Nursing - Theses
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ItemBedtime Stories: An exploratory study of the reasons for, experience and impact of, sleep disturbance for children with cerebral palsy and their parents( 2019)BACKGROUND: Cerebral palsy (CP) is a motor disorder associated with many comorbidities. Published evidence to date suggests that sleep problems are common in children with CP. Chronic sleep problems are often reported in the clinical setting. However, they are often poorly understood and therefore not well managed. This study aimed to explore the frequency and type of sleep problems in children with CP, the experiences of the children and their parents regarding sleep problems, and the impact of those sleep problems on the children and their parents. METHODS: An exploratory mixed methods sequential design was chosen. Critical social theory was used as a theoretical framework. This qualitatively driven study had three phases: qualitative scoping interviews, a quantitative survey that included the use of validated sleep assessment tools, and follow up qualitative interviews. Participants were parents or caregivers of children aged six to twelve years with CP from Victoria, Australia. The data derived from thematic analysis in Phase One was used to inform the design of Phases Two and Three. RESULTS: Phase One consisted of qualitative semi-structured interviews of nine parents. Thematic analysis identified two major themes: Seeking Solutions and Having to Survive. The key finding of this phase was that parents were asking for help with sleep problems, but often did not receive effective advice or treatment. Phase Two involved an online quantitative survey using the REDCap platform, which collected 126 complete data sets. Sleep problems were reported by 46% of the cohort. The parents of children with a high score on a sleep assessment tool (indicating a sleep problem) had a higher mean score than parents of children without sleep problems (mean difference:12.1 (95%CI:9.2-15.0) (p<0.005)). This indicates that parent sleep is affected by child sleep. Parents found finding effective sleep solutions challenging. Phase Three involved qualitative semi-structured interviews of 19 parents. The thematic analysis identified seven major themes: 1) My Child Doesn’t Fit into the Box, 2) A Mother’s Ears are Always On, 3) Sleep Disturbance is like Water Torture, 4) Sleep is One of Many Spot Fires, I Put it on the Backburner, 5) Luck, Money or Jumping Up and Down, 6) There is Never One Silver Bullet and 7) Help: The Earlier the Better. The key finding for this phase was that parents of children with CP often described their child’s needs being different to what is provided for by systems and services. This difference created significant challenges when seeking health solutions. DISCUSSION: The mixed methods interpretation of the three phases of research resulted in six main findings: 1) finding effective sleep solutions can be challenging, 2) sleep problems are prevalent and persistent but are often untreated, and sleep is not a priority, 3) sleep problems have a significant negative impact on parent sleep and daily life, 4) sleep problems are often complex, 5) sleep problems can improve, and 6) overnight care is often the responsibility of mothers. Clinical recommendations arising from this research include: 1) adopting an individualised approach to addressing sleep problems, 2) elevating sleep as a clinical priority for both parents and clinicians, and 3) incorporating nurses and allied health professionals to be both advocates and providers of sleep health care, for children and families. Where sleep problems are refractory to treatment, respite from overnight care needs to be prioritised urgently. Applying a critical social theory lens to the data revealed two dominant ideologies that may contribute to the persistent presence of sleep problems for children with CP: 1) the dominance of the biomedical model and 2) dominant ideologies around motherhood. This research thesis applied an innovative approach to answering the research questions, which resulted in novel findings. This study has addressed a significant gap in the literature and will be used to make transformative clinical change and likely improve sleep for children with CP and their parents.
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ItemAn exploration of the nursing role in a telehealth based stroke secondary prevention program( 2017)This research study set out to explore a specialist nursing role in the field of Telehealth for chronic disease management. This study aimed to explore the role of the nurse through measurement of nursing activity during the one-year period of participant follow-up. The study aimed to effect long-term secondary prevention of stroke through an evidence based approach to the management of modifiable cardiovascular risk factors and post stroke depression in the community setting. Research suggests that up to 80% reduction of risk of successive stroke can be achieved if recommendations from evidence-based guidelines are implemented. Notwithstanding these findings a gap exists in the implementation of preventative strategies for stroke survivors in the community. Results from previous research indicate that Telehealth is cost effective and potentially may significantly reduce socioeconomic burden and the probability of successive stroke. A small number of studies have highlighted potential mechanisms through which Telehealth can benefit the stroke survivor, carers, families and health professionals. Researchers have recommended more research into Telehealth in order to develop and to define effective interventions. A pilot randomised controlled trial (RCT) conducted at two metropolitan hospitals showed positive results in risk factor and depression outcomes. Integral to this model of care was the role of the nurse. In the current nurse-led, nested multicentre RCT, study nurses gained increased telephone access, to follow-up and support stroke survivors and their General Practitioners. There were 93 participants (43 intervention) recruited from four metropolitan hospitals over a period of two years. Nursing staff were integrated with the multidisciplinary team in designated stroke centres and General Practitioners in the community. Specialists were available to participate in shared care. Telephone follow-up was initially attenuated by risk for second stroke, with high-risk individuals receiving a greater frequency of follow-up. The results indicated that nurses engaged in both fundamental nursing process and advanced activities to assist stroke survivors through transitions across the health landscape after stroke. Case management, assessment and care planning were frequent fundamental activities and occupied a relatively large percentage of the nurse’s time. The mean difference in outcome systolic blood pressure was significantly improved in the intervention group. The mean difference in post stroke depression screening score was significantly better for the intervention group. Lifestyle modification in particular physical activity was better in the intervention group. The results add support to the place of nursing in the ongoing care of stroke survivors in the community setting.
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ItemSelf-treatment of wounds: a mixed methods study( 2016)A chronic wound is a disruption of the structure and function of the skin associated with protracted healing. Chronic wounds affect 2% of Australians and cost US$2.85 billion per annum. Chronic wounds have a negative effect on the physical, emotional, social, lifestyle and financial domains of quality of life. Wound treatment involves wound assessment, wound cleansing, debridement of devitalised tissue and the application of wound dressings. Individuals often seek professional services for wound treatment, however the researchers experience and some published evidence suggests that patients sometimes self-treat. Successful self-treatment of chronic wounds has the potential to improve wound healing and the individual’s well-being. A self-care approach to wound treatment may also help to relieve pressure on healthcare services and reduce the economic burden of this condition. The aim of this research was to investigate self-treatment of chronic wounds among people living in the community to inform the development of educational resources and supports for this group. The objectives of this research were to describe the characteristics of people who self-treat, to determine their self-treatment practices and to explore the effect of self-treatment on quality of life. A sequential explanatory design mixed methods study was conducted in Australia and Wales. Data collection involved participants completing one survey (n=113), and a sub-group of the sample completed one in-depth interview (n=25), and one observation of their self-treatment (n=8). The sample was 63.6 years of age on average, self-treated wounds that were 109 weeks duration on average and more than three quarters (n=89, 78.8%) had a leg wound. Health-related quality of life was sub-optimal, 6/10 (ave.) according to the Cardiff Wound Impact Schedule. The majority of self-treaters reported conducting wound cleansing (n=103, 91.2%), wound dressing removal (n=101, 89.4%), wound dressing application (n=100, 88.5%), and wound assessment (n=94, 83.2%). Wound imaging (n=38, 33.6%) and wound debridement (n=46, 40.7%) were conducted by less than half of the sample. The most common reasons for self-treating were to be independent (n=66, 58.4%) and to do the treatment at a time that suited (n=62, 56.6%). Few self-treaters reported receiving structured education to assist them to self-treat (n=6, 5.3%). Self-treaters had spent on average AU$2475 on wound dressing products since the wound started, and AU$121.82 in the most recent 4 weeks which represented 12% of their disposable income. Observations of self-treatment identified that participants conducted the above mentioned self-treatment activities however often not in the most effective manner. The interviews conducted in this study suggested that the effect of self-treatment on quality of life was mainly positive, in particular it improved pain, reduced worry about infection, had financial benefits, and allowed the individual to recapture time lost when receiving professional care. This research has demonstrated the need to develop educational resources and supports for people who self-treat chronic wounds. These resources should include a tool to appraise self-treatment capacity and an e-learning education program to teach patients and their significant other how to self-treat. These resources also have the potential to guide and standardise the practices of healthcare professionals who educate and support self-treaters, and encourage a shared care approach to this self-treatment practice.
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ItemAn evaluation of violence risk screening at triage in one Australian emergency department( 2015)Background: There is an increasing focus in the published literature on the problem of patient violence in hospital emergency departments (ED). Patient violence negatively impacts staff safety and ultimately the quality of care provided to patients. Research and clinical practice guidelines indicate that the prevention of patient violence in hospital EDs requires a systematic process for identifying patients who are at risk; however the evidence supporting the implementation of risk screening processes in practice is limited. This research was conducted to evaluate the processes and outcomes of a violence risk screening decision support process at triage in one Australian ED. A decision support process for identifying patients at risk of becoming violent was developed and integrated into usual patient assessment practices at point of entry (triage). An evaluation of the risk screen process was then conducted to measure its influence on staff, patient, and organisational outcomes. Design : A mixed methods design incorporating both qualitative and quantitative approaches was utilised. Three studies were sequentially conducted to; explore the feasibility and need for a risk screening process, implement a brief risk screening process and evaluate its influence on the use of security and clinical responses to incidents of patent violence (Code Grey events). Setting: The study site was a level one trauma centre located in Melbourne, Australia. This ED has an annual census of 60,000 presentations with a 40% admission rate. Methods: Study One was conducted to explore the need for, and feasibility of, violence risk screening in practice. Semi-structured observations of triage nurses conducting routine patient assessments were made at the study site. In addition, a retrospective analysis of Code Grey responses matched with demographic and clinical information was performed to characterise the patients and situations in which Code Grey responses were activated. Patient and carer interviews were performed to explore the public perceptions and acceptability of violence risk screening at triage. In Study Two, the violence risk screening decision support process was developed and pilot tested. Levels of agreement between independent raters was determined using the risk screening process for a series of triage assessments. In Study Three, a before and after evaluation was conducted of the risk screening process for its influence on Code Grey responses and access to clinical care. Analysis of the predictive ability of the risk screening process including estimates of its sensitivity and specificity, likelihood ratios and predictive values were performed. Matched pair analysis compared triage nurse self-efficacy before and after the intervention. Results : In Study One structured observations of routine patient assessment at triage (N=167) found nurses used the existing triage process to identify at risk individuals. Based on their assessments the nurses identified a small number of patients requiring risk assessment (6%:10/167) This integrated approach to determining risk was observed to be used in all cases and deviated from standard operating procedure that recommended the use of pre-scripted questions. The 12-month retrospective review of Code Grey responses (N= 1959) identified a high risk group of patients who attended the ED on more than one occasion and required a Code Grey response for violence. Although this group represented 12% (105/857) of patients, they accounted for 32% (577/1796) of all Code Grey events audited. Of the 950 presentations requiring a Code Grey, 67% (639/950) were male, 66% (623/950) arrived by ambulance and 36% (350/950) were referred for a mental health assessment. Factors such as arriving escorted by police and requiring a mental health assessment significantly increased the risk of an individual having a Code Grey response while in the ED (OR=18.88; 95%CI=12.9,27.97; OR=11.68, 95%CI=9.13,14.94 respectively). Analysis of the Code Grey data showed that 25% (500/1959) of events occur at entry points to ED and 50% of a Code Grey responses occurred within the 77 minutes of arrival to the ED. Patient and carer interviews found there is a community expectation that patients at risk of violence are identified to allow an opportunity for prevention and improve safety (N=19). In Study Two, pilot testing of the risk screening process showed that triage nurses correctly identified 52% (122/233) of the patients who required a Code Grey response. Emergency department nurses (n=6) reviewed the triage notes for a sample (n=29) of patients not correctly identified at risk of violence. There was an acceptable level of agreement between triage nurses 69-82%, (kappa .25-.65). Of the 29 presentations of patients who required a Code Grey but were not identified at triage, 45% (13/29) did not have warning signs for violence at triage. In Study Three following the introduction of the violence risk screening decision support process, the proportion of Code Grey response at triage reduced from 29% before (258/904) to 22% after (200/897) implementation p<.001. The median duration of Code Grey events decreased from 14 to 13 minutes p<.009. The proportion of planned Code Greys increased from 52% (468/904) before to 62% after (556/897) p<.001. The sensitivity of the risk screening process was estimated at 56% and the specificity 97%. The total number of coercive interventions (physical restraint, medication given during the Code Grey and mechanical restraint) increased from 822 before to 1007 after p<.001. The median time from triage to first Code Grey increased from 71 minutes before (IQR=7-226) to 124 after (IQR=21-304) p<.001. Patients who required a Code Grey response were seen more quickly by medical staff (Median= 47, IQR=19-106) compared to baseline data (Median=51, IQR=14-114) p<.002. The revised violence risk screen resulted in ED nursing and medical staff being alerted to risk of violence by the electronic alert symbol for 61% (494/817) of Code Grey responses. Conclusion : On arrival to ED, the risk for violence was determined by the triage nurse using clinical judgement. This process was found to be feasible, acceptable to clinical staff, integrated into current triage processes, and reflected the public’s expectations of care. Communication of risk was facilitated using the existing clinical information system and normal work flow within the ED. High risk patient groups and locations were identified. Not all patients who require a Code Grey response were found to have observable warning signs at triage. Following the intervention there was an overall reduction in time staff engaged in emergency responses for aggression. Access to care was unchanged following the introduction of the risk screening; however the increase in the use of coercive practices following implementation of the risk screening process is of concern and warrants further exploration.
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ItemA framework for developing competence( 2014)A competent healthcare workforce is essential to ensuring quality care. There are strong professional and societal expectations that nurses will be competent. Despite the importance of the topic, the most effective means through which competence develops and is assessed, remains elusive. The aim of this study was to evaluate a framework intended to promote competence in nurses new to paediatric practice. Applying the principles of program theory evaluation, a two phase, mixed method design was employed. In Phase One, a qualitative exploratory method was applied. Documents related to the Nursing Competency Framework were audited. Twelve focus groups were conducted to gain understanding of the theory thought to underpin the development of nursing competence. Phase Two enabled a subsequent evaluation to be undertaken that was informed by Phase One. Phase Two was conducted as an explanatory sequential mixed method design. In the first strand of Phase Two, a quantitative method was applied to measure the extent to which competence develops over the first six months of a graduate nurse program (GNP). A tool to measure nurse competence, the Nurse Competence Scale (NCS), was administered to 47 graduate nurses at three time points during their GNP. The second strand of Phase Two employed a qualitative design. Twenty one graduate nurses were interviewed to explain the variations in competence development in light of their results from the NCS. The Phase One findings generated a far more complicated program theory than had arisen from the preliminary audit of documents. Focus group participants articulated a range of processes that support the development of competence, created a comprehensive picture of contextual factors to be taken into consideration and drew attention to the many standards that inform competency development. Results from the NCS indicated nurses made statistically significant gains in competence in the first six months of paediatric nursing practice. The findings from the interviews, considered in combination with the theory that had emerged from Phase One and the NCS results, enabled the conceptualisation of the Framework for Developing Competence. Key elements within the Framework for Developing Competence include; the individual within the team, identification and interpretation of standards, asking questions, guidance, and engaging in endeavours, all taking place in a particular context of practice. Competence is recognised as a combination of knowledge, skills, abilities and attributes. Excellence is identified as the hoped for outcome from which nurses return back through various processes to continuously improve. Much time, energy and resources are directed at supporting the development and assessment of competence, with little evidence as to the most effective means. This study led to conceptualisation of a theory thought to underpin development of competence. The findings of this study will contribute to local, national and international knowledge related to competence both in nursing and other health professions.