Knowledge and motivation: two elements of health literacy that remain low with regard to nurse practitioners in Australia.

OBJECTIVE: This paper presents analysis of consumer focus groups that were undertaken as a part of the project to develop the now current Nursing and Midwifery Board of Australia's Nurse Practitioner Standards for Practice. METHODS: Six focus groups were conducted with consumers around Australia, including urban and remote areas. One purpose for these groups was to explore what was known of nurse practitioners and whether consumers could articulate the difference between the regulated titles of enrolled nurse, registered nurse and nurse practitioner. RESULTS: Consumers' knowledge of nurses' roles in the Australian primary healthcare system, and hence system literacy (particularly in terms of navigating the system), was low. Of perhaps greatest importance is the fact that those consumers with low health systems literacy also exhibited a low level of motivation to seek new knowledge. Many consumers relied on the medical profession to direct care. CONCLUSION: The low levels of health literacy raise questions of how to meaningfully include health consumers in innovative health-related policy work.

Trust and decision-making: How nurses in Australian general practice negotiate role limitations.

AIM: To explore the importance of role recognition and relationships between the opportunities for decision-making, social support, and skill development, in a sample of nurses working in general practice in New South Wales, Australia. BACKGROUND: Understanding how nurses make decisions about patients and their care in general practice will benefit organisations and public policy. This understanding is important as the role changes and opportunities for further role development emerge. DESIGN: A sequential mixed methods design was used. Study 1 utilised the internationally validated Job Content Questionnaire to collect data about decision making, social support, skill development, and identity derived from the role. In 2008 a purposive sample of nurses working in general practice (n = 160) completed and submitted an online Job Content Questionnaire. Study 2 used a set of open-ended questions informed by Study 1 to guide semi-structured interviews. In 2010 fifteen interviews were undertaken with nurses in general practice. Demographic characteristics of both samples were compared, and the findings of both studies were integrated. RESULTS: The integration of findings of Study 1 and 2 suggests that nurses defined their expertise as being able to identify patient need and communicate this to the general practitioner, the ability to do so led to the development of trusting relationships. Trusting relationships led to greater support from the general practitioner and this support allowed the nurse greater freedom to make decisions about patient care. CONCLUSIONS: Nurses gained influence in clinical decision-making by building trusting relationships with patients and medical colleagues. They actively collaborated in and made decisions about patient care. These results suggest that there is a need to consider how nursing can more effectively contribute to care in general practice settings.

Clarifying Clinical Nurse Consultant work in Australia: A phenomenological study.

The Clinical Nurse Consultant role in Australia is an Advanced Practice Registered Nurse Role (APRN). This role has been conceptualized from the discrete pillars of research, education, practice, system support and leadership, articulated in the Strong Model of Advanced Practice. This conceptualization has been manifested in job descriptions, workforce. planning and course design. This paper explored whether there was a more refined way of conceptualizing the unique 'value add' of the role. A hermeneutic phenomenological approach was employed to explore the lived experience of the role. It was identified that the pillars of education, practice, leadership and research are interconnected and expressed in the system work of the Clinical Nurse Consultant. The findings have implications for education and workforce planning.

Mental health emergency transport: the pot-holed road to care.

Police have, historically, been the first point of contact for people experiencing a mental health crisis in the Australian community. Changes in the NSW Mental Health Act 2007 extended the powers and responsibilities for involuntary transport to paramedics and accredited mental health practitioners. The Mental Health Act also allows for police assistance to other agencies during transport of people living with mental illness if there are serious safety concerns. Involuntary intervention for people living with mental illness is based on risk-of-serious-harm criteria under the Mental Health Act, implying serious deterioration before the Act may be invoked. At the point of risk of serious harm, police involvement may be more frequently required according to the acuity of the situation. If the legal basis of non-consensual treatment under the Mental Health Act was lack of capacity, it would provide a more comprehensive legal and ethical basis for early intervention. Police contact is intensified in rural and remote regions, particularly after hours, where crisis assessments and intervention by health services are further stretched. Further reducing police involvement using strategies that increase access to consensual pathways of care for people living with mental illness, particularly for people in regional and remote areas, is desirable but not likely in the foreseeable future.

Deriving consensus on the characteristics of advanced practice nursing: meta-summary of more than 2 decades of research.

BACKGROUND: Over recent decades, there has been considerable research and debate about essential features of advanced nursing practice and differences among various categories of advanced practice nurses. OBJECTIVES: This study aimed to derive an integrative description of the defining characteristics of advanced practice nursing through a meta-summary of the existing literature. METHODS: A three-phase approach involved (a) systematic review of the literature to identify the specific activities characterized as advanced practice nursing, (b) qualitative meta-summary of practice characteristics extracted from manuscripts meeting inclusion criteria; and (c) statistical analysis of domains across advanced practice categories and country in which the study was completed. A descriptive framework was distilled using qualitative and quantitative results. RESULTS: Fifty manuscripts met inclusion criteria and were retained for analysis. Seven domains of advanced nursing practice were identified: (a) autonomous or nurse-led extended clinical practice; (b) improving systems of care; (c) developing the practice of others; (d) developing/delivering educational programs/activities; (e) nursing research/scholarship; (f) leadership external to the organization; and (g) administering programs, budgets, and personnel. Domains were similar across categories of advanced nursing practice; the domain of developing/delivering educational programs/activities was more common in Australia than in the United States or United Kingdom. DISCUSSION: Similarity at the domain level was sufficient to suggest that advanced practice role categories are less distinct than often argued. There is merit in adopting a more integrated and consistent interpretation of advanced practice nursing.

Nurse practitioner prescribing practice in Australia: confidence in aspects of medication management.

The findings of the 2010 national survey of nurse practitioner (NP) prescribing in Australia related to confidence in prescribing are reported. A significant correlation between years endorsed as a NP and prescribing confidence was found. NPs in Australia were significantly more confident in the prescribing aspects of commencing a new medication than adjusting or ceasing a medication prescribed by others. These findings are discussed in relation to promotion of the quality use of medicines and identification of potential strategies to promote the ongoing positive evolution of NP practice in Australia.

Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies.

BACKGROUND: This study aimed to reveal nurses' experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. METHOD: A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. RESULTS: Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options. CONCLUSION: Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover.

Development of a tool to describe the role of the clinical nurse consultant in Australia.

AIMS AND OBJECTIVES: To develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia. BACKGROUND: Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the clinical nurse consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of clinical nurse consultants against the listed domains. DESIGN AND METHODS: Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development. RESULTS: A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions. CONCLUSIONS: Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance. RELEVANCE TO CLINICAL PRACTICE: This preliminary study suggests that the tool provides a useful means of measuring advanced nursing practice and responsibilities across different domains and levels of appointment. The tool may be able to be adapted for use with other advanced practice nursing roles both within Australia and internationally.

Management and leadership in nursing: an Australian educational perspective.

AIM: In this article, we present an Australian perspective on issues influencing management and leadership education in nursing. BACKGROUND: Nurse leaders and managers work in a context of high pressure, uncertainty and rapid change, and face unprecedented challenges on a daily basis. EVALUATION AND KEY ISSUES: In the present paper, we reflect on the issues and challenges facing providers of management education for nursing, and consider these challenges in relationship to current trends and imperatives. CONCLUSIONS: Collaborative approaches between educational and clinical settings are needed to ensure quality, relevant educational support for managers and leaders, and enhance curriculum integrity. IMPLICATIONS FOR NURSING MANAGEMENT: There is a need for contemporaneous and relevant research to inform innovative models of collaborative education.

Strengthening the nursing and midwifery unit manager role: an interim programme evaluation.

AIMS: An interim evaluation was conducted on the professional development components of the New South Wales (NSW) Health 'take the lead' ('ttl') programme, an initiative aimed at enhancing nursing/midwifery unit managers' (N/MUM) skills. BACKGROUND: Previous research has highlighted the importance of strong nurse leaders, and shown that training programmes may assist in improving leadership skills. The NSW Nursing and Midwifery Office (NaMO) developed the 'ttl' programme for N/MUMs with the intention of improving hospital quality by strengthening nurse leadership. The programme had three strands, with the professional development modules a key component. METHOD: Semi-structured interviews were conducted with 17 participants who had completed components of the 'ttl' programme. The interviews explored participants' perceptions of the programme, and suggestions for improvement. Qualitative analysis was conducted on the transcribed interviews. RESULTS: The N/MUMs reported feeling increasingly empowered, knowledgeable and supported as a result of attending the 'ttl' workshops. CONCLUSIONS: The results suggest that the studied components of the 'ttl' programme may be effective in assisting nurse leaders gain new leadership skills and institute positive changes in the nursing work environment. IMPLICATIONS FOR NURSING MANAGEMENT: Leadership programmes such as 'ttl' may provide an effective tool for improving N/MUM performance and role confidence.

Nursing work directions in Australia: does evidence drive the policy?

A significant body of research has shown a relationship between nurse staffing (in particular, skill-mix: the proportion of Registered Nurses [RNs]) and both morbidity and mortality. This relationship is typically investigated by measuring the incidence of Nursing Sensitive Outcomes (NSOs) under different skill-mix levels. Yet whilst the evidence suggests that richer skill-mix is associated with a lower incidence of NSOs, recent Australian policy reforms have proposed the replacement of Registered Nurses with less qualified staff. The present study sought to examine the relationship between staffing, skill-mix, and incidence of NSOs at two hospitals in one Australian state. The study sought to determine the rate of occurrence of several NSOs, the relationship of skill-mix to that rate, and the number of patients affected per annum. It was found that the current rate of NSOs across wards ranged from 0.17% to 1.05%, and that there was an inverse relationship between the proportion of hours worked by RNs and NSO rates: an increase of 10% in the proportion of hours worked by RNs was linked to a decrease in NSO rates by between 11% and 45%. It was estimated that increasing the RN staffing percentage by 10% would mean 160 fewer adverse outcomes for patients per year across these two hospitals. Importantly, increases in nursing hours overall (without increases in skill-mix) had no significant effect on patient outcomes. These findings challenge current policy recommendations, which propose increasing the number of unregistered staff without increasing skill-mix.

Expanding the role of practice nurses in Australia.

Like other countries, Australia is looking to reforms in the primary health care sector to meet the growing demand for care. Expansion of the role of practice nurses (PNs) is one way in which this demand may be met. To date the Federal Australian government has played a significant role in encouraging growth in the PN workforce. If PNs tend to be GP directed, with little autonomy, care must be taken to consider whether to expand existing scopes of practice. In contrast, if PNs rely on their own independent clinical judgment and skill, this would support potential expansions to the scope of the PN role. Understanding these issues is important to inform the development of future workforce policy. This paper examines the structural policy dimensions within which these changes are occurring, and makes recommendations for future research on PNs.

Nursing unit managers, staff retention and the work environment.

AIM AND OBJECTIVE: This paper examined the impact of leadership characteristics of nursing unit managers, as perceived by staff nurses, on staff satisfaction and retention. BACKGROUND: A positive work environment will increase levels of job satisfaction and staff retention. Nurse leaders play a critical role in creating a positive work environment. Important leadership characteristics of the front-line nurse manager include visibility, accessibility, consultation, recognition and support. DESIGN: Secondary analysis of data collected on 94 randomly selected wards in 21 public hospitals across two Australian states between 2004-2006. METHODS: All nurses (n = 2488, 80·3% response rate) on the selected wards were asked to complete a survey that included the 49-item Nursing Work Index-Revised [NWI-R] together with measures of job satisfaction, satisfaction with nursing and intention to leave. Subscales of the NWI-R were calculated. Leadership, the domain of interest, consisted of 12 items. Wards were divided into those reporting either positive or negative leadership. Data were analysed at the nurse level using spss version 16. RESULTS: A nursing manager who was perceived to be a good leader, was visible, consulted with staff, provided praise and recognition and where flexible work schedules were available was found to distinguish the positive and negative wards. However, for a ward to be rated as positive overall, nurse leaders need to perform well on all the leadership items. CONCLUSION: An effective nursing unit manager who consults with staff and provides positive feedback and who is rated highly on a broad range of leadership items is instrumental in increasing job satisfaction and satisfaction with nursing. RELEVANCE TO CLINICAL PRACTICE: Good nurse managers play an important role in staff retention and satisfaction. Improved retention will lead to savings for the organisation, which may be allocated to activities such as training and mentorship to assist nurse leaders in developing these critical leadership skills. Strategies also need to be put in place to ensure that nurse leaders receive adequate organisational support from nursing executives.

Factors impacting on career progression for nurse executives.

This discursive paper examines recent research on career progression for nurse executives in Australia. In particular, it focuses on the personal, work-related and professional factors which influence progression. The role of gender, location and the provision of mentoring are also considered. It is suggested that family friendly policies (such as the option to job share or to perform an executive role on a part-time basis), the availability of a mentor, and the opportunity to pursue further education/training are vital in assisting nurses to progress in their executive careers.

National regulation in Australia: a time for standardisation in roles and titles.

BACKGROUND: The past few years has seen a growth in the number of new nursing roles and position titles in many countries, including Australia. The Australian situation is unique due to the lack of professional engagement and debate in determining the purpose of some of these new positions. Often these new roles have been poorly defined, and there is no national consistency in nomenclature. The recent move to a national nursing registration system provides an opportunity for change. METHOD: Discursive paper. RESULTS: New roles arise for a number of reasons, including a change in function or title for a preexisting role or in response to the establishment a completely new position. However, the lack of a co-ordinated approach to introduction of new roles may lead to role proliferation (the rapid increase or spread of new positions and position titles), role blurring (where the boundaries of different positions become less distinct) and role confusion (where both nurses and health system clients experience a lack of clarity regarding the precise scope of roles). CONCLUSION: Professional nursing practice is defined by the impact on patient outcomes, not by position titles. As such, the potential positive impact of a new role on patient outcomes should be the primary consideration when considering its introduction. National regulation of the profession provides an opportunity for the profession to debate and determine some consistency in position titles, responsibilities and areas of specialty practice.

Validity and reliability of the psychometric properties of a child abuse questionnaire.

BACKGROUND: Few valid and reliable measures of professional self-efficacy and its influence on reporting child abuse and neglect (CAN) are available. AIM: To test the psychometric properties of the Child Abuse and Neglect Reporting Self-Efficacy (CANRSE) (English) questionnaire. DISCUSSION: The Psychometric Grading Framework graded the strength of the psychometric properties of CANRSE (English) as 'good'. CANRSE can be measured using this tool, having been tested with a cohort of Australian health professionals. CANRSE can be used in Australian healthcare settings and will benefit health disciplines by examining the influence of self-efficacy on CAN reporting in clinical practice and research. CONCLUSION: The psychometric properties of CANRSE (English) provide evidence to support the assertion that it is a reliable instrument to measure self-efficacy in reporting CAN cases. IMPLICATIONS FOR PRACTICE: The validity and reliability of CANRSE (English) have been established. Future research should focus on larger studies testing a shorter version of the tool.

Lived experience of involuntary transport under mental health legislation.

Police have historically been responsible for transporting people during a mental health crisis in Australia. A major change to the New South Wales (NSW) Mental Health Act (MHA) in 2007 expanded the range of coercive transportation agencies to include NSW Ambulance (paramedics) and NSW Health (mental health nurses). Anecdotal reports, however, describe a lack of clarity around how these changes should be implemented in practice. This research aims to explore this lack of clarity through qualitative analysis of interviews with people with the lived experience of involuntary transport under the MHA. Sixteen interviews were conducted; most (n = 14) interviews in northern NSW regions: six with people who had been transported (consumers), four with carers, and six with service providers (two police, one paramedic, and three mental health nurses). For consumers and carers, the police response was often perceived as too intense, particularly if the person was not violent. Carers were often conflicted by having to call for emergency intervention. Service providers were frustrated by a lack of a coordinated interagency response, resourcing issues, delays at emergency departments, and lack of adequate training. A central theme across all groups was the importance of communication styles. As one participant (consumer) said: 'Everybody needs a lesson in kindness'. All groups agreed that high-risk situations necessitate police involvement. However, invocation of the MHA during a high-risk situation is fraught with stress and difficulties, leaving little room for empathetic communications. Effective and diverse, evidence-based, early intervention strategies - both consensual and non-consensual - are necessary to reduce the requirement for police involvement in mental health transports.

Sources of information used to support quality use of medicines: findings from a national survey of nurse practitioners in Australia.

PURPOSE: The purpose of this study was to investigate the sources, both print and electronic formats, which Australian nurse practitioners (NPs) currently use to obtain information regarding quality use of medicines (QUM). An additional aim was to document NPs' preferences for continuing education in relation to QUM. DATA SOURCES: A national electronic survey of Australian NPs was conducted in 2007 and again in 2010. CONCLUSIONS: Eighty percent of respondents accessed information on QUM from professional literature, which may include scholarly journal articles, reports, and independent publications. There was a decrease in the percentage of respondents who obtained information from drug industry representatives. NPs prefer to receive medicines information in an electronic form, rather than a paper-based version, and over the time period more NPs are utilizing electronic sources rather than paper. IMPLICATIONS FOR PRACTICE: These findings provide important insights into medical information products for the developers who may be able to use these results to ensure that their products meet the needs of NP clinicians. Additionally, the finding that NPs prefer to receive their continuing information related to medicines in electronic format, but also highly value conference proceedings, may help to inform future planning of NP education needs in relation to QUM.

Advancing advanced practice - clarifying the conceptual confusion.

BACKGROUND: In recent years, there has been a substantial increase in the number of nurses holding advanced practice nursing positions. However, the lack of clarity regarding key terms such as 'advanced practice nursing', 'advanced nursing practice', 'scope of practice' and 'extended practice', and international variability in how these terms are used has created significant confusion. This lack of clarity is problematic for nurses, other health professionals, health service consumers, educators and policy makers, particularly given the global mobility of the nursing workforce. OBJECTIVES: 1) To highlight the significant international variability in how advanced practice nursing, and associated terms such as extended and expanded practice, are defined and regulated across a variety of different English speaking countries, including the US, UK, New Zealand, Canada and Australia. 2) To propose innovative formulations for how the nursing profession may attempt to ensure greater precision and agreement around advanced practice terminology. DESIGN: Discursive paper. RESULTS: It was found that there is a considerable lack of clarity regarding the precise definitions of key terms surrounding the discussion of advanced practice. Additionally, there are large disparities in how the five chosen countries regulate advanced practice nursing, and roles such as that of the nurse practitioner. CONCLUSIONS: It is suggested that the confusion regarding advanced practice terminology can be reduced definitionally by minimising the use of the term 'expanded practice'; defining advanced practice nursing to refer to the type of practice in defined and regulated advanced practice nursing scopes; and defining advanced nursing practice as expert practice within a regulated nursing scope.

Empowering the registered nurses of tomorrow: students' perspectives of a simulation experience for recognising and managing a deteriorating patient.

BACKGROUND: Recognising and responding to patients who are deteriorating are key aspects to improving outcomes. Simulations provide students with exposure to deteriorating patient scenarios and the role of nurses in such events. The number of programmes seeking to provide best possible simulation experiences is growing exponentially. Robust evaluation of these experiences is crucial to ensure maximum benefit. OBJECTIVES: To assess the impact of a deteriorating patient simulation experience on students' technical and communication skills; and to determine if differing study programmes and years of previous nursing experience influenced students' responses and experiences. METHODS: A convenience sample of final year nursing students (N=57) in a medical-surgical course at a large urban university completed a descriptive pre/post simulation survey rating their technical skills and communication abilities in recognising and responding to patient deterioration. Changes in pre/post scores were analysed including influence of study programme (3-year, 2-year Enrolled Nurse, 2-year Graduate Entry); gender; and years nursing experience (beyond course clinical practicum). RESULTS: Statistically significant improvements in post-simulation survey scores were demonstrated for combined student group data. Students with greater years of nursing experience had statistically higher scores than those with less experience in both pre- and post-surveys. Specific improvements were identified for: assessing a deteriorating patient; and in seeking help from the medical officer or external service. CONCLUSIONS: All student groups gained benefit in participating in a deteriorating patient simulation. For this group, greater years of prior nursing experience led to higher pre- and post-survey scores. The learning activity provided students an experience of the importance of recognising and responding to an acute situation in a timely manner which may be recalled in subsequent clinical situations.