Low-dose intensive insulin therapy in patients with Acute Coronary Syndrome accompanied by Left Ventricular Failure: audit of two UK hospitals.

AIMS AND OBJECTIVES: To determine whether a low-dose intravenous insulin regimen reduces blood glucose levels at a timely rate and associated side effects among patients with Acute Coronary Syndrome and Left Ventricular Failure. BACKGROUND: Induced hypoglycaemia and the associated risks have questioned the benefits of intensive insulin therapy in patients presenting with raised blood glucose levels and Acute Coronary Syndromes. Local audit data identified that patients with Acute Coronary Syndrome and Left Ventricular Failure experienced more hypoglycaemic episodes than those with Acute Coronary Syndrome alone. Consequently, a new regimen of low-dose insulin for this group was implemented and audited over 12 months. DESIGN: Audit. METHODS: Thirty-six consecutive patient notes with a diagnosis of Acute Coronary Syndrome and blood glucose of ≥10 mmol/l treated with a new insulin therapy regimen were analysed. Data were extracted using a standardised form and entered into an Excel spreadsheet for analysis. RESULTS: The mean age of the sample was 70 years with 66% of subjects being men and 50% presenting with Acute Coronary Syndrome and Left Ventricular Failure. The low-dose regimen was effective in achieving normoglycaemia, (range 4-8 mmol/l) for a consecutive six-hour period. This was achieved in 72% of patients and within a median time of 13 hours. CONCLUSION: The audit suggests that a low-dose insulin regimen can effectively stabilise blood glucose in patients presenting with both Acute Coronary Syndrome and Left Ventricular Failure. The importance of regularly monitoring blood sugar levels is vital and highlights the role of nurses in minimising patient risk and promoting safety. RELEVANCE TO PRACTICE: Nurses are instrumental in the safe implementation of intensive insulin guidelines. Close monitoring of patients is essential, enabling timely adjustments to treatments and ensuring patient safety. Regular audits allow nurses to evaluate care provision and continue to drive practice forward.

South African critical care nurses' views on end-of-life decision-making and practices.

BACKGROUND: Care of patients at the end-of-life (EOL) may be influenced by the experiences, attitudes and beliefs of nurses involved in their direct care. AIM: To investigate South African critical care nurses' experiences and perceptions of EOL care. DESIGN: Cross-sectional survey. METHODS: South African critical care nurses completed a modified version of the 'VENICE' survey tool. Data were collected concerning: attitudes towards EOL care; involvement in EOL decision-making; and beliefs about EOL practices. RESULTS: Of 149 surveys distributed, 100 were returned (response rate 67%). Seventy-six percent stated that they had had direct involvement in EOL care of patients, but a minority (29%) had participated in EOL decision-making processes. Whilst most nurses (86%) were committed to family involvement in EOL decisions, less than two thirds (62%) reported this as routine practice. When withdrawing treatment, around half (54%) of the respondents indicated they would decrease the inspired oxygen level to room air, and the majority (84%) recommended giving effective pain relief. Continued nutritional support (84%) and hydration (85%) were advocated, with most nurses (62%) indicating that they were against keeping patients deeply sedated. Most respondents (68%) felt patients should remain in intensive care at the end of life, with the majority (72%) supporting open-visiting, no restriction on number of family members visiting (70%), and the practising of religious or traditional cultural EOL rituals (93%). CONCLUSIONS: The involvement of Johannesburg critical nurses in EOL care discussions and decisions is infrequent despite their participation in care delivery and definite views about the process. RELEVANCE TO CLINICAL PRACTICE: Use of formal guidelines and education is recommended to increase the nurses' involvement in and their confidence in participating in EOL decisions. Educators, managers, senior nurses and other members of the multi-disciplinary team should collaborate to enable critical care nurses to become more involved in EOL care.

The challenges facing midwifery educators in sustaining a future education workforce.

BACKGROUND: national and international trends have identified concerns over the ability of health and social care workforces in meeting the needs of service users. Attention has increasingly been drawn to problems of recruiting and retaining professionals within higher education; however data in relation to the midwifery profession is scant. AIM: to examine the perceptions and experiences of midwifery educators, in south-west England, about the challenges facing them sustaining the education workforce of the future. DESIGN: a mixed methodology approach was adopted involving heads of midwifery education and midwife educators. METHODOLOGY: midwifery participants were recruited from three higher education institutions in south west England. Data collection comprised of self-administered questionnaires plus individual qualitative interviews with heads of midwifery education (n=3), and tape recorded focus groups with midwife academics (n=19). Numerical data were analysed using descriptive statistics. Textual data were analysed for themes that represented the experiences and perspectives of participants. Ethics approval was granted by one University Ethics committee. FINDINGS: demographic data suggests that within south-west England, there is a clear ageing population and few in possession of a doctorate within midwifery. The six identified sub-themes represented in the data describe challenges and tensions that midwifery academics experienced in their efforts to attract new recruits and retain those in post in a highly changing educational environment which demands more from a contracting workforce. CONCLUSION AND IMPLICATIONS FOR PRACTICE: there remain some serious challenges facing midwifery educators in sustaining the future education workforce, which if unresolved may jeopardise standards of education and quality of care women receive. Active succession planning and more radical approaches that embrace flexible careers will enable educational workforce to be sustained and by a clinically credible and scholarly orientated midwifery workforce.

Patients' perspectives on the educational preparation of cardiac nurses.

BACKGROUND: Over the last two decades the UK health service has endeavoured to place patient and public involvement at the heart of its modernisation agenda. Despite these aspirations the role of patients in the development of nursing curricula remains limited. AIM: A descriptive qualitative design was used to explore the views of cardiac patients about the educational preparation of cardiac nurses. METHOD: Eight participants attending an annual conference of a patient and carer support group were recruited to the study. A focus group was conducted to explore their views on how the educational preparation of cardiac nurses in the UK should develop. Tape-recorded data were transcribed and a thematic analysis was undertaken. FINDINGS: Four themes were identified: contradictions around practice and education; demonstrating compassion; delivering rehabilitation expertise; leadership in practice. Participants perceived that they had a valuable role in the educational development of nurses, enhancing nurses' understanding of how individuals live and adjust to living with cardiovascular disease. CONCLUSION: Cardiac patients believe that the education of cardiac nurses should be driven by experiences in practice, nevertheless they want nurses to be equipped to deliver care that is underpinned by a strong knowledge base and skills combined with an ability to engage, educate and deliver high quality care that is both compassionate and individualised.

Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy.

AIM: To explore the level of moral distress and potential associations between moral distress indices and (1) nurse-physician collaboration, (2) autonomy, (3) professional satisfaction, (4) intention to resign, and (5) workload among Italian intensive care unit nurses. BACKGROUND: Poor nurse-physician collaboration and low autonomy may limit intensive care unit nurses' ability to act on their moral decisions. METHODS: A cross-sectional correlational design with a sample of 566 Italian intensive care unit nurses. RESULTS: The intensity of moral distress was 57.9 ± 15.6 (mean, standard deviation) (scale range: 0-84) and the frequency of occurrence was 28.4 ± 12.3 (scale range: 0-84). The mean score of the severity of moral distress was 88.0 ± 44 (scale range: 0-336). The severity of moral distress was associated with (1) nurse-physician collaboration and dissatisfaction on care decisions (r = -0.215, P < 0.001); and (2) intention to resign (r = 0.244, P < 0.0001). The frequency of occurrence of moral distress was associated with the intention of nurses to resign (r = -0. 209, P < 0.0001). CONCLUSION: Moral distress seems to be associated with the intention to resign, whereas poor nurse-physician collaboration appears to be a pivotal factor accounting for nurses' moral distress. IMPLICATIONS FOR NURSING MANAGEMENT: Enhancement of nurse-physician collaboration and nurses' participation in end-of-life decisions seems to be a managerial task that could lead to the alleviation of nurses' moral distress and their retention in the profession.

Sedation practice in Nordic and non-Nordic ICUs: a European survey.

BACKGROUND AND AIMS: A trend towards lighter sedation has been evident in many intensive care units (ICUs). The aims of the survey were to describe sedation practice in European ICUs and to compare sedation practice in Nordic and non-Nordic countries. DESIGN AND METHODS: A cross-sectional survey of ICU nurses attending the fourth European federation of Critical Care Nursing associations (EfCCNa) in Denmark, 2011. Data included use of protocols; sedation, pain and delirium assessment tools; collaborative decision-making; sedation and analgesic medications; and educational preparation related to sedation. RESULTS: Response rate was 42% (n = 291) from 22 countries where 53% (n = 148) used sedation protocols. Nordic nurses reported greater use of sedation (91% versus 67%, p < 0·01) and pain (91% versus 69%, p < 0·01) assessment tools than non-Nordic nurses. Decision-making on sedation was more inter-professionally collaborative in Nordic ICUs (83% versus 61%, p < 0·01), units were smaller (10 versus 15 beds, p < 0·01) and nurse-patient ratio was higher (1:1, 75% versus 26%, p < 0·01). Nordic nurses reported greater consistency in maintaining circadian rhythm (66% versus 49%, p < 0·01), less use of physical restraints (14% versus 36%, p < 0·01), less use of neuromuscular blocking agents (3% versus 16%, p < 0·01), and received more sedation education (92% versus 76%, p < 0·01). Delirium assessment was not performed systematically in most settings. CONCLUSIONS: Organizational and contextual factors, such as ICU size, staffing ratio and inter-professional collaboration, are contributing factors to sedation management in European ICUs. The Nordic context might be more germane to the goal of lighter sedation and better pain management. RELEVANCE TO CLINICAL PRACTICE: Our study raises awareness of current sedation practice, paving the way towards optimized ICU sedation management.

Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses.

BACKGROUND: Discretionary autonomy is a key factor in enhanced patient outcomes and nurses' work satisfaction. Among nurses, insufficient autonomy can result in moral distress. OBJECTIVES: To explore levels of autonomy among European critical care nurses and potential associations of autonomy with nurse-physician collaboration, moral distress, and nurses' characteristics. METHODS: Descriptive correlational study of a convenience sample of 255 delegates attending a major European critical care conference in 2009. Respondents completed a self-administered questionnaire with validated scales for nurses' autonomy, nurse-physician collaboration, and moral distress. RESULTS: The mean autonomy score (84.26; SD, 11.7; range, 18-108) and the mean composite (frequency and intensity) moral distress score (73.67; SD, 39.19; range, 0-336) were both moderate. The mean collaboration score was 47.85 (SD, 11.63; range, 7-70). Italian and Greek nurses reported significantly lower nurse-physician collaboration than did other nurses (P < .001). Greek and German nurses reported significantly higher moral distress (P < .001). Autonomy scores were associated with nurse-physician collaboration scores (P < .001) and with a higher frequency of moral distress (P = .04). Associations were noted between autonomy and work satisfaction (P = .001). Frequency of moral distress was associated inversely with collaboration (ρ = -0.339; P < .001) and autonomy (ρ = -0.210; P = .01) and positively with intention to quit (ρ = 0.257; P = .004). CONCLUSIONS: In this sample of European intensive care nurses, lower autonomy was associated with increased frequency and intensity of moral distress and lower levels of nurse-physician collaboration.

Sustaining the education workforce in healthcare: challenges for the future.

AIM: The aim of the study was to scope education staff capacity to meet the future needs of the healthcare workforce in practice across South West (SW) England. BACKGROUND: As individual nations come to terms with the impact of the incurred global debt, the university sector also faces a period of financial stringency and review of current resources. Additionally, there is growing evidence world-wide, of an increasing crisis in the recruitment and retention of healthcare educators. METHOD: Using a survey approach, an audit of six universities in South West England completed a bespoke self-administered questionnaire between April and June 2008, when prior to and since these dates, major reforms have taken place. Data were entered into a spreadsheet and analysed using descriptive statistics. RESULTS: Considerable variation across professional groups was observed, particularly in staff/student ratios. Data indicates an ageing workforce with less than 20% of staff in possession of a doctorate. CONCLUSIONS: The results mirror other work and concerns from abroad, particularly in Nursing in identifying areas at risk in the education workforce. The potential for incentives to encourage practitioners into a career in education will do much to entice the best from practice to plan for succession, and, drive quality for patient benefit.

A survey of European intensive care nurses' knowledge levels.

BACKGROUND: The application of knowledge to the care of critically ill patients is a hallmark of professional nursing practice. However, the educational preparation of intensive care nurses varies from country to country, and there has been little research that has investigated knowledge levels of European critical care nurses. OBJECTIVE: The aim of this study was to examine the knowledge levels of European intensive care nurses. DESIGN: The study was an international cross-sectional survey, with data collected from 20 European countries. SETTING AND PARTICIPANTS: 318 European intensive care units participated, and data were collected from 1142 intensive care nurses. METHODS: Data were collected between May and December 2009 using a 100-item multiple choice online questionnaire to assess intensive care nursing knowledge. The questionnaire was available in 16 languages, and data were collected in 11 knowledge areas. RESULTS: A response rate of 60% was achieved; the majority of participants was female (77%). The largest groups of nurses had more than five years' experience and were under 30 years of age. The overall mean knowledge score was 66% (SD 12). The main factor that contributed to variance in scores was nurses' length of intensive care experience; in ten categories knowledge scores were progressively higher according to experience. If 50% is considered to be a pass mark, 90% of participants would have passed. However, in only six countries did all participants achieve a 'pass' score, and in five countries more than 10% of participants failed to meet this 'pass' criterion. The knowledge category which scored lowest was respiration and ventilation (mean score 56%, SD 15). CONCLUSIONS: Although knowledge levels differed among countries, there were no major differences. However, the relatively low scores achieved in the respiration/ventilation category are a cause of concern, and suggest that this is an education area that should be prioritised. The results should be considered within the context of each country's healthcare and professional education systems, and strategies should be developed to improve knowledge in several key areas.

Research priorities of adult intensive care nurses in 20 European countries: a Delphi study.

AIMS: This paper is a report of a three round Delphi study of intensive care nursing research priorities in Europe (October 2006-April 2009). BACKGROUND: Internationally, priorities for research in intensive care nursing have received some attention focusing on healthcare interventions and patient needs. Studies as early as the 1980s identified priorities in the United States, United Kingdom, Hong Kong and Australia. Research priorities of intensive care nurses across the European Union are unknown. METHODS: The participants, invited in 2006, included 110 intensive care nurses, managers, educators and researchers from 20 European Critical Care Nursing Associations. Delphi round one was an emailed questionnaire inviting participants to list important areas for research. The list was content analysed and developed into an online questionnaire for rounds two and three. In round two, participants ranked the topics on a scale of 1-6 (not important to extremely important). Mean scores of round two were added to the questionnaire of round three and participants ranked the topics again. RESULTS: There were 52 research topics in 12 domains. There was a dominance of priorities in five main areas: patient safety; impact of evidence based practice on outcomes; impact of workforce on outcomes; wellbeing of patients and relatives; and impact of end-of-life care on staff and practice. CONCLUSIONS: The results reflect worldwide healthcare concerns and objectives and highlight topics that nurses view as fundamental to the care of critically ill patients. These topics provide a platform for future research efforts to improve clinical practice and care of patients in intensive care.

Gender differences on chest pain perception associated with acute myocardial infarction in Chinese patients: a questionnaire survey.

AIMS: To investigate gender differences in chest pain perception among Chinese patients with acute myocardial infarction. BACKGROUND: Thrombolytic therapy is beneficial to outcomes of acute myocardial infarction if administered within 12 hours from the onset of chest pain. However, cardiac symptom interpretation may impact time of presentation to hospital. Differences in cardiac symptom reports by gender partly explain misdiagnoses and delays in treatment, particularly among women. Whether, such trends apply to Chinese patients with myocardial infarction is unknown. DESIGN: A descriptive prospective study. METHODS: Using questionnaires, data on demographic variables, the number of patients reporting chest pain and other chest sensations at the onset of acute myocardial infarction and chest pain intensity, description, location and radiation across the chest were collected. RESULTS: A total of 128 participants equally divided by gender were recruited. Chest pain was more prevalent among men than women (84.37% vs. 67.19%, p < 0.05). Although no statistical significance was found, Chinese men had higher mean chest pain intensity scores (7.54 SD 2.35 vs. 7.51 SD 2.25) and reported less atypical chest pain (0.00% vs. 9.3%) compared with women. Men had more upper right sided chest pain (40.74% vs. 20.93%, p = 0.038) whereas women experienced increased neck pain and pain to the upper central chest, middle central chest, upper central back, middle central back and middle right back regions. CONCLUSIONS: Discreet gender differences in chest pain perceptions exist between Chinese men and women, with the latter group, who may be considered as a high-risk group for missed and delayed diagnosis from myocardial infarction, reporting more atypical presentations. RELEVANCE TO CLINICAL PRACTICE: Irrespective of culture, women with myocardial infarction tend to present with atypical chest pain symptoms and therefore they should be aggressively investigated.

After death 1: caring for bereaved relatives and being aware of cultural differences.

This first in a two part unit on bereavement and last offices discusses relatives' grief reactions and caring for deceased patients, taking into account spiritual and cultural differences.

After death 2: Exploring the procedures for laying out and preparing the body for viewing.

This second in a two part unit on last offices examines the procedures when preparing thebody of a deceased patient for transfer to the mortuary, and issues to consider when relatives view the body. Part 1 explored relatives' grief reactions and the importance of providing culturally sensitive care.

The views and preferences of resuscitated and non-resuscitated patients towards family-witnessed resuscitation: a qualitative study.

BACKGROUND: A number of international studies have explored the views of family members and healthcare professionals on the concept of family witnessed resuscitation. However, the perspective and preferences of patients have been under-researched. OBJECTIVES: To explore the views and preferences of resuscitation survivors and those admitted as emergency cases, as to whether family members should be present at their resuscitation. DESIGN: This paper reports the qualitative findings of a wider study, whose aim was to explore patient preferences towards family witnessed resuscitation. SETTINGS: Study sites included four acute university hospitals in two large cities of the South-West of England. PARTICIPANTS: A purposive sample of 21 patients who underwent successful resuscitation and 41 patients, who presented to hospital as emergency cases, but without the experience of resuscitation, were recruited to the study. METHODS: To generate in-depth understanding about the phenomenon under inquiry, qualitative data were collected from face-to-face interviews. All responses were hand written and analysed using recognised qualitative techniques. FINDINGS: Three main themes emerged and these included: 'being there', 'welfare of others' and 'professionals' management of the event'. While the majority of participants supported the premise of having loved ones present during resuscitation, their motives varied and often related to the needs of families. Participants recognised that healthcare professionals had to exercise discretionary judgements to manage the resuscitation, which could embrace shielding relatives from distressing scenes and dealing with issues of confidentiality. CONCLUSIONS: The study provides a unique understanding of patient preferences of family witnessed resuscitation with some of their views contesting arguments in the literature. Patients' perspectives suggest both relatives and they themselves benefit in different ways. Although participants recognised that family members had emotional, informational and proximity needs, these had to be balanced with allowing the resuscitation team to manage the clinical emergency and make decisions. It is also evident that not all patients wish their families to be present. Healthcare professionals should strive to identify the wishes of patients and relatives in respect to family witnessed resuscitation and facilitate the presence of loved ones as appropriate. Further research into the area is still required.

Evaluating last offices care and improving services offered to newly bereaved relatives.

The aftercare of deceased patients and performing last offices are important aspects of nurses' role. Regularly auditing care provision can identify whether standards are being met and highlight areas in need of development. This article outlines the background to an audit that was prompted by concerns linked to procedures for last offices. The response to initial audit findings and consequent actions taken to raise awareness and improve services are also discussed.

EfCCNa survey: European intensive care nurses' attitudes and beliefs towards end-of-life care.

BACKGROUND: Available literature suggests that critical care nurses have varied experiences in relation to end-of-life (EOL) care. Few studies have examined the involvement of European intensive care nurses' involvement in EOL care decisions and the extent to which their nursing practice is based on shared beliefs, experiences and attitudes. AIM: To investigate experiences and attitudes of European intensive care nurses regarding EOL care. METHODS: Using a survey method, delegates (n = 419) attending an international critical care nursing conference were invited to complete a self-administered questionnaire about their involvement with EOL care practices. The questionnaire composed of 45 items and was available in three European languages. RESULTS: A total of 164 questionnaires were completed, yielding a response rate of 39%. The majority of respondents (91.8%) indicated direct involvement in EOL patient care, while 73.4% reported active involvement in decision-making process. 78.6% of respondents expressed commitment to family involvement in EOL decisions, however only 59.3% of the participants said that this was routinely undertaken (p < 0.0005, Z = -4.778). In decisions to withdraw or withhold therapy, 65% would decrease the flow of inspired oxygen, 98.8% provide continuous pain relief and 91.3% endorse open visiting. The majority (78%) disagreed that dying patients should be transferred to a single room. A division of views was observed in relation to 44% agreeing that patients should be kept deeply sedated and equal numbers contesting the continuation of nutritional support (41.6% versus 42.3%). CONCLUSIONS: The involvement of European intensive care nurses in EOL care discussions and decisions is reasonably consistent with many engaged in initiating dialogue with coworkers. In general, views and experiences of EOL care were similar, with the exception of the provision of nutrition and use of sedation. RELEVANCE TO PRACTICE: Use of formal guidelines and education may increase nurses' involvement and confidence with EOL decisions.

Pre-hospital thrombolysis for acute ST segment elevation myocardial infarction: A survey of paramedics' perceptions of their role.

BACKGROUND: The effectiveness of pre-hospital thrombolysis (PHT) in reducing mortality following ST segment elevation myocardial infarction (STEMI) is well established. In England, PHT is provided to around 17% of STEMI patients, and responsibility for treatment rests largely with paramedics rather than physicians as in some other countries, but little is known about how paramedics perceive their role, or whether age or experience influence such perceptions. AIM: To describe paramedics' perceptions of PHT. METHODS: Questionnaire survey to all 106 paramedics working within a single ambulance service in England. RESULTS: 60 (56.6%) paramedics responded. Overall, there were few significant differences by age or length of service in responses given. However, paramedics who had administered PHT gave more positive responses compared to those who had not, in relation to duty of care, professional image, individuals' influence on paramedic role development, and preparedness for practice. CONCLUSION: Paramedics hold a range of views and perceptions of their role in delivering PHT; some of which appear to be related to age and length of experience, and actual administration of PHT. The vast majority view PHT as a positive step to providing patient care that is evidence based.

The views and preferences of resuscitated and non-resuscitated patients towards family witnessed resuscitation: a qualitative study.

BACKGROUND: A number of international studies have explored the views of family members and healthcare professionals on the concept of family witnessed resuscitation (FWR). In contrast the perspective and preferences of patients have been under-researched, particularly in relation to those who have survived resuscitation. OBJECTIVES: To explore the views and preferences of resuscitation survivors and those admitted as emergency cases, as to whether family members should be present at their resuscitation. DESIGN: This paper reports the qualitative findings of a study, whose aim was to explore and describe patients' views and preferences towards family witnessed resuscitation. SETTINGS: Study sites included four acute hospitals in two large cities of the South-West of England. PARTICIPANTS: Based on specific criteria, patients (n=21) who had been successfully resuscitated and individuals presenting to hospital as emergency cases but without the experience of resuscitation (control group n=40) comprised the study population. The groups were matched by age and gender. METHODS: To generate in-depth understanding about the phenomenon under inquiry, qualitative data were collected from face-to-face interviews. All responses were hand written and analysed using recognised qualitative techniques. FINDINGS: From the analysis of data three main themes emerged which captured the experiences and perceptions of participants through: 'being there', 'welfare of others' and 'professionals'management of the event'. While the majority of participants supported the premise of having loved ones present during resuscitation, their motives varied and often related to the needs of families and occasionally themselves. Participants also recognised that healthcare professionals had to exercise discretionary judgements to manage the resuscitation, which could embrace shielding relatives from distressing scenes and dealing with issues of confidentiality. CONCLUSIONS: The study provides a unique understanding of patient preferences of FWR and some of their views begin to contest arguments in the literature. Patients' perspectives suggest both relatives and they themselves benefit in different ways. Although participants recognised that family members had emotional, informational and proximity needs, these had to be balanced with allowing the resuscitation team to manage the clinical emergency and make decisions. It is also evident that not all patients wish their families to be present. Healthcare professionals should therefore strive to identify the wishes of patients and relatives in respect to FWR and facilitate the presence of loved ones as appropriate. Further research into the area is still required.