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Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Purpose: The aim of this study was to identify and define core competencies for advanced nursing roles in adult intensive care units across Europe., Methods: Three round electronic Delphi conducted between September 2018 and November 2019, with an expert panel of 184 nurses from 20 countries, supplemented by consensus meetings with 16 participants from 10 countries before each round., Results: In Round 1, participants generated 275 statements across 4 domains (knowledge skills and clinical performance; clinical leadership, teaching and supervision; personal effectiveness; safety and systems management). These were re-worded as competency statements and refined at a consensus meeting resulting in 230 statements in 30 sub-domains. The expert panel rated the 'importance' of each statement in Round 2; further refinement at the consensus meeting and the addition of descriptors for sub-domains resulted in 95 competency statements presented to the panel in Round 3. These were all retained in the final set of competency statements., Conclusion: We have used consensus techniques to generate competencies for advanced practice in intensive care nursing that are relevant across European countries and available in eight languages. These have provided the basis for an outline curriculum from which education programmes can be developed within countries., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To explore health professional views of barriers to the use of evidence-based practice to prevent ventilator-associated events in intensive care units., Design: A qualitative descriptive study was conducted with nurses and doctors with more than six months experience caring for mechanically ventilated patients., Setting: The study was conducted in two intensive care units, in large metropolitan health services in Victoria, Australia., Methods: Individual semi-structured interviews were undertaken with 20 participants (16 nurses and 4 doctors) in 2019. Purposive sampling method was used until data saturation was reached. The interviews were held at the hospital in a private room away from their place of employment. The interview data were analysed using thematic analysis., Findings: Four major themes were inductively identified from nine subthemes: i) prioritising specific situations, ii) inadequate use of evidence to underpin practice, iii) perception of inadequate staffing and equipment and, iv) inadequate training and knowledge of evidence-based guidelines., Conclusions: These themes helped to explain previously reported deficits in nurses' knowledge of and adherence to evidence-based practice in intensive care. Findings suggest the need for a well-established policy to underpin practice. The barriers faced by nurses and doctors in preventing ventilator associated events need to be addressed to optimise quality of patient care in intensive care units., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes., Methods: We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented., Results: Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured., Conclusions: A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care., Competing Interests: Declaration of Competing Interest This paper presents independent research funded by the National Institute for Health Research (Programme Development Grants, Safe staffing in ICU: development and testing of a staffing model, NIHR200100). The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care, neither of whom have had involvement in any aspect of the design, data collection, synthesis, interpretation or writing of, this review., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: There are numerous intricate human, system and cultural factors that can impact upon the safe and effective implementation of patient safety systems (e.g. rapid response systems). Safety climate is one of these factors and is a measure of frontline healthcare workers' shared perceptions, behaviours, beliefs and attitudes towards the organisation's culture of safety. Safety climate scores are also associated with the frequency of errors and adverse events in the healthcare setting. However, there is little evidence regarding the relationships between attitudes to patient safety and staff characteristics such as emergency care expertise and experience. The aims of this study were to measure perceptions of the safety climate in an Australian metropolitan Emergency Department and examine relationships between safety climate perceptions and staff characteristics., Methods: The Victorian Managed Insurance Authority Safety Climate Survey was administered to all doctors (n = 44) and nurses (n = 119) at an Australian emergency department., Results: Completed surveys were received from 127 (78%) respondents, 25 (52%) doctors and 100 (84%) nurses. Reliability analysis showed very good internal consistency of all 43-items of the survey (α = 0.94). With the exception of stress recognition, nurses rated the organisation's commitment to patient safety higher than doctors in all remaining attitudinal domains (p < 0.05). Both groups acknowledge that fatigue, increased workload and stress recognition negatively impacts upon patient safety. There was a significant trend for declining safety climate ratings related to participants' clinical competence level and experience across all domains except stress recognition (p < 0.05)., Conclusions: The Safety Climate Survey appears to be a reliable measure of patient safety climate for use in Emergency Departments. Emergency doctors and nurses did not perceive there to be a strong organisational commitment to patient safety in an Australian Emergency Department. Emergency Departments can provide a safer environment through genuine commitment to safety culture improvement which capitalises on the insights, intrinsic strengths and behaviours characteristic of the ED team's expertise and experience. This kind of commitment can positively influence the effectiveness of actions taken to minimise risk to patient safety and improve ED staff job satisfaction and effectiveness., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: To explore Australian intensive care nurses' knowledge of ventilator-associated pneumonia and self-reported adherence to evidence-based guidelines for the prevention of ventilator-associated events., Design: A quantitative cross-sectional online survey was used., Setting: The study was conducted in two Australia intensive care units, in large health services in Victoria and an Australia-wide nurses' professional association (Australian College of Critical Care Nurses)., Main Outcome Measures: Participants' knowledge and self-reported adherence to evidence-based guidelines., Results: The median knowledge score was 6/10 (IQR: 5-7). There was a significant positive association between completion of post graduate qualification and their overall knowledge score p = 0.014). However, there was no association (p = 0.674) between participants' years of experience in intensive care nursing and their overall score. The median self-reported adherence was 8/10 (IQR: 6-8). The most adhered to procedures were performing oral care on mechanically ventilated patients (n = 259, 90.9%) and semi-fowlers positioning of the patient (n = 241, 84.6%). There was no relationship between participants' knowledge and adherence to evidence-based guidelines (p = 0.144)., Conclusion: Participants lack knowledge of evidence-based guidelines for the prevention of ventilator-associated pneumonia. Specific education on ventilator-associated events may improve awareness and guideline adherence., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs)., Methods: A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records)., Results: The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01)., Conclusions: Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: To explore factors perceived to contribute to 'a good death' and the quality of end of life care in two countries with differing legal and cultural contexts., Design and Methods: Multi-centre study consisting of focus group and individual interviews with intensive care nurses. Data were analysed using qualitative thematic analysis; emotional content was analysed using specialist linguistic software., Settings/participants: Fifty five Registered Nurses in intensive care units in Israel (n=4) and England (n=3), purposively sampled across age, ICU experience and seniority., Findings: Four themes and eleven sub-themes were identified that were similar in both countries. Participants identified themes of: (i) timing of communication, (ii) accommodating individual behaviours, (iii) appropriate care environment and (iv) achieving closure, which they perceive prevent, and contribute to, a good death and good quality of end of life care. Emotional content showed significant amount of 'sadness talk' and 'discrepancy talk', using words such as 'could and 'should' when participants were talking about the actions of clinicians., Conclusions: The qualities of a good death were more similar than different across cultures and legal systems. Themes identified by participants may provide a framework for guiding end of life discussions in the intensive care unit., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The majority of deaths of children and infants occur in paediatric and neonatal intensive care settings. For nurses, managing an infant/child's deterioration and death can be very challenging. Nurses play a vital role in how the death occurs, how families are supported leading up to and after the infant/child's death. This paper describes the nurses' endeavours to create normality amidst the sadness and grief of the death of a child in paediatric and neonatal ICU. Focus groups and individual interviews with registered nurses from NICU and PICU settings gathered data on how neonatal and paediatric intensive care nurses care for families when a child dies and how they perceived their ability and preparedness to provide family care. Four themes emerged from thematic analysis: (1) respecting the child as a person; (2) creating opportunities for family involvement/connection; (3) collecting mementos; and (4) planning for death. Many of the activities described in this study empowered parents to participate in the care of their child as death approached. Further work is required to ensure these principles are translated into practice., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: Midwives' ability to manage maternal deterioration and 'failure to rescue' are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives' ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance., Methods: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data., Findings: The mean total knowledge score was 75% (range 46-91%) with low skill performance, means for both scenarios 54% (range 39-70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario., Conclusion: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation., (Copyright © 2011 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Critical care has been criticised for its inconsistency in implementing and evaluating evidence based practice both at national and international level. A review of the critical care literature by Berenholtz et al. (2002) identified interventions that might help prevent morbidity or mortality in the intensive care unit; from this four elements were developed into the initial ventilator care bundle. The aim of this bundle was to improve the quality of care for mechanically ventilated patients by improving compliance with relevant evidence based practice; implementation of this or an adapted cluster of interventions has been shown consistently to reduce the incidence of ventilator-associated pneumonias across countries. There are now numerous care bundles and the bundle approach to quality improvement has been proven to be effective across a number of problems, international boundaries and in a wide variety of ICU's. The bundle approach recognises that core clinical interventions, are not always consistently applied across all appropriate patients, the range of interventions within a bundle tackles the problem from a variety of different angles. Other strengths include its adaptability to the wide variety of environments and working practices of intensive care units across the world. The bundle and the method of implementation can be adapted to suit individual teams and units; however, this can also be a weakness of this approach as it limits comparability across centres. The bundle approach to quality improvement requires significant multidisciplinary engagement and resources to be effective., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The use of physical restraint has been linked to delirium in ICU patients and a range of physical and psychological outcomes in non-ICU patients. However, the extent of restraint practice in ICUs is largely unknown. This study was designed to examine physical restraint practices across European ICUs. A prospective point prevalence survey was conducted in adult ICUs across European countries to examine: physical and chemical restraint use during the weekend and weekdays, reasons for physical restraint use, timing of restraint use, type of restraint used and availability of restraint policies. Thirty-four general (adult) ICUs in nine countries participated in the study providing information on 669 patients with details of physical and chemical restraint use in 566 patients. Prevalence of physical restraint use in individual units ranged from 0 to 100% of patients. Thirty-three per cent of patients were physically restrained; those that were restrained were more likely to be ventilated (χ(2)=87.56, p<0.001), sedated (χ(2)34.66, p<0.001), managed in a larger unit (χ(2)=10.741, p=.005) and managed in a unit with a lower daytime nurse:patient ratio (χ(2)=17.17, p=0.001). Larger units were more likely to use commercial wrist restraints and smaller units were more likely to have a restraint policy, although these results did not reach significance. As an initial exploration, this study provides evidence of the range of restraint practice across Units in Europe. Variation in the number of units per country limits generalization of findings. However, further examination is needed to determine whether there is a causal element to these relationships. Attention should be paid to developing evidence based guidelines to underpin restraint practices., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

There is a growing requirement to use standardised instruments for collecting research data and monitoring patient progress. Two sets of properties should be addressed when selecting and adapting research instruments: psychometric properties (validity, appropriateness, reliability, and responsiveness) and clinical properties (feasibility and acceptability of the instrument). This paper outlines steps necessary to fulfil these requirements when using a research instrument in different cultures., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Background: The majority of hospitals in the United Kingdom (UK) use some form of track and trigger scoring system, such as early warning scores, to identify deteriorating patients; however, response by the multi-professional team is not always timely and problems with recognition of deterioration persist., Aim: To examine ward nurse and critical care outreach staff perceptions of the management of patients who deteriorate in acute wards., Methods: A qualitative design was used with critical incident (CI) technique employed to structure data collection. Semi-structured interviews were undertaken with nurses who had managed a patient who was referred to the outreach team (n=11) and members of the outreach team (n=3)., Results: Registered nurses in this study looked at trends when assessing their patients visually. However, early warning scoring was not a key component of patient assessment and was used more commonly to quantify deterioration once the patient's changing condition had been recognised. Findings demonstrated some tensions in team communication., Conclusions: The results of this study suggest that clinicians need a better understanding of the value of track and trigger scoring systems in identifying trends in the patient's condition. Further, our data suggest that steps need to be taken in acute hospital wards to improve team members' understanding of each others' roles and capabilities., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research practice.

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasise the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

This research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings: readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

This research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

This research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

Background: International randomised controlled trials conducted over the last two decades have consistently demonstrated improved mortality and morbidity resulting from thrombolytic therapy for patients with acute myocardial infarction (AMI). Subsequently, evidence-based guidelines have been designed and implemented to optimize thrombolytic delivery. The effect of evidence-based clinical guidelines on clinical practice is heavily influenced by strategies used to develop, disseminate and implement those guidelines., Aims: This study evaluated the impact of a collaborative, multifaceted implementation strategy for AMI management guidelines on thrombolytic usage in the Loddon Mallee Region, Victoria, Australia., Intervention: The multi-faceted implementation strategy included an inter-disciplinary team representing all treating venues contributing to the content of the "Guidelines for the Early Management of Acute Myocardial Infarction" followed by education sessions that coincided with the dissemination of the guidelines., Methods: A retrospective medical records audit 12 weeks before and 12 weeks after the intervention was used to evaluate the impact on proportion of those patients eligible and receiving a thrombolytic and door-to-needle time. Variables of treating venue, age, gender, type of AMI, and type of transport to hospital were also measured to determine their impact on results., Results and Conclusions: A retrospective audit of 170 medical records found that the intervention appeared to have had no impact on the proportion of patients eligible and receiving a thrombolytic (74.2% vs. 62.5%: p=0.275), and door-to-needle time (67.7 min vs. 60.5 min: p=0.759). Venue specific influences produced a variety of patterns in thrombolytic delivery that require further exploration. This suggests that a single solution approach across multiple venues will have limited impact.

This descriptive exploratory study investigated the reported practices and perceptions of emergency nurses related to infection control in the context of the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic in Botswana. Quantitative and qualitative data were collected using a self-administered questionnaire. Forty questionnaires were distributed to nurses with emergency department experience in Botswana, with a response rate of 55% (n = 22). Quantitative data were analysed using descriptive statistics while qualitative data were subjected to thematic and content analysis. The majority of respondents reported compliance with universal precautions at the hospital emergency department. However, qualitative data highlighted resource constraints that may hinder compliance with universal precautions such as a lack of appropriate facilities, a shortage of equipment and materials, inadequate staffing and absence of sustainable in-service education programs. Further, the reported compliance with Universal Precautions had not removed the fear of exposure to HIV/AIDS and perceived risk of transmission to family. The authors recommend in-service education and practice initiatives to promote sustainable compliance with universal precautions and realistic risk perception among nurses. Further research is required to evaluate nurses' compliance with universal precautions in developing countries using observational methods or in-depth interviews. This would enable exploration of nurses' actions regarding compliance with universal precautions.

A significant number of patients leave the emergency department (ED) before being treated or after treatment has been initiated but not completed. This paper reports the findings of a study examining the demographics and characteristics of those who did not wait for treatment in an ED in Melbourne. A telephone survey was undertaken to examine the reasons they did not wait. Data were collected in four one-month periods across the year and patients were telephoned within 72 h of their departure from the ED. The majority of those who did not wait were Australian Triage Scale category 4 or 5, male, and with a mean age of 37 years. Sixty per cent of those who did not wait presented between the hours of 6 pm and 6 am and waited an average of 130 min before leaving. Over fifty per cent (127) of those surveyed (n=243) sought treatment elsewhere and over a third (72) thought their problem was inappropriate for an ED. However, the need for communication with patients in the waiting room should not be under-played.

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process. A couple of points: 1. It is artificial to describe research as qualitative or quantitative. Studies often include both dimensions. However, for the purposes of this paper/series, this distinction is drawn for clarity of writing. 2. It is common practice for quantitative studies to refer to study 'subjects' and qualitative studies to refer to study 'participants'. For ease of reading, the latter term will be used throughout this series

This six-part research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process. A couple of points: 1. It is artificial to describe research as qualitative or quantitative. Studies often include both dimensions (for example, Evangelista LS, Doering L, Dracup K. Meaning and life purpose: the perspectives of post-transplant women. Heart Lung 2003;32(4):250-7; Fitzsimmons D, Parahoo K, Richardson SG, Stringer M. Patient anxiety while on a waiting list for coronary artery bypass surgery: a qualitative and quantitative analysis. Heart Lung 2003;32(1):23-31). However, for the purposes of this paper/series, this distinction is drawn for clarity of writing. 2. It is common practice for quantitative studies to refer to study 'subjects' and qualitative studies to refer to study 'participants'. For ease of reading, the latter term will be used throughout this series.

Nurses are increasingly asked to provide expert advice to a court of law, for example through a formal contract as an expert witness or through providing the trust solicitor with a response to a complaint from a patient or relatives. The purpose of this brief paper is to share experiences of undertaking the role of 'expert witness' in the UK and to highlight some of the pitfalls and the wider context in which such a role is undertaken.

This paper reports the findings of a documentary analysis and literature review of general and paediatric intensive care unit (ICU) courses (ENB 100 and ENB 415). The findings are part of a larger review of critical care courses commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB), also incorporating operating department, coronary care and accident and emergency courses. It was important to set the curriculum review in the context of intensive care practice and education, hence the study also comprised interviews with lecturers and ICU managers. The study findings reveal diversity in major aspects of the critical care courses, including the academic level of the programmes and credits they attracted; the assessment strategies for theory and practice, the extent of shared learning and the amount of student effort. Many factors influenced this diversity including contrary opinion among stakeholders about the purpose of the course: to prime the students for working in the specialty; or to consolidate previous experience (in some cases up to 15 years). Course structure and content have changed in response to local university requirements and directives from the statutory bodies, as well as in response to the higher level of academic credit awarded for pre-registration programmes (qualification inflation). The perceived shift in course content as well as the diversity across programmes had led a group of ICU managers to define their own list of competencies (Crunden 1998). However, the majority of the managers interviewed for this study (63% of General ICU managers (n = 19) and 83% (n = 6) of Paediatric ICU managers) were generally satisfied with the competencies and skills of the nurses who had undertaken the ENB course. The authors conclude from the diverse nature of the courses that there is little national comparability in the courses although this finding might be an artefact of documentary analysis. The extent to which this (apparent) diversity results in different levels of competence in practice requires further exploration.

In the UK, recent policy guidelines emphasize the role of nurses in managing the minute-by-minute care of critically ill patients (Department of Health 1996). This article reports on a study that explored the extent to which the nurse at the bedside (the allocated nurse) and the nurse in charge of the shift (the shift leader) make decisions about the needs of children who are critically ill. The study also identified areas of need using a modified Delphi study and explored how nurses perceive and act on the needs of critically ill children. These aspects are presented elsewhere.

There has been a wealth of guidance from both policy-makers (Department of Health, (DoH) 1991, DoH 1997a, DoH 1997b) and other interested parties (Audit Commission 1993, British Paediatric Association 1993, Paediatric Intensive Care Society 1992) regarding how and where care should be provided for critically ill children. Latest recommendations indicate that designated general ICUs will continue to provide care for children requiring life support and that all general ICUs will need to initiate such care (DoH 1997a). The literature relating to how nurses identify and act on the needs of the critically ill child has been anecdotal in nature (Green 1991, Purcell 1993), whilst published studies focus on comparing outcomes (Pollock et al 1991) and addressing the needs of parents (Farrell & Frost 1992, Kasper & Nyamathi 1988). This paper explores the literature regarding the needs of the critically ill child, incorporating the role of parents and previous studies exploring needs. The findings of a modified Delphi study exploring the needs of the critically ill child are also outlined.

Intensive care nurses are an expensive and scarce resource. The internal market within the National Health Service requires greater scrutiny of expenditure in all areas, not least staffing. Inevitably questions are raised regarding the evidence to justify the nurse:patient ratios in specialist areas such as intensive care. This paper addresses some of the issues surrounding staffing in intensive care and discusses the impact of changes in medical practice on the nursing role. The nurse:patient ratio is lower in the USA, therefore a brief comparison between the two countries is provided in order to inform discussion and debate. The importance of these issues for all intensive care nurses is emphasised, together with a plea for a substantive study to provide evidence of nursing work and inform future decision-making by the purchasers and providers of intensive care services.

In its promotional literature for the Higher Award, the English National Board include a logo promoting 'Quality Education for Quality Care'. The purpose of this paper is to examine how we can assess the impact of continuing education, specifically the English National Board (ENB) Course 100, on quality of care in an Intensive Care Unit (ICU). The paper provides an examination of the relationship between education and practice, methods of evaluating education and the impact that the course can make on clinical practice.