Physiological plateaus during normal labor and birth: A novel definition.

BACKGROUND: Diagnoses of labor dystocia, and subsequent labor augmentation, make one of the biggest contributions to childbirth medicalization, which remains a key challenge in contemporary maternity care. However, labor dystocia is poorly defined, and the antithetical concept of physiological plateaus remains insufficiently explored. AIM: To generate a definition of physiological plateaus as a basis for further research. METHODS: This qualitative study applied grounded theory methods and comprised interviews with 20 midwives across Australia, conducted between September 2020 and February 2022. Data were coded in a three-phase approach, starting with inductive line-by-line coding, which generated themes and subthemes, and finally, through axial coding. RESULTS: Physiological plateaus represent a temporary slowing of one or multiple labor processes and appear to be common during childbirth. They are reported throughout the entire continuum of labor, typically lasting between a few minutes to several hours. Their etiology/function appears to be a self-regulatory mechanism of the mother-infant dyad. Physiological plateaus typically self-resolve and are followed by a self-resumption of labor. Women with physiological plateaus during labor appear to experience positive birth outcomes. DISCUSSION: Despite appearing to be common, physiological plateaus are insufficiently recognized in contemporary childbirth discourse. Consequently, there seems to be a significant risk of misinterpretation of physiological plateaus as labor dystocia. While findings are limited by the qualitative design and require validation through further quantitative research, the proposed novel definition provides an important starting point for further investigation. CONCLUSION: A better understanding of physiological plateaus holds the potential for a de-medicalization of childbirth through preventing unjustified labor augmentation.

Factors impacting nursing assistants to accept a delegation in the acute care settings: A mixed method study.

AIMS: To investigate the experience of nursing assistants being delegated nursing tasks by registered nurses. DESIGN: Mixed method explanatory sequential design. METHODS: A total of 79 nursing assistants working in an acute hospital in Australia completed surveys that aimed to identify their experience of working with nurses and the activities they were delegated. The survey data were analysed using descriptive statistics. Interviews with 11 nursing assistants were conducted and analysed using Braun and Clarke's thematic analysis. Results were triangulated to provide a richer understanding of the phenomena. RESULTS: Most nursing assistants felt supported completing delegated care activities. However, there was confusion around their scope of practice, some felt overworked and believed that they did not have the right to refuse a delegation. Factors impacting the nursing assistant's decision to accept a delegation included the attitude of the nurses, wanting to be part of the team and the culture of the ward. Nursing assistants who were studying to be nurses felt more supported than those who were not. CONCLUSIONS: Delegation is a two-way relationship and both parties need to be cognisant of their roles and responsibilities to ensure safe and effective nursing care is provided. Incorrectly accepting or refusing delegated activities may impact patient safety. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Highlights the need for implementing strategies to support safe delegation practices between the registered and unregulated workforce to promote patient safety. IMPACT: Describes the experiences of nursing assistants working in the acute care environment when accepting delegated care from nurses. Reports a range of factors that inhibit or facilitate effective delegation practices between nurses and nursing assistants. Provides evidence to support the need for stronger education and policy development regarding delegation practices between nurses and unregulated staff. REPORTING METHOD: Complied with the APA Style JARS-MIXED reporting criteria for mixed method research. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Integrative review: Factors impacting effective delegation practices by registered nurses to assistants in nursing.

AIM: To identify the evidence on factors that impact delegation practices by Registered Nurses to Assistants in Nursing in acute care hospitals. DESIGN: An integrative review. DATA SOURCES: Database searches were conducted between July 2011 and July 2021. REVIEW METHODS: We used the 12-step approach by Kable and colleagues to document the search strategy. The (Whittemore & Knafl. 2005. Journal of Advanced Nursing, 52(5), 546-553) integrative review framework method was adopted and the methodological quality of the studies was assessed using Joanna Briggs critical appraisal instruments. RESULTS: Nine studies were included. Delegation between the Registered Nurse and the Assistant in Nursing is a complex but critical leadership skill which is impacted by the Registered Nurse's understanding of the Assistant in Nursing's role, scope of practice and job description. Newly qualified nurses lacked the necessary leadership skills to delegate. Further education on delegation is required in pre-registration studies and during nurses' careers to ensure Registered Nurses are equipped with the skills and knowledge to delegate effectively. CONCLUSION: With increasing numbers of Assistants in Nursing working in the acute care environment, it is essential that Registered Nurses are equipped with the appropriate leadership skills to ensure safe delegation practice.

Start Healthy and Stay Healthy: A workplace health promotion intervention for new graduate nurses: A mixed-methods study.

AIMS: This study explored the acceptability of a workplace health promotion intervention embedded into a transition to practice (TTP) programme to assist new graduate nurses in establishing healthy dietary and physical activity (PA) behaviours from career commencement. DESIGN: A sequential mixed methods design. METHODS: The Start Healthy and Stay Healthy (SH&SH) intervention, informed by the Behaviour Change Wheel, was conducted in an Australian Local Health District. It included face-to-face education sessions, the use of a fitness tracker and twice-weekly short answer messages. Participants completed three online surveys: at orientation, 6 weeks and 6 months. A sub-sample participated in semi-structured interviews to explore their experience of the intervention. Interview data were analysed thematically. RESULTS: The intervention was delivered from February to December 2019. A total of 99 nurses completed the baseline survey, 62 at 6 weeks and 69 at 6 months. After 6 months, health knowledge increased as participants correctly identified recommended amounts of fruits, vegetables and PA. Fruit consumption increased at 6 months with little change to vegetable intake. Takeaway consumption decreased, but consumption of some discretionary foods increased. Across the three time points, there was a low engagement in PA during leisure time. The interviews identified three themes: (1) Support of Colleagues and Peers, (2) The Work Environment and (3) Engagement with SH&SH. CONCLUSION: Providing a targeted intervention for new graduate nurses embedded into a TTP programme improved their health knowledge, some dietary behaviours, and participation in PA by some participants. IMPACT: Ensuring a healthy nursing workforce is critical to retaining staff. Implementing a workplace health promotion intervention that targets new graduate nurses can help them adopt and maintain healthy lifestyle behaviours to support them in their future careers.

Nurses' role in accomplishing interprofessional coordination: Lessons in 'almost managing' an emergency department team.

AIM: To describe how nurse coordinators accomplished day-to-day interprofessional coordination in an Australian emergency department team, drawing some lessons for the design of nurse coordinator roles in other settings. BACKGROUND: Previous studies have examined leadership within nursing teams, and there are a growing number of registered nurses employed as care coordinators. There is limited literature on how the day-to-day coordination of interprofessional teams is accomplished, and by whom. METHOD: Nineteen semi-structured interviews with emergency department registered nurses, doctors and nurse practitioners analysed thematically. RESULTS: Three themes describe how coordinators accomplished interprofessional coordination: task coordination and oversight, taking action to maintain patient flow and negotiating an ambiguous role. CONCLUSION: Better-defined nurse coordinator roles with clearer authority and associated training are essential for consistent practice. However, accomplishing interprofessional coordination will always require the situated knowledge of the complex nursing-medical division of labour in the workplace and the interpersonal relationships that are only gained through experience. IMPLICATIONS FOR NURSING MANAGEMENT: The design of nurse coordinator roles must include the thorny question of 'who leads' interprofessional teams in the day-to-day coordination of tasks. New and inexperienced nurses may not have the necessary situated knowledge or interpersonal relationships to succeed. However, such roles offer an important development opportunity for future nurse managers.

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings.

AIMS: To identify the costs associated with nurse sensitive adverse events and the impact of these events on patients' length of stay. DESIGN: Retrospective cohort study using administrative hospital data. METHODS: Data were sourced from patient discharge information (N = 5544) from six acute wards within three hospitals (July 2016-October 2017). A retrospective patient record review was undertaken by extracting data from the hospitals' administrative systems on inpatient discharges, length of stay and diagnoses; eleven adverse events sensitive to nurse staffing were identified within the administrative system. A negative binomial regression is employed to assess the impact of nurse sensitive adverse events on length of stay. RESULTS: Sixteen per cent of the sample (n = 897) had at least one nurse sensitive adverse event during their episode of care. The model revealed when age, gender, admission type and complexity are controlled for, each additional nurse sensitive adverse event experienced by a patient was associated with an increase in the length of stay beyond the national average by 0.48 days (p = .001). Applying this to the daily average cost of inpatient stay per patient (€1456), we estimate the average cost associated with each nurse sensitive adverse event to be €694. Extrapolating this nationally, the economic cost of nurse sensitive adverse events to the health service in Ireland is estimated to be €91.3 million annually. CONCLUSION: These potentially avoidable events are associated with a significant economic burden to health systems. The estimates provided here can be used to inform and prepare the way for future economic evaluations of nurse staffing initiatives that aim to improve care and safety. IMPACT: As many of these nurse sensitive adverse events are avoidable, in addition to patient benefits, there is a potential substantial financial return on investment from strategies such as improved nurse staffing that can reduce their occurrence.

Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper.

AIMS: To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic. BACKGROUND: In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses. DESIGN: Discursive paper. FINDINGS: Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures. CONCLUSION: COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive. RELEVANCE TO CLINICAL PRACTICE: Objective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

The relationship between patient obesity and nursing workload: An integrative review.

AIMS AND OBJECTIVES: To explore the relationship between patient obesity and nursing workload, and discuss the nursing activities most affected by patient obesity. BACKGROUND: The increasing number of patients with obesity, and the severity of obesity, impacts the healthcare workforce, particularly to nurses who provide most direct care to patients. There is growing evidence to suggest that patient obesity may increase nursing workload and time taken for clinical care. DESIGN: Integrative review. METHODS: A comprehensive search of academic databases for primary research related to patient obesity and nursing workload, published since 2000, was conducted. References of relevant articles were hand-searched. RESULTS: 27 articles were analysed. Analysis was undertaken at the levels of patient characteristics, nursing work and the healthcare system. The increasing number of patients with obesity, and the severity of patient obesity, increases nursing workload by affecting nursing time needed to deliver care. An increased number of nurses, particularly with increased clinical skill, are needed to deliver care meeting these increased needs. Organisational change is required to provide infrastructure and bariatric equipment that enables effective nursing care of patients with obesity. Organisations must consider additional time and staff needs when delivering care for patients with obesity. CONCLUSIONS: The current health system is not established to address the challenge of providing nursing care to the increasing numbers of patients with obesity. Further research on accurately and objectively quantifying the impact and severity of patient obesity on nursing clinical activities is required. RELEVANCE TO CLINICAL PRACTICE: When determining staffing, healthcare organisations must consider the increased nursing staff, time and clinical skill required to provide care for patients with obesity. Healthcare organisations should implement policies that ensure sufficient staffing in areas where care of patients with obesity is prevalent, and provide training for and workplace availability of bariatric equipment.

Clarifying workforce flexibility from a division of labor perspective: a mixed methods study of an emergency department team.

BACKGROUND: The need for greater flexibility is often used to justify reforms that redistribute tasks through the workforce. However, "flexibility" is never defined or empirically examined. This study explores the nature of flexibility in a team of emergency doctors, nurse practitioners (NPs), and registered nurses (RNs), with the aim of clarifying the concept of workforce flexibility. Taking a holistic perspective on the team's division of labor, it measures task distribution to establish the extent of multiskilling and role overlap, and explores the behaviors and organizational conditions that drive flexibly. METHODS: The explanatory sequential mixed methods study was set in the Fast Track area of a metropolitan emergency department (ED) in Sydney, Australia. In phase 1, an observational time study measured the tasks undertaken by each role (151 h), compared as a proportion of time (Kruskal Wallis, Mann-Whitney U), and frequency (Pearson chi-square). The time study was augmented with qualitative field notes. In phase 2, 19 semi-structured interviews sought to explain the phase 1 observations and were analyzed thematically. RESULTS: The roles were occupationally specialized: "Assessment and Diagnosis" tasks consumed the largest proportion of doctors' (51.1%) and NPs' (38.1%) time, and "Organization of Care" tasks for RNs (27.6%). However, all three roles were also multiskilled, which created an overlap in the tasks they performed. The team used this role overlap to work flexibly in response to patients' needs and adapt to changing demands. Flexibility was driven by the urgent and unpredictable workload in the ED and enabled by the stability provided by a core group of experienced doctors and nurses. CONCLUSION: Not every healthcare team requires the type of flexibility found in this study since that was shaped by patient needs and the specific organizational conditions of the ED. The roles, tasks, and teamwork that a team requires to "be flexible" (i.e., responsive and adaptable) are highly context dependent. Workforce flexibility therefore cannot be defined as a particular type of reform or role; rather, it should be understood as the capacity of a team to respond and adapt to patients' needs within its organizational context. The study's findings suggest that solutions for a more flexible workforce may lay in the organization of healthcare work.

Harnessing ward-level administrative data and expert knowledge to improve staffing decisions: A multi-method case study.

AIM: The aim of this study was to investigate the impact of changes to bed configuration and patient mix on nurses' workload in a single ward. DESIGN: Multi-method case study. METHOD: The study was undertaken in an acute 28-bed ward in a tertiary referral public hospital in Queensland, Australia. Ward-level administrative data were obtained for a 2-year period, 12 months before bed configuration changes in October 2015 and 12 months after. These data included patient activity (bed occupancy, transfers, length of stay and casemix) and nurse staffing (budgeted and actual staffing levels, employment status and skillmix). Semi-structured interviews were conducted with ward nurses (N = 17) to explore the impact of the bed configuration changes on their workload. RESULTS: Administrative data showed that the bed configuration changes resulted in more complex and dependent patients, increased patient transfers and greater variability in casemix. The interview data found these changes to patient complexity and activity intensified workloads, which were further increased by staffing decisions that resulted in greater reliance on temporary staff. CONCLUSION: Hospitals already possess the data and expert knowledge needed to improve staffing and bed management decisions without the need for additional, costly workload systems. IMPACT: Determining appropriate nurse staffing in light of the complexities and variation of patient needs at the ward level remains a challenge. This study identified increases in patient complexity, dependency, variability and churn that increased workload. Staffing grew but hidden factors associated with temporary staffing and skillmix further intensified nurses' workload. Harnessing existing data and the expertise and experience of nursing unit managers (NUMs) would help staff wards more efficiently and effectively, providing reasonable workloads and appropriate skillmix that can enhance the safety and quality of patient care. To facilitate this, NUMs need access to accurate, timely, data and authority in staffing and bed management decisions.

Manager, clinician or both? Nurse managers' engagement in clinical care activities.

AIM: To explore the extent of Australian nurse managers' engagement in clinical care activities. BACKGROUND: Hybrid nurse manager roles lack clarity in the optimal balance between the clinical and other activities, resulting in stress and challenges in recruiting and retaining nurse managers. METHODS: In a national survey using the Advanced Practice Role Delineation tool, Australian nurses self-assessed their level of engagement in activities across five domains of nursing practice. The subset sample analysed comprised 2,758 registered nurses, 390 clinical (front-line) nurse managers and 43 organisational (middle) nurse managers. Median domain scores were compared with non-parametric tests of difference. RESULTS: Clinical nurse managers were in a hybrid role, reporting high levels of engagement across the domains. Lower scores observed for organisational nurse managers highlight the shift to strategy-focussed activities that occurs as nurses up the management hierarchy. CONCLUSIONS: By indicating their engagement in the clinical care domain, respondents demonstrated that clinically focused activities were not entirely lost from either front-line or middle-management roles. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers equipped with clinical and management skills, and allowed time to remain engage in clinical care activities are critical for patient-centred and cost-effective care in today's complex health care environments.

Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role.

The use of nursing assistants has increased across health systems in the past 20 years, to alleviate licensed nurses' workload and to meet rising health care demands at lower costs. Evidence suggests that, when used as a substitute for licensed nurses, assistants are associated with poorer patient and nurse outcomes. Our multimethods study evaluated the impact of a policy to add nursing assistants to existing nurse staffing in Western Australia's public hospitals, on a range of outcomes. In this article, we draw the metainferences from previously published quantitative data and unpublished qualitative interview data. A longitudinal analysis of patient records found significantly higher rates adverse patient outcomes on wards that introduced nursing assistants compared with wards that did not. These findings are explained with ward-level data that show nursing assistants were added to wards with preexisting workload and staffing problems and that those problems persisted despite the additional resources. There were also problems integrating assistants into the nursing team, due to ad hoc role assignments and variability in assistants' knowledge and skills. The disconnect between policy intention and outcomes reflects a top-down approach to role implementation where assistants were presented as a solution to nurses' workload problems, without an understanding of the causes of those problems. We conclude that policy makers and managers must better understand individual care environments to ensure any new roles are properly tailored to patient and staff needs. Further, standardized training and accreditation for nursing assistant roles would reduce the supervisory burden on licensed nurses.

Development of an Australian nursing critical thinking tool using a Delphi process.

AIM: To develop a critical thinking assessment tool for Australian undergraduate nurses. BACKGROUND: Critical thinking is an important skill but difficult to assess in nursing practice. There are often many responses a nurse can make to a clinical problem or situation. Some responses are more correct than others and these decisions have an impact on a patient's care and safety. Differences in a response can relate to the depth of knowledge, experience and critical thinking ability of the individual nurse. DESIGN: This study used a Delphi process to develop five clinical case studies together with the most appropriate clinical responses to 25 clinical questions. METHOD: The Delphi technique was undertaken using the Qualtrics survey tool between October 2016-January 2017. A panel of 13 nursing experts from various geographical locations in Australia participated in the study to review the case scenarios and answers to questions posed. Four rounds of participation were required to achieve a minimum of 80% agreement between participants. Participants were asked to rank answers for 25 multi-choice questions based on the correct nursing management of case scenarios provided and provide feedback as to the accuracy and relevance of the scenarios and answers. RESULTS: Four rounds of Delphi questions were required to reach consensus on the correct wording and answers for the scenarios. Five case studies have been developed with nursing responses to patient management in rank order from most correct to least correct. CONCLUSION: Use of the tool should provide confidence that a nurse has met a certain level of critical thinking ability.

A protocol to measure the impact of intentional changes to nurse staffing and skill-mix in medical and surgical wards.

AIM: The aim of this research is to measure the impact that planned changes to nurse staffing and skill-mix have on patient, nurse, and organizational outcomes. BACKGROUND: It has been highlighted that there are several design limitations in studies that explore the relationship between nurse staffing and patient, nurse and organizational outcomes; not least that the vast majority of research in this area emanates from studies that are predominantly observational in design. There are limited studies that measure nurse, patient, organizational, and economic outcomes using a longitudinal design following a planned change in nurse staffing. DESIGN: The research will employ a longitudinal, multimethod approach to evaluate the impact that planned changes in nurse staffing and skill-mix have on wards in three pilot hospitals. METHODS: Administrative data collection will take place on a shift-by-shift basis prospectively over a three-year period including the measurement of nursing sensitive outcomes: cross-sectional patient experience data and nurse outcomes (nursing work, job satisfaction, burnout, missed care) will be collected at intervals prior to, during and after the implementation of planned changes in nurse staffing and skill-mix. Data will be analysed using interrupted time-series models, adjusted for key hospital, ward and patient-level factors. An economic costing of the changes will further investigate the resources required for the intervention that can then be aggregated to a national level for future roll-out plans. DISCUSSION: The study aims to provide evidence on the impact of planned changes to nurse staffing and skill-mix based on a systematic approach using a longitudinal design and to determine the extent to which the approach can be implemented at a national level.

Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment.

AIMS AND OBJECTIVES: To explore the impact of an initiative to add unregulated nursing support workers to wards in acute care hospitals. BACKGROUND: Adding nursing support workers to existing nurse staffing may be one solution to reduce nursing workloads and improve outcomes. However, the effects of this addition on nurse, patient and system outcomes are not well documented. In one state of Australia, a trial deployment of nursing support workers to wards across the public health system provided opportunity for the exploration of their impact in a natural, real-world, environment. DESIGN: Cross-sectional study. METHODS: A sample of five wards where nursing support workers had been added matched to a group of five wards where there were no nursing support workers. Data were collected via patient survey (n = 141) and nurse survey (n = 154). Analysis was comparative with regression models constructed for the different ward types. RESULTS: Nursing leadership, staffing and resources, and nurse experience were linked to outcomes on both ward types. Instability was a significant predictor of reduced quality of care and increased turnover intention on wards where support workers were added. CONCLUSION: Adding nursing support workers to ward staffing did not lead to improvements in patient care. Findings suggest that staffing a nursing ward is a complex activity and that a simple approach to staffing is unlikely to be successful. Future research should explore the process of implementation and the conditions under which this strategy is likely to be successful. RELEVANCE TO CLINICAL PRACTICE: Ward-level factors are key in making appropriate staffing and skill mix choices to limit instability and to consequently avoid negative patient, staff and system outcomes. Consideration of the ward context, alongside effective delegation processes and integration into the care team are imperative when adding nursing support workers.

The health of working nurses: Hypertension prevalence, awareness, treatment and control by medication.

AIMS: To investigate hypertension awareness, prevalence and treatment in nurses. BACKGROUND: Nurses are the largest health workforce group, currently facing an ageing demographic and the risk of chronic disease such as hypertension. Little is known about hypertension in nurses despite the potential impact on work productivity. METHODS: A cross-sectional online survey was distributed to nurses and midwives via the professional association and nursing directors. Questions were taken from published longitudinal health studies for blood pressure, hypertension and key sociodemographic and health factors. RESULTS: The participants' (n = 5,041) mean age was 47.99 (SD 11.46) years. The majority knew their blood pressure, more so if they were female, of higher body mass index and aged 45-64 years, but less so if they were smokers. Hypertension prevalence increased with age, peaking at the oldest ages and the majority were treated (anti-hypertensive medication), less so if aged <55 years. Many nurses treated for hypertension had poor blood pressure control, were most often aged 45-54 years and were smokers. CONCLUSIONS: Hypertension prevalence is less in nurses than in the general population, however, once diagnosed treatment is not optimized. IMPLICATIONS FOR NURSING MANAGEMENT: The potential impact of hypertension on older nurses' work productivity justifies work-based support for risk reduction behaviours.

A protocol for the development of a critical thinking assessment tool for nurses using a Delphi technique.

AIM: The aim of this study was to develop an assessment tool to measure the critical thinking ability of nurses. BACKGROUND: As an increasing number of complex patients are admitted to hospitals, the importance of nurses recognizing changes in health status and picking up on deterioration is more important. To detect early signs of complication requires critical thinking skills. Registered Nurses are expected to commence their clinical careers with the necessary critical thinking skills to ensure safe nursing practice. Currently, there is no published tool to assess critical thinking skills which is context specific to Australian nurses. DESIGN: A modified Delphi study will be used for the project. METHODS: This study will develop a series of unfolding case scenarios using national health data with multiple-choice questions to assess critical thinking. Face validity of the scenarios will be determined by an expert reference group of clinical and academic nurses. A Delphi study will determine the answers to scenario questions. Panel members will be expert clinicians and educators from two states in Australia. Rasch analysis of the questionnaire will assess validity and reliability of the tool. Funding for the study and Research Ethics Committee approval were obtained in March and November 2016, respectively. DISCUSSION: Patient outcomes and safety are directly linked to nurses' critical thinking skills. This study will develop an assessment tool to provide a standardized method of measuring nurses' critical thinking skills across Australia. This will provide healthcare providers with greater confidence in the critical thinking level of graduate Registered Nurses.

Building expert agreement on the importance and feasibility of workplace health promotion interventions for nurses and midwives: A modified Delphi consultation.

AIM: To use a Delphi panel to determine the relative importance and feasibility of workplace health promotion interventions to promote and support the health of the Australian nursing and midwifery workforce. BACKGROUND: The nursing workforce experiences rates of ill health above that of other workforces, yet there is little investment in workplace health promotion. DESIGN: The study used a modified Delphi design conducted between September and November 2015. METHODS: Eleven of 19 purposively selected expert panellists discussed, rated and provided feedback through two rounds of an electronic questionnaire about the relative importance and feasibility of 46 workplace health promotion interventions and processes for nurses and midwives. Scores for importance and feasibility were calculated and ranked and a composite score of importance multiplied by feasibility. RESULTS: Mental health strategies were prioritized as the most important and feasible of the intervention topics, followed closely by healthy eating and physical activity interventions; smoking cessation ranked lowest. The most highly ranked interventions targeted healthy eating, stress management and resilience training. Highest ranked processes to support development of a healthy work environment included intersectoral collaboration and employee wellness groups. CONCLUSIONS: Study findings prompt consideration of health promotion opportunities to support nurses' health and well-being. Findings identified key workplace health promotion priorities and provide direction for policy makers and managers to promote nursing and midwifery workforce health.

Barriers and facilitators to healthy eating for nurses in the workplace: an integrative review.

AIM: The aim was to conduct an integrative systematic review to identify barriers and facilitators to healthy eating for working nurses. BACKGROUND: There is growing recognition of the influence of the workplace environment on the eating habits of the workforce, which in turn may contribute to increased overweight and obesity. Overweight and obesity exact enormous costs in terms of reduced well-being, worker productivity and increased risk of non-communicable diseases. The workplace is an ideal place to intervene and support healthy behaviours. This review aimed to identify barriers and facilitators to nurses' healthy eating in the workplace. DESIGN: Integrative mixed method review. DATA SOURCES: Five electronic databases were searched: CINAHL, MEDLINE, PROQUEST Health and Medicine, ScienceDirect and PsycINFO. Reference lists were searched. Included papers were published in English between 2000-2016. Of 26 included papers, 21 were qualitative and five quantitative. REVIEW METHODS: An integrative literature review was undertaken. Quality appraisal of included studies used standardized checklists. A social-ecological framework was used to examine workplace facilitators and constraints to healthy eating, derived from the literature. Emergent themes were identified by thematic analysis. RESULTS: Review participants were Registered, Enrolled and/or Nurse Assistants primarily working in hospitals in middle or high income countries. The majority of studies reported barriers to healthy eating related to adverse work schedules, individual barriers, aspects of the physical workplace environment and social eating practices at work. Few facilitators were reported. Overall, studies found the workplace exerts a considerable negative influence on nurses' dietary intake. CONCLUSION: Reorientation of the workplace to promote healthy eating among nurses is required.

Health, workforce characteristics, quality of life and intention to leave: The 'Fit for the Future' survey of Australian nurses and midwives.

AIM: To examine the quality of life of nurses and midwives in New South Wales, Australia and compare values with those of the Australian general population; to determine the influence of workforce, health and work life characteristics on quality of life and its effect on workforce intention to leave. BACKGROUND: Few studies have examined nurses' and midwives' quality of life and little is known of its effects on workforce longevity. DESIGN: This was a cross-sectional survey conducted in 2014-2015. METHOD: The "Fit for the Future" electronic survey, delivered to nurses and midwives, examined demographic, work and health-related factors, which were compared with Australian general population normative values for physical and mental components of quality of life (the Short Form-12). Univariate and multivariate logistic regression models assessed associations with workforce intention to leave. RESULT: Physical and mental component scores, calculated for 4,592 nurses and midwives, revealed significantly higher physical but lower mental component scores than the general population. Physical component scores decreased with increasing age; higher scores were seen in nurses with better health indices and behaviours. Mental well-being scores increased with increasing age; in nurses who reported job satisfaction, no work injury, sleep problems or frequent pain and non-smokers. The odds of intention to leave decreased with increasing mental well-being. CONCLUSION: Managers and decision-makers should heed study recommendations to implement health promotion strategies for nurses and midwives, aiming to improve mental health, specifically to promote workforce retention.