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Objective: In this study we aimed to identify the cues that ward nurses and doctors use to identify patient deterioration and, secondly, examine the assessment and communication of deterioration in patients on acute wards of a regional hospital., Methods: Mixed methods case study design in a 220 bed regional hospital. Case studies originated from patients admitted unexpectedly to ICU from general wards (n=17). Data collection occurred within 72 h of the patient's admission to ICU. Interviews with 11 nurses and 14 doctors, and chart audit of 17 patient records for the 24 h prior to ICU were undertaken., Results: The results demonstrate reliance on vital signs for nurses and doctors for initial identification of patient deterioration. Subsequent to this, nurses relied on assessment of the patient's physical capabilities whilst doctors undertook additional clinical investigations. Admission category and co-morbidities increased clinicians' identification of deterioration but the extent of assessment was dictated by 'usual practice' for the regional hospital, the ward or particular patient category. A lack of timely referral to more senior clinicians was identified. Chart audit found that 13 (76%) patients had clinical markers prior to ICU admission and 10 (56%) had these markers for >2h in the previous 24h., Conclusions: This study highlights inadequate communication between clinicians and lack of process for ensuring timely management when patients deteriorate in a regional hospital. The use of casual or locum staff who are less familiar with the clinical culture of regional hospitals may influence the recognition of, and response to, deteriorating ward patients.

The aim of the study was to identify the factors influencing the timing of an assessment after contact with a triage program in a community-based area mental health service in Australia. Triage decisions apparently were influenced by several groups of factors: patient characteristics; the source and mode of the contact with triage; and to a large extent by mental health service factors including the training, supervision and support of triage workers and the perceived availability of an assessment. While demand factors such as patient characteristics influenced the triage decision, supply factors also played an important role.

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

Objective: This paper examines strategies used by nurses to manage patients at risk of deterioration in smaller rural hospitals in Victoria, Australia., Design: A two-stage design comprising a postal questionnaire (n = 20) and case studies (n = 7). Case study participants were interviewed and their practice was observed for one shift., Setting: Smaller rural hospitals in Victoria., Participants: Registered Nurses (Division 1)., Main Outcome Measure: Observed and reported strategies used to manage deteriorating patients., Results: Nurses in this study used clinical strategies and communication strategies when managing patients who might deteriorate. These strategies were adapted to suit the individual rural context. The ability to anticipate patient requirements and confidence to act on clinical presentation were central. Nurses also had to learn the art of referral and they tailored communication according to their perception of the knowledge and skills of medical colleagues. Strategies were also influenced by staffing patterns and expectations of the community and health service., Conclusions: We conclude that rural nurses play an essential role in assessing and managing risk of deterioration across a range of patient presentations and often in challenging situations. Strategies used by nurses required an understanding of the rural context of care delivery.

Objective: To explore the extent and impact of professional boundary crossings in metropolitan, regional and rural mental health practice in Victoria and identify strategies mental health clinicians use to manage dual relationships., Method: Nine geographically located focus groups consisting of mental health clinicians: four focus groups in rural settings; three in a regional city and two in a metropolitan mental health service. A total of 52 participants were interviewed., Results: Data revealed that professional boundaries were frequently breached in regional and rural settings and on occasions these breaches had a significantly negative impact. Factors influencing the impact were: longevity of the clinician's relationship with the community, expectations of the community, exposure to community 'gossip' and size of the community. Participants reported greater stress when the boundary crossing affected their partner and/or children. Clinicians used a range of proactive and reactive strategies, such as private telephone number, avoidance of social community activities, when faced with a potential boundary crossing. The feasibility of reactive strategies depended on the service configuration: availability of an alternative case manager, requirement for either patient or clinician to travel. The greater challenges faced by rural and regional clinicians were validated by metropolitan participants with rural experience and rural participants with metropolitan experience., Conclusions: No single strategy is used or appropriate for managing dual relationships in rural settings. Employers and professional bodies should provide clearer guidance for clinicians both in the management of dual relationships and the distinction between boundary crossings and boundary violation. Clinicians are clearly seeking to represent and protect the patients' interests; consideration should be given by consumer groups to steps that can be taken by patients to reciprocate.

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

Objective: This paper aims to evaluate the structures and processes of eating disorders services in two regional cities in Australia., Method: Stakeholder evaluation undertaken between 2002 and 2005 uses interviews, questionnaires and service delivery data to examine: structure and patient profile of the two services, barriers and success factors and local factors influencing development of the services., Results: The Bendigo service provided secondary consultation and specialist management with upskilling of primary care workers as a key goal. Patients were referred to the service via mental health triage. The Geelong service initially offered assessment only, with direct access for the general public. Treatment was offered from early 2004. The Bendigo service assessed 41 patients, 63% were diagnosed with anorexia nervosa or bulimia nervosa. Most patients had a moderate or severe eating disorder. The Geelong service assessed 186 patients, 55% were diagnosed with anorexia nervosa or bulimia nervosa and 80% of this subset had not previously been treated for an eating disorder. General practitioners identified barriers to development of the services as: problems with capacity building and unrealistic expectations. The success factors were providing a locally based service with credible clinicians and effective communication., Conclusions: Activity analysis demonstrates that the goals for both services were met. There is a need to measure both short- and long-term patient outcomes in order to fully assess effectiveness and applicability to other settings. Local factors, such as availability of specialist providers, would need to be taken into account.

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

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

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

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

This paper discusses the diversity of portfolio use highlighted in a study funded by the English National Board for Nursing, Midwifery and Health Visiting exploring the effectiveness of portfolios in assessing learning and competence (). Data collection was undertaken in two stages: through a national telephone survey of Higher Education Institutions (HEIs) delivering nursing programmes (stage 1); and through four in-depth case studies of portfolios use (stage 2). Data collection for stage two was undertaken through field work in four HEIs purporting to use portfolios as an assessment strategy, and their associated clinical placement settings. Four approaches to the structure and use of portfolios were evident from the stage 2 case study data; these were characterised as: the shopping trolley; toast rack; spinal column and cake mix. The case study data also highlighted the evolutionary nature of portfolio development and a range of additional factors influencing the effectiveness of their use, including language of assessment, degree of guidance and expectations of clinical and academic staff.

Objective: This paper aims to provide an overview of the literature on non-sexual dual relationships, and to discuss these in the context of rural mental health practice in Australia., Method: An internet-driven literature search was undertaken using OVID databases, which include MEDLINE, PsycINFO, CINAHL, and EMBASE: Psychiatry. Ethical codes of practice for the mental health professions of psychiatry, psychology, occupational therapy, social work and nursing were referred to. Searches were not limited by year of publication. Other unpublished material or information was included where relevant., Results: Dual relationships are common in rural mental health practice. However, research on non-sexual dual relationship boundary issues in rural mental health is limited. Ethical codes of practice of mental health professional bodies provide little guidance regarding non-sexual dual relationships. Decision-making models addressing the ethics of dual relationships are restricted to considerations of whether to enter a dual relationship rather than how to manage such a relationship., Conclusions: Everyday' dual relationships are a predictable part of rural mental health practice. Further research is required to identify the benefits and/or problems in clinical practice resulting from non-sexual dual relationships. Responsibility for identifying and implementing ways of appropriately managing such relationships should be shared by the patient, the clinician, mental health services and professional organizations.

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

Purpose: The purpose of this paper is to discuss how portfolio assessment processes should be evaluated., Background: Articles in the nursing literature discuss the use of validity and reliability as criteria for evaluating portfolio assessment processes, and recommendations include tighter specification of grading criteria, a standardized national approach to assessing clinical competence in nursing students, and inter-rater reliability checks. On the other hand, some general practitioner educators suggest that these may not be the appropriate criteria because the nature of the evidence in portfolios is descriptive and judgement-based rather than quantifiable., Method: Drawing on multi-method case study data from a recent study evaluating the use of portfolios in the assessment of learning and competence in nursing education in England, we suggest that criteria developed to evaluate qualitative research may be more appropriate for evaluating portfolio assessment processes., Discussion: Multiple sources of evidence from the varied perspectives of students, teachers, practice assessors and external examiners are tapped as part of the portfolio assessment process. Tripartite meetings between students, teachers and clinical assessors to review placements are crucial in verifying both the written evidence and students' ability to communicate and critically analyse their performance. The variety of evidence collected would potentially allow monitoring, using qualitative research evaluation criteria, both of the portfolios themselves and the systems by which they are monitored and evaluated. However, not all this information is collected consistently and systematically, as called for in curriculum documents., Conclusions: Use of qualitative research evaluation criteria offers a potentially productive way forward in evaluating portfolio assessment processes but some aspects of current practice need to be tightened, particularly double marking, internal moderation and external examining.

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

This paper reports the findings from a study commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB), entitled Evaluation of the Effectiveness of Educational Preparation for Critical Care Nursing. One aim of the study was to generate evidence that incorporated the national perspective on the priorities for core competencies and a national threshold standard of the ENB critical care clinical awards. Although these courses are no longer validated by the professional statutory body, the findings illuminate some key insights into the current challenges facing providers and consumers of critical care education as well as into implications for all post-registration education provision. The paper outlines how the study data were collected, how the core competendes were generated and the national consultation exercise and the levers and barriers that affect the introduction of core competencies. Other aspects of the study data are reported elsewhere (Scholes and Endacott, 2002).

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

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

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

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

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

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

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

A telephone survey of 89 GICUs in England was performed, using stratified quota sampling. 75 (84%) units reported changes in practice over the past 3 years. The reported changes were not only task orientated but also encompassed increased autonomy, organisational changes and increased workload. The absence of significant relationships between the activities suggests that nursing practice development is dependent on patient need and/or local factors. The lack of pattern suggests that it may be inappropriate to compare units for the purpose of nurse staffing.

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

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

This article discusses the issues surrounding the measurement of nursing work. The authors highlight a Royal College of Nursing (RCN) survey of critical care units which identified the extent of the use of patient scoring systems. The authors also examine the implications of using scoring systems to determine nursing workload and estimate staffing requirements.

This article addresses some of the practical aspects of auditing in the intensive care setting by comparing two audit tools. An overview of each tool is provided together with a description of how it was used. Recommendations for auditing in intensive care are given.

The incidence of malnourishment in medical and surgical patients is well documented, yet it is obvious that sufficient and appropriate nourishment is as vital to life as the maintenance of effective respiration. The effects of malnourishment are seen in all systems of the body, and cause diminutions in mental and emotional well-being. The highly compromised states of critically ill patients places them at great risk from the adverse effects of sub-nutrition, and much responsibility lies with nurses in intensive care units (ICUs) to ensure such patients are protected. This article considers the key aspects of the nurse's role in the provision of artificial nutrition to adult patients in ICUs who are, by definition, critically ill.

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