Deborah Sundin

Patient‐related violence against emergency department nurses

In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient-related violence in the health-care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under-reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero-tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy-makers and administrators should recognize this issue as a priority for preventative action.In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient-related violence in the health-care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under-reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero-tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy-makers and administrators should recognize this issue as a priority for preventative action.

Patient-related violence at triage: A qualitative descriptive study

AIM The aim of the study was to describe the experiences of a group of triage nurses with patient-related workplace violence during the previous month. BACKGROUND Globally and within the Australian health industry, nurses have been reported to be the occupation at most risk of patient-related violence, with triage nurses identified as a high risk group for both verbal and physical violence. METHOD The study took place in the Emergency Department of a tertiary referral and teaching hospital in regional New South Wales, Australia. Data were collected from August to September 2008, and a qualitative descriptive methodology was employed. FINDINGS The participants all reported experiencing episodes of patient related violence that were perceived as inevitable and increasing in intensity and frequency. Themes included identification of precipitating factors such as long waiting times and alcohol and substance misuse. Organisational issues included lack of aggression minimisation training; lack of formal debriefing following episodes of violence and frustration at lengthy reporting processes. CONCLUSION In the context of the Emergency Department where patients present with a range of diagnoses and behaviours, it is unlikely that the issue of patient-related violence can be totally eliminated. However it can be prevented or managed more effectively on many occasions. Strategies to support staff and prevent and manage violence effectively should be a priority to provide a safe working environment and occupational health and safety for staff.

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives.

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwifes legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery.

Never ending stories: visual diarizing to recreate autobiographical memory of intensive care unit survivors

AIM The aim of this study was to explore the potential use of visual diarizing to enable intensive care unit (ICU) survivors to create their story of recovery. BACKGROUND An ICU experience can have deleterious psychological and physical effects on survivors leading to reductions in quality of life which for some may be of significant duration. Although there has been exploration of many interventions to support recovery in this group, service provision for survivors remains inconsistent and inadequate. DESIGN AND PARTICIPANTS A qualitative interpretive biographical exploration of the ICU experience and recovery phase of ICU survivors using visual diarizing as method. This paper is a component of a larger study and presents an analyses of one participants visual diary in detail. METHODS Data collection was twofold. The participant was supplied with visual diary materials at 2 months post-hospital discharge and depicted his story in words and pictures for a 3-month period, after which he was interviewed. The interview enabled the participant and researcher to interpret the visual diary and create a biographical account of his ICU stay and recovery journey. FINDINGS The analysis of one participants visual diary yielded a wealth of information about his recovery trajectory articulated through the images he chose to symbolize his story. The participant confirmed feelings of persecution whilst in ICU and was unprepared for the physical and psychological disability which ensued following his discharge from hospital. However, his story was one of hope for the future and a determination that good would come out of his experience. He considered using the visual diary enhanced his recovery. CONCLUSIONS The participant perceived that visual diarizing enhanced his recovery trajectory by enabling him to recreate his story using visual imagery in a prospective diary. RELEVANCE TO CLINICAL PRACTICE Prospective visual diarizing with ICU survivors may have potential as an aid to recovery.

Education of ICU nurses regarding invasive mechanical ventilation: Findings from a cross-sectional survey

BACKGROUND Continuing education for intensive care unit nurses on invasive mechanical ventilation is fundamental to the acquisition and maintenance of knowledge and skills to optimise patient outcomes. PURPOSE We aimed to determine how intensive care unit nurses perceived current education provided on mechanical ventilation, including a self-directed learning package and a competency programme; identify other important topics and forms of education; and determine factors associated with the completion of educational programmes on invasive mechanical ventilation. METHODS A cross-sectional, 30-item, self-administered and semi-structured survey on invasive mechanical ventilation education was distributed to 160 intensive care nurses. Analysis included descriptive statistics and logistic regression was used to determine factors associated with current education completion, reported as adjusted odds ratios (AOR) and 95% confidence intervals (CIs). FINDINGS Eighty three intensive care unit nurses responded and the majority (63%) reported not receiving education about mechanical ventilation prior to working in intensive care. Using a Likert rating scale the self-directed learning package and competency programme were perceived as valuable and beneficial. Hands-on-practice was perceived as the most important form of education and ventilator settings as the most important topic. Multivariate analysis determined that older age was independently associated with not completing the self-directed learning package (AOR 0.20, 95% CI 0.04, 0.93). For the competency programme, 4-6 years intensive care experience was independently associated with completion (AOR 17, 95% CI 1.7, 165) and part-time employment was associated with non-completion (AOR 0.23, 95% CI 0.08, 0.68). CONCLUSION Registered nurses are commencing their ICU experience with limited knowledge of invasive MV therefore the education provided within the ICU workplace becomes fundamental to safe and effective practice. The perception of continuing education by ICU nurses from this research is positive regardless of level of ICU experience and may influence the type of continuing education on invasive MV provided to ICU nurses in the future, not only in the ICU involved in this study, but other units throughout Australia.

The nexus of nursing leadership and a culture of safer patient care

AIMS AND OBJECTIVES To explore the connection between +6 nursing leadership and enhanced patient safety. BACKGROUND Critical reports from the Institute of Medicine in 1999 and Francis QC report of 2013 indicate that healthcare organisations, inclusive of nursing leadership, were remiss or inconsistent in fostering a culture of safety. The factors required to foster organisational safety culture include supportive leadership, effective communication, an orientation programme and ongoing training, appropriate staffing, open communication regarding errors, compliance to policy and procedure, and environmental safety and security. As nurses have the highest patient interaction, and leadership is discernible at all levels of nursing, nurse leaders are the nexus to influencing organisational culture towards safer practices. DESIGN The position of this article was to explore the need to form a nexus between safety culture and leadership for the provision of safe care. CONCLUSIONS Safety is crucial in health care for patient safety and patient outcomes. A culture of safety has been exposed as a major influence on patient safety practices, heavily influenced by leadership behaviours. The relationship between leadership and safety plays a pivotal role in creating positive safety outcomes for patient care. A safe culture is one nurtured by effective leadership. RELEVANCE TO PRACTICE Patient safety is the responsibility of all healthcare workers, from the highest executive to the bedside nurse, thus effective leadership throughout all levels is essential in engaging staff to provide high quality care for the best possible patient outcomes.

New graduate registered nurses’ knowledge of patient safety and practice: A literature review

AIMS AND OBJECTIVES To critically appraise available literature and summarise evidence pertaining to the patient safety knowledge and practices of new graduate registered nurses. BACKGROUND Responsibility for patient safety should not be limited to the practice of the bedside nurses, rather the responsibility of all in the healthcare system. Previous research identified lapses in safety across the health care, more specifically with new practitioners. Understanding these gaps and what may be employed to counteract them is vital to ensuring patient safety. DESIGN A focused review of research literature. METHODS The review used key terms and Boolean operators across a 5-year time frame in CINAHL, Medline, psycINFO and Google Scholar for research articles pertaining to the area of enquiry. Eighty-four articles met the inclusion criteria, 39 discarded due to irrelevant material and 45 articles were included in the literature review. RESULTS This review acknowledges that nursing has different stages of knowledge and practice capabilities. A theory-practice gap for new graduate registered nurses exists, and transition to practice is a key learning period setting new nurses on the path to becoming expert practitioners. Within the literature, there was little to no acknowledgement of patient safety knowledge of the newly registered nurse. CONCLUSIONS Issues raised in the 1970s remain a concern for todays new graduate registered nurses. Research has recognised several factors affecting transition from nursing student to new graduate registered nurse. These factors are leaving new practitioners open to potential errors and risking patient safety. RELEVANCE TO CLINICAL PRACTICE Understanding the knowledge of a new graduate registered nurse upon entering clinical practice may assist in organisations providing appropriate clinical and theoretical support to these nurses during their transition.

ICUTogether a web based recovery program for intensive care survivors: a randomized controlled trial protocol (Preprint)

Background Those who experience a critical illness or condition requiring admission to an intensive care unit (ICU) frequently experience physical and psychological complications as a direct result of their critical illness or condition and ICU experience. Complications, if left untreated, can affect the quality of life of survivors and impact health care resources. Explorations of potential interventions to reduce the negative impact of an ICU experience have failed to establish an evidence-based intervention. Objective The aim of this study is to evaluate the impact of a Web-based intensive care recovery program on the mental well-being of intensive care survivors and to determine if it is a cost-effective approach. Methods In total, 162 patients that survived an ICU experience will be recruited and randomized into 1 of 2 groups. The intervention group will receive access to the Web-based intensive care recovery program, ICUTogether, 2 weeks after discharge (n=81), and the control group will receive usual care (n=81). Mental well-being will be measured using the Hospital Anxiety and Depression Scale, The Impact of Events Scale-Revised and the 5-level 5-dimension EuroQoL at 3 time points (2 weeks, 6 months, and 12 months post discharge). Family support will be measured using the Multidimensional Scale of Perceived Social Support at 3 time points. Analysis will be conducted on an intention-to-treat basis using regression modeling. Covariates will include baseline outcome measures, study allocation (intervention or control), age, gender, length of ICU stay, APACHE III score, level of family support, and hospital readmissions. Participants’ evaluation of the mobile website will be sought at 12 months postdischarge. A cost utility analysis conducted at 12 months from a societal perspective will consider costs incurred by individuals as well as health care providers. Results Participant recruitment is currently underway. Recruitment is anticipated to be completed by December 2020. Conclusions This study will evaluate a novel intervention in a group of ICU survivors. The findings from this study will inform a larger study and wider debate about an appropriate intervention in this population. International Registered Report Identifier (IRRID) PRR1-10.2196/10935

Factors influencing medical decision- Making for seriously ill patients in the Acute Care Hospital

Aim: To acquire a fuller understanding of the influences on decision-making in an acute care hospital for seriously ill patients. Background: Fromthe moment of a diagnosis of serious, potentially life-limiting illness, patients and their families are faced withmultiple, complex and significant decisions that will influence the entire illness trajectory, including their end-of-life care (EOLC). Compounding personal factors is the complexity of dying today with acute ward areas in tertiary hospitals use of technological interventions to prolong life, at all costs being the norm. If hospice care is initiated, in these areas, it is often at too late a stage to relieve distressing symptoms and to offer the person the best possible path of care for a dignified death. Design and methods: A retrospective cohort research design was used for this study. Results: Thirty nine (39) medical records that met the inclusion criteria were audited. While medical records are limited in terms of the quality of the information contained in them in terms of social, behavioural and other qualitative information, the audit obtained detailed clinical information on patient characteristics, clinical care, and family and clinician involvement in the care of these patients. Communication between health professionals and patient and or family were limited. Poor documentation in the medical record did not support shared decision-making with decisions to amend the care pathway to palliative not undertaken in most instances despite no improvement in response to care or deterioration in the patient’s condition. Conclusion: Communication between health care professions, patients and their family’s needs to be addressed. The management of patients who are seriously ill in acute ward areas should be altered to reflect the patient’s condition. Nurses, using a person-centred approach, have a role in advocating for the patient and the family in times of stress. Discussions concerning end-oflife of seriously ill patients need to be open, transparent and communicated as these discussions are critical to ensuring the patient’s wishes are realised.