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Aim. To measure levels of anxiety among people accompanying consumers to the emergency department and to explore how anxiety influences satisfaction with care. Background. When people seek treatment in an emergency department they are often accompanied by a next-of-kin, family member or friend. While the accompanying person plays a vital role in providing psycho-social support to consumers, little is known about how they perceive the quality of care. Learning more about how accompanying persons perceive care may inform the development of strategies to enhance communication processes between staff, consumers and accompanying persons. Design. A prospective cross-sectional survey design. Methods. Data were collected from a consecutive sample of accompanying persons at one Australian metropolitan teaching hospital. Of all eligible individuals approached, 128/153 (83.7%) returned completed questionnaires. The questionnaire comprised a series of open- and close-ended questions about perceptions of medical need, urgency and satisfaction with the overall visit. Anxiety was assessed using the Visual Analogue Scale for Anxiety (VAS-A). Results. There was a significant association between the accompanying person's levels of anxiety and satisfaction at point of discharge. In the satisfied group, mean VAS-A scores were 17.4 (SD 17.5) compared to 42.9 (SD 26.6) in the not satisfied group (p = 0.011). Moreover, those participants who were not satisfied with the visit did not show a significant reduction in VAS-A scores from triage to point of discharge. Conclusion. The lower the level of anxiety reported by accompanying persons when leaving the emergency department, the more satisfied they are likely to be with their emergency department visit. Ultimately, well informed and confident accompanying persons are beneficial for ensuring quality patient support. Relevance to clinical practice. Asking accompanying persons about their anxiety level before discharge gives them the opportunity to pose clarifying questions and is, therefore, an effective way of improving their satisfaction with the emergency department visit. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study conducted to examine how irrational thinking affects people's adherence to multiple medicines prescribed to manage their diabetic kidney disease. Background. Approximately 50% of people are non-adherent to their prescribed medicines and the risk of non-adherence escalates as the number of prescribed medicines increases. Adherence to prescribed medicines can slow disease progression in diabetic kidney disease. Methods. A descriptive exploratory design was used. In-depth interviews were conducted with 23 participants recruited from a nephrology outpatient clinic in Australia in 2007. Data were analysed using a 'framework' method. Findings. Participants' mean age was 59 years, they had approximately six chronic conditions in addition to their diabetic kidney disease and were prescribed a median of ten medicines daily. Two major themes of irrational thinking-- heuristics and denial -- and subthemes were identified. Heuristics contributed to inaccurate risk assessment and biases affecting rational judgement concerning medicines, whereas denial was used to enhance coping necessary to manage this complex health condition. Conclusion. Participants underestimated their health risks because they had been taking medicines for many years and preferred not to dwell on their ill health. A large amount of irrational thinking was related to maintaining the emotional strength necessary to manage their comorbid conditions as best they could. Regular assessment and support of medicine adherence throughout the disease course is necessary to avert the development of counterproductive heuristics and denial affecting medicine adherence. [ABSTRACT FROM AUTHOR]

Background. Daily sedation interruption (DSI) has been proposed as a method of improving sedation management of critically ill patients by reducing the adverse effects of continuous sedation infusions. Aim. To critique the research regarding daily sedation interruption, to inform education, research and practice in this area of intensive care practice. Design. Literature review. Method. Medline, CINAHL and Web of Science were searched for relevant key terms. Eight research-based studies, published in the English language between 1995-December 2006 and three conference abstracts were retrieved. Results. Of the eight articles and three conference abstracts reviewed, five originated from one intensive care unit (ICU) in the USA. The research indicates that DSI reduces ventilation time, length of stay in ICU, complications of critical illness, incidence of post-traumatic stress disorder and is reportedly used by 15-62% of ICU clinicians in Australia, Europe, USA and Canada. Conclusions. DSI improves patients' physiological and psychological outcomes when compared with routine sedation management. However, research relating to these findings has methodological limitations, such as the use of homogenous samples, single-centre trials and retrospective design, thus limiting their generalisability. Relevance to clinical practice. DSI may provide clinicians with a simple, cost-effective method of reducing some adverse effects of sedation on ICU patients. However, the evidence supporting DSI is limited and cannot be generalised to heterogeneous ICU populations internationally. More robust research is required to assess the potential impact of DSI on the physical and mental health of ICU survivors. [ABSTRACT FROM AUTHOR]

This study directly addresses controlling aspects of psychiatric nursing practice, which are currently marginalised in practice and research. We first consider the discursive tensions surrounding the mandated goal of social control in public acute psychiatric units, particularly referring to those units located within medical hospitals. We attest to the enduring social control mandate in psychiatric nursing and explore ways in which it is enacted. Specific nursing practices of 'doing the obs' while scanning the ward and 'special observations' are investigated as important activities of social control, based on findings from an ethnographic study in one acute psychiatric unit in Australia. These practices are acknowledged as key modes of nursing surveillance. Contrary to past work, they are regarded as productive for engendering civil conduct among patients in acute psychiatric settings. We reframe these activities of surveillance as liberal therapeutic practices in themselves, to the extent that they assist patients to achieve treatment goals and promote self-surveillance and self-control. Instead of effacing practices of control, we encourage nurses to discriminate between more and less liberal modes of control in everyday practice and to build their skills in liberal controlling strategies. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a literature review to identify research involving interventions to improve medication adherence in people with multiple co-existing chronic conditions. Title. Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review. Background. The importance of managing co-existing, chronic conditions in people of all ages is critical to prevent adverse health outcomes. Data sources. Databases, including Cumulative Index of Nursing and Allied Health Literature, Medline, PubMed and Web of Science were searched for the period January 1997-2007 using the combined keywords adherence, compliance, drug therapy, medication, clinical trial, randomized controlled trial, intervention, chronic condition, chronic disease, multiple morbidity and comorbidity. References of retrieved papers were also considered. Methods. The inclusion criteria were: English language, oral medication adherence, self-administered medications, multiple prescribed medications for three or more chronic conditions and randomized controlled trials lasting at least 3 months. Results. Studies examining medication adherence in people with multiple chronic conditions targeted people over 70 years of age, and were primarily focused on the management of polypharmacy and reducing healthcare costs. Adherence was measured using different tools and estimates of adherence, and interventions were predominantly delivered by pharmacists. The evidence for effective interventions to enhance medication adherence in multiple chronic conditions was weak, and psychosocial interventions were absent. Conclusion. Interventions that improve medication adherence for people with multiple chronic conditions are essential, given the increased prevalence of these conditions in people of all ages. Outcomes of improved adherence, such as disease control and quality of life, require investigation. Psychosocial interventions engaging people in medication self-management offer potential for improved patient outcomes in complex diseases. [ABSTRACT FROM AUTHOR]

Aims and objectives. To investigate the factors that influence satisfaction with emergency care among individuals accompanying patients to the emergency department and explore agreement between the triage nurse and accompanying person regarding urgency. Background. Many patients seeking treatment in hospital are escorted by an accompanying person, who may be a friend, family member or carer. Several factors influence patient satisfaction with emergency care, including waiting time and time to treatment. It is also influenced by provision of information and interpersonal relations between staff and patients. Research on satisfaction has focused on the patient perspective; however, individuals who accompany patients are potential consumers. Knowledge about the ways accompanying persons perceive the patient's medical condition and level of urgency will identify areas for improved patient outcomes. Design and methods. A prospective cross-sectional survey with a consecutive sample (n = 128 response rate 83.7%) was undertaken. Data were collected in an Australian metropolitan teaching hospital with about 32,000 visits to the emergency department each year. The Consumer Emergency Satisfaction Scale was used to measure satisfaction with nursing care. Results. Significant differences in perceptions of patient urgency between accompanying persons and nurses were found. Those people accompanying patients of a higher urgency were significantly more satisfied than those accompanying patients of a lower urgency. These results were independent of real waiting time or the accompanying person's knowledge of the patients' triage status. In addition, older accompanying persons were more satisfied with emergency care than younger accompanying persons. Discussion. Little attention has been paid to the social interactions that occur between nurses and patients at triage and the ways in which these interactions might impact satisfaction with emergency care. Relevance to clinical practice. Good interpersonal relationships can positively influence satisfaction with the emergency visit. This relationship can contribute to improved patient care and health outcomes. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to examine how decisions about managing pain were made between patients with chronic kidney disease and nurses, what affected the decision style and the types of analgesics and adjuvant therapies given for pain relief in relation to a particular decision style. Background. While pain often accompanies chronic kidney disease, little is known of how decisions are made about managing pain in clinical practice. Lack of patient involvement in decision-making may lead to inadequate care provision. In some care situations, nurses have been more concerned with medication side effects than giving effective pain relief. Method. An exploratory study was conducted, using observations and interviews with a purposive sample of 14 nurses and 53 patients in five adult renal units in Australia. The data were collected during 2004. Findings. Of the 103 pain activities observed, 78 involved a passive decision style between the nurse and patient, 19 involved a collaborative decision style, and six used an active decision style. The majority of routine analgesic and adjuvant medications administered involved a passive decision style. Most importantly, 25.6% of passive style decisions observed resulted in no administration of an analgesic or adjuvant medication; however, all collaborative and active style decisions observed resulted in administration of an analgesic or adjuvant medication. Conclusion. Nurses need actively to encourage patient involvement in treatment decisions because this promotes effective pain control. More research is needed into how specific detailed information about pain treatments could improve patient participation in decision-making. [ABSTRACT FROM AUTHOR]

Aims and objectives. This paper reviews the literature concerning nurses' assessment and management of pain in adult patients with chronic kidney disease, and proposes implications for clinical practice to support the control of pain in these patients. Background. Chronic kidney disease is a worldwide public health concern with increasing incidence and prevalence, poor patient outcomes and high cost. Patients with kidney disease often experience pain. Optimal pain assessment and management are key clinical activities; however, inadequate pain control by health professionals persists. Renal failure compounds this problem because of the small margin between pain relief and toxicity, and the patient's concomitant health problems. Conclusions. The literature review uses 93 articles that were published in medical- and other health-related journals, including 12 medical and pharmaceutical studies specifically relating to pain control in adults with kidney disease. Very little research has been conducted on pain in patients with kidney disease prior to requiring dialysis or kidney transplantation for survival. However, past research showed pain is common and analgesics are underprescribed in patients on dialysis in end-stage kidney disease. The review indicates that an interest in nephrotoxicity and analgesic-induced morbidity dominates over an interest in pain relief in patients with kidney disease. Most analgesics are excreted renally or by the liver, and the use of simple analgesics such as paracetamol is cautioned. Relevance to clinical practice. Findings from the literature review highlight specific difficulties relating to effective pain control in patients with chronic kidney disease. Research is required to identify and overcome barriers to effective pain management, including the development of specific tools to facilitate interventions that optimize analgesic outcomes in patients with chronic kidney disease. [ABSTRACT FROM AUTHOR]

Aim. The aim of this paper is to examine communication between patients with chronic kidney disease and nurses about managing pain in the acute hospital setting. Background. While pain often accompanies chronic kidney disease, little is known about managing pain in actual clinical practice. Design. A single group, non-comparative design was used. Methods. Research methods included observations and interviews to examine pain communication in all five adult renal units in the state of Victoria, Australia. A thematic approach was used to analyse the data. Results. Observations and interviews were carried out with 14 nurses and 53 patients and 103 incidents of pain communication occurred during observations. Three themes were identified: complexity of pain, knowledge about pain management and contextual characteristics of the renal units. The nature of the patients' pain and effects of analgesics on the body shaped the complexity of pain in chronic kidney disease. Various causes of pain contributed to difficulties in management. Patients had acute pain from surgical procedures, in particular, phantom limb pain. They also had chronic pain arising from leg cramps, restless leg syndrome, and muscle and bone pain. Knowledge about pain management comprised the use of written resources about analgesics and information exchange among health professionals. Contextual characteristics involved the perceived urgency of pain communication and environmental stressors. Conclusions. The findings emphasize the need to capture dynamic processes of pain management in patients with chronic kidney disease to facilitate understandings about complex communication needs of this vulnerable group. Relevance to clinical practice. Specific analgesic and non-pharmacological guidelines for patients with chronic kidney disease should be developed and made available in practice to facilitate effective pain management. Change champions of renal units are needed to support nurses in dedicating specified time for communicating with patients about managing pain. [ABSTRACT FROM AUTHOR]

AIM: The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement. BACKGROUND: Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis. METHOD: A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005. FINDINGS: Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study. CONCLUSION: Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVE: The purpose of this study was to investigate the impact of role discrepancy on nurses' intention to quit their jobs. BACKGROUND: Nurses experience role discrepancy, which refers to incompatibility between the roles nurses desire and expect to take, and the roles they actually engage in at work. However, there is a paucity of information as to how this role discrepancy affects nurses' intention to quit their jobs. DESIGN: A correlational design was used to investigate the impact of role discrepancy on nurses' intention to quit their jobs. METHODS: A total of 346 Australian nurses participated in this study by completing questionnaires. The results were analysed by t-test, polynomial regression and response surface analysis. RESULTS: Nurses tended to experience role discrepancy, in particular, in decision making with hospital policies and provision of patient education. The overall results show that this role discrepancy contributes to nurses' intention to quit their jobs. Nurses' intention to quit their jobs also increased when they had a low desire to engage in nursing roles and when they only performed a few roles. When specific dimensions of nursing roles were examined, a role discrepancy in the use of nursing skills, such as participation in decision making and providing patient education and emotional support, had little impact on their turnover intention. On the contrary, a role discrepancy in task delegation practice showed a significant association with nurses' intention to leave their jobs. CONCLUSIONS: Role discrepancy has been experienced by many nurses, and this discrepancy partially contributes to nurses' intention to quit their jobs. RELEVANCE TO CLINICAL PRACTICE: To reduce nursing turnover, it is important to create a work environment where nurses are inspired to engage in various nursing roles and their work desires are reinforced by existing work opportunities. [ABSTRACT FROM AUTHOR]

AIM: This paper examines how time is controlled and governed in operating rooms through interpersonal communication between nurses and doctors. BACKGROUND: Time is a valuable commodity in organizations with improvements often directed towards maximizing efficiencies. As a consequence, time can be a source of tension and interpersonal conflict as individuals compete for control of its use. METHODS: The data in this paper emanate from an ethnographic study that explored a range of communication practices in operating room nursing. Participants comprised 11 operating room nurses. Data were collected over two years in three different institutional settings and involved participant observation, interviews and the keeping of a personal diary. A deconstructive analysis of the data was undertaken. RESULTS: Results are discussed in terms of the practices, in which clinicians are engaged in, to govern and control their use of time. The four practices presented in this paper include; questioning judgment and timing, controlling speed, estimating surgeons' use of time and coping with different perceptions of time. CONCLUSIONS: Time and speed were hotly contested by nurses. They used their personal knowledge of individual surgeon's habits of time to govern and control practice. Nurses thought about surgeons in terms of time and developed commonly accepted understandings about the length of surgical procedures. They used this knowledge to manage the scheduling of operations in the departments and to control the workflow in individual operating rooms. Knowledge of individual surgeons was a source of power for operating room nurses. RELEVANCE TO CLINICAL PRACTICE: Nurses have more power in the operating room than might be imagined but they exercise this power in subtle ways. If operating rooms are to work effectively, the operating room team must understand each others' work better. [ABSTRACT FROM AUTHOR]

AIM: This paper reports a study comparing nurses' perceptions of their public image with their self-image, and examining how the relationship between their perceived public image and self-image was associated with their job performance and turnover intentions. BACKGROUND: The stereotypical public image of nursing is a major concern to nurses. However, it is relatively unknown how this image affects nurses. A few studies have investigated how nurses' interpretations of their public image affect their self-image and work behaviour. METHODS: A convenience sample of 346 Australian nurses participated in a questionnaire study in 2003. The results were analysed by t-test, polynomial regression and response surface analysis. Six participants from the survey participated in a focus group to provide further interpretation of the findings. RESULTS: Nurses rated their aptitude for leadership more positively than they thought the public viewed them. In contrast, nurses rated their image as being caring less negatively than their perceived public image. Job performance was predicted by self-image relating to leadership aptitude. On the contrary, the relationship between self-image and perception of the public image as being caring predicted job performance. When nurses perceived their public image as caring less positively than their self-image, their job performance tended to improve. As for turnover intention, both self-image and perceived public images of having an aptitude for leadership and being caring were negatively related to intention to quit the job. CONCLUSION: To enhance nurses' job performance and reduce their turnover intentions, it is important to improve both the public image and self-image of nurses. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: The aim of the study was to determine how graduate nurses use protocols in their medication management activities. The objectives were to: examine the extent of adherence to various protocols in relation to medication activities and determine how the ward environment impacts on graduate nurses' use of protocols to manage patients' medications. BACKGROUND: Protocols help newly qualified nurses integrate new knowledge into practice and promote effective decision-making Design. A descriptive prospective qualitative design was used. Methods. Twelve graduate nurses involved in direct patient care in medical, surgical and specialty wards of a metropolitan teaching hospital participated in the study. Participant observations were conducted with the graduate nurses during a two-hour period when medications were being administered to patients. In-depth interviews were conducted with each nurse immediately after observations and demographic data were collected on participating nurses and patients in their care, including all medications prescribed. Protocols associated with medication management activities for the clinical settings were also transcribed. RESULTS: Six themes were evident from the data: availability and use of protocols, scrutinizing patients' identity before medication administration, double-checking certain medications before administration, writing incident reports, following specific policies and timing the administration of medications. CONCLUSION: Graduate nurses adhered to protocols if they were perceived not to impede with other nursing activities. Participants were also more likely to follow protocols if they felt encouraged to make their own decisions and if there was a decreased likelihood that disciplinary action would be involved. RELEVANCE TO CLINICAL PRACTICE: Experienced health professionals should encourage graduate nurses to comply with medication protocols and to make clinically reasoned decisions about medication activities. By providing peer support and acting as role models, experienced health professionals can also demonstrate to graduate nurses how effective protocol use is an important component of quality patient care. [ABSTRACT FROM AUTHOR]

Job dissatisfaction and turnover are recurring themes in nursing. The current international nursing shortage has resulted in increased interest in investigating the causes of nurses' job dissatisfaction and turnover, and in developing countermeasures to address these issues. This paper involves a review of quantitative nursing studies, which investigated the causes of nurses' job dissatisfaction and turnover intention, and identifies commonly held myths that may inhibit more nurse-centered strategies from being developed. These myths are based on an assumption that a nurse-environment relationship is a one-way interaction in which nurses passively respond to their environment. The paper introduces the person-environment fit theory as an alternative framework, which challenges the assumption by suggesting it is the relationship between person and environment, rather than environmental characteristics alone, that affects nurses' occupational behavior. This theory enables nurse researchers to develop a more mutual approach involving the nurse and environment. [ABSTRACT FROM AUTHOR]

AIM AND OBJECTIVES: The aim was to examine how graduate nurses communicated with other health professionals about their medication management activities in the acute care context. The objectives were to determine the types of information communicated about patients' medications and the communication processes used during interactions with other nurses, doctors and pharmacists. BACKGROUND: Graduate nurses are challenged with enormous responsibilities and their competence is constantly tested in an ever-changing arena. One of their responsibilities involves communicating with other health professionals about patients' medications. DESIGN: A qualitative exploratory research design was used for this study. METHODS: Participant observation and semi-structured interviews were conducted to elicit information from 12 graduate nurses with university degrees employed in a metropolitan public hospital, in Melbourne, Australia. Graduate nurses were observed once for two hours and interviewed on the same day of the observation at a mutually convenient time. The purpose of these interviews was to clarify activities observed and to obtain further information. RESULTS: The results highlighted how work dynamics of the clinical setting had an impact on the ability of graduate nurses to communicate effectively with other nurses, doctors and pharmacists. These work dynamics included the availability of doctors and the structure of ward rounds. The results also demonstrated the value graduate nurses placed on communicating particular information such as evaluating the effect of medication changes and organizing discharge medication. CONCLUSIONS: Graduate nurses were effective in communicating about medication management activities when they initiated or were prepared for such interactions. When graduate nurses were not prepared, such as during impromptu ward rounds, they did not participate effectively and important information was not communicated. RELEVANCE TO CLINICAL PRACTICE: It is important to understand how collegial communication facilitates accurate exchange of information and effective decision-making to achieve optimal health care outcomes for patients. [ABSTRACT FROM AUTHOR]

This case study explores what informs and organizes the assessment of patients, as undertaken by a nurse, a social worker and a psychiatrist in public, metropolitan, acute mental health service settings. The research data are the transcripts of in-depth interviews with three experienced practitioners, one from each of the three disciplines. The analysis draws on Foucauldian concepts: discourse as constructed through practices of discipline and the gaze. We explored examples of taken-for-granted assessment practices and their interplay with discourse. The findings suggest that participating practitioners use language in assessment in ways that support the powerful discourses of the professional disciplines. The competing discourse of management, associated with industry and economics, is evident in hospital admission processes, dictating the times and places of assessment. Professional and management discourses both effectively marginalize the perspective of another player in assessment, the patient. [ABSTRACT FROM AUTHOR]

The complexities accompanying the prescription of antipsychotic medication for people experiencing a mental illness have been extensively documented in the literature. The views and experiences of consumers of mental health services, however, are almost entirely absent. This paper describes the findings of a qualitative study undertaken to examine the experiences of consumers, specifically in relation to education and decision making with regards to medication. The findings from a focus group conducted with consumers (n = 9) revealed an overall dissatisfaction with information provided and the opportunity to participate in decision making. Data analysis revealed four major themes: information to consumers; acknowledgement and recognition of consumers; roles of health professionals; and the experience of wellness and adherence. The findings suggest the need for significant change if the goals of the Third National Mental Health Plan are to be realized. [ABSTRACT FROM AUTHOR]

AIMS: The aim of this paper is to report a study to identify themes and provide a 'snap-shot' of the scope and uses of photography in clinical nursing practice and research. BACKGROUND: Despite the dominance of vision as a way of understanding the world in Western societies, the applications of photography in clinical nursing practice and research have not been well synthesized or reported in the literature. METHODS: A computerized search of CINAHL database was performed using the terms photographs, photography, photographic, photovoice, videorecording and videotaping. Hand searching for additional citations was also undertaken. FINDINGS: The identified papers on photography were categorized into broad themes that reflected the different applications to which photography had been applied: documentation and surveillance; therapeutic intervention; teaching, learning and evaluating performance; research methods; and descriptive and instructional literature. Approaches to the use of photography, as recorded in the nursing literature, are broad and include: wound surveillance, covert patient surveillance, photo essay, art therapy, self-portraits, life albums, simulated recall, participant observation, photovoice, photo hermeneutics, production of research scenarios, and video modelling. CONCLUSIONS: The most common applications of photography in nursing and related journals include photo elicitation to promote understanding in research, videorecording as a method of teaching and learning, and as a method of observation, with more creative approaches tending to be employed in health professions other than nursing. Few reports gave explanations of how researchers negotiated ethical concerns when seeking approval for studies in clinical settings, and few gave details of the processes of data analysis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Nurses in a graduate programme in Australia are those who are in the first year of clinical practice following completion of a 3-year undergraduate nursing degree. When working in an acute care setting, they need to make complex and ever-changing decisions about patients' medications in a clinical environment affected by multifaceted, contextual issues. It is important that comprehensive information about graduate nurses' decision-making processes and the contextual influences affecting these processes are obtained in order to prepare them to meet patients' needs. AIM: The purpose of this paper is to report a study that sought to answer the following questions: What are the barriers that impede graduate nurses' clinical judgement in their medication management activities? How do contextual issues impact on graduate nurses' medication management activities? The decision-making models considered were: hypothetico-deductive reasoning, pattern recognition and intuition. METHODS: Twelve graduate nurses who were involved in direct patient care in medical and surgical wards of a metropolitan teaching hospital located in Melbourne, Australia participated in the study. Participant observations were conducted with the graduate nurses during a 2-hour period during the times when medications were being administered to patients. Graduate nurses were also interviewed to elicit further information about how they made decisions about patients' medications. RESULTS: The most common model used was hypothetico-deductive reasoning, followed by pattern recognition and then intuition. The study showed that graduate nurses had a good understanding of how physical assessment affected whether medications should be administered or not. When negotiating treatment options, graduate nurses readily consulted with more experienced nursing colleagues and doctors. STUDY LIMITATIONS: It is possible that graduate nurses demonstrated a raised awareness of managing patients' medications as a consequence of being observed. CONCLUSIONS: The complexity of the clinical practice setting means that graduate nurses need to adapt rapidly to make sound and appropriate decisions about patient care. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little information is available about patients' perspectives on self- or nurse-related administration of medication. AIM: The aim of the study was to determine patients' perspectives about self-medication in the acute care setting. METHODS: A qualitative approach, using in-depth semi-structured interviews, was taken. Ten patients with a chronic medical illness who had experienced multiple hospital admissions for treatment were interviewed about their experiences of medication administration in the acute care setting. Participants were recruited from two cardiovascular wards in a private, not-for-profit hospital in Melbourne, Australia. Data collection occurred between August and September 2002. FINDINGS: Four major themes were identified from the interviews: benefits of self-administration, barriers to self-administration, assessing appropriateness of self-administration and timing of medication administration. Seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses' heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting. CONCLUSIONS: In planning and implementing self-administration programmes, it is important to consider patients' views. Medication regimes should be simple and flexible enough to adapt to patients' lifestyles and usual routines. Nurses should also take advantage of opportunities to support and facilitate patient autonomy, to enable more effective management of health care needs when patients return home. [ABSTRACT FROM AUTHOR]

There is a paucity of research in investigating agency nursing work from the perspectives of hospital nursing managers and agency nurse providers. This exploratory paper examines the hospital nursing managers' and agency nurse providers' perceptions and experiences of agency nursing work. Individual, in-depth interviews were conducted with three agency nurse providers and eight hospital nursing managers. Because of the lack of previous research in this area, an exploratory, semi-structured interviewing technique was deemed appropriate. Three major themes emerged from interview data: planning for ward allocation, communication and professionalism. In planning for ward allocation, hospital managers were primarily concerned with maintaining adequate numbers of nursing staff in the ward settings. A major concern for agency nurse providers was inappropriate allocation of temporary staff. Communication was valued in different ways. While hospital managers focused on communication between the agency nurse and other permanent members of the health care team, agency providers were concerned with exchanges between agencies and hospital organizations, and between the agencies and agency nurses. For both groups, responsibility for professional development and the status of agency nursing as a career choice for graduate and experienced nurses were the focal aspects for consideration. A limitation of this study is the small number of individual interviews conducted with hospital nursing managers and agency nurse providers. Nevertheless, the findings represent the views of 11 individuals in senior managerial roles. The findings reinforce the need to enhance collaboration between hospitals and nursing agencies, and to examine how divergent views of agency nursing work could be reconciled--with the aim of providing quality patient care. [ABSTRACT FROM AUTHOR]

The use of photography is an underreported method of research in the nursing literature. This paper explores its use in an ethnographic research project, the fieldwork of which was undertaken by the first author. The aim was to examine the governance of operating room nursing in the clinical setting and the theoretical orientation was the work of Michel Foucault. The focus of this paper is on how photography was used as a means of data generation. To establish some context we begin by drawing on writers from sociology and anthropology to provide an overview of the status of vision and visual research methods in contemporary social research. We then move to a brief discussion of the uses of photography in social research and the limitations imposed by ethical considerations of its use in clinical nursing settings. As well, the process and approach involved in this research project, and issues of analysis are discussed. Three 'snap-shots' of operating room nursing, taken by participants, are presented. Each is analysed in terms of its contributions to the research process as well as its substantive contribution to the theoretical framework and the research aims. [ABSTRACT FROM AUTHOR]

As a result of the fact that Australia is a multicultural society with many people who come from non-English speaking backgrounds (NESB), the objective of the present study was to discuss the extent to which transcultural nursing education is incorporated into undergraduate nursing curricula. A survey was undertaken to determine the availability of nursing modules for undergraduate nursing students through Australian university websites on 'transcultural nursing' or related modules. Although the inclusion of these modules into nursing education provide an opportunity for nurses to perceive and respond to different patient behaviors in multicultural societies, it is not sufficient to understand the complexity of the health care needs of a multicultural society. The survey findings suggest that many universities have not included transcultural nursing modules in their nursing curricula. To address this problem, more transcultural nursing modules need to be introduced into nursing curricula and nursing academics need to refine their attitudes about the importance of cultural aspects of patient care within nursing education. [ABSTRACT FROM AUTHOR]

BACKGROUND: Despite increasing knowledge and technological advances, patients continue to experience pain and anxiety in the postoperative setting. AIM OF THE STUDY: The aim of this study was to examine how nurses managed patients' pain and anxiety within the gastro-surgical hospital setting. METHODS: An observational design was selected to examine nurses' management of postoperative patients' pain and anxiety. Six nurses who were involved in direct patient care in one of two gastro-surgical wards in a public teaching hospital in Melbourne, Australia, were randomly selected to participate. The observation period comprised a fixed 2-hour segment, and each nurse was observed on three different occasions. FINDINGS: Patient assessment was a major concern for participants, which was influenced by the modes of assessment used, patients' medical condition and operation procedure, and their self-reports of pain or anxiety. Communication with health care professionals and policy and protocol concerns also affected nurses' pain and anxiety management decisions. Formal communication through the multidisciplinary ward round tended to be somewhat fragmented, as the medical consultant did not seek out the bedside nurse. Nurses had good knowledge of unit policies and protocols and, while attempting to enforce them, spent considerable time encouraging medical colleagues to abide by these guidelines. Finally, nurses made complex clinical judgements which extended beyond the administration of analgesics or antianxiety drugs. STUDY LIMITATIONS: It is possible that nurses demonstrated a raised awareness of how they managed patients' pain and anxiety during observation periods. CONCLUSIONS: The study confirmed the importance of examining the complexities of the clinical context in determining how nurses manage pain and anxiety in the postoperative setting. [ABSTRACT FROM AUTHOR]

The purpose of the present study was to examine prescribing and administering activities for sedative and analgesic medication in postoperative patients, and to describe nurses' documentation practices for pain management in nursing notes. A prospective audit was undertaken of medication order charts and nursing notes of 100 patients on the operation day and over the first four days following surgery. Almost all patients received some form of infusion, while the use of 'as required' analgesics varied from one-third to over two-thirds of patients during the postoperative period. Few patients were prescribed fixed-order analgesics or sedative medications. An audit of nursing entries found that nurses had documented inadequately in four major areas: pain assessment, use of non-pharmacological interventions, use of pharmacological interventions, and outcome of interventions. The findings contribute to improving our understanding of nurses' pain management and identify the need to use clinical judgement that is individualized to patients' needs. [ABSTRACT FROM AUTHOR]

Non-adherence to antipsychotic medication is associated with relapse of psychiatric symptoms and readmission to inpatient mental health services. The important role of the mental health nurse in facilitating adherence has been acknowledged, however, there has been little exploration of how nurses themselves perceive this aspect of their role. A qualitative study was conducted to explore the perceptions of mental health nurses employed in inpatient settings regarding their role in facilitating medication adherence. Focus groups were conducted with 22 nurses from three inpatient settings in metropolitan Melbourne. The main themes to emerge from the data were: nurses' responsibilities in medication management; ways in which nurses are educated about antipsychotic medication; barriers to the provision of medication management, and barriers to effective patient adherence. Recommendations for more effective practice are discussed. [ABSTRACT FROM AUTHOR]

BACKGROUND: Agency nursing is a poorly understood and under-researched phenomenon. Despite the considerable costs and possible benefits of using agency nurses, little is known about the nature of agency nursing from different perspectives, including hospital and agency managers. AIM: To describe the professional relationship between hospitals and nursing agencies, utilization trends of agency nurses, and institutional policies relating to the employment of agency nurses. METHODS: A telephone survey was conveyed to managers of 70 acute hospitals (service purchasers) and 26 agencies (service providers) to provide baseline information on the utilization of agency nurses in acute hospitals in Melbourne, Australia. Introductory telephone calls were made to the chief nursing officers of the hospitals and the chief executive officers of nursing agencies in order to explain and seek approval for the proposed project. Approval to conduct telephone interviews was obtained from 30 acute hospitals and six agencies, representing a response rate of 43% and 23%, respectively. Separate questionnaires were used for the two categories of respondent. In some cases the questionnaire could not be completed using the telephone and a copy was then sent by post for completion. RESULTS: Findings revealed the high utilization of agency nurses in hospitals, the limited nature of continuing education for agency nurses, tensions between matching agency nurse qualifications with acute specialty needs and the notion that agencies preferred nurses to be flexible in their work assignments. CONCLUSIONS: The study was limited by the fact that the final sample was small (30 hospitals and six agencies), and therefore may not be representative of the wider population of Melbourne hospitals or agencies. However, it provided evidence on the utilization of agency nurses in public and private hospitals that will help shape policy on the regulation of the agency nursing workforce. [ABSTRACT FROM AUTHOR]

Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. This observational study sought to investigate nurse-patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings. Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions. Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients. These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics. [ABSTRACT FROM AUTHOR]

BACKGROUND: Nurses have key responsibilities in the administration and management of medication therapy and client education. It is of some concern therefore that the literature indicates that nurses are inadequately prepared in this area. AIMS: This paper explores the perceptions and expectations of lecturers about teaching and learning pharmacology in preregistration nursing courses. RESEARCH METHODS: Questionnaires were distributed to lecturers involved in teaching pharmacology to undergraduate nursing students during 2000. The questionnaire was distributed to all university campuses (n = 13) in Victoria, Australia, that are involved in undergraduate nursing education. The questionnaire was an adaptation of the survey instrument used in the Nursing and Medication Education [NAME] project and examined in this questionnaire: the integration of pharmacology teaching into nursing, range and depth of classroom-based pharmacology teaching, approaches to teaching and learning, nursing practice in a clinical context, related importance of patient education and communication skills, and the appropriate professional background of academics teaching pharmacology to preregistration nursing students. RESULTS: There was great variation between institutions as to the number of hours devoted to pharmacology and when it was offered. A number of respondents indicated that they were dissatisfied with the preparation of graduates and their knowledge base in pharmacology. LIMITATIONS: The study was limited by a low response rate of 34%. CONCLUSIONS: A review of nursing curricula is required to improve the knowledge base of nurses in pharmacology and to facilitate their skills in life-long learning. [ABSTRACT FROM AUTHOR]

* This paper describes the participation of critical care nurses in ward rounds, and explores the power relations associated with the ways in which nurses interact with doctors during this oral forum of communication.* The study comprised a critical ethnographic study of six registered nurses working in a critical care unit.* Data collection methods involved professional journalling, participant observation, and individual and focus group interviews with the six participating nurses.* Findings demonstrated that doctors used nurses to supplement information and provide extra detail about patient assessment during ward rounds. Nurses experienced enormous barriers to participating in decision-making activities during ward round discussions.* By challenging the different points of view that doctors and nurses might hold about the ward round process, the opportunity exists for enhanced participation by nurses. [ABSTRACT FROM AUTHOR]

Health care professionals use policies and protocols in varying ways to guide their clinical activities and to promote quality patient care. The critical ethnographic case study upon which this paper is based, involved a research group comprising six registered nurses who worked in a critical care setting. Research methods included professional journalling, participant observation, and focus group and individual interviews. This paper examines the power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediating communication. While policies and protocols provided nurses with legitimacy of their knowledge in the clinical arena, doctors tended to rely on their past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through policies and protocols to confirm and support their knowledge. Policies and protocols of critical care activities provided nurses with expected standards of care, which they used to legitimize their knowledge and to communicate with doctors about 'undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurses used these written guidelines to assert power and demonstrate resistance. Policies and protocols do not exist in isolation; they occur within a complex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors establish a fine balance between using policies and protocols to provide directions for practice, and to allow sufficient latitude and flexibility in addressing the complexities of patient care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The purpose of this study was to determine, from the nurses' perspective, the contribution made by the patient, next-of-kin, nurse, and doctor to the DNR decision; the influence of the nurses' awareness of a DNR policy on the decision; and the influence of the nurses' practice setting on the decision. DESIGN: Survey. SETTING: Six acute care hospitals located within a 50-km radius of Melbourne, Australia. POPULATION: The sample comprised 360 registered nurses employed in six public acute care hospitals. Of those nurses contacted, 285 participated in the study. INTERVENTIONS: The survey questionnaire consisted of three parts. Part I involved questions relating to the nurses' attitudes and experiences in DNR practice. Part II was unstructured and designed to explore nurses' rewarding or frustrating experiences involving DNR practice. Part III of the questionnaire, consisting of eight items, was designed to obtain demographic information on respondents. The questionnaires were distributed through the internal mailing system of each hospital to nurses comprising the study sample. MAIN OUTCOME MEASURE(S): Nurses' experiences in relation to the decision-making process were compared with nurses' awareness of a DNR policy for their hospital. Results from the scenario indicated the importance nurses placed on patient involvement in the DNR decision; 98% of nurses agreed that the patient's wants should be considered. Ninety-one percent agreed the staff nurse should be involved in determining the patient's DNR status. Nurses also believed that the doctor and charge nurse had prime roles in this scenario. Seventy-one percent of nurses agreed that the next-of-kin should be involved in deciding the patient's DNR status. There was a significant difference for nurses' effectiveness in influencing a DNR order related to nurses' area of practice. RESULTS/CONCLUSIONS: The majority of experiences described were frustrating ones. Nurses clearly were frustrated about their lack of input towards the DNR decision as well as the lack of involvement by the patient and family. Even after the decision was made, nurses still felt concerned that there was little communication about this decision among members of the health care team. Although participants believed that the patient, next-of-kin, and nurse should play a predominant role in the DNR policy, in reality, medical staff usually were solely responsible for this process. Regardless of the nurses' area of practice and level of awareness for a DNR policy, the competent patient, next-of-kin, and nurse rarely were involved in the DNR decision. It appears that guidelines alone did not result in changes to practice. An incongruence between nurses' attitudes of who should make the DNR decision and nurses' experiences of who does make the decision may create ethical dilemmas for nurses as they are unable to act as effective advocates for patients and families. [CINAHL abstract] [ABSTRACT FROM AUTHOR]

Background: Risk factors associated with all-cause hospital readmission are poorly characterised in patients with chronic kidney disease., Objective: A systematic review and meta-analysis were conducted to identify risk factors and protectors of hospital readmission in chronic kidney disease., Design, Participants & Measurements: Studies involving adult patients were identified from four databases from inception to 31/03/2020. Random-effects meta-analyses were conducted to determine factors associated with all-cause 30-day hospital readmission in general chronic kidney disease, in dialysis and in kidney transplant recipient groups., Results: Eighty relevant studies (chronic kidney disease, n = 14 studies; dialysis, n = 34 studies; and transplant, n = 32 studies) were identified. Meta-analysis revealed that in both chronic kidney disease and transplant groups, increasing age in years and days spent at the hospital during the initial stay were associated with a higher risk of 30-day readmission. Other risk factors identified included increasing body mass index (kg/m 2 ) in the transplant group, and functional impairment and discharge destination in the dialysis group. Within the chronic kidney disease ​​​​group, having an outpatient follow-up appointment with a nephrologist within 14 days of discharge was protective against readmission but this was not protective if provided by a primary care provider or a cardiologist., Conclusion: Risk-reduction interventions that can be implemented include a nephrologist appointment within 14 days of hospital discharge, rehabilitation programme for functional improvement in the dialysis group and meal plans in the transplant group. Future risk analysis should focus on modifiable factors to ensure that strategies can be tested and implemented in those who are more at risk., (© 2022 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Aims: Older adults are vulnerable to medication-related harm mainly due to high use of medications and inappropriate prescribing. This study aimed to investigate the associations between inappropriate prescribing and number of medications identified at discharge from geriatric rehabilitation with subsequent postdischarge health outcomes., Method: RESORT (REStORing health of acutely unwell adulTs) is an observational, longitudinal cohort study of geriatric rehabilitation inpatients. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation, using Version 2 of the STOPP/START criteria., Results: In total, 1890 (mean age 82.6 ± 8.1 years, 56.3% female) were included. The use of at least 1 PIM or PPO at geriatric rehabilitation discharge was not associated with 30-day and 90-day readmission and 3-month and 12-month mortality. Central nervous system/psychotropics and fall risk PIMs were significantly associated with 30-day hospital readmission (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.09-2.15), and cardiovascular PPOs with 12-month mortality (AOR 1.34; 95% CI 1.00-1.78). Increased number of discharge medications was significantly associated with 30-day (AOR 1.03; 95% CI 1.00-1.07) and 90-day (AOR 1.06; 95% CI 1.03-1.09) hospital readmissions. The use and number of PPOs (including vaccine omissions) were associated with reduced independence in instrumental activities of daily living scores at 90-days after geriatric rehabilitation discharge., Conclusion: The number of discharge medications, central nervous system/psychotropics and fall risk PIMs were significantly associated with readmission, and cardiovascular PPOs with mortality. Interventions are needed to improve appropriate prescribing in geriatric rehabilitation patients to prevent hospital readmission and mortality., (© 2023 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Introduction: Persistent high rates of prescription opioid use and harms remain a concern in Australia, Europe and North America. Research priority setting can inform the research agenda, strategic responses and evidence-based interventions. The objective of this study was to establish research priorities related to the safe and effective use of prescription opioids in general practice., Methods: Consumers, clinicians and policy makers were invited to participate in a structured consensus workshop in May 2021. A modified nominal group technique was used to explore research priorities for the safe and effective use of opioids in Australian general practice. Research priorities were identified, consolidated and prioritised using a structured process., Results: Seventeen consumer, medical, pharmacy, nursing, allied health and policy participants generated 26 consolidated priorities across three domains: (i) consumer-focused priorities; (ii) clinician and practice-focused priorities; and (iii) system and policy-focused priorities. The highest ranked research priorities in each of the domains were consumer characteristics that influence opioid prescribing and outcomes, opioid deprescribing strategies, and system-level barriers to prescribing alternatives to opioids, in the consumer, clinician and practice, and system and policy domains, respectively., Discussion and Conclusion: The priorities reflect opportunities for research priority setting within Australian general practice. The priorities provide a map for future qualitative and quantitative research that will inform safe and effective opioid prescribing., (© 2022 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Aims: To synthesise associations of potentially inappropriate prescribing (PIP) with health-related and system-related outcomes in inpatient hospital settings., Methods: Six electronic databases were searched: Medline Complete, EMBASE, CINAHL, PyscInfo, IPA and Cochrane library. Studies published between 1 January 1991 and 31 January 2021 investigating associations between PIP and health-related and system-related outcomes of older adults in hospital settings, were included. A random effects model was employed using the generic inverse variance method to pool risk estimates., Results: Overall, 63 studies were included. Pooled risk estimates did not show a significant association with all-cause mortality (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 0.90-1.36; adjusted hazard ratio 1.02, 83% CI 0.90-1.16), and hospital readmission (AOR 1.11, 95% CI 0.76-1.63; adjusted hazard ratio 1.02, 95% CI 0.89-1.18). PIP was associated with 91%, 60% and 26% increased odds of adverse drug event-related hospital admissions (AOR 1.91, 95% CI 1.21-3.01), functional decline (AOR 1.60, 95% CI 1.28-2.01), and adverse drug reactions and adverse drug events (AOR 1.26, 95% CI 1.11-1.43), respectively. PIP was associated with falls (2/2 studies). The impact of PIP on emergency department visits, length of stay, and health-related quality of life was inconclusive. Economic cost of PIP reported in 3 studies, comprised various cost estimation methods., Conclusions: PIP was significantly associated with a range of health-related and system-related outcomes. It is important to optimise older adults' prescriptions to facilitate improved outcomes of care., (© 2021 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Rationale, Aims, and Objectives: Medication discrepancies place patients discharged from hospital at risk of adverse medication events. Patient and family participation in medication communication may improve medication safety. This study aimed to examine older medical patient and family participation in discharge medication communication., Methods: Two-phased mixed-methods study. Data were collected from July 2018 to May 2019. Phase 1 comprised observations and a questionnaire of 30 patients pre-hospital discharge. Phase 2 involved telephone interviews with 11 patients and family members post-hospital discharge. Phase 1 analysis included descriptive statistics and deductive content analysis. Inductive content analysis was used in Phase 2. Phase 1 and 2 findings were integrated., Results: For Phase 1, observational data were deductively coded against the "continuum of patient participation"; information-giving was the most frequent level of participation observed on the continuum, followed by information-seeking, shared decision making, non-involved, and finally autonomous decision making. For descriptive statistics, written communication tools, noise, and interruptions were frequently observed during medication communication. In Phase 2, three categories were found about how patients and families participate, and the factors influencing their participation: (a) obtaining comprehensive medication information; (b) preferred approaches for receiving information; and (c) speaking about medications in hospital. Integrated findings showed that written communication tools and routine hospital tasks may promote, while lack of family presence and environmental factors may hinder medication communication. Patients' and families' role in medication communication ranged from asking questions to influencing decisions, and was enhanced by health care professionals' patient-centred communication., Conclusions: More active patient and family participation could be achieved by encouraging them to identify medication-related problems. To create a climate for patient and family participation, health care professionals should use written communication tools, capitalize on participation opportunities during routine hospital tasks, and use patient-centred communication., (© 2020 John Wiley & Sons Ltd.)

Introduction: Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness., Design: Rapid evidence assessment (REA) methodology was used., Data Sources: A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature., Data Synthesis: Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature., Results: A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV., Conclusion: Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field., (© 2018 John Wiley & Sons, Ltd.)

Rationale, Aims and Objectives: As patients move across transition points, effective medication management is critical for patient safety. The aims of this study were to examine how health professionals, patients and family members communicate about managing medications as patients moved across transition points of care and to identify possible sources of communication failure., Method: A descriptive approach was used involving observations and interviews. The emergency departments and medical wards of two hospitals were involved. Observations focused on how health professionals managed medications during interactions with other health professionals, patients and family members, as patients moved across clinical settings. Follow-up interviews with participants were also undertaken. Thematic analysis was completed of transcribed data, and descriptive statistics were used to analyse characteristics of communication failure., Results: Three key themes were identified: environmental challenges, interprofessional relationships, and patient and family beliefs and responsibilities. As patients moved between environments, insufficient tracking occurred about medication changes. Before hospital admission, patients participated in self-care medication activities, which did not always involve exemplary behaviours or match the medications that doctors prescribed. During observations, 432 instances of communication failure (42.8%) were detected, which related to purpose, content, audience and occasion of the communication., Conclusions: Extensive challenges exist involving the management of medications at transition points of care. Bedside handovers and ward rounds can be utilized as patient counselling opportunities about changes in the medication regimen. Greater attention is needed on how patients in the community make medication-related decisions., (© 2016 John Wiley & Sons, Ltd.)

Rationale, Aims and Objectives: The implementation of automated dispensing cabinets (ADCs) in healthcare facilities appears to be increasing, in particular within Australian hospital emergency departments (EDs). While the investment in ADCs is on the increase, no studies have specifically investigated the impacts of ADCs on medication selection and preparation error rates in EDs. Our aim was to assess the impact of ADCs on medication selection and preparation error rates in an ED of a tertiary teaching hospital., Methods: Pre intervention and post intervention study involving direct observations of nurses completing medication selection and preparation activities before and after the implementation of ADCs in the original and new emergency departments within a 377-bed tertiary teaching hospital in Australia. Medication selection and preparation error rates were calculated and compared between these two periods. Secondary end points included the impact on medication error type and severity., Results: A total of 2087 medication selection and preparations were observed among 808 patients pre and post intervention. Implementation of ADCs in the new ED resulted in a 64.7% (1.96% versus 0.69%, respectively, P = 0.017) reduction in medication selection and preparation errors. All medication error types were reduced in the post intervention study period. There was an insignificant impact on medication error severity as all errors detected were categorised as minor., Conclusion: The implementation of ADCs could reduce medication selection and preparation errors and improve medication safety in an ED setting., (© 2015 John Wiley & Sons, Ltd.)

Rationale, Aims and Objectives: Medication adherence is essential in kidney transplant recipients to reduce the risk of rejection and subsequent allograft loss. The aim of this study was to delineate what 'usual care' entails, in relation to medication management, for adult kidney transplant recipients., Methods: An online survey was developed to explore how nephrologists promote and assess medication adherence, the management of prescriptions, the frequency of clinic appointments and the frequency of clinical screening tests. Nephrologists from all acute kidney transplant units in Victoria, Australia, were invited to participate. Data were collected between May and June 2014., Results: Of 60 nephrologists invited to participate, 22 completed the survey (response rate of 36.6%). Respondents had a mean age of 49.1 ± 10.1 years, with a mean of 20.1 ± 9.9 years working in nephrology and 14 were men. Descriptive analysis of responses showed that nephrologists performed frequent screening for kidney graft dysfunction that may indicate medication non-adherence, maintained regular transplant clinic visits with patients and emphasized the importance of medication education. However, time constraints during consultations impacted on extensive patient education and the long-term medication follow-up support was often delivered by the renal transplant nurse coordinator or pharmacist., Conclusions: This study highlighted that nephrologists took an active approach in the medication management of kidney transplant recipients, which may assist with facilitating long-term graft survival. Ultimately, promoting medication adherence needs to be patient centred, involving an interdisciplinary team of nephrologists, pharmacists and renal transplant nurse coordinators, working together with the patient to establish optimal adherence., (© 2015 John Wiley & Sons, Ltd.)

Rationale, Aims and Objectives: The shortage of kidney donors and benefits of kidney transplantation make graft success imperative. Medication adherence is critical to prevent the risk of graft rejection. This paper examines how adults are prepared and supported by renal transplant co-ordinators and pharmacists to take their medications as prescribed in kidney transplantation., Methods: Renal transplant co-ordinators and pharmacists of all five hospitals offering adult kidney transplantation in Victoria, Australia, were interviewed between November 2013 and February 2014. All data underwent qualitative descriptive analysis., Results: Nine renal transplant co-ordinators and six pharmacists were interviewed. Although there was no standardized approach to education or other evidence-based strategies to facilitate medication adherence, there were similarities between sites. These similarities included printed information, pre-transplant education sessions, the use of medication lists and medication administration aids, intensive education in hospital and ensuring an adequate supply of medications post-discharge., Conclusions: Renal transplant co-ordinators and pharmacists recognized the importance of early patient education concerning immunosuppressant medication. However, each site had developed their own way of preparing a patient for kidney transplantation and follow-up in the acute hospital setting based on experience and practice. Other non-educational strategies involving behavioural and emotional aspects were less common. Differences in usual care reinforce the necessity for evidence-based health care for best patient outcomes., (© 2014 John Wiley & Sons, Ltd.)

Background: The increasing prevalence of chronic kidney disease, the relative shortage of kidney donors and the economic- and health-related costs of kidney transplant rejection make the prevention of adverse outcomes following transplantation a healthcare imperative. Although strict adherence to immunosuppressant medicine regimens is key to preventing kidney rejection, evidence suggests that adherence is sub-optimal. Strategies need to be developed to help recipients of kidney transplants adhere to their prescribed medicines., Findings: This review has found that a number of factors contribute to poor adherence, for example, attitudes towards medicine taking and forgetfulness. Few investigations have been conducted, however, on strategies to enhance medicine adherence in kidney transplant recipients. Strategies that may improve adherence include pharmacist-led interventions (incorporating counselling, medicine reviews and nephrologist liaison) and nurse-led interventions (involving collaboratively working with recipients to understand their routines and offering solutions to improve adherence). Strategies that have shown to have limited effectiveness include supplying medicines free of charge and providing feedback on a participant's medicine adherence without any educational or behavioural interventions., Conclusion: Transplantation is the preferred treatment option for people with end-stage kidney disease. Medicine non-adherence in kidney transplantation increases the risk of rejection, kidney loss and costly treatments. Interventions are needed to help the transplant recipient take all their medicines as prescribed to improve general well-being, medicine safety and reduce healthcare costs., (© 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.)