Nurse wellbeing during the coronavirus (2019) pandemic: A qualitative descriptive study.

BACKGROUND: The wellbeing of individuals influences organisational outcomes. Insight into nurses' wellbeing is crucial to a sustaining a high-quality workforce. AIM: To describe nurses' perceptions and experiences of wellbeing, work wellbeing, and mental health. METHOD: Using a qualitative descriptive design, semi-structured interviews were conducted, transcribed verbatim, analysed inductively and thematically, and reported per consolidated criteria for reporting qualitative research. FINDINGS: Nine Australian nurses were interviewed in 2020, each for 60 to 90 minutes. These nurses had a broad range of clinical roles and years of experience in metropolitan healthcare organisations. Six themes, each related to nurse wellbeing, depicted: (i) value and sense of purpose from nursing, yet also negative consequences of losing sight of oneself within the nursing role; (ii) work nurses did to disengage from their job and create a balance within their life; (iii) significance of the team and senior team as a source of both strength and opportunity for wellbeing; (iv) a range of wellbeing initiatives with a perception these were often developed, and for use, in response to crisis as opposed to preventative or proactive measures; (v) value of additional nurse wellbeing education and promotion of available support; and (vi) novel challenges and ways to wellbeing during times where resources were stretched and usual support systems impacted. DISCUSSION: Identified positive and negative consequences of nursing must be addressed when developing targeted wellbeing interventions. CONCLUSION: New ways of working and supporting individual, team and organisational wellbeing are needed for flourishing working environments. Potential strategies to either leverage or mitigate the positive and negative consequences of nursing are offered.

Socio-demographic and disease related characteristics associated with unplanned emergency department visits by cancer patients: a retrospective cohort study.

BACKGROUND: Emergency department (ED) presentations made by patients having cancer treatment are associated with worth outcomes. This study aimed to explore the socio-demographic and disease related characteristics associated with ED presentation, frequent ED presentations, and place of discharge for cancer patients receiving systemic cancer therapies in the ambulatory setting. METHODS: This was a single site, retrospective observational cohort design. Hospital data for patients treated in the Day Oncology Unit of a large public tertiary hospital in Melbourne, Australia between December 2014 and November 2017 were extracted from clinical databases and retrospectively matched to ED attendance records. Andersen's Behavioral Model of Health Service Utilisation provided the conceptual framework for exploring associations between socio-demographic and disease characteristics and ED use. RESULTS: A total of 2638 individuals were treated in the Day Oncology Unit over the study dates. Of these, 1182 (45%) made an unplanned ED presentation within 28 days of receiving systemic cancer therapy. One hundred and twenty-two (12%) patients attended the ED on two or more occasions within 28 days; while 112 (10%) patients attended the ED four or more times (within 28 days of receiving systemic cancer therapy) within any given 12 month period. Being born outside of Australia was independently related to making an unplanned ED presentation within 28 days of receiving anti-cancer therapy (p < .01) as was being diagnosed with head and neck (p = .03), upper gastrointestinal (p < .001), colorectal (p < .001), lung (p < .001), skin (p < .001) or breast cancer (p = .01). CONCLUSIONS: This study identified a subgroup of cancer patients for whom an ED presentation is more likely. Better understanding of socio-demographic and disease related characteristics associated with the risk of an ED presentation may help inform targeted follow up of patients, to mitigate potentially avoidable ED presentation and optimize outcomes of care.

Factors that influence presentation to an emergency department during systemic anti-cancer therapy: An exploratory qualitative study.

PURPOSE: To explore factors that influence presentation to an emergency department during ambulatory systemic anti-cancer therapy. METHODS: This study was an exploratory qualitative study using semi-structured interviews. A purposive sample of adult patients with any cancer who had commenced systemic anti-cancer therapy in the ambulatory setting up to six months prior participated in semi-structured interviews between November 2016-December 2017. Interviews were transcribed verbatim, and data analysed thematically using a template analysis approach. RESULTS: Twenty patients and four caregivers took part. Five themes were generated from the interview data: 1) the unknown and unpredictable; 2) a change of lifestyle; 3) social determinants and access; 4) trust in care providers; and 5) the unavailability of care. CONCLUSION: As the number of systemic anti-cancer agents and patients eligible for them continues to grow, identifying, implementing and evaluating initiatives to mitigate emergency department presentations present an important area for health services research. Addressing timely access to trusted care and enhancing patient capacity for self-management present important areas for nurse-led system innovation. Findings from this study offer important insights into where and how nurses can mitigate emergency department presentations for individuals receiving systemic anti-cancer therapy by enabling accessible, coordinated and person-centred cancer care.

Reducing stress, anxiety and depression in undergraduate nursing students: Systematic review.

OBJECTIVE: Undergraduate nursing students may experience high levels of stress, anxiety or depression. This can not only influence their personal wellbeing and academic performance, but also communication with patients during clinical placement and the quality and safety of the healthcare delivered. The objective of the review was to identify interventions that target stress, anxiety or depressed mood in undergraduate nursing students during their undergraduate course. REVIEW METHOD: A quantitative systematic review, guided by the Joanna Briggs Institute methodology, was conducted. The review considered studies that included undergraduate nurses, and which evaluated interventions targeting stress, anxiety and depressed mood. The review included experimental studies published in English from 2008 to 2018. A tabulated and narrative summary was utilised to present the results. RESULTS: A total of 1579 studies were identified following a systematic search and 931 studies were screened by title and abstract. A total of 44 studies were critically appraised resulting in 22 studies for inclusion in the systematic review. The studies focused on stress (10 studies), anxiety (14 studies) and depression (7 studies). The majority of the studies (18 of 22) reported a statistically significant reduction in the stress, anxiety or depression experienced by nursing students who participated in interventions targeting these symptoms. Interventions that sought to improve coping management skills, such as mindfulness-based interventions, were most reported. CONCLUSION: There are a range of effective interventions that target stress, anxiety or depressed mood among nursing students. The quality of the studies reporting these interventions was found to be variable and generally samples were small with limited follow-up. Studies of mindfulness interventions comprised the largest sample sizes, displayed the highest levels of evidence, and transcended stress, anxiety and depressed mood. Future research would benefit from a co-ordinated approach to build the strength of the body of evidence.

Establishing quality standards for graduate entry master of nursing curricula in Australia and New Zealand: A Delphi study.

AIM: To describe the common elements of Graduate Entry Master of Nursing curricula and identify a set of standards and quality indicators for benchmarking purposes within and across jurisdictions. BACKGROUND: Internationally, there has been an increase in universities offering Graduate Entry Masters programs in Nursing. Such programs specify a bachelor degree as an entry requirement and then offer an intensive program of study that prepares graduates for registration as a nurse. To date, no formal standards exist to guide evaluation of these curricula. DESIGN: A two phased sequential mixed-methods design comprising thematic content analysis of curricula and a Delphi study. The setting was the Australian and New Zealand tertiary education sectors. Participants were nurse academics who were recruited to participate in the Delphi study. Quota sampling was used to identify educators from the education providers meeting organisational inclusion criteria (program coordinator and one lecturer working as a subject coordinator of the program) and nominated by their Head of Department. METHODS: Phase One of the study involved a thematic analysis of the curricula of nine Graduate Entry Master of Nursing programs to identify common elements of curricula and domains of quality. In Phase Two these themes were used in a series of Delphi rounds to identify a set of agreed quality domains, statements and indicators. RESULTS: Participants (n = 16) responded over three Delphi rounds. A total of nine domains of quality were determined, a set of 26 quality statements were identified based on the acceptance threshold of > 75% level of agreement and 27 quality indicators were established. CONCLUSIONS: Our research provides an agreed set of indicators for evaluating the quality of Graduate Entry Master of Nursing programs. This work will also make it possible to measure the immediate and longer-term impacts of Graduate Entry Master of Nursing programs for the nursing workforce. Future work must focus on testing feasibility and optimising utility while refining indicators across jurisdictions.

New graduate nurse wellbeing, work wellbeing and mental health: A quantitative systematic review.

BACKGROUND: The contribution of work to positive mental health is increasingly apparent. Transition into the workplace causes a range of stressors for new graduate nurses who experience both psychological wellbeing and illbeing in their first year of practice. OBJECTIVE: To determine published prevalence, predictors, barriers and enablers of new graduate registered nurse wellbeing, work wellbeing and mental health. DESIGN: Systematic review of quantitative research. DATA SOURCES: Databases included Cumulative Index of Nursing and Allied Health Literature, Excerpta Medica database, Medical Literature Analysis and Retrieval System Online and Psychological Information. Quantitative and mixed-methods studies were considered for inclusion if published in English from 2009 to 2019 reporting primary data analysis including new graduate nurses' wellbeing, work wellbeing and mental health. REVIEW METHODS: Quantitative studies were systematically identified then screened and appraised against pre-determined inclusion criteria. Analysis was conducted by grouping according to analytical methods and results reported as a narrative synthesis. RESULTS: Thirty-four studies were included. The quality of the evidence was variable with just a quarter of the studies being assessed as meeting the quality criteria on all nine measures. For the new graduate nurses prevalence of wellbeing, levels of resilience, optimism, and hope were found to be high. For work wellbeing, most reported higher job satisfaction by 12-months. For work illbeing, levels of burnout were moderately high, predominantly in terms of emotional exhaustion, and stress was initially high, particularly in terms of workload, but decreased over time. For the predictors, job satisfaction was positively predicted by structural empowerment and career satisfaction, and negatively predicted by co-worker incivility, supervisor incivility and emotional exhaustion. For work illbeing, stress was a positive predictor for intent to leave. Stress reductions were associated with momentary levels of high task mastery, social acceptance and role clarity. CONCLUSIONS: For new graduate nurses, levels of emotional exhaustion, workload and stress were moderately high to high initially, decreasing over time as the graduate nurses' job satisfaction increased. Most studies focused on the nurses' intent to resign or stay and both psychological capital and work engagement positively predicted intent to stay whereas work stress positively predicted intent to resign. Resilience and group cohesion moderated the negative effects of some variables, thus may be potential enablers of work wellbeing. The standards of research reporting or design were generally sub-optimal according to quality indicators. Systematic review registration number: (CRD42020148812).

Review of non-invasive ventilation in the emergency department: clinical considerations and management priorities.

AIMS AND OBJECTIVES: We aimed to synthesise evidence from published literature on non-invasive ventilation to inform nurses involved in the clinical management of non-invasive ventilation in the emergency department. BACKGROUND: Non-invasive ventilation is a form of ventilatory support that does not require endotracheal intubation and is used in the early management of acute respiratory failure in emergency departments. Safe delivery of this intervention requires a skilled team, educated and experienced in appropriate patient selection, available devices and monitoring priorities. DESIGN: Systematic review. METHOD: A multi-database search was performed to identify works published in the English language between 1998-2008. Search terms included: non-invasive ventilation, continuous positive airway pressure and emergency department. Inclusion and exclusion criteria for the review were identified and systematically applied. RESULTS: Terminology used to describe aspects of non-invasive ventilation is ambiguous. Two international guidelines inform the delivery of this intervention, however, much research has been undertaken since these publications. Strong evidence exists for non-invasive ventilation for patients with acute exacerbation of congestive heart failure and chronic obstructive pulmonary disease. Non-invasive ventilation may be delivered with various interfaces and modes; little evidence is available for the superiority of individual interfaces or modes. CONCLUSIONS: Early use of non-invasive ventilation for the management of acute respiratory failure may reduce mortality and morbidity. Though international guidelines exist, specific recommendations to guide the selection of modes, settings or interfaces for various aetiologies are lacking due to the absence of empirical evidence. RELEVANCE TO CLINICAL PRACTICE: Monitoring of non-invasive ventilation should focus on assessment of response to treatment, respiratory and haemodynamic stability, patient comfort and presence of air leaks. Complications are related to mask-fit and high air flows; serious complications are few and occur infrequently. The use of non-invasive ventilation has resource implications that must be considered to provide effective and safe management in the emergency department.

Evaluation of a multifaceted intervention on documentation of vital signs at triage: a before-and-after study.

BACKGROUND: Triage systems provide a centralised safety mechanism where all patients are assessed for clinical urgency at point of entry to the ED. OBJECTIVE: The present study aims to evaluate the effect of a multifaceted intervention on triage documentation rates and guideline adherence. METHODS: A before-and-after design was used. The intervention involved restructuring the computerised interface, regular audit and feedback and education sessions. The setting was one adult tertiary referral hospital and major trauma centre located in Melbourne, Australia. Participants were triage nurses. Data were collected at five time points for a consecutive sample of one month of presentations. RESULTS: Over a 15 month period, we sampled 35.8% (24,862/69,395) episodes of triage performed by 122 nurses. Documentation rates for all vital signs progressively increased from baseline. There were significant increases in the proportion of episodes of triage where any vital sign was documented (32.2% vs 82.6%), and where pair and triplet combinations of vital signs were recorded in the triage field (heart rate and respiratory rate: 17.9% vs 64.6%; heart rate, respiratory rate and temperature: 7.0% vs 30.4%). No significant change in guideline adherence was observed after the intervention. CONCLUSION: Progressive sustained improvements in vital sign documentation were observed over the study period; however, no such increases were noted in guideline adherence. To facilitate evaluation of guideline adherence, we recommend specific vital sign parameters be included in the Australasian Triage Scale Guideline for all levels of urgency.

Perspectives of emergency department staff on the triage of mental health-related presentations: Implications for education, policy and practice.

OBJECTIVE: To explore ED staff perceptions of the factors that influence accuracy of triage for people with mental health problems. METHODS: This qualitative learning needs analysis used a descriptive exploratory design. Participants were Australian emergency nurses and doctors. We used a criterion-based sampling approach. Recruitment was facilitated by the College of Emergency Nursing Australasia and the Australasian College for Emergency Medicine. A semi-structured interview schedule was developed. Telephone interviews were conducted, audio recorded and transcribed verbatim. Thematic analysis was used to identify factors perceived to affect triage outcomes and to explore strategies to optimise the accuracy of triage assessments. RESULTS: Thirty-six staff participated (16 nurses and 20 doctors). Four major factors were perceived to influence accuracy. These were: environmental factors (physical structure, time pressures, activity levels, and interruptions), policy and education (guidelines, training and resources), staff factors (knowledge, experience, attitudes) and patient factors (police presence, patient behaviour, clinical condition). Differences of opinion were expressed by emergency doctors about the validity of the time to treatment objectives included in the Australasian Triage Scale for mental health presentations, and the utility of the scale to differentiate urgency for psychiatric conditions. CONCLUSION: Clinical guidelines and training have been developed to support the use of the Australasian Triage Scale. Further evaluation of the application of this scale to assess mental health problems is indicated. Additional work is also required to reduce variance in urgency assignment based on staff knowledge and attitudes about the causes, assessment and early management of psychiatric disorders.

Optimal management of mental health patients in Australian emergency departments: barriers and solutions.

OBJECTIVES: The study aimed to describe: (i) the perceived barriers faced by emergency clinicians in the assessment and management of patients presenting with a mental health complaint to Australian hospital EDs; and (ii) perceived strategies to optimize care of the mentally unwell in the ED. METHODS: Semistructured interviews with open and closed question formats were used to explore the barriers perceived by ED doctors and nurses in assessing and managing patients with mental health presentations. Interviews were transcribed verbatim and thematically coded by two researchers using the Framework Approach. RESULTS: Thirty-six interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College of Emergency Nursing Australasia representing the various Australian jurisdictions. Thematic analyses revealed that a range of resource, environmental, staff and patient factors contribute to difficulties in managing mental health patients. Solutions suggested by interviewees included improved resources, ED redesign and improved links to resources outside the ED. An overwhelming majority of participants perceived the need for more educational opportunities in mental health. CONCLUSION: Although the provision of timely and quality care is expected for all patients attending EDs, there exist multiple barriers to provision of adequate care for ED patients presenting with mental illness. Many of these are systems-based and thus require systems-based solutions. ED clinician's perceive that improved educational opportunities in mental health, however, might alleviate some barriers they face. Consideration should be given to a comprehensive, quantitative mental health-related learning needs analysis of ED clinicians.

Mental health-related learning needs of clinicians working in Australian emergency departments: a national survey of self-reported confidence and knowledge.

OBJECTIVE: To identify the mental health-related learning needs of doctors and nurses working in Australian EDs. METHODS: A purpose-designed survey was developed, and face validity was verified by 12 doctors and nurses. A cross-sectional survey of a national sample of nurses and senior doctors (registrars and consultants) working in EDs across Australia was then undertaken. The survey consisted of 130 items and required approximately 20 min for completion. The survey was delivered online through email invitation by the College of Emergency Nurses Australasia or the Australasian College for Emergency Medicine. A hardcopy format of the survey was also delivered at a national conference. RESULTS: Mental health presentations that involved a diagnosis of personality disorder, psychosis or behavioural disturbance, and the management of these conditions were patient factors that were considered problematic by up to 46.3% (118/255; 95% CI 40.26-52.40) of doctors and 66.1% (72/109; 95% CI 56.74-74.28) of nurses. Determining care plans, conducting mental status examinations, assessing risk of self-harm, pharmacology for treatment and for chemical restraint, management of patient aggression or violence, and alcohol or drug intoxication were also found to be areas of knowledge deficit. CONCLUSION: Doctors and nurses reported deficits in confidence and knowledge in tasks and patient presentations that they might frequently be expected to manage. These data can be used to inform future curricula at both undergraduate and postgraduate levels. Ultimately, this might pave the way for improved care and management of patients with mental health problems presenting to the ED.

Use of invasive mechanical ventilation in Australian emergency departments.

OBJECTIVE: There are few published reports describing the use of invasive mechanical ventilation in EDs. We explored the characteristics of patients receiving mechanical ventilation, the ventilator modes and parameters used as well as the duration of ventilation and the nature of ventilator decision-making in Australian ED. METHODS: We conducted a 2 month prospective survey of adult patients who received invasive mechanical ventilation in 24 Australian ED. Data forms were completed by ED staff during the patient's ED presentation. We documented ventilator settings post intubation, after a 1 h stabilization period, and immediately before ED discharge or extubation. The person responsible for selection of ventilator settings was noted at each time point. RESULTS: Data were recorded on 307 patients. Altered mental status (179/307 [58%, 95% CI 53-64]) was the most common indication for mechanical ventilation. Volume-controlled modes were most frequently used at all measured time points; with a median tidal volume of 8 mL/kg. Responsibility for initial selection of ventilator settings was shared between ED physicians (157/307 [51%, 95% CI 46-57]), ED nurses (111/307 [36%, 95% CI 31-42]) and ICU or paramedic staff (9/307 [3%, 95% CI 1-5]) (not recorded 30/307 [10%, 95% CI 6-13]). Ongoing responsibility for titration of ventilation was more commonly that of the ED nurse. CONCLUSION: The application of mechanical ventilation was similar to descriptions reported in the critical care literature both in Australia and internationally. Decision-making responsibilities were shared by ED medical and nursing staff.

Factors influencing consistency of triage using the Australasian Triage Scale: implications for guideline development.

OBJECTIVE: To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale. METHODS: A secondary analysis of survey data was conducted. The main study was undertaken to measure the reliability of 237 scenarios for inclusion in a national training programme. Nurses were recruited from a quota sample of Australian ED according to peer group. Analysis was performed to determine concordance: the percentage of responses in the modal triage category. Analysis of variance (anova) and Pearson correlations were used to investigate associations between the explanatory variables and concordance. RESULTS: A total of 42/50 (84%) participants returned questionnaires, providing 9946 scenario responses for analysis. Significant differences in concordance were observed by variables describing the type of patient presentation and level of urgency. Mean scores for the comparison group (adult pain; 70.7%) were higher than the groups involving a mental health or pregnancy presentations (61.4%; P