Pediatric invasive device utility and harm: a multi-site point prevalence survey.

BACKGROUND AND AIMS: Invasive devices are widely used in healthcare settings; however, pediatric patients are especially vulnerable to invasive device-associated harm. This study aimed to explore invasive device utility, prevalence, harm, and clinical practice across three Australian pediatric tertiary hospitals. METHODS: In 2022-2023, a multi-center, observational, rolling-point-prevalence survey was conducted. Fifty-per-cent of inpatients were systemically sampled by random allocation. Patients with devices were then followed for up to 3-days for device-related complications/failures and management/removal characteristics. RESULTS: Of the 285 patients audited, 78.2% had an invasive device (n = 412 devices), with a median of 1 device-per-patient (interquartile range 1-2), with a maximum of 13 devices-per-patient. Over half of devices were vascular access devices (n = 223; 54.1%), followed by gastrointestinal devices (n = 112; 27.2%). The point-prevalence of all device complications on Day 0 was 10.7% (44/412 devices) and period-prevalence throughout the audit period was 27.7% (114/412 devices). The period-prevalence of device failure was 13.4% (55/412 devices). CONCLUSIONS: The study highlighted a high prevalence of invasive devices among hospitalized patients. One-in-ten devices failed during the audit period. These findings underscore the need for vigilant monitoring and improved strategies to minimize complications and enhance the safety of invasive devices in pediatric hospital settings. IMPACT: A high prevalence of invasive devices among hospitalized patients was reported. Of the 285 patients audited, almost 80% had an invasive device (total 412 devices), with a median of 1 device-per-patient and a maximum of 13 devices-per-patient. The most common devices used in pediatric healthcare are vascular access devices (n = 223; 54.1%), however, 16% (n = 36) of these devices failed, and one-third had complications. The point prevalence of all device complications at day 0 was 10.7% (44 out of 412 devices), with a period prevalence of 27.7% (114 out of 412 devices) throughout the audit period.

Feasibility and acceptability of implementing an evidence-based ESCALATION system for paediatric clinical deterioration.

BACKGROUND: The ESCALATION system is a novel paediatric Early Warning System that incorporates family involvement and sepsis recognition. This study aimed to assess the feasibility and iteratively refine the ESCALATION system in a variety of hospital settings in preparation for full-service implementation. METHODS: A series of four multi-methods studies using an Implementation Science and co-design approach were conducted. We examined concepts of implementation, context, and mechanisms of action across a variety of hospitals. Data collected included practice and chart audits, surveys (health professionals), interviews (families) and focus groups (health professionals). Quantitative data were analysed descriptively with qualitative findings assessed by content analysis or thematic analysis. RESULTS: There were 650 audits (Study I-IV), 205 health professional survey responses (Study I), 154 health professionals participated in focus groups (Study II-IV), 13 parents of hospitalised children interviewed (Study I), and 107 parents reported their involvement in the ESCALATION system (Study III-IV). Each of the studies further refined and confirmed the feasibility, specifically the components of family involvement and the sepsis recognition pathway. CONCLUSION: The Implementation Science evaluation of the ESCALATION system resulted in a uniform approach that was feasible and acceptable to users and appropriate for full-service implementation. IMPACT: This series of four studies used a co-production approach built on the Medical Research Council framework to understand feasibility and acceptability of an intervention to improve recognition and response to clinical deterioration in children to the point of full-service implementation. We have reported a detailed, systematic approach to assessing feasibility and acceptability of a complex intervention using established methodologies for whole of health system implementation. The ESCALATION System is an evidence based paediatric early warning system that is a highly refined, well accepted and accommodates a health system that has substantial contextual variation.

Care management trajectories of infants with life-limiting conditions who died before 12 months of age; a retrospective patient health record review.

PURPOSE: To characterise the care management trajectories of infants with life-limiting conditions, who died before 12 months, including clinical decision-making processes, identification of triggers that led to changes in care management from cure-orientated to palliative care and specialist palliative care team involvement. DESIGN AND METHODS: Retrospective patient health record review of infants with life-limiting conditions who died before 12 months of age and received care at three hospitals in Western Australia. Two data analysis methods; directed content analysis and process mapping. RESULTS: A total of 45 patient health records were reviewed. Process mapping led to typology of care management encompassing four trajectories; early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until a significant point; and early treatment limits. Standardised advance care planning processes were used for just over 10% of infants. There was specialist palliative care team involvement for 25% of infants. CONCLUSION: Only a proportion of infants received early integration of palliative care principles and practices. Infants and their families may benefit from earlier integration of palliative care, and standardised processes for advance care planning that are done in parallel to treatment. PRACTICE IMPLICATIONS: There is opportunity to further enhance the delivery of palliative care to infants with life-limiting conditions and optimise the experience for families through education for health professionals, implementation of advance care planning and standardisation through policies and clinical practice guidelines.

Effect of infusion set replacement intervals on catheter-related bloodstream infections (RSVP): a randomised, controlled, equivalence (central venous access device)-non-inferiority (peripheral arterial catheter) trial.

BACKGROUND: The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters. METHODS: We did a randomised, controlled, assessor-masked trial at ten Australian hospitals. Our hypothesis was CRBSI equivalence for central venous access devices and non-inferiority for peripheral arterial catheters (both 2% margin). Adults and children with expected greater than 24 h central venous access device-peripheral arterial catheter use were randomly assigned (1:1; stratified by hospital, catheter type, and intensive care unit or ward) by a centralised, web-based service (concealed before allocation) to infusion set replacement every 7 days, or 4 days. This included crystalloids, non-lipid parenteral nutrition, and medication infusions. Patients and clinicians were not masked, but the primary outcome (CRBSI) was adjudicated by masked infectious diseases physicians. The analysis was modified intention to treat (mITT). This study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12610000505000 and is complete. FINDINGS: Between May 30, 2011, and Dec, 9, 2016, from 6007 patients assessed, we assigned 2944 patients to 7-day (n=1463) or 4-day (n=1481) infusion set replacement, with 2941 in the mITT analysis. For central venous access devices, 20 (1·78%) of 1124 patients (7-day group) and 16 (1·46%) of 1097 patients (4-day group) had CRBSI (absolute risk difference [ARD] 0·32%, 95% CI -0·73 to 1·37). For peripheral arterial catheters, one (0·28%) of 357 patients in the 7-day group and none of 363 patients in the 4-day group had CRBSI (ARD 0·28%, -0·27% to 0·83%). There were no treatment-related adverse events. INTERPRETATION: Infusion set use can be safely extended to 7 days with resultant cost and workload reductions. FUNDING: Australian National Health and Medical Research Council.

Prevalence of high flow nasal cannula therapy use for management of infants with bronchiolitis in Australia and New Zealand.

AIM: To determine the prevalence of high flow nasal cannula (HFNC) therapy in infants presenting to hospital in Australia and New Zealand with bronchiolitis over four bronchiolitis seasons. Secondary aims were to determine temporal trends in HFNC use, and associations between HFNC, hospital length of stay (LOS) and intensive care unit (ICU) admission. METHODS: A planned sub-study of a multi-centre international cluster randomised controlled trial investigating knowledge translation strategies for a bi-national bronchiolitis guideline. Demographics, management and outcomes data were collected retrospectively for infants presenting with bronchiolitis to 26 hospitals between 1 May 2014 and 30 November 2017. Prevalence data are presented as absolute frequencies (95% confidence interval (CI)) with differences between groups for continuous and categorical variables analysed using linear and logistic regression, respectively. RESULTS: 11 715 infants were included with 3392 (29.0%, 95% CI (28.1-29.8%)) receiving oxygen therapy; of whom 1817 (53.6%, 95% CI (51.9-55.3%)) received HFNC. Use of oxygen therapy did not change over the four bronchiolitis seasons (P = 0.12), while the proportion receiving HFNC increased (2014, 336/2587 (43.2%); 2017, 609/3720 (57.8%); P ≤ 0.001). Infants who received HFNC therapy were not substantially different to infants who received oxygen therapy without HFNC. HFNC use was associated with increases in both hospital LOS (P < 0.001) and ICU admissions (P < 0.001). CONCLUSION: Use of HFNC therapy for infants with bronchiolitis increased over 4 years. Of those who received oxygen therapy, the majority received HFNC therapy without improvement in hospital LOS or ICU admissions. Strategies to guide appropriate HFNC use in infants with bronchiolitis are required.

Aboriginal perspectives on recognising clinical deterioration in their child and communicating concerns to clinicians.

AIMS AND OBJECTIVES: To explore the perspectives of family members of Aboriginal children about a) their involvement in recognising clinical deterioration in a hospital setting and b) the effectiveness of a poster designed to promote family involvement. BACKGROUND: To assist in the early recognition and response to clinical deterioration for hospitalised children, many escalation of care processes now include family involvement. Little is currently known about the perspectives of Australian Aboriginal families in recognising deterioration in their child and raising the alarm, or if current escalation of care systems meet the needs of Aboriginal families. DESIGN: Qualitative pragmatist approach using semi-structured interviews. METHODS: Seven interviews were conducted with five mothers and two grandmothers of Aboriginal children who were inpatients at a children's hospital. Thematic analysis was undertaken. FINDINGS: Two themes were identified: Theme one was: Family role in recognising and responding to clinical deterioration, with two subthemes of knowing when to worry and communicating concerns. Participants reported that some families needed more knowledge to recognise clinical deterioration. Communication barriers between families and clinicians were identified. Theme two was: Effective visual communication with three subthemes of linguistic clarity, visual appeal and content. CONCLUSIONS: Additional strategies are needed to promote effective communication between clinicians and families of Aboriginal children in hospital. Posters were considered effective, particularly if including a cultural connection, images and simplified language. PRACTICE IMPLICATIONS: These insights provide important information for health professionals and health service managers to be aware that additional communication strategies are required to support Aboriginal family involvement in recognising clinical deterioration and escalation of care.

Pediatric and child health nursing: A three-phase research priority setting study in Western Australia.

PURPOSE: Priority settings are important to plan and direct future research. The aim of this study was to identify the top ten pediatric and child health nursing research priorities from the perspectives of consumers, community, and healthcare professionals in Western Australia. DESIGN AND METHODS: This study used an adapted James Lind Alliance Priority Setting Partnership design with three phases. 1) A planning workshop to inform a survey. 2) A survey using five open-ended-questions distributed between October 2020 and January 2021 through social media and healthcare professionals' emails. Responders' statements were analyzed with content analysis. 3) A consensus workshop to finalize and rank the themes. RESULTS: The planning workshop participants (n = 25) identified gaps such as community child healthcare and confirmed lack of consumer engagement in previous studies. The survey responses (n = 232) generated 911 statements analyzed into 19 themes. The consensus workshop participants (n = 19) merged and added themes, resulting in 16 final themes. The top three ranked themes were: 'access to service', 'mental health and psychological wellbeing', and 'communication'. CONCLUSIONS: The research themes are necessarily broad to capture the wide range of issues raised, reflecting the scope of pediatric and child health nursing. PRACTICE IMPLICATIONS: The priorities will inform future research to be directed to areas of priority for stakeholders who have often not had a say in setting the research agenda.

Development of an evidence-based ESCALATION system for recognition and response to paediatric clinical deterioration.

AIM: The aim of this study was to develop an evidence-based paediatric early warning system for infants and children that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care. METHODS: A three-stage intervention development framework consisted of Stage 1: evidence review, benchmarking, stakeholder (health professionals, decision-makers, and health consumers) engagement, and consultation; Stage 2: planning and coproduction by the researchers and stakeholders using action research cycles; and Stage 3: prototyping and testing. RESULTS: A prototype evidence-based system incorporated human factor principles, used a structured approach to patient assessment, promoted situational awareness, and included family as well as clinician concern. Family involvement in detecting changes in their child's condition was supported by posters and flyers codesigned with health consumers. Five age-specific observation and response charts included 10 weighted variables and one unweighted variable (temperature) to convey a composite early warning score. The escalation pathway was supported by a targeted communication framework (iSoBAR NOW). CONCLUSION: The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was a novel component of the system.

The support needs of parent caregivers of children with a life-limiting illness and approaches used to meet their needs: A scoping review.

BACKGROUND: Provision of paediatric palliative care is complex and optimally covers meeting the individual needs of a heterogenous population of children and their parent caregivers throughout a life-limiting illness. It is unclear whether existing approaches comprehensively address parent caregivers' needs. AIM: To examine support needs of parents caring for children with life limiting illnesses and identify specific approaches used to identify and address needs. DESIGN: A scoping review. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL and ProQuest Central, were searched for peer reviewed English language full text research published from 2008 to 2019. Study quality appraisal was undertaken. Fourteen quantitative, 18 qualitative and 12 mixed methods studies were synthesised and themed using summative content analysis and mapped to the Parent Supportive Care Needs Framework (PSCNF). RESULTS: Themes were communication, choice, information, practical, social, psychological, emotional and physical. Communication and choice were central and additional to domains of the PSCNF. Unmet were needs for supporting siblings, for respite care, out of hours, psychological, home and educational support. Six articles reported using instruments to identify parent carer support needs. CONCLUSION: Support needs of parent caregivers of children with life limiting illnesses are substantial and heterogenous. While studies report evidence of burden and distress in parent caregivers, this rarely translates into improvements in practice through the development of interventions. A systematic and regular assessment of individual parent caregiver support needs is required by using instruments appropriate to use in clinical practice to move the focus to palliative care interventions and improved services for parents.

Use of professional interpreters for children and families with limited English proficiency: The intersection with quality and safety.

AIM: Linguistic diversity is increasing nationally; patients with limited English proficiency require provision of professional interpreters. We reviewed hospital-wide use of interpreters for low English proficiency in a tertiary hospital across emergency (ED), outpatient and inpatient presentations. METHODS: Two cohorts with low English proficiency presenting to Princess Margaret Hospital were audited. Records of new Refugee Health Service patients (presenting between January and July 2015) and non-Refugee Health Service low English proficiency patients (obtained through Language Services bookings) were reviewed to assess demographic profiles and use of interpreters for any occasion of service over the following 12 months (for each patient). RESULTS: Data from 188 patients were reviewed (Refugee Health Service: 119 patients; non-Refugee Health Service: 69 patients; total 1027 occasions of service); all were under 18 years of age. High socio-economic disadvantage and limited education was noted. Almost all (98.5%) had low English proficiency; 3 Refugee Health Service parents spoke English; 68% of non-Refugee Health Service patients were in families previously transitioned from that service. Interpreter use was poor across all areas. Thirty-four patients had 46 inpatient admissions with documented interpreter use for 59% (20/34) of these. All patients underwent at least one procedure, with no instances of interpreter documentation for procedure consent. Documented interpreter use was minimal in outpatient occasions of service (32/118, 27% Refugee Health Service; 18/222, 8% non-Refugee Health Service). Only one Refugee Health Service patient had evidence of ED interpreter use, out of 78 ED occasions of service (34 patients). CONCLUSIONS: Despite documented low English proficiency, suboptimal and inadequate use of professional interpreters persists. Low English proficiency patients are vulnerable, with socio-economic disadvantage, likely to impact on health outcomes and compliance. Organisational risk also is highlighted, including impact on clinical handover, informed consent and non-compliance with state language services policy. Further staff education and quality improvement work is essential.

A Scoping Review of Nursing Research Priorities in Pediatric Care.

PROBLEM: Priority setting for pediatric nursing is important to plan, coordinate and direct future research. The aim of this scoping review was to systematically identify and synthesise the nature, range and extent of published pediatric nursing research priorities. ELIGIBILITY CRITERIA: English language full text publications focusing generic nursing research priorities for the child or adolescent, indexed in CINAHL, EMBASE, The Cochrane Database of Systematic Reviews, AMED, MEDLINE and PsycINFO and published from 2008 to 2019. SAMPLE: A total of 789 citations were identified, 44 full text articles were retrieved and assessed for eligibility and eight studies were finally reviewed, quality assessed (CREDES) and synthesised. RESULTS: All eight studies used a consensus building method to identify research priorities reported by nurses. Six used Delphi technique, one Nominal Group Technique (NGT) and one consensus workshop. CREDES score range was 10-14 of a possible 16. Synthesis of the 234 nursing research priorities generated four themes; evidenced-based practice, pediatric context, child and family-centered care; pediatric nursing, with 14 subthemes. CONCLUSION: The nursing research priorities reported appear to be still current and important to nurses. There was a focus on acute care, with fewer priorities reflecting areas of child-, school-, or mental- health. Consumer and community priorities have not been reported. IMPLICATIONS: These nursing research priorities can be used to inform the national or local research agenda, although there is a need to establish priorities from the perspective of all stakeholders and in particular, identify what is important to consumers.

Parent escalation of care for the deteriorating child in hospital: A health-care improvement study.

OBJECTIVE: To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition. DESIGN: Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework. METHODS: Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups. SETTING: Australian specialist paediatric hospital. PARTICIPANTS: Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses. MAIN OUTCOME MEASURES: Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation. RESULTS: Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review. CONCLUSIONS: There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

Development of a position statement for Australian critical care nurse education.

Position statements are used by large organisations such as the Australian College of Critical Care Nurses to publically present an official philosophy or beliefs and to propose recommendations. Position statements are increasingly used by health departments and healthcare facilities to allocate resources and to guide and audit nursing practice, yet there are limited resources on the process of their development. A position statement should help readers better understand the issue, communicate solutions to problems, and inform decision-making. It should be supported by the highest level of evidence available and reflect the organisation's governing objectives and goals. In this article, we describe the structured approach used to develop a position statement for Australian critical care nurse education. The formation of an expert advisory panel, synthesis of available evidence using Whittemore and Knafl's integrative review methodology, use of Donabedian's structure-process-outcomes quality framework as a theoretical approach, and multiple layers of consensus building and consultation enabled the development of an important critical care document and informed an implementation plan. The framework and processes we have outlined in this discussion article may provide a useful starting point for other professional organisations wishing to develop similar position statements.

Structures, processes and outcomes of specialist critical care nurse education: An integrative review.

OBJECTIVES: The objective of this study was to review and synthesise international literature to reveal the contemporary structures, processes, and outcomes of critical care nurse (CCN) education. METHOD: An integrative review on specialist critical care education was guided by Whittemore and Knafl's integrative review steps: problem identification; literature search; and data evaluation, analysis, and presentation. Donabedian's Quality Framework (Structure-Process-Outcome) provided a useful analytical lens and structure for the reporting of findings. RESULTS: (1) Structures for CCN education incorporated transition-to-practice and ongoing education programs typically offered by hospitals and health services and university-level graduate certificate, diploma, and masters programs. Structural expectations included a standard core curriculum, clinically credible academic staff, and courses compliant with a higher education framework. Published workforce standards and policies were important structures for the practice learning environment. (2) Processes included incremental exposure to increasing patient acuity; consistent and appropriately supported and competent hospital-based preceptors/assessors; courses delivered with a flexible, modular approach; curricula that support nontechnical skills and patient- and family-centred care; stakeholder engagement between the education provider and the clinical setting to guide course planning, evaluation and revalidation; and evidence-based measurement of clinical capabilities/competence. (3) Outcomes included articulation of the scope and levels of graduate attributes and professional activities associated with each level. The role of higher degree research programs for knowledge creation and critical care academic leadership was noted. CONCLUSIONS: Provision of high-quality critical care education is multifaceted and complex. These findings provide information for healthcare organisations and education providers. This may enable best practice structures and processes for critical care specialist training that meets the needs of industry and safely supports developing CCN expertise. There is an acknowledged tension between the expectations of governing bodies for policies, standards, and position statements to enhance quality and reduce care variance and the availability of high-quality evidence to underpin these across international contexts.

The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline.

BACKGROUND: Bronchiolitis is the commonest respiratory infection in children less than 12 months and cause of hospitalisation in infants under 6 months of age in Australasia. Unfortunately there is substantial variation in management, despite high levels of supporting evidence. This paper reports on the process, strengths and challenges of the hybrid approach used to develop the first Australasian management guideline relevant to the local population. METHOD: An adaption of the nine steps recommended by the National Health and Medical Research Council (NHMRC) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology were utilised. Following establishment of the Guideline Development Committee (GDC), we identified the population, intervention, comparator, outcomes and time of interest (PICOt) questions, undertook a systematic literature search and graded the evidence and recommendations using the NHMRC and GRADE processes. Using Nominal Group Techniques (NGT), consensus was sought in formulating the clinical practice recommendations and practice points. Key health professional bodies were consulted to ensure relevance in the Australasian emergency and ward settings. RESULTS: From 33 PICOT questions, clinical recommendations for practice that were deemed relevant to the Australasian population were identified. Specific considerations for the management of Australian and New Zealand indigenous infants in relation to the use of azithromycin and risk factors for more serious illness are included. Using NGT, consensus demonstrated by a median Likert score > 8 for all recommendations was achieved. The guideline presents clinical guidance, followed by the key recommendations and evidence review behind each recommendation. CONCLUSION: Developing evidence-based clinical guidelines is a complex process with considerable challenges. Challenges included having committee members located over two countries and five time zones, large volume of literature and variation of member's knowledge of grading of evidence and recommendations. The GRADE and NHMRC processes provided a systematic and transparent approach ensuring a final structure including bedside interface, and a descriptive summary of the evidence base and tables for each key statement. Involvement of stakeholders who will ultimately be end-users as members of the GDC provided valuable knowledge. Lessons learnt during this guideline development process provide valuable insight for those planning development of evidence-based guidelines.

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

OBJECTIVE: To identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H). DESIGN: Audits, semi-structured interviews and focus groups guided by the Theoretical Domains Framework. SETTING: Australian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months. PARTICIPANTS: Four children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members. MAIN OUTCOME MEASURES: Parent awareness and involvement in escalating care and factors impacting implementation of C4H. RESULTS: Two audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents' information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent-staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture. CONCLUSIONS: Although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.

What nurses and midwives want: Findings from the national survey on workplace climate and well-being.

AIM: A discussion of the findings from a nationwide study of workplace and well-being issues of Australian nurses and midwives. BACKGROUND: Current discourse only provides a fragmented understanding of a multifaceted nature of working conditions and well-being, necessitating a more holistic investigation to identify critical workplace issues within these professions. DESIGN: Discussion paper. DATA SOURCES: A national survey conducted in July 2016 involving Australian Nursing and Midwifery Federation members. The literature supporting this paper focuses on the nursing and midwifery workforce and studies on attraction and retention issues. IMPLICATIONS FOR NURSING AND MIDWIFERY: Workplace policies and practices in place in health care organizations that are within the control of management are key factors in the negative issues associated with the profession from the survey. Proactive and targeted interventions particularly aimed at salient issues of work intensification, declining engagement, and effective voice mechanisms are needed to address these crucial issues if the attrition of individuals from nursing and midwifery occupations is going to be ameliorated. CONCLUSION: To alleviate workforce issues pushing nurses and midwives to the tipping point of exiting the professions, health care organizations need to take a proactive stance in addressing issues under the control of management.

Empowering Parents of Australian Infants and Children in Hospital: Translation, Cultural Adaptation, and Validation of the EMpowerment of PArents in The Intensive Care-30-AUS Questionnaire.

OBJECTIVES: To translate, culturally adapt, and psychometrically test the EMpowerment of PArents in The Intensive Care-30 questionnaire in Australian pediatric critical care, neonatal, and pediatric ward settings. DESIGN: Cross-sectional, descriptive, multicenter study conducted in two phases; 1) translation and cultural adaptation and 2) validation of the EMpowerment of PArents in The Intensive Care-30 questionnaire. SETTINGS: Two Western Australian sites, the PICU and two pediatric wards of a children's hospital and the neonatal unit of a women's and newborn hospital. PARTICIPANTS: Parents whose baby or child was admitted to the participating wards or units with a length of hospital stay greater than 24 hours. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Phase 1: A structured 10-step translation process adhered to international principles of good practice for translation and cultural adaptation of patient-reported outcomes. Thirty parents participated in cognitive debriefing. Phase 2: A total of 328 parents responded to the EMpowerment of PArents in The Intensive Care-30-AUS questionnaire. Reliability was sufficient (Cronbach α at domain level 0.70 -0.82, for each clinical area 0.56-0.86). Congruent validity was adequate between the domains and three general satisfaction items (rs 0.38-0.69). Nondifferential validity showed no significant effect size between three patient or parent demographic characteristics and the domains (Cohen's d < 0.36). Between the different clinical areas, significant differences in responses were found in all domains. CONCLUSIONS: The translated and culturally adapted EMpowerment of PArents in The Intensive Care-30-AUS is a reliable and valid questionnaire to measure parent-reported outcomes in pediatric critical care, pediatric ward, and neonatal hospital settings. Using this questionnaire can provide a framework for a standardized quality improvement approach and identification of best practices across specialties, hospital services and for benchmarking similar health services worldwide.

Hearing voices: Comparing two methods for analysis of focus group data.

AIM: This paper compares two qualitative approaches used to thematically analyse data obtained from focus groups conducted with critical care nurses from Australia. BACKGROUND: Focus groups are an effective mechanism to generate understanding and gain insight into the research participants' world. Traditional verbatim transcription of participants' recorded words necessitates significant investment of time and resources. An alternative approach under reported in the literature is to directly analyse the audio recordings. To identify the effectiveness of the audio recording only approach, the study aimed to independently compare two qualitative methods of data analysis, namely the traditional transcribed method with the audio recording method. METHODS: The study to revise the specialist critical care competency standards included focus groups conducted in each state in Australia (n=12) facilitated by experienced researchers. Two of the research team analysed transcribed focus group data and two team members were blinded to the transcription process and directly analysed audio recordings from the focus groups. A process of thematic analysis used independently by the two teams was used to identify themes. RESULTS: When the findings were compared, the themes generated using each technique were consistent and there were no different themes or subthemes identified. The two techniques appeared to be comparable. Overarching key themes were consistent with the approach. CONCLUSION: The direct analysis method appears to have advantages. It is cost effective, trustworthy and possibly a superior alternative when used with focus group data. However, the audio only method requires experienced researchers who understand the context and if combining the two approaches takes time to do.

A two phase study to revise the Australian Practice Standards for Specialist Critical Care Nurses.

BACKGROUND: Observational work to develop the ACCCN Competency Standards was undertaken more than 20 years ago. Since then the landscape of critical care nursing as a specialty has changed and it is not known if the Competency Standards reflected contemporary practice. OBJECTIVES: To revise the ACCCN Competency Standards for Specialist Critical Care Nurses to ensure they continue to meet the needs of critical care nurses and reflect current practice. METHODS: A two-phased project was undertaken. In Phase I focus groups were held in all states. Thematic analysis was conducted using two techniques. The standards were revised based on the main themes. Phase II consisted of an eDelphi technique. A national panel of critical care nurses responded to three survey rounds using a 7 point likert-type scale to indicate their level of agreement with the revised standards. A 70% agreement level for each statement was determined a priori. RESULTS: Phase I: 12 focus groups (79 participants) were conducted. Phase II: A panel of specialist critical care nurses (research, management, clinical practice and education) responded to round 1 (n=64), round 2 (n=56), and round 3 (n=40). Fifteen practice standards with elements and performance criteria were grouped into four domains (professional practice, provision and coordination of care, critical thinking and analysis, collaboration and leadership). The revised Practice Standards for Specialist Critical Care Nurses build upon and are additional to the Nursing & Midwifery Board of Australia National Competency Standards for Registered Nurses. The standards reflect contemporary critical care nurse practices using an expanded range of technologies to care for complex critically ill patients across the lifespan in diverse settings. CONCLUSION: The national study has resulted in the 3rd edition of the Practice Standards for Specialist Critical Care Nurses. There was input from stakeholders and agreement that the revised standards capture contemporary Australian critical care nursing practice.