The implementation of best practice in medication administration across a health network: a multisite evidence-based audit and feedback project.

BACKGROUND: Medication errors present a significant risk to patient safety. The "rights" of medication administration represent one approach to potentially reducing this risk. OBJECTIVES: The aim of this project was to implement an evidence-based audit and feedback project to improve compliance with best practice in this area across a health network. METHODS: A baseline audit was conducted to determine compliance with evidence-based standards by trained observers. The results of this audit were analysed and fed back to staff. An analysis of barriers to compliance was undertaken by key staff within the organization, which was followed by the implementation of targeted strategies to improve compliance. A follow-up audit was conducted and the results compared to the baseline audit. RESULTS: There were improvements in the percentage of compliance across all of the eight criteria audited, with statistically significant improvements found in six of the eight. In general, compliance with the criteria was high in both the baseline and follow-up audits. CONCLUSION: This audit and feedback implementation project was successful in increasing compliance and knowledge in this area and providing future direction for sustaining evidence-based practice change. It is now planned to use this approach for rolling out future implementation projects within this health system.

A systematic review of the experiences of undergraduate nursing students choosing to study at an English speaking university outside their homeland.

BACKGROUND: Increasingly overseas students are attending university nursing programs in English-speaking countries to gain additional tertiary qualifications that may not be available in their homeland and also to fill the international nursing shortfall. For these students, some common issues identified and affirmed in qualitative research papers include loneliness, discriminatory experiences, developing communication, and academic skills. This systematic review will help identify and synthesise current issues through exploring the existing literature, giving an insight into the lives of international nursing students. Given the large and increasing number of these students, it is important to acknowledge and improve learning and other outcomes for them. OBJECTIVES: The objective of this systematic review was to determine the best available evidence in relation to the experiences of undergraduate nursing students choosing to study at an English speaking university outside their homeland. INCLUSION CRITERIA: This review sought high quality studies aimed at exploring the experience of undergraduate nursing students studying outside their homeland at an English speaking university. Both qualitative research studies and opinion-based text were considered for this review. SEARCH STRATEGY: An extensive search of the literature was conducted to identify research studies published between January 1990 and April 2011 in English and indexed in 37 major databases. METHODOLOGICAL QUALITY: All included articles were assessed independently by two reviewers (RT and SP), using the appropriate critical appraisal tool from the Joanna Briggs Institute. DATA COLLECTION: Data were extracted from included papers using appropriate standardised data extraction tools developed by the Joanna Briggs Institute. DATA SYNTHESIS: Data from qualitative studies and textual and opinion papers were meta-synthesised separately using standardised instruments. Data synthesis of all included studies involved the pooling of findings and then grouping into categories on a basis of similarity of meaning. The categories were further aggregated into a set of statements representing synthesised findings as a coherent whole. RESULTS: A total of 19 studies were identified as of high quality and meeting the inclusion criteria. From these studies, 254 findings were extracted which were grouped into 13 categories and further aggregated into four synthesised findings. CONCLUSIONS: The four major areas identified in this review in relation to the experiences of undergraduate nursing students studying outside their homeland at an English-speaking university include the need for support and encouragement, valuing and respecting difference, and the desire to succeed despite challenges and inclusion. IMPLICATIONS FOR PRACTICE: Recognising the unique needs of international nursing students, in the clinical, academic and social context, is critical to improve the experiences of this student cohort. Educational and support strategies and programs are needed to respond to these needs. IMPLICATIONS FOR RESEARCH: The implications for research are substantial. Given the outcomes of this review, action and evaluative research is needed to explore, implement and evaluate support strategies for students from non-English speaking backgrounds studying nursing. Research in the areas of curriculum development, supporting students' clinical experiences, and university social and academic support programs is recommended.

A systematic review of Registered Nurses; experiences of the influence of workplace culture and climatic factors on nursing workloads.

BACKGROUND: Nursing workload is an issue that effects both the recruitment and retention of nurses, and patient safety. Historically, measurement has focussed on the delivery of direct patient care and excluded workload of facilitating hands-on care and supporting the organisation via duties that reflect organisation cultural and climate needs. Qualitative research is appropriate to understand this complexity. OBJECTIVE: To determine the best available evidence in relation to registered nurses experiences of workplace cultural and climatic factors that influence nursing workloads, in an acute health care setting. INCLUSION CRITERIA: This review sought high quality studies which explored registered nurses' experiences of the influence of cultural and climatic factors on their workloads. Qualitative research studies and opinion-based text were considered. SEARCH STRATEGY: An extensive search of the literature was conducted to identify published and unpublished studies between January 1990 and June 2011 in English, and indexed in the following databases: CINAHL, Medline, Medline-In Process, PsychINFO, Emerald, Current Contents, TRIP, JSTOR Nursing Consult Psychology & Behavioural Sciences collections, Emerald Management Reviews, Emerald Full Text Journals, Embase, Dissertation Abstracts, ERIC, Proquest and MedNar, EBSCOhost, Science Direct, Wiley Interscience. METHODOLOGICAL QUALITY: Two independent reviewers (CRW and CRC), using appraisal tools from the Joanna Briggs Institute (JBI), assessed fifteen articles; one was excluded. DATA COLLECTION: Data were extracted from included papers using standardised tools developed by the JBI. DATA SYNTHESIS: Data from qualitative studies and textual/opinion papers were meta-synthesised separately using standardised instruments. Data synthesis involved the pooling of findings, then grouped into categories on the basis of similarity of meaning. The categories were further aggregated into synthesised findings. RESULTS: 14 papers were identified as high quality and meeting the inclusion criteria. 81 findings were identified from the 10 qualitative research papers and 39 conclusions from the 4 text/ opinion papers. While the research and non research evidence was analysed separately, both sets of evidence gave the same synthesised findings. The qualitative research findings were grouped into eight categories and textual data into six categories; all textual categories were also identified in the qualitative synthesis. These categories were aggregated into two synthesised findings. CONCLUSIONS: Nursing workloads are influenced by the largely immeasurable cultural factors within hospital environments. These factors signify 'how we do things around here'. Organisational climate influences nursing workloads because of inter-professional relationships, clinical governance, workplace support, non-nursing duties, organisational structure and organisation, work redesign, workflow and diversity within nursing roles. IMPLICATIONS FOR PRACTICE: The component of registered nurses' workloads that are not patient-care should be recognised. Reviewing nursing roles to remove unnecessary work unrelated to patient care would positively influence nursing workloads, giving time for cognitive workload and clinical education and mentorship. IMPLICATIONS FOR RESEARCH: Further qualitative research should explore the complexity of clinical nurses' roles in a diversity of settings, to address the responsibilities that registered nurses routinely assume, but which do not involve direct patient care. New workload models, which capture the non-measurable aspects of a registered nurse's role, should be developed and evaluated.

A comprehensive systematic review of age-friendly nursing interventions in the management of older people in emergency departments.

BACKGROUND: The growing demand on health services due to an ageing population and people living with complex chronic illnesses necessitates an integrated and evidence based care approach. In times of acute illness, trauma or difficult life situations, for many older people the Emergency Department is the first port of call. Despite the benefits of presenting to the Emergency Department, this environment can also be challenging for the older person, particularly those who are frail and have cognitive impairments. Emergency Department nurses play a pivotal role in tailoring the care of the older patient that specifically meets their needs, enhances their level of comfort and decreases the risk of additional distress unrelated to their presenting illness. OBJECTIVES: The objective of this systematic review was to determine the best available evidence in relation to age-friendly nursing interventions in the management of older people presenting to the Emergency Department. INCLUSION CRITERIA: Participants considered for this systematic review included older people aged over 65 who were cared for in the Emergency DepartmentNurse led interventions that enhanced older people's comfort during their stay in Emergency Department, specifically in relation to nutrition, hydration, pressure area care, pain management and communication.Studies using quantitative research methods as well as opinion based papers were considered for this systematic review.Outcomes were assessed in relation to the effectiveness of nursing interventions on pressure area status, hydration status, nutritional status and pain status measured during their stay in the Emergency Department. The text and opinion part of the review focused on the recommended policies for age-friendly nursing interventions. SEARCH STRATEGY: An extensive search of the literature was undertaken to retrieve any English language material published and unpublished materials between January 1999 to October 2010. METHODOLOGICAL QUALITY: All included articles were assessed by two independent reviewers using the appropriate critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION: Data were extracted from included papers using data extraction tools developed by the Joanna Briggs Institute. DATA SYNTHESIS: Data were synthesised and pooled according to their methodological approach, using standardised JBI instruments. Due to the methodological diversity and limited data found, quantitative data were combined in narrative summary. A meta-synthesis was undertaken for the opinion based data. RESULTS: A total of 16 papers were included in the review, two research articles, seven expert opinion and another seven policy documents. This resulted in the identification of 39 findings, which were grouped into seven categories, which were further aggregated into two synthesised findings. CONCLUSIONS: There is little high quality research in relation to effective nursing interventions in the management of older people in the Emergency Department. Identified strategies and interventions are predominately based on suggested practices, rather than based in rigorous research. This provides limited guidance to nurses working in ED Departments; however the expert opinion and other literature in this review strongly suggests that a focus on fundamental nursing interventions such as attention to skin integrity, nutrition and hydration, mobility, comfort, falls prevention and social support are important. IMPLICATIONS FOR RESEARCH/PRACTICE: Future research is urgently needed to identify the nursing needs of older people in the Emergency Department, and to evaluate the efficacy of nursing interventions to enhance outcomes for older people during and beyond their hospital stay.

Management of disruptive behaviour within nursing work environments: a comprehensive systematic review of the evidence.

BACKGROUND: In an increasingly complex health care environment, where nurses are essential to the health system's capacity to respond to the challenges presented by an ageing population, creating positive work environments is fundamental for nurses, their co-workers, and their patients. Disruptive clinician behaviour, which refers to behaviours such as bullying and physical violence, but also to more subtle behaviours such as withholding vital information or gossiping, can be highly destructive within a work environment. The implications of such behaviours within the nursing workforce specifically, and to the health care system more broadly, are profound. Substantial evidence suggests that the pervasiveness of such behaviours has consequences for recruitment and retention, staff morale, job satisfaction, and staff absenteeism, as well as intra and inter-professional communication and teamwork which can ultimate also affect patient safety. The extent of the problem of disruptive behaviour in the workforce is discussed widely in the literature and nurses as a cohort have been studied extensively, however there has been no systematic review of evidence relating to how to manage these behaviours successfully. OBJECTIVE: The objective of this systematic review was to appraise and synthesise the best available evidence in relation to interventions which have been successful in managing disruptive clinician behaviour in the nursing work environment. INCLUSION CRITERIA: Types of participants - The primary participant group of interest for this systematic review includes nurses working in any health care setting; however any other member of the health care team such as medical practitioners or allied health were also considered.Types of intervention(s)/phenomena of interest - Any study that explored behavioural, educational, managerial, organisational and personal interventions to manage disruptive behaviours in the health care setting was considered.Types of studies - Studies using quantitative and qualitative methods as well as opinion based papers were considered for this systematic review.Types of outcomes - Outcomes were assessed in relation to the effect of interventions on patient safety and quality of care, quality of team work and work environment, levels of job satisfaction and nursing staff morale as well as levels of staff retention. SEARCH STRATEGY: Searches were conducted including any published and unpublished material, including grey literature, in the English language. A search of CINAHL, Medline, Medline-in Process, PsychINFO, Emerald and TRIP was undertaken using specifically defined terms and synonyms. Scirus, OpenSIGLE and Google Scholar were also searched. A search of electronic dissertations via Dissertation Abstracts was undertaken. 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) developed by JBI. DATA COLLECTION: Data was identified as quantitative or qualitative data or opinion based and data extraction tools developed by the Joanna Briggs Institute were used to extract the data, where possible. Where this was not possible, findings were presented in narrative form. DATA SYNTHESIS: Data were synthesised according to their methodological approach. Qualitative data were pooled using the QARI instrument and a set of statements were developed that represented a broader overview of a specific aggregation RESULTS: A total of 24 papers, descriptive quantitative, qualitative and textual in approach, were included in the review. The majority of the papers were textual, with a variety of expert opinion provided in relation to managing disruptive clinician behaviour. CONCLUSIONS: Comprehensive review of the literature identified that there has been very little research evaluating the effectiveness of interventions to manage disruptive clinician behaviour in nursing, or more broadly within the health care system. A handful of studies involved localised interventions followed by a qualitative evaluation, with useful but not generaliseable findings. These studies emphasised personal, peer and educational approaches to assist those nurses affected by disruptive clinician behaviour within their work teams, but none were related to specific management strategies aimed at the person exhibiting the disruptive behaviour. Most recommendations in the literature were expert opinion. These recommendations emphasised the importance of a clear and consistent organisational approaches to disruptive clinician behaviour.

Rural men and mental health: their experiences and how they managed.

There is a growing awareness that a primary source of information about mental health lies with the consumers. This paper reports on a study that interviewed rural men with the aim of exploring their mental health experiences within a rural environment. The results of the interviews are a number of stories of resilience and survival that highlight not only the importance of exploring the individuals' perspective of their issues, but also of acknowledging and drawing on their inner strengths. Rural men face a number of challenges that not only increase the risk of mental illness but also decrease the likelihood of them seeking and/or finding professional support. These men's stories, while different from each other, have a common thread of coping. Despite some support from family and friends, participants also acknowledged that seeking out professional support could have made the recovery phase easier. Mental health nurses need to be aware, not only of the barrier to professional support but also of the significant resilience that individuals have and how it can be used.

SEAM--improving the quality of palliative care in regional Toowoomba, Australia: lessons learned.

INTRODUCTION: The proliferation of professional palliative care services in recent years has increased access for people with palliative care needs; however, gaps in services continue to exist, particularly in rural and remote areas of Australia. In order to address one gap in rural health service delivery, the Support, Education, Assessment, and Monitoring (SEAM) Service for regional and rural people in Toowoomba, Queensland, Australia, was introduced. This new model of service delivery aimed to provide palliative services to patients and their families who live in the regional city of Toowoomba and its rural catchment area. It also aimed to facilitate education, support and networking among health-care professionals, particularly general practitioners and nurses employed in general practice (practice nurses). METHOD: The evaluation involved twenty face-to-face interviews with a variety of health professionals who had contact with the SEAM service from June 2003 to June 2004. Qualitative data analysis of the transcribed interviews provided the basis for the evaluation. The emergent themes regarding the SEAM service included: satisfaction and benefit of the SEAM service; knowledge of and contact with the SEAM service; the SEAM role; and expansion of the role. RESULTS: The data indicate that the majority of health professionals who had contact with the SEAM service were satisfied with the service and found it to be of benefit to them and their clients. Participants commented on the extensive networking and support work established by the SEAM nurse with other health service providers. Difficulties experienced with the SEAM service included poor utilisation by GPs and, therefore, clients in need of palliative support. This was predominately due to lack of knowledge of the service as well as limited understanding of the SEAM nurse role. CONCLUSION: The SEAM service has resulted in increased links between health professionals providing palliative care to rural clients. The most successful strategy was the use of multidisciplinary case conferencing which not only built links among health professionals caring for individual clients, but also resulted in improved care for those clients. As a result of better integration and communication, palliative care services to rural people have been improved. However, with regard to the delivery of direct patient care, or in the support of GPs for the management of palliative care patients, it was apparent that the service did not meet its objectives. The lack of use by GPs and patients appears to be related to a lack of awareness of the existence of the service. A positive outcome of this poor utilisation is, however, that the model has allowed the identification of factors that work as barriers to GPs and client/family utilisation of rural palliative care services.

Experiences of regional and rural people with cancer being treated with radiotherapy in a metropolitan centre.

This paper explores the issues related to rural people with cancer whose choice of radiotherapy treatment necessitated travel and accommodation in a metropolitan centre. Semi-structured interviews with 46 participants, from the Toowoomba and Darling Downs region of Queensland, Australia, were conducted and the data thematically analysed. The specific themes identified were: being away from loved ones, maintaining responsibilities whilst undergoing treatment, emotional stress, burden on significant others, choice about radiotherapy as a treatment, travel and accommodation, and financial burden. This study supports the need for a radiotherapy centre in the location of Toowoomba as a way of providing some equity and access to such treatment for the rural people of Queensland.