Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings.

BACKGROUND: Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system. METHODS: A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis. RESULTS: A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation. CONCLUSION: Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.

Hospital Testing of the Effectiveness of Co-Designed Educational Materials to Improve Patient and Visitor Knowledge and Confidence in Reporting Patient Deterioration.

BACKGROUND: Co-designed educational materials could significantly improve the likelihood of patients and visitors (consumers) escalating care through hospital systems. The objective was to investigate patients' and visitors' knowledge and confidence in recognizing and reporting patient deterioration in hospitals before and after exposure to educational materials. METHODS: A multimethod design involved a convenience sample of patients and visitors at a South Australian hospital. Knowledge and confidence of participants to report patient deterioration was assessed using a validated questionnaire. Baseline group was surveyed, and a second group was surveyed after exposure to a poster and on-hold message relating to consumer-initiated escalation-of-care. Nominal data were examined using chi-square analysis, and ordinal data using the Mann-Whitney U test. Open-ended questions were examined using thematic analysis. RESULTS: A total of 407 participants completed the study, 203 undertook the baseline survey, and 204 the postintervention survey. Respondents exposed to the educational materials reported significantly higher recognition of responsibility to report concerns about patient deterioration compared to controls (86.3% vs. 73.1%; p = 0.007). Respondents exposed to the educational materials also had better ability to identify signs that a patient was becoming sicker compared to controls (77.5% vs. 71.3%, p = 0.012). Four overarching themes emerged from the questions: patient/visitor understanding of key messages, patient/visitor recognition of deterioration, patient/visitor response to deterioration and patient/visitor recommendations. CONCLUSION: Following educational interventions, patients and visitors report improved awareness of their role in recognizing and responding to clinical deterioration. They advise additional active interventions and caution that the materials should accommodate language, cultural, and disability needs.

Exploration of Ward-Based Nurses' Perspectives on Their Preparedness to Recognize Clinical Deterioration: A Scoping Review.

BACKGROUND: Despite initiatives in the early recognition of clinical deterioration, the incidence of failure to recognize clinical deterioration in patients continues to occur contributing to the ongoing rise of in-hospital mortality and morbidity. OBJECTIVE: The aim of the study was to explore and appraise the research evidence that related to ward-based nurses' preparedness to recognize the clinically deteriorating patient. METHODS: A scoping review was undertaken as this approach enabled the researchers to investigate the breadth of the available evidence through broad inclusion criteria. A comprehensive database search was conducted through the Cochrane Library; Cumulative Index to Nursing and Allied Health Literature; MEDLINE; ProQuest; PubMed; and Wiley Online Library. Each article was critically appraised and analyzed using a critical appraisal tool and thematic analysis, respectively. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist. RESULTS: Twelve primary sources of literature met the eligibility criteria. Through thematic analyses 6 primary themes were identified: implication of experience on preparedness; interprofessional and intraprofessional relationships; knowledge of calling criteria, process and procedures; requirement for a supportive system and culture; existence of hierarchy within healthcare impacting care; and clinical deterioration as an education opportunity. CONCLUSIONS: This review identified central issues that impacted on ward-based nurses' preparedness. Further development of collaborative, supportive professional relationships across-and-within disciplines is needed. Effective use of clinical deterioration situations as educational opportunities would also assist nurses' preparedness through skill and knowledge development. However, more research evidence will be needed because of the limited data available on the topic.

Towards reduction of preventable hospital readmission: Older people and family members' views on planned self-management of care at home.

AIMS AND OBJECTIVES: To reduce the likelihood of preventable readmissions, the aim was to investigate how older people (with their family members) managed their chronic health conditions at home following hospital discharge. The objectives explored older people and their family members' perspectives on how discharge plans assisted self-management of their chronic conditions, their recognition of deterioration and when to seek treatment/re-attend hospital. BACKGROUND: Chronic conditions have challenged older adults' self-management, particularly after hospital discharge and can impact on preventable readmission. Few studies have examined patients' and their family members' perspectives on the management of their conditions at home after hospitalisation. DESIGN: A qualitative exploratory design known as Interpretive Description was utilised. METHODS: Purposeful sampling involved 27 community-dwelling older adults; nineteen were discharged patients with one or more chronic health conditions. Eight nominated family members were also recruited to enhance understanding of the older persons' self-management at home. Interviews were undertaken and thematic data analysis followed the COREQ guidelines. RESULTS: Five themes emerged: (1) Post-Discharge Advice; (2) Managing at Home; (3) Recognition and Response to Deterioration; (4) Community Care and Support; and (5) The "Burden" on Others of Post-Discharge Care. CONCLUSION: Older people sought a clear plan for self-management at home prior to discharge. This plan should contain potential signs of deterioration and guidance on future action. We found that support given to older people from family and friends was critical to prevent readmission. In addition, their local General Practitioner and Pharmacist played an essential part in the support of their care. For some, social support services were also important. Nurse telephone follow-up in the week following discharge was mostly absent. However, this strategy would be strongly recommended. RELEVANCE TO CLINICAL PRACTICE: To mitigate against preventable readmission, we recommend the above strategies to assist the older person at home with self-management of their chronic conditions.

Could standing orders have a place? A phenomenological exploration of experienced ward-based registered nurses' views on the escalation protocol for patient deterioration.

AIMS AND OBJECTIVES: To explore experienced ward-based Registered Nurses' views on the potential use of standing orders, prior to the escalation protocol, for patient deterioration. BACKGROUND: Ward based nurses are required to follow set steps of the escalation protocol. The introduction of standing order policies would allow nurses to intervene earlier when deterioration was first detected. DESIGN: Hermeneutic Phenomenology. METHODS: Ten experienced ward-based RNs were recruited. Semi-structured interviews were conducted, with the data subjected to thematic analysis. Diekelmann's framework was used to analyse the texts, seeking the highest level of hermeneutic analysis namely, a constitutive pattern. COREQ guidelines were utilised. RESULTS: Four main themes emerged: (1) Ambiguity in perception: the escalation protocol; (2) Observations within acceptable parameters, but the patient is deteriorating; (3) Paradoxes of escalation: well laid out protocol, but hard to escalate; (4) We could intervene with standing orders, but are we permitted? The constitutive pattern namely, Dualism in Perception related to the dissonance conveyed by participants regarding the escalation protocol. CONCLUSIONS: Notwithstanding the benefits of the escalation protocol for junior staff, the RNs offered critique of the established escalation practices and the restrictive role of the protocol. Another aspect of the protocol, that is 'worried criterion' was viewed positively. The participants expressed a desire to apply nurse-driven standing orders, to enable them to intervene earlier for patient deterioration. RELEVANCE TO CLINICAL PRACTICE: Organisations should consider new policies introducing standing orders for implementation by experienced RNs. The engagement of experienced ward-based nurses in forming 'patient at-risk teams' could assist organisations to deal with cases of clinical deterioration prior to activation of the escalation of care protocol.

You're Worried, We're Listening: Online Testing of the Effectiveness of Education Materials to Improve Consumer Knowledge and Confidence in Reporting Patient Deterioration.

OBJECTIVES: Early identification of patient deterioration in hospital is important to reduce mortality, avoidable morbidity, length of stay, and associated healthcare costs. By closely observing physical and behavioral changes, deteriorating patients are more likely to be identified. Patients and family at the bedside can play an important role in reporting deterioration if made aware of how to do so. Therefore, the objective of this study was to undertake an online evaluation of educational materials designed to improve consumers' knowledge and confidence to report patient deterioration. METHODS: A convenience sample was used to recruit community-based participants for an online survey. A self-designed validated instrument was used to undertake a preintervention and postintervention test involving 3 types of educational materials. Quantitative data were analyzed with Wilcoxon signed rank test to compare participants' knowledge and confidence before and after exposure to the intervention. Conventional content analyses examined responses on key messages and recommendations to improve the educational materials. RESULTS: A total of 84 respondents completed both prequestionnaires and postquestionnaires. After exposure to the education materials, analyses confirmed that knowledge and confidence scores were significantly higher than baseline measures. Content analyses indicated a clear understanding of the key messages presented in the materials. Four main recommendations were made regarding the education materials. CONCLUSIONS: Participants readily identified the key messages in the educational materials and demonstrated increased knowledge and confidence to report concerns about deterioration. Further research is required to determine the efficacy of the educational materials in relation to consumer behavior.

Development and Validation of an Evaluation Tool of Consumers' Knowledge and Confidence to Report Patient Deterioration in Hospitals.

OBJECTIVES: Studies have shown that many preventable hospital deaths may be reduced through early reporting of deterioration by patients and their visitors to health professionals. Engagement of patients and families for safer health care was recommended by the World Health Organization. As no validated tool was identified, the objective of the study was to develop and validate a tool to measure the impact of messages contained in self-developed educational materials on consumers' knowledge and confidence to report patient deterioration. METHODS: A tool was created using consumer-based input. A test-retest methodology was used 2 weeks apart, using 37 participants sourced from consumer groups. Fourteen 5-point Likert scale questionnaire items were categorized into knowledge and confidence components to identify the impact of the materials in both of these areas. RESULTS: Test-retest reliability confirmed 10 of the 14 proposed questionnaire items (4 knowledge items and 6 confidence) had at least moderate κ agreement ranging from 0.42 to 0.69 and an intraclass correlation coefficient of 0.66. An exploratory factor analysis of the 10 remaining items indicated a 2-factor solution had the best interpretability accounting for 96.9% of variability. The Cronbach α and factor loadings for the factors, knowledge, and confidence suggested an acceptable level of reliability and validity. CONCLUSIONS: The study confirms our tool for assessment of educational materials to be a reliable, context-specific, and validated instrument. The tool is an appropriate instrument to assess the effectiveness of educational materials in public awareness campaigns that focus on consumer reporting of patient deterioration within hospitals.

Conflict between nursing student's personal beliefs and professional nursing values.

BACKGROUND: Studies have established that negative perceptions of people living with HIV/AIDS exist among nursing students throughout the world, perceptions which can be detrimental to the delivery of high-quality nursing care. OBJECTIVES: The purpose of this research was to explore socio-cultural influences on the perceptions of nursing students towards caring for people living with HIV/AIDS. RESEARCH DESIGN: The study was guided by stigma theory, a qualitative descriptive research approach was adopted. Data collected via semi-structured interviews were thematically analysed. PARTICIPANTS AND RESEARCH CONTEXT: Participants were 21 international and Australian undergraduate nursing students enrolled in a Bachelor of Nursing programme at an Australian university. ETHICAL CONSIDERATIONS: Ethical approval was granted by the Social and Behavioural Research Ethics Committee at the study university. Participation was entirely voluntary; informed consent was obtained before the study commenced; confidentiality and anonymity were assured. FINDINGS: Three major themes were found: blame, othering and values. Complex and interrelated factors constructed participant perceptions of people living with HIV/AIDS, perceptions underscored by the prevailing culturally construed blame and othering associated with HIV/AIDS. The study found discordance between the negative personal beliefs and perceptions some nursing students have towards people living with HIV/AIDS, and the professional values expected of them as Registered Nurses. DISCUSSION: There was considerable commonality between this and previous studies on how homosexuality and illicit drug use were perceived and stigmatised, correlating with the blame directed towards people living with HIV/AIDS. These perceptions indicated some nursing students potentially risked not fulfilling the ethical and professional obligations the Registered Nurse. CONCLUSION: Nursing curriculum should be strengthened in relation to comprehending the meaning of being stigmatised by society. Educational institutions need to work towards enhancing strategies that assist nursing students to reconcile any incongruity between their personal beliefs and requisite professional nursing values.

Do User-Applied Safety Labels on Medication Syringes Reduce the Incidence of Medication Errors During Rapid Medical Response Intervention for Deteriorating Patients in Wards? A Systematic Search and Review.

INTRODUCTION: Intravenous medication errors (MEs) occur during medical emergency situations. An initiative, not yet in common practice, that could address these errors is safety labeling. The aim of this review was to identify and appraise research evidence related to the impact of user-applied medication safety labeling on reducing the incidence of MEs during rapid medical response intervention for patient deterioration in the ward setting. METHODS: A systematic search and review framework was used to conduct the review. A comprehensive database search was conducted of BioMed Central, Clinical Trials, Cumulative Index to Nursing and Allied Health Literature, Expanded Academic ASAP, Joanna Briggs Institute, MEDLINE, OVID, ProQuest Central, PubMed, Wiley Online Library, and World Health Organization Library. The Young and Solomon (2009) critical appraisal tool was used to critically appraise the identified research articles. Each article was then analyzed using a thematic network strategy to identify commonality. RESULTS: Four primary themes were identified; they were as follows: MEs occur during medical emergency responses (MERs); MEs occur throughout the medication administration process; MERs are stressful and are associated with MEs; and role of medication labeling in reducing MEs during MERs. DISCUSSION: Greater vigilance is required by health professionals during the medication administration process. The implementation of specific medication safety labeling into the MER could be beneficial in reducing the overall incidence of MEs. Further research is required to validate the merits of a MER medication safety labeling system.

Consumers' perspectives on their involvement in recognizing and responding to patient deterioration-Developing a model for consumer reporting.

BACKGROUND: Adverse events occur in health care. Detection and reporting of deterioration therefore have a critical role to play. Patient and family member (consumer) involvement in patient safety has gained powerful support amongst global policymakers. Few studies, with none taking a rigorous qualitative approach, have drawn upon consumers' experiences to establish their preferences in consumer reporting of patient deterioration programmes. OBJECTIVE: To explore consumers' experiences of previous reporting of patient deterioration; their preferred educational strategies on this role and recommended pathways in a consumer reporting of patient deterioration model. DESIGN, SETTING AND PARTICIPANTS: An interpretive, qualitative research design was utilized. Nine focus group interviews were undertaken across Adelaide, capital city of South Australia. Interviews were audio-taped, transcribed and analysed thematically. Twenty-six adults described, then reflected, on previous experiences of reporting patient deterioration. RESULTS: Overarching themes incorporated consumers' experiences and patient/family education. Three themes emerged in relation to consumers' experiences: feelings, thoughts and actions. Five themes arose on educating consumers: content, timing, format, information providers and information recipients. The consumers' deep reflections on their past reporting experiences led to the development of a new model for consumer reporting of patient deterioration. CONCLUSIONS: Consumers' views on ways to improve consumer reporting of patient deterioration processes emerged. These improvements include structured educational programmes for staff advocating open health-care professional/consumer communication, educational materials developed and tested with English-speaking and culturally and linguistically diverse consumers and a model with three consumer reporting pathways.

A mixed methods thematic review: Health-related decision-making by the older person.

AIMS AND OBJECTIVES: To undertake a mixed methods thematic literature review that explored how elderly adults approached decision-making in regard to their health care following discharge. BACKGROUND: A critical time for appropriate health decisions occurs during hospital discharge planning with nursing staff. However, little is known how the 89% of elderly living at home make decisions regarding their health care. Research into older adults' management of chronic conditions emerges as an important step to potentially encourage symptom monitoring, prevent missed care and detect deterioration. All should reduce the risk of hospital re-admission. DESIGN: A mixed methods thematic literature review was undertaken. The structure followed the PRISMA reporting guidelines for systematic reviews recommended by the EQUATOR network. METHODS: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus online databases were searched using keywords, inclusion and exclusion criteria. References drawn from relevant publications, identified by experts and published between 1995 and 2017 were also considered. Twenty-five qualitative, quantitative and mixed methods studies and reviews were critically appraised (CASP 2013) before inclusion in the review. Analysis of each study's findings was undertaken using Braun and Clarke's (2006) steps to identify major themes and sub-themes. RESULTS: Four main themes associated with health-related decision-making in the elderly were identified: "the importance of maintaining independence," "decision making style," "management of conditions at home" and "discharge planning." CONCLUSION: Health care decision preferences in the elderly emerged as highly complex and influenced by multiple factors. Development of a tool to assess these components has been recommended. RELEVANCE TO CLINICAL PRACTICE: Nurses play a vital role in exploring and understanding the influence that maintaining independence has with each patient. This understanding provides an initial step toward development of a tool to assist collaboration between patients and healthcare professionals involved in their care.

Culturally construed beliefs and perceptions of nursing students and the stigma impacting on people living with AIDS: A qualitative study.

BACKGROUND: Since HIV and AIDS were discovered, studies have demonstrated that negative perceptions and reluctance to provide care to affected people persist among nursing students throughout the world. This leads to poor quality care. OBJECTIVES: To report on a study that explored socio-cultural influences on the perceptions of international nursing students toward caring for people living with HIV/AIDS. METHODS: A qualitative descriptive research design, guided by stigma theory, was utilised. Participants were 21 international and Australian undergraduate nursing students enrolled in a Bachelor of Nursing program at an Australian university. Data were collected via semi-structured interviews in 2009 and 2011; manual thematic analysis was performed on interview data. FINDINGS: Three major themes emerged: blame; othering; values. Perceptions were influenced by complex, interrelated factors and underscored by culturally construed blame and othering. People living with HIV/AIDS were perceived as alien and assumed as homosexuals, drug users, or promiscuous. They were labelled 'bad people'. Many participants were compassionate but others struggled with differences between their personal values and professional values expected of a Registered Nurse. There was considerable variation in the degree to which participants were willing to embrace different perspectives and values. CONCLUSION: Nursing curricula is vital to patient health and wellbeing and requires increased focus on the impact of HIV/AIDS. It is important for educators to recognise that simply providing information to students does not necessarily change their existing stigmatising perceptions. By addressing the effect of being stigmatised and marginalised by society nursing care to all patients will be enhanced. Students must also reflect on their perceptions and values so as to embrace diversity.

Massage, a complementary therapy effectively promoting the health and well-being of older people in residential care settings: a review of the literature.

AIMS: To explore the potential benefits of massage within daily routine care of the older person in residential care settings. BACKGROUND: Globally, the proportion of people over 65 years is rapidly rising. Increased longevity means older people may experience a rise in physiological and psychological health problems. These issues potentially place an increased demand for quality long-term care for the older person. Complementary approaches such as massage appear to be needed in quality residential care. DESIGN: A critical literature review was undertaken. METHODS: A literature review pertaining to massage in the older resident was conducted using a range of online databases. Fourteen studies dated 1993-2012 met the inclusion criteria and were critically evaluated as suitable resources for this review. RESULTS: Evidence suggests massage may be advantageous from client and nursing perspectives. Clients' perceive massage to positively influence factors such as pain, sleep, emotional status and psychosocial health. Evidence also demonstrates massage to benefit the client and organisation by reducing the necessity for restraint and pharmacological intervention. Massage may be incorporated into care provision and adopted by care providers and family members as an additional strategy to enhance quality of life for older people. CONCLUSION: Massage offers a practical activity that can be used to enhance the health and well-being of the older person in residential care. IMPLICATIONS FOR PRACTICE: Massage offers benefit for promoting health and well-being of the older person along with potential increased engagement of family in care provision. Integration of massage into daily care activities of the older person requires ongoing promotion and implementation.

Consumer participation in early detection of the deteriorating patient and call activation to rapid response systems: a literature review.

AIMS AND OBJECTIVES: This review investigated the impact of consumer participation in recognition of patient deterioration and response through call activation in rapid response systems. BACKGROUND: Nurses and doctors have taken the main role in recognition and response to patient deterioration through hospital rapid response systems. Yet patients and visitors (consumers) have appeared well placed to notice early signs of deterioration. In response, many hospitals have sought to partner health professionals with consumers in detection and response to early deterioration. However, to date, there have been no published research-based reviews to establish the impact of introducing consumer involvement into rapid response systems. DESIGN: A critical research-based review was undertaken. METHODS: A comprehensive search of databases from 2006-2014 identified 11 studies. Critical appraisal of these studies was undertaken and thematic analysis of the findings revealed four major themes. RESULTS: Following implementation of the consumer activation programmes, the number of calls made by the consumers following detection of deterioration increased. Interestingly, the number of staff calls also increased. Importantly, mortality numbers were found to decrease in one major study following the introduction of consumer call activation. Consumer and staff knowledge and satisfaction with the new programmes indicated mixed results. Initial concerns of the staff over consumer involvement overwhelming the rapid response systems did not eventuate. Evaluation of successful consumer-activated programmes indicated the importance of: effective staff education and training; ongoing consumer education by nurses and clear educational materials. CONCLUSIONS: Findings indicated positive patient outcomes following introduction of consumer call activation programmes within rapid response systems. Effective consumer programmes included information that was readily accessible, easy-to-understand and available in a range of multimedia materials accompanied by the explanation and support of health professionals. RELEVANCE TO CLINICAL PRACTICE: Introduction of consumer-activated programmes within rapid response systems appears likely to improve outcomes for patients experiencing deterioration.

A pre-emptive pain management protocol to support self-care following vitreo-retinal day surgery.

AIMS AND OBJECTIVES: To describe the development and evaluation of a pre-emptive and multimodal pain management protocol that aims to improve patient experiences following vitreo-retinal day surgery. BACKGROUND: Vitreo-retinal surgery has been increasingly performed as day surgery that requires patients to undertake postoperative self-care, including the management of pain. While vitreo-retinal surgery is known to be painful in the convalescent period, pain management following day surgery has been described as problematic across many surgical specialties. DESIGN: One hundred patient audit and in-depth qualitative interviews with nine participants. METHODS: A pain management protocol was developed from research evidence, established knowledge and expert opinion, then implemented and evaluated. RESULTS: The pre-emptive and multimodal protocol used intravenous Parecoxib in conjunction with regional ocular anaesthesia and oral paracetamol. Parecoxib 40 mg was administered prior to discharge, and participants were instructed to take the paracetamol six hours post-regional anaesthesia. Rescue analgesia was also provided. Following implementation of the protocol in a single clinical site, low levels of pain were reported in the audited patient cohort and confirmed in the qualitatively explored experiences of nine participants. CONCLUSIONS: The results of this study were encouraging, in that post vitreo-retinal day surgery pain appeared to have been successfully self-managed with a multimodal and pre-emptive protocol. The protocol was flexible and sensitive to patient comorbidities, surgical complexity, previous experiences and medical preferences. Further research is required to consolidate the success of this protocol to effectively support patients' self-care pain management and provide capacity to generalise the findings. RELEVANCE TO CLINICAL PRACTICE: Knowledge developed through this clinically based research has the potential for informing future patient care across many sites where day surgery is an integral component of treatment for people with vitreo-retinal disease.

A qualitative study of regional anaesthesia for vitreo-retinal surgery.

AIM: The aim of this research was to collect experiential knowledge about regional ocular anaesthesia - an integral component of most vitreo-retinal surgery. BACKGROUND: Anaesthesia for vitreo-retinal surgery has predominantly used general anaesthesia, because of the length and complexity of the surgical procedure. However, recent advances in surgical instrumentation and techniques have reduced surgical times; this decision has led to the adoption of regional ocular anaesthesia for vitreo-retinal day surgery. Although regional ocular anaesthesia has been studied from several perspectives, knowledge about patients' experience of the procedure is limited. DESIGN: An interpretive qualitative research methodology underpinned by Gadamer's philosophical hermeneutics. METHODS: Eighteen participants were interviewed in-depth between July 2006-December 2007 following regional ocular anaesthesia. Interview data were thematically analysed by coding and grouping concepts. FINDINGS: Four themes were identified: 'not knowing': the time prior to the experience of a regional eye block; 'experiencing': the experience of regional ocular anaesthesia; 'enduring': the capacity participants displayed to endure regional ocular anaesthesia with the hope that their vision would be restored; and 'knowing': when further surgery was required and past experiences were recalled. CONCLUSIONS: The experience of regional ocular anaesthesia had the capacity to invoke anxiety in the participants in this study. Many found the experience overwhelming and painful. What became clear was the participant's capacity to stoically 'endure' regional ocular anaesthesia, indicating the value people placed on visual function.

Issues that impact on Aboriginal health workers' and registered nurses' provision of diabetes health care in rural and remote health settings.

UNLABELLED: Type 2 diabetes mellitus is an established health problem for Indigenous Australians. One strategy to address this issue is to educate health professionals in diabetes management and education. OBJECTIVE: The objective of this paper is to identify important issues that compromise the clinical practice of rural and remote Aboriginal health workers (AHWs) and registered nurses (RNs) who undertook an accredited Australian Diabetes Educators Association diabetes course and to suggest strategies to improve practice. DESIGN: The design used a qualitative approach and discussion schedule to elicit responses. SETTING: The setting involved two Aboriginal community controlled and seven mainstream health services in the Far Western region of New South Wales. PARTICIPANTS: The participants were experienced diabetes educators (RNs and AHWs), managers and students currently enrolled in the course (n = 17). RESULTS: The results indicated issues that compromise diabetes practice and identified strategies to improve practice. Issues were: the confusing funding practices by health providers, the duplication of health services, the lack of recognition of diabetes qualifications and the transient nature of Indigenous people. Strategies included the need for: continuous dedicated diabetes health funding, a role clarification for diabetes educators, strategic diabetes planning and the importance of diabetes educators working in partnership. CONCLUSION: The conclusion from this study indicates that if the delivery of diabetes health services to Indigenous Australians is to improve it is necessary to address these identified issues.

Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient.

Clinical communication and recognising and responding to a deteriorating patient are key current patient safety issues in healthcare. The aim of this literature review is to identify themes associated with aspects of the hospital clinical handover between paramedics and ED staff that can be improved, with a specific focus on the transfer of care of a deteriorating patient. Extensive searches of scholarly literature were conducted using the main medical and nursing electronic databases, including Cumulative Index to Nursing and Allied Health Literature, Medline and PubMed, during 2011 and again in July 2012. Seventeen peer-reviewed English-language original quantitative and qualitative studies from 2001 to 2012 were selected and critically appraised using an evaluation tool based on published instruments. Relevant themes identified were: professional relationships, respect and barriers to communication; multiple or repeated handovers; identification of staff in the ED; significance of vital signs; need for a structured handover tool; documentation and other communication methods and education and training to improve handovers. The issues raised in the literature included the need to: produce more complete and concise handovers, create respectful and effective communication, and identify staff in the ED. A structured handover tool such as ISBAR (a mnemonic covering Introduction, Situation, Background, Assessment and Recommendations) would appear to provide a solution to many of these issues. The recording of vital signs and transfer of these data might be improved with better observation systems incorporating early warning strategies. More effective teamwork could be achieved with further clinical communications training.

An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.

AIMS: To synthesize studies that explored simulation as preparation of nursing students for recognition and response to the deteriorating patient. BACKGROUND: New graduate nurses are expected to have the skills to recognize and respond to rapidly deteriorating patient conditions. To this end, education programmes have turned increasingly to simulation to assist students to gain the necessary skills. DESIGN: Integrative review. DATA SOURCES: CINAHL, Informit, ProQuest, Ovid MEDLINE, SAGE Journals and Web of Knowledge electronic databases, keywords and inclusion/exclusion criteria were searched. Eighteen studies published between 2004-2012 were found. REVIEW METHODS: Studies were appraised using recognized evaluation tools. Thematic analysis was undertaken and emergent themes were extracted with similar and divergent perspectives sought. RESULTS: Six themes were identified namely, 'transferability of simulation skills to clinical practice', 'exposure to broader range of experiences', 'confidence levels in relation to simulation training', 'competence/performance', 'clinical judgment' and 'student perceptions of preparedness for practice following simulation'. CONCLUSION: Simulation exposes students to a broader range of experiences whilst in a safe environment with transference of skills to clinical practice occurring. Confidence, clinical judgement, knowledge and competence, all vital in the care of a deteriorating patient, were enhanced. However, evidence of simulation used specifically to prepare nursing students to recognize and respond to the deteriorating patient appeared limited. This educational field appears rich for interprofessional collaboration and further research.