Advanced Nursing Practice and Advanced Practice Nursing roles within low and lower-middle-income countries.

INTRODUCTION: Population health initiatives rely on the availability and skills of an appropriate workforce to meet required goals. One global workforce initiative with demonstrated ability to expand health care services and improve access to care is the development of Advanced Nursing Practice and Advanced Practice Nursing roles. Given the sparse published information about these roles in Low and Lower-Middle-Income countries, this study seeks to describe their development and application in these countries. DESIGN: The researchers developed a descriptive cross-sectional multilingual survey for online distribution to nursing experts within the targeted countries. Survey questions addressed demographic information on the population served, Advanced Nursing Practice and Advanced Practice Nursing titles, the time frame and rationale for creating the title, and how the roles relate to the International Council of Nurses' Advanced Practice Nursing guidelines characteristics of education, practice, and regulation. RESULTS: Of the 167 responses received, only 24 participants met the inclusion criteria. This represented five low-income countries and nineteen lower-middle-income countries from four World Bank regions. Seventy-one roles were identified. Roles emerged predominantly over the last 20 years, focusing on care for underserved populations, with an almost even spread across primary and acute care settings. There were differences in education, practice, and regulation amongst the roles. Roles that required a master's education or higher with practice-related characteristics had a broader scope of practice, which is consistent with international guidelines. CONCLUSION: This paper describes how Advanced Nursing Practice and Advanced Practice Nursing roles from Low and Lower Middle-Income Countries have been implemented to address gaps in service and highlights disparities in education, practice and regulation compared to international guidelines. Maintaining and increasing support from organizations and universities internationally may be required to assist in developing and expanding educational programs for advanced nursing roles in these countries. CLINICAL RELEVANCE: Understanding how these advanced nursing roles are operationalized in relation to education, practice, and regulation in Low and Lower-Middle-Income countries can provide baseline information that will inform workforce development policies to address healthcare needs in similar jurisdictions.

Cardiac rehabilitation in the acute care setting: Integrative review.

BACKGROUND: Phase one cardiac rehabilitation (CR) is an essential component of care for patients with coronary heart disease. With optimal program delivery, health outcomes can be improved. OBJECTIVES: To conduct an integrative review that explores Phase one CR for patients hospitalised with coronary heart disease. DESIGN: Integrative literature review (2003-2014) Data sources: The literature search included Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Experta Medica Database (EMBASE), Psycinfo, Clinical Practice Guidelines Portal, Cochrane Library, Clinical Evidence (BMJ) and Google Scholar. REVIEW METHODS: The Joanna Briggs Institute critical appraisal tools relevant to study methodology were utilised. Studies included for review were peer reviewed, published in English. Studies included Phase one CR intervention/s or the provision of education to patients diagnosed with coronary heart disease in the acute care setting prior to hospital discharge. RESULTS: In the past decade cardiac researchers have predominantly focused on patients and health professionals perceptions, CR interventions, and patient education. Factors that impede delivery of Phase one CR, such as time, workload etc. were also reported. CONCLUSIONS: The implementation of Phase one CR delivery requires optimisation to enable patients with coronary heart disease to achieve positive health outcomes post hospitalisation. Future interventions should address the factors that impede delivery of Phase one CR.

The complexities of defining nurse practitioner scope of practice in the Australian context.

AIMS: To explore the legislative and regulatory constraints that defines nurse practitioner scope of practice within the Australian context. BACKGROUND: Nurse practitioners have been endorsed to practice in Australia for over 13 years. However, despite this lengthy period, there still remains confusion amongst newly endorsed nurse practitioners and their employers as to what determines the scope of their practice in Australia. DESIGN: A review of available policy and regulatory documents related to the Australian operational requirements for nurse practitioner scope of practice cited within or referred to by the Nursing and Midwifery Board of Australia. DATA SOURCES: Data were collected over a 2-month period in 2013. This utilized the current standards, codes and guidelines cited by the Nursing and Midwifery Board of Australia related to scope of practice and nurse practitioner, as well as legislation and regulation referred to in relation to nurse practitioner practice. Information was also obtained through government health and professional organization websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant. Implications for nursing: Providing a means of interpreting the determinants of nurse practitioner scope of practice within Australia. CONCLUSIONS: The factors that determine nurse practitioner scope of practice, education, clinical experience, and competence leading to endorsement, are straightforward. However, the context of clinical practice, including jurisdictional restrictions, is major barriers to the expression of nurse practitioner scope of practice. These restrictions, although not insurmountable, continue to hinder nurse practitioners from practicing to their full scope of practice.

Addressing Issues Impacting Advanced Nursing Practice Worldwide.

Advanced practice nursing roles are developing globally, and opportunities for advanced practice nursing are expanding worldwide due to the need for expert nursing care at an advanced level of practice. Yet it is well recognized that barriers exist with respect to APRNs being able to practice to the full extent of their education and training. Addressing barriers to APRN practice worldwide and ensuring that APRNs are able to practice to the full extent of their education and training can help to promote optimal role fulfillment as well as assessment of the impact of the APRN role.

Medical futility in the care of non-competent terminally ill patient: nursing perspectives and responsibilities.

BACKGROUND: Debate continues on the use of medical technology to prolong life independent of the quality of the outcomes. As a consequence, acute care nurses often find themselves in situations where they are asked to carry out physician's orders, in the context of a patient's deteriorating condition, which may be at odds with professional and personal ethical standards. This can cause nurses to become distressed when struggling with the ethical dilemmas involved with medical futility. PURPOSE: This paper is a perspective on nursing considerations of our Code of Ethics and the concept of medical futility in acute nursing care. The utility of the Code is examined through a clinical vignette. METHOD: A database search using the keywords medical futility and acute care limited to 2008 to 2012 and a secondary hand search of these references identified thirty journal publications. The Code of Ethics was examined via a clinical scenario pertinent to an acute environment. FINDINGS: This paper examines the ethical principles that underpin nursing and illustrates how the code of ethics may serve as sign posts when faced with caring for a terminally ill patient that is inappropriately managed. CONCLUSION: Understanding how individual nurses may address ethical dilemmas when faced with medical futility can better enable the nurse to fulfil their role as patient advocate, health promoter and alleviator of suffering. Ongoing education and communication to decrease any ambiguity or anguish associated with a patient's impending death optimises apt outcomes.

Timely treatment for acute myocardial infarction and health outcomes: an integrative review of the literature.

BACKGROUND: Coronary heart disease is the most common condition affecting Australians. The time sensitive nature of treating ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive research for several years. Despite important advances in strategies to reduce time to treatment, time continues to represent a major determinant of mortality and morbidity. Door to balloon time (DTBT) is a key indicator of quality of care for STEMI. Nurses play a pivotal role in streamlining the care processes to influence timely management of STEMI. PURPOSE: The aim of this paper is to review the evidence on the time to treat STEMI, the associated factors impacting upon health outcomes and explore systems of care that reduce time to treatment, using an integrative review approach. METHOD: Established databases were searched from 2000 to 2012. The search terms 'myocardial infarction', 'emergency medicine', 'angioplasty balloon', 'time factors', 'treatment outcome', 'mortality', 'prognosis', 'female', 'age factors', and 'readmission', were used in various combinations. Research studies that addressed the aims of this paper were examined. FINDINGS: Twenty-nine papers were included in this integrative review. The literature demonstrates a strong relationship between shorter DTBT and reduced in-hospital mortality. Factors such as age, gender, time of presentation and co-morbid condition were associated with increased in-hospital mortality. There is sparse literature examining the effect timely reperfusion has on longer-term mortality and other longer-term outcomes such as readmission rates and occurrence of heart failure. Additionally, strategies that effectively reduced DTBT were identified, yet little has been reported on the impact reduced DTBT has had upon health outcomes and whether these improvements were sustained. CONCLUSION: Whilst the importance of timely reperfusion is now well recognised, additional efforts to streamline the process of care and demonstrate sustained improvement for STEMI patients is required. Nurses in the areas of emergency medicine and cardiac care, play an essential role in facilitating this.

An evaluation of a structured learning programme as a component of the clinical practicum in final year bachelor of nursing programme: a pre-post-test analysis.

AIM AND OBJECTIVE: To evaluate the impact of a structured learning programme as a component of the clinical practicum in final year bachelor of nursing course on the student's report of their anxiety and self-efficacy pre-post programme participation. BACKGROUND: Student anxiety and low levels of self-efficacy are known to affect the quality of clinical learning. A three-day structured learning programme at the commencement of an acute care clinical placement was designed to reduce student anxiety and enhance self-efficacy. DESIGN: A pre-post test design. OUTCOME MEASURES: The hospital anxiety and depression scale (The HAD) and the general self-efficacy scale (GSES-12) were administered prior to the commencement of the structured learning programme (time one) and at the end of the programme (time two). RESULTS: One hundred and twenty final year students undertaking an acute care clinical placement participated in the programme in three cohorts and completed the questionnaires at time one and 118 at time two. FINDINGS: Students levels of anxiety >8 with The HAD pre-post programme 53 vs. 30% (p < 0·001). Levels of self-efficacy <40 with the GSES-12 pre-post programme were 7 vs. 4% (p < 0·001). CONCLUSIONS: Participation in the structured learning programme resulted in a statistically significant reduction in student anxiety and increase in self-efficacy across the three cohort groups. This effect can be achieved with the development of a relatively low cost/low technology structured learning programme that is part of an acute care clinical placement. RELEVANCE TO CLINICAL PRACTICE: Nurse educators should not assume that students are less anxious about their acute care clinical placements as the semester proceeds. There is a typical correlation between increased anxiety and decreased self-efficacy which is likely to impact on student learning in the clinical setting. Significant results can be achieved with a relatively low cost and a low technology enabling intervention.

Evaluation criteria for implementation of a sustainable sanitation and wastewater treatment system at Jiuzhaigou National Park, Sichuan Province, China.

The administration of Jiuzhaigou National Park in Sichuan Province, China, is in the process of considering a range of upgrades to their sanitation and wastewater treatment systems. Their case history involves an ongoing series of engineering design flaws and management failures. The administration of the Park identified sustainability, environmental protection, and education goals for their sanitation and wastewater treatment system. To meet the goal of sustainability, environmental and economic concerns of the Park's administration had to be balanced with socio-cultural needs. An advanced reconnaissance method was developed that identified reasons for previous failures, conducted stakeholder analysis and interviews, determined evaluation criteria, and introduced innovative alternatives with records of successful global implementations. This evaluation also helped the Park to better define their goals. To prevent future failures, the administration of the Park must commit to a balanced and thorough evaluation process for selection of a final alternative and institute effective long-term management and monitoring of systems. In addition, to meet goals and achieve energy efficient, cost-effective use of resources, the Park must shift their thinking from one of waste disposal to resource recovery. The method and criteria developed for this case study provides a framework to aid in the successful implementation of sanitation projects in both underdeveloped and developed areas of the world, incorporating socio-cultural values and resource recovery for a complex group of stakeholders.

Developing the clinical mentor role through e-learning.

La Trobe University/Austin Health Clinical School of Nursing's final-year undergraduate students undertake an integrated clinical-theoretical experience during which the clinical practicum is facilitated by registered nurses in a mentor model of education. The success of this model is contingent on the educational preparation of the registered nurse for the role of mentor. This article describes the development of a more flexible Web-based preparation program for registered nurses to assist them to fully adopt the role of mentor.

A snapshot of clinical educational experiences for advanced practice nurses worldwide.

Using a convenience sampling, nurse educators representing 10 countries were surveyed to describe required clinical education for advanced practice beyond basic traditional nursing education. This article explores the many factors currently influencing the structure and diversity of these clinical experiences worldwide.

Carpal tunnel syndrome.

Carpal tunnel syndrome is a very common peripheral neuropathy; however, its symptoms are such that they are often overlooked by patients or misdiagnosed by their primary care physicians or nurse practitioners, leading to progression of the condition so severe that sometimes even surgical options will be of little benefit. This article reviews current literature on carpal tunnel syndrome and its signs and symptoms, diagnosis and differential diagnosis, and treatment options.

Acute (adult clinical inpatient) care nurses' attitudes towards and knowledge of nationally endorsed 5As smoking cessation guidelines.

Nurses are expected to be involved in health promotion, including smoking cessation. This study aimed to assess nurses' knowledge, sense of responsibility and willingness to provide smoking cessation interventions as described in the national 5As guideline. Data were collected by a survey distributed to a convenience sample of nursing staff (n=162) from thirteen different adult acute care wards at a major metropolitan Melbourne hospital. Nearly all respondents (87%) agreed that they had a responsibility to counsel patients, and 22% were already doing so, but only 22% (n=36) of respondents demonstrated an adequate level of knowledge of smoking cessation. Nurses were more likely to counsel patients on health conditions related to their area of practice than those that were not. The findings indicate that greater emphasis is needed in undergraduate courses and in-service programs to increase nurses' awareness, and implementation of the 5As guideline for smoking cessation.

An evaluation of a structured learning program as a component of the clinical practicum in undergraduate nurse education: A repeated measures analysis.

BACKGROUND: There is evidence that nursing students experience stress and anxiety and a reduction in self-efficacy when undertaking clinical placements. Previous reports have identified that a structured three-day program within the Bachelor of Nursing (BN) clinical practicum reduces the students self-report of anxiety and increases self-efficacy. However, it is unreported whether these improved outcomes are sustained for the duration of the clinical placement. OBJECTIVE: The aim of this study was to evaluate the duration of the effect of a three-day structured learning program within the clinical placement on final year Bachelor of Nursing student's report of anxiety and self-efficacy pre- and post-program participation in this intervention and following completion of the clinical practicum. DESIGN: A repeated measures design. SETTING: University-based Clinical School of Nursing, acute care clinical practicum. PARTICIPANTS: Final year Bachelor of Nursing students. METHODS: The intervention comprised the three-day program on starting the clinical practicum. A questionnaire included the anxiety subscale of The Hospital Anxiety & Depression Scale (The HAD) and the General Self-Efficacy Scale (GSES-12). The questionnaire was completed on day one (time one), upon completion of the three-day program (time two) and upon completion of placement on day 18 (time three). RESULTS: The questionnaire response rate varied over time. There was a statistically significant effect in reducing anxiety over time: F(1.73,74.46)=25.20, p<0.001 and increasing self-efficacy over time F(1.32,41.04)=7.72, p<0.004. CONCLUSIONS: This is the first report that we are aware of that has measured final year Bachelor of Nursing student's report of both anxiety and self-efficacy over repeated measures of time. Students continue to benefit from a structured learning program and the benefit of the intervention is sustained for the clinical placement duration.

The impact on long term health outcomes for STEMI patients during a period of process change to reduce door to balloon time.

BACKGROUND: Guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend a 'door to balloon time' (DTBT) within 90 minutes. It is unclear whether strategies to reduce DTBT translate to improved longer-term health outcomes for STEMI patients. AIMS: This study sought to determine whether implemented strategies to improve timely management of STEMI reduced DTBT and impacted upon health outcomes such as length of stay, unplanned readmission and 12-month mortality. Predictors of timely management for STEMI were also examined. METHODS: A five-year review was undertaken on primary percutaneous coronary intervention for STEMI in one tertiary hospital. Comparisons were made between process change groups and DTBT. Logistic regression identified predictors of timely management. RESULTS: 470 STEMI patients underwent immediate primary percutaneous coronary intervention. Process change improved the median DTBT (109 min vs. 72 min, p<0.001) with no significant effect on length of stay (p=0.83), unplanned cardiac readmissions (p=0.68) or 12-month mortality (9.0% vs. 8.6%, p=0.64). Those receiving timely treatment (i.e. DTBT< 90 min) were younger (p<0.05), male (p<0.03), presented via ambulance (p<0.004), during business hours (p<0.0001) and had a lower Thrombolysis In Myocardial Infarction score (p<0.006). Timely treatment was associated with lower 12-month mortality (3.7% vs. 15.7%, p<0.0001) and increased uptake of inpatient cardiac rehabilitation (p<0.005), with length of stay and unplanned readmission similar between groups (p=NS). CONCLUSIONS: Process changes improved DTBT but had no effect on length of stay, readmission rate or 12-month mortality. Yet, timely management was critical to 12-month outcomes. Further studies are required to explore the barriers to timely treatment.

Aneurysmal subarachnoid haemorrhage--Part 2: Post-operative nursing management diagnosis, complications and treatment: a composite case study.

Patients who have been diagnosed with an Aneurysmal Subarachnoid Haemorrhage (ASAH) frequently require surgical intervention to prevent further complications. Due to the complex nature of ASAH it is imperative to be meticulous in monitoring the patient's neurological condition. This is even more relevant post operatively as complications such as cerebral vasospasm peak incidence is between days four to fourteen and as well as complications of surgical and medical intervention may become evident.

Aneurysmal subarachnoid haemorrhage--part 1: Pre-operative nursing management diagnosis, complications and treatment: a composite case study.

Patients who survive an Aneurysmal Subarachnoid Haemorrhage or ASAH describe it as being the worst headache ever, multiplied one hundred-times over. It is a debilitating and life threatening condition, which affects approximately 6.5 people per 100,000 throughout Australia and New Zealand every year (The ACROSS group, 2000). When caring for a patient post Aneurysmal Subarachnoid Haemorrhage or ASAH meticulous monitoring of the patient's neurological, cardiovascular, hepatic, endocrine, renal, and respiratory functions are vital. Due to both the initial ASAH and its complications such as rebleed, cerebral vasospasm, hydrocephalus, cerebral oedema, seizures as well as adverse reactions to counteract these potential problems. All of, which can cause significant long-term morbidity as well as potential mortality if left, undiagnosed and untreated. The following article presets a composite patient highlighting clinical manifestations of ASAH, its associated complications as well as various methods of detecting, preventing and treating them.

Advanced nursing practice hours as part of endorsement requirements for nurse practitioners in Australia: a definitional conundrum.

PURPOSE: To define what can be considered to be nursing practice, time that can be calculated as the practice of nursing as well as what is considered to be advanced nursing practice and how all this can be related to the current endorsement process for nurse practitioner (NP) in Australia. DATA SOURCES: Current codes and guidelines cited by the Nurse and Midwifery Board of Australia related to nursing practice and NPs, cited competency standards from the Australian Midwifery Accreditation Council, as well as published material of peak nursing bodies from within Australia as well as internationally were used. Information was also obtained through government health and professional organization websites. All information in the literature regarding current and past status and nomenclature of advanced practice nursing was considered relevant. CONCLUSIONS: The definitional entanglement of what is considered to be nursing practice, the calculation of specific hours and what is advanced nursing practice interferes with endorsement of NPs in Australia, and a clear understanding of what is meant by advanced practice is required to move forward. IMPLICATIONS FOR PRACTICE: Dependent on how practice is interpreted by the Nurse and Midwifery Board of Australia directly affects the outcome of the endorsement proceedings for individual NP candidates.

Febrile seizures, genetic (generalized) epilepsy with febrile seizures plus, and Dravet's syndrome.

PURPOSE: This article discusses febrile seizures, generalized epilepsy with febrile seizures plus, and Dravet's syndrome. CONCLUSIONS: It can be difficult for patients and their families to comprehend what it means to have a seizure disorder with a genetic cause. Nurses caring for patients with seizure disorders require knowledge of the condition, its causes, treatment, and prognosis to better care for and inform their patients. PRACTICE IMPLICATIONS: It is important for all specialists working with pediatric populations to understand possible causes of seizure disorders linked to febrile episodes, its diagnosis, and treatment, and their responsibility to provide pertinent education to patients and their families.

The use of the term vulnerability in acute care: why does it differ and what does it mean?

OBJECTIVE: Throughout health care literature, vulnerability is widely accepted as a potential issue for all patients yet the consensus on the meaning of and practical strategies to reduce or manage these 'harmful agents' in the clinical context are rarely offered. Three main themes emerge from the related literature which can be further refined into general terms of; social vulnerability--a person's basic statistical data in relation to their potential for illness; psychological vulnerability--the actual or potential harm to the identity of self and/or other emotional effects such as anxiety or stress caused by the ailment or treatment; and physical vulnerability--which refers to the actual physiological state where an individual is susceptible to further morbidity or mortality. SETTING: Acute care facilities. PRIMARY ARGUMENT: Although there is acknowledgment within the literature that individuals will experience some form of vulnerability when hospitalised, the complexity of what defines vulnerability for individuals causes further problems for patients and health professionals alike. CONCLUSIONS: This paper attempts to define vulnerability within the context of Western health care systems and raises the following issues: all states of vulnerability are accurate and appropriate in the context of the study or incidence alluded to, but further discussion and research is required to achieve a consensus to when, how, why and who is vulnerable. It is this recognition of the potentially differing classifications of vulnerability and the particular contexts that can be used that may assist nurses and other health care professionals with, not only problems associated with a patient's hospitalisation, but in the implementation of appropriate strategies to individual patient's cases.