HNE

Handover
For Nurses and Midwives

November 2008
Volume 1, Issue 2

1
Editorial Group
Chief Editor:
Vicki Parker, RN, PhD
Hunter New England Area Health Service
Associate Editor:
Michelle Giles, RN, RM, BA Bus MISys
Hunter New England Area Health Service
Members:
Ann Katherine Williams, RN, PhD
Hunter New England Area Health Service
Bernadette Goddard, RN, RM, BA, MApp Management
Hunter New England Area Health Service
Catherine Turner, RN, RM, B Health Sc (Nurs)
Hunter New England Area Health Service
Professor Diana Keatinge, RN, PhD,
Hunter New England Area Health Service & University
of Newcastle
Glenda Parmenter, RN, PhD
University of New England
Guidelines
HNE Handover aims to
u increase the profile of Nursing and Midwifery within
our region, nationally and internationally
u foster increased skill and confidence in writing for
publication
u build a culture of evidence based practice, critical re-
view and sharing through publication
u provide a vehicle for dissemination of information and
clinical change projects and innovations
u showcase the writing of nurses and midwives, either
individually or in collaboration with other disciplines
Scope: The journal will publish articles with a clinical focus
that highlight the work of nurses and midwives and impact
on patient outcomes across the range of clinical contexts. In
particular, we are seeking articles that represent the diversity
of clinical practice, the unique nature of this Area Health Ser-
vice and its’ populations and their health care needs, the chal-
lenges confronting clinicians and the innovative strategies
they employ to overcome them.
Article categories
Feature articles: Original research and reports of other clini-
cally focussed projects.
Discussion papers: Scholarly papers and literature reviews
that highlight significant issues and challenges, trends and
changing practice.
Inga Kasch, RN, BA (Nurs), MHealth Man
Hunter New England Area Health Service
Professor Isabel Higgins, RN, PhD
Hunter New England Area Health Service & University
of Newcastle
Ass. Professor Mary Cruickshank, RN, RM, PhD
University of New England
Kelvin Smith, RN, MN
Hunter New England Area Health Service
Paula McMullen, RN, PhD
Hunter New England Area Health Service
Penny Paliadelis, RN, PhD
University of New England
Teri Stone, RN, RMN, BA, MHM
Hunter New England Area Health Service
Tracy Levett-Jones, RN, PhD
University of Newcastle
Clinical focus: Practice problem oriented papers that high-
light creative and successful solutions, clinician’s team efforts
and evaluation of change projects.
Local interest: Reports on activities, people and processes
that are unique to a particular area or service within the Area
Health Service and highlight clinicians and their exceptional
work.
Student contributions: Literature reviews, case studies and
other scholarly work, possibly based on assignments. These
may include articles that result from collaborations between
students and academics.
Resource Articles: Comprehensive articles which focus on
writing and reviewing articles for publication or other rel-
evant aspects of professional development and practice.
Abstracts: To showcase work that has been published in an-
other journal or presented at national or international confer-
ences
NB: Although articles undergo a rigorous process of peer re-
view, this journal does not hold copyright over articles. Con-
tributors are encouraged to publish their work elsewhere.
Handover is published twice yearly in May and November.
Deadlines for submissions are the second week in January
and second week in June. For author guidelines see the Nurs-
ing and Midwifery Intranet site at:
http://intranet.hne.health.nsw.gov.au/nm
Table of Contents

FEATURE ARTICLES
An Inter-disciplinary team approach to tracheostomy management in an
acute hospital facility. 4
Vicki Parker, Michelle Giles, Gai Shylan, Nicole Austin, Wendy Archer; Kelvin Smith and Jane Morison.

Pictures and Perspectives: A unique reflection on interdialytic weight gain. 10
Peter Sinclair and Vicki Parker

The lure of the bush: Do rural placements influence student nurses to
seek employment in rural settings? 16
Jackie Lea, Mary Cruickshank, Penny Paliadelis, Glenda Parmenter, Helena Sanderson and Patricia Thornberry

DISCUSSION PAPERS
An ethical dilemma, yours mine or ours? 21
Ludmilla Sneezby

A Literature Review: Nursing assessment in a Post Anaesthetic Care Unit. 25
Lee Lethbridge

Perineal trauma and childbirth: A discussion paper. 28
Christina Teale, Lyn Ebert and Carol Ann Norton

Reflective Practice and the National Continuing Competency Framework. 32
Rowena Masson and Ann Katherine Williams

CLINICAL FOCUS ARTICLES
What really happens to the siblings of the chronically ill child? 36
Dianne Cotterell

Mind Essentials – Mental Illness Nursing Resources. 37
Katie McGill

Conference Review: Advanced practice nursing in multi-cultural environments. 39
Lorna MacLellan and Pamela van der Riet

LOCAL INTEREST ARTICLES

Focus on Stewardship: Reflections by Stewardees. 41
Kelvin Smith and Iris Li

STUDENT CONTRIBUTIONS
Nurse Practitioners in the Emergency Department: A critical review of the literature. 44
Michelle McCoy

Student nurse confidence - A reflection. 48
Elizabeth Bembridge and Sarah Yeun-Sim Jeong

RESOURCE ARTICLE
Writing for publication. The basics Part 2 50
Kathleen Fahy

1
 Editorial

Stand Up and Be Counted on ideas for aligning resources to quality patient outcomes:
Articulating the challenges for nursing and midwifery

By Professor Margaret McMillan RN PhD

The presentations at a recent Hunter New England Health Service (HNEHS) forum once again highlighted the prominence
of the Area on the New South Wales Health (NSWH) map. It was a special occasion for the launch of this journal and a
celebration of local achievements and the appointment of Professor Higgins to the jointly sponsored position in Nursing
Care for the Older Adult. It provided more evidence that the region has a long history of ability to
• Compare existing practice with that of others
• Make innovation portable to other contexts
• Assume ownership in novel approaches in education and practice
• Establish authority in cutting edge research
• Maintain a leading edge in models of practice
• Acknowledge leadership initiatives.

However the forum also demonstrated the major drivers of quality and the pursuit of optimal outcomes for patients and
clients and the extent to which this necessitates maintenance of
• Partnerships between education and research and the health care industry where service is based on person centred
approaches to care
• Ways of finding the evidence of the alignment among the needs of the population, policy frameworks and nursing
practice.

In this edition of the journal nurses and midwives across the area again have promoted Evidence Based Practice (EBP) in
policy and practice through the
• Identification of key issues involved in regulation of service quality
• Case studies of models for the regulation of quality in the service sectors
• Assessment of potential new directions in health care.
The contributors to this edition represent a range of experienced and beginning nurses and midwives caring for a range of
clientele. We are reminded that the concept of educating for professional practice itself warrants careful consideration. There
is also a need to continually think through the implications of what we are advocating as professional as ‘the way forward’.
This will require further testing of our ideas. Hal Alexander (in Fitzgerald and Moor, 2008) reminds us that theory without
practice is sterile but practice without theory is blind. This begs the question: ‘What underpinning conceptual frameworks do
we rely on when we are attempting to think about alternatives to existing practice?’ Numerous ideas were expressed by
the health service personnel at the forum. Critical issues were raised by those who formally engaged in strategic thinking
and planning and issues around quality care, appropriate models of care and meaningful education and training.

On the second day of the forum, a symposium for senior staff members, an important resource within the health service,
engaged in processes through the establishment of discussion groups (senior managers, unit managers and Clinical
Consultants representing the various Area Health Services). In this forum strategic thinking was encouraged and questions
posed like ‘How could it be different?’ Some good ideas can emerge from such forums but the extent to which these ideas
are really worthwhile also needs to be tested by those who actually implement them.

Generally, contemporary government policy attempts to establish an overarching goal to align resources (human and
financial) to quality outcomes for people in health care. This means that nurses and midwives become involved in a
variety of sub-projects specifically reliant on the use of clinicians as key designers, planners, implementers and evaluators
of strategies. However the use of these ideas embedded in policy in determining the value of the outcomes for consumers
needs to be well understood with respect to the quality dimensions outlined below. In an effort to identify the views of
consumers the Picker Institute surveys have been applied in NSW in order to find out what respondents actually say about
their experiences of health care. Such feedback ought to inform new projects or other ongoing projects which can then be
completed in ways which will potentially contribute to the overall evaluation of policy goals and consumer needs.

At the forum we were reminded that health policy directives outline six dimensions of quality which are: Safety of health
care, Effectiveness of health care, Appropriateness of care, Consumer participation, Access to services and Efficiency of service provision.
As noted above each dimension can be used to compare, evaluate or facilitate redesign of any care initiative in the models
of care used by health professionals in a range of diverse health care settings. One can see from this edition of the journal
that nurses and midwives are thinking and writing more about projects that have the following as their central aims:
- Facilitation of a change in practice
- Alignment of the roles of senior clinicians and managers with expectations of what is.
When thinking about those involved in such forums I was alerted to a comment made by Robin Williams (in Fitzgerald
and Moor, 2008) who asked ‘How can you tell if the managers are any good?’ ‘What do they do, apart from meet?’ To
answer questions such as this we need to hear more from our managers and leaders in forums that showcase innovation
in thinking and action. An outcome of the HNE planning forums has often been the definition/redefinition of particular

2
professional roles and functions in an effort to promote and facilitate changes to care delivery models at the care delivery
level. Both managers and clinicians need write about their roles in the manner that Fahy suggests, if their function is to
assist other first-line clinicians and managers to align resources to positive outcomes and convey a need to redefine their
roles with respect to the ‘new breed’ of professionals’ ways of viewing the world. More importantly though, these groups
of professionals need to be able to articulate and ultimately measure what it is that they do which ‘value adds’ particularly,
but not restricted to, the quality outcomes expressed in policies informing care processes.

One can clearly see from the articles presented in this edition that the professions of nursing and midwifery have the
potential to make a difference to the provision of health care in a range of contexts. They showcase the provision of care
for either the acutely or chronically ill, including children (Lethbridge; Cotterill) and the terminally ill (Sneesby). Teale et
al provide a snapshot of midwifery experiences whilst Sinclair and Parker give us insight into some of the complexities of
working with treatment regimes for patients needing haemodialysis. Lea et al remind us of the need to attract clinicians to
work in the rural sector. Given the demographics of all the health professional groups, the diverse skill mix that McCoy and
Johnstone depict and associated distribution of responsibilities for managing and delegating care, the multi-disciplinary
teams demonstrate an enormous capacity to meet the needs of patients and clients in a range of contexts. But we all
have a responsibility to assist the next generation to build the confidence and competence that Bembridge and Jeong and
McGill describe as necessary for effective practice. Part of the latter is an ability to reflect on our practice as we traverse the
professional journey in the manner described by Masson and Williams.

Ageing workforces, trends in professional expectations and changes in practice and consumer expectations have been the
focus of numerous reports and analyses of skill mix and responses to shortages in care personnel. There has been evidence
more recently of a strong policy push to make greater use of qualified workers trained through the Vocational Education
and Training (VET) sector as assistants to professional groups and to up-skill all workers across the health services. Well
recognized examples of changing scopes of practice are the Enrolled Nurse (EN) and the Nurse Practitioner (NP) but all
professionals are witnessing a demand for change in their profiles and the introduction of specialty practice courses via
development of particular skills sets and capability profiles.

It is timely to also reflect on the implications of ageing workforces and an ageing population of recipients of care. The entire
nursing and midwifery demographic profile is different from that many of us grew up with. Entrants to the professions
are now more mature in age than they were several decades ago. We ought to be capitalizing on this maturity as well as
providing mechanisms for a younger generation to be part of the professions.

Having an older workforce can be perceived as having both positive and negative effects on care delivery. I was amused
by various recent references to the aged as seniors, experienced, distinguished or veterans or decrepit or even extinguished
(Williams in Fitzgerald and Moor, 2008). Nurses and midwives with ‘experience’ make significant contributions to planning
for social and capital redevelopment and realignment. Developments across the care services reported in this edition are
evidence of this.

Two decades ago we recognized the need for new approaches to learning which would
• Anticipate change in the world of work
• Respond to the expressed need for employees to be flexible, seek and assume responsibility for all facets of their roles
• Contribute to a sense of efficacy and efficiency in the workplace.

One needs to reflect on the extent to which we have achieved those goals. The challenges have been well documented in
numerous submissions, reports and discussion papers at regional, state and national levels for at least ten years. But there
still needs to be more creative thinking arising from consumer focused perspectives. In this edition there are numerous
ideas that deserve further exploration in practice if we are to demonstrate how to think and behave differently about our
practice.

My thoughts have centered on the health service, the personnel who generate new ideas, others who test the ideas in
practice and the challenges of practice based education suited to the real needs of consumers.

Real change is only evident over decades. On reflection what has emerged from analyses of the ever-changing health
environment is a continuing need for a workforce which is technically skilled for the jobs immediately to hand but we also
need to continue to strive for the workforce that is able to “respond creatively and confidently in any circumstances”. Have
we maintained a reliance on the behaviours consistent with managing an hierarchical workforce in a way that ensures
workers simply take orders but leave their brains (and their good ideas) in the car park (Kay, Fonda & Hayes 1992). I think
not. For me listening to the good ideas put forward in the forum and reading these papers inspired me to believe that we
can listen to consumers’ views on the kind of service they want and respond with innovative ideas for how best to align
our thinking with their needs

References
Fitzgerald, R and Moor, L Editors(2008) Growing Old Disgracefully, ABC Books, Sydney
Kay, Fonda & Hayes (1992) Growing an innovative workforce: A New Approach to Vocational Education and Training” Education+ Training, Vol 34, No 2, pp 4-10
National Health Workforce Taskforce (2008) National Health Workforce Strategic Framework, Australian Government, Canberra

3
FEATURE ARTICLE

An Inter-disciplinary Nurse-led team Approach to the

Management of Patients with a Tracheostomy in an Acute
Hospital Facility
Vicki Parker, Michelle Giles, Gai Shylan, Nicole Austin, Wendy Archer; Kelvin Smith & Jane Morison
Hunter New England Area Health Service.

Abstract

The trend towards early tracheostomy in many Intensive Care Unit (ICU) patients has led to increased numbers of pa-
tients receiving tracheostomies. Together with the push to discharge patients earlier from ICU, this poses challenges for
clinicians across disciplines and wards. Even though tracheostomy is a procedure performed across a broad range of pa-
tient groups, care of the tracheostomy is often seen as the domain of specialist clinicians in critical care and high depen-
dency areas. In the light of increasing demand for beds, it is crucial to ensure quality care is provided regardless of the
patient’s destination after leaving the ICU. This paper reports the findings of a study that evaluated an inter-disciplinary
team approach to the care of patients with a tracheostomy in non-critical care areas of a large tertiary referral hospital.
Aim: To evaluate an interdisciplinary team approach to tracheostomy management in non-critical care areas.
Method: A mixed method approach to evaluation was used involving collection and analysis of pre- and post-implemen-
tation clinical data and staff surveys, and a post-implementation focus group with team members. (For the purposes of
this paper, the terms Pre and Post will differentiate these two groups).
Results: Findings revealed a statistically significant reduction in mean length of stay (LOS) in hospital for survivors in
the Post group from 50 to 27 days (P < 0.0001). There was a statistically significant increase in the number of patients with
a tracheostomy in situ transferred to non-critical care wards in the Post group (p=0.006). The number of wards accepting
patients from ICU with tracheostomy increased from three to seven during the implementation period. There was also
an improvement in levels of knowledge about tracheostomy care and in the confidence of staff in general ward areas.
Staff also indicated a growing awareness of the team and its role.
Conclusion: Implementation of the team approach has been widely accepted across the organisation with an increasing
number of wards indicating willingness to accept patients into their ward. The team themselves report improved ef-
ficiency and communication amongst the team resulting in timely referral and better care outcomes for patients.
Key words: Tracheostomy, inter-disciplinary team, mixed method evaluation.

INTRODUCTION BACKGROUND

The increasing incidence of tracheostomy being performed
on critically ill patients is well reported in the literature and
this increase is predicated on evidence indicating that both
ventilation time and time in ICU are reduced when tracheos-
tomy is performed early (Arabi, Samir, Shirawi & Shimemira,
2004; Combes, Luyt, Nieszkowska, Trouillet, Gibert & Chas-
tre, 2007). Service and flow efficiency also result as patients
are moved out of ICU making way for other patients. Whilst
the benefits for patients and hospital efficiency are clear, little
attention has been given to how this increase has impacted
on patient care, particularly outside of ICU. Traditionally, tra-
cheostomy expertise has been considered the responsibility of
clinicians working in critical and high dependency areas, at
least in the early acute stage of hospitalisation. In such areas,
high numbers of skilled clinicians make for relatively uncom-
plicated routine care. However, increased numbers of tra-
cheostomies mean that patients will be transferred to wards
where staff may lack such expertise
This paper reports the implementation and evaluation of an
interdisciplinary nurse-led tracheostomy team approach to
the management of patients with a tracheostomy in a large
tertiary referral hospital in NSW, Australia. The team ap-
proach to management reported here draws together clini-
cians across disciplines. It applies a systematic, whole of or-
ganisation approach that ensures early notification of patients
being transferred to non-critical care wards, as well as early
assessment and co-ordinated care.
Tracheostomy is frequently performed as part of the routine
management of critically ill patients, particularly those who
are admitted to ICU with head injury or trauma requiring
long term ventilation. Tracheostomy has benefits over endo-
tracheal intubation in that it is better tolerated by patients and
allows for more effective airway clearance and communica-
tion (Griffiths, Barber, Morgan & Young, 2005). The number
of tracheostomies being performed in ICU has been increas-
ing significantly over the last five to ten years (Cox, Carson,
Holmes, Howard & Carey, 2004) and this increase is reported
consistently across countries. Benefits of early tracheostomy
reported include shorter duration of mechanical ventilation
and shorter stay in ICU (Arabi et al. 2004; Griffiths et al. 2005)
and possible improved long-term survival (Scales, Thiruchel-
vam, Kiss & Redelmeier, 2008).
Along with the clinical benefits for patient outcomes, early
tracheostomy allows for better management of limited inten-
sive care resources. Bed and staff shortages create pressure for
clinicians to discharge patients and to make beds available for
newly arriving critically ill patients. Tracheostomy provides
an opportunity to reduce sedation and move more quickly
to transfer patients from ICU to a ward (Tobin & Santamaria
2008). However, these patients are often still acutely ill and
there is a high risk for patients if care provided in non-critical
care areas is sub-optimal (Norwood, 2004).
Once discharged from ICU, patients usually progress from re-

4
liance on the tracheostomy as their airway to mouth breathing
to eventual removal of the tube. Across this trajectory, opti-
mal care is required to ensure adequate ventilation, oxygen-
ation nutrition and communication. This requires assessment
and consultation across a range of clinical expertise, including
nursing, speech pathology, physiotherapy, medicine, dietetics
and possibly social work and occupational therapy. A smaller
number of patients require long term tracheostomy and for
these patients transition to effective community-based care is
critical.
Without specialist care, patients with a tracheostomy are at
risk of possible life threatening complications. Tobin et al
(2007) examined medical emergency team calls related to
tracheostomy and found numerous calls related to hypoxia
and threatened airway. Other possible complications include
trauma related to accidental decannulation, inappropriate
tube selection and suctioning, infection resulting from poor
stoma care or poor tracheostomy management, blocked tubes
due to failure to use an inner cannula and aspiration of food
or fluid due to poor assessment and management of swallow
(Norwood, Spiers, Bailiss & Sayers, 2004).
A Team Approach to Care
The notion of teams and teamwork is central to healthcare. A
team approach to care uses a structured process that guides
the actions of two or more clinicians within the expectations
of the organisation and patients (Drinka & Clark, 2000). The
benefits of a team approach to health care delivery are well
documented across a range of illnesses and services (acute,
chronic and home) (McCallin, 2001). Team success results
from rationalisation of services, a focus on patients and pa-
tient outcomes and improved communication and referral,
together with reduced costs. Tracheostomy teams imple-
mented in hospitals in Australia and overseas have reported
beneficial outcomes (Austin Health 2006; Hunt & McGowan
2005). The team approaches that have been reported are char-
acterised by regular team meetings, enabling co-ordination of
care, and prioritisation of patient goals (Parker et al. 2007). To-
gether, the team members identify specific patient needs and
problem-solve complex cases (Dikeman & Kazandjain 2003).
Team ward rounds ensure clear communication and sharing
of information (Dikeman et al. 2003).
Optimal care of patients with a tracheostomy relies on inter-
professional communication and decision-making A fully
integrated practice by a team of professionals from diverse
backgrounds is referred to as inter-professional or interdis-
ciplinary (McCallin, 2001). An inter-disciplinary approach
to care recognises the specific and synergistic roles that dis-
cipline specialists bring to decision making and care provi-
sion. In contrast to a multi-disciplinary approach where team
members assess and treat patients independently and then
share information, inter-disciplinary practice involves a deep-
er level of collaboration where collective action and process
are emphasised (McCallin, 2001).
Most tracheostomy team approaches reported in the litera-
ture are best described as multi-disciplinary rather than inter-
disciplinary. The introduction of ICU nurse liaison roles, for
example, has focussed on discharge from ICU and follow up
for patients considered at risk. This role has been reported to
facilitate greater information sharing and better communica-
tion across nursing, allied health and medical staff for patients
with tracheostomy (Barbetti & Choate 2003).
An approach described by Tobin et al. (2008) involves an inten-
sivist-led model that oversees ward management and decan-
nulation of non-Ear Nose Throat (ENT) patients discharged
from ICU. Team members included an ICU liaison nurse,
physiotherapist, speech pathologist and dietician. Whilst this
approach has reported a decreased length of stay in ICU, de-
creased time to decannulation and improved patient safety,
it relies upon expertise drawn from the ICU rather than the
development of expertise beyond ICU, and is of questionable
value where there is increased demand for ICU beds and ICU
staff.
Another approach reported by Norwood et al (2004) describes
a physiotherapy-initiated model working in collaboration
with an ICU outreach nurse. The role of this team is to pro-
vide continuing respiratory physiotherapy, airway suction-
ing, tube cleaning, tube changing and decannulation, along
with education of the ward nursing staff. A limitation of this
approach is that is operates only within business hours and is
reliant on ICU staff for out of hours support.
Background and Context
A retrospective audit done in 2006 of John Hunter Hospital in
Newcastle, Australia (JHH) indicated that 144 patients under-
went tracheostomy over a two-year period (2004-2005). The
number of referrals of tracheostomised patients to the hospi-
tal’s Speech Pathology Department increased from 29 in 2003
to 84 in 2005. This increase highlighted the need for coordinat-
ed care across departments and disciplines, and necessitated
critical review of processes and procedures currently in place.
Management of patients needed to be revised to ensure better
patient outcomes, together with greater cost effectiveness and
time efficiency (Parker et al, 2007).
Participation in the inter-disciplinary team was invited from
all clinician stakeholders across the organization including
Medicine, Nursing and Allied Health. Together, the group
examined the available tracheostomy-related hospital data,
including incidence, LOS (in ICU and on wards), destination
from ICU, and adverse events. Gaining a complete picture of
tracheostomy numbers and related activity was hampered
by inconsistent coding and poor documentation. This high-
lighted the need for more effective data capturing processes
(Parker et al, 2007).
Prior to implementing the inter-disciplinary tracheostomy
team, patients were transferred from ICU to a ward where
there are staff known to have expertise in the care of tracheo-
stomies, rather than to the ward most appropriate for care of
their injuries or disease. For example, older patients with or-
thopaedic trauma and no head injury may be transferred to
the neurosurgical unit. Higher admission rates and demand
for ICU and high dependency beds has resulted in increased
numbers of patients with tracheostomies in ward areas. This
increase has resulted in lack of continuity of care and possibly
an increase in adverse events. The need for a shift to inter-
disciplinary team practice was identified.
Design and Development of the Team and its Processes.
The approach brought together clinical nurse consultants,
a physiotherapist, a speech pathologist, a dietician, a social
worker and medical officers. Intensive Care Unit (ICU) and
Respiratory specialists provide a consultative service as re-
quired. The team met weekly to conduct ward rounds and
consult on every inpatient with a tracheostomy on the wards,
and those from ICU referred by ICU medical staff. The tracheo-
5
stomy team fed back to the treating team advice regarding tra-
cheostomy care and progress. At the point of discharge from
ICU the patient’s details were entered on to a customised da-
tabase and made available to all members of the team, which
overcame delays in referral and treatment (Figure 1).
Key features of the team approach include:
 a coordinated and collaborative approach to patient care
 an automated mechanism for alerting team members of
the presence and status of patients with a tracheostomy in
the hospital
 development of a central data repository and collation
system
 efficient sharing of patient information
 development and implementation of standardised guide-
lines
 ongoing review of practice guidelines
 provision of educational support to staff, patients and
families
 application of evidence to practice.
Figure 1. The referral and consultation process
Data Collection
Clinical and patient destination data were collected via a
purpose-built database. Whilst much of the information could
be retrieved from existing databases, data were inconsistent
with some data thought to be unavailable or missing. Even the
presence of a tracheostomy had not been captured. Clinical
data were collected on those patients identified as having a
tracheostomy during their admission in the six-month period
prior to the implementation of the inter-disciplinary team,
from December 2006 to May 2007, and from July 2007 to
January 2008 in the post-implementation period.
A twelve-item survey requiring multiple choice and short an-
swers was distributed one month before (May 2007) and six
months after (January 2008) implementation of the inter-dis-
ciplinary team approach to tracheostomy care. Five hundred
surveys were distributed across all wards.
6
EVALUATION
Aim of the Study
The aim of the study was to evaluate the effectiveness of an in-
ter-disciplinary team approach to tracheostomy management
in a large tertiary referral hospital. In particular it addressed
the following questions:
n
Has the inter-disciplinary approach resulted in
increased dispersion of patients with a tracheostomy across
the hospital?
n
decreased length of stay (LOS) in ICU and in hospital?
n
improved patient safety?
n
increased staff knowledge and confidence in relation to care
of patients with tracheostomies?
Method
A mixed method stakeholder approach was used, involving
sequential collection of data from triangulated sources.
Mixed method inquiry involves the use of multiple and
diverse methods for gathering, analysing and representing
phenomena (Greene, 2005). This approach is gaining increasing
attention because of its potential to capture and combine both
quantitative and qualitative perspectives.
(Parker et al. 2007)
A single focus group was conducted with team members at
the end of the six-month implementation period.
Ethics
Hunter New England Health Ethics committee permission
was granted to undertake the survey and focus group.
Data Analysis
Clinical audit data were analysed to provide a statistical de-
scription of relevant patient characteristics including:
admission classification
n
LOS in ICU and hospital
n
destination on discharge from ICU
n
tracheostomy-related adverse events
n
other tracheostomy details.
n
Pre and Post implementation data were compared for signifi- 5 patients required both a percutaneous and a surgical tra-
cant differences. Descriptive and inferential analysis were uti- cheostomy insertion and one patient required a percutaneous
lised to identify changes in staff views and experiences rated and two surgical insertions.
in the surveys. Qualitative data were analysed using an itera-
tive process of thematic analysis designed to elicit key issues Indications for tracheostomy being performed were categor-
and experiences consistent across participant contributions. ised into two groups:
weaning ventilation;
n

RESULTS airway management post-operatively .

n

Details are outlined in Table 1.

The introduction of the team approach has resulted in signifi-
cant benefits for both patients and staff. Transfer from ICU to Non-Critical Care Wards

Demographic Data There was a significant increase in the number of patients with a
tracheostomy in situ transferred to non-critical care wards in the
There were 41 adult patients identified from hospital infor- Post group. In both groups there were three patients who died in
mation systems who had a tracheostomy performed in the ICU, and 39 patients had their tracheostomy tube removed prior
six-month pre-implementation period. In the post-implemen- to discharge from ICU, High Dependency Unit (HDU) or Acute
tation group there were 75 adult patients. Groups are referred Care Unit (ACU). A total of 74 patients were discharged to non-
to as Pre and Post for the purposes of this report. critical care wards with a tracheostomy in situ. In the Pre group
19 (47.5%) patients were discharged to wards with a tracheos-
Table
Table1:1:
Patient details
Patient details tomy compared with 56 (75%) in the Post group (P=0.0056).
Pre (n 41) Post (n75) In the Post group patients were discharged
to wards more appropriate to care for them
Gender n % % according to their main diagnosis rather than
Male 31 76 53 71 for care of their tracheostomy. In the Pre
Female 10 24 22 29 group there were only three non-critical care
destination wards identified where all pa-
Age
tients with tracheostomies were transferred
Mean 57 56 to from ICU, HDU or ACU. This is compared
Median 53 59 to seven destination wards in the Post group.
In the Post group one patient was transferred
Range 18 - 85 19 - 95
to the Coronary Care Unit with a tracheos-
Specialty Classification n n tomy in situ and this is the first tracheostomy
Cardiothoracic 1 2 the staff in CCU had cared for in that unit.
Cardiovascular 1 2
Length of Stay (LOS)
ENT 15 37% 24 32%
Gastroenterology 3 6 A review of literature indicates a definite re-
Neurology 2 5% 9 12%
lationship exists between shorter length of
stay (LOS) in ICU and the implementation of
Neurosurgical 12 29% 16 21% a team approach to care as well as a possible
Respiratory 2 6 relationship with a shorter LOS in hospital
Sepsis 1 (Hunt & McGowan 2005). It was also hoped
that transfer to peripheral hospitals would
Trauma (Orthopaedic) 1 6
be expedited because of better education and
Trauma (Neurology) 1 support available through the tracheostomy
Trauma (other) 3 team. However in the findings of this study
there was no significant difference in LOS in
Other (Renal & Sepsis) 1 2
ICU/HDU/ACU between the two groups.
Tracheostomy Details No. Mean Median No. Mean Median
Number of tracheostomy 42 78 LOS was calculated on patients discharged
insertions.
either to home, to a peripheral hospital or to
Days tracheostomy in situ 13 7 20 12.5
a rehabilitation unit. In the Post group the
Surg Perc Other Surg Perc Other
Type of Tracheostomy 22 19 1 38 35 5
mean LOS was 30 days with a median of 23
Indication for Wean Airway Wean Airway days, which was lower than the Pre group
tracheostomy vent Post Op vent Post Op mean of 34 and median of 25 days but was
21 20 46 27 not statistically significant (p=0.85).
Both patient groups were similar in age and gender as out-
lined in Table
Transfer 1. Patients’
from ICU primary
to Non-Critical diagnoses
Care Wards were grouped This study also analysed a larger dataset outside the six-month
under specialty with the most common specialties relating to Pre and Post study period, on the basis that larger numbers
may show a greater difference. Seventy-one tracheostomy pa-
ear, nose and throat (ENT) surgery, and neurosurgery in both
tients were
There was a significant increase in the number of patients with a tracheostomy identified with LOS data available in the period
in situ
groups (Table 1) from 2005 to 2006. This was compared to 67 tracheostomy
transferred to non-critical care wards in the Post group. In both groups there were
patients where complete LOS data were available in the 12-
All tracheostomies
three performed
patients who died in ICU, in
andboth groups had
39 patients weretheir
temporary.
tracheostomy tube period since the implementation of the tracheostomy
month
Information on length of time the tracheostomy remained in team approach.
situ was available on 83 patients and is summarised in Table
1. There were 120 tracheostomy tubes inserted in both groups, Results indicted that in this extended group (p<0.0001) mean
12
7
LOS decreased significantly from 50 days in the Pre group to
27 days in the Post group and median LOS from 32 (Pre) to 19
days (Post).
Tracheostomy-related Adverse Events
This study could not demonstrate a statistically significant re-
duction in adverse events resulting from the implementation
of the team approach. There were 44 tracheostomy-related
adverse events recorded on a total of 24 patients in the both
groups in the non-critical care wards. These events were cat-
egorised into 4 groups:
 accidental decannulation
 blockage
 infection
 “other” which included neck swelling and haematoma
which compromised the airway, as well as faulty tubes
and incorrect tube size.
In the Pre group 16 adverse events were recorded for 6 pa-
tients (32%) from the total group of 19 who were transferred
from ICU with a tracheostomy in situ. In the Post group 18
patients (24%) had a total of 28 adverse events recorded.
Although this study demonstrated a decrease in the readmis-
sion rate to ICU of patients with a tracheostomy in situ be-
tween the two groups, from 16% (n=3) in the Pre group to
7% (n=4) in the Post group, this decrease was not statistically
significant (P=0.079).
Successful Cuff Deflation
Tracheostomy cuff deflation details were available on only 22
patients in the Pre group and 82% of first cuff deflation at-
tempts were successful. Since the implementation of the tra-
cheostomy team, data on decannulation have been collected
on 78 patients and in this Post group 88% of cuff deflations
have been successful on the first attempt.
Time to Initial Assessment by Team
Data were recorded on the time frame between when the team
was notified of a referral ,to when the patient was seen by
the team. The mean time in days was two with a median of
one day. The median length of time the team consulted on
patient care was eight days but ranged from one to 108 days.
These results are closely related to the time the tracheostomy
remained in situ as it is routine for the team to discontinue
consultation 24 hours after successful decannulation. Anec-
dotal evidence as reported by the team members indicates
a considerable improvement in the timeliness of notification
and referral when patients with a tracheostomy are trans-
ferred to the ward. Prior to the team’s existence the Clinical
Nurse Consultant may not have been notified of a ward-based
tracheostomy patient until the time of decannulation.
Survey Findings
Key elements reviewed by the Pre and Post implementation
staff survey included knowledge, confidence in caring for a
patient with a tracheostomy and awareness of the team and
its role. There were 103 Pre surveys and 102 Post surveys re-
turned.
Survey participants in both groups were similar in position
classification, age and years of experience. There was evi-
8
dence of improved knowledge in policies, procedures and
practices related to tracheostomy care in the Post survey with
fewer participants reporting minimal knowledge and a larger
number reporting extensive knowledge. There was a decrease
in the minimal knowledge responses from 33% in the Pre sur-
vey results to 16% in the post survey results and an increase in
the extensive knowledge responses from 4% to 12%.
Respondents reported increased confidence, with a larger
number indicating that they felt independently confident to
care for patients with tracheostomies. In the Pre group 50%
were confident with support and only 33% were indepen-
dently confident. In the post survey group only 39% were con-
fident with support and 42 % were independently confident.
There was an obvious improvement in the awareness of the
work of the team and its role. In the Pre survey group 40%
said they had been informed of the implementation of the tra-
cheostomy team, and in the Post survey 71% of respondents
had now had contact with the team, and the majority of this
contact has been through the ENT CNC (71%), Speech thera-
pist (43%) and physiotherapist (33%) in the team.
When asked if the implementation of the tracheostomy team
has improved care for patients with tracheostomy: 57% of re-
spondents said yes, 41% said they were unsure and only 2%
said no.
Similar views were expressed in response to the question
about communication across wards and staff in relation to
care of patients with tracheostomy: 57% believed communica-
tion had improved and 41% were unsure. Half of all respon-
dents in the Post survey reported that they have accessed and
engaged the tracheostomy team, mainly for education and
consultation.
The written comments from the survey were very encourag-
ing and reflected that the tracheostomy team had ‘streamlined
tracheostomy care’ and is viewed as a ‘very beneficial initia-
tive’ because it has provided ‘education’, is ‘very accessible’, is
‘very helpful and supportive’. This appears to have ‘decreased
pressure on ward staff’ who now feel ‘more confident’ when
caring for patients with a tracheostomy. They feel they can
now contact ‘experts’ directly if they need further education.
Team Reflections
A common theme in the team focus group was improved
inter-professional communication and relationships and they
believe that the team’s existence has broken down profession-
al barriers and silos of practice. The team approach to ward
rounds saves time as the team discusses each patient in detail
together rather than each individual team member having to
find out information separately. This eliminates the need for
clinicians to chase up individual discipline specialists about
care management and concerns. The team believe that conti-
nuity of care has improved and there is consistency in deci-
sion-making around issues relating to tracheostomy care. The
team suggested that, in their previous experience of an ad hoc
approach to communication and co-ordination, they are now
more aware of each other’s roles and contributions and can
work to complement each other’s inputs. They expressed the
view that the team approach has led to greater patient comfort
and improved standards of care.
They believe that the team is accepted and its value acknowl-
edged across the organisation. Some commented that they felt
their professional profiles and that of their discipline were en-
hanced as a result of their participation in the team and in the
implementation project. They also reported feeling respected
and valued by other team members.
DISCUSSION
The benefits of the interdisciplinary tracheostomy team ap-
proach have been clearly demonstrated. Improved staff
knowledge, confidence and awareness have been reported,
together with patient-centred improvements such as shorter
time to review and shorter length of stay in hospital.
Organisational benefits arising from the team approach in-
clude rationalisation of resources and reduction in duplica-
tion of services. Greater numbers of patients are being dis-
charged from ICU to general care wards with a tracheostomy
in situ and this has freed up scarce resources and improved
bed access.
Equally, a shift has occurred from reliance on ICU expertise
to support ward staff towards using the team members. The
increased satisfaction and professional collegiality reported
amongst the team members highlight the significant work sat-
isfaction resulting from effective team practice and processes.
Whilst the evaluation was able to demonstrate some efficien-
cies, more research is needed to identify whether or not re-
ductions in tracheostomy related Medical Emergency Team
(MET) calls will occur. Further, better understanding of the
impact on patients’ experiences and satisfaction with the team
approach needs to be achieved.
References
Arabi Y, Samir H, Shirawi N & Shimemira A (2004) Early tracheostomy in intensive
care trauma patients improves resource utilisation: a cohort study and
literature review. In Critical Care, pp. R347-352.
Austin Health TaRMS (2006) A Guide to the creation of Site Specific Tracheostomy
Procedures and Education, Heidelberg,.
Barbetti J, & Choate K (2003): Intensive care liason nurse service. Implementation at
a major metropolitan hospital. Australian Critical Care 16, 46-52.
Combes A, Luyt C, Nieszkowska A, Trouillet J, Gibert C & Chastre J (2007): Is tra-
cheostomy associated with better outcomes for patients requiring long-
term mechanical ventilation? Critical Care Medicine 35, 802-807.
Cox C, Carson S, Holmes G, Howard N & Carey T (2004): Increase in tracheostomy
for prolonged mechanical ventilation in North Carolina, 1993-2002. Crit-
ical Care Medicine 32, 2219-2226.
Dikeman K & Kazandjain M (2003) Communication and swallowing management of tra-
chesotomised and ventilator dependant adults, 2nd edn. Thomson Learning,
California.
Drinka T & Clark P (2000) Health Care Teamwork. Auburn House, Wesport.
Griffiths J, Barber V, Morgan L & Young J (2005) Systematic Review and meta-analy-
sis of studies of the timing of tracheostomy in adult patients undergoing
artifical ventilation. In BMJ.
Hunt K & McGowan S (2005): Tracheostomy management in neurosciences: A sys-
tematic, multidisciplinary approach. British Journal of Neuroscience Nurs-
ing 1, 122-125.
McCallin A (2001): Interdisciplinary practice -a matter of teamwork. An integrated
literature review. Journal of Clinical Nursing 10, 419-428.
Norwood M, Spiers P, Bailiss J & Sayers R (2004): Evaluation of the role of a spe-
cialist tracheostomy service. From critical care to outreach and beyond.
Postgrad Medicine 80, 478-480.
Parker V, Shylan G, Archer W, McMullen P, Smith K, Giles M, Morrison J & Austin
N (2007): Trends and Challenges in the Management of Tracheostomy in
Older People. Contemporary Nurse. Advances in Contemporary Aged Care:
Retirement to End of Life Contemporary Nurse 26 177-183.
Scales D, Thiruchelvam D, Kiss A & Redelmeier D (2008): The effect of tracheos-
tomy timing during critical illness on long-term survival. Critical Care
Medicine 36.
Tobin A & Santamaria J (2008) An intensivist-led tracheostomy review team is asso-
ciated with shorter decannulation time and length of stay: a prospective
cohort study. In Critical Care, p. R48.

One significant finding of this study is the notable increase

in the number of destination wards which now receive tra-
cheostomy patients transferred from ICU. It is anticipated this
will increase in future as the team becomes more established
and education continues. This can only benefit patients who
will be transferred to wards more appropriate to care for their
injury or major diagnosis, rather than their destination being
decided by the need for tracheostomy expertise.
The formation of the team has led to significant outcomes for
those involved in the planning phase of the project and for
the care they provide. Extensive review of the literature has
informed the development of evidence-based guidelines and
education programmes. Team members have successfully ap-
plied for grant funding to support the project and have pre-
sented their work at conferences.

CONCLUSION

This study’s findings support previous studies that have iden-

tified the benefits of a multi-disciplinary or inter-disciplinary
approach to tracheostomy management (Austin Health 2006,
Hunt & McGowan 2005). The results demonstrate that the
team approach leads to greater awareness of the needs of
patients with a tracheostomy and improved education and
participation of staff across the whole service. The team’s suc-
cess is contingent on effective communication, early notifica-
tion and monitoring strategies, together with regular review
rounds. This study’s outcomes indicate the importance of a
team approach for co-ordinated care and the ability to trans-
fer patients to wards that have traditionally not accepted pa-
tients with a tracheostomy. This model has transferability and
applicability to other groups within acute care settings. The
collegial and synergistic involvement of members from the
various disciplines bodes well for future projects that involve
inter-disciplinary practice and communication.

9
FEATURE ARTICLE

Pictures and Perspectives - A Unique Reflection on

Interdialytic Weight Gain
Peter Sinclair, Clinical Nurse Educator Nephrology Services, RN, Master’s candidate
Hunter New England Health

Vicki Parker, RN, PhD, Clinical Nurse Consultant Research and Practice Development
Hunter New England Health

Abstract

Background: People undergoing haemodialysis are required to follow a complex treatment regime that includes dietary
and fluid restrictions. Of these restrictions, interdialytic weight gain is often used as a marker for measuring adherence.
Historically, research into interdialytic weight gain has focussed on interventions devised by clinicians and utilised
quantitative methodologies with little consideration being given to how these people deal with fluid restrictions.
Aim: The purpose of this study is to examine perspectives of managing interdialytic weight gain and describe the mean-
ing of fluid restriction for people on haemodialysis.
Method: This research used a qualitative study that involved in-depth interviews to elicit patients’ stories. Participants
were invited to use images to support their story telling. Data were analysed using an iterative theming process.
Results: Themes that arose from preliminary data analysis include magnitude of loss, constant struggle and transition
to acceptance. Transition to acceptance is not a linear progression to understanding and compliance but a multifaceted,
tortuous struggle unique to individuals and largely dependant upon support, belief in a life worth living and willing-
ness to engage in surveillance and maintenance behaviour.
Conclusion: Appreciating the impact and meaning of fluid restriction for people on haemodialysis will assist health
professionals to identify support strategies that facilitate healthy fluid gain behaviours.

INTRODUCTION multifaceted and often evolving treatment regime that in-

Chronic illness that disrupts or causes the loss of bodily func-
tions encroaches on a person’s understanding of self. It is often
characterised by adjustment to new forms of knowledge, high
levels of uncertainty (Mishel, 1990) and challenges to a per-
son’s understanding of their own identity (Seymour, 1989).
Turner (1996, p.220) suggested that “disease which entails a
loss of self is the most proximate and universal form of human
estrangement”. Chronic illness requires individuals to revise
their sense of self and their relation to the world (Seymour,
1989). The individual uses this process to find meaning in the
transformation from their old self to their new self.
The progression from chronic kidney disease to end stage kid-
ney disease (ESKD) requires the individual to make profound
adjustments to their accepted way of living (Curtin, Mapes,
Petillo, & Oberly, 2002). In order to support people living with
ESKD it is imperative to understand the personal meaning of
disruption and the nature of their experience living with renal
disease. Unfortunately, nursing staff tend to make assump-
tions about understanding the life experiences of those they
care for (Molzahn, Northcott, & Dossetor, 1997).
This paper describes the meaning of fluid restriction and the
perspectives involved in managing Interdialytic Weight Gain
(IDWG) for a small group of people undergoing haemodialy-
sis in a regional dialysis unit. The motivation for this research
was to provide a voice for those who undertake haemodialysis
so that clinicians caring for them will be able to comprehend,
not assume they understand the disruption that managing
IDWG causes to these peoples’ lives.
BACKGROUND
People undergoing haemodialysis are required to follow a
cludes dietary and fluid restrictions that are complex and
often difficult to comprehend. Fluid restriction is suggested
to be the most difficult component of self management for
people with ESKD (Johnstone & Halshaw, 2003; Sharp, Wild,
& Gumley, 2005).
IDWG is influenced by many factors including environmen-
tal, nutritional, behavioural, biological and psychological
(Hwang, Wang, & Chien, 2007; Sarkar, Kotanko, & Levin,
2006). The consequences of high IDWG and associated chron-
ic fluid overload include intradialytic cramping and hypoten-
sive episodes, left ventricular hypertrophy and congestive
heart failure, hypertension, acute pulmonary oedema, and in-
creased mortality (Leggat, 2005; Movilli, Gaggia, Zubani, et al.
2007; Oldenburg, Macdonald, & Perkins, 1988; Saran, Bragg-
Gresham, Rayner, et al. 2003). These co-morbid burdens fur-
ther erode the quality of life for people on haemodialysis.
Much of the attention to IDWG in the renal literature is fo-
cused on predictors of non-adherence, managing the intra-
dialytic consequences of excessive IDWG or interventions
to decrease IDWG. The majority of research has focused on
interventions devised by clinicians to decrease IDWG. This
reflects a positivist approach to health management and re-
search which discounts people’s perspectives or experiences.
Health professionals do not have exclusive ownership over
ideas about health and disease (Seymour, 1989). In fact, in-
terventions devised by clinicians to improve health outcomes
may have less impact because patients do not identify such
measures to be related to their own perceptions of their expe-
rience (Casey, Johnson, & McClelland, 2002; Seymour, 1989).
Although a number of qualitative studies have examined the
experience of living with ESKD (Curtin et al. 2002; Faber, 2000;
Hagren Pettersen, Severinsson, et al. 2001; Hagren, Pettersen,
Severinsson, et al. 2005; Lindqvist, Carlsson, & Sjoden, 2000;

10
Polaschek, 2003a; Polaschek, 2003b; Rittman, Northsea, Hau- Questioning style was congruent with the aim of the study
sauer, et al. 1993), little attention has been given to research- and consisted of a series of broad, open ended, exploratory
ing the experience of the person undertaking haemodialysis questions as well as probing questions to further explore or
in managing IDWG. clarify points that were raised throughout the interview.

Adherence to fluid restrictions necessitates a heterogeneous
array of adaptations to entrenched behaviours and health be-
liefs (Kaveh & Kimmel, 2001). Behavioural based adherence is
a multidimensional phenomenon influenced by health beliefs
and attitudes, patient-health provider relationships, knowl-
edge base, social support structures, coping skills and rela-
tionships, self efficacy, locus of control, and satisfaction with
factors influenced by the treatment regime (Brown & Fitzpat-
rick, 1988; Cameron, 1996; Lindberg, Wikström, & Lindberg,
2007; Mok & Tam, 2001).
METHOD
Research Question
What is the experience of managing interdialytic weight gain
(IDWG) for people on haemodialysis?
Design
This study utilised a mixed method design incorporating qual-
itative and quantitative data. The qualitative phase reported
here aimed to identify themes, patterns and behaviours that
characterise the meaning attached to people’s experiences of
managing their fluid weight between dialysis sessions. Ap-
proval was gained from the Hunter Area Human Research
Ethics Committee prior to commencing the study. Informed
consent was obtained from the participants prior to them be-
ing interviewed. Participants were asked to bring an artifact
(eg: photograph, montage, or statue) to the interview that
they felt would further assist the researcher in understanding
their experiences.
Each interview commenced with the question Can you tell me
what it is like to deal with fluid restrictions as part of your day to day
life? If the participant brought an artifact to the interview, the
following question was asked at an appropriate time during
the interview Please explain the meaning behind the artifact that
you brought along today in terms of your experience with managing
fluid gain?
Data Analysis
Interviews were analysed using an iterative process of read-
ing, coding and interpreting to identify themes that described
shared and divergent experiences, strategies/behaviours
and barriers to effective management of IDWG. Preliminary
themes that emerged were tested by identifying examples
across interviews to ensure that themes were well grounded
and representative of all stories.
Findings
Themes emerging from preliminary data analysis included
magnitude of loss, constant struggle and transition to accep-
tance. Participants experienced each of these themes in vary-
ing degrees and at varying stages of their illness trajectory.
Nine associated sub-themes (see Figure 1) were also identi-
fied which were found to be inextricably linked. Due to the
volume of data generated only the superordinate themes will
be considered.

Participants were drawn from a population of 70 community

satellite haemodialysis patients. Eligible participants were
classified as adults over 18 years of age who undergo com-
munity based haemodialysis; who were able to provide in-
formed consent; and who speak English well enough to be
able to share their experiences without difficulty. Potential
participants were excluded from the study if previous diag-
noses indicated impaired mental capacity. Eleven participants
were excluded from the initial randomisation: five because
they did not speak fluent English; two due to diagnosed cog-
nitive impairment. An additional four participants were ex-
cluded because they had been on haemodialysis for less than
four weeks.

Seven participants, six of whom were female, were randomly
selected by choosing every third person on the eligibility list.
Their ages ranged from 39-82 years old with a mean age of
65.6 years (SD ±15.9). Their average length of time on hae-
modialysis was 2 ½ years (range: ten months to six years, SD
± one year and eight months), with two patients previously
having had renal transplants. The mean IDWG was 1.16kg
(range: 0.15 - 2.1kg, SD ±0.77) with three patients having a
mean monthly IDWG >1.6kg.
Data Collection
In-depth interviews of up to one hour duration were con-
ducted by a single researcher in order to maintain interview
style, consistency and to avoid potential data collection bias.
Figure 1: Summary of results with three superordinate
themes and nine sub-themes
Constant Struggle
All participants identified that their experience with manag-
ing IDWG, whether they successfully managed it or not, was
a constant struggle. Metaphors using ‘battle’ terminology
were used consistently by the majority of participants when
explaining their tortuous struggle. The ‘battle’ is not physical,
rather it is an existential struggle with the desires of self and
the realities of living with fluid restriction. The ‘battle’ meta-
phor was reflected by a wide range of expressions including:
‘occasional win’, ‘it beats me’, ‘it’s a constant battle’, ‘fighting na-
ture’ and ‘I was really fighting it’.

11
Participant 2, an 82 year old male highlighted his challenge in
the present tense and described his personal experience using
a ‘battle’ metaphor. The nature of explaining both the struggle
and his transition to acceptance were highlighted by his use of
present and past tense to describe the experience:
Very trying, very trying. I do my best but I don’t manage very
well…I’m getting used to it… I have the occasional win, it beats
me more than I’d like it to… It’s a constant battle.
Participant 3, a 55 year old female, highlighted the unnatu-
ralness of the struggle. Fighting nature is like fighting against
yourself and it takes strength:
the artifact was not solely used to identify loss, it was also
used to describe her constant struggle:
I think it was sort of the loss of freedom and I think during that
early stage of my dialysis I would have been what you might
classify as ‘tense’. I lost some of my buoyancy and I tie all that
up with freedom and perhaps in the early stages I didn’t want to
talk about it very much and as far as the ‘tied up’ business goes
it was sort of, it goes with the word ‘restricted’. I was restricted
and symbolically that would have been I was tied with a rope.

… it’s like fighting nature all the time because you want to drink
all the time. You have to have a really strong will to do that… I
get to the stage where I fantasise about it…

Participant 1, an 80 year old female described her early ex-

periences with managing IDWG and the emergent symbolic
theme of her struggle with unwanted restraint:

I felt as if I was tied up. You know I wasn’t as free and I was
being brought in and tied up with the restrictions that I had to
undergo.

Participant 3 designed a montage (see Artifact 1) to describe

the paradox she experiences ‘almost all the time’:

I was thinking this guy, a man in the desert crawling along
with his tongue hanging out. That’s how I feel, almost all of the
time… You know not only do I feel like that but I’m doing this
fantasising about drinks. And if I go into a shop and see those
big walls of fridges with drinks in it. It’s really embarrassing I
just sit there waiting to be served and I just look at it all and I
think, you know, to me that’s just like heaven. And um, that’s
the story of my obsession about fluids.
Artifact 2: Participant 1
Participant 1 elaborated on the impact fluid restriction has
had on her:
I think a loss of independence and a loss of just that ordinary
bodily function is a big thing…I’ve had to say good bye to that
and good bye to that, good bye to taking as much fluid as I want
to, good bye to participating in my community activities as
much as I would like to, good bye to the community that I’m not
living in with anyone else.

Participant 4, a 69 year old female described her experience

of loss using a distinctly Australian landmark and a story of a
family holiday to the Northern Territory (see artifacts 3 and 4):

Ayres Rock it’s nine kilometres around, we walked and I remem-

ber how thirsty we were…what you’d done socially before fluid
restriction you can’t do now… you know and our happy hour,
well we really looked forward to our happy hour when we pulled
into a caravan park and that defines it more than anything, the
Artifact 1: Participant 3 things that you can’t do… those days are over… those social
days have gone.
The narrative informing artifact 1 illustrates clearly the
struggle participants endure: the dichotomy between the
‘thirsty’ man in the desert and the mirage of desired fluid.
The struggle between wanting to the point of obsession and
knowing that surveillance and maintenance behaviours are
required in order to maintain well being.

Magnitude of Loss

Loss was consistently associated with loss of function and

loss of social interaction as a consequence of having to man-
age IDWG.
Throughout the interview participant 1 frequently used words
including: tied up, bound, restricted and tied with a rope to il-
lustrate her experience with adjusting to life with fluid restric-
tion. She used artifact 2 to describe that experience, however Artifact 3: Participant 4

12

Artifact 4: Participant 4
Participant 3 also described the experience of social restric-
tion:
…it’s frustration…socially limiting. If I go to a party I’m an
absolute party pooper because I suck ice all night.
Participant 5, a 57 year old female also alluded to social loss.
However, as with all participants a relationship between
living through the struggle and dealing with the weight of
loss was clearly evident. Participants identified an existential
struggle related to their loss that required them to redefine
their identity particularly within social contexts:
It’s like when we go out with our friends on their boat sometimes
and everybody is just socially drinking and I sit there and I can’t
do that and it’s warm and it’s lovely, and you feel like doing it,
but you can’t, and yeah, I suppose it’s a feeling that you’ve done
that always in your life. Everyone told you that drinking lots of
water was really good for you and suddenly everybody’s telling
you you’re not allowed to do that…
Participant 5 further described:
I feel cross being where I am at. Because I can’t live my normal
life like I used to. I can’t just drink whatever I want to drink
whenever I want to drink it … we weren’t massively social, but
we did sort of go out quite a bit and that sort of thing… you just
know that you can’t do that like you used to…It’s not only how
much, it’s what you can have. I really loved soups and casseroles
and wet food, what I would call wet food… I enjoy wet food and
I can’t have wet food.
Transition to Acceptance
Transition to acceptance was not identified as a linear pro-
gression to understanding and adherence but a multifaceted,
tortuous struggle unique to each participant. It consisted of
three dependent sub-themes: support, consequence and a be-
lief in a life worth living.
Participant 1, who successfully manages her IDWG, reflected
on her transition to acceptance:
I was really fighting it, but I couldn’t release myself from what
was binding me. I couldn’t say, ‘well I’ll just get rid of those
ropes or whatever, no this is going to be how it is, but you’re
going to have to release yourself from that, otherwise you’re go-
ing to go down a negative path’, and so I did release myself from
that and become more free and I don’t think about that now very
much…I said to myself, ‘It’s either accept it and go along with
it or accept the result of not co-operating with the dialysis busi-
ness’ and I came to an acceptance…I mean negative things can
bind you, that’s what the negativity that was binding me and
making me less free and I think it was more or less by ponder-
ing about it and trying to find a way out of this restriction and
it was to let go and just go with what was happening to me and
enjoying the support and friendship I was getting and living as
normally as I could.
Participant 1 concluded with reference to the symbolism of
artifact 2 that her acceptance had released the bonds of fluid
restriction:
There’s less, the rope is down there much more…Now that I’ve
released myself from some of those shackles, the word is ‘accep-
tance’ of the reality of what my life is now. It’s changed from
what it was and I say in the journey situation, I’m walking a
different road but I still have some of these things from the other
life there too to help me.
Participant 2, who admitted continuing to struggle in man-
aging IDWG, realises his transition to acceptance is not
complete. He acknowledges that he is on the right track but
that the psychological challenge continues as he attempts to
successfully manage his day to day fluid maintenance activi-
ties:
…the challenge is in the mind. That one has to realize that that’s
it and that’s part of it you know. You’ve got to realize that you’ve
got this and be practical about it but if, first of all you’ve got to
have it sorted out in your mind what you’ve got to do and try to
impose that onto your physical state.
The transition to acceptance was also influenced by perceived
consequences of failure to adhere to fluid restrictions and not
maintaining adequate IDWG. Participant 3 elaborated:
I’ve worked out what I can and can’t do in certain stages of the
dialysis cycle. So I just work around that.
She said that her motivations were influenced partly by con-
sequences:
Long term the heart thing. Short term if I’m over my dry weight
when I come to dialysis and I have to take off a lot I cramp really
badly and it makes it very unpleasant and its easier just to keep
your weight down a bit and have a reasonable dialysis where you
don’t cramp.
Personal belief that life was worth living for various motiva-
tions was also evident. Participant 2 suggested:
I accept it as part of the deal, it is part of living longer and if I
don’t, if I don’t do it, well obviously it’s going to be detrimental
to myself and my family.
Participant 4, who had struggled with all aspects of her treat-
ment regime identified that despite the continued pressures
that it placed on her life she has come to accept it. Her ratio-
nale for acceptance is multifaceted, it is about doing the ‘right
thing’ in addition to goals that she still wants to achieve. In
particular she wants to see her great grandchildren. At the
time of the interview she had just become a grandmother for
the first time:
…I have accepted this as part and parcel of my life so the fluid is
yeah, I think about it a lot but it’s, I accept it. It was a big deal,
but it’s not a big deal now. I’m handling it…I want to be there
a bit longer for my girls, my grandkids, my great grandkids…
with the fluid restriction I think if I’m going to come here four
hours, three times a week and go home and drink what I want,
eat what I want then it’s a complete waste of time., I’m wasting
13
 the nurses’ time, I’m wasting the doctors’ time and I’m wasting
my time, so while I’m on dialysis I try to do the right thing.
Participant 6, a 39 year old female asserted her reason for
maintaining adequate IDWG is because:
… I want to live longer, yeah. I’m too young, like I’m too young
to go now. I don’t want to go now, like yeah.
DISCUSSION
The aim of this study was to describe the meaning of fluid
restriction and perspectives of managing interdialytic weight
gain for people on haemodialysis. As clinicians, our express
focus should be on people as they identify themselves, not as
medical entities; the meaning of their experiences for them-
selves, not as clinical subjects (Seymour, 1989). Therefore it
stands that we can more deeply understand our patients’ ex-
periences by examining their experiences of their bodies and
how they interpret and make sense of their own bodily dis-
turbances, in this case the loss of the ability to drink what ever
they want!
The use of artifacts afforded a descriptive mechanism for par-
ticipants to reflect on their experiences with managing IDWG.
The addition of this data collection method was chosen to
augment participants’ stories and acknowledges the often in-
effable nature of understanding peoples’ illness experiences.
It serves as a powerful medium to assist clinicians in better
appreciating the impact that managing IDWG has on these
people’s lives. Images can capture an essence or fundamental
characteristic of human experience that is not easily expressed
in words. Visual images are remembered and have immense
power to dictate a narrative that informs, educates and per-
suades others (Lester, 2006). Affording participants the oppor-
tunity to share their experience in this way we circumvented
the natural tendency of clinicians to assume that they ‘know’
what the patient needs. The power of the narrative behind the
artifacts assists in addressing the disparity of understanding
that exists between clinicians and patients.
This study considered a specific aspect of managing ESKD,
namely managing IDWG. The themes that emerged are con-
sistent with studies that have described the broader experi-
ence of living with ESKD. Curtin and Mapes (2001) identi-
fied that vigilant oversight of care was one of the common
characteristics of long term dialysis survivors. Our findings
were consistent with this theme. We found that regardless of
the degree of loss identified by participants, surveillance and
maintenance behaviours supported their transition to accep-
tance of healthy fluid gain behaviours.
This study’s findings also further validated themes identified
by Lindqvist, et al. (2000) and Hagren, et al. (2005). Hagren, et
al. (2005) described both major themes: ‘not finding space for
living’ and ‘attempting to manage restricted life’ and a sub-
theme of ‘loss of freedom’. ‘Not finding space for living’ con-
sisted of two sub-themes: ‘struggling with time-consuming
care’ and ‘feeling that life is restricted’. Lindqvist, et al. (2000)
identified four main themes in investigating perceived conse-
quences of living with ESKD including ‘deprivations of one’s
normal life’ which included an associated sub-theme of loss.
Limitations of the Study
As with most qualitative research the generalisation of our
findings to the wider haemodialysis population may be lim-
14
ited. However the consistency of our findings with previous
studies considering the broader experience of living with
ESKD suggests that this group of participants would not be
unrepresentative of other people living with ESKD.
The analysis of this study’s preliminary findings may be
viewed by some members of the research community as mini-
malist. This is deliberate. The presentation of the findings is
grounded in the cultural and philosophical term mimesis.
Mimesis, historically has been an evolving concept with links
to the arts including literary creation, sculpture and theatre.
From an Aristotelian viewpoint it is concerned with the ef-
fect any of these artistic forms has on its audience (Woodruff,
1992). Where Plato attempted to eradicate the notion of mi-
mesis or using the Latin equivalent imitatio or imitation in the
narrative, Aristotle embraced it (Kirby, 1996). In theatrics, Ar-
istotle suggested that the audience responded emotionally to
the actor’s mimesis in order for them to experience empathy
or understanding of the character (Lear in Rorty, 1992). Find-
ings from this study have been deliberately presented in this
way to augment the cathartic process so that health profes-
sionals not only consider the meaning and experience of man-
aging IDWG but how they interact with their patients. The
intention of the combination of artifacts and the participants’
narratives is to enable the reader to temporarily enter the
participants’ reality. Therefore it is vital that the participants’
own words are used to describe their experiences and that the
researchers minimised any potential bias derived from their
assumptions.
Suggestions for Future Research
To the authors’ knowledge, this is the first study to explore
the meaning of fluid restriction and perspectives of manag-
ing interdialytic weight gain for people on haemodialysis.
Therefore further qualitative studies are required to validate
our findings and identify additional relationships between
themes. During the course of this study further avenues for
research have become evident. Firstly, it would be sensible to
conduct a systematic comparison between people who achieve
‘acceptable’ IDWG and those who do not. Follow up studies
could then be devised to test interventions that are specifi-
cally designed to support people who struggle in achieving
‘acceptable’ IDWG. These studies would be based on patients’
perspectives and experiences not clinicians’ assumptions.
Such interventions may prove successful considering clini-
cian-devised interventions to improve health outcomes have
less impact because patients do not identify such measures to
be related to their own perceptions of their experience (Casey,
et al. 2002; Seymour, 1989).
Secondly, it would be worthwhile to further explore the
theme of transition to acceptance in relation to theorems of
behaviour change, notably the trans-theoretical model. The
trans-theoretical model of behaviour change suggests that the
adaptation of addictive behaviours requires an individual to
progress through various non-linear stages (Prochaska & Ve-
licer, 1997). Further research in this area would have practical
benefits to patients as health professionals seek to develop suc-
cessful strategies to support healthy fluid gain behaviours.
Real World of Practice
To create a culture of shared care where the patients and the
health care team work in partnership to achieve mutually ac-
ceptable goals it is vital for the health care team to engage with
their patients. We need to appreciate their experiences, health
beliefs, attitudes and expectations of both their illness and
treatment and to work in partnership (Constantini, 2006).
Health care staff can improve their dialogue with patients
about interdialytic fluid management by appreciating both the
patients’ experience and their positioning along the continu-
um of transition to acceptance. Avoiding the use of negative
and paternalistic language within this dialogue will enhance
partnership in health management and the attainment of mu-
tually acceptable fluid maintenance goals. Customised strate-
gies can then be identified to support individual patients and
assist them to understand and accept fluid restriction while
simultaneously engaging successfully in healthy fluid gain
behaviours. Our role as clinicians is to assist people living
with the complexities of dealing with IDWG to understand
themselves in the context of their own reality.
CONCLUSION
To support people living with ESKD it is imperative to un-
derstand the personal meaning of disruption and the nature
of their experience of living with renal disease. This study
enabled a small group of people undertaking haemodialysis
to describe the meaning they attached to fluid restriction and
their perspectives of managing IDWG. The study identified
the themes of magnitude of loss, constant struggle and tran-
sition to acceptance. Participants experienced each of these
themes in varying degrees and at varying stages of their ill-
ness trajectory.
Transition to acceptance was not identified as a linear progres-
sion to understanding and compliance but a multifaceted, tor-
tuous struggle unique to individuals and largely dependant
upon support, belief in a life worth living and willingness to
engage in surveillance and maintenance behaviour. Under-
standing where patients are positioned along this continuum
will assist nursing staff to identify strategies to support pa-
tients, to help them understand and accept fluid restriction
and to engage in healthy fluid gain behaviours. The transi-
tion from understanding the experience of the patient to using
that understanding to inform support strategies will augment
nursing practice, improve patient outcomes and provide sup-
port and direction for future research.
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15
FEATURE ARTICLE
Re-printed with the permission of the editors of the journal “Collegian” (2008) 15 , 77-82

The lure of the bush: Do rural placements influence student

nurses to seek employment in rural settings?
Jackie Lea, Master of Nursing (Hons), Mary Cruickshank, PhD, Penny Paliadelis, PhD, Glenda Parmenter,
PhD, Helena Sanderson, Master of Nursing, Patricia Thornberry, Master of Health Science

School of Health, University of New England, Armidale, NSW 2351, Australia School of Health, UNE, Australia
Accepted 11 October 2007

SUMMARY

The aim of this study was to investigate whether rural clinical placements for student nurses at a rural university in
New South Wales influence their decision to join the rural and remote Registered Nurse workforce. The study utilised a
convenience sample of final year Bachelor of Nursing students at a rural university campus, and consisted of two stages
of data collection. Stage One employed a pre- and post-clinical placement survey design that elicited both demographic
and qualitative data. Stage Two consisted of individual interviews with a sample of final year nursing students while
they were on a rural clinical placement. The findings highlight the factors that influence final year students’ decisions
to seek employment in rural healthcare facilities. These findings will be of interest to nurse academics concerned with
ensuring that undergraduate nursing curricula relate to rural nursing practice in Australia and to those involved in
recruitment of new graduate RN’s to rural nursing practice.
Keywords: Rural nursing practice; Rural clinical placements; Nursing students

Crown Copyright © 2008 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

INTRODUCTION ing the recruitment and retention issues facing rural health
Rural nursing is a distinct practice and rural nurses consti-
tute the largest group in the rural health workforce. However,
the rural nursing workforce is ageing, the turnover of nurses
in rural areas is increasing, and attracting nurses to these ar-
eas is becoming more difficult. The possibility of attracting a
substantial number of nurses from metropolitan and urban
areas remains remote while there is an over-all shortage of
nurses in Australia. As a result, rural health services are ex-
periencing recruitment and retention difficulties and a lack of
attention to these workforce issues from universities and the
Federal Government has further com-pounded the problem.
Because of this little is known about the barriers surrounding
the recruitment and retention of new graduate nurses in rural
areas and if this situation is left to continue, the potential long-
term investment that graduate nurses could make to the rural
workforce will be lost.
In recent years, there has been increasing attention on nurse
workforce planning both at state, territory and national levels
in response to the nursing shortage in Australia. In 2004, the
Federal Government announced additional nursing places in
the higher education sector for 2005. However, according to
the Australian Health Workforce Advisory Committee An-
nual Report (2004, p. 33), while these additional places will
benefit the nursing workforce, ‘they will not be sufficient to
meet projected demand based on replacement (turnover and
retirements), population growth and ageing and increasing
demand for health services’. An inadequate supply of nurses
entering, and remaining in, the Australian nursing workforce
will further compound the problem of recruitment in rural
areas.
Background to the study
care facilities and even less is known about the recruitment of
new graduate nurses in rural areas. According to Orpin and
Gabriel (2005, p. 412), ‘there are still large gaps in the evidence
base for the effectiveness of Australian undergraduate rural
coursework and placements programs designed to increase
the numbers of health graduates choosing rural practice’. This
is highly significant to the rural nursing work-force because
without current data regarding recruitment and retention is-
sues and effective strategies to recruit new graduates into ru-
ral settings, problems concerning the adequacy of the rural
workforce will remain unsolved.
New graduate nurses who enter the rural workforce enter a
professional practice very different from metropolitan prac-
tice. Hegney (1996) believes that the difference between rural
and metropolitan nursing practice may be attributed partly
to the scope and diversity of rural nursing practice whereby
the level of responsibility and skills differs from that of their
metropolitan peers. The literature also identifies the positive
and negative characteristics of rural practice. The positive
characteristics include the broad, diverse clinical role associ-
ated with rural practice, greater autonomy enjoyed by rural
health professionals, and the benefits of living in a small com-
munity such as com-munity recognition, a country lifestyle
that includes family and friends, and familiarity with patients
(Barney, Russell, & Clark, 1998; Mitchell, 1996; Peach & Bath,
2000; Smith, Edwards, Courtney, & Finlayson, 2001; Talbot
and Ward, 2000; Wolfenden, Blanchard, & Probst, 1996). Pre-
vious studies (Hegney, McCarthy, Rogers-Clark, & Gorman,
2002; Lea & Cruickshank, 2005; Neill & Taylor, 2002) have
identified the negative aspects of rural nursing which include
staff shortages, physical and emotional demands of the job,
issues related to isolation, and inadequate support for new
graduates.

While much has been written in the past about remote area While authors have identified the specific characteristics of
nursing in Australia, little empirical literature exists regard- rural nursing practice little is known about the effectiveness

16
of recruitment strategies for undergraduate nursing students
into rural settings. Some authors have suggested that gradu-
ates’ decisions regarding their choice of workplace employ-
ment can be influenced by the workplace exposure they gain
as undergraduate students (Courtney, Edwards, Smith, &
Finlayson, 2002; Glover, Clare, Longston, & De Bellis, 1998;
Gum, 2007; Talbot & Ward, 2000). Further-more, Nugent,
Ogle, Bethune, Walker, and Wellman (2004) suggest that
evidence, from the work of Courtney et al. (2002), indicates
that pre-registration nursing students who have completed
courses at rural and remote campuses may be more likely to
enter the rural and remote nursing work-force. Murray and
Wronski (2006, p. 37) also believe that ‘there is compelling
evidence for the success of the ‘‘rural pipeline’’ (rural student
recruitment and rural based education and professional train-
ing) in increasing the workforce’. There is also a strong belief
that a rural background influences the choice of employment
in a rural area (Courtney et al., 2002; Lea & Cruickshank, 2005;
Orpin & Gabriel, 2005; Playford, Larson, & Wheatland, 2006).
In contrast, offering a rural clinical placement to students who
are not from a rural background can provide them with the
opportunity to become familiar with a rural work environ-
ment. Neill and Taylor (2002, p. 239) believe that encourag-
ing and assisting students ‘especially those from an urban
background to experience living and working in rural areas
has been overlooked as a potential recruitment strategy’. The
emphasis in the literature is predominately focused on rural
placements for non-rural students and there is not a lot of
evidence to suggest that exposure to rural practice through
rural clinical placements is having any substantial effect in a
commitment to the rural nursing workforce (Orpin & Gabriel,
2005, p. 12). Therefore, the aim of this study was to investi-
gate whether rural clinical placements for final year nursing
students’ at a university located in rural New South Wales
did influence their decision to join the rural Registered Nurse
workforce.
The university is located in a large rural town whose popula-
tion base and geographical location, or distance from metro-
politan centres is such that it is considered to be rural using the
Rural, Remote and Metropolitan Areas Classification Method
(Department of Primary Industries and Energy, 1994, cited in
Handley, 1998, p. 2). Furthermore, the university used for the
current study, has previously been described by Nugent et al.
(2004) as a rural and remote campus. Although the Uni-
versity provides students with a choice of non-compulsory
rural clinical placements throughout their 3-year undergradu-
ate program, at the time of this study, there was limited rural
curriculum content. It was anticipated that the findings from
this study would assist nurse academics with the planning
and design of greater rural curriculum content and rural clini-
cal placements, which would better prepare student nurses
for the rural workforce.
METHODS
This study, consisting of two stages, was conducted in the fi-
nal semester of the nursing students’ undergraduate 3 year
program. The study utilised a convenience sample of all 75
final year Bachelor of Nursing students at a rural university in
New South Wales in 2005.
Stage One employed a descriptive survey design. Data col-
lection included two surveys which consisted of closed (yes/
no) and open-ended questions. The pre-clinical placement
survey asked students to identify why they had chosen a par-
ticular clinical placement and what factors encouraged them
to choose this placement. The post-clinical placement survey
sought to explore students’ perceptions of their clinical place-
ment. In addition, this survey sought to identify positive and
negative factors that could impact on their decision to enter
the rural nursing workforce as a new graduate. The surveys
were coded to assist in the identification of non-respondents
and to match the pre-and post-survey respondents. Both sur-
veys were piloted on a small sample of second year nursing
students prior to distribution.
Stage Two consisted of individual in-depth interviews with
a sample of final year nursing students while they were on
a rural clinical placement. This stage utilised an interpretive
approach to gain understanding of the student’s perspec-
tives of their experience working in a rural health service, the
skills they felt were required to work in rural health services,
the undergraduate preparation for rural nursing practice and
the factors that would influence their choice to enter the ru-
ral nursing workforce. An Interview Schedule was developed
from the data obtained in Stage One. Ethical approval to con-
duct this study was obtained from the University Human Eth-
ics Committee prior to data collection.
Population and sampling method
The population under study consisted of all final year Bach-
elor of Nursing students at a rural university of New South
Wales who were enrolled in clinical units of study in 2005 (n
= 75). To ensure the avoidance of sampling bias and sampling
error all final year student nurses enrolled in final semester
clinical units were surveyed.
Procedure
Stage One
Prior to clinical placement, the pre-clinical placement survey
plus duplicate Consent Forms were distributed to each final
year nursing student and a copy of the Consent Form was re-
tained by each participant. The post-clinical placement survey
was placed in the students Clinical Practice Record Book which
they took with them on clinical placement to have signed by
the healthcare agency staff. The students were asked to fill in
this survey at the completion of their clinical placement and
prior to returning their Clinical Record Book by mail to the
university. This method of returning the post-clinical place-
ment survey with their Clinical Record Book helped ensure
a high response rate, as return of the Clinical Record Book to
the university is compulsory.
Stage Two
This stage was conducted while the students were on a ru-
ral clinical placement in Semester Two, 2005. Prior to clinical
placement, potential participants were invited to participate
in an individual interview. All final year students who indi-
cated, in the pre-clinical placement survey form, a willingness
to be interviewed during their rural clinical placement were
included in the individual interviews (n = 30). The aims of this
stage of the study were explained and participants were asked
to sign a Consent Forms. The participants were informed that
the data collected during the study would be cleaned of any
identifying names prior to data analysis to maintain confiden-
tiality. Individual interviews were conducted with thirty final
year students across rural northern New South Wales. A semi-
structured interview technique was used and the 40—50 min
interviews were audio-taped with the participants’ permis-
sion. A recursive interviewing approach was used to collect
data and four data generating questions guided the interviews:
17
n
Can you tell me about your clinical placement experience
working in a rural health service?
n
What skills do you think are required to work in rural their future employment intentions. Negative aspects of the
health services?
n
Do you feel the undergraduate nursing program has pre-
pared you for rural nursing practice?
n
Can you tell me what factors would influence your return
to a rural health service as a Registered Nurse?
Interviews were conducted away from the clinical placement
healthcare facility and in the participant’s own time to ensure
privacy and confidentiality for the participants. The research-
ers believed that conducting the interviews with the students
away from their clinical placement agency would reassure the
participants that the study would in no way affect their future
employment prospects within that healthcare facility, and it
would also allow participants to speak freely about their ex-
periences in the rural context.
In Stage One, analysis of the demographic items consisted of
frequency distributions and the data from the open-ended
questions were analysed using content analysis processes to
draw common themes from the written text regarding stu-
dents views and opinions regarding: experiences of rural
clinical placements, career intentions, influences on seeking
rural employment, preparation and skills required for rural
nursing practice. Two of the researchers conducted separate
content analysis of the data and then compared and contrast-
ed their findings to establish interrater reliability. For Stage
Two, the individual in-depth interviews were recorded and
transcribed and thematic analysis was used to identify the key
concepts and themes in the data.
RESULTS
Stage 1: pre-clinical placement survey
There was an 81% response rate (n = 57) for the pre-clinical
placement survey. The majority of the respondents were aged
between 18 and 25 years and were currently living or had pre-
viously resided and worked in a rural area. More than 50%
of respondents indicated that their choice of a rural clinical
placement was influenced by personal and financial factors.
For example, the learning experiences available in rural health
services, the culture of rural environments, financial consid-
erations, and the students’ rural origins emerged as recurrent
themes that influenced clinical placement choices.
The majority of respondents stated they had chosen a rural
clinical placement because they felt they could obtain valu-
able experience in a rural practice setting that would assist
them in their overall development as a registered nurse. Stu-
dents believed that the broad experience they were exposed to
would allow them to develop more independence and respon-
sibility at this crucial time in their undergraduate preparation,
particularly in an environment that would expose them to a
wide variety of clinical experiences. In addition, respondents
believed that smaller rural hospitals would allow them to
practise and refine their generalist skills in a non-threatening
environment where they felt they were included and made to
feel part of the team
Stage 1: post-clinical placement survey
The post-clinical placement survey yielded a response rate of
57% (n = 40). Respondents identified the relaxed and friendly
working environment of rural health services and the proxim-
18
ity of the rural health service to friends and family as positive
aspects of their rural clinical placement that would influence
clinical placement that students believe would discourage
them from seeking rural employment were a lack of resources
and technology, the patient acuity in rural health services, and
the lack of support available for staff. Eighty percent of re-
spondents believed that their under-graduate education had
prepared them for rural nursing practice while 85% indicated
that they would consider working in a rural health service at
some stage in their career. This is consistent with the findings
of Orpin and Gabriel’s (2005) study. Of these respondents,
35% indicated that they wished to work in a rural health ser-
vice upon completion of their undergraduate program. Re-
current themes in identifying the attributes that students felt
were important for working in a rural health service were a
broad knowledge and skill base, good interpersonal skills and
effective time management and organisational skills.
Stage 2: results of in-depth interviews
Four main themes emerged from the data in Stage Two in re-
lation to the students’ experience of the rural clinical place-
ment.
Characteristics and positive influences of rural clinical
placements
The respondents focused predominately on the support of-
fered to students by rural nursing staff. Students perceived
the rural clinical environment as positive and friendly, nurs-
ing staff were ‘approachable and more supportive’, and ‘staff
had more time to teach, encourage and give more attention’.
Additionally, the students commented that rural nurses were
very knowledgeable about the rural communities in which
they worked, and the staff, ‘know exactly where the patients
were coming from’. Students’ perceived the clinical experi-
ences gained in the rural health services as having ‘provided
a global view of what nursing was about’.
Skills required for rural nursing practice
The respondents believed that the skills required in order to
function as a rural nurse includes an ability to carry out the
workload in isolation and switch their clinical focus quickly
as well as being able to multitask. In addition, the students
observed that rural nurses need confidence and initiative with
decision-making and they also require an ability to commu-
nicate on many different levels. For example, one participant
commented that staff members were ‘able to talk about the
weather and know that rainfall is talked about in inches’. Re-
fined observation and assessment skills were also observed to
be imperative to the rural nurses scope of practice and many
respondents commented that the rural nurses were confident
in their scope of practice which is a necessity for effective ru-
ral nursing practice.
Adequacy of undergraduate preparation for rural
nursing practice
Many of the respondents believed that block clinical place-
ments that utilised a preceptorship model had greatly assisted
them in their preparation for rural nursing practice. Howev-
er, some participants felt that this model of clinical education
was inadequate, as it had an isolating effect because there
was not always sufficient registered nursing staff available to
provide debriefing or support for the student. The students
also revealed that more emphasis on the application of assess-
ment skills specifically for rural clinical practice would have
enhanced their undergraduate preparation because they rea-
lised how important it was for rural nurses to possess compe-
tent assessment skills.
Influences that impact on seeking rural employment
Many respondents felt that their final clinical placement in a
rural health service had provided them with good insight into
what their graduate year would be like in a rural health ser-
vice. They also believed they would spend part of their pro-
fessional life practising in a rural area which is consistent with
the findings of the post-clinical placement survey and Orpin
and Gabriel’s (2005) study.
However, participants expressed concern and disappointment
with the skill mix, the demanding workloads, and the gradu-
ate programs, particularly as they had observed that there did
not appear to be a specific support person allocated to new
graduates in rural health services. Even when a support per-
son was available they were required to fulfil many roles and
so were not available to provide ‘hands on’ assistance to new
graduates. One participant remarked ‘they might have the
best educator in the state but that person is not easy to get
hold of and talk to’, while another also expressed her concern
by saying ‘with 10 patients (to care for) I need to be able to ac-
cess somebody all the time, day and night’! The respondents
believed the graduate programs in rural health services did
not provide adequate support for them with respect to skill
mix and workload allocation and this was a factor that would
discourage them from seeking rural employment. For exam-
ple, one participant stated, ‘in the 3 days I have been here I
have been given nothing positive of why I should come here’.
These findings are consistent with the findings of Hegney et
al. (2002) and Neill and Taylor (2002) that showed that emo-
tional and physical demands of the job, staff shortages and
inadequate support significantly impacted on the retention of
nurses in the rural workforce.
The clinical rotations offered during a graduate program were
of particular importance for the participants. Many of them
wanted to rotate through specialty areas such as Intensive
Care and Emergency Departments. The limited availability to
these areas for new graduates was cited as a key factor in their
choice for a graduate employment program.
DISCUSSION
In this study many of the participants had rural origins and so
their rural background increased the chances of them choos-
ing a rural placement. This is not surprising as a correlation
between a rural background and rural practice is well estab-
lished in the literature (Courtney et al., 2002; Lea & Cruick-
shank, 2005; Orpin & Gabriel, 2005; Playford et al., 2006).
Half of the participants in this study opted to undertake rural
clinical placements because of the nature of the rural working
environment that students had previously experienced as be-
ing supportive, friendly and offering a diverse clinical experi-
ence. As a result, many participants felt that the rural environ-
ment would allow them to advance their nursing knowledge
and skills. These findings are consistent with Dalton’s (2004)
study in which it was found that clinical practice undertak-
en in the rural environment provides optimal learning op-
portunities for students to advance their clinical knowledge
and skills, and assists them with developing a professional
identity. Students in this study confirmed the unique skills
that rural nurses possess which allow them to communicate
and function on many different levels. For example, the abil-
ity of the rural nurse to multitask and change their clinical
focus quickly made a lasting impression on many of the par-
ticipants. Students’ identified refined and well developed as-
sessment and communication skills with individuals and the
community, as specific skills required for rural nursing. This
is consistent with the findings of previous studies that found
that the rural nurse—patient relationships are at a deeper lev-
el, based on intimate understandings, because of the nature
of the small rural community (Dalton, 2004; Orpin & Gabriel,
2005).
While the participants in this study felt well prepared for ru-
ral practice they could not recall specific coursework prepara-
tion for rural practice throughout their 3-year program. This
finding is similar to Orpin and Gabriel’s (2005, p. 12) finding
which showed that students had ‘a patchy recall of course-
work’. However, Orpin and Gabriel (2005, p. 12) also found
that ‘the rural course content actually discouraged them from
pursuing rural practice’, a finding which is not consistent with
the findings of this study nor the previous findings by Lea and
Cruickshank (2005).
Of particular concern in this study was that the participants
had changed their minds in the final semester about seek-
ing rural employment upon graduation. Initially, they be-
lieved that rural clinical placements throughout their 3-year
program had encouraged them to pursue rural practice even
though at times the preceptorship model was isolating and
often not supportive of individual students needs. However,
with the prospect of graduation looming, some participants
now felt that the final rural clinical placement experience had
actually discouraged them from pursuing rural practice. So,
although they were initially keen to pursue rural practice, it
appears that perhaps their interest may have been lost be-
cause of their expectations as new graduates and the realities
of rural practice that were not consistent with their expecta-
tions of the graduate year. For example, the lack of allocated
support persons for new graduates, the skill mix, and the
demanding workload expectations that are experienced in
rural health services were cited as factors that would discour-
age them from choosing rural practice. These factors need to
be addressed by encouraging the ‘‘rural pipeline’’ which ‘in-
volves recruiting students from rural backgrounds, delivering
training in the regions, rural curriculum providing repeated
rural exposures, and building regionally based postgradu-
ate training pathways’ (Murray & Wronski, 2006). While the
literature emphasises the need to recruit students from rural
backgrounds, Neill and Taylor (2002, p. 239) also believe that
students from both urban and non-urban backgrounds should
be encouraged to undertake rural and remote clinical place-
ments and identifying strategies to support students should
be ‘an important strategic and funding priority’.
CONCLUSION
This study builds on previous work and it has provided fur-
ther insight into rural healthcare facilities and rural nursing
practice that positively and negatively influence students’ em-
ployment intentions. It has also identified factors that influ-
ence final year students’ choice for rural graduate positions. A
limitation of this study is that these results only represent the
responses of final year nursing students in one university so
they cannot be generalized. Nevertheless, the results are con-
sistent with the findings of previous studies and while many
participants in this study indicated that they would take up a
rural position, a longitudinal study is required to explore how
19
many students actually followed through with their rural in-
tentions once they graduated. Further evaluative research is
also needed into undergraduate rural clinical placement ex-
perience, which will assist when planning and implementing
the rural component in under-graduate curricula.
While government bodies, professional nursing groups, and
rural employers are attempting to address the problem of
recruitment and retention within the rural workforce, nurse
academics can play a significant role at the grass roots level
by providing more comprehensive exposure to rural nursing
practice and rural course content in undergraduate curricula.
They can also offer more support to rural clinicians who are
often expected to preceptor student nurses and facilitate new
graduates.
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Discussion Papers
An Ethical Dilemma: Mine, Yours Or Ours?
Ludmilla Sneesby, RN, BN, MN
CNC in Palliative care, Division of Palliative Care, Calvary Mater Newcastle
INTRODUCTION
This paper presents a challenging case study that not only
raises issues of the ethical and legal obligations of health care
workers, and the rights of terminally ill patients to refuse or
reject treatment, but actually changed practice with the for-
mulation of procedures and guidelines about self-harm and
the wider issue of euthanasia and the responsibilities of health
care workers in such cases. At the time of his attempted sui-
cide, Bernie (pseudonym) was a patient of the Palliative Care
Program of the Mater Misericordiae Hospital. In extreme
cases (such as that of Bernie, the patient in this case study)
the right to or to attempt to take their own life is the basis for
discussion.
Death by suicide is a relatively uncommon event (occurring at
a rate of about 1 per 10,000 of population per year), but the hu-
man and economic costs are substantial (ABS, 2005). Further,
according to the Australian Bureau of Statistics (ABS, 2005),
male suicides outnumber female suicides in Australia by four
to one.(ABS, 2005). Age range distribution suggests that male
suicides are more frequent in those aged 30 – 35, and those
80 and over (ABS, 2005). Using a case study, this article will
discuss suicide as an end of life decision, the legal and ethical
responsibilities of health care workers, how health care work-
ers can support patients like Bernie at the end of their life, and
the current guidelines provided for palliative care staff.
ETHICS
Kerridge, Lowe and McPhee (2005, p. 1.) describe ethics as
’what should be done’. Ethics is based on the universal ethical
principles of autonomy, beneficence, non-malfeasance and
justice (Beauchamp & Childress 1994; Johnstone 2004) upon
which nurses can base their actions and decision-making. Al-
though appearing straightforward, ethics cannot provide so-
lutions to all issues or dilemmas, defined by Johnstone (2004,
p. 102) as ‘situations requiring choice between what seem to
be two equally desirable or undesirable alternatives’ that may
arise in health care settings.
Beauchamp and Childress (1994) described the principle of
autonomy as the right of individuals to be self-governing and
to make decisions about their own destiny. It is the right of
individuals to have wishes and decisions respected, to be lis-
tened to, and to be able to make informed choices free from
manipulative or coercive pressures. Autonomy encompasses
a sense of both self (shaped by the sum of life experiences),
and self-determination and is a reflection of our goals, values
and beliefs. All individuals have different and varying experi-
ences and belief systems. In upholding this principle it must
be recognised that the autonomy of individual members of
society can be in conflict (Kerridge, Lowe & McPhee, 2005). As
Johnstone (2004) argued individuals should be able to act au-
tonomously as long as those actions do not interfere, impede
or infringe on the autonomous rights of others. Therefore an
individual autonomous decision may have to be sacrificed if
it conflicts with the rights of others.
In effect, the right to autonomy is a prima facie right, one which
can be over-ridden by a stronger and/or competing moral
claim (Johnstone, 2004, p. 50).
NURSING ETHICS
The new National Code of Ethics for Nurses and Midwives,
released in August 2008, is a set of guidelines for ethical,
moral and professional behaviour which contains eight value
statements or principles on which to base decision-making
(ANMC, 2008).
LEGAL CONSIDERATIONS
Overriding any ethical or moral decision-making is the Aus-
tralian legal system. Debate and controversy surround the
moral and ethical issue of euthanasia however it is illegal to
take someone’s life or to assist another person to suicide in
all Australian jurisdictions (Kerridge, Lowe & McPhee, 2005;
Skene, 2004; Johnstone, 2004; Wallace, 2001).
CASE STUDY
A case study that exemplifies these issues is Bernie’s story.
This article looks at his journey and the impact he had on the
people and the health care professionals who cared for him.
To understand why and how Bernie made his decisions and
choices at the end of his life requires some insight into the
man he was and his life experiences.
Bernie was an extremely intelligent man of many talents. He
was a sportsman, politician, teacher, author, husband, father
and grandfather. Not a modest man, Bernie liked to talk –
mainly about himself. He was a good conversationalist, inter-
esting and witty. Among his many feats was gymnastics and
he represented his country in the Olympic Games. He was
very proud of his trim, lean and muscular physique and he
enjoyed showing off his gymnastic photos. During World War
II he worked as a deep sea diver for his country’s submarine
fleet, until he was captured and became a prisoner of war. Af-
ter the war, life in East Germany was extremely hard. He tells
the story of his first born baby becoming ill. The local doctor
would not treat her without money and the Russian Army
doctor refused to treat Germans, so Bernie placed the baby
in a suitcase strapped to his bicycle and rode many miles to a
hospital only to find when he got there that the baby had died.
That experience filled him with a deep-seated loathing of the
medical profession. He also mistrusted ministers of religion,
describing himself as an atheist and saying that churches and
religions are all money-making businesses.
After the war, he studied politics and became a university lec-
turer in East Berlin, but he soon became disillusioned with life
under communist rule. Bernie and his family escaped to the
West – that was another remarkable story. He lived in South
Africa for some years, working as a deep sea diver. It was this
that eventually brought him to Australia in 1967 as, according
to Bernie, Australia was calling for deep sea clearance divers
21
to find missing Prime Minister Harold Holt. The Prime Min-
ister was never found but Bernie and his family found their
home here.
Bernie and his wife Irene raised a family, became grandpar-
ents and in their retirement enjoyed many travels together.
Irene died in 1994 of carcinoma of the colon and her death had
a huge impact on Bernie. He described her death as extremely
undignified, focusing on her incontinence and repeatedly say-
ing he was not going to die on a plastic sheet in a hospital.
After Irene’s death, Bernie sold his home and belongings and
became a nomad, travelling the world on his bicycle. Eventu-
ally (after a few years) he returned to Newcastle to be close to
his family, and lived in a caravan park.
After pressure from his family, he presented to his General
Practitioner (GP) (Irene’s doctor) with weight loss, dysphagia
and reflux, previously having been a fit and active eighty-four
year old. A gastroenterologist performed an endoscopy and
diagnosed inoperable, infiltrating carcinoma of the stomach.
He was referred to the Palliative Care Service by his GP after
two suicide attempts. The first time Bernie tried to overdose
on Ordine but vomited. Then he tried to gas himself in his
car but the hose became dislodged in the wind. He said he
could not live due to pain, saying that his quality of life was
intolerable. There had been no previous history of depressive
illness.
Bernie had resisted any help in the past, but consented to the
involvement of the Palliative Care Service, saying he would
give them a chance to make his life liveable. If this objective
was not achieved, he would try to kill himself again. He said
he had heard about the Not For Resuscitation (NFR) policy
of the Palliative Care Service and thought that it was a great
idea. He had expressed his wish that he did not want to be
resuscitated, whether it be basic life support, active treatment
or cardio-pulmonary resuscitation. To the author’s knowl-
edge, no discussion took place regarding the health care pro-
fessional’s responsibilities and legal obligations to patients
who self-harm and attempt suicide. A palliative care special-
ist doctor visited his home at the caravan park. Bernie spoke
openly of his intent to suicide if his symptoms did not im-
prove. His medications at that time were MS Contin 20mgs
BD and Maxalon 10mg QID. He wasn’t taking any aperients.
His main symptoms were abdominal pain, absolute constipa-
tion (bowels had not been not opened for 4-6 weeks, but was
passing flatus), nausea and faecal vomiting. A thorough and
comprehensive assessment was conducted and the problems
identified were psycho-spiritual issues, frailty, lethargy and
weakness, general physical deterioration, emaciation, weight
loss, abdominal pain, constipation, nausea and vomiting.
A subcutaneous infusion pump (SCIP) was commenced by the
Palliative Care Outreach (PCO) nurse with Morphine 30mgs,
Cyclizine 100mgs and Dexamethasone 12mgs over 24 hours.
Aperients were commenced. For breakthrough pain Bernie
was provided with a bottle of Ordine 10mg/ml by his GP,
and he was instructed to take 0.5mls PRN for pain.
Referrals were made to the Pastoral Care worker but Bernie
refused to talk to anyone remotely connected to religion or to
discuss psycho-spiritual issues. The services of a social worker
were suggested however Bernie became quite offended at this
suggestion. When occupational therapy was offered Bernie
stated that he did not want any equipment cluttering up his
caravan and reminding him of hospitals. His views on phys-
22
iotherapists were that they were only useful in the sporting
arenas and he refused to talk to them. Life story recording vol-
unteers were offered and Bernie was greatly amused at this
suggestion as he had already written three autobiographies.
The Day Hospice program was rejected as he did not want to
mix with people who may be ‘old and boring’.
At the initial nursing visit the Palliative Care Outreach (PCO)
nurse reported Bernie as being extremely rude and irritable.
However after twenty-four hours on the SCIP there was a re-
markable change in Bernie. His pain was well controlled, and
no breakthrough analgesia had been required. He was able to
tolerate small amounts of food and fluid and reported that his
bowels had been opened. He was friendly, talkative, relaxed
and congenial. He spoke about his family with much love and
said he felt so much better that he was arranging a family bar-
beque on the weekend. He was looking forward to watching
the Tour de France bicycle race now that his symptoms were
so much better and he was very grateful that palliative care
could make such a difference.
Bernie continued to feel reasonably well and it was obvious
that he looked forward to the nurse’s daily visit, as there was
always a biscuit and coffee waiting. Bernie made sure that
the nurse stayed for a chat. By day eight of PCO involve-
ment Bernie started to complain of feeling dizzy, weak and
anorexic. His condition deteriorated and hospice admission
was offered. However Bernie said he would rather die. His
pain remained well controlled, and he did not require any
breakthroughs. His bowels were working, and there was no
nausea or vomiting. Bernie just felt extremely weak and le-
thargic, and eventually his daughter persuaded him to come
and live with her.
By day twelve of PCO involvement, his family reported that
Bernie was irritable and hard to live with. Bernie said he was
unhappy and ‘out of sorts’ but denied pain (still no break-
throughs and it was noted that he had an unopened bottle of
Ordine). Bernie requested the morphine be increased in the
SCIP although he had no pain. Midazolam 2.5mgs was added
to the SCIP. Again Bernie was offered pastoral care or coun-
selling. Bernie refused and appeared rather offended saying
he was an intelligent human being and that people were for-
getting that now that he was in an old man’s body.
On day thirteen of PCO involvement, Bernie’s daughter
phoned to say Bernie had driven back to his caravan the night
before, and she hadn’t been able to stop him. She had been
trying to call him but the telephone was constantly engaged.
Bernie was found unconscious by the PCO nurse. He was
sitting in his armchair, peripherally cyanosed, his pulse was
weak and thready, and his breathing slow and laboured. On
the small table next to him were an empty bottle of Ordine
10mg/ml (previously noted to be full), a bottle of Maxalon
tablets and a note. The phone was off the hook. This and
knowing Bernie, led the PCO nurse to suspect that Bernie had
taken an overdose of Ordine. An ambulance was called, the
nurse contacted the Registrar and the Nurse Unit Manager
and informed them of her suspicions. Both agreed that Ber-
nie was appropriate for the Hospice. The family was notified
and reassured that Bernie was being admitted for comfort
care only. Whilst the PCO nurse was contacting Bernie’s GP,
the ambulance officers arrived and commenced resuscitation
or basic life support (administration of oxygen, insertion of
IV cannula for IV fluids and medications). This was aborted
when the ambulance officers were directed by a phone call
from Bernie’s GP to stop. The PCO nurse was unaware of any
legal obligation to ensure basic or advanced life support mea-
sures were to be carried out in palliative care patients who
have attempted self harm or suicide.
Bernie was admitted to the Hospice unconscious and with a
clinical history of having taken a Morphine overdose. After
consultation and deliberation between the Director of Medi-
cine and the Toxicology Team it was decided to transfer Ber-
nie to an acute setting for active treatment. His family was
distraught, angry and confused. They could not understand
why the decision was made to actively treat an elderly man
suffering from terminal cancer who wanted to die. Intrave-
nous Naloxone was administered to Bernie and he regained
consciousness and was clinically responsive. His first words
were ‘why couldn’t you have left me to die in peace?’ Bernie
was able to make a statement to police saying he acted alone.
The act of attempted suicide is not illegal but assisting sui-
cide is, making it illegal to help somebody do something legal
(Skene, 2004, Staunton & Chiarella, 2003).
After regaining consciousness Bernie developed renal and
cardio-respiratory failure. As a result of developing multi-
system failure, treatment was withdrawn, and Bernie died on
day fifteen. His family found his suicide letter expressing his
love for them all. As Johnstone (2004), Kerridge, Lowe, and
McPhee (2005) and Skene (2005) argued, discontinuing medi-
cal procedures and treatments where the burden, harm and
risks are out of proportion to any reasonable hope of benefit is
not the equivalent of suicide and as Wallace (2004) and Skene
(2005) argued neither is the withdrawal of futile treatment.
Bernie’s post mortem toxicology showed the presence of
morphine (6mg/L) and cyclizine (0.6mg/L) and midazolam
(20.1mg/L). His morphine level was well above the reported
fatal level (0.08 -1.6mg/L) and must have been many times
higher on his admission prior to the Naloxone therapy.
POLICIES AND GUIDELINES
At the time of Bernie’s involvement in the Palliative Care Ser-
vice there were no clear guidelines for nurses on how to act
in the event of an attempted suicide. The PCO nurse was un-
aware of any policy or procedure and was not given any alter-
native instructions other than to admit Bernie to the Hospice.
Bernie’s death had an impact on practice, bringing the issue of
self harm and attempted suicide into the open, and influenced
the development of policy and guidelines.
These policies state that professionals have an obligation to
resuscitate ‘any action or omission which of itself and by in-
tention causes death constitutes euthanasia, and is both illegal
and contrary to the philosophy of Little Company of Mary
Health Care’ (LCM Health Care, 2007 Management of Self
Harm in the Palliative Care Program, Division of Palliative
Care Policy & Procedure Manual PC 2.2.12, Issued 06/03 Re-
vised 10/06).
This is a very broad statement, open to interpretation and
does not distinguish between omissions and acts of the pa-
tient or health care team. At Calvary Mater Newcastle the De-
partment of Palliative Care has now developed policies and
procedures for the management of attempted self harm in the
Palliative Care Program. They are:
• the patient should be transferred to Calvary Mater Hos-
pital Emergency Department immediately for assessment
and management by the Clinical Toxicology Team;
• palliative care patients with suspected excessive opioid
dosing will have appropriate treatment and management
instigated.
These are clear guidelines for nurses being orientated to the
Palliative Care Outreach Team. They are made aware of them
and it must be demonstrated that they have a clear under-
standing of them. All patients (and their families/carers) on
the Palliative Care Service are now made aware of this policy
as it relates to self harm and suicidal behaviour.
ADVANCED CARE DIRECTIVES
In the absence of a Not for Resuscitation (NFR) order or Ad-
vanced Care Directive, if the overdose had been accidental,
not attempting to initiative treatment could constitute medi-
cal negligence. The issues surrounding Advanced Care Direc-
tives including risks, benefits and the moral dimensions of
such decisions have been discussed by Johnstone (2004, pp
316 -322). However Johnstone (2004) argued that for the most
part, they are under-utilised in clinical contexts (p.319) and
that they will gain increasing authority in health care to guide
end of life decision - making (p.319). However, even if an Ad-
vanced Care Directive with instructions as to Bernie’s consent
(or refusal) for treatment had been developed, suicide is not
endorsed or covered by the Directive (NSW Department of
Health (2007). Euthanasia and assisted suicide both involve
deliberate acts or omissions to end a person’s life. It has been
general practice in Australia to resuscitate or provide emer-
gency treatment to people who have attempted suicide for
as Wallace (2001) has argued, attempted suicide may not be
genuine but cries for help or attention, where the individual
does not actually want to end their life. In this case study Ber-
nie had articulated his desire to suicide and had left a suicide
note.
DISCUSSION
Ethically, one could argue that Bernie’s autonomy was
breached by the use of Naloxone to reverse the effect of mor-
phine. Bernie had previously discussed with medical staff
that under no circumstance should he be resuscitated or
given life-saving treatment. Bernie’s discussions can be used
as an Advanced Care Directive as these Directives can be in
the form of unwritten communication between that person’s
family and/or attending health care professional. However,
attempted suicide invalidates an Advanced Care Directive
(Johnstone, 2004; NSW Department of Health, 2007). Bernie
had made an autonomous decision to end his life and after he
regained consciousness he admitted that this was his intent.
Bernie talked freely of suicidal ideation to various members
of the team. However, as Staunton and Chiarella (2003, p. 29)
stated, the ethical principle of autonomy is not upheld in law
regarding euthanasia and assisted suicide ’as people do not
have the right to be assisted to die at any time they choose’.
Both his GP and the Palliative Care Medical Officer found no
indication of mental illness or disorder, although a psychiat-
ric assessment was suggested, which Bernie had refused. Fol-
lowing Bernie’s death a peer review interdisciplinary team
meeting recommended that all patients expressing suicidal
ideation have a psychiatric assessment conducted. There is an
interesting debate in the literature about both rational suicide
(Fontana, 2004; Rich & Butts, 2004) and moral considerations
of suicide (Johnstone, 2004). As Johnstone (2004, p. 289) has
argued, ‘suicide and parasuicide [sic] is an issue of impor-
tance and concern to all nurses, not just to those working in
the area of mental health’.
Clinical depression is a high risk factor in patients receiving
palliative care (Filiberti et al, 2001). Because symptoms such
as weight loss, anorexia, lethargy, fatigue and insomnia are
23
common in both cancer patients, as well as depression, they
are of little value as diagnostic criteria of depression (Miller &
Massie, 2006). Although Bernie had not been diagnosed with
clinical depression he demonstrated many of the risk or vul-
nerability factors to suicide identified by Filiberti et al (2001),
and Miller & Massie (2006). These included a great concern
about the lack of autonomy and independence; a fear of losing
control; a fear of being a burden on others; feelings of hope-
lessness; a strong character and having been a member of a
managerial profession; a history of having talked about sui-
cide; a history or prior suicide attempts; a family history of
suicide; feeling hopeless; and a sudden hostility towards the
caregivers and/or relatives that may have been an indication
or warning sign.
CONCLUSIONS
There are some questions to consider in the light of this case
study. For example:
• How is depression assessed in terminally ill patients?
• Can sadness and hopelessness be distinguished from de-
pression?
• How do we overcome the barriers to making the diagno-
sis of depression in terminally ill patients?
• How should the team react to patients with suicidal ide-
ation?
• How are team members supported within their work
place when faced with critical incidents?
• Is there a formal process of professional support, such as
clinical supervision, to explore and reflect on practice?
(All Hunter New England Health employees have access
to Employment Assistance Program (EAP), which is out-
side the workplace).
• Do policies and procedures offer clear guidelines and are
staff made aware of them at orientation? (Nurses have a pro-
fessional responsibility to be aware of the legal, moral and
The Neophytes Writing Group
Are you studying this year?
Planning to write a clinical paper?
Planning to give a conference presentation?
Involved in postgraduate study?
Research, writing and publishing can be solitary and difficult activities. Are you interested in attending a workshop or
accessing ongoing peer support and feedback?
Ongoing support is available for aspiring writers who are nurses and midwives intending to present a paper at a
conference.
Groups meet regularly in the Newcastle and Northern areas, for further information please contact:
Newcastle - Teri Stone: teresa.stone@hnehealth.nsw.gov.au or
Tracy Levett-Jones: Tracy.Levett-jones@newcastle.edu.au
(this group meets at 8am on a Thursday once per month)
Northern-Penny Paliadelisl: ppaliade@une.edu.au
A lunch time group has commenced in Newcastle please contact:
Margaret Harris: Margaret.Harris@newcastle.edu.au
(this group meets at 11am on a Thursday once per month)
24
ethical implications related to their professional practice.)
• Are palliative care patients and their families made aware
of these policies pertaining to resuscitation and treatment
for those who self harm and/or attempt suicide?
Given the medical, legal, and ethical issues involved, these
cases should challenge staff to examine their work, reflect
on their attitudes, knowledge and skills, seek out informa-
tion and support their colleagues to improve clinical practice
and to allow staff to reflect on their own feelings and motives
(Khanna & Bulow, 2003).
References
Australian Bureau of Statistics (2005) available at www.abs.gov.au
Australian Nursing and Midwifery Council (2008) available at www.anmc.org.au
Beauchamp, T.L., & Childress, J. (1994). Principles of biomedical ethics.
(4th ed.). New York: Oxford University Press.
Filiberti A., Ripamonti C., Totis A., Ventafridda, V., DeConno F., Contiero P., &
Tamburini, M. (2001). Characteristics of terminal cancer patients who
committed suicide during a palliative care program, Journal of Pain and
Symptom Management, 22(l), 544 – 553.
Fontana, J. (2004). Rational suicide in the Terminally Ill. Journal of Nursing Scholar-
ship, 3(2)147-151.
Johnstone, M. J. (2004). Bioethics: a nursing perspective. (4th ed.). Sydney: Churchill
Livingstone.
Kerridge, I., Lowe, M., & McPhee, J. (2005). Ethics and law for the health professions.
Sydney: The Federation Press.
Khanna, P., & Bulow, K. (2003). Attempted suicide by a terminally ill patient. Journal
of Palliative Medicine 6(4), 629 – 632.
Miller, K., & Massie, M. (2006). Depression and anxiety. The Cancer Journal, 12(5),
388 – 397.
Management of self harm in the palliative care program. Division of Palliative Care
P&P Manual PC 2.2.12. Issued 06/03 Revised: 10/06.
NSW Department of Health, (2007). Guidelines for end–of-life care and decision-making.
Sydney: Better Health Centre-Publications Warehouse.
Philosophy of the Little Company of Mary (2007). Code 11,1.14;5.20. LCM Health
Care Ltd.
Rich, K. & Butts, K. (2004). Rational suicide: uncertain moral ground. Journal of Ad-
vanced Nursing, 46(3), 270-283.
Skene, L. (2004). Law and medical practice. Melbourne: Lexisnexis Butterworths.
Skene, L. (2005). Terminally ill infants, parents and the courts, Journal of Medicine
and Law, 24, 663 – 671.
Staunton, P., & Chiarella, M. (2003). Nursing and the law. Sydney: Churchill Living-
stone.
Wallace, M. (2001). Health care and the law. Sydney: Lawbook Co.
A Literature Review: Nursing Assessment In A Post
Anaesthetic Care Unit
Lee Lethbridge, RN, Bach Nursing, Bachelor Nursing Honours
Belmont Operating Theatres, Belmont Hospital

Abstract

Introduction: The nurse in the Post Anaesthetic Care Unit (PACU) is required to assess, and make clinical judgements
about the patient’s recovery and his or her readiness to be transferred out of the PACU to the usually higher patient to
staff ratio surgical ward.
Background: A literature review was conducted with the focus of uncovering how registered nurses assess patients and
make clinical judgements about patients’ readiness for transfer out of a PACU, and to what extent they are influenced
by currently available evidence and other factors.
Method: Literature searches were conducted on the NEWCAT, Proquest, Ovid and CINHAL databases using the
search terms of <recovery room nursing>, <nursing assessment in PACU>, <PACU discharge criteria> and <post an-
aesthetic assessment for discharge>.
Findings: The findings consisted of primary research (usually journal) publications, and secondary textbook publica-
tions. The date of publication was limited from 1983 to 2008 to provide an overview of the topic. Articles that were not
available in full text or from unconfirmed authors were discarded. The large amount of research available on ambula-
tory (day only / outpatient) peri-operative nursing care was not included as the primary focus of this literature review
centred on the assessment of patients that return to a surgical ward.
Discussion: The main areas of discussion within the literature focus on the role of a PACU nurse, the assessment crite-
ria, length of stay and the nurse’s responsibility for discharge back to a surgical ward. No published papers could be
located that reported the use of qualitative research methods to explore how PACU nurses assess a patient’s readiness
to return to the surgical ward. The literature shows a pattern that has changed little over the years. The literature
search conducted for this study failed to produce evidence that PACU nurses are questioning the practices within their
specialty area.
Conclusion: This study concludes that qualitative research is required to explore how PACU nurses assess a patient’s
readiness to return to the surgical ward. There is an identified gap in the literature that is currently available. There is
a need to focus on this area of nursing practice. To build on the foundations that have been established by this research
will move the profession towards best practice, evidence based post anaesthetic nursing care.
Key Words: Assessment, discharge, PACU, post anaesthetic, recovery room.

INTRODUCTION review centred on the assessment of patients that return to a

Accurate assessment of a patient is the cornerstone of sound
nursing practice. This is especially so in situations where the
patient’s condition is unstable or likely to change, and where
potential for the rapid onset of complications exists. The post-
anaesthetic patient, one that has just undergone anaesthesia
and surgery, presents such a situation. The nurse in the Post
Anaesthetic Care Unit (PACU) is required to assess, and make
clinical judgements about the patient’s recovery and his or her
readiness to be transferred out of the PACU to the usually
higher patient to staff ratio surgical ward.
A literature review was conducted with the focus of uncover-
ing how registered nurses assess patients and make clinical
judgements about those patients’ readiness for transfer out of
a post-anaesthesia care unit.
Literature searches related to this topic were conducted on the
NEWCAT, Proquest, Ovid and CINHAL databases using the
search terms of <recovery room nursing>, <nursing assess-
ment in PACU>, <PACU discharge criteria> and <post anaes-
thetic assessment for discharge>. The findings consisted of
primary research (usually journal) publications, and second-
ary textbook publications. The date of publication was limited
from 1983 to 2008 to provide an overview of the topic. Articles
that were not available in full text or from unconfirmed au-
thors were discarded. The large amount of research available
on ambulatory (day only / outpatient) peri-operative nursing
care was not included as the primary focus of this literature
surgical ward.
LITERATURE REVIEW
The main areas of discussion within the literature focus on the
role of a PACU nurse, the assessment criteria, length of stay
and the nurse’s responsibility for discharge back to a surgical
ward. Existing literature suggests that there are two phases
of recovery for a patient who has undergone anaesthesia and
surgery. The initial phase, involving the first two hours, is
considered to be the acute phase and is the focus of the litera-
ture review. The subsequent period of recovery (in hospital
or at home), phase two of the patient’s recovery was not con-
sidered.
THE ROLE OF THE PACU NURSE
As anaesthetic and surgical procedures have evolved, the
need for a specialised nursing service in the acute post-oper-
ative phase was recognised (Radford, 2003). The Australian
Council of Operating Room Nurses (ACORN) (2008, NR6:1)
defines the role of the Post-Anaesthesia Recovery (PAR) nurse
as providing ‘care for patients immediately following an an-
aesthetic (general anaesthesia, sedation or regional anaesthe-
sia), surgery or any procedure that has the potential to pro-
duce life threatening complications’. The role of nurses in the
PACU environment is seen as essential to the safe post-oper-
ative care of the patient (ACORN, 2008; Australian and New
Zealand College of Anaesthetists (ANZCA), 2006; Hatfield &

25
Tronson, 2001). Drain (2003, p 12) supports this by stating
that ‘The most important ingredient in a successful PACU
is a well-educated, highly skilled, flexible nursing staff’. It
appears that the need for professional registered nurses to
provide direct patient care is reinforced by the need to incor-
porate the maintenance of a safe environment and necessary
equipment. As patients that have received an anaesthetic are
extremely vulnerable, the role of the registered nurse in the
PACU is
To meet a need for constant observation of patients by trained
personnel within facilities equipped for specialized care until re-
covery from anaesthesia is stabilized sufficiently for safe trans-
fer elsewhere.(Kohn & Atkinson, 1992, p 28).
What is evident in the nursing textbooks is that the focus of
the PACU nurse is seen to centre on the physiological status
of the patient and related nursing care. This primarily relates
to the promotion of normal respiratory, cardiovascular, and
renal functions, and fluid and electrolyte balance (Hatfield &
Tronson, 2001). Kohn and Atkinson (1992) widen the focus to
include not only the monitoring of ventilation and other vital
signs, but also preventing shock, alleviating pain and admin-
istering intravenous fluids and other therapies. Drain (2003)
adds the need to include general patient comfort, safety mea-
sures, airway management, “ Knowledge of cause of delay in
emergence from anaesthetic”. Administering oxygen therapy,
infection control and providing reassurance. Reporting any
abnormalities to anaesthetists, surgeons or in some cases both,
together with documentation and patient advocacy should
not be overlooked (ACORN, 2008; ANZCA, 2006).
ASSESSMENT CRITERIA FOR DISCHARGE
FROM PACU TO A WARD
Determining guidelines for the care of acute post-operative
patients in the PACU should involve the collaboration of
anaesthetists, surgeons and expert peri-operative nurses to
produce clear guidelines that promote safe practice. ACORN
(2008) and ANZCA (2006) support this approach, as promot-
ing these written criteria produces standards of practice that
can then be measured (Sullivan, 2002; Odom, 2003). ACORN
(2008, NR6:3) requires that written policies for admission
and discharge be present in all functioning PACUs and that
PACU nurses conduct their practice within established poli-
cies, whilst at the same time being able “to utilise appropriate
clinical judgement to improve patient outcomes” (ACORN,
2008, NR6:3) . The nurse is required to assess the individual
patient’s health status and response to care provided.
Fraulini (1987) highlights a change in responsibilities of PACU
nurses when decisions are made to discharge patients back
to the ward environment, by proposing that patients should
only be discharged after vitals signs are stable and an evalua-
tion of the patient’s condition has been made by a responsible
anaesthetist. In other words, the nurse could undertake the
delegated tasks of monitoring patients’ recovery but not take
the responsibility for discharging the patient out of the PACU
environment.
The most common criteria for discharging a patient back to
the surgical ward are stable vital signs; the patient orientated
to person, place and time; satisfactory airway; absence of sig-
nificant bleeding; stabilisation of acute problems and move-
ment of extremities following regional anaesthesia. Hatfield
and Tronson (2001) detailed that the patient must have a sta-
ble pulse rate and rhythm and blood pressure, be conscious
26
and able to lift their head off the pillow, take deep breaths on
command, touch their nose with their forefinger, have pain
relieved, and have no excessive fluid loss from drains or pro-
cedure site. Nevertheless, these authors added that the pa-
tient should also be clean, dry, warm and comfortable, and
have all observations documented. They went further, stating
that all unnecessary equipment should be removed (such as
intravenous lines, electrocardiograph (ECG) connection dots
and diathermy pads), and all post-operative orders and charts
completed for return to the ward. They added that at least
thirty minutes must elapse between the last analgesic admin-
istration and transfer, and that a concise summary must be
written so that ward staff can easily identify any deterioration
(Hatfield & Tronson, 2001).
Other writers have argued that there is very little evidence to
support the requirement for a minimum thirty minute period
from the last administration of opioid or other analgesia and
transfer out of a PACU, indicating that this requirement could
be relaxed in relatively healthy patients (Colwill, 2001).
Reflecting a more holistic approach of the recent years, Bar-
hydt (1996,p.398) goes beyond the focus on the physiological
indicators of recovery and states that “any emotional respons-
es that the patient may be experiencing” must also be docu-
mented and mentioned to staff in the surgical ward at the time
when the patient is discharged from the PACU.
Since the 1980s, such qualitative concerns have been comple-
mented with a growing emphasis on measurable (and thus
standardised) indicators of post-operative recovery. Drain
(2003), for example, discusses using a post-anaesthesia re-
covery score (PARS) to assess the five major areas of: activ-
ity, respirations, circulation, neurological status and oxygen
saturations. Using a zero (inadequate or absent) to 2 (normal)
scale for each of the major areas, they suggest that a patient
needs to achieve a perfect score of 10 to be transferred to the
surgical ward. The anaesthetist, surgeon or both must review
any patient scoring fewer than 10 points. This quantitative
assessment instrument is provided by the Aldrete post-an-
aesthetic scoring system, developed by Aldrete and Kroulik
in the 1970s and since modified for use in the PACU setting
(Drain, 2003).
Hatfield and Tronson (2001) advocate the use of any scoring
system that aims to safely assess the PACU patient. These
authors also present a patient admission assessment instru-
ment (with a 0 – 2 scale), that focuses on respirations, perfu-
sion, power (muscle control), circulation, sedation and tem-
perature. It is extended to include comfort needs in the areas
of pain and nausea assessment. Hatfield and Tronson (2001,
p17) suggest that these parameters provide “objective evi-
dence on which to base quality assessment and educational
programme” in the peri-operative context.
Drain (2003) has drawn attention to the fact that many of the
assessment instruments fail to include other important clini-
cal indicators, such as fluid loss, urine output, oxygen satura-
tion, and body temperature as relevant criteria for discharge
back to the ward. Kiekkas, Poulopoulou, Papahaizi & Soule-
les (2005) confirm that intra-operative hypothermia has di-
rect links to increased PACU length of stay. Ang, Pagan and
Lewis (2002) have endorsed the use of the Aldrete scoring sys-
tem, suggesting that when combined with a systematic ‘head
to toe’ assessment, it could provide adequate assessment for
discharge from a PACU.
The American Society of Anaesthesiologists’ Task Force on
Post-Anaesthetic Care (2002) published a report of their re-
search into the practice guidelines used in the context of post-
anaesthetic care. Data were collected in the form of opinion
surveys, reviews of guideline drafts, a random survey of ac-
tive members, and an open forum. There was supporting evi-
dence that level of consciousness, stable vital signs and specif-
ic discharge criteria for specific types of surgery should be the
basis of guidelines for discharging a patient from the PACU
area. It is relevant to note that voiding, and retaining clear
fluids without vomiting, did not have to be achieved prior to
discharge back to the surgical ward. The reason given was
that voiding or drinking ability were affected only by specific
types of surgery or anaesthesia, and therefore should not have
to be regarded as mandatory. Ang, Pagan and Lewis (2002)
take a slightly different position by proposing that a 2 hour
stay in PACU with a PARS score of 10/10, being pain free, no
complications from surgical site, and a urine output, should
serve as adequate evidence of readiness for discharge to a sur-
gical ward.
None of these authors used qualitative research to explore
what happens in the context of clinical decision-making in the
PACU environment, or to provide any qualitative evidence
for their recommendations. Qualitative, descriptive research
is undertaken with the primary aim of identifying current is-
sues through the utilisation of an holistic approach that places
focus on understanding human experiences from the perspec-
tive of the participants involved (Mills & Sullivan, 2000). This
approach would allow for the experiences of PACU nurses
to be understood from “the inside”, that is, from the perspec-
tive of those making the assessments and clinical judgements,
rather than from the perspective of the observers (Creswell,
1998; Sandelowski, 2000).
LENGTH OF STAY IN PACU
When deciding on the appropriate length of patients’ stay in a
PACU, factors that are usually considered include the length
and type of anaesthetic used, the surgical procedure under-
taken, and any underlying medical condition of the patient.
Kohn and Atkinson (1992) state that patients should remain in
the unit until they have reacted (sic) from anaesthesia and their vital
signs have stabilized. Fraulini (1987) supports this viewpoint,
but takes a pragmatic stance by also mentioning the impor-
tance of having available bed space in the PACU. Such factors
not withstanding, there is general consensus in the literature
for a minimum stay of 1 hour for patients that have under-
gone a general anaesthetic (Fraulini, 1987; Hatfield & Tron-
son, 2001; Atkinson & Howard-Fortunato, 1996.)
Drain (2003, p 38), on the other hand, proposes that individual
patient assessment is more important and required lengths of
stay in the PACU should not be enforced because, “Profes-
sional judgement is required to determine when the patient is
ready for discharge from the PACU.” A report by the Ameri-
can Society of Anaesthesiologists’ Task Force on Post-Anaes-
thetic Care (2002) supports this view, suggesting instead that
the focus should be on stabilising patients’ cardiopulmonary
and neurological functioning, with every patient treated on a
case by case basis.
PROFESSIONAL RESPONSIBILITY FOR
DISCHARGING THE PATIENT FROM A PACU
In most Australian hospitals and elsewhere, it is ultimately
the anaesthetist who is formally responsible for PACU pa-
tients, and for their discharge to general wards. Invariably,
however, such responsibilities are shared with registered
nurses (Kohn & Atkinson, 1992). Fraulini (1987) outlines two
common methods for discharging patients from a PACU. The
direct method involves the anaesthetist assessing the patient
and signing to indicate the patient is fit for discharge. The
indirect method involves a policy and procedure method that
incorporates a clear assessment protocol and specified, mea-
surable levels of functioning that the patients must achieve,
before they can be discharged back to the ward. This method
allows the registered nurse to discharge the patient. As Lunn
(1994) observed, assessment of the patient’s readiness for dis-
charge from the PACU is usually delegated to the nursing
staff that must ensure that the patient is adequately stabilised
before permitting transfer to the ward.
SUMMARY
No published papers could be located that reported the use
of qualitative research methods to explore how PACU nurses
assess a patient’s readiness to return to the surgical ward.
The literature shows practice and thought patterns that have
changed little over the years (Hooper, 2005). The advent of
high dependency units and greater use of intensive care units
for immediate post-operative patient care has affected the
work of PACU nurses in larger hospitals. Management of pa-
tients being transferred to general surgical wards, on the other
hand, appears to have gone largely unchanged. More impor-
tantly, there is a lack of qualitative research that has explored
how PACU nurses make decisions to safely discharge the pa-
tient. As the PACU patient is in a vulnerable position, it is
imperative that nursing practice in this area is based on sound
evidence and clear understanding of the issues involved.
The literature search conducted for this study failed to pro-
duce evidence that PACU nurses are questioning the practices
within their specialty area. For this reason, even a small-scale,
qualitative study, with the aim of gaining insight into, and
understanding of the assessment of PACU nurses as to the
readiness of patients for discharge to a surgical ward, is justi-
fied and timely.
Qualitative research is required to explore how PACU nurses
assess a patient’s readiness to return to the surgical ward. As
there is a gap in the literature that is currently available, fur-
ther research should focus on this area of nursing practice. To
build on the foundations of the work already done will move
forward research into best practice, evidence based post an-
aesthetic nursing care.
Acknowledgements
I would like to thank Professor Irena Madjar for introducing me
to the challenging and interesting world of nursing research. For
your encouragement and guidance I am truly grateful. To Tony,
Luke, Megan, Samuel, my family and friends, I thank you for
your support and understanding. To Dr Tracy Levett-Jones and
Dr Vicki Parker, I thank you for your time, support and encour-
agement in assisting me to take the next step forward in publish-
ing and conducting further research.
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Ang, P., Pagan, A., & Lewis, M. (2002). Determining patients’ readiness for release
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27
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Colwill, B. (2001). Nurse autonomy: Pain control and discharge from recovery. Brit-
ish Journal of Perioperative Nursing, 11(7), 300-306.
Creswell, J. W. (1998). Qualitative Inquiry and Research Design: Choosing Among Five
Traditions. London, Sage.
Drain, C. B. (2003). Perianesthesia Nursing: A Critical Approach. (4th ed). Sydney: W.B.
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Fraulini, K. (1987). After Anesthesia: A guide for PACU & ICU Medical-Surgical Nurses.
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Hatfield, A., & Tronson, M. (2001). The Complete Recovery Room Book. (3rd ed). New
York: Oxford University Press.
Hooper, V. (2005). 20 years of History: Has that much changed? Journal of Perianes-
thesia Nursing, 20(1), 1-2.
Kiekkas, P., Poulopoulou, M., Papahaizi, A. & Souleles, P. (2005). Is postanesthesia
care unit length of stay increased in hypothermic patients? AORN Jour-
nal, 81(2), 379 – 392.
Kohn, M. L. & Atkinson, L. J. (eds). (1992). Berry & Kohn’s Operating Room Technique.
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Lunn, J. N. (1994). Recovery from anaesthesia. British Medical Journal, 308(6932),
804.
Mills, M., & Sullivan, K. (2000). Patients with operative oesophageal cancer: Their
experience of information-giving in a regional thoracic unit. Journal of
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Odom, J. (2003). The Perianesthesia Nurse: Standard Bearer. Journal of Perianesthesia
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Radford, M. (2003). Recovery nursing services: An evolution. British Journal of Peri-
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Sandelowski, M. (2000). Focus on research methods: Whatever happened to qualita-
tive description? Research in Nursing and Health, 23, 334-340.
Sullivan, E. E. (2002). Standards of Perianesthesia Nursing Practice 2002. Journal of
Perianesthesia Nursing, 17(4), 275-276.

Perineal Trauma And Childbirth: A Discussion Paper

Christina Teale, Bn student
School of Nursing & Midwifery, Faculty of Health, University of Newcastle

Lyn Ebert, M Phil (UoN), Midwifery lecturer

School of Nursing & Midwifery, Faculty of Health, University of Newcastle

Carol Ann Norton, Lecturer

School of Nursing & Midwifery, Faculty of Health, University of Newcastle

Abstract
Objective: The aim of this paper is to identify midwifery and medical strategies that reduce pain and morbidity result-
ing from perineal trauma. The question put forward was What midwifery and medical strategies reduce pain and mor-
bidity associated with perineal trauma resulting from birth?
Method: A review of the literature was undertaken. Both qualitative and quantitative research-based literature related
to perineal pain was examined.
Findings: Cold therapy and analgesia reduce pain and oedema in the immediate postnatal period, while pelvic floor
exercises reduce incontinence in the longer term.
Conclusion: Prevention of perineal trauma is most favourable outcome for birthing women. Where perineal trauma ex-
ists, women should be offered analgesia and/or cold therapy to relieve immediate and short-term pain and morbidity.
Longer-term morbidity and the incidence of postnatal incontinence is reduced with adherence to exercise programs.
Midwives must become more proactive in preventative measures that reduce perineal trauma and provide pain relief
strategies when perineal trauma exists.
Key Words: Perineum, Pain, Perineal Trauma, Childbirth

INTRODUCTION initiation of breastfeeding and affect mother-infant bonding.

Perineal trauma contributes to longer term morbidity follow-
ing childbirth (Williams, Herron-Marx, & Hicks, 2007; Nilsen
& Reinar, 2000; Hedayati, Parsons & Crowther, 2003). In 2004,
data revealed that 44.2% of birthing women in Australia sus-
tained first or second degree perineal lacerations, 17% had
an episiotomy (Laws, Grayson & Sullivan, 2006), and 1.3%
had third or fourth degree tears (Laws, Grayson & Sullivan,
2006). These figures indicate that a large number of Australian
women sustain perineal trauma with the potential to cause
pain and the likelihood of longer term complications (Laws,
Grayson & Sullivan, 2006).
For women suffering perineal trauma, pain and oedema are
the most crucial concerns in first few days following birth
(Chiarelli & Cockburn, 1999). These women have an initial
decrease in mobility and the ability to perform daily activities.
Difficulty in sitting as a result of perineal pain may impede the
These restrictions add pressure to new mothers attempting to
socialize into the role of motherhood (East, Marchant, Begg &
Henshall, 2006). Perineal trauma contributes to urinary and
fecal incontinence and sexual dysfunction (Williams, Herron-
Marx, & Hicks, 2007). Up to 60% of women with perineal trau-
ma report pain during intercourse three months after birth,
with 30% experiencing pain at six months (Nilsen & Reinar,
2007).
Perineal wounds requiring medical care and pain manage-
ment may result in longer hospital stays, causing further
stress on women, their families and the health care system
(Laws, Grayson & Sullivan, 2006). Women discharged early
also require extra attention from community midwives for
ongoing management of wounds. Women suffering longer
term postpartum complications are reluctant to seek help, re-
sulting in silent suffering of treatable conditions (Calvert &
Flemming, 2007). There is a possibility that these issues lead

28
to significant psychological problems (Dahlen, Ryan, Homer
& Cooke. 2006).
Prevention of perineal trauma is the best option for birthing
women. Pain and morbidity associated with perineal trauma
have been reduced in the immediate postpartum period as a
result of improved techniques in perineal repair and suture
materials. Research around strategies aimed at improving
perineal well being in the longer term is scarce (Calvert &
Flemming, 2000). A discussion of published research focusing
on perineal trauma follows.
SEARCH STRATEGY
Databases were searched, initially using the terms “episioto-
my” and “perineal trauma”. Wild cards and truncation were
then used to refine the search (Hek, Langton & Blunden, 2000).
Various online nursing and medical journals were searched
(Schneider, Elliot, LoBiondo-Wood, Haber, 2003), and finally
the reference lists of articles accessed were examined for addi-
tional sources of published research (Davies & Logan, 2003).
Initially, only studies published since 1998 were to be includ-
ed. However, an initial search revealed a paucity of material.
A decision was then made to include relevant studies pub-
lished earlier than 1998. Inclusion criteria for studies were
constructed allowing for specific groups, such as primiparous
women birthing vaginally, mulitparous women with previ-
ous perineal trauma (including episiotomy) and women ex-
periencing urinary incontinence. To reduce confounding
variables, exclusion criteria for studies were also set. These
included women with co-morbidity, mothers of stillborn chil-
dren or women with a retained placenta. Studies focusing
on surgical management of perineal repair, such as suturing
materials and techniques were not included.
RESULTS
The search resulted in a number of recurring topics, which
were reviewed according to their relevance and ability to pro-
vide an answer to the question What midwifery and medical
strategies reduce pain and morbidity associated with perineal
trauma resulting from birth? The findings from individual
studies and systematic reviews have been grouped accord-
ing to the focus of the intervention or study. Research around
perineal trauma focused generally on preventative measures,
medication to alleviate perineal pain, alternative and compli-
mentary therapies to reduce perineal discomfit, and pelvic
floor exercises. A discussion of these areas of research fol-
lows.
Preventative Measures
The single most effective means of reducing pain and morbid-
ity associated with perineal trauma is to prevent trauma in the
first place. A systematic review by Beckmann & Garret (2006)
concluded that antenatal perineal massage from 35 weeks
gestation helps reduce perineal trauma during birth and pain
afterwards. The review included three large studies and re-
ported an overall reduction in trauma requiring suturing
(mostly episiotomies) by 9%. The impact of antenatal perineal
massage was clear for primiparous women, but was less clear
for multiparous women (Beckmann & Garrett, 2006).
Two single studies examining intrapartum perineal massage
reavealled no benefit for women in terms of perineal trauma
or postpartum pain (Stamp, Kruzins & Crowther, 2001; Al-
bers, Sedler, Bedrick, Teaf & Peralta, 2005). Positioning of
the woman during labour and birth has been examined with
mixed results. Lithotomy and squatting positions in labour
are associated with increased incidences of anal sphincter
tears (Gottvall, Allebeck & Ekeus, 2007). On the other hand
left sided positioning in labour decreases the rate of perineal
tears (Nicholl & Cattell, 2006).
In Australia a significant improvement in perineal tear statis-
tics was achieved for women requiring interventions during
labour and/or birthing with the implementation of a clini-
cal practice improvement strategy (Nicholl & Cattell, 2006).
The Plan, Do, Study, Act (PDSA) process improved the rate
of perineal tears at Royal North Shore Hospital, Australia.
Clinicians were advised to cease directed pushing during the
second stage of labour. Women were encouraged to birth on
their left side rather than in the lithotomy position and vacu-
um extraction was employed rather than forceps for assisted
birthing (Nicholl & Cattell, 2006).
Medication to Alleviate Perineal Pain
For women who have sustained perineal trauma during child-
birth the best strategies to minimize pain and suffering must
be offered. A systematic review of rectal analgesia following
birth concluded that rectal analgesia provides pain relief for
up to 24 hours with reduced need for further pain medication
(Hedayti, Parsons & Crowther, 2003). A later systematic re-
view by Hedayti, Parsons & Crowther (2005) examined topi-
cally applied anaesthetics and found compelling evidence to
support the use of topically applied medications. Outcomes
were measured up to four days after birth.
Three single studies have examined medication effectiveness
using self-reported numerical pain scores at timed intervals,
and the women’s need for additional analgesia (Corkhill, Lav-
ender & Walkinshaw, 2001; Peter, Janssen, Grange & Douglas,
2001; Searles & Pring, 1998). Participants in all three studies
had recently given birth. They were randomly allocated into
either a placebo or treatment group. There were no substan-
tial differences in the demographics of the sample group.
Searles & Pring (1998) tested rectal diclofenac against a pla-
cebo. Rectal diclofenac provided good pain management for
two days postpartum and reduced the need for additional an-
algesia (Seales & Pring, 1998).
Peter, Janssen, Grange & Douglas (2001) used randomised
groups who were given oral ibuprofen or acetaminophen
with codeine. No variation in efficacy was detected, however
ibuprofen’s ease of use and cost-effectiveness was noted (Pe-
ter, Janssen, Grange & Douglas, 2001).
A double blind randomised control trial comparing 2% ligno-
caine gel with a placebo concluded a reduction in pain at 24
hours after birth for women allocated to the lignocaine group
(Corkhill, Lavender & Wilkinshaw, 2001). Although these
findings contradict the systematic review by Hedayti, Par-
sons & Crowther (2005), the findings were limited to 24 hours
after birth, and the authors state there was no difference in
the need for oral analgesia between the treatment group and
placebo group. Further research into women’s acceptance of
treatments and compliance with self-medication for perineal
pain is required.
All systematic reviews and single studies examined short-
term outcomes. No studies included the impact on initiation
and maintenance of breastfeeding or effects on daily activities
as measured outcomes.
29
Alternative Therapies to Reduce Perineal Discomfit
Alternative or complimentary therapies to reduce perineal
discomfit have also been researched (Steen, Cooper, March-
ant, Griffiths-Jones & Walker, 2000; Hill, 1989; Hur & Han,
2004; Knobloch, 1987). All four studies selected participants
at random.
Outcomes from the studies were derived from subjective
measurements:
two studies relied on midwives’ visual appraisal of the effec-
tiveness of the intervention (Hur & Han, 2004; Hill, 1989);
two studies included patient response as part of the evalua-
tion tool (Knobloch, 1987; Steen, et al. 2000).
When examining the effects of hot and cold therapies, cold
sitz baths were found to provide greater relief (Knoblovh,
1987). Alternating cold and warm perineal packs as opposed
to warm sitz baths resulted in no significant differences in
outcomes for either treatment (Hill, 1989). The inclusion of
aromatherapy in sitz baths proved beneficial in reducing dis-
comfit (Hur & Han, 2004). Maternity gel pads were found to
provide a high level of relief (Steen, Cooper, Marchant, Grif-
fiths-Jones & Walker, 2000).
The findings from these studies indicate that cold therapies
provided some relief from perineal pain, due to numbing of
the local area and possibly reduction of oedema. However
this was not conclusively tested in any of the studies. Treat-
ments were not tested against ‘no treatment’ and as such the
absolute effectiveness cannot be measured. Sample groups
were small, with all the authors discussing the need for larger
studies to confirm findings.
Pelvic Floor Exercises
Pregnancy and birth place great stress on the pelvic floor
muscles. This group of muscles is vitally important for uri-
nary, faecal and sexual well being (Berzuk, 2007). A literature
review by Briggs (2006) concluded that pelvic floor exercise
programs promote compliance and are effective in alleviat-
ing and preventing urinary incontinence (Briggs, 2006). Two
single studies involved random selection of participants into
a postnatal intervention or standard care group, and also re-
ported a reduction in incontinence and reduced severity of
the incontinence. The intervention groups received guided
pelvic floor exercises (Glazener, et al. 2001; Chiarelli, Murphy
& Cockburn, 2002). A study by Reilly, et al. (2002) trialed an-
tenatal supervised pelvic floor exercises. The incidence and
severity of incontinence was reduced.
However Mason, Glenn, Walton & Hughes (2000) suggests
that clinical trials of pelvic floor exercises are unreliable.
Women trained and supported by professionals have higher
compliance rates, which may artificially improve results (Ma-
son, Glenn, Walton & Hughes, 2001; Chiarelli & Cockburn,
2002). Information retrieved through questionnaires indicates
women feel they are given insufficient instructions and rarely
comply with pelvic floor exercise programs without ongoing
support or encouragement (Mason, Glenn, Walton & Hughes,
2000). Self-reporting may result in biased results. For exam-
ple, women may feel uncomfortable reporting incontinence
and women experiencing a negative birth experience may
give prejudicial information (Chiarelli & Cockburn, 2002; Gla-
zener, et al. 2001; Reilly, et al. 2002; Mason, Glenn, Walton &
Hughes, 2000; Chiarelli, Murphy & Cockburn, 2003).
30
DISCUSSION
This paper reviewed current literature in an attempt to an-
swer the question What midwifery and medical strategies
reduce pain and morbidity associated with perineal trauma
resulting from birth?
In order to reduce perineal pain and morbidity associated
with childbirth, health professionals need to educate and be
educated. Women need to be educated about the changes
to and recovery of their perineum during childbirth (Boyle,
2006). Women must be educated in how to assess their own
perineum to ensure good healing, and health professionals
must be knowledgeable regarding the degree of the trauma
and the outcomes for women (Boyle, 2006). Nicholl & Cattell,
(2006) suggest that health professionals need to look towards
evidence when discussing care options with women.
Effective wound care and pain relief must be provided. The
Royal Women’s Hospital clinical practice guidelines (2006)
recommend management of perineal wounds that should in-
clude ice therapy to reduce oedema and laxatives to prevent
constipation. Good perineal hygiene after bowel and blad-
der use reduces the risk of infection (Chiarelli & Cockburn,
1999). The rectal analgesia diclofenac was reported to pro-
vide good pain relief postpartum with no adverse side effects
(Hedayati, Parsons & Crowther, 2003; Searles & Pring, 1998).
Sitz baths provide effective pain relief and contrary to anec-
dotal evidence, do not increase the risk of infection or wound
breakdown (Oladokun, Babarinsa, Adewole, Omigbodun &
Ojengbede, 2000). Although cold sitz baths are reported to
provide greater pain relief, the study indicates that women
prefer warm baths (Boyle, 2006).
Preventative health care as well as long-term perineal well
being strategies should be initiated by clinicans. Pelvic floor
exercises have been shown to assist in alleviating urinary
incontinence associated with perineal trauma (Briggs, 2006).
Correct pelvic floor exercises provide greater blood flow and
increase oxygen to the perineum (Berzuk, 2007).
Implications for Clinical Practice
Health professionals working with birthing women can re-
duce the incidence of perineal trauma by:
• Avoiding the practice of directed pushing with contrac-
tions during the second stage of labour;
• Encouraging women to birth on their left side rather than
the lithotomy position; and
• Performing vacuum extraction rather than using forceps
where possible for assisted birthing.
When perineal trauma exists, women should be offered:
• Cold therapy and/or analgesia for pain relief;
• Laxatives to reduce constipation; and
• Education regarding perineal hygiene and pelvic floor
exercises.
Implications for Education
Health professionals working with pregnant and birthing
women and new mothers must provide advice using evi-
denced-based practice. The care provided should be aligned
with best practice guidelines to ensure optimal perineal well
being during childbirth. Health professionals can be educated
about perineal well being through pre-registration programs,
Mandatory educational sessions, practical workshops (for
perineal suturing techniques), and reflective practice, evaluat-
ing their own care and seeking feedback from women.
Implications for Future Research
Research of postnatal morbidity is limited and further explo-
ration into women’s postnatal experiences is necessary. Re-
search in the following areas may further reduce pain and
morbidity associated with perineal trauma:
• Antenatal interventions aimed at improving perineal well
being prior to birth;
• Birthing practices to reduce the incidence of intrapartum
perineal trauma; and
• Strategies aimed at improving post-birth perineal well
being in the longer term.
Conclusion
Perineal pain and morbidity associated with childbirth can be
reduced. Research examined by this paper’s author supports
the following midwifery and medical strategies that should
be employed to reduce pain and morbidity associated with
perineal trauma.
These are the use of cold therapies to alleviate perineal dis-
comfit and oedema and the use of analgesia postpartum to
relieve perineal pain and reduce short-term complications.
In terms of reducing long-term morbidity, pelvic floor exercis-
es carried out effectively are linked to a reduction in urinary
incontinence. Birthing positions and techniques need to be
further scrutinized. There is an indication that perineal tears
during labour can be prevented by the use of different po-
sitions and techniques. Further research is required around
preventative measures, long-term outcomes, and women’s
experiences of perineal trauma, and treatments.
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31
Reflective Practice And The National Continuing Competency
Framework
Rowena Masson RN, CNE
Clinical Nurse Educator, Division of Medicine, John Hunter Hospital

Ann Katherine Williams, RN PhD

Nurse Educator Division of Medicine, John Hunter Hospital

Abstract

It is proposed that the recommendations of the Australian Nursing and Midwifery Council (ANMC) for a National
Continuing Competence (NCC) Framework (currently in its third draft) be introduced from 2010. One of the more
interesting requirements of the Framework is the need for self-assessment through the practice of reflection.
This article will discuss the recommendations of the ANMC regarding the NCC Framework and briefly outline the
components of the NCC Framework with a specific emphasis on self-assessment. Further, this article will discuss what
reflective practice is, why it is important to nurses, and techniques that can be used to develop the skills for reflective
practice.
Anecdotal evidence suggests that as a concept essential to professional development, reflection is poorly understood,
unexplored or a foreign concept for some nurses and midwives. For those who are familiar with the concept, reflection
is commonly not part of routine practice. The purpose of this article is to begin their journey into reflective practice,
thereby enabling a smoother transition towards 2009.
Key Words: Reflection; Reflective Practice; Reflective Thinking; Critical Thinking; Critical Incident Analysis.

BACKGROUND Professions (http://www.coag.gov.au). As a consequence,

Over two thousand years ago, Socrates, a Greek philosopher,
accused by the Athenian court of ‘failing to acknowledge
the city’s gods, introducing new divinities and corrupting
youth’ (Plato, 1977, p. 31) refused to offer counter proposals
to a death sentence such as imprisonment or exile (West, 1979,
pp. 213 – 214) and died of poisoning by drinking hemlock
(Barrow, 1977, p.1). In his second speech to the court Socrates
claimed ‘the unexamined life is not worth living’ (West, 1979,
p. 217). According to Barrow (1977, p.16), ‘Socrates died for
philosophy, the pursuit of truth and the exercise of critical
thought unhampered by tradition, authority or prejudice’.
From this time, the notion of the ‘unexamined’ life has been
the source of philosophical debate and continues to be relevant
in the twenty-first century along with dialectical reasoning
defined by Burchfield (2000, p. 210) as ‘logical disputation’.
Reflection, essential to an ‘examined life’ is a key concept
in nursing theory and education and a central theme of this
article.
The Australian Nursing and Midwifery Council Incorporated
(ANMC) is ‘a peak national nursing and midwifery
organisation established in 1992 with the purpose of
developing a national approach to nursing and midwifery
regulation’ (ANMC National Competency Standards for the
Registered Nurse, 2008). As stated on the ANMC website,
‘working in conjunction with state and territory nursing and
midwifery regulatory authorities (NMRAs), the ANMC works
to produce national standards as an integral component of the
regulatory framework to assist nurses and midwives to deliver
safe and competent care’ (ANMC National Competency
Standards for the Registered Nurse, 2008).
both the ANMC and the NMRAs have completed a substantial
amount of work on how the national scheme might best be
implemented for nursing and midwifery (Australian Nursing
and Midwifery Council, home page http://www.anmc.org.
au, accessed 5 September, 2008). However as outlined in
the July 2008 edition of NMB update, the scheme has been
deferred for two years and, on current information, the New
South Wales Nurses and Midwives Board will continue to
function until mid 2010 (NMB Update, 11, July, 2008, p.2).
The purpose behind the development of the NCC Framework
by the ANMC was to provide consistency, at a national
level, for the Australian regulating bodies, employers and
nurses/midwives in relation to the clinical abilities of nurses/
midwives. The impetus for the development included
‘increased consumer expectations, demographic and social
changes, changing relationships between health workers,
new technology and a greater focus on research and evidence-
based practice’ (ANMC Continuing Competence Framework,
(Draft II) 2007, p. 1).
Competency is to be evaluated by an assessment process. It
is proposed that from 2009, it will be mandatory to complete
the requirements for the NCC Framework in order to renew
registration to practice in all Australian states and territories.
New South Wales is the only state/ territory that has yet to
introduce similar requirements to those drafted by the NCC
Framework. The components of the NCC Framework are
a Professional Portfolio; Assessment (self-assessment and
performance appraisal); Proof of Continuing Professional
Development (CPD); Hours of Practice and a Declaration of
Continuing Competence (ANMC Continuing Competence
Framework (Draft III) 2008, p. 5).

INTRODUCTION TO NATIONAL The main requirement of the Professional Portfolio is that it

CONTINUING COMPETENCY FRAMEWORK
On March 26, 2008, the Council of Australian Governments
signed the Intergovernmental Agreement (IGA) for a National
Registration and Accreditation Scheme for the Health
32
provides sufficient evidence to demonstrate Competence in
the other components of the NCC Framework. The Portfolio
should include proof of self-assessment and professional
feedback, proof of practice hours, evidence of CPD and
a declaration of self-competence (ANMC Continuing
Competence Framework (Draft III) 2008, p. 5). The nurse/
midwife does not need to submit the Portfolio to ensure
continuing registration, however it may be requested as part
of an auditing process. It is expected that 5% of nurses/
midwives across Australia will be randomly selected and
requested to submit evidence to prove compliance with the
NCC Framework in any given year (ANMC Continuing
Competence Framework (Draft III) 2008, p.13).
If audited, the nurse/midwife will be required to show CPD
of a minimum of 90 hours over three years. That is 30 hours of
in-service or ongoing education that can be proven. They will
also be required to show a minimum of 420 hours of practice
for every three years, equal to 10.5 weeks of full time roster
and there is a pro rata equivalent for part time employees. It
is proposed that the Annual Declaration will be sent out with
Registration renewals. By signing the declaration the nurse/
midwife is stating that they are compliant with the NCC
Framework (ANMC Continuing Competence Framework
(Draft III) 2008, pp. 10 - 12).
Self-assessment is expected to take the form of a declaration
of competence. As stated in the NCC Framework, it is
expected that the nurse/midwife will use reflection to assist
in this process, including the value or impact on practice of
participation in the learning activities (ANMC Continuing
Competence Framework (Draft III) 2008, p.10). Therefore,
it is timely to discuss the emergence of reflection and what
reflection involves.
For a comprehensive overview of the evolution of scholarly
contributions in reflection in Australia see Usher & Holmes
(in Daly, Speedy & Jackson, 2006, p. 104) who acknowledged
Emden, 1991, Gray & Forsstrom, 1991, Cox et al, 1991, Crane,
1991, and Lumby,1991 as key exponents in the field.
Emden (in Gray & Pratt, 1991, p. 335) argued that Reflective
Practice is of “pre-eminent interest to nurses […] and that
to be a reflective practitioner suggests professional maturity
and a strong commitment to improving practice, a reasonable
aspiration for every registered nurse.“ Reflective Practice, as
defined by McGill & Brockbank (2004, p. 94), is a means by
which a professional develops ”the capacity to continuously
engage in critical dialogue about professional activity,
individually and with others” and as “a reflective process that
is constant and continuing”. Given both these definitions, it is
simple to accept that Reflective Practice is a continuous action
that directly affects anyone who is a practitioner.
Similarly, Jasper (2006, p. 53) argued that the benefit to the
profession is in the development of the nursing knowledge
base and in the recognition that nurses are contributing
to both patient care and improved practice surrounding
that care. Further, while reflection, reflective practice and
reflective learning are phrases that in the past have been used
interchangeably, Jasper (2006, p. 43) explains that Reflective
Practice is the foundation upon which reflection and reflective
learning are based. Jasper illustrated this process graphically
with the following Reflective Process equation.
Experience + reflection + learning = change in behaviour/ action.
DISCUSSION ON STRENGTHS AND
LIMITATIONS OF REFLECTIVE PRACTICE
Reflective Practice is not without its critics. Detractors of
reflective practice include Scanlan, Care, & Udod (2002, p. 2 – 3)
who cited recall-related discrepancies as a potential limitation
of the reflective process; Hyrkas, Tarkka & Paunonen-
Ilmonen (2001, p. 505) cite ineffectual practice habits and
ineffective training techniques. Gustafsson, Asp & Fagerberg
(2007, p.155) claim contextual bias where practitioners choose
not to study negative memories and/or choose those that
reflect positive outcomes. A recent Australian contribution
to the debate is that offered by Cotton (2002), who, drawing
on Foucauldian concepts of power-knowledge and discourse
challenges what she refers to as the ‘hegemonic discourse of
reflection in nursing’ and an uncritical acceptance by some
authors that reflection is necessarily good for nurses.
Proponents of reflective practice include Usher & Holmes
(cited in Daly, Speedy & Jackson, 2006 pp. 104 -105) who see
some of the benefits of this practice as assisting the practitioner
to educate their emotions, re-sensitising the practitioner to
marginalised and less fortunate people within our society,
and assisting in the understanding of theoretical relationship
between practice and reality. The two main benefits they
see are that firstly action leads to decision, and secondly that
reflection ‘helps to make you a better person and not just a
better nurse’.
Other supporters include Jasper (2006, pp. 47 – 49) who
argued that the list of benefits of Reflective Practice is long
and includes not only the practitioner but also the patient,
the work environment and the profession as a whole. The
following are the benefits Jasper (2006, pp. 47 – 49) sees for the
individual (nurse) and the patient.
Benefits for the individual
• Ensures you are giving evidence-based care
• Avoids routine practice
• Focuses on patients as individuals rather than cases
• Maximises learning opportunities identifies shortfalls in
your knowledge and skills
• Identifies learning needs
• Values your own good practice
• Continually develops your practice
• Continually develops your own knowledge base
• Creates your own ‘practice theory’
Benefits for patients
• Receiving a better quality of care
• Individualised and evidence-based care derived from
their needs
• Better standards of patient safety
• Improved decision-making
• Care using recent knowledge
• A reduction in the number of adverse patient incidents
(such as drug errors, operating practice errors, falls)
• Higher confidence in professional practitioners
THE REFLECTIVE PROCESS
The reflective process equation is the sum of
Experience+ reflection+ learning = change in behaviour/ action
(Jasper, 2006, p.43).
These elements are examined below.
Experience
Experience includes knowledge that which is learned at a
tertiary level (epistemology) and that which is learned at and
during the process of nursing work (experiential knowledge).
33
Schön (1930 – 1997) an eminent scholar in the field of education
whose seminal work The Reflective Practitioner: How Professionals
Think in Action was published in 1982, differentiated between
the concepts of ‘reflection in’ (1982, pp. 49 – 54) and ‘reflection
on’ (1982, pp. 176 – 278). Schon referred to these processes
as propositional knowledge and knowing in action (1982, p. 59),
the difference between the swampy lowlands of experience,
trial and error, intuition, and muddling through (1982, p. 43),
and the high ground of technical rigour (1982, p. 43). Schon’s
contribution was the ‘development of an epistemology
of practice which placed technical problem solving, also
referred to as ‘technical rationality’, within a broader context
of reflective inquiry’ (1982, p. 69).
Reflection
Beginning with reflection in action, the practitioner makes
every day decisions, reflects on the appropriateness of
responses and continues to work. Reflection in action leads to
reflection on action, the point where the nurse, as practitioner,
needs to take the time to acknowledge their own memories,
emotions and to really look at their own practice. This is
where nurses can learn. This learning affects the working
environment and brings about all of those benefits for nurses
and to their patients (Brockbank & McGill, 2006, pp. 95 - 99).
Learning
Another approach to learning in relation to reflection is
that proposed by Jack Mezirow, whose seminal work,
Transformative Dimensions of Adult Learning was published in
1991. Mezirow argued that transformative theory is based on
the premise that it is not so much what happens to people but
how they interpret and explain what happens to them that
determines their actions, their hopes, their contentment and
emotional well-being and their performance (Mezirow, 1991,
p. xiii). Further, ‘the basis of constructivist transformation of
adult learning is overcoming limited, disturbed and arbitrarily
selected modes of perception and cognition through reflection
on faulty and previously uncritically accepted assumptions’
(Mezirow, 1991, p. 5). For Mezirow, learning from reflection
should lead to a redefining of the individual’s actions and
practice.
REFLECTIVE TECHNIQUES
There are many useful frameworks and tools that have been
devised to allow for and promote the practice of reflection.
One of the simplest is that devised by Borton (1970) and
described by her as the ‘What, so what and now what sequence
a continuous integrated flow that grew out of attempts to
‘systematise intuition’ (Borton, 1970, pp. 93 – 97). The validity
of the model according to Borton ‘relies not only empirical or
scientific proof but on its usefulness in real situations’ (1979,
p. 9). Each of Borton’s three questions can be expanded to suit
clinical situations which lead to reflection.
BORTON’S FRAMEWORK
What….
…Is the problem that I am facing?
…Role was I in during this incident?
…Am I trying to achieve?
…Appropriate actions did I/did I not take?
…Was my response to the incident and that of others?
…Were the consequences for all involved?
…Feelings did this incident evoke for all involved?
34
…Was viewed as a positive or negative outcome of
this incident?
So what…..
…Does this incident tell/teach me about me, my patient
and others? …Does this mean about me, my patient
and others?
…Does this mean about our working relationship?
…Does this mean about the model of care that I am
using, my attitudes and those of my patients?
…Was I thinking of as I acted?
…Did I base my responses on?
…Other knowledge can I bring to this incident:
experiential, personal, scientific?
…Could/should I have done to make it better?
…Is my understanding of the situation?
…Other issues arise from this incident?
Now What….
…Do I need to do in order to improve my nursing
practice and patients care?
…Do I need to do to resolve the negative outcomes
from this incident? …Can I do to enhance the positive
outcomes of this incident?
…Broader issues need to be considered if action on this
incident is to be successful?
…Might be the potential consequences of this action,
both negative and positive?
REFLECTIVE PRACTICE STRATEGIES
Following Borton’s (1970) framework, what are some
strategies that can be used to make answering these
questions less problematic? Strategies within Reflective
Practice include journaling, critical incident analysis, clinical
supervision, poetry, letter writing, story telling, photography
and creative arts. The choice of expressive mode is left up to
the practitioner. There is no correct or incorrect way. There
are however inexperienced and experienced practitioners.
A suggested strategy for the beginner is journaling. The
following technique has been adapted for the purpose from
Usher & Holmes (cited in Daly, Speey & Jackson 2006, pp.
106-107).
Find an environment where you will not be disturbed and
get comfortable. In a book using one side of the page write a
descriptive account of the incident that is being examined. Leave
the other side of the page for later reflection and comments. Be
as vivid and descriptive as possible. Include your remembrances
of emotion, thoughts and reactions to what happened. If you
feel it needed include pictures, diagrams and drawings to help
prompt your memory at a later date.
Critical incident analysis may help practitioners used to
reflective practice. While the term ‘critical incident analysis’
may imply negative connotations, the practice is positive
as it helps bring meaning and significance to an event. The
following technique has been adapted for the purpose of
this article from Usher & Holmes (cited in Daly, Speedy &
Jackson, 2006, pp. 109 -110). This form of reflection allows for
distancing staff from the incident under examination, in turn
allowing a better understanding of that incident. It works very
well if used in conjunction with the questions from Borton’s
(1970) framework.
Describe the incident under review. Be clear and concise.
Outline the reasoning for the choice of this incident and why
 you feel it is in need of review. Identify any issues relating to
this incident that stand out more than others. Reflect on those
points and decide within your own mind your involvement,
the involvement of others, any ethical or moral issues that need
addressing, and the rational for any action to be taken.
Once the nurse as a practitioner of Reflective Practice develops
basic proficiency and understanding of the practice of reflection
there are many simple micro-cues that can be utilised. One
such form of micro-cueing is the 5WH technique (Jasper, 2006,
p. 69). This is a basic six question technique that asks what,
why, when, where, who and how. The use is simple in that
the word cue initiates the reflective process offering guidance
and focus to the topic.
5WH Technique
‘What’ questions help with the selection of the incident to
be written about or reflected upon. “Why’ questions focus
attention onto the importance of reflecting on this incident.
‘When’ questions attempt the planning of an appropriate time
for reflection. ‘Where’ questions the availability of needed
equipment and space. ‘Who’ questions the need for someone
else’s involvement. ‘How’ questions the learning achieved
from the reflective incident (Jasper, 2006, pp. 69 - 72).
CONCLUSION
The Australian Nursing and Midwifery Council’s draft
National Continuing Competence Framework clearly
outlines the expectations that nurses and midwives become
reflective practitioners and use reflection for the benefit of
their professional development. Nurses need to become
comfortable with reflection on and of their practice in order
to use the process for their own benefit as well as the benefit
of the recipients of their care, their workplace and for the
advancement of the profession. This article has overviewed
the importance of reflective practice within the confines of
current practice and has suggested strategies for reflection.
Acknowledgements: With special thanks to Nicky Churms
CNC BDH for her assistance in the preparation of this article
References
Australian Nursing and Midwifery Council Homepage (http://www.anmc.org.au)
Australian Nursing and Midwifery Council (2008). National Competency Standards for
the Registered Nurse.
Australian Nursing and Midwifery Council (ANMC) (2007). Continuing Competence
Framework (Draft II).
Australian Nursing and Midwifery Council (ANMC) (2008). Continuing Competence
Framework (Draft III).
Australian Nursing and Midwifery Council [ANMC] (2007). National Continuing
Competence Project: Progress Summary, December 2007 ANMC: Dickson,
ACT.
Barrow, R. (1977). The apology of Socrates. London: Joint Association of Classical
Teachers.
Borton, T. (1970). Reach, teach, touch: student concerns and process education. New York:
McGraw Hill.
Brockbank, A., & McGill, I. (2006). Facilitating reflective learning through mentoring and
coaching. Philadelphia, PA: Kogan Page.
Burchfield, R. W. (2000). The New Fowler’s Modern English Usage. New York: Oxford
University Press.
Cotton, A. H. (2002). Private thoughts in public spheres: issues in reflection and
reflective practices in nursing. Journal of Advanced Nursing 36(4), 512 –
519.
Council of Australian Government website (http://www.coag.gov.au)
Emden, C. (1991). Becoming a reflective practitioner. In G. Gray., & R. Pratt (Eds.)
Towards a discipline of nursing (pp. 335  354). Melbourne: Churchill
Livingstone.
Gustafsson, C., Asp, M., & Fagerberg, I. (2007). Reflective practice in nursing care:
embedded assumptions in qualitative studies. International Journal of
Nursing Practice, 13, 151-160.
Hyrkas, K., Tarkka, M., & Paunonen-Ilmonen, M. (2001). Teacher candidates’ reflective
teaching and learning in a hospital setting  changing the pattern of
practical teaching: a challenge to growing into teacherhood. Journal of
Advanced Nursing, 33(4), 503  511.
Jasper, M. (2006). Professional development, reflection and decision making. Oxford UK:
Blackwell Publishing.
McGill, I., & Brockbank, A. (2004). The action learning handbook. London: Rouledge
Falmer
Mezirow, J. (1991). Transformative dimensions of adult learning: San Francisco: Jossey
Bass.
NMB update (2008). Sydney: New South Wales Nurses Registration Board, 11, 2.
Plato (1977). The last days of Socrates: Translated by H. Tredinnick and H. Tarrant.
London: Penguin.
Scanlan, J., Care, W., & Udod, S. (2002). Unravelling the unknowns of reflection in
classroom teaching. Journal of Advanced Nursing, 38(2), 136- 143.
Schon, D. (1982). The reflective practitioner: how professionals think in action. New York:
Basic Books.
Usher, K.,& Holmes, C. (2006). Reflective practice: what, why and how. In J. Daly, S.
Speedy., & D. Jackson (Eds.). Contexts of nursing (2nd ed.). (pp. 99 113).
Melbourne: Churchill Livingstone.
West, T. G. (1979). Plato’s apology of Socrates: an interpretation, with a new translation.
London: Cornell University Press.
35
Clinical Focus
What Really Happens to the Siblings of the Chronically Ill Child?
Dianne Cotterell, RN, MN, Oncology Cert, Haematology Cert.
Clinical Nurse Consultant,. Children’s Cancer and Haematology Service, John Hunter Children’s Hospital
INTRODUCTION
The sudden diagnosis of cancer in a child or adolescent brings
on new significant stressors for each patient and their family.
The situation is very real and immediate, with hospital
admissions, many tests and procedures to be done even before
the administration of chemotherapy commences. Some of
these patients may spend up to 2 months as inpatients for
their first admission. Parents’ focus tends to shift to their sick
son/daughter and often the siblings have to take a back seat.
This article outlines practices at the John Hunter Children’s
Hospital which are aimed at supporting the siblings of children
and adolescents with cancer after the initial diagnosis period.
LITERATURE REVIEW
A search in the Ovid database using the search terms siblings
of children with cancer, siblings, and children with cancer
identified fifty-five articles. The general theme of these articles
is the detrimental effects siblings may experience when their
brother/sister is newly diagnosed with cancer. These articles
discuss current research and its findings, including reduced
emotional support, poor self-concept, depression, sorrow,
anxiety and impaired cognitive and emotional quality of
life. Alderfer, Labay and Kazak (2003) reported on their
investigation into post traumatic stress (PTS) in siblings of
childhood cancer survivors. Participants included seventy-
eight adolescent siblings of adolescent cancer survivors
who completed self-report measures of anxiety, PTS and
perceptions of the cancer experience. They identified that 49%
of their sample reported mild PTS and 32% reported moderate
to severe PTS. A quarter of the sample indicated that they
thought that their sibling would die during treatment and over
half found the cancer experience scary and difficult. Further,
Woodgate (2006) described the results of her longitudinal
qualitative study that involved thirty sibling participants.
These siblings took part in individual interviews, focus group
interviews, and participant observation. For these siblings,
cancer was experienced as a different way of being within the
family and involved siblings undergoing a loss of a family
way of life and a loss of self within the family.
KEY FEATURES OF THE PATHWAY
Based on these finding, the paediatric oncology unit at the
John Hunter Children’s Hospital introduced a Siblings Day.
This is a day that is totally dedicated to siblings and where
attention is paid to having fun, learning more about hospital
procedures and learning more about themselves and their
peers. Evaluation of the programme indicates that many of
these siblings believe that they are the only person to have
a brother/sister with cancer. The programme for the day
is conducted collaboratively between the social worker,
play therapist and the author. This day incorporates visits
to the Operating Theatre (OT) as many of the siblings of
the programme participants have a significant number
of trips to the OT for procedures. The siblings are given
masks, hats and shoe covers that they are able to play with
later in the day when we visit the Paediatric Oncology Day
Unit. One very important unit visited during the day is the
36
Pharmacy Department. The siblings see the Pharmacist in
the sterile room dressed in appropriate personal protective
equipment (PPE) making the chemotherapy. Evaluation of
the programme indicates that they think this is “pretty cool”
and they get a better understanding of the chemotherapy and
its significance. The participants also spend some time in the
Day Unit where they play with medical equipment (under
supervision). During this period of play they try out being
the patient, the nurse and the doctor.
After lunch there are much more serious themes to the day.
The participants discuss their concerns, such as the death of
their brother or sister, or lack of attention from Mum/Dad.
They then break into age appropriate groups and discuss
these issues.
Evaluation of the programme indicates that many of these
siblings feel a real loss of support. They are helped to elaborate
on this by using visual tools, for example, smiley/angry faces
that they may identify with and enable them to pinpoint
what makes them angry/happy or sad. One participant
commented in relationship to this “I can’t go to cricket or
football practice because my parents are busy with my
sibling”. The second face on the tool we use is the worry face
which has assisted siblings to describe their worries including
“Will my brother/sister survive?”, “Will their cancer grow
back?”, “Was it my fault that they are sick?”, “Can I catch the
disease and will my Mum ever stop crying?” The third face is
the sad face. Siblings also indicate the sorrow that they feel
for their brothers/sisters. Their sadness includes the general
loss of “normalcy” of family life. Lastly, the happy face helps
siblings to identify the joy they feel when the end of treatment
occurs. Some siblings have identified that the fact that their
brothers/sisters have survived is a reason to celebrate. Mostly
happiness has been identified as the family being together
again doing “normal” things including going on holidays and
participating in school, church and play.
CONCLUSION
There is research evidence regarding the stresses experienced
by, and ways of coping used by siblings of childhood cancer
patients. The evaluation of the John Hunter Children’s
Hospital programme indicates that it is contributing to
helping this group of children with their significant issues
and anxieties. Unfortunately hospital staff struggle with
the private conversations that the siblings have with them
in terms of privacy and confidentiality and how staff should
manage the sibling’s information. Our current practice is to
give feedback in general terms to parents. The staff are in a
position of trust with the siblings who may tell their concerns
with the belief that their secrets will be safe. This does not
negate the legal responsibility of staff in terms of mandatory
reporting for child protection.
References
Alderfer, M., Labay, L. & Kazak, A. (2003). Brief Report: Does Posttraumatic
[sic] Stress Apply to Siblings of Childhood Cancer Survivors. Journal of Pediatric
Psychology, 28(4), 281-286.
Woodgate, R. (2006). Life is never the same: childhood cancer narratives. European
Journal of Cancer Care, 15(1), 8-18.
Mind Essentials – Mental Illness Nursing Resource
Katie McGill, M. Psych (Clin)
Program Manager, Hunter Institute of Mental Health
LAUNCH OF MIND ESSENTIALS
In November 2008 the Hunter Institute of Mental Health
(HIMH) released MIND Essentials a new online resource for
nurses and midwives working in hospital and community
settings across the Hunter New England region. MIND
Essentials provides nurses and midwives with practical
information and strategies for supporting people in their care
who present with behaviours related to a range of mental
health issues. The resource is freely available online (via both
the HIMH website and Nursing and Midwifery homepage on
the Hunter New England Health Intranet), as well as in hard
copies that are located within each ward and service across
the Hunter Region.
The MIND Essentials project was born out of an identified
need within the Hunter New England Area Health Service
(HNEAHS). This was the need for a range of easily accessible
and user friendly resources, that could have a positive
impact on nurses’ and midwives’ confidence and competence
in providing professional assessment and care to people
presenting with mental illness.
Funded through the Hunter New England Health Nurse and
Midwife Strategy Reserve Funding, the objectives of MIND
Essentials are to:
1. increase nurses’ and midwives’ knowledge and
understanding about common mental disorders, the
symptoms associated with the disorders and their
treatment;
2. promote positive attitudes towards nursing people
with mental illness and hence possibly reduce the stress
involved in providing nursing care; and
3. promote best nursing practice by communicating
strategies that can be used by nurses for the management
of behaviours that can be associated with mental disorders
including mania, depression, delusions, hallucinations,
refusing to eat, suicidal thinking and aggression.
BACKGROUND TO THE PROJECT
One in five Australians will experience a mental illness
(Australian Bureau of Statistics, 1998). Persons with mental
illness use general hospitals for a range of health care services,
along with the rest of the community. Thus, nursing staff
require an understanding of a patient’s psychiatric condition
and treatment in order to support the management of the
illness while in hospital, irrespective of the reason for the
patient’s admission (Sharrock & Happell, 2006). This is not
dissimilar to the support required to maintain a patient’s usual
treatment for chronic illnesses such as asthma and diabetes.
In addition, admission to hospital or experiencing a physical
illness may act as a stressor resulting in the exacerbation of
a person’s psychiatric symptoms (Sharrock & Happell, 2006).
Therefore understanding of symptoms of mental illness and
how to respond is essential for the delivery of good quality
health care.
Psychiatric patients when they are unwell are also more
likely to present or be taken initially to the Emergency
Department of a General Hospital where nursing staff
usually do not have specialist training in mental health (NSW
Health, 1998). In primary care, there is a nation-wide trend
towards employment of Practice nurses (Annells, 2007) who
may have limited training or experience in working with
patients who are mentally ill, yet potentially these patients
may require a large proportion of their workload. Nurses
working in primary, community or hospital settings are likely
to encounter frequent presentations of mental illness in their
routine work.
Research on the attitudes of health care staff to patients with
mental illness has identified that presentation of mental illness
can be associated with responses of fear, anxiety and anger
(Bailey, 1998; Brinn, 2000). Stigma associated with mental
illness can also mean that consumers are treated differently
once it is known that they have been diagnosed with mental
illness (Kuey, 2008). However, a range of studies (Reed &
Fitzgerald, 2005; Payne et al., 2002; Kolodziej & Johnson,
1996) has shown that levels of confidence and comfort in
working with people with mental illness increase when health
care workers are provided with information and when they
experience positive contacts with consumers. This highlights
the important role that practical information resources and
opportunities for positive consumer contact can have in
supporting nurses.
However, one of the problems facing nurse educators nation-
wide is the difficulty experienced by employers in releasing
nursing staff to attend face-to-face training (Cleary & Walter,
2006). Information available online is seen as one solution to
this problem.
The design of MIND Essentials as a free online resource was
seen as an appropriate response to providing clear, relevant
and practical mental health information for nurses and
midwives working within the Hunter New England Region.
POTENTIAL BENEFITS OF MIND ESSENTIALS
The MIND Essentials resource is particularly aimed at those
nurses and midwives who have not had specialised training
or wide experience in mental health. Benefits of using the
resource may include: increased confidence and comfort in
nursing people who have a psychiatric diagnosis; decreased
work-related stress; and increased job satisfaction. For nursing
and practice managers, the resources may provide a means
of supporting staff who experience discomfort or express a
lack of confidence in caring for people who have a psychiatric
diagnosis. For persons with mental illness, the resource may
potentially decrease the impact of stigma associated with
having a psychiatric diagnosis.
The Hunter Institute of Mental Health encourages all nurses
and midwives to use these resources as a way of improving
knowledge and ensuring that the nursing care provided to
our patients, including those with mental illness, is the best
possible.
37
MIND ESSENTIALS RESOURCE CONTENT
The MIND Essentials resource covers a range of mental health related information and is divided into the following four
sections outlined in table 1.
Table 1: Sections of mental health related information

Section 1. Information Section 2. Information on caring Section 3. Assessment Section 4.

on caring for a person for a person presenting with tools Consumer stories
experiencing a mental behaviours, features or symptoms
illness that may be associated with the
presence of a mental illness

Topics include: Topics include: Tools and information Stories about general
o Anxiety o Aggressive or violent that can be used to help hospital experiences
o Delusions behaviour inform a person’s care by people with a
o Dementia o Intoxication and management plan mental illness, who
o Depression o Suicidal behaviour include: have attended the
o Eating disorders o Psychosocial hospital for reasons
o Hallucinations assessment other than their
o Mania o Drug and alcohol psychiatric illness
o Mental illness within assessment
the perinatal period o Suicide risk
o Personality disorders assessment

References
Australian Bureau of Statistics. (1998). Mental health and wellbeing: profile of adults,
Australia – 1997 (No. 4326.0). Canberra, Australian Bureau of Statistics.
Annells, M. (2007). Where does practice nursing fit in primary health care?
Contemporary Nurse, 26(1), 15-26.
Bailey, S.R. (1998). An exploration of critical care nurses’ and doctors’ attitudes
towards psychiatric patients. Australian Journal of Advanced Nursing,
15(3), 8-14.
Brinn, F. (2000). Patients with mental illness: general nurses’ attitudes and
expectations. Nursing Standard, 14(27), 32-36.
Cleary, M. & Walter, G. (2006). Educating mental health nurses in clinical settings:
tackling the challenge. Contemporary Nurse, 21(1), 153-157.
Kolodziej, M. & Johnson, B. (1996). Interpersonal contact and acceptance of persons
with psychiatric disorders: a research synthesis. Journal of Consulting and
Clinical Psychology, 64, 1387-1396.
Kuey, L. (2008). The impact of stigma on somatic treatment and care for people with
comorbid mental and somatic disorders. Current Opinion in Psychiatry,
21, 403-411.
NSW Health. (1998). Working group for mental health care in emergency departments
– final report and recommendations. Sydney: Better Health Publications
Warehouse. Retrieved 15 October 2008 from http://www.health.nsw.
gov.au/pubs/1998/pdf/working980083.pdf.
Payne, F., Harvey, K., Jessopp, I., Plummer, S., Tylee, A., & Gournay, K. (2002).
Knowledge, confidence and attitudes towards mental health of nurses
working in NHS Direct and the effects of training. Journal of Advanced
Nursing, 40(5), 549–559.
Reed, F. & Fitzgerald, L. (2005). The mixed attitudes of nurses to caring for people
with mental illness in a rural general hospital. International Journal of
Mental Health Nursing, 14(4), 249-257.
Sharrock, J. & Happell, B. (2006). Competence in providing mental health care: a
grounded theory analysis of nurses’ experience. Australian Journal of
Advanced Nursing, 24(2), 9-15.

Useful Resources for Writers

Nurse Author & Editor is an international publication dedicated to nurse authors, editors and reviewers. Each
issue of Nurse Author & Editor consists of articles offering advice on writing quality manuscripts, avoiding rejection,
finding publishing opportunities, editing and reviewing. Also included are short articles to update readers on new
developments in nursing journals and journal publishing. Web address is: http://www.nurseauthoreditor.com

Writing for publication: References and Resources is a pdf document available on the Nursing and Midwifery
HNE Health Intranet site and contains an extensive list of resources and references on writing for publication.
The document is available from the following intranet web address: http://intranet.hne.health.nsw.gov.au/nm/
HNEHandover

38
Conference Review Report on 1st NUS-UH Conference: Advanced Practice Nursing in
Lorna MacLellan, RN, MN, MNP
Convenor of Master of Nursing (Nurse Practitioner) Program
Dr Pamela van der Riet RN, ICU/CCU cert, Dip Ed(Nursing), BA, MEd, PhD
Deputy Head of School University of Newcastle
The 1st National University of Singapore (NUS) and University of Hawaii at Manoa (UH) Conference: Advanced Practice Nursing
in Multicultural Environments took place at the Alice Lee Centre for Nursing Studies in Singapore from 27-29 May 2008. The
conference was attended by almost 200 nurses representing 19 countries. This paper reports on the keynote address and two
plenary presentations from the conference.
THE GLOBAL EMERGENCE OF ADVANCED
NURSING PRACTICE
The keynote address was presented by Ms Madrean Schober,
a qualified primary health care Nurse Practitioner (NP) who
has been closely involved with the implementation and further
development of the NP role for over 20 years. Madrean is a
Visiting Fellow at the NUS and Past Chair of the International
Council of Nurses (ICN): International Nurse Practitioner/
Advanced Practice Nursing Network (INP/APNN). She is
widely respected internationally for her involvement with the
ICN and for her extensive contribution to the nursing literature
on the topic of advanced nursing roles. She is co-author of
Advanced Nursing Practice (2008) published by Blackwell.
The United States is recognised as being the first country to
implement advanced practice roles in the mid 1960s but
Canada, Thailand and Botswana were also pioneers in this
field in the early 1970s. In each of these countries, the role
was primarily introduced in response to health care reforms
and nurses with expertise in specialty areas of practice were
seen as a solution to the problem of an overburdened health
care system.
The ICN network has been attempting to estimate the
global development of the role but has been restricted by
the confusion in nomenclature and in poor role definitions.
However, an initial survey in 2001 demonstrated that 33 of
the 40 countries that were surveyed identified an advanced
practice role which required the registered nurse to undertake
postgraduate education. A further project in 2007 indicated
that 14 out of 18 countries surveyed have some form of
advanced practice role.
Nurse practitioner roles have now been successfully
implemented in most developed countries around the world
including Australia, New Zealand, the United Kingdm, United
States, South Africa, Jamaica, the islands of the Western Pacific,
Hong Kong, Singapore, Japan, the Nordic countries, Spain,
Switzerland, Latin America and many others. “The history and
stories behind these successes rest on the shoulders of pioneers and
committed individuals with vision” (Schober & Affara, 2008).
Each country is trying to clarify what advanced nursing
practice is now and what potential it has to meet the needs of
the future. The ICN network is planning to undertake a more
comprehensive survey later in 2008, which may further clarify
the global situation.
In an attempt to achieve uniformity and international
standards the ICN (INP/APNN) has developed International
Multi-cultural Environments 28 May 2008, Singapore
Guidelines which have recently been released. These are
available from the ICN website on http://icn.ch and include
The Scope of Practice, Standards and Competencies of the Advanced
Practice Nurse and the Nursing Care Continuum Framework and
Competencies.
PROMISING RESULTS FOR THE
CHRONICALLY ILL IN THE NETHERLANDS BY
ANP/NP SERVICES.
This paper was presented by Professor Petrie Roodbol,
Professor of Applied Science in Nursing and Head of the
Weckbach Institute, The Netherlands. Petrie is President elect
of the ICN (INP/APNN) and will commence her presidency
at the bi-annual conference in Toronto, Canada in September
2008.
Nurse Practitioners were implemented in The Netherlands
in 1997 in response to a shortage of medical staff, the need
for continuity and coordination between clients and health
professionals and the lack of career opportunities for
clinical nurses. There was no opposition to the role and its
implementation was “virtually noiseless”. As the NPs are
dependent on medical staff for training, the implementation
of the role has been a positive move towards collaboration
between the two disciplines. NPs are recognized by other
health professionals as being experts in their field, well
educated, excellent role models for junior medical staff and
nurses, effective communicators and advocates for patient
friendly care.
There are now over 2,000 NP roles in The Netherlands and
educational programs are offered in nine cities. Research
shows that the NP role encourages patient self management,
improves patient’s quality of life and is cost effective. Similar
to other western nations it is predicted that by 2030, twenty-
five 25% of the population in The Netherlands will be over
65 years of age. Planning is underway to ensure that the
population is appropriately cared for by multi-disciplinary
health care teams with the NP being recognized as a vital
member of that team.
GLOBAL CHILD HEALTH ISSUES, LOCAL
SOLUTIONS: ADVANCED PRACTICE
PAEDIATRIC NURSING
Dr Victoria Niederhauser, from the University of Hawaii
at Manoa presented the third paper of the conference.
Niederhauser is a Paediatric NP who is convenor of the
Paediatric NP program at UH so is well qualified and respected
within the specialty. She discussed the historical perspectives
of the Paediatric Advance Practice Nurse (APN) role which
39
began in the 1960s under the leadership of Dr Loretta Ford,
the first NP in the United States. Dr Ford identified a need for
paediatric nurses to provide a higher level of care to children
who were disadvantaged by living in rural and underserved
communities. She developed an educational program which
combined well child care, patient education and preventative
health care as well as research training to support an advanced
level of clinical practice.
Dr Niederhauser highlighted the current childhood global health
issues, in particular nutrition, congenital conditions, infectious
diseases and mental health. APNs are in a perfect position
to improve the outcomes for many of these children. Their
contribution positively affects the morbidity and mortality of
their patients by working within their communities to promote
and maintain good health.
Dr Loretta Ford, the first Nurse Practitioner in the United States
had a vision that:
Advanced Practice Nurses would become the nurse for all settings
and a vital part of the healthcare team; Serving [sic] patients of all
ages, at all stages of living and dying, with all kinds of needs, and
in all settings around the world. (Silver, Ford & Stearly 1967)
The role of the Advanced Practice Nurse has been demonstrated
to be an accepted part of the healthcare system both in Australia
and overseas. The Advanced Practice Nurse has an important
role globally in our healthcare communities in the provision
of holistic and preventative care. It is argued that advanced
practice roles are not fully utilized and that these roles are
evolving and have the potential to offer much more to meet the
changing needs of healthcare in the future.
References
Schober, M., & Affara, F. (2008). Global perspectives on advanced nursing practice,
in L. Joel (Ed) Advanced Practice Nursing, 2nd Edition, Sage Publishing
Silver, H.K., Ford, L.C., & Stearly, S.G. (1967). A program to increase health care for
children: the pediatric nurse practitioner program. Pediatrics, 39, 756-760
Local Interest
Centre for Practice, Opportunity and Development – Focus on
Stewardship
The Nursing and Midwifery Centre for Practice, Opportunity
and Development (CPOD) was established in November
2006 with the appointment of Clinical Nurse consultants with
expertise in research and practice development. Its main aim
is to increase nurses’ use of clinical research by supporting and
guiding individuals and groups of clinicians to develop their
capacities in research, education and technological expertise.
Since its inception, CPOD has facilitated the implementation
of a number of research and practice development projects
that are focused on improved patient and practice outcomes,
supported funding applications and run workshops in
collaboration with the Centre for Education and Nursing
Research in Child health (cENRiCH) for nurses and midwives
across the Hunter New England Area Health Service.
For the Centre to achieve its aims it is essential to build interest
and capacity amongst clinicians at all levels, particularly
Reflections by stewardees
Pui Ling ( Iris) Li, RN, MN (Gerontic), Dip of Nursing,
RN Nephrology, John Hunter Hospital
In this paper I provide a brief discussion on my experience
with a stewardship program offered through the Centre
for Practice, Opportunity and Development (CPOD) and
supported by the Division of Medicine at the John Hunter
Hospital (JHH).
When I was studying the Master of Nursing (Gerontic) at
the Victoria University of Technology from 2003 to 2005, I
learned about evidence-based practice (EBP) and carrying
out literature reviews and minor research studies in order
to improve my knowledge about the care of older people.
My interest in research was developed at that time. I believe
research is the key to quality care for older people and that
much work needs to be done in this area. I saw the stewardship
as a way of building my research knowledge and skills.
Once selected for stewardship I negotiated with my Nurse
Unit Manager (NUM) to do the program one day per week.
As I was interested in the care of older people in an acute
care setting, I decided to take part in a project relating to the
Older Person Model of Care (OPAC) (Peek, Higgins, Milson-
Hawke, Harper, McMillan, 2007). I had my first meeting with
Professor Isabel Higgins where we discussed my goals for the
stewardship. I left this meeting excited and optimistic about
being part of one of the important projects being offered.
MY GOALS
My main goal was to contribute to improving the quality of
care and services at the JHH by learning to do research and
at ward and unit level. To this end a stewardship program
has been established for clinicians who have an interest in
extending their expertise in research processes and facilitation
of practice development. This scheme offers mentorship and
guidance from staff in the unit and the opportunity to be
part of a research team. Stewardees are expected to engage
in research and practice development activities including
literature reviews, ethics applications, running focus groups
and interviews, analysing data, writing research reports and
writing for publication.
On return to their ward, stewardees are expected to take a
leadership role in practice change projects and to remain a
vital part of CPOD’s team and its activities.
implementing EBP. In particular I wanted to be able to:
• Identify and define a researchable problem
• Locate and critique EBP data sources
• Search and review the relevant literature
• Select an appropriate study design
• Write a project proposal
• Compile and submit an ethics application
• Apply for research funding
• Develop skills in data collection
• Design, develop and pilot a survey
• Design focus group interview questions
• Facilitate focus group(s)
• Set up a data base and enter data
• Store and retrieve electronic data
• Data analysis
• Write a research report and paper for publication
• Enhance skills in presentation
• Improve my leadership and communication skills
• Reflect on my learning by keeping a reflective journal
THE PROJECT: EVALUATION OF THE
DELIRIUM PILOT STUDY ON WARD J3
Of the projects offered through CPOD I felt I could learn and
contribute a lot from doing an evaluation of a delirium pilot
project conducted in ward J3 in 2007. A research team was
41
formed and I was invited to act as the project leader under the
supervision of Professor Higgins.
My first job was to update my knowledge by doing a
literature review and to start writing the research proposal
for the project. I found that reviewing the literature was an
interesting process. Reading a substantial number of studies
helped me to understand more about the topic. I found that it
was useful to write down the critical points whenever I came
across them and as they related to the project. From reviewing
the literature to writing the research proposal I realised that
doing research raised many factors for me to consider.
REFLECTIONS ON THE CHALLENGES AND
HIGHLIGHTS
Conducting research is challenging. I found that you have to
be able to foresee problems about research design and learn
to solve them. It was interesting to see that questions could
emerge at different phases during the research. For example,
I did not see the problems with my chart-auditing tool until
I tested it on the ward, and I did not anticipate the problems
in my survey questions until I consulted others. I realized
that carrying out research requires teamwork: the processes
of discussing, clarifying and reflecting with my mentor
and other members of the team were very valuable. Open
communication is very important for success of the project.
Reflections by stewardees
Kelvin Smith, RN, Graduate Certificate Intensive Care, Masters in Nursing
Clinical Nurse Consultant, Intensive Care, John Hunter Hospital
Tell me, I’ll forget, show me, I may remember but involve me and
I’ll understand (Chinese proverb)
During 2007 - 2008 I was fortunate to be given an opportunity
to work in a stewardship role with the Nursing and Midwifery
Centre for Practice, Opportunity and Development (CPOD).
I undertook the stewardship for half my time whilst still
performing my Clinical Nurse Consultant (CNC) role in
Intensive Care Unit (ICU) for the other half. Over a period
of six months I worked with the CPOD staff, commenced my
own project and assisted in the development of other projects.
It was envisaged that the stewardship would go beyond the
allocated timeframe and that I would continue to maintain
a strong link with and gain part ownership in the CPOD
model. Below is a narrative of my experience and how this
has provided a pathway for my professional development.
The opportunity to take part in the stewardship was
invigorating and I began the experience with my mind full of
ideas. Like most nurses I had an abundance of ideas but lacked
time and focus to translate them into practice. Unfortunately
this can lead to the uncertain habit of pondering and over
thinking what may be a good project or area of interest. It
became evident to me that it was time to get on with the job
and actually do something. For me this was research. Part
of the requirement for my role as Clinical Nurse Consultant
is involvement in research, and here was an opportunity to
involve myself in more than just the project itself. Projects
require structure, teamwork, leadership and many individual
skills to see them flourish. The time spent in the stewardship
42
I was quite nervous about leading the focus group, as it was
my first time. However, my anxiety was lessened after my
mentor explained what I should say and do as a facilitator and
reinforced the questions that needed to be asked and what
data we should seek. In addition, my mentor accompanied
me, which made me feel more comfortable. Because the focus
group interview was so positive it made me see the value of
doing action research even though it can be time consuming.
CONCLUSION
My stewardship program will finish in October 2008. I
have achieved most of my stewardship goals and I am now
preparing the report of this evaluation study as a publication
for a peer-reviewed journal. By looking at the outcomes of
the study, I am more determined to undertake research and
participate in practice development. Improving the quality
of care and outcomes for older patients is my ultimate vision
and responsibility as a nurse.
Reference
Peek, C., Higgins, I., Milson-Hawke, S., Harper, D., McMillan, M. (2007) Towards
innovation: the development of a person-centred model of care for older
people in acute care Contemporary Nurse Journal. 26(2): 164-176.
with CPOD and the wonderful role modelling provided by
the CPOD staff has helped me reflect on my own leadership
style, and assisted in my coordination of the research project:
Toward prevention of unplanned readmissions to the ICU of a major
tertiary hospital. A mixed method approach.
Evidence has shown that patients readmitted to ICU have
poorer outcomes. Characteristics such as respiratory failure
and cardiac complications feature highly in readmitted
patients (Elliott, 2006). What is lacking in the literature are
the other reasons that surround patients being readmitted
to the ICU. The purpose of doing this study is to discover
the characteristics of and reasons behind unplanned adult
readmissions to the John Hunter Hospital’s ICU. We want to
understand the impact on ward staff caring for patients when
their condition deteriorates and they require readmission to
the ICU. We hope the study will facilitate risk assessment,
early intervention and prevention of readmissions to ICU. We
have built a team with a vested interest in the research project
that will lead to commitment to preventative strategies, on-
going research and improved communication between ICU
and receiving ward staff. This team includes the ICU Liaison
CNC, Nurse Unit Manager (NUM), Ward G1, Ward G2, ICU
data manager, ICU Performance Improvement Coordinator,
CPOD staff and ward staff.
The project journey so far has been challenging. I have gained
valuable knowledge along the way in areas such as writing
grant applications. Unfortunately we were unsuccessful with
both a Nursing and Midwifery Office (NaMo) and Nursing
Registration Board (NRB) scholarship for funding the project.
It would have been very easy to lose hope at this stage but
with the guidance of the CPOD staff and their attitude
of seeing opportunity rather than obstacle a great deal of
learning occurred. Both applications for funding required a
large amount of work that was pushed along by the mentors
in CPOD with challenging deadlines. Understanding the
process you must go through and being part of writing for
ethics approval and applications for funding opened my eyes
to challenges that all researchers face as beginners. We were
fortunate to receive Nurse Strategy Funding from Hunter New
England Area Health Service that has allowed the project to
move forward.
Many opportunities presented themselves during my
stewardship and one of these was attending the International
Practice Development School in Melbourne. I had not had
any structured experience in Practice Development and the
‘hands on’ learning and the openness of group projects made
the School a very positive experience. The creative approach
to discovering how I can use practice development in my own
work was challenging but very rewarding. Attending the
school became the starting point for an ongoing journey of
learning through practice.
I was involved in many other projects during the stewardship
program which provided a broad range of experiences from
which to grow and gain skills in group work, research design,
project management, publication and facilitation. I became a
member of the Multidisciplinary Tracheostomy Team Project
(MTTP) as well as the Hunter New England publication
group (HNE Handover). Both projects have been excellent
for learning and practicing group skills and provided the
opportunity to make links with others from outside the Critical
Care environment. As a group the MTTP has published one
article to date and will publish the results of the project when
completed.
The HNE Handover journal is important for beginner writers
such as myself. It communicates and promotes the work that
people are doing throughout the Area Health Service. This
has been an invaluable opportunity to study the process of
creating a project of this size and I hope to become more
involved in the journal in the future.
The personal gain from the stewardship experience needs to be
promoted so that others will continue to benefit from working
with CPOD and the staff that drive it. I was supported by
CPOD to challenge myself and to leap into research and
discover the complexities that surround doing a research
project. This has also given me a better understanding of
what is required to build a research culture in the ICU and
how to lead this. This experience has provided me with a
greater understanding of what is happening throughout the
Hunter New England Area and links with many people doing
innovative work.
References
Elliott, M. (2006). Readmissions to Intensive Care: a review of the literature.
Australian Critical Care, 19(3), 96 -104.
43
Student Contributions

Nurse Practitioners in the Emergency Department: A Critical

Review of the Literature
Michelle A. McCoy, 3rd Year Bachelor of Nursing Student
School of Nursing and Midwifery, The University of Newcastle

Dr. Julie Johnstone RN BA(Hons) PhD, Lecturer

School of Nursing and Midwifery, The University of Newcastle

Abstract

The aim of this critical review is to evaluate the effectiveness of nurse practitioners in the emergency department. A
search strategy was refined and entered into relevant databases. Nine articles were deemed suitable for review and
common themes emerged within these articles including cost-effectiveness, waiting time, scope of practice and staff
attitudes towards nurse practitioners. The findings of these articles were evaluated and compared revealing that nurse
practitioners generally have a clear scope of practice in the emergency department and that most staff welcomed the
introduction of the role. It was concluded that further research is needed to identify the impact on cost-effectiveness and
waiting time.
Keywords: nurse practitioner, effectiveness, emergency department, scope of practice, waiting time

A nurse practitioner (NP) is a registered nurse (RN) authorised
and educated at an advanced level to diagnose and manage
patients autonomously (Australian Nurses and Midwifery
Council, 2006). The introduction of NPs began in the 1960s
in response to increasing patient numbers, extended waiting
times and medical staff shortages in Emergency Departments
(ED) in the United States (Cole & Ramirez, 2002). Forty years
later the role of the NP in EDs has become well established in
the United States of America (USA) and United Kingdom (UK).
Christofis (2001) argues that the use of nurse practitioners can
help to address congestion issues in Australian Emergency
Departments (EDs).
ATS timeframe (Australian Institute of Health and Welfare,
2007). The Australian Medical Association (2007) claims that
patients waiting for hospital admission are blocking access for
new patients to ED and suggest the backlog issues are apparent
throughout the hospital system. Furthermore, the 2005 NSW
Population Health Survey found that 19.4 per cent of adults
that presented to an ED were dissatisfied with the care they
received. Extended waiting times and staff shortages were
rated in the top three reasons for their dissatisfaction (NSW
Health, 2007). These issues demonstrate the need for a critical
review to identify whether NPs can play a role in alleviating
the crisis in ED.

In 2006 over sixty NPs were registered in NSW (Wand & METHOD
Fisher, 2006). This represents only a fraction of a percentage
(0.001 per cent) of the 39,804 RNs employed in NSW health The terms used for database searches were “nurse practitioner
facilities (Audit Office of NSW, 2006). It is estimated that the AND emergency AND effect*”. The results were selected by:
number of NPs will increase significantly in the future due being published between 1997 and 2007; being of a primary
to the demand on healthcare systems (Cooper, 2001). The research nature; and having a demonstrated an association
introduction of NPs into healthcare has not been easy. Fisher to the topic in review. The databases searched included
and Cox (2006) claim that medical practitioners initially felt CINAHL, EBSCO Mega File, Expanded ASAP, Medline,
threatened; and some nurses felt that NPs were abandoning Mosby’s Nursing Consult, Nursing Journal (Proquest),
nursing to become inferior medical practitioners (Brook & Proquest 5000, PubMed and Scopus.
Crouch, 2004). Others advocate that NPs have an extended
nursing role that includes diagnosis, prescription, advanced
RESULTS
clinical skills and ordering medical tests (Wand & Fisher,
2006).
Nine articles were deemed relevant from the above search
strategy and included a systematic review, a cohort study,
In Australia each state has different legislation governing the
a case-control study, two descriptive studies, a survey, a
registration of NPs and their scope of practice. In NSW RNs
prospective study and two studies using grounded theory.
must complete postgraduate education recognised by the
Articles were from Canada, Australia, the United Kingdom
Nurses and Midwives Board (NMB) (NMB, 2007) and have
(UK) and the United States (US). Several themes emerged
over 5000 hours of experience in their areas of practice (NSW
in relation to the effectiveness of NPs in the ED including
Health, 2008). Prescription rights in NSW are authorised by
cost-effectiveness, waiting times, scope of practice and staff
the Director-General of Health or NSW Health depending on
attitudes toward the introduction of NPs in ED. Strengths
the specialty of NP (NMB, 2007).
and limitations of each study are outlined in Table 1.
The number of patients attending Australian EDs is increasing
by 7.6 per cent each year (Australian Bureau of Statistics,
2007). Patients are triaged according to the Australasian
Triage Scale (ATS) which rates patients on priority of need
(Australasian College for Emergency Medicine, 2000). Only
73 per cent of these patients are seen within the recommended

44
Table 1 Summary of Review Articles

Article Thematic Methodology Sample Size Strength(s) Limitation(s)

Issue
Non-randomisation
decreased the study’s
Minimal bias external validity
Sakr et al Cost- Descriptive 51,043
(2003) effectiveness study patients Large sample size enhancing the study’s Self-reported error rates
internal validity of calculation and cost
analysis
Cost-
Carter & effectiveness Results of articles reviewed
Systematic
Chochinov 59 articles 59 articles reviewed did not have concurrent
review
(2007) Waiting findings
time
Non-randomisation was
present adding selection
Considine,
Increased internal validity as the study and sample bias and
Martin, 725 patients
Waiting Case-control measures time of presentation to time of reducing the study’s
Smit, Winter with hand or
time study discharge only external validity
& Jenkins wrist injuries
(2006a)
One ED only
The non-randomisation strengthens the
Mills & Descriptive 1545 internal validity as the national survey The non-randomisation
Scope of
McSweeny exploratory emergency measures reasons for patients seeing weakens the external
practice
(2005) study departments NPs. validity
Considine,
Validity is strong as data was gathered The study demonstrates
Martin,
Scope of using tools that were developed by key bias as only one NP was
Smit, Jenkins Cohort study 476 patients
practice staff members in the hospital examined in the study
& Winter
(2006b)
Reliability was strong as results between
participants were comparable and The study was subjected
Martin & Prospective
Staff 148 doctors the content validity of the study was to response bias as fewer
Considine pretest post-
attitudes and nurses strengthened as the same survey was participants completed the
(2005) test design
used for both the pretest and post-test post-test survey.
Sampling and response bias
was present as participants
were selected because they
The survey had face validity as it was worked for one health
Griffin & Staff 80 doctors
Survey developed in consultation with nursing authority. The authors
Melby (2006) attitudes and nurses
experts report that an overall
response rate of 74.8% was
attained.
Thrasher Grounded
Methodology allowed for authors to Small sample size
& Purc- Staff theory
24 ED staff interview subjects without preconceived
Stephenson attitudes interview-
ideas
(2007) based
Grounded
Methodology allowed for authors to Small sample size
Tye & Ross Staff theory
9 ED staff interview subjects without preconceived
(2000) attitudes interview-
ideas
based

Cost-Effectiveness of NPs
The cost-effectiveness of NPs in ED was evaluated by Sakr,
Kendall, Angus, Saunders, Nicholl and Wardrope (2003)
by gathering prospective data on all 51,043 patients that
presented to a specific ED in the UK in one year. Costs per
patient for the study were measured against a cost evaluation
tool published by the national health authority (Sakr et al,
2003). The researchers measured costs including investigation
and treatment costs plus staff wages for each patient and
compared the costing of medical staff to NP staff on a cost per
workload unit basis. Results indicated that NP care was more
expensive than resident medical care and NPs were caring for
patients of similar triage to that of residential medical staff
(Sakr et al, 2003). The authors suggest that this finding is due
to higher NP wages compared to resident medical staff and
that the NPs made more referrals and follow-up appointments
than medical staff.
Similarly, Carter and Chochinov’s (2007) systematic review
of fifty-nine studies on NPs in the ED concluded that NPs
are more expensive than resident medical staff. However,
the authors noted that several of the studies reviewed found
contrary results and suggested that this is due to staffing
arrangements in a country’s ED. For example, Australia uses
senior medical staff, while the US uses residents overseen by
senior medical staff (Carter & Chochinov, 2007). This indicates
that more investigation into this area is needed (Carter &
Chochinov, 2007).
Waiting Time
Research on the impact of NPs on waiting times included a
systematic review and a case-control study. The studies had
conflicting findings. Carter and Chochinov (2007) found that
NPs decreased waiting time while Considine, Martin, Smit,
Winter and Jenkins (2006a) found no difference.
The Considine, Martin, Smit, Winter and Jenkins (2006a)
study measured patient waiting time and total length of ED
stay for patients with similar hand or wrist conditions and
similar triage categories. Patients were either cared for by
medical staff or NPs and waiting time and length of ED stay
were compared. It was concluded that NPs did not decrease

45
patient waiting time or length of stay. The study by Carter
and Chochinov (2007) was a systematic review that concluded
that NPs significantly decrease patient waiting time, however
it is difficult to compare results of a systematic review with
the findings of a single study. The effect of waiting time on
NP effectiveness requires further research to clearly define the
impact of the NPs.
Scope of Practice
A NP’s scope of practice is the clinical area in which the NP can
practice and what skills and procedure they are authorised to
perform (NSW Health, 2007). Articles on the scope of practice
of NPs included an exploratory cohort and retrospective study
on the types of injuries or conditions that their patients had.
Mills and McSweeny (2005) examined and compared patient
numbers, reason for presentation, tests, investigations and
treatments from an annual national hospital survey over four
years gathered from 1545 representative rural and urban
hospitals EDs in the US. It was concluded that NPs cared
for a wide variety of patients with an array of presentation
reasons from simple fractures to more serious head/neck
injuries and multi-traumas. The Considine, Martin, Smit,
Jenkins and Winter (2006b) study replicated the Mills and
McSweeny study and collected data from 476 patients seen by
a NP over several months. They found NPs effectively care for
minor injury patients with presentations such as lacerations,
gastrointestinal problems, influenza and cold symptoms and
minor burns (Considine, Martin, Smit, Winter & Jenkins,
2006b).
The results of both studies were comparable since similar
conditions and injuries were documented, for example,
lacerations, limb injuries and viral infections. However, Mills
and McSweeny (2005) reported that NPs in the USA treat
patients with head and/or neck injuries and this result was
not the case in the Considine, Martin, Smit, Jenkins & Winter
(2006b) Australian study. This difference is accounted for by
differences in the scope of practice.
Staff Attitudes
The research on ED staff attitudes to NPs included two
quantitative and two qualitative studies. The quantitative
studies included a descriptive study and prospective pretest-
post-test designs. Both used surveys to gather data on nursing
and medical staff attitudes. The qualitative studies used
grounded theory with semi-structured interviews.
Martin and Considine (2005) conducted surveys pre and post
introduction of NPs in an ED in Melbourne, Australia. The
initial survey examined nursing and medical staff members’
knowledge and attitudes towards the role of NPs in ED
(Martin & Considine, 2005). After the implementation of
NPs in the ED and in-service education, a follow up survey
identified positive changes in attitudes among staff in the ED
(Martin & Considine, 2005).
A survey by Griffin and Melby (2006) examined nursing and
medical ED staff as well as local referring general practitioners.
Unlike Martin and Considine (2005) only one survey was
completed following implementation of NPs to determine
the attitudes of staff directly involved with NPs in ED. The
results of both studies are comparable as positive attitudes
towards NPs in the ED were reported. Conversely, Martin
and Considine (2005) noted confusion and ambiguity among
staff regarding the role of the NP in the pretesting, however,
46
this was resolved in the results of the post-test survey.
Staff attitudes cannot be considered by quantitative measures
such as surveys alone. Thrasher and Purc-Stephenson (2007)
and Tye and Ross (2000) both conducted a series of semi-
structured interviews with staff members of EDs regarding
their attitudes towards NPs. Despite differences in sample
size (twenty-four and 9 respectively) they produced similar
findings (Thrasher & Purc-Stephenson, 2007; Tye & Ross,
2000). Both studies demonstrated initial apprehension
towards the introduction of NPs in ED. However, the Martin
and Considine (2005) study found that educating staff
alleviated these apprehensions. This research suggests further
studies are needed.
DISCUSSION: IMPLICATIONS FOR PRACTICE
The implications for practice of this critical review of NPs in
the ED are discussed in terms of cost, waiting time, scope of
practice and staff attitudes.
The study by Sakr et al (2003) demonstrated that NPs are
more expensive than medical staff in the ED. The conclusions
of Carter and Chochinov (2007) concurred with Sakr et
al (2003) however they also noted that a number of the
studies in their review found the reverse. If the cost of NPs
in the ED compared to medical staff is unclear then further
research should be conducted. Individual countries need to
establish cost-effectiveness within their own contexts because
differences between countries make comparison difficult
(Carter & Chochinov, 2007; Sakr et al, 2003).
Research reporting differences in patient waiting time
findings were also contradictory. Carter and Chochinov
(2007) found that NPs decrease waiting time, however
the study of Considine, Martin, Smit, Winter and Jenkins
(2006a) emphasised that NPs had no effect on waiting time.
One issue that is not raised in the research is whether NPs
are supernumerary to medical staff or whether NPs replace
medical staff as this could influence results. The effectiveness
of NPs on waiting time also requires further research.
The studies show NPs have a wide scope of practice (Considine,
Martin, Smit, Jenkins & Winter, 2006b; Mills & McSweeny,
2005). This demonstrates the effectiveness of NPs in the ED as
they can manage and treat low triage patients autonomously.
The clinical implication of this is that practice should continue
in its present form.
The research regarding staff attitudes on NPs in the ED
produced comparable findings. Confusion around the
introduction of NPs into the ED suggests the need for more
education of ED staff to enhance transition of NPs into the ED
team (Griffin & Melby, 2006; Tye & Ross, 2000). However,
most ED staff demonstrated positive attitudes with high
levels of awareness of the NP role (Martin & Considine, 2005;
Thrasher & Purc-Stephenson, 2007).
CONCLUSION
The studies examined suggest that, on the whole, NPs have
been welcomed into the ED by staff and that their scope of
practice allows them to care for low triage patients effectively,
thus alleviating some of the burden on Australian EDs. The
history of NPs in Australia is short compared to that of the
US and UK. As the role of the NP in EDs develops so will the
evidence to support their implementation. However, in the
meantime further investigation is needed to clearly define the
effectiveness of NPs in terms of cost-effectiveness and patient
waiting time.
References
Australian Bureau of Statistics. (2007). Australian hospital statistics 2005-6. Retrieved
on August 21, 2007 from http://www.aihw.gov.au/publications/hse/
ahs05-06/ahs05-06.pdf
Australasian College for Emergency Medicine. (2000). The Australasian triage scale.
Retrieved on August 24, 2007 from http://www.medeserv.com.au/
acem/open/documents/triage.htm
Australian Institute of Health and Welfare. (2004). Hospitals at a glance. Retrieved
on August 21, 2007 from http://www.aihw.gov.au/hospitals/
ataglance/2004/index.cfm#s12
Australian Medical Association. (2007). Public hospital report card. Retrieved on
October 26, 2007 from http://www.ama.com.au/web.nsf/doc/WEEN-
78A37P/$file/AMA_Public_Hospital_report_card_2007_final.pdf
Australian Nurses and Midwifery Council. (2006). National competency
standards for the nurse practitioner. Retrieved on August
24, 2007 from http://www.anmc.org.au/docs/publications/
competencystandardsforthenursepractitioner.pdf
Audit Office of New South Wales. (2006). Retrieved on October 26, 2007 from http://
www.audit.nsw.gov.au/Publications/reports/performance/2006/
nurses/inbreif-nurses.pdf
Brook, S. & Crouch, R. (2004). Doctors and nurses in emergency care: where are the
boundaries now? Trauma, 6, 211-216.
Carter, A.J.E. & Chochinov, A.H. (2007). A systematic review of the impact of nurse
practitioners on cost, quality of care, satisfaction and wait times in the
emergency department. Canadian Journal of Emergency Medicine, 9(4), 286-295.
Christofis, L. (2001). Nurse practitioners: An exploration of the issues surrounding
their role in Australian emergency departments. Australian Emergency
Nursing Journal, 4(2), 15-20.
Cole, F.L. & Ramirez, E. (2002). A profile of nurse practitioners in emergency care
settings. Journal of the American Academy Nurse Practitioners, 14(4), 180-4.
Considine, J., Martin, R., Smit, D., Winter, C. & Jenkins, J. (2006a). Emergency nurse
practitioner care and emergency department patient flow: case control
study. Emergency Medicine Australasia, 18(4), 385 –390.
Considine, J., Martin, R., Smit, D., Jenkins, J. & Winter, C. (2006b). Defining the scope
of practice of the emergency nurse practitioner role in a metropolitan
emergency department. International Journal of Nursing Practice, 12(4),
205-213.
Cooper, R.A. (2001). Health care workforce for the twenty-first century: The impact
of nonphysician clinicians. Annual Review of Medicine, 52, 51-61.
Fisher, J. & Cox, C. (2006). Developing the A&E nurse practitioner role. Emergency
Nurse, 13(10), 26-31.
Griffin, M. & Melby, V. (2006). Developing an advanced nurse practitioner service
in emergency care: attitudes of nurses and doctors. Journal of Advanced
Nursing, 56(3), 292-301.
Martin, R. & Considine, J. (2005). Knowledge and attitude of emergency department
staff before and after implementation of the emergency nurse practitioner
role. Australasian Emergency Nursing Journal, 8(3), 72-8.
Millis, A.C. & McSweeny, M. (2005) Primary reasons for emergency department visits
and procedures performed for patients who saw nurse practitioners.
Journal of Emergency Nursing, 31(2), 145-149.
NSW Health. (2007). Emergency departments. Retrieved on August 24, 2007 from
http://www.health.nsw.gov.au/public-health/survey/PHS/reports/
hs05prodout/toc/toc.htm
NSW Health. (2008). Retrieved on May 8, 2008 from http://www.health.nsw.gov.
au/nursing/npract.html
Nurses and Midwives Board. (2007). Being a nurse practitioner in NSW.
Retrieved on August 24, 2007 from http://www.nmb.nsw.gov.au/
ArticleDocuments/104/Being_a_Nurse_Practitioner_in_NSW.pdf.aspx
Sakr, M., Kendall. R., Angus. J., Saunders, A., Nicholl, J. & Wardrope, J. (2003)
Emergency nurse practitioners: a three part study in clinical and cost
effectiveness. Emergency Medicine Journal, 20, 158-163.
Thrasher, C. & Purc-Stephenson, R.J. (2007) Integrating nurse practitioners into
Canadian emergency departments. Canadian Journal of Emergency
Medicine, 9(4), 275-281.
Tye, C.C. & Ross, F.M. (2000). Blurring boundaries: professional perspectives of the
emergency nurse practitioner role in a major accident and emergency
department. Journal of Advanced Nursing, 31(5), 1089-96.
Wand, T. & Fisher, J. (2006). The mental health nurse practitioner in the emergency
department: An Australian experience. International Journal of Mental
Health Nursing, 15, 201-208.
47
Student Nurse Confidence – A Reflection
Elizabeth Bembridge, 3rd Year Bachelor of Nursing Student
University of Newcastle
Sarah Yeun-Sim Jeong, RN. PhD., MN (Research), GradDip (Adv Prac in Aged Care), BN
Lecturer, Master of Nursing (Adv Prac) Program Convenor, The University of Newcastle
BRIEF INTRODUCTION OF THE PATIENT AND
THE WARD
As part of a six week clinical placement I was working in
the children’s ward of a regional hospital. I had completed
4 weeks of clinical placement at the children’s ward and
was confident of my clinical skills and communication with
patients, families and staff. Then I met Sammy (pseudonym).
Sammy is a delightful 9 year old who has a chronic illness
and disability. His mother Rachel (pseudonym), who is his
primary carer, is an active participant with his medical care
and has routine methods for completing his daily needs. Both
Rachel and Sammy had no hesitation in allowing me, as a
student, to participate in Sammy’s care.
During the first day of my involvement with Sammy, Rachel
often commented on her method of completing a task and
advised me of ‘the best way’ to complete nursing tasks for
Sammy. This left me feeling inadequate as Rachel during
the course of the day constantly commented on how I should
do something or said ‘I don’t do it like that’. My feelings of
inadequacy arose partly because of Rachael’s strong assertion
of her position as primary carer and I thought, partly as a
result of my lack of self confidence in my skill level.
The next day I took the time to go over what needed to be
done for this patient. I then approached the nurse educator of
the ward and asked if she would mind watching me rehearse
all of the tasks to be done for the patient. This was to confirm
for myself that I was not doing anything incorrectly and to
improve confidence in my skill level.
Over the period that I had spent at the children’s ward I felt
that my confidence had grown both on a clinically professional
level and personally. However when I was confronted by a
parent who questioned why I completed tasks the way I did I
was unable to provide a clear rationale, despite knowing the
rationale. This in turn affected my confidence. I found myself
focusing on completing the task or skill that was required and
not on the holistic care of the patient. I had sought out an
educator to confirm that my skill level was adequate to the
task at hand.
What I had failed to realise was that my lack of confidence
was not skill-related but related to my inability to effectively
communicate the evidence-based reason for completing the
skill under pressure from an anxious parent. This left me in a
position where I felt unsure of myself and my skill level.
My strength throughout this was my ability to reflect on
my practice, identify my confidence issues and be proactive
in seeking out a more experienced professional to assist in
developing confidence in my skill level. My weakness was
maintaining confidence in difficult or unfamiliar circumstances,
and recognising factors that influence confidence levels as a
student.
48
CLINICAL OBJECTIVE
Improve self confidence through the identification of factors
that influence the confidence of student nurses.
LITERATURE REVIEW
The level of confidence that a nursing student has or obtains
whilst on clinical placement has significant effects on the
student, other staff, patients and their families (Holland,
1999). A student who has a high level of confidence without
corresponding knowledge or skill level “may increase the
likelihood of error” (Kissinger, 1998, p. 18) and may work
outside their scope of practice, possibly posing a danger
to themselves, other staff and patients (Kissinger, 1998). A
student nurse with a low level of confidence may limit
their involvement with practical skills, and patient and staff
interaction thus reducing learning opportunities and limiting
the possibility of self confidence growth (Hoffman & Elwin,
2004). The compentent student who is self confidence and
has communication skills is able to interact with the patient
whilst completing tasks. This allows the student to shift the
focus from completing a skill correctly to a more holistic and
patient-centred level of care (Arja, Helena, & Jouko, 2008).
Latham and Fahey (2006) state that nursing students “often
experience a lack of self-confidence and hesitation when faced
with increased responsibility and accountability for patients’
health”. (p. 46). Factors that influence the confidence of student
nurses range from achieving competence in a skill or set of
skills to achieving meaningful and effective communication
with patients, relatives and multidisciplinary team members.
The achievement of competence in a skill or skill set enables the
student to develop personal and professional confidence and
develop their identity as a nurse (Edwards, Smith, Courtney,
Finlayson, & Chapman, 2004; Godson, Wilson, & Goodman,
2007; Lundberg, 2008).
However, it is also important to note that effective and
meaningful communication plays a significant role in
confidence by providing the student with information,
validating self worth and integrating professional self value
(Arja, Helena, & Jouko, 2008). These authors also identified
that personality and a supportive clinical environment all
have a significant part to play in building confidence levels of
nursing students.
Although there have been attempts to improve students’
confidence and competence, Lofmark, Carlsson & Wikblad
(2001, p. 91) pointed out that “tasks that are very practical in
nature attract great attention … from students and staff are
more likely to expose students to technical procedures than
to help them develop more general skills”. Interestingly, in
an earlier study, Holland (1999) suggested three stages which
resulted in improving not only clinical skills but also self-
confidence, as well as communication skills:
 (a) more interest in expanding their role
(b) becoming more independent [and]
(c) professional socialisation.
The ultimate goal for nursing students is to obtain a level
of confidence that is equivalent to a student’s skill level,
therefore allowing students the ability to work within their
scope of practice safely and yet maintain the ability to reflect
on areas that require further knowledge, training and/or
practice without causing harm to current levels of confidence
(Edwards, Smith, Courtney, Finlayson, & Chapman, 2004).
Student nurses should recognise that as novices a level of
“not knowing” is acceptable and in fact expected (Idczak,
2007; Latham & Fahey, 2006). More attention should be
given to self confidence in one’s psychological level as well as
communication skills in variable situations.
REFLECTION
The past weeks have enabled me to recognise that confidence
is an important aspect of the practice of nursing and plays
a major role in development for student nurses. After an
incident earlier in the week, I recognised that despite my lack
of confidence the skill set that required to be completed for a
particular patient was within my scope of practice, within my
ability and within my knowledge base.
On reflection it is clear that my lack of confidence in my
ability, when put ‘on the spot’ by Rachel contributed to my
feelings of inadequacy. Through reflection and use of a
mentor I was able to clarify that my weakness was not skill
mastery or knowledge level but my inability to effectively
communicate when under close scrutiny, which in turn led to
a lack of confidence in my skill level and clinical knowledge.
To develop my confidence and communication skill I adopted
Holland’s (1999) three stages. I became proactive and requested
the assistance of a senior clinical educator to critically assess
my skills and knowledge base. By doing this I reinforced my
knowledge and skills but more importantly developed self
confidence. My efforts in seeking assistance and assessment
of my skills could be seen as a step in ‘becoming more
independent’. By gaining input and validation from a senior
clinical educator (professional socialisation), I ensured that I
was able to successfully communicate with the parent while
completing the necessary skills unassisted, thus becoming
more independent. Through reflection, practice, repetition,
the use of a mentor and awareness of factors that affect my
confidence I was able to confidently complete the appropriate
nursing interventions for Sam, provide Rachel with a rationale
for the skills, and instruct others on the procedurally correct
method of skill completion.
References
Arja, S., Helena, L.K., & Jouko, K. (2008). Factors related to the nursing student-
patient relationship: the students’ perspective. Nurse Education Today,
28, 539-549
Edwards, H., Smith, S., Courtney, M., Finlayson, K., & Chapman, H. (2004). Impact
of clinical placement location on nursing students competence and
preparedness for practice. Nurse Education Today, 24(4), 248-255.
Godson, N. R., Wilson, A., & Goodman, M. (2007). Clinical education: evaluating
student nurse learning in the clinical skills laboratory. British Journal of
Nursing, 16(5), 942-945.
Hoffman, K., & Elwin, C. (2004). The relationship between critical thinking and
confidence in decision-making. Australian Journal of Advanced Nursing,
22(1), 8-12.
Holland, K. (1999). A journey to becoming: the student nurse in transition. Journal of
Advanced Nursing, 29(1), 229-236.
Idczak, S. (2007). I am a nurse: nursing students learn the art and science of nursing.
Nursing Education Perspectives, 28(2), 66-71.
Kissinger, J. (1998). Overconfidence: a concept analysis. Nursing Forum, 33(2),18.
Latham, C., & Fahey, L. (2006). Novice to expert advanced practice nurse role
transition: guided self-reflection. Journal of Nursing Education, 45(1), 46-
48.
Lofmark, A., Carlsson, M., & Wikblad, K. (2001). Student nurses’ perceptions of
independence of supervision during clinical nursing practice. Journal of
Clinical Nursing, 10(1), 86-93.
Lundberg, K. (2008). Promoting self-confidence in clinical nursing students. Nurse
Educator, 33(2), 86-89.
49
rESOURCE aRTICLE

Reproduced with the permission of the editors of the Journal “Women and birth” (2008). We would like to thank Professor Kathleen Fahy from
the University of Newcastle for allowing us to share this valuable article with our readership.

Writing for Publication: Part Two

Kathleen Fahy

Abstract

The rules for writing a research report for publication are well defined but are much less clear for scholarly scientific
papers.

The purpose of this paper is to enable new writers to confidently apply the skills of scientific writing within a scholarly
paper for publication.

Similarities and differences between scientific argument and debating are discussed. Achieving the right ‘tone’ and
emphasis in writing is considered. How to use the correct verb tense is outlined. The importance of a clearly defined
question is explained. The elements of an effective scholarly paper are presented and examples given. The elements are
the: question, thesis, introduction, body of the paper, conclusion and finally, an abstract.

INTRODUCTION What is needed, I believe, is a brief, simply written, guide

In an earlier paper: Writing for Publication: the Basics (1) I
presented basic English writing skills. These skills are: careful
and consistent word choices; short, clear and direct sentences;
writing in the active voice; writing unified, coherent and well
structured paragraphs; and maintaining brevity. The ‘basics’
paper (1) is a necessary foundation to being able to write for
publication but, due to word limitations, it doesn’t go far
enough in teaching the skills of writing for publication. Clear
thinking and the development of logical, coherent argument
are the keystones of all scientific endeavours and this should
be reflected in all papers that are submitted for publication.
New writers often have difficulty because they try to write
on an ill-defined topic. This results in a paper without an
argument. Writing on an ill-defined topic causes the writer
to ramble on, to explore multiple aspects of the topic, without
ever really taking a position. A scholarly scientific paper that is
not in the form of argument and evidence is usually confusing
and boring. The reader of this type of paper is initially left
with the vague feeling that maybe they have missed the point.
Experienced journal reviewers, however, easily recognise that
poor writing, not poor reading, is the source of their feeling of
having missed the point. This article aims to help you to write
in effective, engaging and interesting ways and that means
taking a position and then defending it with evidence.
There are good texts on academic writing (2-9). For the majority
of potential writers, however, these books remain unread.
There are a number of possible reasons why midwives don’t
read books on how to write, these reasons were discussed in the
previous paper (1). A review of midwifery and nursing journal
articles was also presented in that paper. In the ‘basics’ paper
I argued that existing articles on writing for publication focus
mostly on the process of writing and publication process (10-
19). Alternatively the articles are limited, like Ann Thomson’s
paper, to how to write a research report (20). The structure
for writing a research report is well defined and expected by
all journal editors. For more in depth coverage about writing
research papers readers are recommended Zeigler’s Essentials
of Writing Biomedical Research Papers (4). What is less clear is
how to write the other types of academic papers for journals;
it is this gap that the paper is intended to fill.
to writing a scholarly paper for publication. The skills of
academic writing are easier to learn from this paper. This is
because the paper is focussed on the knowledge and skills gaps
that I currently encounter in the writing of research higher
degree students and new writers of journal articles. Further,
midwives should find it easier to learn the required skills
from the present paper because the examples given are from
articles written by and for midwives. The examples which
I use here are re-worked sections of previous papers that I
have either authored or co-authored. The discussion I present
below on how to structure a scholarly paper is consistent with
the texts on academic writing that I have already mentioned.
Prospective authors can take my suggestions as advice that
does not have to be slavishly followed. There is less definitive
agreement about the elements a scholarly academic paper
than there is about a research report.
The scientific argument
A scientific argument is a form of debate. A debate is a formal
method of taking a position and arguing for what you want the
audience to believe. Debating involves both logical argument
and emotional persuasion. For example, lawyers arguing in
a court room or politicians arguing in parliament are forms
of debating. In that form of argument there are two sides
that argue two different positions about the topic of debate.
A scientific argument, like a debate, is based upon a clearly
defined topic. As only one side is being presented in a paper
for publication it is important to think of your paper as one
‘side’ of an academic argument. Authors must also be ready
to have their ideas criticised by other scientific writers; that
is what makes it an argument. The advancement of scientific
knowledge depends upon open, clear and direct argument
and evidence.
Tone
Unlike legal or political arguments scientific arguments
should read as a dispassionate search for ‘truth’ or better
knowledge. Direct attempts at emotional persuasion are not
acceptable. Your tone should be somewhat humble and
certainly, not arrogant. Your writing should demonstrate that

50
you are respectful of writers who have a different view. Your
respect for midwifery and women should also be evident.
You should use woman-centred language: e.g. ‘woman’ not
‘lady’ or ‘patient’.
You are advised to avoid qualifying words or phrases that
are meant to convey how strongly you believe something. For
example if you find that you have written words like ‘very’
‘extremely’ ‘strongly’ or ‘always’, this probably indicates that
you are trying to influence the reader to your position by
use of emotion rather than argument and evidence. What is
required is to remove these qualifying words that are meant
to provide additional emphasis and instead present better
examples or evidence.
Emphasis
Not all the information that you could include in your
argument is equally important. You want the reader to
get your main message. You do not want readers getting
confused and thinking that less important information in the
paper is the main message. You need, therefore, to focus and
limit your argument. According to Zeigler (4) the techniques
for sharpening emphasis include:
1. Stating, rather than implying, important information
2. Emphasising important information by placing it
first and/or last
3. Condensing, subsuming or omitting less important
information
4. Signposting important information
5. Repeating important information
Much of the skill of scientific writing concerns you being
clear about what is most important in your paper and
then emphasising it. Having a guiding research question,
writing a thesis statement, a conclusion and an abstract are
all opportunities to emphasis important information. In my
experience writers usually write too many words initially
and they are frequently not the best words for conveying the
most important information. Sometimes writers find that they
have strayed from directly answering their research question.
In the editing process, more important information should
be emphasised and less important information should be
removed or de-emphasised. Removing, condensing or sub-
subsuming less important information sometimes involves
removing entire paragraphs. It always involves sentences
within paragraphs. Writers always have to edit their work
(usually multiple times). This is needed to achieve a paper
that clearly and succinctly conveys the main message, backs it
up with good evidence and does not confuse the reader.
Verb Tense
The tense of a verb, past or present, depends upon the type
of statement and its meaning. When writing about what
was done, or what was found, the verb should be written in
the past tense because it was done or found in the past. For
example: “We reviewed (past tense) the research literature”.
“We found (past tense) that woman who experienced (past
tense) a home-like environment for labour had (past tense)
fewer medical interventions in birth.”
A knowledge statement it is written in the present tense because
knowledge is current. Indeed the statement above can be
written as a knowledge claim if you believe there is sufficient
evidence to support such a claim. For example “Women
who experience (present tense) a home-like environment for
labour have (present tense) fewer medical interventions in
birth.” Another example is: women who smoke in pregnancy
are (present tense) more likely to be (present tense) socio-
economically disadvantaged.
The Question
The writing of a scientific paper is the end point of a larger
project which involves a period of enquiry and reflection. The
enquiry phase of the project is most efficient and effective if it
is guided by a research problem or question (21). See table 1
for example ‘questions’.
Table 1 Examples of Guiding Questions
Example 1: In cases of postpartum haemorrhage, can amniotic
fluid embolus (AFE) be accurately diagnosed as a causative factor
(23)?
Example 2: Why do women continue to smoke in pregnancy (21)?
Example 3: Can the Cochrane Review of birth setting be relied
upon to make valid statements about whether or not there may be
an added risk of perinatal mortality associated with experiencing
intrapartum care in a birth centre (24)?
The Thesis
The actual writing stage should begin with a thesis statement
that will organise and limit the scientific argument. A thesis
is a positive declaration that the whole paper then seeks to
support with argument and evidence. A thesis answers the
question of the paper. The thesis is your main point; what it is
you are trying to ‘prove’. The thesis is the take-home message
you want to reader to remember (7). See Table 2 for examples
of thesis statements.
Table 2 Examples of Thesis Statements
NB These statements relate to the questions given in Table 1.
Example 1: In cases of postpartum haemorrhage, amniotic
fluid embolus may be incorrectly ruled out as a diagnosis
because it is not possible to accurately diagnose AFE by any
currently available laboratory tests (23).
Example 2: Smoking cessation programs in pregnancy are
ineffective because smoking is addictive and the women who
smoke in pregnancy are socio-economically disadvantaged
women and lack alternative sources of pleasure and
satisfaction in their lives (22).
Example 3: Because of methodological problems with the
original randomised trials the Cochrane review of birth
setting cannot be relied upon to make valid statements about
whether there may be an added risk of perinatal mortality
associated with experiencing intrapartum care in either
setting (24).
The Introduction
Introductions to scholarly papers take a different form when
compared with research papers. Research introductions take
the form of writing first about what is already known; then
about what is unknown. Next the research question is given.
Then the research methods are summarized and finally the
significance of the research is stated. In research papers,
therefore, it is normal to write an introduction that encompasses
the review of related literature. This section is often labeled
‘Background’ rather than ‘Introduction’ in research reports (4).
Most scholarly papers, by contrast, do have an introductory
section, because the related literature either forms the body of
the paper or it is integrated throughout the paper.
The structure of an introduction for a scholarly paper should
51
begin with a question or problem statement about the topic
under consideration. You may present a brief summary of the
background literature to identify what is already known. Any
key terms should be defined. The thesis of the paper, which
is your main message, must be included. The introduction
should make clear the importance of your paper in terms of
what is known about the topic. You may also briefly outline
the structure of the paper but this is not essential. A summary
of these elements of a scholarly introduction are presented in
Table 3. An example of an introduction to a scholarly paper
is presented in Table 4. Please note that I have removed the
references to simplify reading. Also, I’ve inserted comments
in [CLOSED BRACKETS] to make clear how the example
‘introduction’ provided is in line with the structural elements
outlined above.
Table 3 Elements of an Introduction to a Scholarly Paper
• There is a clear and unambiguous question or problem
statement
• A brief summary of what is already known on the topic
may be given
• Key terms are defined
• There is a clear and unambiguous thesis statement (main
message)
• Importance of the paper is made clear (relevance or
significance)
Table 4 Example Introduction to a Scholarly Paper
How has it happened that medicine holds a power monopoly
over a natural, rite-of-passage event like healthy childbirth?
[PROBLEM STATEMENT] A search of the literature
showed that histories of midwifery have been published in
the journals for New Zealand, Scotland, Ireland, the UK and
the USA (refs). Annette Summer’s published a paper that
focussed on nursing’s takeover of midwifery but her account
was limited to the years of the takeover (refs). The current
paper incorporates the era that Summers’ reported upon
and provides an historical analysis of professionalisation
of medicine from the mid 19th until the early 20th century.
Medical professionalisation was inextricably linked to an
obedient nursing profession which in turn was the key
player in the eradication of midwifery as an independent
occupational group. [BRIEF REFERENCE TO WHAT
IS ALREADY KNOWN BASED ON BACKGROUND
LITERATURE].
Ultimately social power rests with the State therefore the
focus of critical analysis within this paper includes the role
that the State played in supporting and legitimising medical
domination. An understanding of the socio-historical
medical domination and virtual obliteration of midwifery
as an independent discipline is contextual to understanding
the contemporary organisation of maternity services by the
state. The analysis shows that medicine’s power strategies
are essentially the same today as they were 100 years ago.
[THESIS STATEMENT] This is important because it means
that midwifery can learn from history and develop more
effective strategies to promote and protect for the wellbeing
of women and babies. [WHAT THIS PAPER ADDS TO
WHAT IS ALREADY KNOWN] (25)
The Structure of a Paper
The structure of an effective paper follows the same rules
about the structure of effective paragraphs. Both a good
52
paragraph and a good paper will demonstrate the elements
of unity, coherence and development (7). Firstly, ‘unity’,
which means that each sentence in a paragraph is related to
the topic sentence; likewise, each paragraph is clearly related
to the thesis of the paper. Secondly ‘coherence’, which means
that the relationship between the sentences in a paragraph is
clear and logical and likewise, the relationship between each
of the paragraphs in a paper is clear. Thirdly, ‘development’,
means that main idea of each paragraph is well supported
with specific evidence and, likewise, the thesis of the paper is
supported with evidence and examples (4, 7).
An example of the ordering structure of a literature review is
presented below. This structure was developed in order to
answer the question: Why do women continue to smoke in
pregnancy (22)?
• Introduction
• Australian Anti-Smoking Policy Background (H 3, part
of introduction)
• Literature Search Strategy: Research on Smoking in
Pregnancy
• Quit Smoking Interventions: The Systematic Review
• Smoking Behaviours in the Childbearing Period
• Research about Smoking and Social Disadvantage
• The Physiology of Pleasure and Addiction
• How Women Feel About Smoking in Pregnancy
• Women’s Views on Smoking Cessation Interventions
• Conclusion
This structure is ordered appropriate for the question that was
asked because it encompasses all the elements that are needed
to fully answer the question. The logic of this structure is that
moves from the general to the specific in terms of level of
detail (an alternative logic could be to move from specific to
general). The logic of the structure also moves from the more
important, or more firmly established, to the less important.
Importantly, each structural element is needed to answer the
question; there are no side tracks or superfluous sections to
the paper.
There are, of course, other logical ordering structures. If one is
writing an historical paper, for example, then a chronological
order would normally be most suitable. If one is writing
about a clinical problem then an appropriate structure might
be to state the problem, then give the reasons for the problem,
then state the proposed change in practice and finally discuss
possible hurdles to be overcome before the new practice can
be widely adopted.
The Conclusion
The main function of the conclusion it to conclude; do not
add new information. In a conclusion you draw the threads of
your argument together. You answer the question, or give the
solution to the problem that you set out in the introduction.
You should explain how the evidence, provided in the paper,
supports your thesis and undermines alternative explanations.
In a paper for publication you should show that your paper
is presenting new knowledge. You should make clear how
this new knowledge relates to prior or existing conceptions
of knowledge. The implications for practice, research, theory
or policy should be specified. A summary of these elements of
an effective conclusion are provided in Table 5. An example
conclusion is given in Table 6.
 Table 5 Elements of Effective Conclusions
An effective conclusion:
• Concludes the argument; it does not add any new
information
• Draws the threads of the argument together
• Provides an answer the question, or the solution to the
problem given in the introduction
• Explain how the evidence, provided in the paper, supports
the thesis and undermines alternative explanations
• The knowledge presented in a paper for publication must
be new
• The implications for practice, research, theory or policy
should be specified
Table 6 Example Conclusion
The conclusion below is part of a paper that was written to
answer the question: “In cases of postpartum haemorrhage,
can amniotic fluid embolus be accurately diagnosed as a
causative factor”? (22)
Conclusion
It is not possible to accurately diagnose AFE by any currently
available laboratory tests. [THESIS]
The contemporary model of AFE as a form of hypersensitivity
explains why large amounts of amniotic fluid do not cause
a response in primate models. In the original post-mortem
research, doctors excluded 34 of the 42 women had died
with suspected AFE. The clinical cases of the excluded
women did not differ from the remaining 8 women who
had their diagnosis confirmed by finding amniotic matter in
their lungs. It now seems likely that the original research,
which was conducted over fifty years ago, under-diagnosed
AFE due to inadequacies in methods of detection.
[UNDERMINES ALTERNATIVE VIEW]
Even today, in cases of postpartum haemorrhage, amniotic
fluid embolus may be incorrectly ruled out as a causative
factor because of lack of specificity of existing tests. The
diagnosis of AFE, therefore, needs to be based on a careful
clinical assessment and should be considered in all cases
of sudden maternal collapse. It should not be ruled out
because of failure to detect amniotic material in the lungs.
[IMPLICATION OR SIGNIFICANCE]
The Abstract
The function of an abstract is to provide an overview of the
paper. The abstract should be brief – between 100-250 words.
The abstract should be neither vague and general nor fussily
detailed; it should pull out the highlights from each section
of the paper (4). The structure of the abstract for a scholarly
paper should include: the question or problem statement; a
brief description of what was done to answer the question; the
thesis statement (or answer to the question) and finally the key
significance of the paper. An example abstract is given in Table 7.
Table 7 Example Abstract
This review of the literature answers the question why
do women who continue to smoke during pregnancy?
[QUESTION] Research on the effectiveness of quit smoking
interventions is reviewed. The physiology of smoking,
pleasure and addiction are described. the demographics of
women who continue to smoke are compared with those
who quit. Women’s views on smoking and anti-smoking
interventions during pregnancy are discussed. [WHAT
WAS DONE TO ANSWER THE QUESTION]
Smoking cessation programs in pregnancy are ineffective
because smoking is addictive and the women who smoke
in pregnancy are socio-economically disadvantaged women
and lack alternative sources of pleasure and satisfaction in
their lives. [THESIS]
We recommend a woman-centred continuity of care
approach to supporting pregnant women to improve their
overall health which, of course, includes quitting smoking
for good. [IMPLICATION FOR PRACTICE]
CONCLUSION
This paper was written with the aim of enabling new writers
to confidently develop and support an argument within a
scholarly paper for publication.
The similarities and differences between scientific argument
and debate have been made explicit. Potential writers have
been given guidance and examples of how to write a well
defined question and how to write with an acceptable tone.
The elements of an effective scholarly paper have been
presented and examples given.
New writers are advised to keep this paper and the earlier
‘basics’ paper with them as they begin, and work through,
the writing process. With careful attention to following the
guidelines given here many wasted hours will be avoided. An
acceptance letter will be your reward for care and diligence in
preparing your paper for publication.
References
1. Fahy K. M. Writing for publication: the basics. Women and Birth 2008;21(2).
2. Murray R, Metheny N. Writing for publication: the transition from course
assignments and presentations to journal publication. Missouri Nurse 2002:18-
21.
3. Zilm G, Entwistle C. The smart way: an introduction to writing for nurses. 2nd
ed. Toronto: Elsevire; 2002.
4. Zeiger M. Essentials of Writing Biomedical Research Papers. 2nd ed. New York:
McGraw-Hill; 2000.
5. Bailey S. Academic writing: a practical guide for students. Cheltenham UK:
Nelson Thornes; 2003.
6. Gimenez J. Writing for nursing and midwifery students. London: Palgrave;
2007.
7. Fowler HR, Aaron JE. The Little Brown Handbook. New York: HarperCollins;
1989.
8. Department of Finance and Administration. Style manual for authors, editors
and printers. 6th ed. Melbourne: Wiley and Sons; 2002.
9. American Psychological Association. Publication Manual. 5th ed. Washington:
American Psychological Association; 2002.
10. Burnard P. Education. Where do I begin? Writing for publication. Accident &
Emergency Nursing 1997;5(4):226-229.
11. Black J. Writing for publication: advice to potential authors. Plastic Surgical
Nursing 1996;16(2):90-93.
12. Duff D. Writing for publication. AXON/ L’AXONE 2001; 22(4):36-39.
13. Happell B. Disseminating nursing knowledge - a guide to writing for publication.
International Journal of Psychiatric Nursing Research 2005;10(3):1147-1155.
14. Jackson K, Sheldon L. Writing for publication. Nurse Researcher 2000; 7(4):68-
74.
15. Plawecki H, Plawecki J. Writing of publication: understanding the process.
Journal of Holistic Nursing 1998; 16(1):23-32.
16. Rassool G. Moving in the right direction: first step in writing for publication in
nursing. Revista Latino-Americana de Enfermagem 2005;13(6):1035-1038.
17. Robinson J. Editorial: writing for publication in a peer-reviewed journal. Journal
of Advanced Nursing;31(5):991-992.
18. Taylor J, Lyon P, Harris J. Writing for publication: a new skill for nurses? Nurse
Education in Practice 2005;5(2):91-96.
19. Thompson D. R. Writing for publication. European Journal of Cardiovascular
Nursing 2002;1(4):221-222.
20. Thomson A. M. Writing for publication in this refereed journal. Midwifery
2005;21(2):190-194.
21. Wickham S. Appraising research into childbirth. Edinburgh: Elsevier; 2006.
22. Ebert L, Fahy K. Why do women continue to smoke in pregnancy? Women and
Birth 2007;20 (4):161-168.
23. Fahy K. Amniotic Fluid Embolism: A review of the research literature. MIDIRS
2001;11(3):373-376.
24. Fahy K, Tracy S. Home-like vs conventional setting for birth: a critique and re-
analysis. International Journal of Evidence Based Healthcare 2007;5(3):360-364.
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29.
53
Table of Contents

FEATURE ARTICLES
An Inter-disciplinary team approach to tracheostomy management in an
acute hospital facility. 4
Vicki Parker, Michelle Giles, Gai Shylan, Nicole Austin, Wendy Archer; Kelvin Smith and Jane Morison.

Pictures and Perspectives: A unique reflection on interdialytic weight gain. 10
Peter Sinclair and Vicki Parker

The lure of the bush: Do rural placements influence student nurses to
seek employment in rural settings? 16
Jackie Lea, Mary Cruickshank, Penny Paliadelis, Glenda Parmenter, Helena Sanderson and Patricia Thornberry

DISCUSSION PAPERS
An ethical dilemma, yours mine or ours? 21
Ludmilla Sneezby

A Literature Review: Nursing assessment in a Post Anaesthetic Care Unit. 25
Lee Lethbridge

Perineal trauma and childbirth: A discussion paper. 28
Christina Teale, Lyn Ebert and Carol Ann Norton

Reflective Practice and the National Continuing Competency Framework. 32
Rowena Masson and Ann Katherine Williams

CLINICAL FOCUS ARTICLES
What really happens to the siblings of the chronically ill child? 36
Dianne Cotterell

Mind Essentials – Mental Illness Nursing Resources. 37
Katie McGill

Conference Review: Advanced practice nursing in multi-cultural environments. 39
Lorna MacLellan and Pamela van der Riet

LOCAL INTEREST ARTICLES

Focus on Stewardship: Reflections by Stewardees. 41
Kelvin Smith and Iris Li

STUDENT CONTRIBUTIONS
Nurse Practitioners in the Emergency Department: A critical review of the literature. 44
Michelle McCoy

Student nurse confidence - A reflection. 48
Elizabeth Bembridge and Sarah Yeun-Sim Jeong

RESOURCE ARTICLE
Writing for publication. The basics Part 2 50

HNE

Handover