Practice priorities for acute care nursing: A Delphi study.

AIMS AND OBJECTIVES: To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus. BACKGROUND: Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care. DESIGN: Delphi Method. METHOD: A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist. RESULTS: High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care. CONCLUSION: The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise. RELEVANCE TO CLINICAL PRACTICE: This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.

Resident transfers from aged care facilities to emergency departments: can they be avoided?

OBJECTIVE: Residents from aged care facilities make up a considerable proportion of ED presentations. There is evidence that many residents transferred from aged care facilities to EDs could be managed by primary care services. The present study aimed to describe the characteristics of residents transferred from residential aged care facilities to EDs, and to evaluate the appropriateness and cost of these presentations. METHODS: A retrospective review of ED records was undertaken for residents transferred from residential aged care facilities to two EDs in Melbourne, Victoria, in 2012. Data examined included residents' mode and time of arrival to ED, presenting complaint, triage category, procedures within ED, diagnosis, length of stay, and disposition. Data were examined against a previously established tool to identify resident transfers that might be 'potentially avoidable'. RESULTS: There were 2880 resident transfers included in the sample, of which 408 transfers were randomly selected for scrutiny of documentation. Seventy-one residents (17.4%) were identified as being potentially avoidable transfers. CONCLUSION: Many resident transfers might have been avoided with better primary care services in place. Future strategies to improve resident care might include aged care staff skill mix and the availability of outreach or primary care services.

Shortfalls in residents' transfer documentation: challenges for emergency department staff.

BACKGROUND: Increasing numbers of residents are transferred from aged care facilities to emergency departments. Frequently, residents arrive with inadequate documentation regarding their presenting complaint or medical history, making it difficult for emergency department staff to make decisions about care. METHODS: A retrospective review of emergency department records was undertaken for residents transferred from residential aged care facilities to two emergency departments in Melbourne, Victoria in 2012. RESULTS: 2880 resident transfers were included in the sample, of which 408 transfers were randomly selected for documentation review. Clinically important documentation was frequently absent including: the reason for transfer to the ED (n=197, 48.2%); baseline cognitive function (n=244, 59.7%); and vital signs at time of complaint (n=285, 69.9%). When the reason for transfer was absent, residents with an altered conscious state had more investigations and spent longer in the emergency department than when the reason for transfer was recorded. CONCLUSION: Inadequate documentation negatively impacted the resident's journey through the emergency department. There is evidence that inadequate documentation contributes to poor patient outcomes. To minimise the gaps in the transfer documentation regular staff development and quality assurance programs may be required in residential aged care facilities.

Keeping childbearing safe: midwives' influence on women's use of complementary and alternative medicine.

The use of complementary and alternative medicine during pregnancy is common. However, many modalities have not been well researched and safety concerns have been raised. This article describes a grounded theory study which explored how midwives interact with women regarding use of these therapies. Participants were recruited from metropolitan hospitals in Victoria, Australia. Twenty-five midwives were interviewed and a subgroup was also observed. The findings revealed that when working with women interested in complementary and alternative medicine, midwives usually aimed to facilitate informed decisions whilst prioritising safety. However, participants assessed the risk associated with various therapies differently. Although many endorsed the use of various therapies, only a few were integrated into practice. In conclusion, midwives play an important role in mediating women's behaviour towards complementary and alternative medicine. Yet, currently many do not have the appropriate education to appreciate the associated risks, as well as the potential benefits.

From alternative, to complementary to integrative medicine: supporting Australian midwives in an increasingly pluralistic maternity environment.

BACKGROUND: The use of complementary and alternative medicine during pregnancy has become increasingly popular over the past decade in Australia. AIM: The purpose of this discussion paper to make recommendations and foster a constructive debate regarding the appropriate response by the midwifery profession. DISCUSSION: Midwives should receive basic education regarding the use of complementary and alternative medicine. All women should be routinely question women about their use and this should be documented. While a few therapies could be safely integrated, in most situations interested women should be referred to a qualified practitioner. Referral frameworks and flexible clinical guidelines should be investigated. CONCLUSION: With the appropriate education and support, midwives are in an excellent position to engage women in open dialogue and raise awareness of the benefits and risks of CAM practices. The way forwards for midwifery profession is to focus on self-governance, education and flexible clinical guidelines.

Navigating a safe path together: a theory of midwives' responses to the use of complementary and alternative medicine.

OBJECTIVE: this paper presents the findings from a qualitative study that aimed to explain the processes midwives engaged in when considering the use of complementary and alternative medicine by pregnant women. DESIGN: grounded theory methodology was employed for the study. Data was generated from in-depth interviews and non-participant observation of midwives interacting with expectant mothers. Twenty-five midwives who worked in four hospitals and associated community clinics in Victoria, Australia, participated. FINDINGS: the theory 'Navigating a safe path together' offers a possible explanation of how midwives are responding. When working with women interested in the use of complementary and alternative medicine, midwives move through an iterative process of individualising pregnancy care, encountering diverse perspectives and minimising the risks associated with childbearing. KEY CONCLUSION: at the heart of the theory is the meaning midwives' construct around safe childbirth and their professional roles. Despite widespread support for the therapies, midwives' actions in clinical practice are mediated by a number of factors including the context of their professional work, their beliefs and knowledge, and the woman's expectation and health. IMPLICATIONS FOR PRACTICE: the research highlights the need for improved education and greater professional guidance to equip midwives to respond with greater understanding, and confidence to the increasing prevalence of CAM in the maternity setting.

Complementary and alternative medicine in midwifery practice: managing the conflicts.

BACKGROUND: Midwives commonly endorse the use of complementary medicine. However many work in hospitals where there can be significant opposition to use of these therapies. This paper describes how one group of midwives negotiated the conflicting perspectives. METHOD: Grounded theory was employed. Twenty five participants were recruited from metropolitan hospitals in Australia. Data was collected from interviews and observations. RESULTS: Midwives' behaviour was influenced by the meaning they constructed around their professional role and authority. Some emphasised ideological congruence, historical ties, and the ability of certain complementary therapies to reduce medical interventions, in order to legitimise their use. However, many were aware of biomedical opposition and undertook various strategies to protect themselves from conflict. CONCLUSIONS: Conflict regarding the use of complementary and alternative medicine is context specific. In some situations midwives can successfully negotiate the competing perspectives and expectations, while at other times they struggle to reconcile the disparities.

Complementary and alternative medicine for induction of labour.

BACKGROUND: Induction of labour is a common obstetric procedure. Some women are likely to turn to complementary and alternative medicine in order to avoid medical intervention. AIM: The aim of this paper is to examine the scientific evidence for the use of complementary and alternative medicine to stimulate labour. METHOD: An initial search for relevant literature published from 2000 was undertaken using a range of databases. Articles were also identified by examining bibliographies. RESULTS: Most complementary and alternative medicines used for induction of labour are recommended on the basis of traditional knowledge, rather than scientific research. Currently, the clinical evidence is sparse and it is not possible to make firm conclusions regarding the effectiveness of these therapies. There is however some data to support the use of breast stimulation for induction of labour. Acupuncture and raspberry leaf may also be beneficial. Castor oil and evening primrose oil might not be effective and possibly increase the incidence of complications. There is no evidence from clinical trails to support homeopathy however, some women have found these remedies helpful. Blue cohosh may be harmful during pregnancy and should not be recommended for induction. Other complementary and alternative medicine (CAM) therapies may be useful but further investigation is needed. CONCLUSIONS: More research is needed to establish the safety and efficacy of CAM modalities. Midwives should develop a good understanding of these therapies, including both the benefits and risks, so they can assist women to make appropriate decisions.

Midwives' support for Complementary and Alternative Medicine: a literature review.

OBJECTIVE: There is evidence that the use of Complementary and Alternative Medicine by childbearing women is becoming increasingly popular in industrialised countries. The aim of this is paper is to review the research literature investigating the midwives' support for the use of these therapies. METHOD: A search for relevant research published from 2000 to 2009 was undertaken using a range of databases and by examining relevant bibliographies. A total of thirteen studies were selected for inclusion in this review. RESULTS: The findings indicate that the use of Complementary and Alternative Medicine is widespread in midwifery practice. Common indications for use include; labour induction and augmentation, nausea and vomiting, relaxation, back pain, anaemia, mal-presentation, perineal discomfort, postnatal depression and lactation problems. The most popular therapies recommended by midwives are massage therapy, herbal medicines, relaxation techniques, nutritional supplements, aromatherapy, homeopathy and acupuncture. Midwives support the use Complementary and Alternative Medicine because they believe it is philosophically congruent; it provides safe alternatives to medical interventions; it supports the woman's autonomy, and; incorporating Complementary and Alternative Medicine can enhance their own professional autonomy. CONCLUSIONS: There is considerable support by midwives for the use of Complementary and Alternative Medicine by expectant women. Despite this enthusiasm, currently there are few educational opportunities and only limited research evidence regarding CAM use in midwifery practice. These shortfalls need to be addressed by the profession. Midwives are encouraged to have an open dialogue with childbearing women, to document use and to base any advice on the best available evidence.

The use of complementary and alternative medicine by pregnant women: a literature review.

BACKGROUND: The use of complementary and alternative medicine (CAM) has become increasingly prevalent in industrialised countries, with women being the most prolific users. Some women continue to consume these therapies when they become pregnant. AIM: To review the literature exploring prevalence and motivation for use of complementary and alternative medicine by pregnant women. METHOD: A search for relevant literature published from 2001 was undertaken using a range of databases and by examining relevant bibliographies. RESULTS: Although the estimates vary widely from 1% to 87%, the general trend indicates that a significant number of pregnant women use complementary and alternative medicine. Common modalities used include massage, vitamin and mineral supplements, herbal medicine, relaxation therapies and aromatherapy. Reasons for use are varied and include the belief that these therapies offer safe alternatives to pharmaceuticals, they allow greater choice and control over the childbearing experiences, and they are congruent with their holistic health beliefs. The influence of traditional cultural practices on the use of these therapies is unclear. Most expectant women rely on advice from family and friends, and many do not disclose their use to their pregnancy care providers. CONCLUSIONS: Many women use complementary and alternative medicine when they are pregnant. Further research is needed to gain a greater understanding of the true prevalence and expectant women's motivation for the use of complementary and alternative medicine. Health-care professionals are encouraged to ask women about their use of these treatments and seek out relevant information.