Nursing - Research Publications

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    Hospital in the Home nurses' recognition and response to clinical deterioration.
    Gray, E ; Currey, J ; Considine, J (Wiley, 2018-05)
    AIMS AND OBJECTIVES: To obtain an understanding of how Hospital in the Home (HITH) nurses recognise and respond to clinical deterioration in patients receiving care at home or in their usual place of residence. BACKGROUND: Recognising and responding to clinical deterioration is an international safety priority and a key nursing responsibility. Despite an increase in care delivery in home environments, how HITH nurses recognise and respond to clinical deterioration is not yet fully understood. DESIGN: A prospective, descriptive exploratory design was used. A survey containing questions related to participant characteristics and 10 patient scenarios was used to collect data from 47 nurses employed in the HITH units of three major health services in Melbourne, Australia. The 10 scenarios reflected typical HITH patients and included medical history and clinical assessment findings (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, conscious state and pain score). RESULTS: The three major findings from this study were that: (i) nurse and patient characteristics influenced HITH nurses' assessment decisions; (ii) the cues used by HITH nurses to recognise clinical deterioration varied according to the clinical context; and (iii) although HITH nurses work in an autonomous role, they engage in collaborative practice when responding to clinical deterioration. CONCLUSION: Hospital in the Home nurses play a fundamental role in patient assessment, and the context in which they recognise and respond to deterioration is markedly different to that of hospital nurses. RELEVANCE TO CLINICAL PRACTICE: The assessment, measurement and interpretation of clinical data are a nursing responsibility that is crucial to early recognition and response to clinical deterioration. The capacity of HITH services to care for increasing numbers of patients in their home environment, and to promptly recognise and respond to clinical deterioration should it occur, is fundamental to safety within the healthcare system. Hospital in the Home nurses are integral to a sustainable healthcare system that is responsive to dynamic changes in public health policies, and meets the healthcare needs of the community.
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    Current practices related to family presence during acute deterioration in adult emergency department patients.
    Youngson, MJ ; Currey, J ; Considine, J (Wiley, 2017-11)
    AIMS AND OBJECTIVES: To explore the characteristics of and interactions between clinicians, patients and family members during management of the deteriorating adult patient in the emergency department. BACKGROUND: Previous research into family presence during resuscitation has identified many positive outcomes when families are included. However, over the last three decades the epidemiology of acute clinical deterioration has changed, with a decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite the decrease in cardiac arrests, research related to family presence continues to focus on care during resuscitation rather than care during acute deterioration. DESIGN: Descriptive exploratory study using nonparticipatory observation. METHODS: Five clinical deterioration episodes were observed within a 50-bed, urban, Australian emergency department. Field notes were taken using a semistructured tool to allow for thematic analysis. RESULTS: Presence, roles and engagement describe the interactions between clinicians, family members and patients while family are present during a patient's episode of deterioration. Presence was classified as no presence, physical presence and therapeutic presence. Clinicians and family members moved through primary, secondary and tertiary roles during patients' deterioration episode. Engagement was observed to be superficial or deep. There was a complex interplay between presence, roles and engagement with each influencing which form the other could take. CONCLUSIONS: Current practices of managing family during episodes of acute deterioration are complex and multifaceted. There is fluid interplay between presence, roles and engagement during a patient's episode of deterioration. RELEVANCE TO CLINICAL PRACTICE: This study will contribute to best practice, provide a strong foundation for clinician education and present opportunities for future research.
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    Emergency nurses' decisions regarding frequency and nature of vital sign assessment.
    Lambe, K ; Currey, J ; Considine, J (Wiley, 2017-07)
    AIMS AND OBJECTIVES: To explore the factors emergency nurses use to inform their decisions regarding frequency and nature of vital sign assessment. BACKGROUND: Research related to clinical deterioration and vital sign assessment in the emergency department is in its infancy. Studies to date have explored the frequency of vital sign assessment in the emergency department; however, there are no published studies that have examined factors that emergency nurses use to inform their decisions regarding frequency and nature of ongoing vital sign assessment. DESIGN: A prospective exploratory design was used. Data were collected using a survey consisting of eight patient vignettes. METHODS: The study was conducted in one emergency department in metropolitan Melbourne. Participants were emergency nurses permanently employed at the study site. RESULTS: A 96% response rate was achieved (n = 47/49). The most common frequency of patient reassessment nominated by participants was 15 or 30 minutely, with an equal number of participants choosing these frequency intervals. Abnormality in initial vital sign parameters was the most common factor identified for choosing either a 15- or 30-minute assessment interval. Frequency of assessment decisions was influenced by years of emergency nursing experience in one vignette and level of postgraduate qualification in three vignettes. Heart rate, respiratory rate and blood pressure were all nominated by over 80% of participants as vital signs that participants considered important for reassessment. The frequency and nature of vital signs selected varied according to vignette content. There were significant negative correlations between assessment of conscious state and years of nursing experience and assessment of respiratory rate and years of emergency nursing experience. Level of postgraduate qualification did not influence selection of parameters for reassessment. CONCLUSION: Emergency nurses are tailoring vital sign assessment to patients' clinical status, and nurses are integrating known vital sign data into vital sign decision-making. RELEVANCE TO CLINICAL PRACTICE: Accurate assessment and interpretation of vital sign data is fundamental to patient safety. Emergency nurses are responsible for the initial and ongoing assessment of undiagnosed or undifferentiated patients. Prior to medical assessment, emergency nurses are solely responsible for patient assessment, escalation of care and implementation of interventions within nursing scope of practice.
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    A framework for transition to specialty practice programmes.
    Morphet, J ; Plummer, V ; Kent, B ; Considine, J (Wiley, 2017-08)
    AIM: To develop a framework for emergency nursing transition to specialty practice programmes. BACKGROUND: Transition to Specialty Practice programmes were introduced to fill workforce shortages and facilitate the transition of nurses to specialty nursing practice. These programmes are recognized as an essential preparation for emergency nurses. Emergency nursing Transition to Specialty Practice programmes have developed in an ad hoc manner and as a result, programme characteristics vary. Variability in programme characteristics may result in inconsistent preparation of emergency nurses. DESIGN: Donabedian's Structure-Process-Outcome model was used to integrate results of an Australian study of emergency nursing Transition to Specialty Practice programmes with key education, nursing practice and safety and quality standards to develop the Transition to Specialty Practice (Emergency Nursing) Framework. METHODS: An explanatory sequential design was used. Data were collected from 118 emergency departments over 10 months in 2013 using surveys. Thirteen interviews were also conducted. Comparisons were made using Mann-Whitney U, Kruskal-Wallis and Chi-square tests. Qualitative data were analysed using content analysis. RESULTS: Transition to Specialty Practice programmes were offered in 80 (72·1%) emergency departments surveyed, to improve safe delivery of patient care. Better professional development outcomes were achieved in emergency departments which employed participants in small groups (Median = 4 participants) and offered programmes of 6 months duration. Written assessments were significantly associated with articulation to postgraduate study (Chi-square Fisher's exact P = <0·001). CONCLUSION: The Transition to Specialty Practice (Emergency Nursing) Framework has been developed based on best available evidence to enable a standardized approach to the preparation of novice emergency nurses.
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    Vital signs as predictors for aggression in hospital patients (VAPA)
    Considine, J ; Berry, D ; Johnson, R ; Sands, N (WILEY, 2017-09-01)
    AIMS AND OBJECTIVES: To examine and describe the relationship between physiological status and violent and aggressive behaviours in hospital patients. BACKGROUND: The majority of adverse events are preceded by physiological abnormalities; whether physiological deterioration is a predictor of violent or aggressive behaviours remains unknown. DESIGN: Prospective case-control study. METHODS: Prospective audit of 999 patients from two major health services in Melbourne, Australia. There were 333 cases who required an emergency response for aggressive or violent behaviour (Code Grey) in the emergency department, medical or surgical units, or inpatient mental health unit between January-June 2015. Two control patients who did not have a Code Grey were randomly selected from the same unit and same day that the Code Grey occurred for the case patient. RESULTS: Patient locations were 54·4% medical or surgical units, 23·7% emergency department and 21·9% mental health units. Code Grey patients had less documentation of physiological assessment and were more likely to have respiratory rate, heart rate and conscious state abnormalities in the 12 hours preceding Code Grey. After adjusting for confounders, the risk of Code Grey was highest for patients with confusion. CONCLUSION: Patients experiencing behavioural disturbance had lower standards of patient assessment, greater incidence of physiological abnormalities and more inpatient deaths. Early recognition of, and response to, patient and physiological predictors of Code Grey should be a strategy to prevent behavioural escalation to the point of Code Grey. RELEVANCE TO CLINICAL PRACTICE: Strategies are needed to improve physiological assessment of patients with behavioural disturbance while ensuring staff safety. There are patient and physiological factors associated with increased risk of Code Grey that may be used to prevent behavioural escalation to the point of an emergency response.
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    Predictors for clinical deterioration of mental state in patients assessed by telephone-based mental health triage
    Sands, N ; Elsom, S ; Corbett, R ; Keppich-Arnold, S ; Prematunga, R ; Berk, M ; Considine, J (WILEY, 2017-06-01)
    Patient safety research focussing on recognizing and responding to clinical deterioration is gaining momentum in generalist health, but has received little attention in mental health settings. The focus on early identification and prompt intervention for clinical deterioration enshrined in patient safety research is equally relevant to mental health, especially in triage and crisis care contexts, yet the knowledge gap in this area is substantial. The present study was a controlled cohort study (n = 817) that aimed to identify patient and service characteristics associated with clinical deterioration of mental state indicated by unplanned admission to an inpatient psychiatric unit following assessment by telephone-based mental health triage. The main objective of the research was to produce knowledge to improve understandings of mental deterioration that can be used to inform early detection, intervention, and prevention strategies at the point of triage. The results of the study found that the clinical profile of admitted patients was one of complexity and severity. Admitted patients were more likely to have had complex psychiatric histories with multiple psychiatric admissions, severe psychotic symptoms, a history of treatment non-adherence, and poorer social functioning than non-admitted patients.
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    A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation.
    Munroe, B ; Curtis, K ; Murphy, M ; Strachan, L ; Considine, J ; Hardy, J ; Wilson, M ; Ruperto, K ; Fethney, J ; Buckley, T (Wiley, 2016-08)
    AIMS AND OBJECTIVES: The aim of this study was to evaluate the effect of the new evidence-informed nursing assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) on the quality of patient assessment and fundamental nontechnical skills including communication, decision making, task management and situational awareness. BACKGROUND: Assessment is a core component of nursing practice and underpins clinical decisions and the safe delivery of patient care. Yet there is no universal or validated system used to teach emergency nurses how to comprehensively assess and care for patients. DESIGN: A pre-post design was used. METHODS: The performance of thirty eight emergency nurses from five Australian hospitals was evaluated before and after undertaking education in the application of the HIRAID assessment framework. Video recordings of participant performance in immersive simulations of common presentations to the emergency department were evaluated, as well as participant documentation during the simulations. Paired parametric and nonparametric tests were used to compare changes from pre to postintervention. RESULTS: From pre to postintervention, participant performance increases were observed in the percentage of patient history elements collected, critical indicators of urgency collected and reported to medical officers, and patient reassessments performed. Participants also demonstrated improvement in each of the four nontechnical skills categories: communication, decision making, task management and situational awareness. CONCLUSION: The HIRAID assessment framework improves clinical patient assessments performed by emergency nurses and has the potential to enhance patient care. RELEVANCE TO CLINICAL PRACTICE: HIRAID should be considered for integration into clinical practice to provide nurses with a systematic approach to patient assessment and potentially improve the delivery of safe patient care.
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    Patient physiological status at the emergency department-ward interface and emergency calls for clinical deterioration during early hospital admission
    Considine, J ; Jones, D ; Pilcher, D ; Currey, J (WILEY, 2016-06-01)
    AIMS: To examine the relationship between physiological status at the emergency department-ward interface and emergency calls (medical emergency team or cardiac arrest team activation) during the first 72 hours of hospital admission. BACKGROUND: Ward adverse events are related to abnormal physiology in emergency department however the relationship between physiology at the emergency department-ward interface and ward adverse events is unknown. DESIGN: Descriptive and exploratory design. METHODS: The study involved 1980 patients at three hospitals in Melbourne Australia: i) 660 randomly selected adults admitted via the emergency department to medical or surgical wards during 2012 and who had an emergency call; and ii) 1320 adults without emergency calls matched for gender, triage category, usual residence, admitting unit and age. RESULTS/FINDINGS: The median age was 78 years and 48·8% were males. The median time to the first emergency call was 18·8 hours and ≥1 abnormal parameters were documented in 34·9% of patients during the last hour of ED care and 47·1% of patients during first hour of ward care. Emergency calls were significantly more common in patients with heart rate and conscious state abnormalities during the last hour of emergency care and abnormal oxygen saturation, heart rate or respiratory rate during the first hour of ward care. Medical emergency team afferent limb failure occurred in 55·3% patients with medical emergency team activation criteria during first hour of ward care. CONCLUSION: The use of physiological status at the emergency department-ward interface to guide care planning and reasons for and outcomes of medical emergency team afferent limb failure are important areas for future research.
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    Translating research findings to clinical nursing practice.
    Curtis, K ; Fry, M ; Shaban, RZ ; Considine, J (Wiley, 2017-03)
    AIMS AND OBJECTIVES: To describe the importance of, and methods for, successfully conducting and translating research into clinical practice. BACKGROUND: There is universal acknowledgement that the clinical care provided to individuals should be informed on the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice, decisions and change to improve the way we deliver care. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients, families and society. Despite its importance, translating research into clinical practice is challenging. There are more nurses in the frontline of health care than any other healthcare profession. As such, nurse-led research is increasingly recognised as a critical pathway to practical and effective ways of improving patient outcomes. However, there are well-established barriers to the conduct and translation of research evidence into practice. DESIGN: This clinical practice discussion paper interprets the knowledge translation literature for clinicians interested in translating research into practice. METHODS: This paper is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We provide practical, evidence-informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse-led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are presented in conjunction with supporting evidence. CONCLUSIONS: Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician/consumer behaviour change and it is critical that implementation strategy includes this. RELEVANCE TO PRACTICE: Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central.
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    Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) protocol: testing the effectiveness of a facilitation intervention in a pragmatic, cluster-randomised trial with an embedded process evaluation and cost analysis.
    Bucknall, TK ; Harvey, G ; Considine, J ; Mitchell, I ; Rycroft-Malone, J ; Graham, ID ; Mohebbi, M ; Watts, J ; Hutchinson, AM (Springer Science and Business Media LLC, 2017-07-11)
    BACKGROUND: Vital signs are the primary indicator of physiological status and for determining the need for urgent clinical treatment. Yet, if physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, unplanned intensive care admissions, cardiac arrest and death may ensue. Although evidence demonstrates the benefit of early recognition and management of deteriorating patients, failure to escalate care and manage deteriorating patients remains a relatively frequent occurrence in hospitals. METHODS/DESIGN: A pragmatic cluster-randomised controlled trial design will be used to measure clinical effectiveness and cost of a facilitation intervention to improve nurses' vital sign measurement, interpretation, treatment and escalation of care for patients with abnormal vital signs. A cost consequence analysis will evaluate the intervention cost and effectiveness, and a process evaluation will determine how the implementation of the intervention contributes to outcomes. We will compare clinical outcomes and costs from standard implementation of clinical practice guidelines (CPGs) to facilitated implementation of CPGs. The primary outcome will be adherence to the CPGs by nurses, as measured by escalation of care as per organisational policy. The study will be conducted in four Australian major metropolitan teaching hospitals. In each hospital, eight to ten wards will be randomly allocated to intervention and control groups. Control wards will receive standard implementation of CPGs, while intervention wards will receive standard CPG implementation plus facilitation, using facilitation methods and processes tailored to the ward context. The intervention will be administered to all nursing staff at the ward level for 6 months. At each hospital, two types of facilitators will be provided: a hospital-level facilitator as the lead; and two ward-level facilitators for each ward. DISCUSSION: This study uses an innovative, networked approach to facilitation to enable uptake of CPGs. Findings will inform the intervention utility and knowledge translation measurement approaches. If successful, the study methodology and intervention has potential for translation to other health care standards. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12616000544471p.