How registered nurses balance limited resources in order to maintain competence: a grounded theory study.

BACKGROUND: Nurses have limited time outside of work for continuing professional development. Consequently, strategies need to be explored to enable them to better maintain their competence. This article describes recent research investigating if nursing behaviours in the use of mobile technologies could be leveraged to better facilitate mobile learning. It addresses a gap in the existing literature around how nurses resource their own professional development and learning in the absence of appropriate learning resources in the workplace. METHODS: The research employed a classic grounded theory methodology which was conducted with 27 registered nurses from Public and Private Hospitals in Queensland and external postgraduate nursing students from Victoria, South Australia and the Northern Territory enrolled at the University of Southern Queensland. RESULTS: The Theory of Economising Learning describes how nurses maintain competence with limited resources. Unfavourable staffing levels and a fast-paced workplace mean that nurses rarely prioritise their professional learning while at work. Instead, it requires the nurse to contribute personal resources including time and money. Though the research revealed nurses were unconcerned about using mobile technologies, they were concerned about maintaining competence with limited resources. To counter this, nurses economised their learning by balancing personal resources against their motivation to maintain competence. The process of economising learning begins and ends with the development of the nurse's personal curriculum in response to what they identify as being the most significant knowledge deficits at work that jeopardise their competence. A learning opportunity that addresses the knowledge deficit is sought. Nurses balance the opportunity to address the deficit against the cost of personal resources, to decide if they will engage with the opportunity and update their personal curriculum accordingly. CONCLUSIONS: It is suggested that workplaces need to create reasonable expectations within nurses to address knowledge deficits and provide the resources, including time, to allow them to do so without personal cost. It is also necessary for workplaces to moderate the flow of learning opportunities so as not to overwhelm and demotivate the nurses. Currently, nurses use several strategies to optimise their learning using mobile technologies which could be leveraged in the workplace.

Higher degrees in nursing: traditional research PhD or professional doctorate?

Doctoral-level study is increasingly popular for clinicians who wish to advance their clinical, research and academic career pathways. A range of alternatives to the traditional PhD are now well-established. This article aims to outline the different approaches and discuss some advantages and drawbacks of doctoral-level postgraduate study. By comparing the various doctoral programmes, the authors seek to clarify the issues for clinicians who may wish to embark on a future doctorate. Primary clinical or medical degrees are not discussed.

Barriers to implementing the Sepsis Six guidelines in an acute hospital setting.

AIM: To identify the barriers to implementation of the Sepsis Six pathway. BACKGROUND: Research has suggested that compliance with the Sepsis Six pathway remains low. METHODS: A convenience sample of doctors and nurses from one emergency department, two medical wards and two surgical wards were asked to complete a survey questionnaire. RESULTS: Data from 108 respondents were available for analysis. Doctors and nurses agreed that lack of sepsis recognition during observation rounds and failure to associate sepsis with deranged temperature and blood results acted as barriers to the identification of sepsis. Doctors and nurses agreed that nursing delays and knowledge deficits were the top barriers leading to delay in sepsis treatment. CONCLUSION: Knowledge deficits, lack of resources and practical issues were barriers identified in this survey. This will inform the educational and process needs of both doctors and nurses in order to improve sepsis care.

The perceptions of homeless people regarding their healthcare needs and experiences of receiving health care.

AIMS: To understand the perspective of the homeless about their healthcare encounters and how their experiences of receiving healthcare influence their health-seeking behaviour. BACKGROUND: A phenomenological study was undertaken because of the increasing levels of homelessness in the United Kingdom. Most of the current literature is American or Canadian. DESIGN: An interpretive phenomenological inquiry. METHOD: An opportunistic sample of fourteen single homeless adults was recruited from one male hostel and one non-residential day centre. Data collection was done in 2013. Semi-structured audio-recorded interviews were conducted one-to-one. Colaizzi's method for data analysis was used. FINDINGS: Three major themes were identified. Expressed Health Need, Healthcare Experiences and Attitudes to health care. Health problems are recognized by the homeless but the need for intervention is not always prioritised. Obstacles in access to health care in the UK are both perceived (attitudes towards the homeless; previous bad experience) and actual (difficulty in registering with a general practitioner, difficulty travelling to services, being forced to move to new area). Some homeless people feel that they are treated with prejudice and receive substandard care. Positive healthcare experiences were also reported. CONCLUSIONS: Positive and negative healthcare encounters can profoundly affect the homeless. RECOMMENDATIONS: Address apparent inconsistency of care; promote greater interdisciplinary communication and referrals to homeless services from prisons and hospitals; increase the availability of intermediate services; reduce obligation of homeless to move area; research experiences of homeless families.

How common medicines can affect bone health.

Many people have weak bones and this is a global public health concern. Lifestyle factors can reduce bone density, as can some common drugs. This article describes some of these drugs, the conditions for which they may be prescribed and how they can threaten bone health. Strategies to reduce the risk of fracture and weak bones are outlined.

Cognitive mental workload of emergency nursing: A scoping review.

AIM: Emergency nurses work in an environment of high cognitive mental workload. Excessive cognitive mental workload may result in patient harm and nurses' burnout. Therefore, it is necessary to understand nurses' subjective experience of cognitive workload. This scoping review aimed to curate literature about the subjective experience of cognitive mental workload reported by nurses and psychometric measures of the phenomenon. DESIGN: The scoping review was conducted in accordance with JBI methodology and reported using PRISMA extension for scoping review checklist. METHODS: A priori protocol was created with Peer Review of Electronic Search Strategies checklist and registered in the OSF registry. Databases including PubMed, CINAHL, ProQuest, Scopus, Science Direct, Web of Science and Google Scholar were searched. Published reports were reviewed against the eligibility criteria by performing Title and Abstract screening, followed by Full-text screening. The initial search yielded 1373 studies. Of these, 57 studies met the criteria for inclusion in this study. RESULTS: The search revealed five general measures of cognitive mental workload and their variations. Only one customised measure specifically for medical-surgical nurses was found in the study. Identified measures were collated and categorised into a framework for conceptual clarity. NASA Task Load Index and its variations were the most popular subjective measure of cognitive mental workload in nursing. However, no measure or self-report scale customised for emergency nurses was identified. PATIENT OR PUBLIC CONTRIBUTION: The findings of this scoping review can inform future research into the cognitive mental workload of nurses. The findings have implications for workplace health and safety for nurses and patients.

A randomized controlled trial to compare two techniques for partial digital local anesthetic blocks.

The administration of local anesthetic before surgery to the great toe is often associated with significant difficulties, delaying surgery and increasing risk. Anxious patients can faint, refuse injection, or withdraw the foot while an anesthetic is being delivered. Such events led us to consider whether delivering a small amount of anesthetic throughout the injection site, before the main injection, may reduce pain intensity and duration. This study was designed to test this possibility. A randomized controlled, single-blinded, parallel-grouped clinical trial was carried out with a sample of 50 patients. All study participants received each injection method (1 or 2 stage) to either the medial or lateral side of the great toe. The primary end points were pain intensity, measured by scores on a visual analogue scale and duration, recorded by the patient with a stopwatch. The 2-stage method was associated with less intense pain (reduced from moderate to mild visual analogue scale level) of a shorter duration. The differences were highly statistically significant. In the 2-stage method, it is believed that they were due to the initial infiltration of a small quantity of the anesthetic solution throughout the injection site, with the remainder being administered, after a 2-minute interval, into tissue that was predominantly anesthetized. This differs from raising a traditional bleb where a small amount of anesthetic is infiltrated into superficial tissue. The 2-stage technique is therefore recommended as the method of choice for adults.

Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study.

BACKGROUND: The nature of the sesamoid complex in the development of hallux rigidus or limitus (HL) has been poorly characterized and the role of the sesamoids in the surgical management of this condition has not been explored. Previous surgical approaches in younger active patients unsuited to destructive procedures have been limited. MATERIALS AND METHODS: Thirty-three patients (36 procedures) were reviewed between 2 and 4 years following total sesamoidectomy for the management of hallux rigidus/limitus. The American Orthopedic Foot & Ankle Society hallux (AOFAS) clinical rating system was used to compare pre and postoperative scores. The range and quality of motion and transfer metatarsalgia were noted. The three most important patient problems and the degree to which these had been addressed by the surgery and the time to maximal improvement were noted. RESULTS: No significant functional impairment or malalignment were found. There were no instances of pain on metatarsal compression, or of transfer metatarsalgia with or without callus formation. A highly statistically significant improvement in AOFAS scores was found (p < 0.001). CONCLUSION: High levels of clinical improvement and patient satisfaction were found following total sesamoidectomy. No deleterious consequences of sesamoid removal were observed. For symptomatic patients where a joint replacement/fusion is not indicated, total sesamoidectomy was beneficial as an interim procedure, for joints with a moderate (grades 2 to 3) degree of arthrosis.

Local Antibiotic Delivery Systems: Current and Future Applications for Diabetic Foot Infections.

Foot infections are common among diabetic patients with peripheral neuropathy and/or peripheral arterial disease, and it can be the pivotal event leading to a minor or major amputation of the lower extremity. Treatment of diabetic foot infections, especially deep-seated ones, remains challenging, in part because impaired blood perfusion and the presence of biofilms can impair the effectiveness of systemic antibiotics. The local application of antibiotics is an emerging field in the treatment of diabetic foot infections, with demonstrable advantages. These include delivery of high concentrations of antibiotics in the affected area, limited systemic absorption, and thus negligible side effects. Biodegradable vehicles, such as calcium sulfate beads, are the prototypical system, providing a good elution profile and the ability to be impregnated with a variety of antibiotics. These have largely superseded the nonbiodegradable vehicles, but the strongest evidence available is for calcium bead implantation for osteomyelitis management. Natural polymers, such as collagen sponge, are an emerging class of delivery systems, although thus far, data on diabetic foot infections are limited. There is recent interest in the novel antimicrobial peptide pexiganan in the form of cream, which is active against most of the microorganisms isolated in diabetic foot infections. These are promising developments, but randomized trials are required to ascertain the efficacy of these systems and to define the indications for their use. Currently, the role of topical antibiotic agents in treating diabetic foot infections is limited and outside of routine practice.

Australian consumers' expectations for expanded nursing roles in general practice--choice not gatekeeping.

While research has focussed on the current and potential role of the practice nurse (PN) in Australia, the acceptability of this role by consumers has not been investigated. In 2002, two independent studies were carried out into consumer perceptions of PNs. A disscussion between the two groups of researchers at the inaugural National Pratice Nurse Conference in 2003, identifiied significant similarities in the findings of the tese studies. This article reports the combined findings as they relate to consumer's desire for access to the health practitioner of their choice, and their concern that PNs may assume a Gatekeeping role. These perceptions may have significant impact on the acceptance of PNs across Australia.

Does patient satisfaction with foot surgery change over time?

BACKGROUND: The national podiatric surgery audit tool PASCOM has a key role in determining patient satisfaction with service received and outcomes. The study aim was to examine the effects of time after surgery on satisfaction scores, by undertaking a retrospective longitudinal study utilising the patient satisfaction questionnaire known as the PSQ-10. A secondary objective was to examine test-retest reliability, since this has not been previously reported. METHOD: NHS and private patients having undergone forefoot surgery were sent a further PSQ-10 satisfaction questionnaire after the standard 6-month PSQ-10 had been completed. The main outcome measure reflected a change in the score between the original and repeat PSQ-10 response. Internal consistency was measured by correlation between baseline questions for a subset of patients who were sent the second questionnaire within 6 months of the first. RESULTS: Of a total cohort of 204 patients, no significant differences were seen in overall scores. 46% showed increased satisfaction at the stage of the repeat questionnaire, with 41% a decline in score and 13% no change. Neurectomy patients improved the most with time and digital surgery was associated with the greatest decline in score. Significant correlations were demonstrated between all baseline questions for the test-retest cohort (13 patients). CONCLUSION: Time does not significantly influence patient satisfaction after discharge. There was satisfactory consistency between PSQ-10 responses. Further investigation into digital procedure outcomes is required.

Tricortical calcaneal bone graft and management of the donor site.

The clinical outcomes of 19 patients requiring autogenous grafts for foot surgery were followed up until healing at the donor site occurred. In all cases, tricortical bone was extracted from the calcaneus for use at another pedal site. The first cohort of 9 patients had the calcaneal deficit replaced with allogenic cubes. The second cohort received no tissue replacement. Patients were reviewed postoperatively with a questionnaire and clinical examination to evaluate the outcome of the operations. Radiographic outcomes were observed at the donor and recipient sites in both groups until healing was confirmed as bridging trabeculation. Incorporation of the graft at the donor site was also reviewed. Clinical outcomes, namely pain, local sensory function, and return to footwear, were satisfactory in all patients and were not significantly different between groups. One patient from each group sustained a heel fracture. The donated autogenous grafts at the recipient sites were all incorporated uneventfully at 6 months. In the first cohort, allogenic graft incorporation in the calcaneus was complete in only 2 patients at the 12-month stage. The remaining 7 cases showed reduction of the deficit by new bone formation arising from the calcaneus. Donor sites with allogenic bone replacement healed at a median of 18 months (interquartile range, 18-18 months). In the group without replacement, healing occurred at a median of 6 months (interquartile range, 6-12 months), a highly statistically significant difference (P < .001). In the second cohort without allogenic graft replacement, radiographic filling at the donor site was complete within a 12-month period. Tricortical bone can be successfully harvested from the calcaneus, but there may an associated risk of heel fracture. The role of replacement allogenic bone in assisting healing at the donor site is unclear.

Hemiphalangectomy and syndactylization for treatment of osteoarthritis and dislocation of the second metatarsal phalangeal joint: an outcome study.

End-stage osteoarthritis or severe dislocation at the second metatarsophalangeal joint typically presents with chronic pain and is often unrelieved by conservative treatment. The aim of this article is to review the preliminary outcomes of surgery involving resection of the base of the second proximal phalanx with syndactylization to the third toe for stability. Thirteen patients (13 feet) with second metatarsophalangeal osteoarthritis and 15 patients (15 feet) with a dislocated second toe underwent the procedure and were reviewed after a mean 12.4 months (range, 5-25 months). Patients were evaluated preoperatively and postoperatively with the American Orthopedic Foot and Ankle Society's scoring system and clinical review. A patient questionnaire was devised to yield information regarding toe alignment, cosmesis, and reflection on the procedure. Pain and activities were significantly improved in both subgroups (P < .01). Eighty-two percent were very satisfied or satisfied with the reduction in symptoms, with 11% satisfied with reservations and 7% not satisfied. Seventy-nine percent were very satisfied or satisfied with the appearance. Thirty-nine percent stated the outcome was better than expected, 14% as expected, and 14% felt the result was worse than expected. Twenty-three patients (82%) had no postoperative cosmetic concerns, and 7 patients (25%) felt there was a moderate or severe difference in the alignment with respect to the other toes. In conclusion, syndactylization can significantly improve pain and activity levels and was found to be cosmetically acceptable.