Developing nurse-sensitive outcomes in acute inpatient mental health settings-A systematic review.

BACKGROUND: While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings. AIM: To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care. METHODS: Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. A meta-analysis was not possible because of the large number of variables and measurement inconsistencies. RESULTS: A total of 57 studies were reviewed. Studies were categorised according to whether they found a significant or non-significant relationship between nurse variables and patient outcomes. Seven outcomes-aggression, seclusion, restraint, absconding, pro-re-nata medications, special observations and self-harm-were identified. For each outcome, there were significant findings for several nurse variables indicating that all included outcomes could be used as NSOs. However, evidence for aggression, seclusion and restraint use as suitable NSOs was more robust than the evidence for self-harm, absconding, pro-re-nata medications and special observations. CONCLUSION: All the seven outcomes can all be used to develop an NSO indicator suite in mental health inpatient settings. More work is needed to establish high-quality studies to clearly demonstrate the relationship between these outcome measures and changes in nurse variables such as nurse staffing, skill mix, work environment, nurse education and nurse experience. PATIENT AND PUBLIC CONTRIBUTION: Patient or public contribution was not possible because of the type of the variables being explored.

Factors influencing the development and implementation of nurse practitioner candidacy programs: A scoping review.

BACKGROUND: To meet the growing needs of a diverse population, it is critical that healthcare service provision is underpinned by innovative, cost-effective, and sustainable services and solutions. The role of the nurse practitioner creates an opportunity to meet the increasing demands of complex care and enables greater access to high quality care. Understanding how best to support nurse practitioner candidates to develop into the nurse practitioner role will create greater opportunities to transform service delivery and improve healthcare outcomes. AIM: To identify key factors that support and positively impact the implementation of nurse practitioner candidacy programs and candidate experiences. METHODS: A scoping review of research and grey literature was conducted using Joanna Briggs Institute methodology. For the research literature, eight electronic databases (Embase, Medline, CINAHL, Web of Science, Cochrane Library, Joanna Briggs Institute, PubMed and PsycINFO) were searched followed by a hand search of the reference lists of published systematic reviews and relevant topical papers. A review of national and international grey literature sources was completed. FINDINGS: Identification of a service gap, developing and promoting a clear role for the nurse practitioner candidate, integration into a multi-disciplinary team with strong mentorship/preceptorship support, continuing professional development, and evaluation of the program were identified as key factors in the research and grey literature. CONCLUSION: A well-designed candidacy program can facilitate transition of the candidate into an autonomous, fully independent nurse practitioner. Recommendations to support the implementation of these roles into the clinical setting have been generated. Tweetable abstract: Key to nurse practitioner candidate programs: Identification of a service gap, clear role, integration, mentorship, training and evaluation.

The development of the Western Australian Haemodialysis Vascular Access Complexity instrument.

BACKGROUND: The Western Australian Haemodialysis Vascular Access Classification instrument was developed to classify the cannulation complexity of the arteriovenous fistula or arteriovenous graft as simple, challenging, or complex. Although the instrument was developed by experts in haemodialysis nursing, the instrument had not undergone formal validity or reliability testing. OBJECTIVES: Evaluate the Western Australian Haemodialysis Vascular Access Classification instrument for content validity, interrater and test-retest reliability. DESIGN: Prospective cohort study. PARTICIPANTS: Content validity was assessed by haemodialysis nursing experts (n = 8). The reliability testing occurred in one in-centre and one satellite haemodialysis unit in Western Australia from September to November 2019. Reliability testing was performed by 38 haemodialysis nurses in 67 patients receiving haemodialysis and 247 episodes of cannulation. MEASUREMENTS: Interrater and test-retest reliability assessment was conducted using κ, adjusted κ, Bland-Altman plots, intraclass correlation coefficient and Pearson's correlation coefficient. RESULTS: The final version of the instrument (n = 20 items) had individual item-level content validity indices ranging from 0.625 to 1.00 with a scale-level content validity index of 0.89. For both interrater (n = 172 pairs) and test-retest (n = 101 pairs), most individual variables had excellent adjusted κ (n = 33 variables), some fair to good agreement (n = 6 variables) and one variable with poor agreement. The classification of simple, challenging and complex demonstrated adjusted κ of fair to good, to excellent agreement for interrater reliability with lower levels of agreement for test-retest reliability. CONCLUSIONS: This instrument may be used to match a competency-assessed nurse to perform the cannulation thereby minimising the risk of missed cannulation and trauma.

The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review.

AIM: Aim of this study is to systematically review and synthesize available evidence to identify the association between nurse staffing methodologies and nurse and patient outcomes. DESIGN: Systematic review and narrative synthesis. DATA SOURCES: A search of MEDLINE (EBSCO), CINAHL (EBSCO) and Web of Science was conducted for studies published in English between January 2000 and January 2020. REVIEW METHODS: The reporting of this review and narrative synthesis was guided by the preferred reporting items for systematic and meta-analysis guidelines (PRISMA) statement and data synthesis guided by the Synthesis Without Meta-analysis (SWiM) guideline. The quality of each article was assessed using the Mixed Methods Appraisal Tool. RESULTS: Twenty-two studies met the inclusion criteria. Twenty-one used the mandated minimum nurse-to-patient ratio methodology and one study assessed the number of nurse hours per patient day staffing methodology. Both methodologies were mandated. All studies that reported on nurse outcomes demonstrated an improvement associated with the implementation of mandated minimum nurse-to-patient ratio, but findings related to patient outcomes were inconclusive. CONCLUSIONS: Evidence on the impact of specific nurse staffing methodologies and patient and nurse outcomes remains highly limited. Future studies that examine the impact of specific staffing methodologies on outcomes are required to inform this fundamental area of management and practice.

Experiences of Western Australian rural nursing graduates: A mixed method analysis.

AIMS AND OBJECTIVES: To determine whether the current rural graduate programmes in Western Australia adequately support new graduate nurses transitioning into practice. BACKGROUND: Graduate nurse's transition to employment is a time of significant change and challenge, often resulting in periods of transition shock. These challenges are magnified in rural areas where graduates have to relocate to commence their career with limited rural nursing experience. Graduate programmes were developed to smooth the transition for university trained bachelor's degree registered nurses into the workforce. Supportive graduate nursing programmes are essential for enabling transition to practice and reduce attrition rates. DESIGN: Longitudinal convergent mixed method parallel design was informed by Duchscher's transition stage model. METHOD: Thematic analysis was applied to all interviews. COREQ checklist was completed. Descriptive statistics and content analysis were used to analyse the survey responses. RESULTS: New graduates cycled through both transition shock and honeymoon periods on commencement of employment, reporting high levels of satisfaction in simultaneity with signs of transition shock. Satisfaction dropped within 7 months indicating a transition crisis before an adjustment period occurred at the end of their graduate year. Limited resources were highlighted as obstacles to providing adequate support to rural graduate nurses. CONCLUSION: The honeymoon stage of transition co-existed with transition shock at the commencement of graduate programmes, which may obscure the need for continuing adequate support. Inadequate and/or a lack of preceptorship was evident throughout the Western Australian rural graduate programmes. Graduate programmes need to be structured but flexible to allow for individual differences in graduates' and clinical contexts. RELEVANCE TO CLINICAL PRACTICE: Structured but flexible graduate programmes allow for individual differences in graduates and clinical situations. New graduate nurses would benefit from a break midway through their graduate year to assist and overcome the transition crisis stage. Education of nurses undertaking the preceptor role is required to deliver adequate support to graduate nurses and decrease transition shock.

Evaluation of a Remote Symptom Assessment and Management (SAM) System for People Receiving Adjuvant Chemotherapy for Breast or Colorectal Cancer: Mixed Methods Study.

BACKGROUND: The Symptom Assessment and Management (SAM) program is a structured, online, nurse-supported intervention to support symptom self-management in people receiving adjuvant chemotherapy post surgery for breast or colorectal cancer. OBJECTIVE: The objective of this study was to describe the development, implementation strategy, and evaluation of the SAM system. METHODS: The development of the SAM program involved 3 phases. In phase 1, the web app was developed through consultation with consumers and clinicians and of the literature to ensure that the system was evidence-based and reflected the realities of receiving treatment and supporting patients through treatment. In phase 2, 7 participants recorded the severity of 6 symptoms daily over the course of 1 cycle of chemotherapy. In phase 3, 17 participants recorded their symptoms daily over the course of 3 cycles of chemotherapy. Once symptoms were recorded, participants received immediate feedback on the severity of their symptoms and self-management recommendations, which could include seeking immediate medical attention. Data on quality of life, symptom burden, anxiety and depression, distress, and self-efficacy were collected during treatment; participants' perceptions of the SAM program were evaluated following participation via interview. RESULTS: The outcomes of the SAM project include the development of a system that is reliable and easy to use and navigate. Participants reported benefits related to using the SAM program that included feeling more in control of managing their symptoms and feeling reassured. Engagement with the system on a daily basis was variable, with some participants completing the symptom tracker daily and others engaging some of the time. The feedback from all participants was that the system was easy to navigate and the information was relevant and supportive. CONCLUSIONS: The SAM program has the potential to enhance the management of symptoms for people receiving chemotherapy treatment. The system creates an accurate repository of symptoms that can be accessed easily and highlight patterns in symptom experience. These can be shared with clinicians, with patient permission, to inform and support treatment plans. The potential to predict the risk of developing severe symptoms can be developed to anticipate the need for care and support. Further considerations on how to increase engagement with the system, the value of the system for people diagnosed with other tumor types and treatment regimes, and the incorporation of the system into everyday clinical practice are needed.

Contemporary nursing graduates' transition to practice: A critical review of transition models.

AIM AND OBJECTIVE: To critically review contemporary transition theories to determine how they apply to the newly qualified graduate registered nurse programmes. BACKGROUND: Graduate nurse transition to employment is the time of significant change which has resulted in high attrition rates. Graduates are often challenged by their expectation of nursing practice and the reality of the role. The transition from hospital-based training to university-based training has resulted in the need for primary employment to commence with graduate/orientation/internship programmes to help support new graduates transition into clinical practice. One transition model, Duchscher's stages of transition theory, utilised three former theories to develop a final model. DESIGN: A narrative critical literature review. METHOD: The theories selected for the review were Kramer's reality shock theory, Benner's novice to expert theory, Bridges transition theory and Duchscher's stages of transition theory. CONCLUSION: Duchscher's stages of transition theory reflects the experiences of registered nursing transition into the workforce directly from university. The application of the theory is effective to guide understanding of the current challenges that new graduate nurse's experience today. There is a need for new graduates to complete their university degree as advanced beginners in order to decrease the experience of transition shock and keep pace with rapidly changing demands of the clinical environment. This may be achieved by increasing ward-based simulation in university education. A theoretical framework can provide a deep understanding of the various stages and processes of transition and enable development of successful programmes. RELEVANCE TO CLINICAL PRACTICE: Both universities and hospitals need to adapt their current practice to align with the needs of new graduates due to large student numbers and ongoing systematic advancements to decrease the attrition rate.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting.

AIMS: To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals. DESIGN: A quantitative systematic review included studies published in English between January 2000 - September 2018. DATA SOURCES: Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria. REVIEW METHODS: The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association. RESULTS: Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure. CONCLUSION: Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes. IMPACT: Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

Variables associated with successful vascular access cannulation in hemodialysis patients: a prospective cohort study.

BACKGROUND: Successful vascular access (VA) cannulation is integral to the delivery of adequate dialysis, highlighting the importance of ensuring the viability of arteriovenous access in hemodialysis (HD) patients. Missed VA cannulation can lead to infection, infiltration, hematoma or aneurysm formation resulting in the need for access revision, central venous catheter (CVC) placement, or permanent loss of VA. Cannulation-related complications can also negatively impact on a patient's dialysis experience and quality of life. This study aimed to identify patient, VA and nurse factors associated with unsuccessful VA cannulations. METHODS: A prospective cohort study was conducted in HD patients with a permanent VA from three HD units. Data on patient, VA and nurse characteristics, plus, cannulation technique were collected for each episode of cannulation. General Estimating Equation was used to fit a repeated measures logistic regression to determine the odds of cannulation success. RESULTS: We collected data on 1946 episodes of cannulation (83.9% fistula) in 149 patients by 63 nurses. Cannulation included use of tourniquet (62.9%), ultrasound (4.1%) and was by rope ladder (73.8%) or area (24.7%) technique. The miscannulation rate was 4.4% (n = 85) with a third of patients (n = 47) having at least one episode of miscannulation. Extravasation (n = 17, 0.9%) and use of an existing CVC (n = 6, 0.6%) were rare. Multivariable characteristics of successful cannulation included fistula compared with graft [OR 4.38; 95%CI, 1.89-10.1]; older access [OR 1.68; 95%CI, 1.32-2.14]; absence of stent [OR 3.37; 95%CI, 1.39-8.19]; no ultrasound [OR 13.7; 95%CI, 6.52-28.6]; no tourniquet [OR 2.32; 95%CI, 1.15-4.66]; and lack of post graduate certificate in renal nursing [OR 2.27; 95%CI, 1.31-3.93]. CONCLUSION: This study demonstrated a low rate of miscannulation. Further research is required on ultrasound-guided cannulation. Identifying variables associated with successful cannulation may be used to develop a VA cannulation complexity instrument that could be utilised to match to the cannulation skill of a competency-assessed nurse, thereby minimising the risk of missed cannulation and trauma.

Exercise, fitness and musculoskeletal health of undergraduate nursing students: A cross-sectional study.

AIMS: To describe the exercise, physical fitness and musculoskeletal health of nursing students. BACKGROUND: Nursing students are prone to musculoskeletal disorders restricting work ability. Physical fitness and leisure-time exercise may affect responses to workplace exposures and risk for work-related musculoskeletal disorders. DESIGN: A cross-sectional study. METHOD: Between August 2013 and April 2015, a convenience sample of 111 nursing students performed submaximal exercise tests. Nursing work, exercise and musculoskeletal health were surveyed and analysed descriptively. RESULTS: Students' mean age was 30.0 years, 89.2% were female and 20.0% worked in nursing while studying. Highest annual prevalence of musculoskeletal trouble was in low back (45.6%), neck (32.0%) and shoulder (18.5%) regions. Most exercised regularly but did not meet weekly cardiorespiratory, resistance, neuromotor and flexibility exercise recommendations and had poor to average fitness levels. Approximately 40% were overweight or obese; 26.1% had risk for obesity-related disease. CONCLUSIONS: Interventions to improve nursing students' physical condition before entering the nursing workforce appear warranted. IMPACT: Imbalance between physical work capacity and demanding workloads increases musculoskeletal disorder risk amongst undergraduate nursing students. A large proportion studied reported recent musculoskeletal trouble (particularly low back, neck and shoulder). They exhibited modifiable characteristics of overweight/obese, poor fitness and inadequate leisure-time exercise, predisposing them to work-related musculoskeletal disorders. Undergraduate preparation should raise nursing students' health literacy about physical fitness and ways to achieve it, for their musculoskeletal health and work capacity. Improving nursing students' fitness may enhance their work preparedness and help them achieve longevity in this physically demanding occupation.

Issues impacting on enrolled nurse education for Aboriginal and Torres Strait Islander students: a discussion.

Background: Achieving increased participation of Aboriginal and Torres Strait Islander peoples in Australia's health workforce, particularly nursing, is federal government policy imperative. However, the uptake of Aboriginal and Torres Strait Islander students into nursing has stalled and their attrition from tertiary nursing courses is considerably higher than for other students. Aim: To alert the profession to issues impacting enrolled nursing education for Aboriginal and Torres Strait Islander students. Design: Discussion paper. Results: Studies of Aboriginal and Torres Strait Islander students mainly focus on tertiary education for registered nurses whereas vocational education and training (VET) for enrolled nurses is usually overlooked. It is generally assumed that the issues influencing the recruitment, attrition, and retention of Aboriginal and Torres Strait Islander students in higher education universities and other institutions similarly impact enrolled nursing students in the VET sector. Conclusion: Research that contributes robust evidence-based knowledge specifically on strategies addressing issues in enrolled nursing education for Aboriginal and Torres Strait Islander students and their employment uptake is required.

An integrative review of rural and remote nursing graduate programmes and experiences of nursing graduates.

AIMS AND OBJECTIVES: To examine international studies that specifically focus on transition to practice for graduate registered nurses in rural and remote areas. BACKGROUND: Supportive graduate nursing programmes are essential for enabling nursing graduates' transition to practice and reducing attrition rates. Literature examining support measures for nursing graduates within metropolitan areas is abundant. However, there is a paucity of evidence on effective graduate programmes for rural and remote-based nursing graduates. DESIGN: A systematic approach was used to identify robust research within appropriate electronic databases. METHOD: Eligible articles were critically reviewed using the Mixed Method Appraisal Tool critical appraisal tool. Eligible articles were thematically analysed using the Braun and Clark approach. RESULTS: Eight articles met the selection criteria for inclusion. Findings revealed that while most graduate nurses survived the transition process, they often felt overwhelmed and abandoned with intense feelings of frustration. Many suffered transition shock and did not feel ready for the role. Socialisation of graduates to the clinical environment was lacking. Support offered in many graduate programmes was ad hoc and unstructured. Senior staff were inadequately supported in their roles as preceptors to assist with the transition. Critical support measures recommended included both debrief sessions and regular one-on-one support. CONCLUSIONS: Graduate programmes need to be structured yet flexible to accommodate the needs of rural and remote nurse graduates. Graduates need to be transitioned into practice with decremental support processes for both workloads and education. Preceptors require education on how to mentor before they can provide the appropriate support for graduates. Without these measures in place, a decrease in transition shock may not be possible. RELEVANCE TO CLINICAL PRACTICE: Graduate programmes need to be structured yet flexible, including assistance with both clinical skills and socialisation. Senior staff require education before they can adequately support new graduates.

Adaptation and pretesting of the College Persistence Questionnaire V3 (Short Form) for measuring intention to persist among Aboriginal Diploma of Nursing students.

BACKGROUND: Culturally appropriate health care delivery is essential to improve health outcomes for Aboriginal peoples. There is a shortage of Aboriginal and Torres Strait Islander nurses partly due to disproportionately high non-completion rates among tertiary sector students. The College Persistence Questionnaire V3 (Short Form) provides scales for gauging major predictors of retention. OBJECTIVE: To adapt an instrument for measuring intention to persist among Aboriginal Diploma of Nursing students. DESIGN: Instrument adaptation and pretesting. PARTICIPANTS: A convenience sample of Aboriginal Diploma of Nursing students (N=21) at a registered training organisation in Australia. METHODS: The instrument was mapped against the domain of interest and modified. Ten experts reviewed its content validity; its reading ease and educational grade reading level were assessed. RESULTS: The expert panel endorsed individual items as valid (item-level Content Validity Index 0.90-1.00) and scale-level validation was acceptable (average scale-level Content Validity Index=0.98). The minimally-adapted instrument was 'fairly easy' to read and suitable for general adult audiences (Flesch Reading Ease score 71.3) and was below the United States 8th grade reading level (Flesch-Kincaid Grade Level 6.7). Students took <30min to complete the questionnaire. All understood its purpose, found instructions clear, and questions easy to answer. Most rated its length 'Just right'. CONCLUSION: The College Persistence Questionnaire - Registered Training Organisation Version appears suitable for assessing factors influencing retention/attrition among Aboriginal Diploma of Nursing students. Piloting and psychometric evaluation is recommended.

Impact of the Orthopaedic Nurse Practitioner role on acute hospital length of stay and cost-savings for patients with hip fracture: A retrospective cohort study.

AIMS: To compare acute hospital length of stay and cost-savings for patients with hip fracture before and after commencement of the Orthopaedic Nurse Practitioner and identify variables that increase length of stay in hospital. BACKGROUND: Globally, hip fractures are associated with significant morbidity and mortality. Whilst the practical benefits of the Orthopaedic Nurse Practitioner have been anecdotally shown, an analysis showing the cost-saving benefits has yet to be published. DESIGN: A retrospective cohort study. METHODS: Data from two population-based cohorts (2010, 2013) of hip fracture patients aged ≥65 years were extracted from the electronic hospital database at a large Western Australian tertiary metropolitan hospital. Multivariate linear regression was used to model factors affecting length of stay in hospital. A simple economic analysis was undertaken and cost-savings were estimated. RESULTS: For comparison (n = 354) and intervention (n = 301) groups, average age was 84 years and over 70% were female. Analyses showed length of stay was shorter in 2013 compared with 2010 (4.4-5.3 days). Shorter length of stay was associated with type of procedure and surgery within 24-hr and longer length of stay was associated with co-morbid conditions of pulmonary disease, congestive heart failure, dementia, anaemia on admission and complications of delirium, urinary tract infection, myocardial infarction and pneumonia. The cost-savings to the hospital over one year was $354,483 and the net annual cost-savings per patient was $1,178. CONCLUSION: Implementation of the Orthopaedic Nurse Practitioner role for care of hip fracture patients can reduce acute hospital length of stay resulting in important cost-savings.

A comparison of nursing tasks undertaken by regulated nurses and nursing support workers: a work sampling study.

AIMS: The aim of this study was to determine which tasks unregulated nursing support staff spend their work time undertaking and to determine differences between the work undertaken by licensed/regulated nurses on units which have nursing support workers and those on units which do not. BACKGROUND: Acute hospital nursing teams often include nursing support staff; little is known about what kinds of tasks these unregulated support workers do and how it affects the work tasks of their licensed/regulated team members. DESIGN: Cross-sectional analysis of nurse work sampling data. METHODS: Data collection took place between March-October 2013. The proportion of time spent on 25 work activities by nursing support staff and licensed/regulated nursing staff was compared. Logistic regression models estimated whether nursing support staff or licensed/regulated nurses were more likely to conduct direct and indirect patient care tasks and whether licensed/regulated nurses on units with nursing support staff were more likely to conduct direct or indirect tasks compared with those on units without nursing support workers. RESULTS: Nursing support staff spent the majority of their time engaged in direct care tasks, e.g. admission and assessment, hygiene and mobility. Although licensed/regulated nurses were less likely to undertake direct care tasks compared with support workers, those who worked on units with support workers undertook more direct care compared with those who worked on units without support workers. CONCLUSIONS: Nursing support workers were given tasks that required substantial amounts of patient interaction. These staff may be associated with an increase in direct care tasks for licensed/regulated nurses, who may duplicate the direct care done by nursing support workers.

The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data.

OBJECTIVES: The aim of this study was to assess the impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes using administrative health data. DESIGN: Logistic regression modelling was used with linked administrative health data to examine the association between seven adverse patient outcomes and use of assistants in nursing utilising a pre-test/post-test design. Outcomes included were in-hospital 30-day mortality, failure to rescue, urinary tract infection, pressure injury, pneumonia, sepsis and falls with injury. SETTING: Eleven acute care metropolitan hospitals in Western Australia. SAMPLE: Patients were retained in the dataset if they spent any time on a medical, surgical or rehabilitation ward during their admission and excluded if they only spent time on other ward types, as the outcomes used in this study are only validated for these patient populations. There were 256,302 patient records in the total sample with 125,762 in the pre-test period (2006-2007) and 130,540 in the post-test period (2009-2010). RESULTS: The results showed three significant increases in observed to expected adverse outcomes on the assistant in nursing wards (failure to rescue, urinary tract infection, falls with injury), with one significant decrease (mortality). On the non-assistant in nursing wards there was one significant decrease (pneumonia) in the observed to expected adverse outcomes and one significant increase (falls with injury). Post-test analysis showed that spending time on assistant in nursing wards was a significant predictor for urinary tract infection and pneumonia. For every 10% of extra time patients spent on assistant in nursing wards they had a 1% increase in the odds of developing a urinary tract infection and a 2% increase in the odds of developing pneumonia. CONCLUSION: The results suggest that the introduction of assistants in nursing into ward staffing in an additive role should be done under a protocol which clearly defines their role, scope of practice, and working relationship with registered nurses, and the impact on patient care should be monitored.

Barriers and enablers to retention of Aboriginal Diploma of Nursing students in Western Australia: An exploratory descriptive study.

BACKGROUND: Nursing education appropriate to the learning needs of Aboriginal and Torres Strait Islander students is essential to prepare them for registration as nurses. Despite incentives to encourage the recruitment and retention of such students, a disproportionate number commence but do not finish their nursing studies. OBJECTIVES: To describe the barriers and enablers to the retention of Aboriginal students in a Diploma of Nursing course (Enrolled/Division 2) in Western Australia. DESIGN: An exploratory descriptive design was used. SETTINGS: One metropolitan educational facility catering for Aboriginal people offering an 18-month course in a block release format. PARTICIPANTS: A convenience sample of 16 students aged 18+years. METHODS: Newly enrolled students (n=10) participated in an investigator-developed survey to explore their motivation for entering the course. Nine of these students and a further seven students who were nearing the end of their course participated in focus groups to explore their experiences of nursing education. RESULTS: Survey respondents had a mean age of 32.7years; most were female, had nominated family as influential in the decision to enroll, and commenced with a friend. Regarding recruitment and retention, the qualitative data highlighted the importance of students': perceptions of the training organisation, characteristics, experiences of nursing education, and sources of support. CONCLUSIONS: Strategies that develop individual's resilience and engage supportive networks can assist Aboriginal students to negotiate tertiary nursing study. Academic skills assessments supplemented with tailored educational support at entry can resource students to navigate increasingly complex course content. Flexibility throughout the course enables students to negotiate study in a context of ongoing family and financial obligations.

Validity and reliability of an online extended version of the Nordic Musculoskeletal Questionnaire (NMQ-E2) to measure nurses' fitness.

AIMS AND OBJECTIVES: To describe modifications to a second extended version of the Nordic Musculoskeletal Questionnaire for online use in nursing populations, and check validity and reliability. BACKGROUND: The Nordic Musculoskeletal Questionnaire has been used to assess the severity and impact of musculoskeletal symptoms in occupational groups. The reliability of a previous extended version was established for paper-based, self-administration among nursing students. This current study extended the questionnaire to collect more information regarding musculoskeletal symptoms in all nine body regions and their work-relatedness, as an instrument is needed to gather evidence about the impact of fitness levels on occupational musculoskeletal disorders among nurses. DESIGN: Psychometric evaluation. METHOD: Sixty-five undergraduate nurses completed the online extended Nordic Musculoskeletal Questionnaire twice. Content validity was examined by expert review and construct validity by exploratory factor analysis of 90 responses from the first completion. Reliability was checked by examining internal consistency, kappa statistics, proportions of observed, and positive and negative agreements, intra-class correlation coefficient and standard error of measurement. RESULTS: The instrument had high internal consistency and exploratory factor analysis revealed it was a relatively homogenous (unidimensional) measure of musculoskeletal symptom severity. Age of onset of symptoms questions were reliable, with high mean intra-class correlation coefficients and low mean standard errors of measurement. Overall, questions showed high mean strengths of agreement and proportions of observed agreement: three-quarters of the prevalence questions and 99% of the severity/impact questions had 10% or fewer disagreements. CONCLUSIONS: Modifications to the Nordic Musculoskeletal Questionnaire and online administration did not diminish its validity or reliability for obtaining information about the severity of nurses' musculoskeletal symptoms. RELEVANCE TO CLINICAL PRACTICE: Occupational musculoskeletal disorders are an issue for nurses. This questionnaire can be used to monitor nurses' musculoskeletal health, and in musculoskeletal disorder prevention studies.

The impact of understaffed shifts on nurse-sensitive outcomes.

AIM: To explore the relationship between exposure to understaffed shifts and nurse-sensitive outcomes at the patient level. BACKGROUND: Nurse-sensitive outcomes are adverse patient outcomes that can be used as indicators of the quality of nursing care. DESIGN: This study was conducted in 2014 and was a secondary analysis of administrative data from a large acute care hospital in Western Australia. The sample included 36,529 patient admissions over a two-year period from October 2004-November 2006. METHODS: An understaffed indicator variable was created from nurse staffing data and used to examine patient data to create a variable indicating the total number of understaffed shifts each patient had been exposed to during their hospital stay. Logistic regression was used to determine the odds of acquiring a nurse-sensitive outcome for those exposed to understaffed shifts. RESULTS: The prevalence ratio showed that for each of the nurse-sensitive outcomes there was an increase in prevalence for those who were exposed to an understaffed shift, with all ratios being greater than one. After adjusting for patient characteristics, nurse-sensitive outcomes found to have the understaffed variable significant in the logistic regression model were surgical wound infection, urinary tract infection, pressure injury, pneumonia, deep vein thrombosis, upper gastrointestinal bleed, sepsis and physiological metabolic derangement. All odds ratios were small effects. CONCLUSION: Preventing understaffing is a consideration for improving the quality of care for patients. Attributing the understaffing variable at the patient level enables exposure to be captured across ward changes increasing the sensitivity with which this variable can be measured.

Impact and costs of home-based trial of void compared with the day care setting.

AIMS: This paper presents the relative merits and comparative costs of conducting trial of void using Hospital-In-The-Home vs. the Day Procedure Unit. BACKGROUND: Hospitals increasingly discharge patients with acute urinary retention with indwelling urinary catheters. For these to be removed and patients supported to return to normal urinary function, outpatient or in-home services are used. To date, the relative effectiveness and costs of Hospital-In-The-Home care and Day Procedure Unit care for trial of void have not been examined. DESIGN: This retrospective study used a static-group comparison design. METHODS: Hospital administrative data from 1 February 2009-30 March 2011 for patients having trial of void in the Day Procedure Unit (n = 107) and Hospital-In-The-Home (n = 163) of a tertiary hospital in Western Australia were compared in terms of patient outcomes and costs. RESULTS: Day Procedure Unit patients had longer wait times than Hospital-In-The-Home patients; there was no difference between the two groups for average per patient days of service or successful first trials. Hospital-In-The-Home care did not increase the overall period of care. Per patient average ward-equivalent cost in the Day Procedure Unit was A$396 higher than the Hospital-In-The-Home ward-equivalent cost. The average cost saving per patient for Hospital-In-The-Home care including trial of void cost and emergency department visits was A$117. CONCLUSION: Patient outcomes from Hospital-In-The-Home trial of void in low-risk patients were comparable to those of Day Procedure Unit care and less costly. Hospital-In-The-Home care for this well-defined procedure could permit more efficient management of patient throughput.