The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project).

BACKGROUND: Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital. METHODS/DESIGN: A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient's body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool. DISCUSSION: Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions. TRIAL REGISTRATION: ACTRN12611000020987.

The impact of receiving treatment for cancer at a large metropolitan teaching hospital as recorded by patients using unstructured journals.

The aim was to obtain patients' experiences of the cancer treatment pathway at a tertiary teaching hospital using unstructured journals to enable health care professionals to be educated on how to improve patient care. Most of 38 patients (22 females and 16 males), average age of 58 (range 29-80), who returned diaries were starting chemotherapy for a range of cancers. Data entries were transcribed and entered into the NVIVO software to facilitate thematic analysis. Women wrote more, and more often than men, and disclosed more. For most, physical side effects dominated, comprising 25-75 % of diary entries. The most commonly mentioned were fatigue (74 %), pain (63 %), sleep disturbances (50 %), nausea (45 %) and changes in appetite (45 %). Collectively, 22 patients reported 261 separate emotional reactions including depression, anger, guilt, shame, grief, panic and confusion. The treatment environment, including personnel, impacted upon patients. Where survival is unpredictable, evidence of consistency of practitioners' approaches attains heightened significance.

The role of the nurse sedationist.

AIM AND OBJECTIVES: This paper aims to provide a quality improvement review to identify the benefits and level of satisfaction for the role of the nurse sedationists. BACKGROUND: Traditionally procedural sedation was only administered by an anaesthetist or dentist and it was not until the early 1990s that nurses in America commenced administering procedural sedation. A literature review on the role of the nurse sedationist undertaken identified no documented evidence of such a role in Australia. The role of the nurse sedationist was pursued as a strategy to meet the increased demand for anaesthetic services, manage the shortage of anaesthetists and address concerns associated with the administration of procedural sedation by healthcare workers untrained in this area. METHOD: Evaluation of the role of the nurse sedationist was essential to ensure that the role met both the needs of the organisation, patients and key stakeholders. Due to the variety of stakeholders and associated expectations a variety of evaluation methods were used. RESULTS: Results indicate that the introduction of the nurse sedationist role has been recognised as value adding through increases in patient safety, a more collaborative approach to patient care, improved work environments for all staff groups and strengthened multi disciplinary relationships. Patients also indicate a very high level of patient satisfaction with the service. CONCLUSION: The role of nurse sedationist has been successfully introduced in an Australian acute public hospital. The introduction of the role has assisted to address an increased demand for anaesthetic services and to address patient safety concerns. RELEVANCE TO CLINICAL PRACTICE: Recent years have seen an expansion of advanced practice nursing roles throughout Australia. This expansion of roles has resulted in an increase in nursing expertise, high quality patient outcomes and an improved multidisciplinary approach to healthcare. The role of the nurse sedationist has been a result of expansion in this area.

Engaging consumers in safety and quality at Royal Adelaide hospital.

Objective The objective of this study was to elicit barriers and enablers of safe, high-quality care as identified by consumers, and to position consumers as 'possessors' of valuable knowledge related to systems and practices (as they had experienced these directly) rather than the receivers of knowledge and information. The central aim was to develop recommendations for consumer input into quality improvement, generated from the analysis of narrative accounts of their experiences. Methods The four-phase methodology adopted for this project involved the development of quality improvement strategies as identified (phase one) and validated (phase two) by consumers through the conduct of discovery interviews with 30 consumers over the age of 18 years who had experienced an adverse event. Clinicians and quality managers were then provided with an opportunity to validate the strategies identified through participation in a focus group (phase three). All data collected through discovery interviews and focus groups were transcribed and entered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The final phase of the study involved integrating this process of consumer involvement and of identified improvement strategies into the quality improvement program of Royal Adelaide Hospital. Results A total of 28 findings were entered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The process of meta-synthesis embodied in these programs involves the aggregation or synthesis of findings or conclusions. Six categories and four syntheses were derived through this process with key themes relating to assessment and prevention strategies, a necessity for improved education and communication, the hospital environment and the potential life impact that the experience of an adverse event may have. Conclusion Consumers identified a number of strategies that could contribute to improved safety and clinical outcomes in hospital and a reduction in adverse events. This current study provides a solid foundation upon which future research may be conducted.

Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare.

Objectives The objective of this review was to evaluate evidence on the structures and processes that support development of effective culturally competent practices and a healthy work environment. Culturally competent practices are a congruent set of workforce behaviours, management practices and institutional policies within a practice setting resulting in an organisational environment that is inclusive of cultural and other forms of diversity. Inclusion criteria This review included quantitative and qualitative evidence, with a particular emphasis on identifying systematic reviews and randomised controlled trials. For quantitative evidence, other controlled, and descriptive designs were also included. For qualitative evidence, all methodologies were considered. Participants were staff, patients, and systems or policies that were involved or affected by concepts of cultural competence in the nursing workforce in a healthcare environment. Types of interventions included any strategy that had a cultural competence component, which influenced the work environment, and/or patient and nursing staff in the environment. The types of outcomes of interest to this review included nursing staff outcomes, patient outcomes, organisational outcomes and systems level outcomes. Search strategy The search sought both published and unpublished literature written in the English language. A comprehensive three-step search strategy was used, first to identify appropriate key words, second to combine all optimal key words into a comprehensive search strategy for each database and finally to review the reference lists of all included reviews and research reports. The databases searched were CINAHL, Medline, Current Contents, the Database of Abstracts of Reviews of Effectiveness, The Cochrane Library, PsycINFO, Embase, Sociological Abstracts, Econ lit, ABI/Inform, ERIC and PubMed. The search for unpublished literature used Dissertation Abstracts International. Methodological quality Methodological quality was independently established by two reviewers, using standardised techniques from the Joanna Briggs Institute (JBI) System for the Unified Management, Assessment and Review of Information (SUMARI) package. Discussion with a third reviewer was initiated where a low level of agreement was identified for a particular paper. Following inclusion, data extraction was conducted using standardised data extraction tools from the JBI SUMARI suite for quantitative and qualitative research. Data synthesis was performed using the JBI Qualitative Assessment and Review Instrument and JBI Narrative, Opinion and Text Assessment and Review Instrument software to aggregate findings by identifying commonalities across texts. Quantitative data were presented in narrative summary, as statistical pooling was not appropriate with the included studies. Results Of the 659 identified papers, 45 were selected for full paper retrieval, and 19 were considered to meet the inclusion criteria for this review. The results identified a number of processes that would contribute to the development of a culturally competent workforce. Appropriate and competent linguistic services, and intercultural staff training and education, were identified as key findings in this review. Conclusions The review recommends that health provider agencies establish links with organisations that can address needs of culturally diverse groups of patients, include cultural competence in decision support systems and staff education as well as embed them in patient brochures and educational materials. The review also concluded that staff in-service programs consider the skills needed to foster a culturally competent workforce, and recruitment strategies that also explicitly address this need.

Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare.

Objectives The objective of this review was to appraise and synthesise the best available evidence on the feasibility, meaningfulness and effectiveness of nursing leadership attributes that contribute to the development and sustainability of nursing leadership to foster a healthy work environment. Inclusion criteria This review considered quantitative and qualitative research papers that addressed the feasibility, meaningfulness and effectiveness of developing and sustaining nursing leadership to foster a healthy work environment in healthcare. Papers of the highest level of evidence ratings were given priority. Participants of interest were leaders and those who were affected by leadership, specifically staff and patients. Interventions of interest including positive leadership attributes, as well as system and policy constructs, that impact on the development and sustainability of nursing leadership within the healthcare environment were considered in the review. Search strategy The search strategy sought to find both published and unpublished studies and papers, limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the paper. A second extensive search was then undertaken using all identified key words and index terms. Methodological quality Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. Results A total of 48 papers, experimental, qualitative and textual in nature, were included in the review. The majority of papers were descriptive and examined the relationships between leadership styles and characteristics and particular outcomes, such as satisfaction. Because of the diverse nature of these papers meta-analysis of the results was not possible. For this reason, this section of the review was presented in narrative form. The qualitative and textual papers were analysed using The Joanna Briggs Institute-Qualitative Assessment and Review Instrument and The Joanna Briggs Institute-Narrative, Opinion and Text Assessment and Review Instrument. The process of meta-synthesis embodied in these programs involves the aggregation or synthesis of findings or conclusions. Eight syntheses were derived with key themes related to collaboration, education, emotional intelligence, organisational climate, professional development, positive behaviours and qualities and the need for a supportive environment. Conclusion A combination of leadership styles and characteristics was found to contribute to the development and sustainability of a healthy work environment. The current work conducted in this area provides a solid foundation for future directions in research.

Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare.

OBJECTIVES: The objective of this review was to evaluate evidence on the structures and processes that support development of effective culturally competent practices and a healthy work environment. Culturally competent practices are a congruent set of workforce behaviours, management practices and institutional policies within a practice setting resulting in an organisational environment that is inclusive of cultural and other forms of diversity. INCLUSION CRITERIA: This review included quantitative and qualitative evidence, with a particular emphasis on identifying systematic reviews and randomised controlled trials. For quantitative evidence, other controlled, and descriptive designs were also included. For qualitative evidence, all methodologies were considered. Participants were staff, patients, and systems or policies that were involved or affected by concepts of cultural competence in the nursing workforce in a healthcare environment. Types of interventions included any strategy that had a cultural competence component, which influenced the work environment, and/or patient and nursing staff in the environment. The types of outcomes of interest to this review included nursing staff outcomes, patient outcomes, organisational outcomes and systems level outcomes. SEARCH STRATEGY: The search sought both published and unpublished literature written in the English language. A comprehensive three-step search strategy was used, first to identify appropriate key words, second to combine all optimal key words into a comprehensive search strategy for each database and finally to review the reference lists of all included reviews and research reports. The databases searched were CINAHL, Medline, Current Contents, the Database of Abstracts of Reviews of Effectiveness, The Cochrane Library, PsycINFO, Embase, Sociological Abstracts, Econ lit, ABI/Inform, ERIC and PubMed. The search for unpublished literature used Dissertation Abstracts International. METHODOLOGICAL QUALITY: Methodological quality was independently established by two reviewers, using standardised techniques from the Joanna Briggs Institute (JBI) System for the Unified Management, Assessment and Review of Information (SUMARI) package. Discussion with a third reviewer was initiated where a low level of agreement was identified for a particular paper. Following inclusion, data extraction was conducted using standardised data extraction tools from the JBI SUMARI suite for quantitative and qualitative research. Data synthesis was performed using the JBI Qualitative Assessment and Review Instrument and JBI Narrative, Opinion and Text Assessment and Review Instrument software to aggregate findings by identifying commonalities across texts. Quantitative data were presented in narrative summary, as statistical pooling was not appropriate with the included studies. RESULTS: Of the 659 identified papers, 45 were selected for full paper retrieval, and 19 were considered to meet the inclusion criteria for this review. The results identified a number of processes that would contribute to the development of a culturally competent workforce. Appropriate and competent linguistic services, and intercultural staff training and education, were identified as key findings in this review. CONCLUSIONS: The review recommends that health provider agencies establish links with organisations that can address needs of culturally diverse groups of patients, include cultural competence in decision support systems and staff education as well as embed them in patient brochures and educational materials. The review also concluded that staff in-service programs consider the skills needed to foster a culturally competent workforce, and recruitment strategies that also explicitly address this need.

Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare.

OBJECTIVES: The objective of this review was to appraise and synthesise the best available evidence on the feasibility, meaningfulness and effectiveness of nursing leadership attributes that contribute to the development and sustainability of nursing leadership to foster a healthy work environment. INCLUSION CRITERIA: This review considered quantitative and qualitative research papers that addressed the feasibility, meaningfulness and effectiveness of developing and sustaining nursing leadership to foster a healthy work environment in healthcare. Papers of the highest level of evidence ratings were given priority. Participants of interest were leaders and those who were affected by leadership, specifically staff and patients. Interventions of interest including positive leadership attributes, as well as system and policy constructs, that impact on the development and sustainability of nursing leadership within the healthcare environment were considered in the review. SEARCH STRATEGY: The search strategy sought to find both published and unpublished studies and papers, limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the paper. A second extensive search was then undertaken using all identified key words and index terms. METHODOLOGICAL QUALITY: Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appropriate critical appraisal instrument from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. RESULTS: A total of 48 papers, experimental, qualitative and textual in nature, were included in the review. The majority of papers were descriptive and examined the relationships between leadership styles and characteristics and particular outcomes, such as satisfaction. Because of the diverse nature of these papers meta-analysis of the results was not possible. For this reason, this section of the review was presented in narrative form. The qualitative and textual papers were analysed using The Joanna Briggs Institute-Qualitative Assessment and Review Instrument and The Joanna Briggs Institute-Narrative, Opinion and Text Assessment and Review Instrument. The process of meta-synthesis embodied in these programs involves the aggregation or synthesis of findings or conclusions. Eight syntheses were derived with key themes related to collaboration, education, emotional intelligence, organisational climate, professional development, positive behaviours and qualities and the need for a supportive environment. CONCLUSION: A combination of leadership styles and characteristics was found to contribute to the development and sustainability of a healthy work environment. The current work conducted in this area provides a solid foundation for future directions in research.

A comprehensive systematic review of evidence on the structure, process, characteristics and composition of a nursing team that fosters a healthy work environment.

Objectives The overall aim of this comprehensive systematic review was to identify the best available evidence on the effect of team characteristics, processes, structure and composition within the context of collaborative practice among nursing teams that create a healthy work environment. Search strategy The search strategy sought to find both published and unpublished studies and papers written in the English language. An initial limited search of Medline and CINAHL databases was undertaken to identify optimal search terms. A second extensive search using all identified keywords and index terms was then undertaken. Methodological quality Two independent reviewers assessed the methodological quality of retrieved papers using the corresponding checklist from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. Results The papers included in the review included nine experimental or quasi-experimental studies, 11 descriptive studies and four qualitative studies. A variety of different team structures such as interdisciplinary teams, primary nursing, team nursing, multidisciplinary models of care delivery and the use of a Partner in Patient Care model were investigated. Team characteristics should include accountability, commitment, enthusiasm and motivation. Social support within a team from a supervisor or colleague increased satisfaction levels of staff. Conclusion The results of the review lead to the development of a number of recommendations for practice that could assist with creating a health work environment.

A systematic review of evidence on the professional practice of the nurse and developing and sustaining a healthy work environment in healthcare.

Objectives The overall aim of this systematic review was to identify the best available evidence on the relationship between the knowledge, competencies and behaviours of nurses exhibiting professional practice in their workplace; and the development of a healthy work environment. Search strategy The search strategy sought to find both published and unpublished studies written in the English language. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms. A second extensive search using all identified key words and index terms was then undertaken. Methodological quality Two independent reviewers assessed the methodological quality of retrieved papers using the corresponding checklist from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. Results Of the 4238 papers found in the search: 219 were selected for full paper retrieval; 19 of these papers were unable to be located; 200 full papers were assessed for methodological quality; 181 studies were excluded; and 19 were included in the review. Of these 19, four quantitative studies evaluated a professional nursing practice model and its impact on a variety of outcomes; five descriptive studies examined elements of nurses' professional practice and the impact these elements had on specified outcomes; and 10 qualitative papers examined varying behaviours, competencies and knowledge levels of nurses. Various methods were used, such as focus groups and open-ended interviews. Overall, the evidence suggests that professional practice has a positive impact on the work environment in terms of nurses' role satisfaction and patient outcomes. The evidence is, however, equivocal in many areas and the impact of the professional practice of the nurse requires further investigation. Conclusion The results of the review suggest a number of recommendations for practice and research on creating a healthy work environment.

Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments.

UNLABELLED: Background This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '. . . a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment. Objectives The review sought to determine the impact of: • Patient characteristics, nurse characteristics, system characteristics and system processes on workload, scheduling and concepts of productivity and utilisation • Workload, scheduling and concepts of productivity and utilisation on the quality of outcomes for clients, nurses and the system/organisation Search strategy The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies. Selection criteria Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies. TYPES OF PARTICIPANTS: The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes. Data collection and analysis Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form. Results Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as: • A greater proportion of regulated staffing (i.e. registered nurses, enrolled nurses, practical or vocational nurses) is associated with improved outcomes related to the Functional Independence Measure score, the Short Form Health Survey (SF-36) vitality score, patient satisfaction with nursing care, patient adverse events (including atelectasis, decubitus ulcers, falls, pneumonia, postsurgical and treatment infection and urinary tract infections) • An increase in the number of registered nurse hours available is associated with improved patient outcomes in relation to falls, pneumonia, pressure ulcers, urinary tract infection, length of stay and postoperative infection rates.

A comprehensive systematic review of evidence on the structure, process, characteristics and composition of a nursing team that fosters a healthy work environment.

OBJECTIVES: The overall aim of this comprehensive systematic review was to identify the best available evidence on the effect of team characteristics, processes, structure and composition within the context of collaborative practice among nursing teams that create a healthy work environment. SEARCH STRATEGY: The search strategy sought to find both published and unpublished studies and papers written in the English language. An initial limited search of Medline and CINAHL databases was undertaken to identify optimal search terms. A second extensive search using all identified keywords and index terms was then undertaken. METHODOLOGICAL QUALITY: Two independent reviewers assessed the methodological quality of retrieved papers using the corresponding checklist from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. RESULTS: The papers included in the review included nine experimental or quasi-experimental studies, 11 descriptive studies and four qualitative studies. A variety of different team structures such as interdisciplinary teams, primary nursing, team nursing, multidisciplinary models of care delivery and the use of a Partner in Patient Care model were investigated. Team characteristics should include accountability, commitment, enthusiasm and motivation. Social support within a team from a supervisor or colleague increased satisfaction levels of staff. CONCLUSION: The results of the review lead to the development of a number of recommendations for practice that could assist with creating a health work environment.

Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments.

BACKGROUND: This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '… a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment. OBJECTIVES: The review sought to determine the impact of: SEARCH STRATEGY: The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies. SELECTION CRITERIA: Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies. TYPES OF PARTICIPANTS: The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes. DATA COLLECTION AND ANALYSIS: Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form. RESULTS: Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as.

A systematic review of evidence on the professional practice of the nurse and developing and sustaining a healthy work environment in healthcare.

OBJECTIVES: The overall aim of this systematic review was to identify the best available evidence on the relationship between the knowledge, competencies and behaviours of nurses exhibiting professional practice in their workplace; and the development of a healthy work environment. SEARCH STRATEGY: The search strategy sought to find both published and unpublished studies written in the English language. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms. A second extensive search using all identified key words and index terms was then undertaken. METHODOLOGICAL QUALITY: Two independent reviewers assessed the methodological quality of retrieved papers using the corresponding checklist from the System for the Unified Management, Assessment and Review of Information (SUMARI) package. RESULTS: Of the 4238 papers found in the search: 219 were selected for full paper retrieval; 19 of these papers were unable to be located; 200 full papers were assessed for methodological quality; 181 studies were excluded; and 19 were included in the review. Of these 19, four quantitative studies evaluated a professional nursing practice model and its impact on a variety of outcomes; five descriptive studies examined elements of nurses' professional practice and the impact these elements had on specified outcomes; and 10 qualitative papers examined varying behaviours, competencies and knowledge levels of nurses. Various methods were used, such as focus groups and open-ended interviews. Overall, the evidence suggests that professional practice has a positive impact on the work environment in terms of nurses' role satisfaction and patient outcomes. The evidence is, however, equivocal in many areas and the impact of the professional practice of the nurse requires further investigation. CONCLUSION: The results of the review suggest a number of recommendations for practice and research on creating a healthy work environment.

Patterns of nursing: a review of nursing in a large metropolitan hospital.

In this Clinical Practice Development (CPD) project we set out to identify and describe current approaches to the management and delivery of nursing care in an Australian Metropolitan Teaching Hospital. Using a simple descriptive design, data were collected to elicit patterns of care provided by nursing teams. We sought to demonstrate patterns described by nursing teams (interviews) and actual patterns of care (observation). As expected there was a degree of incongruence between the espoused and actual patterns of care. Interview data revealed that most study wards had a view of nursing that emphasizes meeting the total care needs of patients and their families through offering biopsychosocial and educative care. The observational data revealed that a relatively large proportion of time was expended on activities that were not regarded as important by staff when interviewed (e.g. documentation) while relatively small amounts of time were observed to be spent educating patients or communicating with relatives of patients. The identification of this type of gap creates a dissonance in clinicians that can be used to stimulate change through CPD. Clinicians used the information to stimulate discussion and to rewrite team value statements.