Donna Waters

Liver Disease and Common-Bile-Duct Stenosis in Cystic Fibrosis

To determine the incidence of common-bile-duct lesions and their relation to liver disease in cystic fibrosis, we performed hepatobiliary scanning in 50 of 61 patients with cystic fibrosis who had hepatomegaly, abnormal liver function, or both and in 31 of 92 patients with cystic fibrosis who did not have hepatomegaly or abnormal liver function. Ninety-six percent of the patients with liver disease had evidence of biliary tract obstruction, which was defined cholangiographically as a stricture of the distal common bile duct in the majority of cases. All the patients without liver disease had normal intrahepatic and common-duct excretion of tracer. Abdominal pain was significantly more common in patients with common-duct obstruction (P less than 0.001), and enlarged gallbladders occurred only in such patients. Since fasting levels of serum bile acids were elevated in nearly half these patients, irrespective of the severity of their liver disease, serum bile acids may be markers of the severity of the common-duct lesion. We conclude that strictures of the distal common bile duct are common in patients with cystic fibrosis and liver disease. This association requires further study, since surgical relief of common-duct obstruction may prevent or ameliorate the hepatic complications of cystic fibrosis.

Clinical outcomes of newborn screening for cystic fibrosis.

AIM To determine how early diagnosis of cystic fibrosis, using neonatal screening, affects long term clinical outcome. METHODS Fifty seven children with cystic fibrosis born before neonatal screening was introduced (1978 to mid 1981) and a further 60 children born during the first three years of the programme (mid 1981 to 1984), were followed up to the age of 10. The cohorts were compared on measures of clinical outcome, including height, weight, lung function tests, chest x-ray picture and Shwachman score. RESULTS Age and sex adjusted standard deviation scores (SDS) for height and weight were consistently higher in children screened for cystic fibrosis than in those born before screening. At 10 years of age, average differences in SDS between groups were 0.4 (95% CI −0.1, 0.8) for weight and 0.3 (95% CI −0.1, 0.7) for height. This translates to an average difference of about 2.7 cm in height and 1.7 kg in weight. Mean FEV1 and FVC (as percentage predicted) were significantly higher in the screened cohort at 5 and 10 years of age, with an average difference of 9.4% FEV1(95% CI 0.8, 17.9) and 8.4% FVC (95% CI 1.8, 15.0) at 10 years. Chest x-ray scores were not different between the groups at any age, but by 10 years screened patients scored an average 5.3 (95% CI 1.2, 9.4) points higher on the Shwachman score. CONCLUSION Although not a randomised trial, this long term observational study indicates that early treatment made possible by neonatal screening may be important in determining subsequent clinical outcomes for children with cystic fibrosis. For countries contemplating the introduction of neonatal screening for cystic fibrosis, its introduction to some areas in a cluster randomised design will permit validation of studies performed to date.

Pancreatic function in infants identified as having cystic fibrosis in a neonatal screening program

The use of the dried-blood immunoreactive-trypsin assay for the detection of cystic fibrosis in newborns has been questioned on the grounds that it may fail to identify patients with enough pancreatic function to have normal fat absorption. To investigate this possibility, we assessed pancreatic function in 78 patients identified in a neonatal screening program as having cystic fibrosis. The diagnosis of cystic fibrosis was confirmed by abnormal results on a sweat chloride test. The results of measurements of fecal fat excretion, pancreatic-stimulation tests, and estimations of the serum level of pancreatic isoamylase indicated that 29 of the 78 children (37 percent) had substantial preservation of pancreatic function. These children (median age, four years) had growth that was close to normal and comparable to growth in children with severe pancreatic insufficiency who received oral enzyme therapy. Pancreatic insufficiency subsequently developed in 6 of the 29 patients, at 3 to 36 months of age. We conclude that the serum immunoreactive-trypsin assay used in neonatal screening programs identifies patients with cystic fibrosis who have sufficient pancreatic function to have normal fat absorption and that a substantial proportion of infants identified as having cystic fibrosis are in this category.

The Australian experience of nurses' preparedness for evidence-based practice

AIM This study aimed to determine current knowledge and attitudes towards evidence-based practice (EBP) among pre- and post-registration nurses in New South Wales (NSW), Australia. BACKGROUND Educational and clinical strategies for EBP in nursing assume a readiness to interpret and integrate evidence into clinical care despite continued reports of low levels of understanding and skill in this area. METHOD Perceptions of EBP were examined through a self-complete, anonymous postal survey distributed to 677 (post-registration) clinical nurses and to 1134 final year (pre-registration) nursing students during 2002 and 2003. RESULTS A completed survey was returned by 126 post-registration and 257 final year nursing students (combined 21% response rate). Both pre- and post-registration nurses had a welcoming attitude towards EBP. Pre-registration nurses expressed more confidence in their EBP skills but self-rated knowledge and skill were low to moderate in both groups. CONCLUSION Nurses in Australia are clearly supportive of EBP but it is incorrect to assume that even recent graduates have a level of knowledge and skill that is sufficient to permit direct engagement in evidence implementation. IMPLICATIONS FOR NURSING MANAGEMENT Among a range of clinical supports, nurse managers and leaders can contribute to evidence-based health care by understanding the EBP knowledge and skills of their workforce and demanding a more practical approach in nursing education towards evidence-based guidelines and summaries appropriate to the clinical context.

The personality of emergency nurses: Is it unique?

BACKGROUND With ever increasing demands on emergency services it is necessary to consider how to enhance the recruitment and retention of emergency nurses in public hospitals. Personality is known to influence occupational choice, yet there is a lack of research exploring how personality may influence the workforce decisions of emergency nurses. METHODS A standardised personality test instrument, the NEO™-PI-3, was used in a survey design inclusive of demographic questions to measure personality characteristics. Data were collected from 72 emergency nurses working at an Australian Emergency Department between July and October 2012. The personality scores of emergency nurses were compared against general population norms in each of five personality domains and their 30 associated facets. RESULTS Participants scored higher than population norms in the domains of Extraversion (p < .001), Openness to experience (p < .001) and Agreeableness (p = .001), and in twelve facets, including excitement-seeking (p < .001) and competence (p = .003). CONCLUSION The personality profile of this sample of emergency nurses is different to the population norm. Assessment of personality and knowledge of its influence on specialty selection may assist in improving retention and recruitment in emergency nursing.

Development of the Nurse Practitioner Standards for Practice Australia

This article describes the context and development of the new Nurse Practitioner Standards for Practice in Australia, which went into effect in January 2014. The researchers used a mixed-methods design to engage a broad range of stakeholders who brought both political and practice knowledge to the development of the new standards. Methods included interviews, focus groups, surveys, and work-based observation of nurse practitioner practice. Stakeholders varied in terms of their need for detail in the standards. Nonetheless, they invariably agreed that the standards should be clinically focussed attributes. The pillars common in many advanced practice nursing standards, such as practice, research, education, and leadership, were combined and expressed in a new and unique clinical attribute.

Midwifery-led care: finding evidence for an antenatal model

Conducted as the first phase of the Improving Patient Outcomes Project, a structured literature review aimed to determine an evidence base for the development of a midwifery-led antenatal model of care. In particular, evidence was sought for those elements of antenatal care that were proven effective and were valued by women. There is good quality evidence that women are satisfied with receiving antenatal care from midwives and that antenatal visit schedules can be made more flexible. The literature provided practical assistance in defining maternity outcome measures but was not able to provide a strong evidence base for all aspects of antenatal care. This paper reports on a systematic approach to reviewing literature in which the intuitive and practical experience of expert reviewers and clinicians contributes to assessing the overall quality of currently available research evidence. This combined approach ensures a judicious and sensitive application of available evidence to the development of safe and appropriate models of care.

Is there a relationship between personality and choice of nursing specialty: an integrative literature review

BackgroundPersonality is deemed to play a part in an individual’s choice of work, with individuals’ preferencing a profession or field of work that will satisfy their personal needs. There is limited research exploring the personality characteristics of nurses within clearly defined nursing specialty areas. Retaining nurses within specialty areas has workforce implications when vacancies are unable to be filled by appropriately experienced staff.The aim of the review was to determine the current state of knowledge regarding the personality profiles of nurses in specialty areas of nursing practice.MethodsAn integrative literature review was undertaken.Five electronic databases were searched using personality and nursing based keywords. No date limit or research design restriction was applied. Rigorous screening and quality appraisal was undertaken considering the research design, methods and limitations of each manuscript.ResultsA review of the 13 included articles demonstrated some variability in the personality characteristics of the nursing specialty groups studied. A relationship was identified between personality characteristics and levels of nursing stress and burnout.ConclusionThere is some evidence to suggest a relationship between personality characteristics and nursing specialty choice, burnout and job satisfaction. The published literature is limited and the effect of personality on retention is not well established.

Comparison of Psychophysiological Stress in Physiotherapy Students Undertaking Simulation and Hospital-Based Clinical Education.

Introduction Simulation-based clinical education often aims to replicate varying aspects of real clinical practice. It is unknown whether learners’ stress levels in simulation are comparable with those in clinical practice. The current study compared acute stress markers during simulation-based clinical education with that experienced in situ in a hospital-based environment. Methods Undergraduate physiotherapy students’ (n = 33) acute stress responses [visual analog scales of stress and anxiety, continuous heart rate (HR), and saliva cortisol] were assessed during matched patient encounters in simulation-based laboratories using standardized patients and during hospital clinical placements with real patients. Group differences in stress variables were compared using repeated measures analysis of variance for 3 time points (before, during the patient encounter, and after) at 2 settings (simulation and hospital). Results Visual analog scale stress and anxiety as well as HR increased significantly from baseline levels before the encounter in both settings (all P < 0.05). Stress and anxiety were significantly higher in simulation [mean (SD), 45 (22) and 44 (25) mm; P = 0.003] compared with hospital [mean (SD), 31 (21) and 26 (20) mm; P = 0.002]. The mean (SD) HR during the simulation patient encounter was 90 (16) beats per minute and was not different compared with hospital [mean (SD), 87 (15) beats per minute; P = 0.89]. Changes in salivary cortisol before and after patient encounters were not statistically different between settings [mean (SD) simulation, 1.5 (2.4) nmol/L; hospital, 2.5 (2.9) nmol/L; P = 0.70]. Conclusions Participants’ experienced stress on clinical placements, irrespective of the clinical education setting (simulation vs. hospital). This study revealed that psychological stress and anxiety were greater during simulation compared with hospital settings; however, physiological stress responses (HR and cortisol) were comparable. These results indicate that psychological stress may be heightened in simulation, and health professional educators need to consider the impact of this on learners in simulation-based clinical education. New learners in their clinical education program may benefit from a less stressful simulation environment, before a gradual increase in stress demands as they approach clinical practice.

Development of a best practice model of midwifery-led antenatal care

Abstract The development and implementation of a model of midwifery-led antenatal care was the second phase of a larger project known as the Improving Patient Outcomes Project. The overall project aim was to demonstrate the effectiveness of evidencebased models and systems of care on improving patient outcomes. Survey results from local antenatal clinics had revealed an absence of evidence-based guidelines for the provision of antenatal midwifery care. Midwives and expert reviewers combined their experience to appraise the quality and relevance of currently available research evidence to develop a best practice model of antenatal care for low risk women in which the midwife is the lead antenatal care professional. The model offered a care plan for the pregnancy trimesters and outlined circumstances requiring referral to, or consultation with, a medical officer. In addition it offered women a flexible visit schedule and continuity of carer throughout the antenatal period. The methods used in this study may have general applicability to developing best practice models of antenatal care and for the validation of contemporary midwifery antenatal practice. The value of the model will be realised through its successful implementation by the midwifery profession and the evaluation of its effectiveness for women and their families.