Robyn Cant

How death anxiety impacts nurses' caring for patients at the end of life: a review of literature.

Nurses are frequently exposed to dying patients and death in the course of their work. This experience makes individuals conscious of their own mortality, often giving rise to anxiety and unease. Nurses who have a strong anxiety about death may be less comfortable providing nursing care for patients at the end of their life. This paper explores the literature on death anxiety and nurses’ attitudes to determine whether fear of death impacts on nurses’ caring for dying patients. Fifteen quantitative studies published between 1990 and 2012 exploring nurses’ own attitudes towards death were critically reviewed. Three key themes identified were: i). nurses’ level of death anxiety; ii). death anxiety and attitudes towards caring for the dying, and iii). death education was necessary for such emotional work. Based on quantitative surveys using valid instruments, results suggested that the level of death anxiety of nurses working in hospitals in general, oncology, renal, hospice care or in community services was not high. Some studies showed an inverse association between nurses’ attitude towards death and their attitude towards caring for dying patients. Younger nurses consistently reported stronger fear of death and more negative attitudes towards end-of-life patient care. Nurses need to be aware of their own beliefs. Studies from several countries showed that a worksite death education program could reduce death anxiety. This offers potential for improving nurses’ caring for patients at the end of their life.

FIRST2ACT: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education.

Delayed assessment and mismanagement of patient deterioration is a substantial problem for which educational preparation can have an impact. This paper describes the development of the FIRST(2)ACT simulation model based on well-established theory and contemporary empirical evidence. The model combines evidence-based elements of assessment, simulation, self-review and expert feedback, and has been tested in undergraduate nurses, student midwives and post-registration nurses. Participant evaluations indicated a high degree of satisfaction and substantial self-rated increases in knowledge, confidence and competence. This evidence-based model should be considered for both undergraduate and post-registration education programs.

Managing Deteriorating Patients: Registered Nurses’ Performance in a Simulated Setting

Aim: To examine, in a simulated environment, rural nurses’ ability to assess and manage patient deterioration using measures of knowledge, situation awareness and skill performance. Background: Nurses’ ability to manage deterioration and ‘failure to rescue’ are of significant concern with questions over knowledge and clinical skills. Simulated emergencies may help to identify and develop core skills. Methods: An exploratory quantitative performance review. Thirty five nurses from a single ward completed a knowledge questionnaire and two video recorded simulated scenarios in a rural hospital setting. Patient actors simulated deteriorating patients with an Acute Myocardial Infarction (AMI) and Chronic Obstructive Pulmonary Disease (COPD) as the primary diagnosis. How aware individuals were of the situation (levels of situation awareness) were measured at the end of each scenario. Results: Knowledge of deterioration management varied considerably (range: 27%-91%) with a mean score of 67%. Average situation awareness scores and skill scores across the two scenarios (AMI and COPD) were low (50%) with many important observations and actions missed. Participants did identify that ‘patients’ were deteriorating but as each patient deteriorated staff performance declined with a reduction in all observational records and actions. In many cases, performance decrements appeared to be related to high anxiety levels. Participants tended to focus on single signs and symptoms and failed to use a systematic approach to patient assessment. Conclusion: Knowledge and skills were generally low in this rural hospital sample with notable performance decrements as patients acutely declined. Educational models that incorporate high fidelity simulation and feedback techniques are likely to have a significant positive impact on performance.

The FIRST2ACT simulation program improves nursing practice in a rural Australian hospital

OBJECTIVE To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST(2) ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital. DESIGN Interrupted time series analysis. SETTING A rural Australian hospital. PARTICIPANTS All registered nurses (Division 1) employed on an acute medical/surgical ward. INTERVENTION The FIRST(2) ACT simulation program. OUTCOME MEASURES Appropriate frequency of a range of observations and administration of oxygen therapy. RESULTS Thirty-four nurses participated (83% of eligible nurses) in the FIRST(2) ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis. CONCLUSION FIRST(2) ACT was associated with measurable improvements in nursing practice.

The place of knowledge and evidence in the context of Australian general practice nursing

BACKGROUND The purpose of the study was to ascertain the place of knowledge and evidence in the context of Australian general practice nursing. General practice nursing is a rapidly developing area of specialized nursing in Australia. The provision of primary care services in Australia rests largely with medical general practitioners who employ nurses in a small business model. METHODS A statistical research design was used that included a validated instrument: the developing evidence-based practice questionnaire (Gerrish et al. 2007). A total of 1,800 Victorian practice nurses were surveyed with a return of 590 completed questionnaires, equaling a response rate of 33%. FINDINGS Lack of time to access knowledge for practice was a barrier for participants in this study. In-service education and training opportunities were ranked as the number one source of knowledge for general practice nurses. Experiential learning and interactions with clients, peers, medical practitioners, and specialist nurses were also considered very important sources of knowledge. Research journals were ranked much lower than experiential learning and personal interactions. Participants assessed their own skills at sourcing and translating evidence into practice knowledge as low. Younger general practice nurses were more likely than older nurses to assess themselves as competent at using the library and Internet to locate evidence. DISCUSSION The predominantly oral culture of nursing needs to be identified and incorporated into methods for disseminating evidence from research findings in order to increase the knowledge base of Australian general practice nurses. CONCLUSIONS Findings from this study will be significant for policy makers and funders of Australian nursing in general practice. The establishment of a career structure for general practice nurses that includes salaried positions for clinical nurse specialists would assist in the translation of evidence into knowledge for utilization at the point of care.

Managing patient deterioration: a protocol for enhancing undergraduate nursing students' competence through web-based simulation and feedback techniques

AimsTo describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.BackgroundThere are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.Design/MethodsA mixed methods triangulated convergent design.In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.ConclusionThis project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

Measuring non-technical skills in medical emergency care: a review of assessment measures

Aim To review the literature on non-technical skills and assessment methods relevant to emergency care. Background Non-technical skills (NTS) include leadership, teamwork, decision making and situation awareness, all of which have an impact on healthcare outcomes. Significant concerns have been raised about the rates of adverse medical events, many of which are attributed to NTS failures. Methods Ovid, Medline, ProQUEST, PsycINFO and specialty websites were searched for NTS measures using applicable access strategies, inclusion and exclusion criteria. Publications identified were assessed for relevance. Results A range of non-technical skill measures relevant to emergency care was identified: leadership (n = 5), teamwork (n = 7), personality/behavior (n = 3) and situation awareness tools (n = 1). Of these, 9 have been used with emergency care populations/clinicians. All had varying degrees of reliability and validity. In the last decade there has been some development of teamwork measures specific to emergency care with a predominantly global and collective rating of broad skills. Conclusion A variety of non-technical skill measures are available; only a few have been used in the emergency care arena. There is a need for an increase in the focused assessment of teamwork skills for a greater understanding of team performance to enhance patient safety in medical emergency care.

Investing in big ideas: utilisation and cost of Medicare Allied Health services in Australia under the Chronic Disease Management initiative in primary care

OBJECTIVE To critically examine utilisation of the 13 allied health services provided through Medicare Chronic Disease Management program and related general practitioner (GP) care planning initiatives. METHODS Statistics generated from national billing data from July 2005 to June 2009 were extracted from Medicare data and compared by profession, State or Territory and population. RESULTS Most services grew over 4 years although nationally consistent service levels were not found for any allied health provider profession. On referral from GPs, podiatry, physiotherapy and dietetics provided most services (82%) in 2008-09. Professions had unique patterns of referral instanced by age range and sex of clientele. Wide variation was apparent in per capita utilisation of allied health services by State or Territory; some with far less than average national use and others with high use. Annual number of GP Management Plans or Team Care Arrangements was low (mean: ≤22 per GP in 2008-09), indicating low use of care planning. CONCLUSION Inequality of accessibility for patients was apparent. Five years into the program, a review of Medicare Allied Health CDM policy is warranted. Implications. Research and evaluation is needed to identify whether the program is meeting the needs of GPs, allied health providers and chronic disease patients.

Teaching teamwork: an evaluation of an interprofessional training ward placement for health care students

The establishment of interprofessional teamwork training in the preprofessional health care curriculum is a major challenge for teaching faculties. Interprofessional clinical placements offer an opportunity for teamwork education, as students in various professions can work and learn together. In this sequential, mixed-method study, focus group and survey techniques were used to evaluate students’ educational experiences after 2-week ward-based interprofessional clinical placements. Forty-five senior nursing, medicine, and other health care students cared for patients in hospital wards under professional supervision, with nursing-medicine student “teams” leading care. Thirty-six students attended nine exit focus groups. Five central themes that emerged about training were student autonomy and workload, understanding of other professional roles, communication and shared knowledge, interprofessional teamwork/collaboration, and the “inner circle”, or being part of the unit team. The learning environment was described as positive. In a postplacement satisfaction survey (n=38), students likewise rated the educational experience highly. In practicing teamwork and collaboration, students were able to rehearse their future professional role. We suggest that interprofessional clinical placements be regarded as an essential learning experience for senior preprofessional students. More work is needed to fully understand the effect of this interactive program on students’ clinical learning and preparation for practice.

Patterns of Delivery of Dietetic Care in Private Practice for Patients Referred under Medicare Chronic Disease Management: Results of a National Survey

A national survey was used to examine patterns of delivery of dietetic care for patients referred to private practitioners under Medicare Chronic Disease Management (CDM). This asked dietitians about referrals from general practitioners, patient management, fees charged and patient billing. There were 356 (47%) Australian private practice dietitians who responded to the questionnaire; 330 (94%) were Medicare providers. They described a counselling-type service and inability to complete initial patient education within funded consultation time. Many provided a longer consultation than was reported as being funded by Medicare. Fees for initial appointments were generally higher than the scheduled Medical Benefit Scheme fee of AU