Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review.

AIM(S): To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients. DESIGN: Scoping review of international, peer-reviewed research studies. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023. REPORTING METHOD: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. RESULTS: Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies). CONCLUSION: Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Australian and Danish nurses' and midwives' wellbeing during COVID-19: A comparison study.

Background: Most investigations of nurses' and midwives' psychological wellbeing during the COVID-19 pandemic have been conducted in a single setting. Aim: To assess and compare the psychological wellbeing of nurses and midwives in Australia and Denmark during the COVID-19 pandemic. Methods: Nurses and midwives employed at four metropolitan health services in Australia and one in Denmark completed an anonymous online survey, which assessed depression, anxiety, and stress symptoms (The Depression, Anxiety and Stress Scale - 21 Items (DASS-21)), and sociodemographic and employment factors. Findings: Completed surveys were received from 3001 nurses and midwives (1611 Australian and 1390 Danish). Overall, approximately one in seven of the nurses and midwives surveyed reported moderate to extremely severe levels of depression (n = 399, 13.5%), anxiety (n = 381, 12.9%) and stress (n = 394, 13.4%). Australian nurses' and midwives' scores on all DASS-21 subscales were significantly higher (representing higher levels of depression, anxiety and stress) than the scores for the Danish nurses and midwives. Fewer years of clinical experience, living in Australia and being employed on a part-time basis were significantly associated with higher levels of psychological distress. Discussion: A considerable proportion of nurses and midwives experienced distress during the COVID-19 pandemic; however, the proportion and severity varied by country. Australian nurses and midwives experienced higher levels of distress than their Danish colleagues. Conclusion: Nurses and midwives working in countries with relatively low numbers of COVID-19 cases and deaths are also likely to experience psychological distress. Nurses and midwives would benefit from targeted country-specific support and wellbeing initiatives.

Nurse-Initiated Acute Stroke Care in Emergency Departments: The Triage, Treatment, and Transfer Implementation Cluster Randomized Controlled Trial.

Background and Purpose- We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods- A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke <48 hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt (<4 hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions; (2) face-to-face, online, and written education; (3) national and local clinical opinion leaders; and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2); secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale; monitoring and management of tPA, fever, hyperglycemia, swallowing; prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Results- Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P=0.24) or secondary outcomes. Conclusions- This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration- URL: http://www.anzctr.org.au. Unique identifier: ACTRN12614000939695.

Designing a standardised emergency nurse career pathway for use across rural, regional and metropolitan New South Wales, Australia: A consensus process.

BACKGROUND: Emergency nurses are the first clinicians to see patients in the ED; their practice is fundamental to patient safety. To reduce clinical variation and increase the safety and quality of emergency nursing care, we developed a standardised consensus-based emergency nurse career pathway for use across Australian rural, regional, and metropolitan New South Wales (NSW) emergency departments. METHODS: An analysis of career pathways from six health services, the College for Emergency Nursing Australasia, and NSW Ministry of Health was conducted. Using a consensus process, a 15-member expert panel developed the pathway and determined the education needs for pathway progression over six face-to-face meetings from May to August 2023. RESULTS: An eight-step pathway outlining nurse progression through models of care related to different ED clinical areas with a minimum 172 h protected face-to-face and 8 h online education is required to progress from novice to expert. Progression corresponds with increasing levels of complexity, decision making and clinical skills, aligned with Benner's novice to expert theory. CONCLUSION: A standardised career pathway with minimum 180 h would enable a consistent approach to emergency nursing training and enable nurses to work to their full scope of practice. This will facilitate transferability of emergency nursing skills across jurisdictions.

Education interventions and emergency nurses' clinical practice behaviours: A scoping review.

BACKGROUND: Many education interventions in emergency nursing are aimed at changing nurse behaviours. This scoping review describes and synthesises the published research education interventions and emergency nurses' clinical practice behaviours. METHODS: Arksey and O'Malley's methodological framework guided this review, which is reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). CINAHL, MEDLINE complete, ERIC, and Psycinfo were searched on 3 August 2023. Two pairs of researchers independently conducted all screening. Synthesis was guided by the Behaviour Change Wheel and Bloom's Taxonomy of Educational Objectives. RESULTS: Twenty-five studies were included. Educational interventions had largely positive effects on emergency nurses' clinical practice behaviours. Ten different interventions were identified, the most common was education sessions (n = 24). Seven studies reported underpinning theoretical frameworks. Of the essential elements of behaviour change, seven interventions addressed capability, four addressed motivation and one addressed opportunity. Mapping against Bloom's taxonomy, thirteen studies addressed analysis, eleven studies addressed synthesis and two studies addressed evaluation. CONCLUSION: Few studies addressed elements of behaviour change theory or targeted cognitive domains. Future studies should focus on controlled designs, and more rigorous reporting of the education intervention(s) tested, and theoretical underpinning for intervention(s) selected.

The Emergency nurse Protocols Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) trial: protocol for a stepped wedge implementation trial.

INTRODUCTION: Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care-Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes. METHODS AND ANALYSIS: This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped-wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys. ETHICS AND DISSEMINATION: Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022. TRIAL REGISTRATION: Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration.

BACKGROUND: Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients. METHODS: In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat. RESULTS: From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)). CONCLUSION: Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes. TRIAL REGISTRATION NUMBER: ACTRN12616000544471p.

Nurses' occupational physical activity levels: A systematic review.

BACKGROUND: Nurses' physical performance at work has implications both for nurses' occupational health and patient care. Although nurses are the largest healthcare workforce, are present 24-hours a day, and engage in many physically demanding tasks, nurses' occupational physical activity levels are poorly understood. OBJECTIVES: The aim of this systematic review was to examine nurses' occupational physical activity levels, and explore how nurses accumulate their physical activity during a shift. DESIGN: This narrative systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. DATA SOURCES: EBSCOHost (MEDLINE, CINAHL, Age Line, Academic Search Complete, Global Health, Health Business Centre, Health Policy Reference Centre, Health Source (Consumer and Nursing/Academic Edition) and SPORTDiscus), Embase, Informit, ProQuest Health and Medical, Science Direct, Scopus, and Web of Science databases. REVIEW METHODS: A systematic search of seven databases were completed to locate peer-reviewed journal articles documenting nurses' occupational physical activity levels from January 1990. Papers were included if they were original research papers; measured physical activity objectively and/or subjectively; reported nurses' occupational physical activity; and were published in English. Articles were excluded if nurses' data were not reported separately from other professional groups. Two researchers independently screened the articles, extracted data, and undertook the methodological quality assessments. RESULTS: Fifteen studies met the inclusion criteria. Nursing work predominantly comprised of light-intensity physical activity. In nine studies how nurses' accumulated occupational physical activity were documented and showed that the majority of a nurses' shift was spent standing or walking whilst completing direct patient care tasks. However, the definition of the nursing populations studied were often poorly reported, and few researchers reported the validity and the reliability of the measurement tools used. CONCLUSIONS: Nurses' occupational physical activity levels largely consist of light-intensity physical activity interspersed with moderate-intensity tasks. It is not known whether physical activity during one shift affects the activity levels in the following shift. This systematic review is the first step towards understanding the physical demands of nursing work, and how nurses' physical activity may impact workplace wellbeing and patient safety. LIMITATIONS: A meta-analysis was not possible due to the variability in how physical activity outcomes were presented. Several studies had heart rate outcomes that were converted, where possible, by the authors into physical activity outcomes. REGISTRATION: This systematic review is registered with PROSPERO; Registration number: CRD42016045427.