Characteristics and processes of registered nurses' clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review.

OBJECTIVE: The objective of this review was to examine the characteristics and processes of clinical reasoning used by registered nurses in clinical practice, and to identify factors reported to relate to the use of clinical reasoning by registered nurses in clinical practice. INTRODUCTION: Significant variability in the clinical reasoning of graduate registered nurses has been identified in research, with underdeveloped and unsafe clinical reasoning being linked to failure-to-rescue and sentinel events in the clinical setting. The identification of characteristics and processes of clinical reasoning, and factors relating to registered nurses' clinical reasoning when engaged in clinical practice, will increase understanding of the clinical reasoning requirements for undergraduate registered nurses and of potential factors that may affect their clinical reasoning. INCLUSION CRITERIA: Studies including registered nurses who met the criteria for registered nurse registration in Australia and who used clinical reasoning to engage with health care consumers in all practice environments were eligible for inclusion. METHODS: Eight databases were searched, with articles identified through CINAHL, MedNar, PubMed, Science Direct, ERIC, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Database searches were conducted on December 31, 2020, and updated August 20, 2021, with primary qualitative and quantitative research studies in English from 2000 onwards considered for inclusion. Opinion papers, text, and reports were not included. Data were extracted based on the draft charting tool from the scoping review protocol, with results presented in tabular format and in a narrative summary. RESULTS: The 29 qualitative and 5 quantitative research studies included in the scoping review utilized exploratory descriptive, descriptive rationalist, narrative, ethnography, correlational, observational, and grounded theory methodologies in their research designs. Observation, think-aloud sessions, questionnaires, surveys, interviews, and focus groups were used to collect data from the 1099 participants in 9 countries. Multiple concepts related to the characteristics (n=35) and processes (n=30) of clinical reasoning were detected in the research studies, with 5 categories identified: i) situation management, ii) data management, iii) interpreting, iv) implementing and evaluating, and v) professional practice, with an additional processes category identified (decision-making processes). The factors (n=26) reported to relate to clinical reasoning were categorized into environment of care, care requirements, professional practice, experience, knowledge, and decision-making processes. Connections between the various concepts were evident throughout the review. CONCLUSIONS: The scoping review identified characteristics and processes of clinical reasoning, as well as factors reported to relate to clinical reasoning in all studies. The concepts that comprise the clinical reasoning of registered nurses in clinical practice must be considered in undergraduate registered nurse education. Registered nurses must complete their baccalaureate program with well-developed clinical reasoning to ensure safe clinical practice. Understanding the characteristics and processes of registered nurses' clinical reasoning in clinical practice, and the factors reported to relate to clinical reasoning, supports the creation of targeted resources for development and assessment of clinical reasoning.

Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review.

INTRODUCTION: There is limited research available on safe medication management practices in emergency medical services (EMS) practice, with most evidence-based medication safety guidelines based on research in nursing, operating theater and pharmacy settings. Prevention of errors requires recognition of contributing factors across the spectrum from the organizational level to procedural elements and patient characteristics. Evidence is inconsistent regarding the incidence of medication errors and multiple sources also state that errors are under-reported, making the true magnitude of the problem difficult to quantify. Definitions of error also vary, with the specific context of medication errors in prehospital practice yet to be established. The objective of this review is to identify the factors influencing the occurrence of medication errors by EMS personnel in the prehospital environment. METHODS AND ANALYSIS: The review included both qualitative and quantitative research involving interventions or phenomena related to medication safety or medication error by EMS personnel in the prehospital environment. A search of multiple databases was conducted to identify studies meeting these inclusion criteria. All studies selected were assessed for methodological quality; however, this was not used as a basis for exclusion. Each stage of study selection, appraisal and data extraction was conducted by two independent reviewers, with a third reviewer deciding any unresolved conflicts. The review follows a convergent integrated approach, conducting a single qualitative synthesis of qualitative and "qualitized" quantitative data. RESULTS: Fifty-six articles were included in the review, with case reports and qualitative studies being the most frequent study types. Qualitative analysis revealed seven major themes: organizational factors (with reporting as a sub-theme), equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors (with pediatrics as a sub-theme) and cognitive factors. Both contributing factors and protective factors were identified. DISCUSSION: The body of evidence regarding medication errors is heterogenous and limited in both quantity and quality. Multiple factors influence medication error occurrence; knowledge of these is necessary to mitigate the risk of errors. Medication error incidence is difficult to quantify due to inconsistent measure, definitions and contexts of research conducted to date. Further research is required to quantify the prevalence of identified factors in specific practice settings.

Development of an Electronic Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Proforma (E-ICP) to Improve Interdisciplinary Guideline Adherence in the Emergency Department: Modified Delphi Study.

Introduction: Chronic obstructive pulmonary disease guideline non-adherence is associated with a reduction in health-related quality of life in patients (HRQoL). Improving guideline adherence has the potential to mitigate fragmented care thereby sustaining pulmonary function, preventing acute exacerbations, reducing economic health burdens, and enhancing HRQoL. The development of an electronic proforma stemming from expert consensus, including digital guideline resources and direct interdisciplinary referrals is hypothesised to improve guideline adherence and patient outcomes for emergency department (ED) patients with COPD. Aim: The aim of this study was to develop consensus among ED and respiratory staff for the correct composition of a COPD electronic proforma that aids in guideline adherence and management in the ED. Methods: This study adopted a mixed-method design to develop the most important indicators of care in the ED. The study involved three phases: (1) a systematic literature review and qualitative interdisciplinary staff interviews to assess barriers and solutions for guideline adherence and qualitative interdisciplinary staff interviews, (2) a modified Delphi panel to select interventions for the proforma, and (3) a consensus process through three rounds of scoring through a quantitative survey (ED and Respiratory consensus) and qualitative thematic analysis on each indicator. Results: The electronic proforma achieved acceptable and good internal consistency through all iterations from national emergency department and respiratory department interdisciplinary experts. Cronbach's alpha score for internal consistency (α) in iteration 1 emergency department cohort (EDC) (α = 0.80 [CI = 0.89%]), respiratory department cohort (RDC) (α = 0.95 [CI = 0.98%]). Iteration 2 reported EDC (α = 0.85 [CI = 0.97%]) and RDC (α = 0.86 [CI = 0.97%]). Iteration 3 revealed EDC (α = 0.73 [CI = 0.91%]) and RDC (α = 0.86 [CI = 0.95%]), respectively. Conclusion: Electronic proformas have the potential to facilitate direct referrals from the ED leading to reduced hospital admissions, reduced length of hospital stays, holistic care, improved health care and quality of life and improved interdisciplinary guideline adherence.

Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review.

BACKGROUND: COPD guidelines non-concordance is a challenge frequently highlighted by respiratory experts. Despite the provision of comprehensive evidence-based national and international guidelines, the COPD burden to frontline healthcare services has increased in the last decade. Suboptimal guidelines concordance can be disruptive to health-related quality of life (HRQoL), hastening pulmonary function decline and surging overall morbidity and mortality. A lack of concordance with guidelines has created an escalating economic burden on health-care systems. Identifying interdisciplinary interventions to facilitate improved adherence to guidelines may significantly reduce re-admissions, enhance HRQoL amongst patients and their families, and facilitate economic efficiency. MATERIALS AND METHODS: This review adhered to the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews and the PRISMA ScR reporting guidelines. Two independent reviewers screened abstracts and full text articles in consonance with inclusion criteria. The convergent integrative JBI method collated quantitative, qualitative and mixed methods studies from nine databases. JBI critical appraisal tools were utilised to assess the quality of research papers. The theoretical domains framework (TDF) along with a specifically developed COPD data extraction tool were adopted as a priori to collect and collate data. Identified barriers and corresponding clinical behavioural change solutions were categorised using TDF domains and behavior change wheel (BCW) to provide future research and implementation recommendations. RESULTS: Searches returned 1068 studies from which 37 studies were included (see Figure 1). COPD recommendations identified to be discordant with clinical practice included initiating non-invasive ventilation, over- or under-prescription of corticosteroids and antibiotics, and a lack of discharging patients with a smoking cessation plan or pulmonary rehabilitation. TDF domains with highest frequency scores were knowledge, environmental resources, and clinical behaviour regulation. Electronic order sets/digital proforma with guideline resources at point of care and easily accessible digital community referrals to target both pharmacological and non-pharmacological management appear to be a solution to improve concordance. CONCLUSION: Implementation of consistent quality improvement intervention within hospitals for patients with COPD may exclude any implementation gap and prevent readmissions. Electronic proformas with digital referrals will assist with future evaluation audits to prioritise and target interventions to improve guidelines concordance. ETHICS AND DISSEMINATION: Ethical approval is not required, and results dissemination will occur through peer-reviewed publication. PROSPERO REGISTRATION NUMBER: CRD42020156267.

Associated factors, assessment, management, and outcomes of patients who present to the emergency department for acute exacerbation of chronic obstructive pulmonary disease: A scoping review.

OBJECTIVE: The purpose of the scoping review was to examine the extant literature for factors contributing to presentations of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) to Emergency Departments (ED). METHODS: The review followed Arksey and O'Malley, and Levac's frameworks supplemented with the PRISMA-ScR checklist. We searched Cochrane Library, CINAHL, JBI, and PubMed from January 1, 2008 to March 23, 2020 for inclusions. We included studies reporting ED presentations for AECOPD among adults (≥18 years). The investigation included: pre-hospital factors; ED-related assessment, management and referral practices; holistic management (i.e., interdisciplinary); patient outcomes, admission/discharge status, and readmission. RESULTS: Forty-four studies were included. Environmental factors (e.g., air pollution, seasonal change); social determinants (e.g., poor literacy, ethnicity); and physical health (e.g., comorbidities, obesity, poor exercise capacity) contributed to ED presentation/re-presentation, and admission to hospital. Cigarette smoking was associated with hospital admission. Mortality was associated with longer-term oxygen therapy, poor exercise capacity, age, and loss of consciousness. Compliance with clinical guideline recommendations were generally low or mixed. Further, there was a lack of appropriate referral practices upon discharge. CONCLUSIONS: While there is considerable literature on factors contributing to AECOPD admission more research is required that investigates the impact that inter-professional care models can have on the discharge planning cycles for patients with COPD who are regular presenters to an ED.

Does distance to hospital affect emergency department presentations and hospital length of stay among chronic obstructive pulmonary disease patients?

BACKGROUND: The primary goal of chronic obstructive pulmonary disease (COPD) management is to optimise a patient's functional status and quality of life. By encouraging effective patient self-management within primary healthcare, unplanned and potentially avoidable COPD admissions to the emergency department (ED) can be avoided. AIM: The aim of this study is to examine whether distance to hospital influences the rate of ED presentation, hospital admission and hospital length of stay for COPD patients. METHODS: The 2016 to 2018 resulted in a total of 5253 patient presentations with a primary medical diagnosis code of J44 (COPD). These were at the main hospitals of three Queensland Hospital and Health Services: Toowoomba, Ipswich and Gold Coast. To examine the variations in patient characteristics based on distance, a one-way ANOVA (analysis of variance) test was conducted. The Kruskal-Wallis test indicated that there were group differences. RESULTS: This study identified significant variation in COPD-related hospital length of stay and distance to hospital among COPD patients within three hospitals in South East Queensland, Australia. These results confirm that distance plays an important role in determining duration of hospital stay (in number of days) among COPD patients, with clear evidence of the distance 'decay phenomenon'. It appears from the findings of the current study that distance to the hospital is not associated with the greater likelihood of ED presentation but may influence length of stay. CONCLUSIONS: Several distance-specific studies have concluded that lower utilisation of hospital care is associated with distance to hospital.

How registered nurses balance limited resources in order to maintain competence: a grounded theory study.

BACKGROUND: Nurses have limited time outside of work for continuing professional development. Consequently, strategies need to be explored to enable them to better maintain their competence. This article describes recent research investigating if nursing behaviours in the use of mobile technologies could be leveraged to better facilitate mobile learning. It addresses a gap in the existing literature around how nurses resource their own professional development and learning in the absence of appropriate learning resources in the workplace. METHODS: The research employed a classic grounded theory methodology which was conducted with 27 registered nurses from Public and Private Hospitals in Queensland and external postgraduate nursing students from Victoria, South Australia and the Northern Territory enrolled at the University of Southern Queensland. RESULTS: The Theory of Economising Learning describes how nurses maintain competence with limited resources. Unfavourable staffing levels and a fast-paced workplace mean that nurses rarely prioritise their professional learning while at work. Instead, it requires the nurse to contribute personal resources including time and money. Though the research revealed nurses were unconcerned about using mobile technologies, they were concerned about maintaining competence with limited resources. To counter this, nurses economised their learning by balancing personal resources against their motivation to maintain competence. The process of economising learning begins and ends with the development of the nurse's personal curriculum in response to what they identify as being the most significant knowledge deficits at work that jeopardise their competence. A learning opportunity that addresses the knowledge deficit is sought. Nurses balance the opportunity to address the deficit against the cost of personal resources, to decide if they will engage with the opportunity and update their personal curriculum accordingly. CONCLUSIONS: It is suggested that workplaces need to create reasonable expectations within nurses to address knowledge deficits and provide the resources, including time, to allow them to do so without personal cost. It is also necessary for workplaces to moderate the flow of learning opportunities so as not to overwhelm and demotivate the nurses. Currently, nurses use several strategies to optimise their learning using mobile technologies which could be leveraged in the workplace.

Exploring Factors Contributing to Chronic Obstructive Pulmonary Disease (COPD) Guideline Non-Adherence and Potential Solutions in the Emergency Department: Interdisciplinary Staff Perspective.

PURPOSE: Acute exacerbations of chronic obstructive pulmonary disease (COPD) have a significant and prolonged impact on health-related quality of life, patient outcomes, and escalation of pulmonary function decline. COPD-X guidelines published in 2003 subsist to facilitate a shift from the emphasis on pharmacological treatment to a more holistic multi-disciplinary interventions approach. Despite the existing comprehensive recommendations, readmission rates have increased in the last decade. Evidence to date has reported sub-optimal COPD guidelines adherence in emergency departments. This qualitative study explored contributing factors to interdisciplinary staff non-adherence and utilisation of COPD-X guidelines in a major Southern Queensland Emergency Department. METHODS: Semi-structured qualitative interviews with interdisciplinary staff were conducted in an emergency department. A purposive sample of doctors, nurses, physiotherapists, pharmacist and a social worker were recruited. Interviews were digitally recorded, de-identified and transcribed verbatim. Data analysis followed a coding process against the Theoretical Domains Framework (TDF) to examine implementation barriers and potential solutions. Identified factors affecting non-adherence and underutilisation of guidelines were then mapped to the capability, opportunity, motivation, behaviour model (COM-B) and behaviour change wheel (BCW) to inform future implementation recommendations. RESULTS: Prominent barriers influencing the clinical uptake of COPD guidelines were identified using TDF analysis and included knowledge, professional role clarity, clinical behaviour regulation, memory, attention, and decision process, beliefs about departmental capabilities, environmental context and resources. Potential interventions included education, training, staffing, funding and time-efficient digitalised referrals and systems management reminders to prevent COPD readmissions, remissions and improve patient health-related quality of life. CONCLUSION: Implementation strategies such as electronic interdisciplinary COPD proforma that facilitates a multimodal approach with appropriate patient/staff resources and referrals prior to discharge from an ED require further exploration. Greater clarity around which components of the COPD X guidelines must be applied in ED settings needs to stem from future research.

Estimating the frequency and cost of emergency department presentations and hospitalisation of chronic obstructive pulmonary disease patients: A retrospective analysis from regional Queensland.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) patients commonly have frequent visits to the ED. Consequently, COPD has a significant effect on total healthcare expenditure. The objective was to measure the frequency of ED presentation and hospitalisation among COPD patients and to estimate the costs resulting from such care utilisation. METHODS: This was a causal-comparative non-experimental research design conducted in three regional hospitals between 2016 and 2018. Two different original data sets were used: an automated hospital data set and an audit of patient charts. Secondary cost data were also used. Data were analysed using Pearson's χ2 test to estimate the relationship between several patient and treatment-related characteristics. RESULTS: There were 5253 patient presentations at ED and hospital length of stay data were available for 5079 COPD patients. The total cost of hospital stays was $42.14 million for the time period and the mean average cost was $8297 for ED patients who were admitted to hospital. Factors significantly associated with hospital length of stay were age and time spent in the ED. Noticeably, one (51.7%) in two COPD patients were discharged from ED (all destinations) within 4 h irrespective of their triage category. CONCLUSIONS: COPD patient presentation to ED and admission to hospital is an expensive method of providing healthcare to manage this chronic condition. Clinical practitioners and policy makers need to develop and implement optimal integrated care management systems to reduce this hospitalisation rate and reduce the societal costs associated with COPD patient management.

Mapping of modifiable barriers and facilitators with interdisciplinary chronic obstructive pulmonary disease (COPD) guidelines concordance within hospitals to the Theoretical Domains Framework: a mixed methods systematic review protocol.

INTRODUCTION: Multifarious chronic obstructive pulmonary disease (COPD) guidelines have been published by local, national and global respiratory societies. These guidelines subsume holistic evidence based on recommendations to diagnose, treat, prevent and manage acute exacerbation with COPD. Despite the existing comprehensive recommendations, readmission rates and hospitalisations have increased in the last decade. Evidence to date has reported suboptimal clinical guidelines concordance. Acute exacerbations of COPD (AECOPD) is a common hospital presentation due to varied causes such as infective exacerbations, worsening disease condition, medication non-adherence, lack of education and incomprehensive discharge planning. AECOPD directly and indirectly causes economic burden, disrupts health-related quality of life (HRQol), hasten lung function decline and increases overall morbidity and mortality. COPD being a multimodal chronic disease, consistent interdisciplinary interventions from the time of admission to discharge may reduce readmissions and enhance HRQol among these patients and their families. METHODS AND ANALYSIS: This protocol adheres to the Joanna Briggs Institute methodology for mixed methods systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. Qualitative, quantitative and mixed methods studies will append this study to explore determinants of COPD guidelines concordance. Comprehensive three-tier search strategies will be used to search nine databases (COCHRANE, EBSCO HOST, MEDLINE, SCIENCE DIRECT, JBI, SCOPUS, WEB OF SCIENCE, WILEY and DARE) in May 2020. Two independent reviewers will screen abstracts and full-text articles in consonance with inclusion criteria. The convergent integrative method narrative review will contribute a deeper understanding of any discrepancies found in the existing evidence. Quality of the studies will be reported and Theoretical Domains Framework (TDF) will be used as a priori to synthesis data. Identified barriers, facilitators and corresponding clinical behavioural change solutions will be categorised using TDF indicators to provide future research and implementation recommendations. ETHICS AND DISSEMINATION: Ethical approval is not required and results dissemination will occur through peer-reviewed publication.

Contributing factors that influence medication errors in the prehospital paramedic environment: a mixed-method systematic review protocol.

INTRODUCTION: There is limited reliable research available on medication errors in relation to paramedic practice, with most evidence-based medication safety guidelines based on research in nursing, operating theatre and pharmacy settings. While similarities exist, evidence suggests that the prehospital environment is distinctly different in many aspects. The prevention of errors requires attention to factors from the organisational and regulatory level down to specific tasks and patient characteristics. The evidence available suggests errors may occur in up to 12.76% of medication administrations in some prehospital settings. With multiple sources stating that the errors are under-reported, this represents significant potential for patient harm. This review will seek to identify the factors influencing the occurrence of medication errors by paramedics in the prehospital environment. METHODS AND ANALYSIS: The review will include qualitative and quantitative studies involving interventions or phenomena regarding medication errors or medication safety relating to paramedics (including emergency medical technicians and other prehospital care providers) within the prehospital environment. A search will be conducted using MEDLINE (Ovid), EBSCOhost Megafile Search, the International Committee of Medical Journal Editors trial registry, Google Scholar and the OpenGrey database to identify studies meeting this inclusion criteria, with initial searches commencing 30 September 2019. Studies selected will undergo assessment of methodological quality, with data to be extracted from all studies irrespective of quality. Each stage of study selection, appraisal and data extraction will be conducted by two reviewers, with a third reviewer deciding any unresolved conflicts. The review will follow a convergent integrated approach, conducting a single qualitative synthesis of qualitative and 'qualitised' quantitative data. ETHICS AND DISSEMINATION: No ethical approval was required for this review. Findings from this systematic review will be disseminated via publications, reports and conference presentations.

Recommendations and practices for holistic chronic obstructive pulmonary disease (COPD) assessment and optimal referral patterns in emergency department presentations: a scoping review protocol.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that causes persistent respiratory symptoms and decline in lung function over many years. This chronic disease significantly affects health-related quality of life and is known to contribute to frequent emergency department (ED) presentations. Multidimensional management of these patients, including interconnecting health disciplinarians will allow holistic care provision in the ED. The purpose of this scoping review is to synthesise current evidence on holistic management and assessment, and referral practices stemming from acute COPD presentation in the ED. Specifically, to determine: (1) What are the known causal factors associated with COPD ED presentations and (2) Is there an identified connection with appropriate healthcare professional assessment within ED presentations and reported referral pathways? METHODS AND ANALYSIS: The iterative stages of the Arskey and O'Malley, and Levac advanced scoping review framework informs this review. Using published and unpublished studies in English, a three-tiered search strategy will be applied. After duplicates are removed, screen 1 (title and abstract) and screen 2 (full-text) will be conducted by two independent reviewers to determine eligibility of articles. Disputes will be settled through discussion or by using a third reviewer. A data collection tool developed by the authors will inform the data extraction process. Schematic tabular format of results with a narrative summary will depict how the results link with the scoping review objectives. Categorisation of results will be narrowed down as key conceptual findings and will align with the strategic intent of this review. ETHICS AND DISSEMINATION: Ethics approval was not required for this study. A multidisciplinary team of authors will participate in dissemination activities (publications, reports, conference presentations, framework development).

Face-to-face instruction combined with online resources improves retention of clinical skills among undergraduate nursing students.

BACKGROUND: There is growing evidence that online resources used to develop clinical skills among students in the healthcare professions can produce equivalent learning outcomes to traditional face-to-face training methods. Whether clinical competence is retained equally well for online and face-to-face training methods is not yet established. OBJECTIVES: The objective of the study was to compare retention of competence in using an IV infusion pump among nursing students trained in its use using three different protocols. DESIGN: A quasi-experimental design was used. SETTING: The study was conducted in the School of Nursing and Midwifery at a regional university in Queensland, Australia. PARTICIPANTS: Participants were 102 first year nursing students (female=89, male=13) enrolled in a medications course, ranging in age from 18 to 44years. METHODS: Three groups of participants were trained in the use of an IV infusion pump and competence was assessed following a 26-week period of no access to the pump. Group 1 participants (ONL; n=34) were trained online using an Intravenous Pump Emulator (IVPE); Group 2 participants (ONC; n=38) were trained on campus using an actual IV pump in a traditional face-to-face setting; Group 3 participants (ONL+ONC; n=30) were trained both on campus using the actual IV pump and online using the IVPE. RESULTS: As hypothesised, no significant differences in learning outcomes, measured by assessment scores out of 80 points, were found between the ONL (M=68.7±5.9) and ONC (M=65.5±11.5; p>0.05) groups. The ONL+ONC group recorded the highest mean assessment score (M=70.0±5.0) and completed the assessment task significantly faster (p<0.001) than the other two groups. CONCLUSIONS: This study suggests that nursing students retained clinical competence in preparing and administrating IV infusions better when face-to-face and online learning were combined.

Characteristics and processes of clinical reasoning in nurses and factors related to its use: a scoping review protocol.

REVIEW QUESTION/OBJECTIVE: The objectives of the scoping review are to.

Does metabolic syndrome predict surgical complications? A protocol for a systematic review and meta-analysis.

BACKGROUND: Metabolic syndrome (MetS) is defined by an accumulation of risk factors that include cardiovascular disease, diabetes, chronic high blood pressure, obesity, and hypercholesterolaemia which results in an increased risk of developing serious chronic diseases. MetS is widespread as it is estimated to affect up to 30% of the global population. For people with MetS who undergo surgery, an emerging body of literature points to significantly poorer postoperative outcomes compared with non-affected populations. Surgical patients with MetS are at significantly higher risk of a range of adverse outcomes including death, morbid cardiovascular events, coma, stroke, renal failure, myocardial infarction, and surgical site infections. Increased complication rates result in prolonged hospital stays, a greater need for post-hospitalisation care, and reduced effectiveness of surgical interventions. METHODS/DESIGN: We will search the following electronic bibliographic databases: MEDLINE, EMBASE, ScienceDirect, and CINAHL, and the reference lists of included articles. We will also search for unpublished literature. Two authors will screen titles and abstract information independently and select studies according to established inclusion and exclusion criteria. Data will be extracted by the study investigators using Review Manager 5 and will include information on demographics, incidence, prevalence, and outcome variables. Subgroup analysis and sensitivity analysis will be performed to assess the heterogeneity of included studies. Meta-analysis will also be carried out if appropriate study groups are identified. A descriptive narrative for statistical data will also be provided to highlight findings of the systematic review and meta-analysis. DISCUSSION: This study will report and summarise adverse outcomes among adult patients with MetS undergoing surgery across a range of surgical specialties. Developing insights into outcomes of this population of interest is necessary to develop guidelines towards better management of surgical patients with metabolic syndrome. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016051071.

Online intravenous pump emulator: As effective as face-to-face simulation for training nursing students.

BACKGROUND: The expansion of online education for nursing students has created the challenge of finding innovative ways to teach clinical skills. An online intravenous pump emulator (IVPE) modelled on actual IV pumps used in clinical healthcare settings was developed to facilitate online education delivery. OBJECTIVES: The objectives of the study were to implement the online IVPE and evaluate student learning outcomes and perceptions of device use. DESIGN: A mixed method, quasi-experimental design was used. SETTING: The study was conducted in the School of Nursing and Midwifery at a regional university in Queensland, Australia. PARTICIPANTS: Participants were 179 first year nursing students enrolled in a medications course, ranging in age from 18 to 44years, of whom 150 were female. METHODS: Participants were assigned to one of three groups and trained in the use of IV infusion pumps. Group 1 (n=57) were trained online using the IVPE (ONL); Group 2 (n=73) were trained on-campus using an actual IV pump (ONC); Group 3 (n=49) were trained both on-campus using the actual IV pump and online using the IVPE (ONL+ONC). Competence in using the actual IV pump was assessed for all participants at the conclusion of the training period. RESULTS: No significant differences in learning outcomes, measured by assessment scores out of 80 points, were found between the ONL (M=65.5±9.2) and ONC (M=62.0±14.8; p>.05) groups. Significantly better learning outcomes were evident for the ONL+ONC group (M=68.7±4.9) compared to the ONC group (p<.01). CONCLUSIONS: This study highlights that the nursing students became more competent in the skill of preparing and administrating IV infusions when face-to-face and online learning were combined.

An evidence-based approach to the prevention and initial management of skin tears within the aged community setting: a best practice implementation project.

BACKGROUND: Maintaining skin integrity in a community setting is an ongoing issue, as research suggests that the prevalence of skin tears within the community is greater than that in an institutional setting. While skin tear prevention and management principles in these settings are similar to those in an acute care setting, consideration of the environmental and psychological factors of the client is pivotal to prevention in a community setting. Evidence suggests that home environment assessment, education for clients and care givers, and being proactive in improving activities of daily living in a community setting can significantly reduce the risk of sustaining skin tears. OBJECTIVES: The aim of this implementation project was to assess and review current skin tear prevention and management practices within the community setting, and from this, to implement an evidence-based approach in the education of clients and staff on the prevention of skin tears. As well. the project aims to implement evidence-based principles to guide clinical practice in relation to the initial management of skin tears, and to determine strategies to overcome barriers and non-compliance. METHODS: The project utilized the Joanna Brigg's Institute Practical Application of Clinical Evidence System audit tool for promoting changes in the community health setting. The implementation of this particular project is based in a region within Anglicare Southern Queensland. A small team was established and a baseline audit carried out. From this, multiple strategies were implemented to address non-compliance which included education resources for clients and caregivers, staff education sessions, and creating skin integrity kits to enable staff members to tend to skin tears, and from this a follow-up audit undertaken. RESULTS: Baseline audit results were slightly varied, from good to low compliance. From this, the need for staff and client education was highlighted. There were many improvements in the audit criteria following client and staff education sessions and staff self-directed learning packages. Future strategies required to sustain improvements in practice and make further progress are to introduce a readily available Anglicare Skin Integrity Assessment Tool to the nursing staff for undertaking new client admissions over 65 years, and to provide ongoing education to staff members, clients and care givers in order to reduce the prevalence of skin tears in the community setting. CONCLUSIONS: This implementation project demonstrated the importance of education of personal care workers, clients and their caregivers for prevention of skin tears in the community setting. This in turn created autonomy and empowered clients to take control of their health.

Behavioural intention and user acceptance of research evidence for Queensland nurses: provision of solutions from the clinician.

In order to maintain high standards of care in practice, renal nurses must become effective utilisers of research and evidence based practice. Many models for effective evidence based implementation have been published in an attempt to encourage a positive cultural shift in meeting this necessary nurse competency. Yet in reality a great disparity still exists between what the profession knows to be an ideal world and what they are actually able to achieve. This paper presents an evaluation of that reality through the eyes of Queensland renal nurses. Initially known barriers to research or evidence based practice utilisation will be discussed in addition to some home grown solutions from those clinicians. Nurses who participated in this study presented some unique perspectives on known barriers to research utilisation, re-affirming those detailed within the literature and conversely revealing new concepts worth additional exploration. New concepts warranting a broader in-depth exploration included the influence of family on nurse decision making and the effect of overseas trained health professionals on necessary change. In addition Queensland renal nurse's overwhelming supported the need for a filtered or a controlled approach to research activity naming this model in post interview discussions "The Spillway Model".