Helen McCutcheon

Policies that drive the nursing practice of postoperative observations

Postoperative nursing care traditionally has involved the utilisation of regulated, routine patient observation to monitor patient progress. This study was designed to review the policy/procedure documentation that drives this practice and to determine who contributes to policy development. In all, 75 surgical hospitals were surveyed, producing 47 procedures for content analysis. Findings suggest that there is a great diversity in procedures between organisations. The most common pattern of postoperative vital sign collection is hourly for 4 h and then 4 hourly in 27% of the regimes. On average a patient receives 10 sets of observation in the first 24 h, with neurovascular, wound and drain checks the most frequent observations collected in addition to vital signs.

Postnatal depression: a review of current literature

The print and other forms of media offer significant amounts of information to women about pregnancy, parenthood and the birth process, but much less information exists about postnatal depression and how to cope with the frequently painful realities involved in childbirth and parenting--especially when debilitated by postnatal depression (PND). Even less information exists about such womens reactions to interventions by health professionals, which is the subject of my Ph.D study in progress. This article reviews current literature about the clinical presentation of postnatal depression, the three major types of mood disorders following childbirth, the risk factors for postnatal depression, detection and treatment of postnatal depression and the need for further research on treatment outcomes for women with PND.

Nursing practice and oral fluid intake of older people with dementia.

AIM This paper describes the findings of a descriptive study about what nurses do to ensure that older people with dementia have adequate hydration. BACKGROUND Frail nursing home residents, particularly those who cannot accurately communicate their thirst as a result of Alzheimers disease and who depend on nursing staff for their fluid intake, are at risk of dehydration. While the interventions that promote nutrition in older people with dementia are documented, the specific interventions for improving oral hydration in older people with dementia remain poorly studied and understood. DESIGN Observational study. METHODS Ten care workers and seven residents were observed for the types of behavioural nursing interventions and assistance provided to residents when promoting oral fluid intake. Observational data were compared with resident-care plans to determine whether what was carried out by care workers was consistent with what was being documented. RESULTS Care workers provided a wide variety of behavioural interventions to the residents when promoting oral fluid intake. The resident-care plans did not sufficiently represent the specific interventions implemented by care workers. CONCLUSIONS A more rigorous approach is required in defining the specific behavioural interactions practised by care workers, which promote oral fluid intake in older people with dementia. Nurses determined the content of care documented in care plans, yet they were not the predominant implementers of that care. Care plans need to be accurate in terms of the specific nursing actions that respond to the level of assistance required by the resident, both behaviourally and physically. RELEVANCE TO CLINICAL PRACTICE Sound knowledge and reflective practices should be implemented by care workers of the nursing interventions that promote adequate oral fluid intake. Care plans should serve a dual purpose and facilitate communication between staff members and provide sufficient flexibility to allow for the contribution of novel ways in which to promote oral fluid intake while also being educative.

The safety and efficacy of midlines compared to peripherally inserted central catheters for adult cystic fibrosis patients: A retrospective, observational study

BACKGROUND Intravenous antibiotics are the cornerstone of treatment for patients with cystic fibrosis (CF). Midlines are a type of vascular access device (VAD) used exclusively in one treatment facility within Australia, most other centres use peripherally inserted central catheters (PICCs). OBJECTIVE To ascertain the safety and efficacy of midlines for CF patients receiving intravenous antibiotics. DESIGN Retrospective observational. SETTING A large, major metropolitan teaching hospital in Adelaide, South Australia. PARTICIPANTS Adult patients with a diagnosis of CF, who had a PICC or midline inserted for the commencement of antibiotic therapy during the period 2004-2010 to treat a respiratory exacerbation. METHODS Medical records and hospital reports were used to record rates of adverse events and unexpected removal of VADs. The primary outcome was a composite measure of adverse events (catheter-related blood stream infection, deep vein thrombosis, occlusion, pain, infiltration, bleeding, phlebitis, catheter leakage and dislodgement) and whether the VAD was removed unexpectedly. RESULTS There were 231 midlines and 97 PICCs inserted into 64 patients (39 male and 25 female; age range 18-47 years old). Presented as per 1000 VAD days, patients with PICCs and midlines had similar rates of adverse events (14 and 11 adverse events per 1000 VAD days, respectively). Unexpected removal was higher for patients with midlines (6.90 per 1000 VAD days) than for PICCs (2.89 per 1000 VAD days). Incident rate ratios (IRRs) showed that patients with midlines and PICCs had similar rates of adverse events (IRR 1.18, P=0.617, CI 0.62-2.22) although the removal rate of patients with midlines was twice that of patients with PICCs (IRR 2.24, P=0.079, CI 0.91-5.56). As an absolute risk there were only 4.09 more cases of removal for patients with midlines per 1000 VAD days than those with PICCs. CONCLUSIONS Midlines may be an alternative to PICCs for adult CF patients although further research is required with a larger sample size to enable definitive conclusions.

Tradition, rituals and standards, in a realm of evidenced based nursing care

Abstract Evidenced-based nursing is seen as the future of nursing but the real world in which practice occurs is limiting the possibilities for change. The practice of post-operative (PO) vital sign collection in the general ward setting is described as an example of the complexities that surround practice. Despite the ongoing work around evidenced-based practice, elements of nursing practice remain based on tradition. Routines and rituals are driving care rather than clinical judgement. The complexities of practice limit the possibilities for change. These complexities include the systems in which nurses’ practice, the fear of medico-legal repercussions, and the sense of security that rituals provide. This paper discusses these themes including the barriers to change and the implications for practice. The development of evidenced-based practice is only one component of the solution to the provision of best practice. Care is required to ensure that the evidenced-based movement does not lead to recipe book care rather than patient centred practice.

A comprehensive systematic review of evidence on the effectiveness and appropriateness of undergraduate nursing curricula.

Objectives  The objective of this review was to appraise and synthesise the best available evidence on the effectiveness and appropriateness of undergraduate nursing curricula. Inclusion criteria  This review considered research papers that addressed the effectiveness and appropriateness of undergraduate nursing curricula. Studies of higher evidence levels were given priority over lower-evidence studies. Participants of interest were undergraduate nursing students, nursing staff and healthcare consumers. Nursing staff outcomes, consumer outcomes and system outcomes (e.g. competency, satisfaction, critical thinking skills, healthcare consumer rights and cost-effectiveness) that impact on the evaluation of undergraduate nursing curricula were considered in the review. Search strategy  The search strategy sought to find both published and unpublished studies and reports limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of the text contained in the title and abstract, and of the index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. Finally, the reference list of all identified reports and articles was searched for additional studies. Methodological quality  Each paper was assessed by two independent reviewers for methodological quality before inclusion in the review using an appropriate critical appraisal instrument from the Unified Management, Assessment and Review of Information (SUMARI) package. Results  A total of 16 papers, experimental and textual in nature, were included in the review. The majority of papers was descriptive and examined the relationships between nursing curricula and specific learning outcomes such as critical thinking skills. Because of the diverse nature of these papers, meta-analysis of the results was not possible and this section of the review is presented in narrative form. In this review, four undergraduate nursing curriculum models were identified: integrated curriculum, subject-centred curriculum, problem-based learning, and an integrated critical thinking model. It was possible to examine the effectiveness of an integrated curriculum model and a subject-centred curriculum model; however, the other two models could not be compared because of a lack of evidence. Conclusion  The evidence regarding the effectiveness and appropriateness of undergraduate nursing curricula is notably weak because of the paucity of high-quality comparative studies and meaningful outcome measures of available studies. Therefore, no strong conclusion can be made regarding the effectiveness and appropriateness of undergraduate nursing curricula.

A randomised controlled trial comparing the use of manual versus mechanical compression to obtain haemostasis following coronary angiography

Cardiac interventions have become a commonly accepted treatment option for patients with coronary heart disease. Managing the arterial puncture site and femoral sheath removal is an important aspect of cardiac nursing practice for patients who have had cardiac diagnostic and interventional procedures. The purpose of this study was to compare the use of manual compression with a mechanical compression device in achieving haemostasis after femoral sheath removal in coronary angiography patients and to determine the ability of these two techniques to reduce groin complications. A randomised controlled trial comparing two compression protocols (manual and QuicKlamp) was undertaken on a sample of 100 patients scheduled to have coronary angiography. Descriptive statistics were used to analyse and describe the data. Inter-group comparisons were analysed using either Chi-squared analysis for nominal data, or the Mann-Whitney U-test for continuous variables. The results indicated that the QuicKlamp device took longer to effect haemostasis after femoral sheath removal (P=0.000) and subjects took longer to mobilise than after manual compression (P=0.001). More haematomas occurred following manual compression after pressure dressing removal (P=0.027). At 5-day follow-up, more bruising was identified in those subjects in the QuicKlamp compression group (P=0.046), as was swelling in female subjects (P=0.044). More episodes of chest pain at 5-day follow-up were identified in the manual compression group (P=0.014). The findings demonstrate that QuicKlamp mechanical compression is a safe alternative to manual compression for attaining haemostasis after femoral sheath removal.

Acute respiratory illness in the first year of primary school related to previous attendance at child care

Abstract: The aim of this study was to assess the relationship between previous child care outside the home (day care or family care) and acute respiratory illness in the first year at primary school. Participants were 445 Adelaide school children (mean age 5 years 2 months), 73 per cent of those eligible. Information about early childhood, family, child care arrangements and illness history was obtained from a questionnaire completed by parents. A respiratory illness score was calculated from the parental reports of respiratory illness experience in the winter months of the second school term in 1992. Absences from school owing to respiratory illness were counted from school records. Children who had attended child care before commencing school had fewer episodes of acute respiratory illness and had fewer absences from school than children with no child care experience. Children who had attended child care prior to commencing school experienced half as many episodes of asthma as those children who had never attended child care. Children who attend day care before age five tend to experience less acute respiratory illness than their peers on school entry. Possible explanations include selection of illness‐prone children into home care, protection against respiratory illness as a result of early exposure, and a shift in the age‐related peak of illness.

Improving antibiotic treatment outcomes through the implementation of a midline: Piloting a change in practice for cystic fibrosis patients

Midline catheters have many advantages for chronically ill patients needing up to six weeks intravenous therapy and medications, and when inserted in a sterile environment and correctly monitored and maintained, have a significantly lower association of infection and thrombus than previously suggested. Furthermore, there is a reduction in central collateral vessel formation from incursions into the superior vena cava, associated with peripherally inserted central catheters. Midline use was examined in a cystic fibrosis control group. Lines were checked daily until removal. All midline catheter tips were sent for culture on removal and data from 42 midlines placed in 2006 were retrieved from the hospital scientist for analysis. Twenty-seven inpatients with cystic fibrosis were identified and informed of the trial and possible risks of midline use. Outcome variables included infection and thrombus rates. On conclusion of the trial, data demonstrated both zero infection and thrombus rates in the study patient population. Midline catheters were monitored for a further 12 months following conclusion of the trial and infection rates continued to be below 1% and thrombus rates lower than 2%. In the specified group, the parameters of use for midlines fit with international cystic fibrosis intravenous antibiotic protocols currently adhered to. The study has begun to generate evidence to inform clinical practice, improve patient outcomes and supports the role of the specialist nurse in implementing midlines for cystic fibrosis patients.

Maternal blood pressure in pregnancy and stillbirth: A case-control study of third-trimester stillbirth

An immense body of literature on the effects of hypertension on perinatal morbidity and mortality exists, but only a handful of studies have reported adverse outcomes associated with low maternal blood pressure during pregnancy. This study aimed to investigate if there is an increased risk of fetal loss associated with hypotension during pregnancy. A matched case-control study of stillbirth and maternal blood pressure was conducted in which maternal blood pressures for a total of 124 pregnancies culminating in stillbirth were compared with maternal blood pressures in 243 (matched) pregnancies resulting in a liveborn infant. Women whose diastolic blood pressures fell in a borderline range (60 to 70 mm Hg) were consistently at greater risk of stillbirth relative to normotensive pregnancies. Women who had three or more mean arterial pressure values < or = 83 mm Hg during the course of their pregnancy were at nearly twice the risk of stillbirth (odds ratio 1.78; 95% confidence interval [CI] 1.06 to 2.99; P = 0.03). Systolic hypotension was not significantly associated with stillbirth, but proportionately more control women were noted to have systolic hypertension (SBP > or = 130 mmHg) than cases, and the adjusted odds of stillbirth in women who were hypertensive at either their first or last antenatal visit or whose antenatal average SBP was > or = 130 mm Hg were all very close to 0.4 (95% CI 0.37 to 0.43; P = 0.02 to 0.03) relative to normotensives. We concluded that maternal hypotension, particularly borderline hypotension, may be a contributory risk factor for stillbirth. Women with hypertension in pregnancy may now be at a decreased risk of stillbirth as a result of the close care and treatment they receive.