Evidence based nursing and midwifery practice in a regional Australian healthcare setting: Behaviours, skills and barriers.

AIM: To establish self-reported skill levels, behaviours and barriers in relation to evidence-based practice (EBP) among a representative sample of regional Australian nurses and midwives in senior roles. BACKGROUND: It has been widely established that nurses and midwives continue to face challenges in relation to putting evidence into practice on the clinical floor. Prior to conducting an EBP capacity building activity in a regional Australian Local Health District, a survey assessing needs and skill and barrier areas was conducted. METHODS: A quantitative descriptive survey which utilised the 'Developing Evidence Based Practice Questionnaire' (DEBPQ) was conducted in early 2012 among senior nurses and midwives of a regional New South Wales Local Health District (LHD). The survey results were contrasted with reported DEBPQ results from a sample of UK metropolitan nurses and a sample of Australian general practice nurses (GPNs). RESULTS: One hundred and sixty nine nurses completed the survey (response rate 42%). Survey respondents' reliance on accepted evidentiary knowledge sources was found to be low. Research literature-related knowledge sources were ranked outside of the top 10 sources, compared with numerous personalised and subjective sources, which ranked within the top 10. Access to and understanding of research material was a primary barrier to reviewing evidence in the study sample. Time-related barriers to changing practice on the basis of evidence figured prominently in the study sample and the UK and Australian GPN samples. The study sample rated their EBP skill levels significantly higher than both their UK counterparts and the Australian GPN sample (P < 0.0001). CONCLUSION: Capacity building interventions are needed among senior nurses and midwives in Australian regional LHDs, as the most prominent knowledge sources reported are non-evidentiary in nature and barriers to finding and reviewing evidence, along with barriers to making practice change, remain significant.

Preparing a 21st century workforce: is it time to consider clinically based, competency-based training of health practitioners?

Health workforce training in the 21st century is still based largely on 20th century healthcare paradigms that emphasise professionalisation at the expense of patient-focussed care. This is illustrated by the paradox of increased training times for health workers that have corresponded with workforce shortages, the limited career options and pathways for paraprofessional workers, and inefficient clinical training models that detract from, rather than add to, service capacity. We propose instead that a 21st century health workforce training model should be: situated in the clinical setting and supported by outsourced university training (not the other way around); based on the achievement of specific milestones rather than being time-defined; and incorporate para-professional career pathways that allow trainees to 'step-off' with a useable qualification following the achievement of specific competencies. Such a model could be facilitated by existing technology and clinical training infrastructure, with enormous potential for economies of scale in the provision of formal training. The benefits of a clinically based, competency-based model include an increase in clinical service capacity, and clinical training resources become a resource for the delivery of healthcare, not just education. Existing training models are unsustainable, and are not preparing a workforce with the flexibility the 21st century demands.

Addressing the mental health nurse shortage: undergraduate nursing students working as assistants in nursing in inpatient mental health settings.

The population of mental health nurses is ageing and in the next few years we can expect many to retire. This paper makes an argument for the employment of undergraduate nursing students as Assistants in Nursing (AINs) in mental health settings as a strategy to encourage them to consider a career in mental health nursing. Skill mix in nursing has been debated since at least the 1980s. It appears that the use of AINs in general nursing is established and will continue. The research suggests that with the right skill mix, nursing outcomes and safety are not compromised. It seems inevitable that assistants in nursing will increasingly be part of the mental health nursing workforce; it is timely for mental health nurses to lead these changes so nursing care and the future mental health nursing workforce stay in control of nursing.

A global review of the inferred meaning of woman centred care within midwifery professional standards.

BACKGROUND: As an integral and guiding approach, woman centred care is well-grounded as the cornerstone of midwifery training and practice. A previous global review established that the concept, even though acknowledged as pivotal, has limited attention within the professional standards documents that underpin the discipline [1]. Whilst not detracting from the overall importance of woman centred care, it is further suggested that a broader meaning is generally being implied. OBJECTIVE: Whether other related inferences and meanings of the actual term 'woman centred care' are also being utilised, has not yet been established. Therefore, this review of professional documents sought to investigate the occurrence of further depictions of the concept. METHODS: With an implied and inferred meaning of 'woman centred care' as the focus, a review and synthesis of narrative from a global sample of midwifery professional standards was conducted. The principles of meta-ethnography were utilised to develop a qualitative approach. Rather than the actual words 'woman centred care' further phrases implying or inferring the concept were sought. 'A priori' phrases were developed and narrative and examples were synthesised for each. FINDINGS: Standards and governance documents were located from within Australia, the United Kingdom and New Zealand and a further 139 nations. Overall, the seven phrases, each considered as an inference to woman centred care, were all substantiated. As a proportion of all documents, these were collated with the outcomes being a woman's right to choice (89%), being culturally sensitive (80.5%), a woman's voice and right to be heard (78%), the woman as an individual (68%), universal human rights (40%), being holistic (39%) and being self-determined (17.5%). CONCLUSION: The outcomes of this review demonstrate that woman centred care may be a multidimensional concept. There were occurrences of all seven phrases across a broad scope of global professional midwifery documents, and each can be shown through its meaning to contribute something to an understanding of woman centred care. The creation of a universal meaning is recommended.

A conversation about practice development and knowledge translation as mechanisms to align the academic and clinical contexts for the advancement of nursing practice.

Practice development (PD) and knowledge translation (KT) have emerged recently as methodologies which assist advancement in gathering and using evidence in practice. For nursing to benefit from these methodologies there is a need to advance the dialogue between academia and the service sector concerning the use and further development of these methodologies as well as how we create the most effective partnerships between academia and practice. To advance this dialogue and to gain insights into the similarities and differences between KT and PD and between the academic and the service sectors, four conversations from different leaders in these sectors have been gathered and are presented here. These four discrete narratives are presented to showcase the diversity of sector contexts in relation to PD and KT methodologies. Narrative One focuses on some of the theoretical and policy issues related to creating partnerships between traditional "knowledge creation systems" (universities) and "knowledge utilization systems" Narrative Two discusses how a large school of nursing responded to the challenge of creating partnerships for practice development in an attempt to bridge the academic/service divide and produce benefits to both organisations. Narratives Three and Four describe the view of practice development from the service side. The final section of the paper presents an agenda for discussion and action based on the emerging set of principles.

Towards a conceptualisation of woman centred care - A global review of professional standards.

BACKGROUND: Woman centred care is purported to underpin Midwifery philosophy. However, the evidence and focus of this concept within midwifery professional standards has yet to be verified. Further to this, woman centred care is, at this time, mostly depicted as a way of assisting, supporting and interacting with a woman and her family. It is however, without a substantive universally accepted definition. OBJECTIVE: This study aimed to review midwifery standards documents. An organised and targeted methodology was conducted to identify the approaches to woman centred care that currently underpin midwifery governance. METHODS: A comprehensive and specific search for 'woman centred care' was conducted across a global collection of midwifery standards. A professional document was included if it represented either or all of the underpinnings of midwifery education, contained statements related to standards of practice, overall governance or any equivalence. Individual documents were initially searched for the words 'woman centred care', followed by 'women centred care', 'patient/person centred care' and 'client centred care'. FINDINGS: An extensive review of 142 documents was undertaken. These included: thirty independent nations, thirty represented by the European Midwives Association and a further twenty-one identified through the International Confederation of Midwives (ICM). The World Health Organisation (WHO), yielded midwifery information from a further sixty-one nations. The phrase 'woman centred care' was located within 3.5% of the documents reviewed. Overall, five examples were found that directly referred to the actual phrase 'woman centred care' and one to the use of 'person centred care'. Therefore, it was established, that at the time of this review, there was limited formal depiction of the concept of woman centred care.

The search for the discipline of nursing.

AIM: This is a personal reflection on the need for visible academic leadership of the Discipline of Nursing. BACKGROUND: Health care is under tremendous pressure to reform. Therefore, does nursing have a strong enough discipline base to provide solutions to the reform agenda, or is it simply seen as a service agency. EVALUATION: The author draws upon a number of health policy references, and nurse leader position statements, to form an argument for leadership. KEY ISSUES: Nursing has always been described as invisible within health service development and activity. Therefore, if academic leadership is not articulated this will remain the case and nurses will continue to be seen as task-orientated skilled workers. CONCLUSIONS: Nurse Managers need to have a clear model of nursing and its discipline firmly embedded in their thinking before they can lead anything. IMPLICATIONS FOR NURSE MANAGEMENT: The implications are that Nurse Managers need to have a thorough grounding in the discipline of nursing, possess a clear vision of what nursing is, and should be, and possess the skills to bring this about. This paper provides some perspectives for Nurse Managers to consider with regard to their development.

Identification of service development needs for incarcerated adults with autism spectrum disorders in an Australian prison system.

PURPOSE: The purpose of this paper is to identify and deliberate the service development needs required for the improvement of service provision for incarcerated adults with autism spectrum disorder (ASD) in NSW, Australia. DESIGN/METHODOLOGY/APPROACH: Consultation groups were conducted to bring together n=5 key stakeholders from heath and correctional-based services in the prison system. A facilitated asynchronous e-mail-based discussion occurred amongst group members between consultation group meetings. FINDINGS: Two main themes were identified: detecting persons with ASD and providing appropriate care. Participants discussed current service gaps with regard to the identification of people with ASD at the point of contact with the prison service, and the difficulties associated with diagnosing prisoners with ASD. The need for effective alert systems to detect persons with ASD in custody was identified. The current absence of ASD-specific support services in prison was highlighted, and recommendations for improvement suggested. PRACTICAL IMPLICATIONS: Current health and correctional-based service provision failed to adequately support incarcerated adults with ASD. Improvements in prison-entry screening processes, alert systems and diagnostic practices are required. Multidisciplinary collaboration between prison-based and external service providers is required for the development of a model of care based on individualised case management to adequately support incarcerated adults with ASD in prison. ORIGINALITY/VALUE: Given the lack of reported service provision for incarcerated adults with ASD internationally, other prison-based services are likely to experience similar service development needs and see the relevance of the recommendations made directly from the study findings.

Comparison of seating, powered characteristics and functions and costs of electrically powered wheelchairs in a general population of users.

PURPOSE: To profile and compare the seating and powered characteristics and functions of electrically powered wheelchairs (EPWs) in a general user population including equipment costs. METHOD: Case notes of adult EPW users of a regional NHS service were reviewed retrospectively. Seating equipment complexity and type were categorized using the Edinburgh classification. Powered characteristics and functions, including control device type, were recorded. RESULTS: 482 cases were included; 53.9% female; mean duration EPW use 8.1 years (SD 7.4); rear wheel drive 88.0%; hand joystick 94.8%. Seating complexity: low 73.2%, medium 18.0%, high 8.7%. Most prevalent diagnoses: multiple sclerosis (MS) 25.3%, cerebral palsy (CP) 18.7%, muscular dystrophy (8.5%). Compared to CP users, MS users were significantly older at first use, less experienced, more likely to have mid-wheel drive and less complex seating. Additional costs for muscular dystrophy and spinal cord injury users were 3-4 times stroke users. CONCLUSIONS: This is the first large study of a general EPW user population using a seating classification. Significant differences were found between diagnostic groups; nevertheless, there was also high diversity within each group. The differences in provision and the equipment costs across diagnostic groups can be used to improve service planning. Implications for Rehabilitation At a service planning level, knowledge of a population's diagnostic group and age distribution can be used to inform decisions about the number of required EPWs and equipment costs. At a user level, purchasing decisions about powered characteristics and functions of EPWs and specialised seating equipment need to be taken on a case by case basis because of the diversity of users' needs within diagnostic groups. The additional equipment costs for SCI and MD users are several times those of stroke users and add between 60 and 70% of the cost of basic provision.

Reflections on a 'virtual' practice development unit: changing practice through identity development.

AIMS: This paper draws together the personal thoughts and critical reflections of key people involved in the establishment of a 'virtual' practice development unit of clinical nurse specialists in the south of England. BACKGROUND: This practice development unit is 'virtual' in that it is not constrained by physical or specialty boundaries. It became the first group of Trust-wide clinical nurse specialists to be accredited in the UK as a practice development unit in 2004. DESIGN AND METHODS: The local university was asked to facilitate the accreditation process via 11 two-hour audio-recorded learning sessions. Critical reflections from practice development unit members, leaders and university staff were written 12 months after successful accreditation, and the framework of their content analysed. FINDINGS AND DISCUSSION: Practice development was seen as a way for the clinical nurse specialists to realize their potential for improving patient care by transforming care practice in a collaborative, interprofessional and evolutionary manner. The practice development unit provided a means for these nurses to analyse their role and function within the Trust. Roberts' identity development model for nursing serves as a useful theoretical underpinning for the reflections contained in this paper. CONCLUSIONS: These narratives provide another example of nurses making the effort to shape and contribute to patient care through organizational redesign. This group of nurses began to realize that the structure of the practice development unit process provided them with the means to analyse their role and function within the organization and, as they reflected on this structure, their behaviour began to change. RELEVANCE TO CLINICAL PRACTICE: Evidence from these reflections supports the view that practice development unit participants have secured a positive and professional identity and are, therefore, better able to improve the patient experience.

A reflective discussion: questions about globalization and multiculturalism in nursing as revealed during a student/staff exchange programme.

The purpose of this paper is to present elements of a discussion on the discipline of nursing that arose from a student-faculty exchange programme, as a reflection of the experiences the students and faculty had during the 3-year exchange. It suggests that the globalization of health and the international migration of nurses might prove to be an opportunity for nurses to learn more about nursing practice. It became apparent to the participants that the phenomenon of nursing, although understood by them all, was not easy to describe, and words used in Swedish, Finnish or British or American English were often not easy to interpret or explain. These reflections were noted by the authors when the group came together to plan the programme and design experiences for the participants. We were concerned how nursing could contribute to health-care improvement globally if it wasn't universally understood within the four countries concerned.

Promoting leadership: the development of a nurse executive team in an acute hospital trust.

AIM: The purpose of this study was to evaluate how an executive nursing team, within an acute hospital trust in the south of England, developed their leadership characteristics through the use of a professional development programme. BACKGROUND: This paper offers an insight into how this team worked together to clarify their views of their new role and how the role would be enacted. METHOD: A questionnaire using quantitative and qualitative measures was used to explore the group's leadership style and evaluate the professional development programme. FINDINGS: The findings show how the development programme worked and what clarity it afforded the group in terms of their leadership style. Group work, building on the findings, helped them define their particular characteristics, skills and leadership ability and what further work was needed to demonstrate this. CONCLUSIONS: The issues raised, such as team-working, mutual purpose and personal development, are discussed in terms of their function within an integrated executive team with vision and goals. IMPLICATIONS FOR NURSING MANAGEMENT: In ensuring that the nursing service has positive purpose, direction and goals, there needs to be a strategic approach to corporate development; otherwise, nursing will struggle to lead itself within a fast changing health care system.

Qualitative study of peer workers within the 'Partners in Recovery' programme in regional Australia.

In Australia and internationally, Peer Workers are increasingly being incorporated into the mental health workforce. Underpinning this trend is the conviction that the inclusion of workers with lived experience in overcoming mental health challenges is central to transforming service delivery. Given there are few identified Australian studies into the experiences of Peer Workers, this paper reports findings from qualitative interviews conducted in a Partners In Recovery programme in one regional area in Australia. The interviews formed part of a larger mixed-method study evaluating Peer Worker roles in the programme. Thematic analysis of interview transcripts with Peer Workers and other staff employed in the programme (n = 22) was undertaken. Central to the five themes that emerged was the concept of lived experience expertise in overcoming mental health challenges. The themes were: (i) role variance, (ii) the challenges and opportunities for Peer Worker, (iii) the processes Peer Workers employed as they attempted to shape an identify and language, (iv) the inconsistencies and challenges of employing lived experience as a defining feature of the peer worker role, and (v) the nature of trust arising from lived experience relationships. From this study, it is evident that the Peer Worker role remains underdeveloped. The difficulties experienced by Peer Workers in establishing a homogenous identity and role is not unique. The process and lack of clarity around role identity revealed from the narratives, parallels the experiences of Mental Health Nursing.

Evaluating nurse consultants' work through key informant perceptions.

AIM: To evaluate the work of nurse consultants in the NHS by exploring the views of key informants and nurse consultants. METHOD: A multi-site evaluative study commissioned by and undertaken in four trusts. The evaluation was based on the 360 degree feedback process and used case study methodology, inviting key informants to provide information on their work with nurse consultants. FINDINGS: The findings are discussed in relation to the following themes: role aspirations and lived reality; challenging boundaries; impact and outcomes and leadership. The findings concur with previous studies demonstrating a series of common themes associated with leadership, clinical expertise, research and educational activity. These findings express the ways in which nurse consultants are working to develop unique services to meet patient needs. CONCLUSION: The nurse consultant has an important role in the modernisation of the NHS. The role's impact, in terms of the informants, is in leadership, clinical expertise, research and educational activity. The findings reveal an urgent need to support consultant nurses in developing their leadership potential and skills in researching practice.

Control devices for electrically powered wheelchairs: prevalence, defining characteristics and user perspectives.

PURPOSE: To determine the prevalence of control devices for electrically powered wheelchairs (EPWs), related characteristic features and users' views on their utility. METHOD: Postal survey of users of a regional NHS wheelchair service using a purpose-designed questionnaire (n = 262, ≥18 years old). RESULTS: Mean age 54.4 years, female 56.8%, mean duration EPW use 10.1 years, mean usage 6.7 days per week and 9.2 h per day. Largest diagnostic groups: Multiple Sclerosis 28.3%, Cerebral Palsy 13.8% and Spinal Cord Injury 11.7%. Control device types 94.6% hand joystick, 2.3% chin joystick, 2.7% switches and 0.4% foot control. 42.4% reported fatigue or tiredness and 38.8% pain or discomfort limited EPW use. 28.0% reported an accident or mishap. CONCLUSIONS: This is the first study of control devices on a large, general population of EPW users. The majority have control devices that meet their needs, with high levels of user satisfaction, though some might benefit from adjustments or modifications to their current provision and others might benefit by changing to a different type of control device. High proportions reported fatigue or tiredness and pain or discomfort limit their EPW use. The study provides indicators for prescribers and manufacturers of control devices for EPWs. Implications for Rehabilitation Most users have control devices that meet their needs, with high levels of satisfaction, but some would benefit from adjustments or modifications or a change of type. A high proportion reported fatigue or tiredness and pain or discomfort limit their use of their EPW and prescribers need to be mindful of these issues when determining the most suitable type of control device and where it should be positioned. The vast majority of users have a hand joystick as a control device with alternative control devices (such as chin joysticks and switches) being far less prevalent. Adverse incidents may arise due to difficulty with manoeuvring or accidental activation of the hand joystick that can lead to collisions and even entrapment.

Recurrent acute hepatitis in patient receiving pulsed methylprednisolone for multiple sclerosis.

We report clinically significant, recurrent acute hepatitis in a 48-year-old woman receiving pulsed treatment with methylprednisolone for multiple sclerosis. No other cause was found for the episodes and the temporal and histological correlations were consistent with immune-allergic type drug-induced hepatitis.

Supporting the role of the nurse consultant -- an exercise in leadership development via an interactive learning opportunity.

This paper discusses how a group of consultant nurses were supported over a period of three years by a process of interactive learning. The purpose of this learning was to help them develop the personal and professional abilities necessary for them to achieve success in the role. These personal and professional abilities are not new clinical skills, but the skills of leadership, self-awareness, confidence, self-belief and value clarification and a clear mental model of what it is they want to be within healthcare. An evaluation of the action learning methods reveals their success in helping the participants to achieve some competence and awareness in these personal and professional abilities, to reach a comfort zone in the role. However, the analysis also reveals the polarities and paradoxes such practitioners will have to negotiate if they are to achieve success and establish themselves within the role.

Advanced practice nursing: continuation of the dialogue.

This column continues the dialogue about advanced practice nursing. Professor Iain Graham of Bournemouth University shares his ideas about advanced practice nursing in the United Kingdom and answers questions about the tasks and responsibilities of advanced practice nurses within the National Health Service.

Intramuscular hemangioma of the posterior belly of the digastric muscle failing to highlight on magnetic resonance imaging.

Intramuscular hemangiomas of the digastric muscle are rare. We present the fifth case reported and the second to be imaged in vivo with magnetic resonance imaging. Accurate preoperative diagnosis of these lesions is difficult, but may be facilitated by a high degree of clinical suspicion and imaging. Magnetic resonance imaging using T2-weighted sequencing has been reported to effectively highlight these lesions. We present a case in which magnetic resonance imaging failed to highlight an intramuscular hemangioma of the posterior belly of the digastric muscle. Possible reasons for this failure are discussed.