' needs.

AIM

The purpose of this paper is to report a study that sought to answer the following questions: What are the barriers that impede graduate nurses' clinical judgement in their medication management activities? How do contextual issues impact on graduate nurses' medication management activities? The decision-making models considered were: hypothetico-deductive reasoning, pattern recognition and intuition.

METHODS

Twelve graduate nurses who were involved in direct patient care in medical and surgical wards of a metropolitan teaching hospital located in Melbourne, Australia participated in the study. Participant observations were conducted with the graduate nurses during a 2-hour period during the times when medications were being administered to patients. Graduate nurses were also interviewed to elicit further information about how they made decisions about patients' medications.

RESULTS

The most common model used was hypothetico-deductive reasoning, followed by pattern recognition and then intuition. The study showed that graduate nurses had a good understanding of how physical assessment affected whether medications should be administered or not. When negotiating treatment options, graduate nurses readily consulted with more experienced nursing colleagues and doctors.

STUDY LIMITATIONS

It is possible that graduate nurses demonstrated a raised awareness of managing patients' medications as a consequence of being observed.

CONCLUSIONS

The complexity of the clinical practice setting means that graduate nurses need to adapt rapidly to make sound and appropriate decisions about patient care.

Nosocomial infection surveillance and control policies

PURPOSE OF REVIEW

In the majority of countries costs for health care are increasing and strategies to reduce adverse events in medical treatment have an increasing importance. Nosocomial infection remains the most common type of complication affecting hospitalized patients. As preventive strategies have indeed become more important they now have to show not only that they are effective in reducing nosocomial infections but also that they are cost effective. This paper investigates the contribution made by articles published in the last year to the development of nosocomial-infection surveillance and control policies.

RECENT FINDINGS

At least 15 randomized controlled studies and six meta-analyses investigating various infection-control policies were published last year. They did not lead to any changes in present guidelines, but rather endorsed existing recommendations. At least nine studies were found reporting a substantial reduction in nosocomial infections by the introduction of quality management principles under routine working conditions. Furthermore there were a lot of studies published which focused on optimizing surveillance measures and investigating the use of reference data for reducing infection rates. Only seven studies estimating the burden of disease were found in the literature of the past year.

SUMMARY

The predominant opinion voiced in the studies was that in many medical institutions some 30% or more of nosocomial infections could be prevented.

Critical care nurses' perceptions about their involvement in significant decisions regarding patient care

The purpose of the study was to explore and describe the perceptions of critical care nurses' (CCNs) actual and preferred levels of involvement in significant decisions regarding patient care in critical care areas. A convenience sample of CCNs was recruited from two centres (one public and one private) and a researcher generated survey distributed to participants. Of the 131 questionnaires distributed, 90 were completed, giving a response rate of 68.7%. Results showed that, although most CCNs believed that they had important information to contribute to decisions relating to patient care, less than half felt that they were actively involved in such decisions. They were aware of the legal limits to their scope of practice but, despite this, most admitted that they made decisions beyond these limits. Approximately three quarters of the respondents thought CCNs should not be making decisions beyond legal boundaries. On the whole, CCNs wanted to be more involved formally and to have more power in decisions regarding patient care. One way forward is for the CCNs to have an advanced practice role.

An insight into Australian nurses’ experience of withdrawal/withholding of treatment in the ICU

BACKGROUND

The success of biotechnology has created moral and ethical dilemmas concerning end-of-life care in the Intensive Care Unit (ICU). Whilst the competent individual has the right to refuse or embrace treatment, ICU patients are rarely able to exercise this right. Thus, decision-making is left to medical professionals and family/significant others.

AIM

This study aimed to explore the lived experience of ICU nurses caring for clients having treatment withdrawn or withheld, and increase awareness and understanding of this experience amongst other health professionals.

METHODS

Van Manens' (1990) phenomenological framework formed the basis of this study as it provided an in-depth insight into the human experience. A convenience sample of ten ICU Nurses participated in the study. Conversations were transcribed verbatim and analysed using a process of thematic analysis.

RESULTS

Five major themes emerged during the analysis. These were: (1) comfort and care, (2) tension and conflict, (3) do no harm, (4) nurse-family relationships and (5) invisibility of grief and suffering.

CONCLUSION

The experience of providing care for the adult having treatment withdrawn or withheld in the ICU represents a significant personal and professional struggle. Improvements in communication between health professionals, debriefing and education about the process of withdrawing or withholding treatment would be beneficial to both staff and families and has the potential to improve patient care and reduce burden on nurses.

Documentation on Withdrawal of Life Support in Adult Patients in the Intensive Care Unit

• Background Patients’ charts have been a source of data for retrospective studies of the quality of end-of-life care. In the intensive care unit, most patients die after withdrawal of life support. Chart reviews of this process could be used not only to assess the quality of documentation but also to provide information for quality improvement and research.

• Objective To assess the documentation of end-of-life care of patients and their families by care providers in the intensive care unit.

• Method Charts of 50 adult patients who died in the intensive care unit at a large midwestern hospital after initiation of withdrawal of life support (primarily mechanical ventilation) were reviewed. A form developed for the study was used for data collection.

• Results The initiation of the decision making for withdrawal was documented in all 50 charts. Sixteen charts (32%) had no information on advance directives. Eight charts (16%) had no documentation on resuscitation status. About two thirds of the charts documented nurses’ participation during the withdrawal process; only one tenth documented physicians’ participation. A total of 13 charts (26%) had no information on the time of initiation of the withdrawal process, and 11 (22%) had no documentation of medications administered for withdrawal. Thirty-seven charts (74%) had information on whether the patient was or was not extubated during withdrawal.

• Conclusion Comprehensive documentation of end-of-life care is lacking.

Clinical review: moral assumptions and the process of organ donation in the intensive care unit

The objective of the present article is to review moral assumptions underlying organ donation in the intensive care unit. Data sources used include personal experience, and a Medline search and a non-Medline search of relevant English-language literature. The study selection included articles concerning organ donation. All data were extracted and analysed by the author. In terms of data synthesis, a rational, utilitarian moral perspective dominates, and has captured and circumscribed, the language and discourse of organ donation. Examples include "the problem is organ shortage", "moral or social duty or responsibility to donate", "moral responsibility to advocate for donation", "requesting organs" or "asking for organs", "trained requesters", "pro-donation support persons", "persuasion" and defining "maximising donor numbers" as the objective while impugning the moral validity of nonrational family objections to organ donation. Organ donation has recently been described by intensivists in a morally neutral way as an "option" that they should "offer", as "part of good end-of-life care", to families of appropriate patients. In conclusion, the review shows that a rational utilitarian framework does not adequately encompass interpersonal interactions during organ donation. A morally neutral position frees intensivists to ensure that clinical and interpersonal processes in organ donation are performed to exemplary standards, and should more robustly reflect societal acceptability of organ donation (although it may or may not "produce more donors").

Survey of interventions for the prevention and treatment of acute respiratory distress syndrome

OBJECTIVE

To determine physicians' opinions and practices related to the management of patients with acute respiratory distress syndrome.

DESIGN

Cross-sectional mail survey.

SETTING

Province of Ontario, Canada.

PARTICIPANTS

Physicians treating patients with acute respiratory distress syndrome at university-affiliated and unaffiliated hospitals.

INTERVENTIONS

We searched the literature and consulted experts to generate a list of potential interventions for acute respiratory distress syndrome. Eight intensive care unit physicians selected the most relevant, available, and controversial of these interventions for prevention (n = 5) and treatment (n = 30). Fourteen physicians reviewed the questionnaire before administration to ensure clarity, realism, and clinical sensibility. We asked participants to report their views on a) the efficacy of each intervention; b) published research evaluating efficacy; c) the frequency with which they use each intervention; and d) determinants of utilization.

MEASUREMENTS AND MAIN RESULTS

One hundred ten of 194 eligible physicians responded. Respondents varied considerably in their reported use of the 35 interventions. Although physicians cited published research findings as the most powerful determinant of prescribing these interventions, they were unaware of many relevant trials. Physicians also commonly cited "usual local practice" as a determinant of use, although formal practice guidelines were rarely in operation. Other variables directly associated with use of these interventions included increasing frequency of exposure to acute respiratory distress syndrome (p <.0001), increasing size of the intensive care unit in which physicians work (p =.004), and the presence of residents in the intensive care unit (p =.02).

CONCLUSIONS

Wide variation in the management of acute respiratory distress syndrome appears related to limited awareness of relevant research, conflicting interpretations of research findings, and adherence to varying local practice patterns. Given physicians' desire to tailor their practice to research findings and to practice in a manner that is consistent with their local intensive care unit colleagues, future research and educational efforts related to evidence-based protocols for the management of patients with acute respiratory distress syndrome might be worthwhile.

Medical hegemony in decision-making - a barrier to interdisciplinary working in intensive care?

BACKGROUND

Health care policy in the United Kingdom identifies the need for health professionals to find new ways of working to deliver patient-focussed and economic care. Much debate has followed on the nature of working relationships within the health care team.

AIM

This paper reports on an ethnographic study that examined the nursing role in clinical decision-making in intensive care units. This was chosen as a case for analysis due to the close doctor-nurse relationships that are essential in this acute and complex care setting.

METHODS

Data were collected during two-stages of fieldwork using participant observation, in-depth ethnographic interviews and documentation across three clinical sites.

FINDINGS

The findings revealed the different types of knowledge used for, divergence of roles involved in and degree of authority in clinical decision-making. Furthermore, conflict arose between doctors and nurses due to these differences and in particular because medicine dominated the decision-making process.

CONCLUSIONS

The nursing role, whilst pivotal to implementing clinical decisions, remained unacknowledged and devalued. Medical hegemony continues to render nurses unable to influence substantially the decision-making process. This has fundamental ramifications for the quality of team decision-making and the effectiveness of new ways of inter-professional working in intensive care.

Biological and physiological knowledge and skills of graduating Finnish nursing students to practice in intensive care

This study describes the basic biological and physiological knowledge and skills of graduating nurse students in Finland against the requirement of their being able to practice safely and effectively in intensive care. The study describes also their interest and willingness to work in intensive care. Measurements were based on the Basic Knowledge Assessment Tool (BKAT-5) developed by Toth in the United States. The sample consisted of 130 nursing students graduating in December 2001 and January 2002. The data were analysed statistically. The students were most knowledgeable in the areas of appropriate precautions, living will and medical calculation, followed by neurology and endocrinology. Scores were poorest for pulmonary, gastrointestinal and cardiovascular knowledge. Intensive care studies and the desire to work in intensive care correlated significantly with the respondents' basic intensive care knowledge. It is important for nursing education to concentrate on developing those areas of intensive care studies where the performance of students is weakest.

Nursing

OBJECTIVE

To identify the range of positions to which registered nurses moved when they left the profession and to explore the perceptions of respondents about the skills and experiences gained from performing nursing work.

BACKGROUND DATA

Many nurses do not remain employed in nursing positions for the duration of their working life. This pattern of career change has been seen in many countries, including Australia, the United Kingdom, the United States, and Canada.

METHODS

A mailed questionnaire was completed by respondents who had left nursing. This questionnaire covered demographic information, the industry and role in which respondents were currently working, ease of adjustment to the current industry and role, perceptions of the skills they had gained from nursing, reasons for becoming a nurse, and reasons they left nursing.

RESULTS

Many respondents moved to management positions outside the health industry, and most undertook additional study after leaving nursing. In addition, few identified difficulties in adapting to non-nursing employment, and most agreed that their nursing skills and experiences had assisted them in attaining these positions.

CONCLUSIONS

The findings are reassuring that employment as a nurse provides invaluable skills for a range of employment prospects should an individual wish to change careers.

Sex differences in public restroom handwashing behavior associated with visual behavior prompts

Handwashing after using the restroom is generally poor across the population, and one common method used to increase the frequency of handwashing is to place signs reminding individuals to wash their hands. The current study examined the association between the absence and presence of signs reminding one to wash their hands and handwashing in public restrooms. Signs prompting handwashing behavior remind restroom patrons of acceptable behavior, and the presence of these signs is hypothesized to be associated with an increase in handwashing. Observation of 175 individuals (95 women and 80 men) using public restrooms on a university campus indicated that 61% of the women and 37% of the men observed washed their hands, e.g., washing hands with soap, in the absence of the sign, and 97% of the women and 35% of the men observed washed their hands in the presence of the sign. Further, 53% of the men and 38% of the women observed rinsed their hands, e.g., washing hands without soap, in the absence of the sign, and 55% of the men and 2% of the women observed rinsed their hands in the presence of the sign. Results are discussed in terms of possible factors associated with sex differences in handwashing and the absence and presence of visual prompts for handwashing behavior.

Effects of acetaminophen on myocardial infarct size in rats

OBJECTIVE

Acetaminophen is widely prescribed as an analgesic agent in hospitals and clinics. However, acetaminophen theoretically could influence myocardial infarct size by reducing prostaglandin synthesis in vivo. To date, the effect of acetaminophen on myocardial infarct size is unknown. The present study investigated (1) whether acetaminophen has any effect on myocardial infarct size when given in an analgesic dose and (2) whether acetaminophen can affect the cardioprotective effect of the early phase of ischemic preconditioning in rats.

METHODS

Female Sprague-Dawley rats were randomly assigned to four groups (n=12 each). Group 1 (no preconditioning): Vehicle (intravenous ethanol, 0.9 mL/kg) was given 39 minutes prior to ischemia. Group 2 (acetaminophen plus no preconditioning): intravenous acetaminophen (125 mg/kg) was given 39 minutes prior to ischemia. Group 3 (preconditioning): The heart was preconditioned before ischemia, and the vehicle (intravenous ethanol, 0.9 mL/kg) was given 39 minutes prior to the ischemia. Group 4 (acetaminophen plus preconditioning): The heart was preconditioned before ischemia, and intravenous acetaminophen (125 mg/kg) was given 39 minutes prior to the ischemia. The preconditioning protocol consisted of three cycles of 3 minutes of coronary occlusion and 5 minutes of reperfusion. The left coronary artery was then occluded for 60 minutes, followed by 3 hours of reperfusion. The end points were hemodynamics, body temperature, and risk area and area of necrosis of the left ventricle.

RESULTS

The area of risk was similar among the four groups. The area of necrosis, expressed as a percentage of the area at risk, was 55.7% +/- 6.1% in the no-preconditioning group, 62.8% +/- 2.4% in the acetaminophen plus no-preconditioning group, 24.7% +/- 7.3% in the preconditioning group, and 17.2% +/- 6.4% in the acetaminophen plus preconditioning group. The area of necrosis/area at risk was decreased significantly in the preconditioning group and in the acetaminophen plus preconditioning group compared with the no-preconditioning group (P<.05); but there were no significant differences between the no-preconditioning group and the acetaminophen plus no-preconditioning group (P=.29), or between the preconditioning group and acetaminophen plus preconditioning group (P=.45). Among the four groups, heart rate and body temperature were similar. The infusion of the vehicle or acetaminophen increased blood pressure in the four groups, but to a lesser extent in the acetaminophen group. However, during coronary artery occlusion and reperfusion, the four groups had comparable blood pressures.

CONCLUSION

Acetaminophen had no beneficial or adverse effects on infarct size in nonpreconditioned rats, and the beneficial effects of preconditioning were not blocked or prevented by acetaminophen at this analgesic dose.

The impact of a liaison nurse on ICU nurses' perceptions of discharge planning

The objective of the study was to examine the impact of a discharge liaison nurse on intensive care unit (ICU) nurses' perceptions of discharge planning. The discharge liaison nurse coordinated the discharge of patients from ICU to the ward, assisted with hospital discharge, provided clinical teaching and support to both ICU and ward nurses and supported patients and families during hospitalisation. A block intervention design was used. All ICU nurses within one Australian teaching hospital were surveyed prior to and following the implementation of the discharge liaison nurse. Measures included the perceptions of discharge planning scale and the general perceived self-efficacy scale. Following implementation of the liaison nurse, less nurses perceived that discharge planning in the ICU was premature (chi2(2, n=117)=7.759, p=0.021) and that ICU nurses lack an understanding of the discharge planning process (chi2(2, n=118)=15.557, p<0.001). Discharge planning was more frequently seen as the responsibility of the bedside nurse (chi2(2, n=115) =15.270, p<0.005) but there was greater recognition of discharge planning as a time consuming process (chi2(2, n=117)=8.560, p=0.015). Self efficacy in relation to discharge planning did not change over time. Some support was found for the role of the discharge liaison nurse in promoting attitudinal change towards discharge planning in the ICU. Future research is needed to investigate the processes by which the liaison nurse fosters attitudinal change and to document the actual discharge planning practices undertaken in ICU.

Part one: Restoring patients to health outcomes and indicators of advanced nursing practice in adult critical care

The key characteristics of advanced nursing practice have been a subject of international debate over the past decade. To address this debate, a grounded theory study was undertaken by one of the authors which sought to identify the key characteristics of advanced nursing practice in adult critical care. The outcome of the main study was a theory of legitimate influence in which enhancing patient stay and improving patient outcome represented the dual purpose of advanced nursing practice in critical care. Fundamental to these factors is strategic activity. This encompasses improving patient care, facilitating continuity of care and engaging in patient education. The outcome of these strategic activities can be evaluated through evidence of eased transition across complex hospital networks, patient satisfaction and enabling of independence. The findings reflect a change in the focus and delivery of care to the critically ill and their relatives by nurses practising at an advanced level. In the second paper of this series, the intervening conditions that affect the expression of legitimate influence will be discussed.

Home management of the dying NICU patient

Intensive aggressive medical therapy does not always result in cure. For some neonates it is a futile exercise that may prolong a short life of suffering. In this article, we will discuss the babies for whom aggressive therapy may not be appropriate, and how home centered palliative care can be effectively managed. We will outline the holistic multidisciplinary approach to care, with the parents as primary carers, empowered to make informed choices in the medical care of their dying baby. Symptom management will be discussed, based on the experience of an established palliative care team. We will also look at the practical and emotional preparation for death and bereavement support for the family. We hope that more families will be given the opportunity to spend time at home with their dying baby and that, through appropriate care and support, the memory of this time will be treasured.

Das Stewart-Modell

About twenty years ago, Peter Stewart had already published his modern quantitative approach to acid-base chemistry. According to his interpretations, the traditional concepts of the mechanisms behind the changes in acid-base balance are considerably questionable. The main physicochemical principle which must be accomplished in body fluids, is the rule of electroneutrality. There are 3 components in biological fluids which are subject to this principle: a)Water, which is only in minor parts dissociated into H+ and OH-, b)"strong", i.e. completely dissociated, electrolytes, which thus do not interact with other substances, and body substances, such as lactate, and c)"weak", i.e. incompletely dissociated, substances. Peter Stewart strictly distinguished between dependent and independent variables and thus indeed described a new order of acid-base chemistry. The 3 dependent variables (bicarbonate concentration [Bic(-)], pH, and with this also hydrogen ion concentration [H(+)]) can only change if the 3 independent variables allow this change. These 3 independent variables are: 1. Carbon dioxide partial pressure, 2.the total amount of all weak acids ([A-] (Stewart called these ATOT), and 3.strong ion difference (SID). [A(-)] can be calculated from the albumin (Alb) and the phosphate concentration (Pi): [A(-)]=[Alb x (0.123 x pH - 0.631)] + [Pi x (0.309 x pH - 0.469)]. An apparent SID (or "bedside" SID) can be calculated using measurable ion concentrations: SID=[Na(+)] + [K(+)] - [Cl(-)]-lactate. Regarding the metabolic disturbances of acid-base chemistry, according to Stewart's terminology, changes in pH, [H(+)], and [Bic(-)] are only possible if either SID or [A(-)] itself changes. If, for example, SID decreases (e.g. in case of hyperchloremia), this increase in independent negative charges leads to a decrease in dependent negative charges in terms of [Bic(-)] resulting in acidosis (and vice versa). Therefore, according to Stewart, the decrease in SID during hyperchloremic acidosis results from the increase in serum chloride concentration and is the causal mechanism behind this acidosis. Contrary for example, a decrease in [A(-)] (e. g. during hypoalbuminemia) leads to an increase in [Bic(-)] and therefore to an alcalosis (and vice versa). Thus, by Stewart's approach, completely new acid-base disturbances, like "hyperchloremic acidosis" or "hypoalbuminemic alcalosis" (which, of course, can also exist in combination) can be detected, which had been unrecognised by the classic acid-base concepts. Consequently, Stewart's analysis can lead to a better understanding of the mechanisms behind the changes in acid-base balance.

The benefits and use of shock advisory defibrillators in hospitals

Survival to discharge following a cardiac arrest is dependent on rapid and effective basic and advanced life support. Paramount to a rapid response is access to sufficiently trained health care providers, who have a duty to perform basic life support and initiate early defibrillation. In hospitals, defibrillation remains the domain of specially prepared staff and the type of defibrillator used might be crucial to rapid and effective defibrillation. The advent of automatic external defibrillators has increased the range of people who can use a defibrillator successfully. For nurses, arguably a lack of familiarity about the benefits of and the use of automatic external defibrillators are the greatest barriers to nurse-initiated defibrillation programmes. This paper explores the use of automatic external defibrillators, their relationship to the associated defibrillator waveforms and the benefits of their use by registered nurses within the hospital setting.

The Intensive Care Unit liaison nurse: towards a clear role description

In Australia, Intensive Care Unit (ICU) liaison nurses, have recently emerged as a group of nurse practitioners whose goal is to enhance the transition from the ICU to the ward. Internationally, there has been little uniformity in the roles or functions undertaken by these specialist nurses, a factor that has made evaluation of the role difficult. In order to develop a clearer role description that could be used to test for effectiveness, this paper reports on a qualitative study of the context, and activities undertaken by the six known ICU liaison nurses in Australia. Using a naturalistic inquiry approach, semi-structured in-depth interviews were conducted with six ICU liaison nurses by one interviewer. Thematic analysis was undertaken. System demands and professional interest were the two categories that emerged within the domain of historical development. The structure of the role included its focus, practice guidelines and professional relations and reporting mechanisms. The activities of the liaison nurse role included staff education and support; ward assessment and liaison; patient care and support; and family education and support. By clearly articulating new roles as they emerge, opportunities arise for all professional groups to work together to assimilate, test and further develop the directions and activities of the new roles.

Environmental elements affecting the decision-making process in nursing practice

BACKGROUND

In their practice nurses constantly make decisions in a dynamic context including complex situations. Besides affecting elements related to the decision-maker and the task itself, the setting where the decision-making process takes place are of decisive importance to the quality of the decision-making outcome.

AIM

The aim of this study was to explore environmental elements related to the decision-making process in nursing practice.

METHODS

Six expert nurses, from three Swedish nursing settings, participated voluntarily in the study, which were designed of participated observations in everyday nursing practice. Permission to carry out the study was given by the clinics and an ethical committee. A content analysis was used to analyse the field notes where themes emerged which were found to be environmental elements affecting decision-making process of nurses.

CONCLUSIONS

The most striking theme, environmental elements, included the sub-themes interruptions and the work procedures are presented in this report. The implications of environmental elements, are discussed from a perspective of nurses' competence, where the elements could be seen as a facilitator or as a hindrance to developing nursing competence. It were concluded that environmental elements have to be well considered before knowledge can be reached about decision-making in practice.

RELEVANCE TO CLINICAL PRACTICE

Interpersonal and technological interruptions were features highlighted in the study, features which could jeopardize the decision-making outcome. Therefore, it is of greatest importance that nurses learn to use decision-making strategies to guarantee patient care security and patient care quality.

Overcoming structural constraints to patient utilization of electronic medical records: a critical review and proposal for an evaluation framework

There are constraints embedded in medical record structure that limit use by patients in self-directed disease management. Through systematic review of the literature from a critical perspective, four characteristics that either enhance or mitigate the influence of medical record structure on patient utilization of an electronic patient record (EPR) system have been identified: environmental pressures, physician centeredness, collaborative organizational culture, and patient centeredness. An evaluation framework is proposed for use when considering adaptation of existing EPR systems for online patient access. Exemplars of patient-accessible EPR systems from the literature are evaluated utilizing the framework. From this study, it appears that traditional information system research and development methods may not wholly capture many pertinent social issues that arise when expanding access of EPR systems to patients. Critically rooted methods such as action research can directly inform development strategies so that these systems may positively influence health outcomes.

Can the caged bird sing? Reflections on the application of qualitative research methods to case study design in homeopathic medicine

BACKGROUND

Two main pathways exist for the development of knowledge in clinical homeopathy. These comprise clinical trials conducted primarily by university-based researchers and cases reports and homeopathic "provings" compiled by engaged homeopathic practitioners. In this paper the relative merits of these methods are examined and a middle way proposed. This consists of the "Formal Case Study" (FCS) in which qualitative methods are used to increase the rigour and sophistication with which homeopathic cases are studied. Before going into design issues this paper places the FCS in an historical and academic context and describes the relative merits of the method.

DISCUSSION

Like any research, the FCS should have a clear focus. This focus can be both "internal", grounded in the discourse of homeopathy and also encompass issues of wider appeal. A selection of possible "internal" and "external" research questions is introduced. Data generation should be from multiple sources to ensure adequate triangulation. This could include the recording and transcription of actual consultations. Analysis is built around existing theory, involves cross-case comparison and the search for deviant cases. The trustworthiness of conclusions is ensured by the application of concepts from qualitative research including triangulation, groundedness, respondent validation and reflexivity. Though homeopathic case studies have been reported in mainstream literature, none has used formal qualitative methods--though some such studies are in progress.

SUMMARY

This paper introduces the reader to a new strategy for homeopathic research. This strategy, termed the "formal case study", allows for a naturalistic enquiry into the players, processes and outcomes of homeopathic practice. Using ideas from qualitative research, it allows a rigorous approach to types of research question that cannot typically be addressed through clinical trials and numeric outcome studies. The FCS provides an opportunity for the practitioner-researcher to contribute to the evidence-base in homeopathy in a systematic fashion. The FCS can also be used to inform the design of clinical trials through holistic study of the "active ingredients" of the therapeutic process and its clinical outcomes.

The challenges of pain measurement in critically ill young children: A comprehensive review

This article addresses the issues in measuring pain in critically ill children, provides a comprehensive review of the pain measures for children aged between 0 and 3 years, and discusses their applicability to this group of children. When children are critically ill, pain can only exacerbate the stress response that already exists, to the extent that homeostasis cannot be maintained. Severity of illness is thus likely to affect physiologic and behavioural pain responses that would normally be demonstrated in healthy children. The problem of differentiating pain from other constructs adds to the complexity of assessing pain in non-verbal children. A pain measure to be useful clinically must be adapted to the developmental age of the target population. Search of electronic databases and other electronic sources was supplemented by hand review of relevant journals to identify published and unpublished pain measures for use in children aged between 0 and 3 years. Twenty eight pain measures were identified in the literature; 11 for neonates only, 11 for children aged between 0 and 3 years, and six for children more than 12 months. These measures vary in relation to their psychometric properties, clinical utility and the context in which the study was performed. These measures may not be suitable for the critically ill young child, because the items included were derived from observations of healthy or moderately sick children, and may not reflect pain behaviour in those who are critically ill. It is therefore recommended to develop new pain scales for this population of compromised children.

Who, when and where? Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice

Patients who suffer an adverse event (AE) are more likely to die or suffer permanent disability. Many AEs are preventable. Nurses have long played a pivotal role in the prevention of AEs. Much of the literature to date pertains to the role of nurses in the prevention of AEs such as falls, pressure areas and deep vein thrombosis. Prominent risk factors for AEs are the presence of physiological abnormality, failure to recognize or correct physiological abnormality, advanced patient age and location of patient room. Ongoing physiological assessment of patients is a nursing responsibility and the assessment findings of nurses underpin many patient care decisions. The early recognition and correction of physiological abnormality can improve patient outcomes by reducing the incidence of AEs, making nurses' ability to identify, interpret and act on physiological abnormality a fundamental factor in AE prediction and prevention. This paper will examine the role of nurses in AE prevention, using cardiac arrest as an example, from the perspective of physiological safety; that is, accurate physiological assessment and the early correction of physiological abnormality.

BiPAP ventilation as assistance for patients presenting with respiratory distress in the department of emergency medicine

BACKGROUND

Noninvasive ventilatory support (NIVS) is intended to provide ventilatory assistance for a wide range of respiratory disturbances. The use of NIVS for treatment of respiratory distress may be applicable in the emergency department (ED). It may prevent endotracheal intubation and, likewise, may favorably influence the course of the patient's hospitalization, depending on the primary disease or ventilatory disturbance.

OBJECTIVE

To evaluate the efficacy of bilevel positive airway pressure (BiPAP) ventilation in patients with acute respiratory distress presenting in the ED.

METHODS

A prospective, uncontrolled, nonrandomized, nonblind study enrolled 30 patients. They were cooperative and hemodynamically stable, aged over 18 years, and presented with acute respiratory distress as defined by predetermined criteria. They were connected to a BiPAP machine through a face mask, using an initial pressure of 8/3 cm H(2)O, which was gradually raised to 12/7 cm H(2)O inspiratory positive airway pressure/expiratory positive airway pressure. Standard drugs, inhalation and oxygen therapies were administered as needed. The BiPAP was disconnected either upon relief of respiratory distress or on deterioration of the patient's condition.

RESULTS

Of the 30 patients in the study, 19 had cardiogenic pulmonary edema, four had acute asthma, three had exacerbation of COPD, three had pneumonia and one had malignant pleural effusion. BiPAP was instituted subsequent to failure of standard therapies. Twenty-six patients were classified as responders to the BiPAP ventilation and four as nonresponders (three patients were intubated after 1 hour and one patient 24 hours, post BiPAP). The total length of stay (LOS) in the ED was 3-5 hours and the mean LOS in hospital was 4.1 +/- 1.5 days, versus 6.5 +/- 1.2 days in LOS reports of similar patients in the same hospital during 1999, who did not undergo BiPAP ventilation. No other complications were observed.

CONCLUSIONS

We found BiPAP ventilation simple, safe, effective and well tolerated by patients in respiratory distress. The rate of endotracheal intubation after successful BiPAP ventilation was low. In carefully selected patients with respiratory distress, BiPAP ventilation may successfully replace endotracheal intubation.