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Aims: To address knowledge gaps by (i) developing a theoretical understanding of escalation and (ii) identifying escalation success factors., Design: Non-participant observations were used to examine deteriorating patient escalation events., Methods: Escalation event data were collected by a researcher who shadowed clinical staff, between February 16th 2021 and March 17th 2022 from two National Health Service Trusts. Events were analysed using Framework Analysis. Escalation tasks were mapped using a Hierarchical Task Analysis diagram and data presented as percentages, frequency and 95% CI., Results: A total of 38 observation sessions were conducted, totaling 105 h, during which 151 escalation events were captured. Half of these were not early warning score-initiated and resulted from bleeding, infection, or chest pain. Four communication phenotypes were observed in the escalation events. The most common was Outcome Focused Escalation, where the referrer expected specific outcomes like blood cultures or antibiotic prescriptions. Informative Escalations were often used when a triggering patient's condition was of low clinical concern and ranked as the second most frequent escalation communication type. General Concern Escalations occurred when the referrer did not have predetermined expectations. Spontaneous Interaction Escalations were the least frequently observed, occurring opportunistically in communal workspaces., Conclusion: Half of the events were non-triggering escalations and understanding these can inform the design of systems to support staff better to undertake them. Escalation is not homogenous and differing escalation communication phenotypes exist. Informative Escalations represent an organizational requirement to report triggering warning scores and a targeted reduction of these may be organizationally advantageous. Increasing the frequency of Spontaneous Escalations, through hospital designs, may also be beneficial., Impact Statement: Our work highlights that a significant proportion of escalation workload occurs without a triggering early warning score and there is scope to better support these with designed systems. Further examination of reducing Informative and increasing Spontaneous Escalations is also warranted., Patient and Public Contribution: Extensive PPIE was completed throughout the lifecycle of this study. PPIE members validated the research questions and overarching aims of the overall study. PPIE members contributed to the design of the study reviewed documents and the final data generated., (© 2024 The Author(s). Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Aims: To explore healthcare professionals' experiences of patient-witnessed resuscitation in hospital., Design: Descriptive phenomenology., Methods: Healthcare professionals involved in hospital resuscitation activities were recruited from medical, intensive care, resuscitation and education departments in a university hospital in England. Data were collected through face-to-face and focus group interviews, between August 2018 and January 2019. Data were analysed using Giorgi's phenomenological approach., Results: Nine registered nurses, four healthcare assistants and seven doctors participated in four individual interviews and three focus groups. Findings were related to three themes: (1) Protecting patients from witnessing resuscitation: healthcare professionals used curtains to shield patients during resuscitation, but this was ineffective. Thus, they experienced challenges in explaining resuscitation events to the other patients and communicating sensitively. (2) Emotional impact of resuscitation: healthcare professionals recognized that witnessing resuscitation impacted patients, but they also felt emotionally affected from performing resuscitation and needed coping strategies and support. (3) Supporting patients who witnessed resuscitation: healthcare professionals recognized the importance of patients' well-being, but they felt unable to provide effective and timely support while providing life-saving care., Conclusion: Healthcare professionals involved in hospital resuscitation require specific support, guidance and education to care effectively for patients witnessing resuscitation. Improving communication, implementing regular debriefing for staff, and allocating a dedicated professional to support patients witnessing resuscitation must be addressed to improve clinical practice., Impact: The WATCH study uncovers patients' and healthcare professionals' experiences of patient-witnessed resuscitation, a phenomenon still overlooked in nursing research and practice. The main findings highlight that, in common with patients, healthcare professionals are subject to the emotional impact of resuscitation events and encounter challenges in supporting patients who witness resuscitation. Embedding the recommendations from this research into clinical guidelines will impact the clinical practice of healthcare professionals involved in hospital resuscitation and the quality and timeliness of care delivered to patients., (© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Aims: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates., Background: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence., Methods: Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis., Findings: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes., Conclusions: Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well-being, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies., Implications for Nursing Management: In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services., (© 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.)

Aims: The aim of the study was to explore the experiences of hospital patients who witnessed resuscitation of a fellow patient., Design: Descriptive phenomenology., Methods: Patients who witnessed resuscitation were recruited from nine clinical wards in a university hospital in England. Data were collected through face-to-face individual interviews. Participants were interviewed twice,in 1 week and 4 to 6 weeks after the resuscitation event. Data were collected between August 2018 and March 2019. Interviews were analysed using Giorgi's phenomenological analysis., Results: Sixteen patients participated in the first interview and two patients completed follow-up interviews. Three themes were developed from the patients' interviews. (1) Exposure to witnessing resuscitation: patients who witness resuscitation felt exposed to a distressing event and not shielded by bed-space curtains, but after the resuscitation attempt, they also felt reassured and safe in witnessing staff's response. (2) Perceived emotional impact: patients perceived an emotional impact from witnessing resuscitation and responded with different coping mechanisms. (3) Patients' support needs: patients needed information about the resuscitation event and emotional reassurance from nursing staff to feel supported, but this was not consistently provided., Conclusion: The presence of other patients during resuscitation events must be acknowledged by healthcare professionals, and sufficient information and emotional support must be provided to patients witnessing such events. This study generates new evidence to improve patients' experience and healthcare professionals' support practices., Impact: The phenomenon of patient-witnessed resuscitation requires the attention of healthcare professionals, resuscitation officers and policymakers. Study findings indicate that witnessing resuscitation has an emotional impact on patients. Strategies to support them must be improved and integrated into the management of in-hospital resuscitation. These should include providing patients with comprehensive information and opportunities to speak about their experience; evacuating mobile patients when possible; and a dedicated nurse to look after patients witnessing resuscitation events., (© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Aims: To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models., Design: Exploratory qualitative study., Methods: Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England., Findings: The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing., Conclusions: Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change., Impact: In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes., (© 2021 John Wiley & Sons Ltd.)

Aims and Objectives: To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus., Background: Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care., Design: Delphi Method., Method: A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist., Results: High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care., Conclusion: The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise., Relevance to Clinical Practice: This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care., (© 2020 John Wiley & Sons Ltd.)

Aim: The aim of this study was to explore the experiences of patients and healthcare professionals regarding patients witnessing resuscitation on another patient in hospital clinical wards., Design: Phenomenological qualitative study., Methods: Participants will be recruited from nine wards in a university hospital in England. Data collection will include two in-depth interviews with patients who witnessed resuscitation: the first interview one week after witnessing resuscitation and the second interview after one month. Individual and focus group interviews with healthcare professionals will be also conducted. Data will be transcribed, managed in NVivo 11 and analysed using phenomenological analysis. The National Health Service, Health Research Authority and University Ethics Committee approved the study (May 2018). The study is funded by Resuscitation Council UK (December 2017) and will be conducted between May 2018-March 2019., Conclusion: While witnessed resuscitation is a major topic of interest in nursing, specific research on the impact of patients who witness resuscitation on fellow patients is limited. This study will use qualitative methodology to inform the evidence base of a clinical problem with limited understanding. The findings of this study will contribute to the framework of witnessed resuscitation and to identifying the barriers and enablers towards a greater support of patients who witness resuscitation in hospital. This new acquired knowledge will be beneficial to the improvement of future nursing care., Impact: The evidence gained from this study can support the development and implementation of guidelines and inform hospital policies to support patients witnessing resuscitation to optimize the quality of nursing care provided., (© 2018 John Wiley & Sons Ltd.)

Aims and Objectives: To determine, from the perspectives of enrolled nurses and registered nurses, the current scope of enrolled nurse practice and to identify the activities that most enrolled nurses frequently performed in their workplace., Background: Enrolled nurse scope of practice in Australia has evolved and expanded over the past decade. However, the unclear role, function and competency differentiation between enrolled nurse and registered nurse leads to role confusion and ongoing professional debate., Design: Exploratory Descriptive Study., Methods: A cross-sectional online survey of enrolled nurses and registered nurses across Australia was conducted examining their levels of agreement on statements related to the scope of practice and the clinical and nonclinical activities that enrolled nurses were required to perform in their workplace., Results: Valid responses were received from 892 enrolled nurses and 1,198 registered nurses. Enrolled nurses mostly agreed that they understood their scope of practice; did not undertake roles for which they were unprepared; sometimes undertook activities other than direct patient care; and believed that they operated equally to many registered nurses. The majority of enrolled nurses reported that they performed tasks mostly related to basic patient care in their workplace. There were a number of significant differences between perspectives of registered nurses and enrolled nurses., Conclusions: Clarifying the roles and scope of practice between the registered nurse and the enrolled nurse is important, and explicit differences in responsibility and accountability between their roles must be clearly articulated to harmonise perceptions about role and capability. Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned., Relevance to Clinical Practice: Health service providers, policymakers and education providers need to work collaboratively to ensure that facets of enrolled nurse education and scope of practice in line with regulation are affirmed by all concerned., (© 2017 John Wiley & Sons Ltd.)

Aims and Objectives: To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language., Background: Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language., Design: Factorial survey design., Methods: Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement., Results: Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges., Conclusions: The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases., Relevance to Clinical Practice: The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services., (© 2017 John Wiley & Sons Ltd.)

Aim: To examine attitudes to patient safety in two intensive care units from the perspective of health care professionals in Saudi Arabia., Background: Despite adverse errors leading to poor patient outcomes, there is a paucity of literature, including staff perceptions, on adverse errors in Saudi Arabian intensive care units., Methods: A descriptive cross-sectional design was used. Health professionals (n = 144) completed the safety attitude questionnaire-intensive care unit., Results: The scores from the six safety domains of the safety attitude questionnaire-intensive care unit showed all respondents had a negative attitude towards patient safety, with participants in one intensive care unit scoring lower in all domains. The mean scores across all domains ranged from 47.1 to 70.3 on a 100-point scale, with the lowest score reported in the "perceptions of management" domain. Respiratory therapists reported a significantly higher job satisfaction score than nurses, and physicians rated communication amongst themselves and nurses as high., Conclusion: There are significant challenges for safety culture in this study, with negative attitudes across all domains., Implication for Nursing Management: Managers may need to review and consider policies relating to safety culture including workforce planning, leadership and patient centred care. Further research into this global health priority is required to contribute to improving patient safety in intensive care units., (© 2017 John Wiley & Sons Ltd.)

Aims and Objectives: To explore how nurses navigate communication with families during withdrawal of life-sustaining treatment in intensive care., Background: Death in the intensive care unit is seldom unexpected and often happens following the withdrawal of life-sustaining treatment. A family-centred approach to care relies on the development of a therapeutic relationship and understanding of what is happening to the patient. Whilst previous research has focused on the transition from cure to palliation and the nurse's role in supporting families, less is known about how nurses navigate communication with families during treatment withdrawal., Design: A qualitative descriptive approach was used. Semi-structured focus groups were conducted with adult critical care nurses from four intensive care units, two in Australia and two in New Zealand., Results: Twenty-one nurses participated in the study. Inductive content analysis revealed five key themes relating to how nurses navigate family communication: (1) establishing the WHO; (2) working out HOW; (3) judging WHEN; (4) assessing the WHAT; and (5) WHERE these skills were learnt., Conclusions: Navigating an approach to family communication during treatment withdrawal is a complex and multifaceted nursing activity that is known to contribute to family satisfaction with care. There is need for support and ongoing education opportunities that develop the art of communication in this frequently encountered aspect of end-of-life care., Relevance to Clinical Practice: How nurses navigate communication with families during treatment withdrawal is just as important as what is communicated. Nurses need access to supports and education opportunities in order to be able to perform this vital role., (© 2016 John Wiley & Sons Ltd.)

Aim: The aim of this study was to conduct an integrative review on how nurses prepare families for and support families during withdrawal of life-sustaining treatments in intensive care., Background: End-of-life care is widely acknowledged as integral to the practice of intensive care. However, little is known about what happens after the decision to withdraw life-sustaining treatments has been made and how families are prepared for death and the dying process., Design: Integrative literature review., Data Sources: MEDLINE, CINAHL Plus, PsychINFO, PUBMED, Scopus, EMBASE and Web of Knowledge were searched for papers published between 2000-May 2015., Review Methods: A five stage review process, informed by Whittemore and Knafl's methodology was conducted. All papers were reviewed and quality assessment performed. Data were extracted, organized and analysed. Convergent qualitative thematic synthesis was used., Results: From an identified 479 papers, 24 papers were included in this review with a range of research approaches: qualitative (n = 15); quantitative (n = 4); mixed methods (n = 2); case study (n = 2) and discourse analysis (n = 1). Thematic analysis revealed the nurses: equipped families for end of life through information provision and communication; managed the withdrawal of life-sustaining treatments to meet family need; and continued care to build memories., Conclusion: Greater understanding is needed of the language that can be used with families to describe death and dying in intensive care. Clearer conceptualization of the relationship between the medically focussed withdrawal of life-sustaining treatments and patient/family-centred end-of-life care is required making the nursing contribution at this time more visible., (© 2016 John Wiley & Sons Ltd.)

Aims and Objectives: To redefine the practice of rural nurses and describe a model that conceptualises the capabilities and characteristics required in the rural environment., Background: The way in which the practice of rural nurses has been conceptualised is problematic. Definitions of rural nursing have been identified primarily through the functional context of rural health service delivery. The expert generalist term has provided a foundation theory for rural nurses with understandings informed by the scope of practice needed to meet service delivery requirements. However, authors exploring intrinsic characteristics of rural nurses have challenged this definition, as it does not adequately address the deeper, intangible complexities of practice required in the rural context. Despite this discourse, an alternative way to articulate the distinctive nature of rural nursing practice has eluded authors in Australia and internationally., Design: A theoretical paper based on primary research., Methods: The development of the model was informed by the findings of a study that explored the nursing practice of managing telephone presentations in rural health services in Victoria, Australia. The study involved policy review from State and Federal governments, nursing and medical professional bodies, and five rural health services; semi-structured interviews with eight Directors of Nursing, seven registered nurses and focus group interviews with eight registered nurses., Results: An ambiguity tolerance model drawn from corporate global entrepreneurship theory was adapted to explain the findings of the study. The adapted model presents capabilities and characteristics used by nurses to successfully manage the ambiguity of providing care in the rural context., Conclusions: Redefining the practice of rural nurses, through an adapted theory of ambiguity tolerance, highlights nursing characteristics and capabilities required in the rural context. This perspective offers new ways of thinking about the work of rural nurses, rural nurse policy, education, recruitment, retention and clinical governance., Relevance to Clinical Practice: A greater understanding of rural nurse practice will assist in achieving positive care outcomes in an environment with competing stakeholder needs, and limited resources and options for care., (© 2016 John Wiley & Sons Ltd.)

Aims and Objectives: To examine nursing students' and registered nurses' teamwork skills whilst managing simulated deteriorating patients., Background: Studies continue to show the lack of timely recognition of patient deterioration. Management of deteriorating patients can be influenced by education and experience., Design: Mixed methods study conducted in two universities and a rural hospital in Victoria, and one university in Queensland, Australia., Methods: Three simulation scenarios (chest pain, hypovolaemic shock and respiratory distress) were completed in teams of three by 97 nursing students and 44 registered nurses, equating to a total of 32 student and 15 registered nurse teams. Data were obtained from (1) Objective Structured Clinical Examination rating to assess performance; (2) Team Emergency Assessment Measure scores to assess teamwork; (3) simulation video footage; (4) reflective interview during participants' review of video footage. Qualitative thematic analysis of video and interview data was undertaken., Results: Objective structured clinical examination performance was similar across registered nurses and students (mean 54% and 49%); however, Team Emergency Assessment Measure scores differed significantly between the two groups (57% vs 38%, t = 6·841, p < 0·01). In both groups, there was a correlation between technical (Objective Structured Clinical Examination) and nontechnical (Team Emergency Assessment Measure) scores for the respiratory distress scenario (student teams: r = 0·530, p = 0·004, registered nurse teams r = 0·903, p < 0·01) and hypovolaemia scenario (student teams: r = 0·534, p = 0·02, registered nurse teams: r = 0·535, p = 0·049). Themes generated from the analysis of the combined quantitative and qualitative data were as follows: (1) leadership and followership behaviours; (2) help-seeking behaviours; (3) reliance on previous experience; (4) fixation on a single detail; and (5) team support., Conclusions: There is scope to improve leadership, team work and task management skills for registered nurses and nursing students. Simulation appears to be beneficial in enabling less experienced staff to assess their teamwork skills., Relevance to Clinical Practice: There is a need to encourage less experienced staff to become leaders and for all staff to develop improved teamwork skills for medical emergencies., (© 2014 John Wiley & Sons Ltd.)

Aim: This article is a report of a study examining the practices of acute care nurses when administering medication via enteral tubes., Background: Administering medication via enteral tubes is predominantly a nursing responsibility across countries. It is important to establish what nurses actually do when giving enteral medication to inform policy and continuing education development., Method: In 2007, a survey was conducted using a random sample of acute care nurses at two large metropolitan hospitals in Melbourne, Australia. There were 181 Registered Nurses who participated in the study; 92 (50.8%) practised in intensive care units, 52 (28.7%) in surgical areas, 30 (16.6%) in medical areas and 7 (3.9%) were from combined medical-surgical areas. The questionnaire was developed by the researchers and a pilot study was conducted in August 2006 to test reliability, face validity and user-friendliness of the tool., Results: Nurses reported using a range of methods to verify enteral tube position prior to administering enteral medication; some were unreliable methods. A majority reported administering enteric-coated and slow or extended release forms of medication, and giving solid forms of medication when liquid form was available. Nearly all (96%) reported flushing a tube after giving medication, 28% before, and 12% always flushed between each medication., Conclusion: Enteral medication administration practices are inconsistent. Some nurses are using unsafe practices and may therefore compromise patient care., (© 2011 Blackwell Publishing Ltd.)

Objective: To identify factors that clinicians consider when a patient is dying, enabling implementation of the Liverpool Care Pathway., Background: In order to improve the care of the dying patient and their families it is helpful to implement the Liverpool Care Pathway for the dying. It therefore is necessary to identify the dying patient in a timely fashion., Method: A phenomenological study using semi-structured interviews (n=five nurses and five doctors) conducted on a hospice inpatient unit., Findings: There was a prominent theme of anxiety about getting the timing of diagnosing dying right, with an emphasis how the dying patient and their families would cope if this were wrong. The main factors identified were: support for decision making, understanding the patient's journey and concern that the care given is appropriate. CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE: All clinicians interviewed for this study had concerns about increasing the patient's/carers' distress if the Liverpool Care Pathway implementation was mistimed. There is a risk that clinicians are avoiding difficult conversations with families and there may be a lack of understanding around the reasons for use of the Liverpool Care Pathway. Specific communications training may help clinicians in this role., (© 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.)

Aim: This is a report of a study investigating processes used by final-year nursing students to recognize and act on clinical cues of deterioration in a simulated environment., Background: Initial decisions about patients who are deteriorating in medical and surgical wards are often made by newly qualified nurses and doctors, increasing the risk of clinical error. There has been an emphasis on the use of teams in simulation; however, signs of deterioration are missed by individual clinicians., Methods: During July 2008, final-year undergraduate nursing students in Australia attended a simulation laboratory for 1·5 hours and completed a knowledge questionnaire and two (mannequin-based) scenarios simulating deteriorating patients with hypovolaemic and septic shock. Scenarios were video-recorded and reflective interviews conducted. Additionally, scenarios were stopped around the midpoint to ascertain students' level of Situation Awareness., Results: Fifty-one students participated in the study, providing a total of 102 videoed scenarios and 51 interviews. Thematic analysis of video data and reflective interviews identified considerable differences in processes used by students to identify cues. Four aspects of cue recognition were evident: initial response, differential recognition of cues, accumulation of signs and diversionary activity., Conclusion: Nursing skills training should emphasize the importance of trends in identifying and acting on deterioration and the need for systematic assessment in stressful situations. Nursing curricula should focus on enhancing the ability to piece information together, including linking pathophysiology with patient assessment, and identify trends, rather than seeing observations as parallel to each other., (© 2010 The Authors. Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.)

Aim: To examine, in a simulated environment, the ability of final-year nursing students to assess, identify and respond to patients either deteriorating or at risk of deterioration., Background: The early identification and management of patient deterioration has a major impact on patient outcomes. 'Failure to rescue' is of international concern, with significant concerns over nurses' ability to detect deterioration, the reasons for which are unknown., Design: Mixed methods incorporating quantitative measures of performance (knowledge, skill and situation awareness) and, to be reported at a later date, a qualitative reflective review of decision processes., Methods: Fifty-one final-year, final-semester student nurses attended a simulation laboratory. Students completed a knowledge questionnaire and two video-recorded simulated scenarios (mannequin based) to assess skill performance. The scenarios simulated deteriorating patients with hypovolaemic and septic shock. Situation awareness was measured by randomly stopping each scenario and asking a series of questions relating to the situation., Results: The mean knowledge score was 74% (range 46-100%) and the mean skill performance score across both scenarios was 60% (range 30-78%). Skill performance improved significantly (p < 0.01) by the second scenario. However, skill performance declined significantly in both scenarios as the patient's condition deteriorated (hypovolaemia scenario: p = 0.012, septic scenario: p = 0.000). The mean situation awareness score across both scenarios was 59% (range 38-82%). Participants tended to identify physiological indicators of deterioration (77%) but had low comprehension scores (44%)., Conclusion: Knowledge scores suggest, on average, a satisfactory academic preparation, but this study identified significant deficits in students' ability to manage patient deterioration., Relevance to Clinical Practice: This study suggests that student nurses, at the point of qualification, may be inadequately prepared to identify and manage deteriorating patients in the clinical setting.

Aim: To determine activities and outcomes of intensive care unit Liaison Nurse/Outreach services. The review comprised two stages: (1) integrative review of qualitative and quantitative studies examining intensive care liaison/outreach services in the UK and Australia and (2) meta-synthesis using the Nursing Role Effectiveness Model as an a priori model., Background: Acute ward patients are at risk of adverse events and patients recovering from critical illness are vulnerable to deterioration. Proactive and reactive strategies have been implemented to facilitate timely identification of patients at risk., Design: Systematic review., Methods: A range of data bases was searched from 2000-2008. Studies were eligible for review if they included adults in any setting where intensive care unit Liaison Nurse or Outreach services were provided. From 1423 citations and 65 abstracts, 20 studies met the inclusion criteria., Results: Intensive care liaison/outreach services had a beneficial impact on intensive care mortality, hospital mortality, unplanned intensive care admissions/re-admissions, discharge delay and rates of adverse events. A range of research methods were used; however, it was not possible to conclude unequivocally that the intensive care liaison/outreach service had resulted in improved outcomes. The major unmeasured benefit across all studies was improved communication pathways between critical care and ward staff. Outcomes for nurses in the form of improved confidence, knowledge and critical care skills were identified in qualitative studies but not measured., Conclusion: The varied nature of the intensive care liaison/outreach services reviewed in these studies suggests that they should be treated as bundled interventions, delivering a treatment package of care. Further studies should examine the impact of critical care support on the confidence and skills of ward nurses., Relevance to Clinical Practice: Advanced nursing roles can improve outcomes for patients who are vulnerable to deterioration. The Nursing Role Effectiveness Model provides a useful framework for evaluating the impact of these roles.

Background: Contemporary nursing leadership roles in critical care are a reflection of the changing environment in which critical care is provided., Key Issues: In the UK, critical care nursing faces challenges in the form of: reduced number and seniority of medical staff cover for acute wards; mandated responsibility for management of patients outside of critical care units, without corresponding responsibility for managing staff; increased public and political awareness of deficits in critical care; increased use of Assistant Practitioners; and emphasis on longer-term outcomes from intensive care., Evaluation: New leadership roles have met these challenges head on with two main foci: patient management across the acute/critical care interface and hospital wide policies and practice., Conclusions: The leadership roles examined in this paper highlight three underpinning goals: improved quality and safety of patient care; improved communication between professionals; and empowerment of junior nurses and doctors., Implications for Nursing Management: There has been considerable investment in strategic leadership roles for critical care nursing; evidence is developing of the return on this investment for patient and service outcomes. Consideration must now be given to the preparation, mentorship and development of leadership roles for the next generation of nurse leaders.

Aim: This paper is a report of a study to identify experienced rural nurses' perceptions of key issues related to the provision of effective psychosocial care for people with cancer in rural settings., Background: A cancer diagnosis has a major impact on psychological and emotional wellbeing, and psychosocial support provided by nurses is an integral part of ensuring that people with cancer have positive outcomes. Although, ideally, people with cancer should be managed in specialist settings, significant numbers are cared for in rural areas., Methods: Using a qualitative descriptive approach, three focus groups were conducted in 2005 with 19 nurses in three hospitals in rural Victoria, Australia., Findings: Participants indicated that a key issue in providing psychosocial care to patients with cancer in the rural setting was their own 'emotional toil'. This Global Theme encapsulated three Organizing Themes- task vs. care, dual relationships and supportive networks--reflective of the unique nature of the rural environment. Nurses in rural Australia are multi-skilled generalists and they provide care to patients with cancer without necessarily having specialist knowledge or skill. The fatigue and emotional exhaustion that the nurses described often has a major impact on their own well-being., Conclusion: In the rural context, it is proposed that clinical supervision may be an important strategy to support clinicians who face emotional exhaustion as part of their cancer nursing role.

Background: A portfolio captures learning from experience, enables an assessor to measure student learning, acts as a tool for reflective thinking, illustrates critical analytical skills and evidence of self-directed learning and provides a collection of detailed evidence of a person's competence., Aims: This paper reports data on how assessors and nursing students match learning outcomes and/or competencies to their practice and then reconstruct those experiences into the format required by the portfolio documentation. The data were gathered as part of a larger study to evaluate the use of portfolios in the assessment of learning and competence in England., Methods: This three phase stakeholder evaluation was designed to gain the views of those involved in designing, implementing and using portfolios in nurse education. In phase 2, 122 students and 58 nurse teachers were interviewed about their perceptions of portfolio use, and a further 32 students and 26 assessors were interviewed after they had been observed taking part in an assessment process. Thematic data analysis was used., Findings: Assessors and students underwent a complex process of deconstructing learning outcomes/competences to fit these to their practice. These then had to be reconstructed through the written medium to fit the structure of the portfolio. Confirmation that this met teachers' expectations was essential to allay feelings of insecurity., Conclusions: To achieve maximum benefit from the portfolio as a learning tool to link theory and practice, there needs to be a clear fit between the model of portfolio and the professional practice that is to be assessed. Outcomes and competences, as well as the type of evidence required to demonstrate their achievement, and integration of the whole experience should match the students' stage of professional and academic development. Over-complex approaches to practice assessment, particularly in the early stages of students' careers, can detract from clinical learning in favour of learning how to complete the portfolio successfully.

* This article reports on the clinical phase of a study commissioned by the English National Board for Nursing, Midwifery and Health Visiting to evaluate the effectiveness of educational preparation for critical care nursing [Scholes & Endacott (2002) Evaluation of the Effectiveness of Educational Preparation for Critical Care Nursing. ENB, London]. The authors draw on observation and interview data from clinical settings (general and paediatric intensive care units; operating theatre departments; accident and emergency departments and coronary care units), focusing specifically on the way in which curricular intentions were made a reality in clinical practice. The reality of learning in practice is examined, with evidence from the data to illustrate the real world of clinical practice. * Different models of support and supervision are identified, alongside strategies used to create different learning opportunities. The majority of students remained in their own workplace when undertaking the English National Board for Nursing, Midwifery and Health Visiting clinical course. This raised a number of issues for the students and their colleagues which we have labelled the practitioner:student gap. The authors discuss the impact this has on supernumerary status, perceptions of learning and opportunities to undertake placements.

Background: The literature review presented here was conducted as part of an English National Board for Nursing, Midwifery and Health Visiting funded project to evaluate the use of portfolios in the assessment of learning and competence. Initial consideration of the topic revealed the need to clarify the terminology and approaches used to assess competence using portfolios, and therefore the literature review was conducted to inform the study., Aims: To clarify definitions, theoretical bases and approaches to competence and the use of portfolios in the assessment of learning and competence in nursing education., Methods: A comprehensive literature review was conducted using the CINAHL and MEDLINE databases and the keywords competenc*, portfolios and nursing. Articles published in the period 1989-2001 in English were obtained and their reference lists scrutinized to identify additional references. Twenty articles were found using a combination of the keywords competenc* and portfolios, and 52 using the combination portfolios and nurse education. Articles were included in the review if they focused on the use of portfolios in nursing, and those concerned with professional or transitional portfolios were excluded. This article will analyse definitions of and approaches to competence and its measurement and to portfolios and their use as discussed in the articles identified., Results: Three approaches to competence were identified, each with its appropriate forms of assessment. With regard to portfolios, a number of definitions were again found, but there was a consensus that the theoretical basis of their use is theories of adult learning. A number of reasons for and advantages and disadvantages of their use were found, as well as varying ideas about what a portfolios should consist of and how it should be assessed., Conclusion: A holistic approach to competence seems to be compatible with the use of portfolios to assess competence in nursing students, but the concept and its implementation is still evolving. A variety of assessment methods are needed for assessment and portfolios appear to have the potential to integrate these. Reflection is an essential component of a portfolio, as are the student-teacher relationship and explicit guidelines for constructing the portfolio. Issues of rigour in assessment of portfolios need to be addressed, but the assessor's professional judgement will inevitably enter into this assessment.

This paper is based on a documentary analysis and literature review of critical care nursing commissioned by the English National Board for Nursing, Midwifery and Health Visiting. Five critical care programmes were included in the analysis: ENB 100, 124, 199, 176/183, and 415. In total, 105 curricula were reviewed from 30 institutions. Data were extracted and analysed using an adapted grounded theory approach. The documentary analysis was supplemented by two telephone surveys with lecturers (n = 84) and clinical managers (n = 81). There was great diversity in the programmes in terms of the academic level at which the courses were set, module configuration, approaches to practice assessment and the amount of student effort for the same professional award. Diversity arose because of different university module formulae, different methods to differentiate level 2 and level 3 practice, different views about the purpose of the course, and an attempt to make the programmes increasingly flexible to accommodate a heterogeneous student population. Documentary analysis has its limitations, and although the research team were able to check out issues with lecturers throughout the analysis, they were unable to capture the lived experience of the curriculum. A second study has been commissioned by the ENB to explore how these issues influence practice.

The Delphi technique enables the structuring of group opinion and discussion using a survey approach, maintaining the anonymity of panel members and preventing contamination of individual responses through peer pressure. The Delphi technique was used by the authors to form an expert opinion regarding the needs of a critically ill child. The abstract and evaluative nature of need was a key issue to arise during early pilot work and stimulated the first author to undertake a concept analysis of the term 'need'. The defining attributes arising from the concept analysis were used to construct two hypothetical case studies for the modified Delphi; these were used as part of the questionnaire for all three rounds. In the first round, the panel was asked to identify the needs of the child in the two case studies; in subsequent rounds the panel activity involved modifying these need statements and indicating the importance, frequency and maximum acceptable delay in meeting each need. Extensive pilot work was required for each round of the modified Delphi. This article evaluates the use of this technique to identify needs, discusses key features arising from the results and examines the difficulties experienced by the respondents in completing the time scales.

Meeting needs is the aim of health care frequently espoused in textbooks, policy documents and reports of research studies; provision of health care is also now described as 'needs-based', rather than 'service-based'. The purpose of this paper is to explore the concept of need, using concept analysis, with the aim of providing greater clarity. Two approaches to concept analysis are compared: the linear model proposed by Walker and Avant and Rodgers' cyclical model. On both a philosophical and practical level, Rodgers' model was felt to be more appropriate for analysis of the concept of need. The rigid divisions which the Walker and Avant model seeks to establish (particularly in relation to the construction of additional cases) were felt to restrict, rather than clarify the concept. The attributes, antecedents, consequences and references of need are described, following stratified random sampling of the available literature, and a model case is presented. The themes of priority and perception of need arose consistently within the literature, highlighting the value-laden nature of the concept and the importance of achieving a common understanding to enable purchasers, providers and consumers to better satisfy health care needs.