Exposure to patient aggression and health outcomes for forensic mental health nurses: A cross-sectional survey.

AIMS: The aims of the study were to determine the types and prevalence of forensic mental health nurse exposure to patient aggression and explore the impact of these exposures on their physical and mental health and work absences. DESIGN: Cross-sectional survey conducted January to April 2020. METHODS: All 205 nurses working in an Australian high-security inpatient forensic mental health hospital were invited to participate. An online survey included the Perception of Prevalence of Aggression Scale to measure respondent exposure to types of patient aggression, and the SF-36v2 to measure mental and physical health. Absence from work and other work and individual characteristics were also explored. RESULTS: Sixty-eight respondents completed the survey. Verbal abuse was the most experienced aggression type, followed by physical violence and observing violence, patient self-harming behaviours and sexual violence. Nurses who worked in acute units experienced significantly more exposure to overall aggression than nurses in non-acute units. Higher level of aggression was associated with number of days sick leave taken and days off due to aggression or violence. Higher level of aggression was associated with poorer mental health, and patient self-harming behaviour was associated with poorer physical health. CONCLUSIONS: Nurses in acute units experience higher levels of inpatient aggression and are therefore at increased risk of being impacted by the exposure. Findings indicate a psychological impact of exposure to frequent aggression and potential for an accumulative effect of exposure to traumatic events on nurse well-being. Nurses who are victim of, or witness, physical violence are most likely to take time off work. IMPACT: This study provides further evidence that forensic mental health nurses are frequently exposed to various forms of patient aggression. For some nurses, this exposure to patient aggression negatively impacted their mental and physical health. Employing organizations should therefore prioritize provision of formal support for nurses. No patient or public contribution.

Vicarious Trauma and Health Outcomes in Forensic Mental Health Nurses.

BACKGROUND: Nurses working in forensic mental health settings are at risk of vicarious trauma because of their exposure to traumatized patients and distressing material such as the aversive details of patient crimes. AIM: The aim of this study was to determine the incidence of vicarious trauma and explore its impact on health and absence from work. METHODS: A cross-sectional descriptive correlational study was undertaken. All 205 forensic mental health nurses working in a high-security inpatient facility were invited to participate. An online survey included the Vicarious Trauma Scale and the SF-36v2 to measure mental and physical health. Absence from work was also explored. RESULTS: Sixty-seven respondents completed the survey. Almost half of respondents had a moderate level of vicarious trauma, and only over one-quarter experienced high levels. Higher levels of vicarious trauma were associated with poorer mental health (r = -0.59, p < 0.000) and absence from work (r = 0.27, p < 0.010). CONCLUSIONS: Forensic mental health nurses are at a greater risk of vicarious trauma than nurses working in mainstream mental health services, given their exposure to aversive details of patients' violent crimes. Adverse mental health consequences of vicarious trauma, and other forms of workplace trauma experienced by forensic mental health nurses, are likely to include trauma-related symptoms, depression, and anxiety. Forensic mental health nurses experiencing vicarious trauma may use sick leave as time away from work to care for their own mental health or a coping mechanism for workplace-induced psychological distress.

Exploration of a rapid response team model of care: A descriptive dual methods study.

BACKGROUND: Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration. OBJECTIVE: To explore the characteristics of a collaborative rapid response team model. DESIGN: Dual methodology was used for this descriptive study. SETTING: The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia). PARTICIPANTS: Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards. METHODS: A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically. RESULTS: The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation. CONCLUSIONS: Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Exploration and model development for emergency department waiting room nurse role: Synthesis of a three-phase sequential mixed methods study.

BACKGROUND: To improve flow and care in waiting rooms, some emergency departments introduced a specific nursing role to care for this patient cohort with the aim of commencing interventions early, improving patient safety by reassessing and enhancing communication. The objective of the research was to explore to what extent does qualitative interviews and quantitative survey contribute to describing emergency department waiting room nurses, through integration and synthesis of findings from a multiphase mixed methods study. METHODS: Multiphase mixed methods exploratory sequential design with integration of findings. Data integration occurred during the phases and when assimilating all findings. FINDINGS: Experienced emergency nurses, preferably with graduate qualifications, who are autonomous practitioners with highly developed communication skills, clinical decision making and proficiency in assessment and monitoring are required to perform the role. The waiting room nurse provides patient-centered care and ensures safe, timely care is delivered to those in the waiting room. A standardised approach and high risk of exposure to occupational stressors need to be considered. CONCLUSIONS: This mixed methods sequential design explored the waiting room nurse role from the perspective of emergency nurses generating new knowledge into the role. This advanced practice nursing role contributes to patient safety and delivery of patient centred care in the emergency department waiting room.

Applying real-time Delphi methods: development of a pain management survey in emergency nursing.

The modified Delphi technique is widely used to develop consensus on group opinion within health services research. However, digital platforms are offering researchers the capacity to undertake a real-time Delphi, which provides novel opportunities to enhance the process. The aim of this case study is to discuss and reflect on the use of a real-time Delphi method for researchers in emergency nursing and cognate areas of practice. A real-time Delphi method was used to develop a national survey examining knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses. While designing and completing this real-time Delphi study, a number of areas, emerged that demanded careful consideration and provide guidance to future researchers.

Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III.

OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.

Exposure to workplace trauma for forensic mental health nurses: A scoping review.

BACKGROUND: Forensic mental health is a challenging workplace, with nurses subject to various trauma exposures in their professional role. OBJECTIVES: To identify the key concepts related to the nature, extent and impact of workplace trauma for forensic mental health nurses. DESIGN: A scoping review, informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool. METHODS: Sources of evidence were identified and assessed for inclusion using an explicit search strategy. Relevant information was extracted and synthesised to present a descriptive summary of existing evidence. RESULTS: Of the 16 articles on workplace trauma for forensic mental health nurses included in the review, nine reported data related to extent (incidence and severity) and 14 described the impact. The incidence (per bed/per year) of each workplace trauma type ranged from 0.95 - 7.15 for physical violence, 0.39-5.12 for verbal abuse, 0.03-0.12 for sexual violence, and 1.47-7.9 for self-harming behaviour. The proportion of incidents at the lowest severity rating ranged from 15.1% to 84.7%, and the range for the highest severity rating was 0% to 38.7%. In the single study that examined the incidence of vicarious trauma, 14.9% reported low levels and 27.7% reported high levels. Psychological distress was the most commonly reported impact of workplace trauma, identified in eight studies. Seven studies reported limited data for physical injury from workplace trauma. The impacts of exposure to workplace trauma reported in the remaining studies included needing to access psychological support, experiencing physiological symptoms, feeling less safe at work, and requiring time off work. With the exception of two studies providing limited data related to absenteeism, the impact for organisations was not explored in existing literature. CONCLUSIONS: While studies indicated that forensic mental health nurses are frequently exposed to various forms of workplace trauma, reports of severe assaults on staff were rare. Although limited, these findings suggest that cumulative exposure to workplace trauma over time, or exposure to more severe forms of physical violence, increase forensic mental health nurse vulnerability to experiencing detrimental impacts on their personal and professional wellbeing.

Basic Life Support Training for undergraduate nursing students: An integrative review.

The aim of this review was to identify the role of basic life support training interventions in international undergraduate nursing education, that support optimal acquisition and retention of knowledge, psychomotor skills and resuscitation self-efficacy. Twenty-four articles were identified and analysed using an integrative review approach. Studies were reviewed for quality using a Critical Appraisal Skills Programme checklist. Common objective and standardised methods of basic life support education practice were identified: instructor led, simulation experiences, self-directed learning, skills training combined with clinical practicum, and computer-based training. Evaluation of competency was collected primarily from multiple-choice questionnaires or researcher-designed checklists, with a lack of objective performance data noted. Importantly, current teaching approaches do not guarantee acquisition or retention of basic life support skills. Objective feedback from technologies supporting cardiopulmonary resuscitation training may be useful in acquisition and retention of psychomotor skills, and therefore requires further exploration. Development of robust, psychometrically sound instruments are needed to accurately and consistently measure nursing students' skills performance.

Use of the Delphi method to generate guidance in emergency nursing practice: A systematic review.

AIM: To examine the application and methodological quality of the Delphi method used in developing guidance for emergency nursing practice. BACKGROUND: Emergency nursing scope of practice has rapidly expanded in response to increasing patient acuity, complexity and technological innovation. Determining best practice is crucial for delivering high quality, safe and effective emergency nursing care. The Delphi method has been used to identify, prioritise complex issues and develop evidence-driven guidance in emergency nursing practice. The use and quality of the Delphi method in emergency nursing practice has not been examined. DESIGN: Systematic literature review. DATABASES AND DATA TREATMENT: A systematic literature search was conducted using the following databases: SCOPUS, EMBASE, Medline and ProQuest from date of inception to August 2019. The database search was limited to scholarly articles or peer-reviewed journals. No language restrictions were applied. The Cochrane Collaboration method and PRISMA checks were utilized to conduct the review. RESULTS: Of 246 records identified 22 (8.9%) studies met the inclusion criteria. A modified Delphi method was commonly used (n = 15; 68.2%) and often conducted online (n = 11; 50.0%). Eight practice guidance themes were identified. Overall study quality was high (score 12/14; range 4-13), transparency of reporting varied. CONCLUSION: Based on this review, the Delphi method is an appropriate method for exploring emergency nursing practice. The studies reviewed demonstrated that knowledge, skills and clinical expertise has progressively expanded in the specialty of emergency nursing. Variation in the application, conduct and transparency of reporting in Delphi studies developing guidance for emergency nursing practice is discussed.

Pain assessment and interventions by nurses in the emergency department: A national survey.

AIM: The aim of this study was to examine the knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses. BACKGROUND: Pain is the most commonly reported symptom in patients presenting to the emergency department, with over half rating their pain as moderate-to-severe. Patients unable to communicate, such as critically ill intubated patients, are at greater risk of inadequate pain management. DESIGN: This cross-sectional exploratory study used survey methodology to explore knowledge, perceptions and factors influencing pain management practices among Australian emergency nurses. METHODS: Australian emergency nurses were invited to complete an online survey comprising 91 items. The response rate was 450 of 1,488 (30.2%). STROBE guidelines were used in reporting this study. RESULTS: Variations in level of acute pain management knowledge, especially in older, cognitively impaired or mechanically ventilated patients were identified. Poor interprofessional communication, workload and staffing negatively impacted on nurses' intention to administer analgesia. For intubated patients, validated observation pain assessment instruments were rarely used, although respondents recognised the importance of pain management in critically ill patients. CONCLUSIONS: Emergency nurses recognise the importance of pain relief. The ability to nurse-initiate analgesia, education and training in pain management education is variable. Little education is provided on assessing and managing acute pain in elderly, cognitively impaired or mechanically ventilated patients. Use of validated pain assessment instruments to assess pain in critically ill patients is poor. RELEVANCE TO CLINICAL PRACTICE: While pain management is the responsibility of all healthcare professionals, in the emergency department, it is a core role of emergency nursing. This study highlights the variation in ability to nurse-initiate analgesia, level of acute pain knowledge, education and training, and use of validated pain assessment instruments to guide pain management in critically ill intubated patients.

Intensive care nurses on social media: An exploration of knowledge exchange on an intensive care virtual community of practice.

AIMS AND OBJECTIVES: To explore the nature of knowledge exchange on a multi-disciplinary Australasian intensive care virtual community of practice, "ICUConnect." BACKGROUND: Current organisational structures and cultures constrain the social networks of healthcare professionals, limiting access to contemporary best practice knowledge. While virtual communities can facilitate knowledge and clinical expertise exchange in professional networks, their effectiveness has not been established. DESIGN: A sequential mixed-methods design with a quantitative core and qualitative supplementary component was used to explore the content of discussions from an intensive care virtual community. SRQR has been used to report this study. METHODS: Email archives of an intensive care listserv (2003-2013) were mined using a two-stage sampling technique to identify discussion threads (with >2 posts) concerning ventilator or airway practices (cluster) and two sets of 20 threads (stratified across years). Summative content analysis was used to examine both manifest and latent content. RESULTS: Forty threads containing 326 emails posted by 133 individuals from 80 organisations were analysed. Nurses contributed 68% (55% were in clinical leadership roles) and physicians 27%. Three subject areas were identified: clinical practices (71%); equipment (23%); and clinical governance (6%). "Knowledge-requested" and "knowledge-supplied" posts were categorised as follows: experiential and explicit (33% and 16%, respectively); experiential (27% and 35%); or explicit (40% and 17%). Knowledge supplied was also categorised as "know-how" (20%); "know-why" (5%) or "no knowledge" exchanged (6%). The central construct of virtual community work was identified with six elements that facilitated participation and knowledge exchange including: (a) the discussion thread; (b) sharing of artefacts; (c) community; (d) cordiality; (e) maven work; and (f) promotion of the VC. Members asked questions to benchmark their practice, while those who answered were focused on ensuring that best practices were delivered. CONCLUSIONS: ICUConnect reflected characteristics of a virtual community of practice, enabling key benefits for members and the broader Australasian intensive care community, especially access to best practice knowledge from clinical experts. RELEVANCE TO CLINICAL PRACTICE: This study demonstrated that a practice-based VC can function effectively as a VCoP to establish an effective professional network where members have access to up-to-date best practice knowledge. Healthcare organisations could leverage VCs to support the professional development of HCPs and ensure that local clinical practices are based on contemporaneous knowledge. Participation by nurses in these communities facilitates individual professional development and access to important clinical knowledge and expertise, and ultimately reinforcing the unique position of nursing in delivering effective, consistent high-quality patient care.

Why Health Care Professionals Belong to an Intensive Care Virtual Community: Qualitative Study.

BACKGROUND: Clinical practice variation that results in poor patient outcomes remains a pressing problem for health care organizations. Some evidence suggests that a key factor may be ineffective internal and professional networks that limit knowledge exchange among health care professionals. Virtual communities have the potential to overcome professional and organizational barriers and facilitate knowledge flow. OBJECTIVE: This study aimed to explore why health care professionals belong to an exemplar virtual community, ICUConnect. The specific research objectives were to (1) understand why members join a virtual community and remain a member, (2) identify what purpose the virtual community serves in their professional lives, (3) identify how a member uses the virtual community, and (4) identify how members used the knowledge or resources shared on the virtual community. METHODS: A qualitative design, underpinned by pragmatism, was used to collect data from 3 asynchronous online focus groups and 4 key informant interviews, with participants allocated to a group based on their posting behaviors during the previous two years-between September 1, 2012, and August 31, 2014: (1) frequent (>5 times), (2) low (≤5 times), and (3) nonposters. A novel approach to focus group moderation, based on the principles of traditional focus groups, and e-moderating was developed. Thematic analysis was undertaken, applying the Diffusion of Innovation theory as the theoretical lens. NCapture (QRS International) was used to extract data from the focus groups, and NVivo was used to manage all data. A research diary and audit trail were maintained. RESULTS: There were 27 participants: 7 frequent posters, 13 low posters, and 7 nonposters. All participants displayed an external orientation, with the majority using other social media; however, listservs were perceived to be superior in terms of professional compatibility and complexity. The main theme was as follows: "Intensive care professionals are members of ICUConnect because by being a member of a broader community they have access to credible best-practice knowledge." The virtual community facilitated access to all professionals caring for the critically ill and was characterized by a positive and collegial online culture. The knowledge found was credible because it was extensive and because the virtual community was moderated and sponsored by a government agency. This enabled members to benchmark and improve their unit practices and keep up to date. CONCLUSIONS: This group of health care professionals made a strategic decision to be members of ICUConnect, as they understood that to provide up-to-date clinical practices, they needed to network with colleagues in other facilities. This demonstrated that a closed specialty-specific virtual community can create a broad heterogeneous professional network, overcoming current ineffective networks that may adversely impact knowledge exchange and creation in local practice settings. To address clinical practice variation, health care organizations can leverage low-cost social media technologies to improve interprofessional and interorganizational networks.

Challenges and reflections from an international, humanitarian, short-term surgical mission on collecting ethnographic data in a remote environment.

BACKGROUND: The experiences of nurses participating in ethnographic fieldwork have been well documented, but often feature short-term, intermittent periods in the field of less than a day. AIM: To provide an overview of methodological issues related to collecting data while undertaking a focused ethnography of nurses volunteering with a humanitarian organisation providing surgical care in a remote setting. DISCUSSION: Particular challenges during the fieldwork included limited space and privacy influencing data collection and secure storage; sporadic and unreliable communications limiting contact with other members of the research team; the challenges of withdrawing from the intensity of the setting; and navigating blurred boundaries between the roles of clinician and researcher. CONCLUSION: Social research in practice, despite the best of intentions and significant planning, may not always travel the expected path of rational enquiry. IMPLICATIONS FOR PRACTICE: Awareness of the challenges involved before embarking on longer term entry into remote environments may help prepare future nurse ethnographers.

The forgotten mothers of extremely preterm babies: A qualitative study.

AIMS AND OBJECTIVES: To explore the experiences of mothers of extremely premature babies during their Neonatal Intensive Care Unit stay and transition home. BACKGROUND: Mothers of extremely preterm infants (28 weeks' gestation or less) experience a continuum of regular and repeated stressful and traumatic events, during the perinatal period, during the Neonatal Intensive Care Unit stay, and during transition home. METHOD: An interpretive description method guided this study. Ten mothers of extremely premature infants who had been at home for less than six months were recruited via a Facebook invitation to participate in semi-structured telephone interviews exploring their experiences in the Neonatal Intensive Care Unit and the transition home. The data were examined using a six-phase thematic analysis approach. The COREQ checklist has been used. RESULTS: Two main themes emerged: (a) things got a bit dire; and (b) feeling a failure as a mother. Participants had a heightened risk of developing a mental disorder from exposure to multiple risk factors prior to and during birth, as well as during the postnatal period in the Neonatal Intensive Care Unit and their infant's transition to home. Mothers highlighted the minimal support for their mental health from healthcare professionals, despite their regular and repeated experience of traumatic events. CONCLUSION: The mothers were at high risk of developing post-traumatic stress symptoms and/or other mental health issues. Of note, study participants relived the trauma of witnessing their infant in the Neonatal Intensive Care Unit, demonstrated hypervigilance behaviour and identified lack of relevant support needed when their infant was at home. RELEVANCE TO CLINICAL PRACTICE: This study highlights the need for nurses to include a focus on the mothers' psychosocial needs. Supporting maternal mental health both improves maternal well-being and enables mothers to be emotionally available and responsive to their extremely preterm infant.

Cognitive impairment in intensive care unit patients: A pilot mixed-methods feasibility study exploring incidence and experiences for recovering patients.

BACKGROUND: Despite improvements in survival after critical illness and intensive care unit (ICU) treatment, some recovering patients still face ongoing challenges. There are few investigations exploring the incidence, risk factors, and trajectory for cognitive impairment (CI) in former ICU patients in Australia. OBJECTIVES: To test the feasibility of a study protocol designed to ascertain the incidence and impact of CI during recovery from a critical illness. METHODS: We conducted a mixed-methods longitudinal single-centre pilot study. Participants were adult patients mechanically ventilated for ≥48 h. Cognitive function was assessed during hospitalisation and at 1 week, 2 months, and 6 months after hospital discharge, using the Montreal Cognitive Assessment instrument. Factors potentially affecting cognitive function were also collected, including demographic and clinical variables and fatigue, frailty, and muscle strength. Semistructured interviews were conducted to further explore participants' experiences during recovery. RESULTS: We screened 2068 patients (10% met the inclusion criteria). Participants (n = 20) were mostly male with a mean age 61.9 years and a median of 4 days of mechanical ventilation. Data collection was complete for 14 and 11 participants at 2 months and 6 months, respectively. Pre-illness patients were not cognitively impaired; one patient had delirium in ICU. The proportion of patients with CI ranged from 80% (17/18) while in hospital to 35% (5/14) at 6 months. Participants were challenged by fatigue and sleep disruption during recovery but were not particularly concerned about CI. CONCLUSIONS: Recruitment in ICU was challenging as few patients received prolonged mechanical ventilation. The protocol was feasible, but some attrition was noted. A significant proportion of patients had mild CI, largely confined to recall, and language cognitive domains; quantitative findings were supported by interview findings. Further investigations are required to ascertain the most appropriate inclusion criteria to enable identification of those at highest risk of CI.

A profile of the waiting room nurse in emergency departments: An online survey of Australian nurses exploring implementation and perceptions.

BACKGROUND: In response to increasing waiting times, adverse patient outcomes and patient dissatisfaction, some emergency departments introduced a Waiting Room Nurse role. Despite implementation into routine practice, there remains limited formal evaluation of the role. AIM: To explore the implementation of a Waiting Room Nurse role in Australian emergency departments and emergency nurses' perceptions. METHODS: Survey design. A 40-item survey was developed, piloted and then distributed to members of a professional College for online completion. Responses for closed-ended and open-ended items were reported using frequencies or proportions, and quantitative content analysis, respectively. RESULTS: Respondents (n = 197) reported that 51 emergency departments allocated a Waiting Room Nurse, with varying hours of operation. Five key areas of responsibility were: patient care, patient safety, escalation of care, triage and communication. Role variations were identified in experience, preparation and supporting policies. Challenges, including workload and personal safety issues, were reported. CONCLUSIONS: The role was perceived as vital, especially at times of high demand, in ensuring that patients were safe to wait, detecting deterioration and escalating care as needed. Communication and therapeutic relationships were key to effective performance. Challenges identified had clear implications for the welfare of nurses performing the role.

Antimicrobial prescription patterns and ventilator associated pneumonia: findings from a 10-site prospective audit.

OBJECTIVE: To examine anti-microbial prescribing practices associated with ventilator-associated pneumonia from data gathered during an audit of practice and outcomes in intensive care units (ICUs) in a previously published study. RESULTS: The patient sample of 169 was 65% male with an average age of 59.7 years, a mean APACHE II score of 20.6, and a median ICU stay of 11 days. While ventilator-associated pneumonia was identified using a specific 4-item checklist in 29 patients, agreement between the checklist and independent physician diagnosis was only 17%. Sputum microbe culture reporting was sparse. Approximately 75% of the sample was administered an antimicrobial (main indications: lung infection [54%] and prophylaxis [11%]). No clinical justification was documented for 20% of prescriptions. Piperacillin/tazobactam was most frequently prescribed (1/3rd of all antimicrobial prescriptions) with about half of those for prophylaxis. Variations in prescribing practices were identified, including apparent gaps in antimicrobial stewardship; particularly in relation to prescribing for prophylaxis and therapy de-escalation. Sputum microbe culture reports for VAP did not appear to contribute to prescribing decisions but physician suspicion of lung infection and empiric therapy rather than ventilator-associated pneumonia criteria and guideline concordance.

Quality and impact of nurse-initiated analgesia in the emergency department: A systematic review.

AIM: This paper reports a systematic literature review evaluating the impact and quality of pain management associated with nurse initiated analgesia in patients presenting to the emergency department (ED). BACKGROUND: Pain is a major presenting complaint for individuals attending the ED. Timely access to effective analgesia continues to be a global concern in the ED setting; emergency nurses are optimally positioned to improve detection and management of pain. DESIGN: Systematic review. DATABASES AND DATA TREATMENT: Four databases - CINAHL, EMBASE, Medline, ProQuest - the Cochrane Library and the National Institute of Clinical Excellence were searched from date of inception to December 2017; with no language restrictions applied. Studies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published valid criteria. RESULTS: Twelve articles met inclusion, comprising a wide range of analgesics and administration routes to manage mild to severe pain. Overall study quality was high; 7 studies included a form of comparison group. Patient outcome measures included time to analgesia (n = 12; 100%), change in pain score (n = 6; 50.0%); adverse events (n = 6; 50.0%); patient satisfaction (n = 5; 41.7%) and documenting pain assessment (n = 2; 16.7%). CONCLUSION: Nurse-initiated analgesia was associated with safe, timely and effective pain relief.

Emergency department waiting room nurses in practice: An observational study.

AIMS AND OBJECTIVES: To identify the activities and behaviours of waiting room nurses in emergency department settings. BACKGROUND: Emergency care has expanded into waiting rooms in some emergency departments. Often viewed as an adjunct to triage, the aim of waiting room nurses is to commence care early, reassess patients and improve communication between patients, families and staff. There is however a paucity of literature relating to waiting room nurses, especially in relation to their current activities and behaviours. DESIGN AND METHODS: Part of a larger exploratory sequential mixed methods designed study. This phase used a nonparticipant observer role to observe waiting room nurses in their natural setting undertaking normal care and responsibilities. One observer, using a tool and reflective journal, collected data on participant interactions, processes and practices on eight waiting room nurses over 13 episodes of observation (total 65 hr:50 min) in two emergency departments. Data analysis used descriptive statistics and thematic analysis. RESULTS: Participants were observed to anticipate and prioritise to deliver holistic, patient-centred care in emergency department waiting rooms. Waiting room nurses had a varied and unpredictable workload, including facilitating the flow of patients from the waiting room. They contributed to patient safety in the waiting room, primarily by reassessing and detecting clinical deterioration. CONCLUSION: Further research into this role is required, including linking efficacy with experience of nurses, impact the role has on patient safety, and patient and family perceptions of the role. RELEVANCE TO CLINICAL PRACTICE: Therapeutic engagement allowed waiting room nurses to reassure and calm patients and families, and deliver holistic, patient-centred care. Waiting room nurses contributed to patient safety in the waiting room, by promptly commencing episodes of care in the waiting room and through close monitoring and assessment to detect patient deterioration.

Exploring how nurses assess, monitor and manage acute pain for adult critically ill patients in the emergency department: protocol for a mixed methods study.

BACKGROUND: Many critically ill patients experience moderate to severe acute pain that is frequently undetected and/or undertreated. Acute pain in this patient cohort not only derives from their injury and/or illness, but also as a consequence of delivering care whilst stabilising the patient. Emergency nurses are increasingly responsible for the safety and wellbeing of critically ill patients, which includes assessing, monitoring and managing acute pain. How emergency nurses manage acute pain in critically ill adult patients is unknown. The objective of this study is to explore how emergency nurses manage acute pain in critically ill patients in the Emergency Department. METHODS: In this paper, we provide a detailed description of the methods and protocol for a multiphase sequential mixed methods study, exploring how emergency nurses assess, monitor and manage acute pain in critically ill adult patients. The objective, method, data collection and analysis of each phase are explained. Justification of each method and data integration is described. DISCUSSION: Synthesis of findings will generate a comprehensive picture of how emergency nurses' perceive and manage acute pain in critically ill adult patients. The results of this study will form a knowledge base to expand theory and inform research and practice.