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Background Emergency departments (ED) are challenging environments but critical for early management of patients with stroke. Purpose To identify how context affects the provision of stroke care in 26 Australian EDs. Method Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. Findings Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. Discussion Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

Background The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. Methods Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. Results Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. Conclusions Despite initial high ‘buy-in’ from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12614000939695).

Background and Purpose— We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). Methods— A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke 3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2; (2) Treatment: tPA eligibility screening and appropriate administration; clinical protocols for managing fever, hyperglycemia, and swallowing; (3) prompt ( Results— Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%]; control n=266 [48.7%]; P =0.24) or secondary outcomes. Conclusions— This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. Clinical Trial Registration— URL: http://www.anzctr.org.au . Unique identifier: ACTRN12614000939695.

Background The International Society for Heart and Lung Transplantation recommended in 2006 that intervention studies to maximize psychological outcomes after transplantation should be conducted. Potentially, studies reporting on the effectiveness of non-pharmacological interventions in improving psychological outcomes for heart transplant recipients may have been published since the call for this research. Thus, further evidence may currently be available to inform policy and practice decision-making regarding the implementation of such interventions. Accordingly, an evaluation of the evidence is required. Objectives The objective of this review was to identify the effectiveness of non-pharmacological interventions on psychological outcomes for heart transplant recipients.

Aims and objectives To discuss the evidence of poor recruitment rates in randomised clinical trials and relate this to existing recruitment methodology before a novel approach to recruitment is suggested. Background Recruitment is crucial to the success of research projects. Effective recruitment leads to effective retention, an increased pool of data and in-time completion of projects. Robust evidence indicates that recruitment remains a challenge in many clinical trials. Design Discursive article. Methods The complexity of recruitment is mandated based on the findings from a literature review that summarises common threats to successful recruitment. Nursing theories and models that incorporate recruitment are critically reviewed before recruiting, and its planning is related to existing complex intervention methodology. Conclusion Threats to sufficient recruitment are inherent in the planning of studies, the recruiting process and triadic relationships between institutions, recruiter and participants. Existing nursing theories and models address important recruitment issues but do not account for all aspects that jeopardise sufficient recruitment. Hence, available frameworks for complex intervention planning and evaluation are useful to guide recruitment and its planning as an umbrella methodology. Relevance to clinical practice Using complex intervention methodology for recruitment and its planning enhances a nurse researcher's awareness of the challenges and pitfalls recruitment poses and may translate to improved recruitment rates and overall success of clinical trials.

Background In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models. Methods A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics. Results Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners’ and medical practitioners’ adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals. Conclusions Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0503-2) contains supplementary material, which is available to authorized users.

Internationally recognised evidence-based guidelines recommend appropriate triage of patients with stroke in emergency departments (EDs), administration of tissue plasminogen activator (tPA), and proactive management of fever, hyperglycaemia and swallowing before prompt transfer to a stroke unit to maximise outcomes. We aim to evaluate the effectiveness in EDs of a theory-informed, nurse-initiated, intervention to improve multidisciplinary triage, treatment and transfer (T3) of patients with acute stroke to improve 90-day death and dependency. Organisational and contextual factors associated with intervention uptake also will be evaluated. This prospective, multicentre, parallel group, cluster randomised trial with blinded outcome assessment will be conducted in EDs of hospitals with stroke units in three Australian states and one territory. EDs will be randomised 1:1 within strata defined by state and tPA volume to receive either the T3 intervention or no additional support (control EDs). Our T3 intervention comprises an evidence-based care bundle targeting: (1) triage: routine assignment of patients with suspected stroke to Australian Triage Scale category 1 or 2; (2) treatment: screening for tPA eligibility and administration of tPA where applicable; instigation of protocols for management of fever, hyperglycaemia and swallowing; and (3) transfer: prompt admission to the stroke unit. We will use implementation science behaviour change methods informed by the Theoretical Domains Framework [1, 2] consisting of (i) workshops to determine barriers and local solutions; (ii) mixed interactive and didactic education; (iii) local clinical opinion leaders; and (iv) reminders in the form of email, telephone and site visits. Our primary outcome measure is 90 days post-admission death or dependency (modified Rankin Scale >2). Secondary outcomes are health status (SF-36), functional dependency (Barthel Index), quality of life (EQ-5D); and quality of care outcomes, namely, monitoring and management practices for thrombolysis, fever, hyperglycaemia, swallowing and prompt transfer. Outcomes will be assessed at the patient level. A separate process evaluation will examine contextual factors to successful intervention uptake. At the time of publication, EDs have been randomised and the intervention is being implemented. This theoretically informed intervention is aimed at addressing important gaps in care to maximise 90-day health outcomes for patients with stroke. Australian and New Zealand Clinical Trials Registry ACTRN12614000939695 . Registered 2 September 2014.

Nurse-led clinics offer the possibility of patient education, support and continuity of care for patients with Coronary Heart Disease (CHD) to address and reduce risk factors. The objective of this review is to present the best available evidence related to nurse-led cardiac clinics for adults with CHD by updating an existing systematic review.Twenty databases for published literature and 11 databases or websites for unpublished literature were searched for the period September 2002 to March 2008. Additionally, reference lists of retrieved articles were reviewed and relevant journals were hand searched. Assessment for methodological quality, data extraction and synthesis was undertaken using a systematic review management tool (JBI-SUMARI).Seven RCTs formed the basis for this systematic review, however, in many cases meta-analysis was not possible because of a lack of relevant data. The major nurse-led intervention applied in the clinics consisted of health promotion through educating and counselling the patients. There were no harmful effects on patients with CHD identified when exposed to a nurse-led clinic. Few risk factors were significantly reduced by attending nurse-led clinic, but particular in the long-term no success in risk factor reduction was achieved. Difficulties were obvious in modifying behaviour changes concerning smoking cessation and diet adherence. Nurse-led clinics may positively influence perceived quality of life and general health status, especially physical functioning.The results indicated that care was equivalent to non-nurse led clinics, and there was no greater risk of poorer outcomes in the nurse-led clinics. The effectiveness of clinics might be dependent on the intensity of the nursing support. The combination of counselling and regular assessment of risk factors and health status delivered at nurse-led clinics is supported by the available research, and given that outcomes were in general equivalent between nurse-led and other clinics, further research should investigate the cost effectiveness of the different models of care.Before establishing a nurse-led clinic appropriate qualification and responsibilities, as well as the particular structure of the health care system and funding possibilities have to be considered.Additional research on the effectiveness of selected interventions in nurse-led clinics is necessary. A systematic review on cost-effectiveness should be undertaken.

Background: Post-heart transplant psychological distress may directly hinder physiological health as well as indirectly impact on clinical outcomes by increasing unhealthy behaviors, such as immunosuppression non-adherence. Reducing psychological distress for heart transplant recipients is therefore vitally important in order to improve not only patients’ overall health and well-being but also clinical outcomes, such as morbidity and mortality. Evidence from other populations suggests that non-pharmacological interventions may be an effective strategy. Aim: The purpose of this study was to appraise the efficacy of non-pharmacological interventions on psychological outcomes after heart transplant. Method: A systematic review was conducted using the Joanna Briggs Institute methodology. Experimental and quasi-experimental studies that involved any non-pharmacological intervention for heart transplant recipients were included, provided that data on psychological outcomes were reported. Multiple electronic databases were searched for published and unpublished studies and reference lists of retrieved studies were scrutinized for further primary research. Data were extracted using a standardized data extraction tool. Included studies were assessed by two independent reviewers using standardized critical appraisal instruments. Results: Three studies fulfilled the inclusion and exclusion criteria, which involved only 125 heart transplant recipients. Two studies reported on exercise programs. One study reported a web-based psychosocial intervention. While psychological outcomes significantly improved from baseline to follow-up for the recipients who received the interventions, between-group comparisons were not reported. The methodological quality of the studies was judged to be poor. Conclusions: Further research is required, as we found there is insufficient evidence available to draw conclusions for or against the use of non-pharmacological interventions after heart transplant.

Aim To investigate characteristics of collaboration between nurse practitioners and medical practitioners in the primary healthcare setting in Australia. Background Recent definitions of collaboration in the literature describe it as being based on communication, shared decision-making and the respect and equality of team members. However, research demonstrates a tension between this theoretical ideal and how collaboration between nurse practitioners and medical practitioners occurs in practice. Different socialization processes of the two professions and legislative requirements influence collaborative practice. The way these two professions overcome traditional boundaries and realize collaborative practice in the primary healthcare setting needs to be examined. Design Mixed methods multiple case study including up to six sites with a minimum of six and a maximum of 20 participants in total. Methods Data on collaborative practice between nurse practitioners and medical practitioners in primary health care will be collected in three phases: (1) two-week direct observation in the practice setting to capture actual behaviour and context; (2) questionnaire to measure dimensions of collaboration; and (3) one-to-one semi-structured interviews with nurse practitioners, medical practitioners and practice managers to record experiences, perceptions and understanding of collaboration. Discussion Triangulation of findings will generate a comprehensive understanding of how collaboration between nurse practitioners and medical practitioners in Australia occurs in the primary care setting. The results of this study will inform nurse practitioners, medical practitioners practice managers and policy makers on successful models of collaboration.

Background This integrative review synthesises research studies that have investigated the perceptions of nurse practitioners and medical practitioners working in primary health care. The aggregation of evidence on barriers and facilitators to working collaboratively and experiences about the processes of collaboration is of value to understand success factors and factors that impede collaborative working relationships. Methods An integrative review, which used systematic review processes, was undertaken to summarise qualitative and quantitative studies published between 1990 and 2012. Databases searched were the Cochrane Library, the Joanna Briggs Institute Library, PubMed, Medline, CINAHL, Informit and ProQuest. Studies that met the inclusion criteria were assessed for quality. Study findings were extracted relating to a) barriers and facilitators to collaborative working and b) views and experiences about the process of collaboration. The findings were narratively synthesised, supported by tabulation. Results 27 studies conducted in seven different countries met the inclusion criteria. Content analysis identified a number of barriers and facilitators of collaboration between nurse practitioners and medical practitioners. By means of data comparison five themes were developed in relation to perceptions and understanding of collaboration. Nurse practitioners and medical practitioners have differing views on the essentials of collaboration and on supervision and autonomous nurse practitioner practice. Medical practitioners who have a working experience with NPs express more positive attitudes towards collaboration. Both professional groups report concerns and negative experiences with collaborative practice but also value certain advantages of collaboration. Conclusions The review shows that working in collaboration is a slow progression. Exposure to working together helps to overcome professional hurdles, dispel concerns and provide clarity around roles and the meaning of collaboration of NPs and MPs. Guidelines on liability and better funding strategies are necessary to facilitate collaborative practice whether barriers lie in individual behaviours or in broader policies.

Background Psychosocial factors and physical health are associated with increased psychological distress post-heart transplant. Integrating findings from qualitative studies could highlight mechanisms for how these factors contribute to psychological well-being, thus aiding the development of interventions. Objective To integrate qualitative findings regarding adult heart transplant recipients experiences, such as their emotions, perceptions and attitudes. Methods A systematic review and meta-summary were conducted. Data from seven studies were categorized into 16 abstracted findings. Results The most prominent finding across the studies related to recipients' perceptions of the importance of social support. Other prominent findings related to factors that promoted psychological well-being, such as faith, optimism and sense of control. Conclusions Psychological well-being may be improved by enhancing perceived control over health and daily life, promoting an optimistic outlook by facilitating access to social support from other heart transplant recipients and ensuring post-transplant recipient–caregiver partnerships adequately support the transition back to independence.

German: Die schmerztherapeutische Versorgung von chirurgischen Patienten ist trotz vorhandener Möglichkeiten sowohl von pflegerischer als auch ärztlicher Seite mangelhaft. Ziel dieser Arbeit ist es, durch Identifikation und Berücksichtigung von Schmerzprädiktoren Patienten mit einem erhöhten Risiko für starke postoperative Schmerzen frühzeitig zu erkennen und damit das pflegerische Schmerzmanagement zu verbessern. Neben der Identifizierung von Prädiktoren in der Literatur wurden mittels Querschnittstudie in einer Gelegenheitsstichprobe von 84 chirurgischen Patienten Variablen erhoben, die als Prädiktoren wirksam werden können. Die Erhebung erfolgte anhand eines präoperativ auszufüllenden Fragebogens sowie der persönlichen Befragung zur Schmerzintensität nach der Operation. Patientenvariablen und Operationsparameter wurden in einer Korrelationsanalyse auf ihre Vorhersagequalität für starke postoperative Schmerzen überprüft. Von den 14 Variablen zeigte sich lediglich der präoperative Schmerz als Prädiktor von starken postoperativen Schmerzen. Ein Vergleich mit anderen Studien lässt ein Schmerzmanagement, das auf Schmerzprädiktoren beruht, fragwürdig erscheinen, da keine einheitlichen Ergebnisse über Prädiktoren gefunden werden konnten. English: Pain treatment of surgical patients is still a deficient area, even if there are evidence-based possibilities of pain management. The aim of this study is to identify patients with a higher risk of severe postoperative pain at an early stage and improve nurses' pain management by identifying pain predictors whilst including them in analgesic treatment. In addition to the identification of predictors by a literature review, a cross-sectional study with 84 surgical patients of a convenience sample was undertaken to find possible predictors. The enquiry was conducted by means of a questionnaire which the patient had to fill in prior surgery. The intensity of pain was surveyed in a personal interview on the first post-operative day. Correlation analysis was applied to verify the statistical significance of patient characteristics as well as surgical variables. Out of the14 variables preoperative pain was found to increase the risk of postoperative pain. Comparison with other studies showed inconsistent results for pain predictors, and therefore nursing pain management based on pain predictors seems questionable.