Sally Wilson

Research priorities for nursing care of infants, children and adolescents: a West Australian Delphi study

AIMS AND OBJECTIVES This paper describes a study that aimed to identify research priorities for the care of infants, children and adolescents at the sole tertiary referral hospital for children in Western Australia. The secondary aim was to stimulate nurses to explore clinical problems that would require further inquiry. BACKGROUND Planning for research is an essential stage of research development; involving clinicians in this exercise is likely to foster research partnerships that are pertinent to clinical practice. Nursing research priorities for the paediatric population have not previously been reported in Australia. DESIGN Delphi study. METHOD Over 12 months in 2005-2006, a three-round questionnaire, using the Delphi technique, was sent to a randomly selected sample of registered nurses. This method was used to identify and prioritise nursing research topics relevant to the patient and the family. Content analysis was used to analyse Round I data and descriptive statistics for Round II and III data. RESULTS In Round I, 280 statements were identified and reduced to 37 research priorities. Analysis of data in subsequent rounds identified the top two priority research areas as (1) identification of strategies to reduce medication incidents (Mean=6·47; SD 0·88) and (2) improvement in pain assessment and management (Mean=6; SD 1·38). Additional comments indicated few nurses access the scientific literature or use research findings because of a lack of time or electronic access. CONCLUSIONS Thirty-seven research priorities were identified. The identification of research priorities by nurses provided research direction for the health service and potentially other similar health institutions for children and adolescents in Australia and internationally. RELEVANCE TO CLINICAL PRACTICE The nurse participants showed concern about the safety of care and the well-being of children and their families. This study also enabled the identification of potential collaborative research and development of pain management improvement initiatives.

Quality nursing care in Australian paediatric hospitals: A Delphi approach to identifying indicators

AIM To identify indicators of quality nursing care by identifying structures, processes and outcomes perceived as valid, feasible, reliable and suitable for Australian paediatric hospitals by nursing experts. BACKGROUND Although measuring the quality of nursing care in acute care settings is being practised, there are few indicators validated for use in paediatric nursing. Using adult indicators for quality care measures in childrens nursing has inherent problems. To contribute to quality improvement and safety in the paediatric population, it is essential to identify and validate indicators that will be useful in this context. DESIGN A modified Delphi technique. METHOD Fifty-seven indicators that potentially measure the quality of nursing care in paediatrics were identified following a review of the literature. Three online surveys where panellists rated these indicators for perceived validity in paediatric nursing, feasibility of data collection, reliability based on existing documentation and suitability in the paediatric context were completed between March-May 2010. RESULTS Fifty-two nurses contributed to the expert panel. Consensus of 75% for validity in paediatric nursing was reached on 42 indicators, which were then ranked for suitability of use. Nineteen indicators were deemed inappropriate, which included indicators commonly used in adult settings. CONCLUSION Face and content validity were reached for 42 indicators identified as potential valid measures of quality care in paediatric nursing. Further work is required to solve issues of reliability and feasibility of data collection and to ascertain whether the indicators occur frequently enough within Australian hospitals to be clinically useful. RELEVANCE TO CLINICAL PRACTICE Identification of nursing-sensitive indicators that are valid in the paediatric setting is the first step in measuring the quality of care provided to children. Once established, measurement of the indicators may lead to improved patient safety and care in hospitals.

The effect of nurse staffing on clinical outcomes of children in hospital: a systematic review.

AIM The aim of the present study was to identify any association between nurse staffing and clinical outcomes in hospitalised children. INCLUSION CRITERIA Quantitative studies that evaluated the effect of nurse staffing on clinical outcomes of hospitalised children aged from 0-18 years. Measures of nurse staffing included nursing hours per patient day, nurse-to-patient ratio, skill mix and nurse characteristics such as level of education and years of experience. The clinical outcomes were those believed to be potentially sensitive to nursing care. Specifically, where the provision, or lack, of competent nursing care have made a difference to the outcome for the child (a nursing-sensitive outcome). Examples included mortality, healthcare-associated infections, failure to rescue, medication administration errors, postoperative complications and pressure ulcers. SEARCH STRATEGY The search strategy aimed to find published and unpublished studies written in English between 1993 and 2010. Following an initial search of the Cochrane and Joanna Briggs Institute Libraries of Systematic Reviews, a three-step search strategy was utilised. First, a limited search of MEDLINE and CINAHL using keywords was undertaken and the words contained in the titles, abstracts and the index terms used to describe each article were analysed. A second search using all identified keywords and index terms was done. Third, the reference lists of all identified reports and articles were searched for additional relevant studies. METHODOLOGICAL QUALITY Using the critical appraisal instrument from the Joanna Briggs Institute, each article was assessed by two independent reviewers for methodological quality before inclusion. RESULTS Eight studies were included of which six were cohort, one case-control and one cross-sectional. Comparison across studies was limited as few clinical outcomes were the same; similarly there was a lack of consistency in the measures of nurse staffing. Fourteen different healthcare-associated infections and ten further clinical outcomes, of which eight were adverse events, were reported. Predictor variables were 10 different definitions of nurse staffing. Measures of Registered Nurse staffing were used most frequently. Increased Registered Nurse nursing hours per patient day was associated with decreases in eight adverse events. Similarly, higher Registered Nurse skill mix contributed positively to three clinical outcomes in children. However, there appears to be a level where increasing Registered Nurse hours no longer has a significant effect on decreasing adverse events. Results reporting association between childrens outcomes and casual/agency nurses are equivocal. CONCLUSIONS There is evidence that levels of nurse staffing are associated with clinical outcomes of children. Standardisation of nurse-sensitive indicators and measures of nurse staffing will enable empirical research. Further research to find the levels of Registered Nurse hours per patient day and proportion of Registered Nurse in the skill mix that maximises childrens clinical outcomes is still required.

Health-care providers' experiences with opt-out HIV testing: a systematic review.

HIV is now a manageable chronic disease with a good prognosis, but early detection and referral for treatment are vital. In opt-out HIV testing, patients are informed that they will be tested unless they decline. This qualitative systematic review explored the experiences, attitudes, barriers, and facilitators of opt-out HIV testing from a health-care provider (HCP) perspective. Four articles were included in the synthesis and reported on findings from approximately 70 participants, representing diverse geographical regions and a range of human development status and HIV prevalence. Two synthesized findings emerged: HCP attitudes and systems. The first synthesized finding encompassed HCP decision-making attitudes about who and when to test for HIV. It also included the assumptions the HCPs made about patient consequences. The second synthesized finding related to systems. System-related barriers to opt-out HIV testing included lack of time, resources, and adequate training. System-related facilitators included integration into standard practice, support of the medical setting, and electronic reminders. A common attitude among HCPs was the outdated notion that HIV is a terrible disease that equates to certain death. Some HCPs stated that offering the HIV test implied that the patient had engaged in immoral behaviour, which could lead to stigma or disengagement with health services. This paternalism diminished patient autonomy, because patients who were excluded from opt-out HIV testing could have benefited from it. One study highlighted the positive aspects of opt-out HIV testing, in which participants underscored the professional satisfaction that arose from making an HIV diagnosis, particularly when marginalized patients could be connected to treatment and social services. Recommendations for opt-out HIV testing should be disseminated to HCPs in a broad range of settings. Implementation of system-related factors such as electronic reminders and care coordination procedures should be considered, and a social-justice commitment among HCPs should be encouraged.

Perceptions of infection control practices among health professionals

Abstract Infection control practice is a cornerstone of modern health care. However, there is minimal research into health professionals’ perception of infection control practices and how those perceptions influence staff compliance with recommended protocols.The objective of this study was to explore health care professionals’ perceptions of infection control practices in relation to the management of infectious diseases. A grounded theory approach was used as the research framework. Semi-structured interviews were completed with a sample of 16 nurses and doctors working at hospitals in Western Australia. Four major categories emerged from the data. These were: knowledge, culture, conflict, and risk assessment. The findings indicate the importance of both individual and organisational factors in determining clinicians’ levels of compliance with recommended infection control practices. Identification of the factors that influence health professionals’ level of compliance can be uased to develop strategies to support long-term compliance with infection control practices.

The use of oral sucrose for procedural pain relief in infants up to six months of age: a randomized controlled trial.

The aim of this study was to evaluate the effectiveness of oral sucrose in decreasing pain during minor procedures in infants of 1-6 months corrected age. A blinded randomized controlled trial with infants aged 4-26 weeks who underwent venipuncture, heel lance or intravenous cannulation were stratified by corrected age into > 4-12 weeks and > 12-26 weeks. They received 2 mL of either 25% sucrose or sterile water orally 2 minutes before the painful procedure. Nonnutritional sucking and parental comfort, provided in adherence to hospital guidelines, were recorded. Pain behavior was recorded using a validated 10 point scale at baseline, during and following the procedure. Data collectors were blinded to the intervention. A total of 21 and 20 infants received sucrose and water, respectively, in the > 4-12-week age group, and 21 and 22, respectively, in the > 12-26-week age group. No statistical differences were found in pain scores between treatment and control groups at any data collection points in either age group. Infants aged > 4-12 weeks who did nonnutritional sucking showed statistically significantly lower median pain scores at 1, 2, and 3 minutes after the procedure than those who did not suck. Infants aged > 4-26 weeks exhibited pain behavior scores that indicated moderate to large pain during painful procedures; however, there was insufficient evidence to show that 2 mL 25% sucrose had a statistically significant effect in decreasing pain. Infants should be offered nonnutritional sucking in compliance with the Baby Friendly Health Initiative during painful procedures.

Australian health care providers’ views on opt-out HIV testing

BackgroundOpt-out HIV testing is a novel concept in Australia. In the opt-out approach, health care providers (HCPs) routinely test patients for HIV unless they explicitly decline or defer. Opt-out HIV testing is only performed with the patients’ consent, but pre-test counselling is abbreviated. Australian national testing guidelines do not currently recommend opt-out HIV testing for the general population. Non-traditional approaches to HIV testing (such as opt-out) could identify HIV infections and facilitate earlier treatment, which is particularly important now that HIV is a chronic, manageable disease. Our aim was to explore HCPs’ attitudes toward opt-out HIV testing in an Australian context, to further understanding of its acceptability and feasibility.MethodsIn this qualitative study, we used purposeful sampling to recruit HCPs who were likely to have experience with HIV testing in Western Australia. We interviewed them using a semi-structured guide and used content analysis as per Graneheim to code the data. Codes were then merged into subcategories and finally themes that unified the underlying concepts. We refined these themes through discussion among the research team.ResultsTwenty four HCPs participated. Eleven participants had a questioning attitude toward opt-out HIV testing, while eleven favoured the approach. The remaining two participants had more nuanced perspectives that incorporated some characteristics of the questioning and favouring attitudes. Participants’ views about opt-out HIV testing largely fell into two contrasting themes: normalisation and routinisation versus exceptionalism; and a need for proof versus openness to new approaches.ConclusionMost HCPs in this study had dichotomous attitudes toward opt-out HIV testing, reflecting contrasting analytical styles. While some HCPs viewed it favourably, with the perceived benefits outweighing the perceived costs, others preferred to have evidence of efficacy and cost-effectiveness.

Identifying paediatric nursing-sensitive outcomes in linked administrative health data

BackgroundThere is increasing interest in the contribution of the quality of nursing care to patient outcomes. Due to different casemix and risk profiles, algorithms for administrative health data that identify nursing-sensitive outcomes in adult hospitalised patients may not be applicable to paediatric patients. The study purpose was to test adult algorithms in a paediatric hospital population and make amendments to increase the accuracy of identification of hospital acquired events. The study also aimed to determine whether the use of linked hospital records improved the likelihood of correctly identifying patient outcomes as nursing sensitive rather than being related to their pre-morbid conditions.MethodsUsing algorithms developed by Needleman et al. (2001), proportions and rates of records that identified nursing-sensitive outcomes for pressure ulcers, pneumonia and surgical wound infections were determined from administrative hospitalisation data for all paediatric patients discharged from a tertiary paediatric hospital in Western Australia between July 1999 and June 2009. The effects of changes to inclusion and exclusion criteria for each algorithm on the calculated proportion or rate in the paediatric population were explored. Linked records were used to identify comorbid conditions that increased nursing-sensitive outcome risk. Rates were calculated using algorithms revised for paediatric patients.ResultsLinked records of 129,719 hospital separations for 79,016 children were analysed. Identification of comorbid conditions was enhanced through access to prior and/or subsequent hospitalisation records (43% of children with pressure ulcers had a form of paralysis recorded only on a previous admission). Readmissions with a surgical wound infection were identified for 103 (4.8/1,000) surgical separations using linked data. After amendment of each algorithm for paediatric patients, rates of pressure ulcers and pneumonia reduced by 53% and 15% (from 1.3 to 0.6 and from 9.1 to 7.7 per 10,000 patient days) respectively, and an 84% increase in the proportion of surgical wound infection (from 5.7 to 10.4 per 1,000 separations).ConclusionsAlgorithms for nursing-sensitive outcomes used in adult populations have to be amended before application to paediatric populations. Using unlinked individual hospitalisation records to estimate rates of nursing-sensitive outcomes is likely to result in inaccurate rates.

Experiences of acute pain in children who present to a healthcare facility for treatment: a systematic review of qualitative evidence

Background Pain is a universal and complex phenomenon that is personal, subjective and specific. Despite growing knowledge in pediatric pain, management of childrens pain remains sub-optimal and is linked to negative behavioral and physiological consequences later in life. As there is no synthesis of these studies, it was timely to undertake a systematic review. Objectives To identify, evaluate and synthesize the existing qualitative evidence on childrens experiences of acute pain, including pain management, within a healthcare facility. Inclusion criteria Types of participants Children aged four to 18 years (inclusive) attending a healthcare facility who experienced acute pain associated with any injury, medical condition or treatment. Phenomena of interest Childrens experiences and perceptions of their acute pain, pain management and expectations of others in managing their pain. Studies on childrens experiences of pain in the postoperative context were excluded as a systematic review exploring this phenomenon had previously been published. Studies reporting on childrens experiences of chronic pain were also excluded. Context Any healthcare facility including general practitioners’ surgeries, hospitals, emergency departments and outpatient clinics. Types of studies Qualitative studies including phenomenology, grounded theory, ethnography, action research and feminist research designs. Search strategy Using a three-step search strategy, databases were searched in December 2015 to identify both published and unpublished articles from 2000 to 2015. Studies published in languages other than English were excluded. Methodological quality All studies that met the inclusion criteria were assessed by at least two independent reviewers for methodological quality using a standardized critical appraisal tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Data extraction Data were extracted from the papers included in the review using standardized data extraction tool from JBI-QARI. Data synthesis Findings were pooled using JBI-QARI. Findings were rated according to their level of credibility and categorized based on similarity in meaning and then were subjected to a meta-synthesis. Results Four studies were included in this review. Two meta-syntheses were generated from five categories based on 21 findings: first, children can express their pain experiences in terms of cause, location, meaning and quality. Childrens pain experiences include both physical and psychological dimensions. Childrens pain experiences are influenced by their previous pain experiences, pain expectations and sociocultural factors. Second, children use a range of cognitive/behavioral and sensory/physical self-soothing strategies not only to help manage their pain, but also rely on the actions and presence of others as helpers when they are in pain. Conclusion Childrens pain is a multi-dimensional complex phenomenon relying upon a multi-modal approach to management. Children as young as four years are capable of articulating their pain in terms of location, intensity and depth. The way children perceive, express and respond to pain is shaped by sociocultural factors, previous pain experiences and their expectations of pain. Children, parents and healthcare professionals play an important role in managing childrens pain experiences.

Effectiveness of psychosocial interventions in reducing grief experienced by family carers of people with dementia: a systematic review protocol.

REVIEW OBJECTIVE The objective is to examine the existing evidence regarding the effectiveness of psychosocial interventions to assist grief pre- and post-bereavement for family carers of people with dementia residing in the community or in a health or social care facility. REVIEW QUESTION What psychosocial interventions for family carers of people with dementia are most effective in reducing: (1) anticipatory grief, (2) post-death grief (bereavement), and (3) complicated grief?