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Background A midwife’s ability to fully support women’s autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman’s agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. Objectives A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. Methods Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. Findings Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife’s ability to offer and the woman’s decision to use water immersion under the themes ‘the reality of the system’, ‘the authoritative ‘others’’ and ‘the pseudo decision-makers’. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. Conclusions The insight gained from examining midwives’ views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.

Trauma-informed care or psychosocial care can prevent or reduce the long-term impacts of hospitalization on children and their families, but few hospital staff members receive formal training in the optimal delivery of this care. This study aimed to (a) identify predictors of staff knowledge, confidence, use, and barriers regarding psychosocial care, and investigate whether these differed by profession; (b) identify pathways to increasing the use of psychosocial care; and (c) understand the association between psychosocial care and staff stress and burnout. Surveys were conducted with staff members (N = 180) within a large pediatric hospital. Questions were based on those used in similar research, and stress and burnout were assessed using the Professional Quality of Life scale. The study found that although all staff members reported using psychosocial care, only 27.2% had received training in these skills. There were no substantial differences in knowledge, confidence, and use of psychosocial care between different professions (medical, nursing, allied health, and administration staff), although nursing staff members reported a higher number of barriers to using psychosocial care. Training was indirectly associated with greater use via greater confidence and greater knowledge. Low confidence and a higher number of barriers were associated with staff burnout, and greater skill use and a higher number of barriers were associated with staff stress. Overall, these findings suggest that training that improves confidence and knowledge may support staff to deliver psychosocial care, with potential benefits for staff well-being. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background Accessibility of water immersion for labour and/or birth is often dependent on the care provider and also the policies/guidelines that underpin practice. With little high quality research about the safety and practicality of water immersion, particularly for birth, policies/guidelines informing the practice may lack the evidence necessary to ensure practitioner confidence surrounding the option thereby limiting accessibility and women’s autonomy. Aim The aims of the study were to determine how water immersion policies and/or guidelines are informed, who interprets the evidence to inform policies/guidelines and to what extent the policy/guideline facilitates the option for labour and birth. Method Phase one of a three-phase mixed-methods study critically analysed 25 Australian water immersion policies/guidelines using critical discourse analysis. Findings Policies/guidelines pertaining to the practice of water immersion reflect subjective opinions and views of the current literature base in favour of the risk-focused obstetric and biomedical discursive practices. Written with hegemonic influence, policies and guidelines impact on the autonomy of both women and practitioners. Conclusion Policies and guidelines pertaining to water immersion, particularly for birth reflect opinion and varied interpretations of the current literature base. A degree of hegemonic influence was noted prompting recommendations for future maternity care policy and guidelines’. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

Hospitalization for illness or injury can be experienced by children and their families as traumatic, which can impede recovery and lead to ongoing problems. The provision of quality trauma-informed or psychosocial care by hospital staff may mitigate trauma-related problems; however, there is great variability in the use of psychosocial care practices. Most previous research is based on self-report data and focuses primarily on nurses and physicians. The current study aimed to investigate the use of psychosocial care practices among a range of staff in a large urban pediatric hospital, using observations and interviews. A coding matrix of practices and a set of interview questions were developed based on previous research. Participants included 18 direct care hospital staff and 10 patients. Trained observers observed 13 staff and 10 patients, and coded instances of psychosocial care; 17 staff participated in interviews. A large number of instances of psychosocial care were observed but there was substantial variability in overall use and the use of individual practices. Interviewed staff reported many benefits of psychosocial care for patients and staff, although there were some costs, including emotional fatigue. Contrary to current evidence, most staff reported they rely on visible triggers of distress or need before providing psychosocial care. Future research could investigate the optimal ratio of psychosocial to physical care practices, taking into account patient feedback and psychosocial and medical outcomes. To improve the consistency of psychosocial care, training could incorporate the practice examples documented here, include staff self-care, and encourage informal avenues of learning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background: Water immersion for labour and birth is an option that is increasingly favoured by women.Australian water immersion policies and guidelines commonly specify that practitioners, such as midwives, must undertake further education and training to become accredited. Method: A three-phase mixed methods approach was used. Phase one used critical discourse analysis to determine who or what informs policies and guidelines related to water immersion for labour and/or birth. Phase two examined policy and guideline informants’ experiences of the development of policies/guidelines, whilst phase three surveyed Australian midwives’ views and experiences of water immersion and their use of and/or involvement in the development of policies and guidelines. Findings: Practitioner accreditation for the facilitation of water immersion was a common finding across all phases of the study. An examination of policies and guidelines found that practitioners, namely midwives, were required to meet additional training requirements to facilitate water immersion.Participants of phases two and three identified and discussed accreditation as a significant challenge to the option of water immersion, particularly where there were inconsistencies across documents and in the interpretation of their content. Conclusion: The need for practitioners to be accredited to facilitate water immersion was identified as a major barrier to availability and therefore, women’s ability to access the option. Given these findings, the need for accreditation should be challenged. Refereed/Peer-reviewed

Older people living in residential aged care often experience complex persistent pain because of the presence of multiple comorbidities and geriatric syndrome. Complex persistent pain is associated with physical, psychological and emotional burdens. All of these factors can result in existential suffering. Current pain management in aged care is targeted at passive strategies. More consideration needs to be given to how assessment and management of pain in this population can be improved, using a biopsychosocial model, to decrease unnecessary suffering.

Background Water immersion for labour and birth is consistently challenged as a practice lacking support from high quality evidence. Despite this, the option is available to Australian women. Practitioners are guided by policies and guidelines however, given the research paucity, questions surround the way in which water immersion policies and guidelines are informed. Aims The aims of the study were to determine how water immersion policies and/or guidelines are informed and to what extent the policy/guideline facilitates the option of water immersion for labour and birth with respect to women’s choice and autonomy. Methods Phase two of a three phase mixed methods study used critical, post structural interpretive interactionism to examine the process of development and implementation of water immersion policies and guidelines from informant’s experience. Semi-structured interviews were conducted with 12 Australian participants. Findings Participants highlighted that the lack of randomised controlled trials had resulted in other forms of evidence being drawn upon to inform water immersion policies and guidelines. This was influenced in part by individual interpretations of evidence with medical views taking precedence. This sometimes resulted in policy and guideline documents that were restrictive with this impacting on women’s ability to access the option. Conclusion Perceived limitations of research and the subsequent translation of this perceived paucity of evidence into policies and guidelines, has impacted on women’s ability to exercise choice and autonomy with respect to water immersion and indeed, on the professional autonomy of practitioners who wish to facilitate it.

Using a Constructivist Grounded Theory approach (Charmaz, 2006), this research examined the social construct of the “professional boundary” necessary in mental health therapeutic work and the problem of professional boundary violations in the therapeutic relationship. Thirteen mental health clinicians from various professional disciplines commonly found in mental health clinical practice responded to three specific questions designed to gain an understanding about how clinicians gauge the differences between minor and serious boundary violations. The three questions facilitated further exploration of boundary violations specifically to explore the difficulties of determining what is and what is not considered a boundary violation often resulting in polarised views or “black and white” descriptions and opinions. However many shades of grey were also revealed during the interviews. Almost all participants rated intimacy or sexual contact with a client or an ex-client as being a serious boundary violation, on the other hand there was a great deal of variety in the examples offered as minor boundary violations. Whilst the “Black” is clearly defined by clinicians in this research, the “White” only seemed to create more “Grey” areas, with descriptions of behaviours that fell into the Grey area being more difficult to define. Refereed/Peer-reviewed

ObjectivesThe main aim of the study was to explore the potential sources of variation and understand the meaning of safety climate for nursing practice in acute hospital settings in the UK.DesignA sequential mixed methods design included a cross-sectional survey using the Safety Climate Questionnaire (SCQ) and thematic analysis of focus group discussions. Confirmatory factor analysis (CFA) was used to validate the factor structure of the SCQ. Factor scores were compared between nurses working in operating theatres, critical care and ward areas. Results from the survey and the thematic analysis were then compared and synthesised.SettingA London University.Participants319 registered nurses working in acute hospital settings completed the SCQ and a further 23 nurses participated in focus groups.ResultsCFA indicated that there was a good model fit on some criteria (χ2=1683.699, df=824, p2/df=2.04; root mean square error of approximation=0.058) but a less acceptable fit on comparative fit index which is 0.804. There was a statistically significant difference between clinical specialisms in management commitment (F (4,266)=4.66, p=0.001). Nurses working in operating theatres had lower scores compared with ward areas and they also reported negative perceptions about management in their focus group. There was significant variation in scores for communication across clinical specialism (F (4,266)=2.62, p=0.035) but none of the pairwise comparisons achieved statistical significance. Thematic analysis identified themes of human factors, clinical management and protecting patients. The system and the human side of caring was identified as a meta-theme.ConclusionsThe results suggest that the SCQ has some utility but requires further exploration. The findings indicate that safety in nursing practice is a complex interaction between safety systems and the social and interpersonal aspects of clinical practice.

Background There is little published research that has examined practitioners’ views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. Aims The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. Methods Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. Findings Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice. Conclusion Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

This study sought to understand how mental health clinicians (MHC) establish and maintain the professional boundary in their everyday practice. The findings indicate the establishment and maintenance of the professional boundary and the continual process of engaging the client are inextricably linked. Furthermore the use of interpersonal and professional skills are necessary to establish and maintain the professional boundary on an ongoing basis. A basic social process of engaging clients emerged from the analysis and indicated that a broader understanding of establishing and maintaining boundaries within the mental health context was warranted.

Objective to gain an in-depth understanding of subsequent children's experiences of being born into and raised in a family following an infant death. Design an exploratory qualitative study. Setting semi-structured interview in the participants' homes. Data were collected over a five-month period in 2009 and analysed using thematic analysis. Participants a purposive sample of 10 subsequent children (five boys and five girls) was used. Children whose parents had accessed the support services offered by two bereavement support agencies were recruited. Participants were asked to describe their experiences of being a subsequent child. Interviews were conducted when the subsequent child was at least 13 years of age. Findings all participants spent time describing how they felt about being a subsequent child. They described how they had experienced life as a subsequent child, how they considered others felt about them (especially their mother), and finally how they felt about their deceased sibling. Key conclusions and implications for practice all participants in this study provided a picture of emotional well-being. They were aware of their family history, and all appreciated the grief and loss which their parents had suffered. However, they did not believe that this had impacted negatively on them; rather, most talked about positive effects including feeling loved and special because of the circumstances resulting in their birth. Even those who recognised that they may not have been born had their sibling lived accepted this and appeared to be emotionally secure and well adjusted. These findings suggest that intervention with bereaved parents at the time of the perinatal/infant death and soon after is beneficial to the experiences of the subsequent child. Further research to determine the nature and extent of this benefit is warranted.

Objective: to identify existing literature which addresses the topic of detecting, assessing and intervening when a pregnant woman who has quit smoking relapses. This literature review was conducted in the light of findings of a case-control study which suggest that a quit smoking status is associated with increased risk of late stillbirth (odds ratio 3.03, 95% confidence interval 1.27-7.24, p=0.01). Method: a structured review was conducted to identify literature related to quitting smoking in early pregnancy, prevalence and likelihood of relapse, possible methods for detecting smoking resumption, potential intervention strategies for the relapsed smoker and the societal burden of continuing to smoke in pregnancy. Findings: there is a wide variety of evidence for the effectiveness of intervention strategies aimed at assisting women to quit smoking during pregnancy. However, few studies have specifically aimed to identify strategies to assist those women who report quitting in early pregnancy to maintain that status throughout pregnancy. Conclusions: in light of the results of the case-control study and this literature review, it is important that changes are made to prenatal care in order to enable midwives to better identify women who are struggling with abstinence or who resume smoking during pregnancy. Implications for practice: midwives should discuss and monitor smoking status with women at every prenatal visit. If a midwife finds that a woman has relapsed into smoking, they can be offered a range of quit smoking intervention strategies, including referral to a dedicated cessation service, counselling support, alternative therapies and, perhaps, nicotine replacement therapy. Further research aimed at identifying the extent of relapse among these women and the impact this may have on pregnancy outcome is warranted. Research to ascertain the most appropriate interventions to prevent relapse is also needed. Refereed/Peer-reviewed

Aims. To improve nutritional care and the mealtime experience of older people in a residential aged care setting by assisting nurses to create change to their practice and to the mealtime environment. Background. Despite being preventable and treatable, inadequate nutrition remains a problem for many older people in residential aged care and tertiary health care settings. Nevertheless, many organisations are uniquely positioned to implement solutions that will lead to better care. Design. The study used a qualitative, action research approach, grounded in the participatory worldview. Methods. The multimethod approach of data and between-method triangulation were chosen to assist in understanding the multidimensional issues associated with resident mealtimes and the provision of nutritional care. The collection of non-participant observations was informed by aspects of the Developmental Research Sequence. Action group meetings and non-participant observations were qualitatively analysed using the Analytic Hierarchy. Results. Protected Mealtimes was tailored for the residential aged care unit. The most significant change involved the transformation of system processes by creating the space in nurses’ busy schedules and thus reclaiming time for nurses to reconnect with nutritional care. Fixed role boundaries were made flexible by assisting individuals to understand and extend their roles in nutritional care. Most importantly, sustainability of Protected Mealtimes was achieved and long-term changes around nutritional care continued to be resident focused. Conclusions. This study demonstrates that lasting changes to nursing practice in nutritional care can be achieved by applying the principles of a participatory worldview and action research. Relevance to clinical practice. Change is challenging to achieve in complex health care organisations. This study bridges the gap between theory and practice and has shown that nurses can create change by employing a participatory worldview and action research as part of their toolkit for problem solving.

There are increased opportunities for online delivery innovation within the education sector because of rapid advances in Internet technology. This paper describes a unique and efficient approach to simulation called ‘scenariation’. The scenariation project aimed to establish efficient processes for the development of scenariation content and evaluate the use of a specific scenariation nurse education module. Students were presented with video simulating the workplace and then prompted to make clinical decisions such as selecting treatment options. The scenariation approach was implemented with a group of 380 1st-year nursing students and evaluated using multifaceted online evaluation. The results of this qualitative evaluation highlight not just the potential of scenariation but also some of the difficulties associated with online delivery to large and diverse student groups. Students valued the relevance to practice and interactive nature of scenariation, but some reported technical difficulties. The paper concludes by extending the discussion of scenariation to the areas of inter-professional learning and the integration of scenariation with face-to-face high fidelity simulation.

Aims and objectives: The aim of this study was to determine whether there is a relationship between placental position and stillbirth with the objective of establishing if placental position impacted on stillbirth risk. Background: Whilst there has been extensive research on low placental implantation because of the importance of detecting placenta praevia, little research has been undertaken on other aspects of placental position and possible impact on pregnancy outcome. Design: A matched case‐control study of stillbirth and placental position was conducted using case‐notes from two tertiary obstetric referral centres. Methods: Notes were retrospectively examined and Placental position as documented in the case‐notes at the routine mid‐trimester (20 week) ultrasound was identified. Placental position for a total of 124 pregnancies culminating in stillbirth was compared with placental position in 243 (matched) pregnancies resulting in a live born baby. Results: Women who had a posterior located placenta were statistically more likely to suffer a stillbirth than women who had a placenta in any other position OR 1·64 (95%CI 1·02–2·65 p = 0·04). Conclusion: Posterior located placenta may be a contributory risk factor for stillbirth. Further research is warranted. Implications for practice: Nurses and midwives should be aware of this potential risk factor to monitor foetal well‐being closely. Refereed/Peer-reviewed

Purpose: This study examined the experiences of postnatal depression between a group of Chinese and Caucasian women. Design & methods: This was a secondary analysis of two phenomenological studies. Thirty-five Chinese women and 12 Australian women were interviewed. Findings: Women felt being trapped in the depression. The Hong Kong women attributed their depression to their mothers-in-law and husbands, and expressed much anger. The Australian women attributed their depression to not being able to live up to the ideal mother image, and felt guilty. Practice implications: Interventions were recommended with consideration for the cultural values that influenced women's experiences of postnatal depression. Refereed/Peer-reviewed

Aim. This paper describes the findings of a descriptive study about what nurses do to ensure that older people with dementia have adequate hydration.Background. Frail nursing home residents, particularly those who cannot accurately communicate their thirst as a result of Alzheimer's disease and who depend on nursing staff for their fluid intake, are at risk of dehydration. While the interventions that promote nutrition in older people with dementia are documented, the specific interventions for improving oral hydration in older people with dementia remain poorly studied and understood.Design. Observational study.Methods. Ten care workers and seven residents were observed for the types of behavioural nursing interventions and assistance provided to residents when promoting oral fluid intake. Observational data were compared with resident-care plans to determine whether what was carried out by care workers was consistent with what was being documented.Results. Care workers provided a wide variety of behavioural interventions to the residents when promoting oral fluid intake. The resident-care plans did not sufficiently represent the specific interventions implemented by care workers.Conclusions. A more rigorous approach is required in defining the specific behavioural interactions practised by care workers, which promote oral fluid intake in older people with dementia. Nurses determined the content of care documented in care plans, yet they were not the predominant implementers of that care. Care plans need to be accurate in terms of the specific nursing actions that respond to the level of assistance required by the resident, both behaviourally and physically.Relevance to clinical practice. Sound knowledge and reflective practices should be implemented by care workers of the nursing interventions that promote adequate oral fluid intake. Care plans should serve a dual purpose and facilitate communication between staff members and provide sufficient flexibility to allow for the contribution of novel ways in which to promote oral fluid intake while also being educative.

We evaluated whether a collar-worn pounce protector, the CatBib™, reduces the number of vertebrates caught by pet cats and whether its effectiveness was influenced by colour or adding a bell. Fifty-six cats identified as hunters were studied in Perth, Australia over six weeks in November/December 2005 (southern hemisphere spring/summer). Cats spent three weeks wearing a device and three weeks without it and we recorded the number of prey brought home during each period. Cats caught 65 birds (13 species), 67 herpetofauna (11 species) and 164 mammals (five species). Alone or together with bells CatBibs stopped 81% of cats from catching birds, 33% from catching herpetofauna and 45% from catching mammals. Cats wearing CatBibs or CatBibs and bells caught only 25% of all birds, 43% of all herpetofauna and 36% of all mammals captured. Both colours were equally effective. Adding bells conferred no additional protection. Only one cat did not adjust to the CatBib and there was no long-term evidence that CatBibs altered cats’ fighting or wandering behaviour. Owners volunteered because of one or more of: environmental concern (81%), curiosity (38%), personal (35%) or family (24%) distress caused by hunting. Most owners (70%) said they would continue to use CatBibs although only 17% were doing so eight months later because some cats had stopped hunting or lost their CatBibs. Although confinement of pet cats is the complete solution to preventing predation on wildlife, deterrents such as the CatBib are effective if used consistently.

Despite being preventable and treatable, undernutrition remains a problem for many older people in tertiary healthcare settings. Nurses have a crucial role in assisting people who are unable to eat independently and are uniquely positioned to implement solutions that will lead to better nutritional care. However, what is known about the management of undernutrition is not informing nursing practice. This study used action research, underpinned by the ‘participatory world view’, to address the theory-practice gap. Data and between-method triangulation were used to collect and analyse qualitative non-participant observations and action research group data. Set Up Ready For Dining (SURFD) was developed and implemented by nurses to improve patient mealtimes. Findings show that nursing practice in nutritional care is influenced by technique within the healthcare context that emphasises operational efficiency, and by the choices that nurses made around being the patient advocate during mealtimes. Refereed/Peer-reviewed

Understanding the evolution of nursing in a country provides perspective on the origins of current successes and dilemmas and enables the development of strategies and plans for future trends in the profession. This article explores the evolution of nursing services and education in Sri Lanka and the effects on developing professionalism in nursing. Internet database searches, personal communication, and published and unpublished literature and reports were reviewed to obtain historical information on nursing services and education in Sri Lanka. The Sri Lankan health system is reviewed, and the establishment of Western medicine in Sri Lanka and its effects on developing institutionalized nursing education is presented, with a focus on the evolution of nursing education. Major challenges for the nursing profession in Sri Lanka are discussed, and some recommendations are shared. AUTHORS Received: February 27, 2005 Accepted: June 30, 2005 Mr. Jayasekara is a PhD candidate, Discipline of Nursing, The University of Adelaide, and Dr. McCutcheon is Head and Professor of Nursing, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia. Address correspondence to Rasika S. Jayasekara, MNSc, RN, Eleanor Harrold Building, Level 3, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia 5005; e-mail: rasika.jayasekara@adelaide.edu.au.

Objectives The objective of this review was to appraise and synthesise the best available evidence on the effectiveness and appropriateness of undergraduate nursing curricula. Inclusion criteria This review considered research papers that addressed the effectiveness and appropriateness of undergraduate nursing curricula. Studies of higher evidence levels were given priority over lower-evidence studies. Participants of interest were undergraduate nursing students, nursing staff and healthcare consumers. Nursing staff outcomes, consumer outcomes and system outcomes (e.g. competency, satisfaction, critical thinking skills, healthcare consumer rights and cost-effectiveness) that impact on the evaluation of undergraduate nursing curricula were considered in the review. Search strategy The search strategy sought to find both published and unpublished studies and reports limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of the text contained in the title and abstract, and of the index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms. Finally, the reference list of all identified reports and articles was searched for additional studies. Methodological quality Each paper was assessed by two independent reviewers for methodological quality before inclusion in the review using an appropriate critical appraisal instrument from the Unified Management, Assessment and Review of Information (SUMARI) package. Results A total of 16 papers, experimental and textual in nature, were included in the review. The majority of papers was descriptive and examined the relationships between nursing curricula and specific learning outcomes such as critical thinking skills. Because of the diverse nature of these papers, meta-analysis of the results was not possible and this section of the review is presented in narrative form. In this review, four undergraduate nursing curriculum models were identified: integrated curriculum, subject-centred curriculum, problem-based learning, and an integrated critical thinking model. It was possible to examine the effectiveness of an integrated curriculum model and a subject-centred curriculum model; however, the other two models could not be compared because of a lack of evidence. Conclusion The evidence regarding the effectiveness and appropriateness of undergraduate nursing curricula is notably weak because of the paucity of high-quality comparative studies and meaningful outcome measures of available studies. Therefore, no strong conclusion can be made regarding the effectiveness and appropriateness of undergraduate nursing curricula.

The print and other forms of media offer significant amounts of information to women about pregnancy, parenthood and the birth process, but much less information exists about postnatal depression and how to cope with the frequently painful realities involved in childbirth and parenting--especially when debilitated by postnatal depression (PND). Even less information exists about such women's reactions to interventions by health professionals, which is the subject of my Ph.D study in progress. This article reviews current literature about the clinical presentation of postnatal depression, the three major types of mood disorders following childbirth, the risk factors for postnatal depression, detection and treatment of postnatal depression and the need for further research on treatment outcomes for women with PND.

The assessment of pain in a person with an intellectual disability (ID) is often a difficult undertaking complicated by idiosyncratic reactions or vague descriptions. The person with an ID may also be unable to verbally communicate their discomfort. For the carer who knows the individual with an ID, knowing how they respond to painful stimuli assists the carer to detect new instances of pain. The emergency nurse is unlikely to have met the person with an ID and therefore detecting pain by observing behaviour or using self-report measures is unlikely to succeed. There have been some attempts to categorize behavioural responses to pain by people with an ID, however, they have not been developed into a useful assessment tool. Emergency nurses must therefore rely on the person who knows the person with an ID.

Violence in the emergency department (ED) is a significant problem world wide. Psychiatric and emergency settings are widely considered as high-risk areas, with the incidence of nurses' exposure to violence ranging from 60% to 90%. Besides the impact on the health professionals, violence also directly and indirectly affects the quality of patient care and satisfaction of patients. Inevitably, it also contributes to an escalation of health care costs. Understanding the nature of violence in the ED, its risk factors (patient, staff, situational and interaction factors) and the perceptions of health professionals is an important step towards minimising this problem. Knowledge about the theories of violence and the culture that contributes to violence is also critical to the development of effective long-term violence management strategies for the ED. However, a review of the literature about violence in the ED has revealed many gaps in the research such as the potential for identifying the indicators of violence at triage, over reliance on the reactive and coercive traditional violent management strategies, and the paucity of perception from patient perspective pertaining to this problem. This paper provides a descriptive review of the contemporary research in this area and identifies gaps in the research.

Objectives Research was conducted in two teaching hospitals in Australia to collect data on the care of patients dying in the acute care setting. Methodology Non-participant observation of the care of dying patients in medical wards was the primary method of data collection and selected staff were interviewed. Observers collected data on the type of care, who gave the care, and the time given to care. Thematic analysis was applied to both the observational and interview data. Participants Patients selected were over the age of 18 years, with a terminal diagnosis and an estimated six days to live. Results Three major factors emerged from the data to form the context in which patients were cared for and died: 1) the organizational factor, 2) the environmental factor, and 3) the human factor. The presence or absence of family members influenced the amount of care given. If family members were not present, dying could be an isolating experience, with minimal care focused on routine hospital activities. Conclusion This research indicated that the principles of palliative care are yet to be incorporated in the acute care hospital setting.

There has been a tremendous growth in day surgery units to meet the demand for cost-effective healthcare. As a result of increased outpatient use of these units, procedures for administrative and clinical management have been developed. The effectiveness of the use of these protocols, however, has not been tested. This article reports on a study that examined nurses' compliance with a protocol for postprocedural vital signs measurement in a gastrointestinal day unit. The protocol's effectiveness in detecting postprocedure complications and the resource implications of the protocol were examined. The rate and type of postprocedure complications detected are also reported. Analysis of the observation data suggests staff are undertaking observations according to the protocol for most patients. Some patients appear, however, to be having their observations done outside the time frame recommended by the protocol. It is possible that staff are exercising their clinical judgement and continuing observations on some patients, though this is speculation and requires further research. Findings from the study raise questions regarding whether postprocedure monitoring is resource efficient.

Many nurses have a desire to travel and work overseas for both long- and short-term periods. Some may continue postgraduate study, while others may simply wish to gain experience working in another country. Depending on the country where the nurse wishes to travel and work, the process of having qualifications assessed may be quite different, usually difficult and time consuming. There are several models of assessment currently used in various countries; from examinations for all to qualification comparability, the range is diverse. These models are very relevant given that the profession has experienced a global shortage of nurses that is unlikely to improve with the current work force predictions. Reasons for the shortages range from an aging nursing population to the profession's inability to attract young people. This has lead some countries to entice nurses from other countries to lessen their shortages. This paper discusses the issues in relation to the assessment of overseas qualified nurses applying to migrate or seek employment in Australia. Some of the issues highlighted are English language assessment, qualification assessment, competency assessment, timeliness, cost and equity. Assessment models from the global market and the impact these models have on attracting nurses to Australia are discussed.

This study, building on work on irritable bowel syndrome conducted by Letson and Dancey (1996), explores Taiwanese nurses' knowledge, perceptions and beliefs about caring for patients with irritable bowel syndrome (IBS). A 46-item questionnaire was completed voluntarily by 120 registered nurses from a large tertiary acute care facility in Taiwan. The study used a descriptive research design and a questionnaire was developed that used a five-point Likert scale (strongly agree = 5, to strongly disagree = 1). The questionnaire consisted of six categories: demographic information; nurses' sources of IBS information; nurses' knowledge about IBS; nurses' perceptions about patients with IBS; nurses' beliefs about IBS; and learning requirements for nurses. Overall, the results indicted that Taiwanese nurses who participated in this study had little specific knowledge of IBS. The researchers developed a booklet containing information on the condition of IBS that may be used by the participants in this study to fill the knowledge gaps about this condition and provide useful information.

This paper concentrates on the specific impact that living in rural Australia has on the experience of chronic illness, and draws on data collected in a larger phenomenological study. Eighteen rural Australians in New South Wales described their experiences and referred particularly to issues that related to their rural context. A secondary analysis of the data revealed three sub-themes related to the concept of rural, choice of doctor, travelling and life style. The shortfalls in service identified by these participants deserves further investigation and could become fertile ground for an expanded nursing service.

Intuition: an important tool in the practice of nursing Aim. The aim of the study reported here was to evaluate the role of intuition, to examine nurses’ understanding of intuition and their perceptions of their use of intuition, and to assess the impact of intuition on nursing practice. Background. When we read the dictionary definition of intuition, we have a sense of the meaning but there is also a sense of something still not quite defined. Yet we instinctively know what intuition is. That is, of course, an example of intuition in itself: an understanding of the concept based on our feelings, knowledge and experience. Intuition is a concept neither clearly articulated nor adequately theorized in nursing. There is evidence to suggest that practising nurses use intuition and that its use can change outcomes for patients. Because of its influence on patient well being, it needs to be recognized as an important tool in the practice of nursing. The very nature of intuition determines that there will be little agreement on a precise definition and little empirical evidence to support its existence or worth. Neither of these issues detracts from the fact that intuition is an important part of nursing. Methods. Grounded theory was used as the overarching theoretical and methodological framework for this study. Using focus group interviews and the Delphi survey technique, data were collected from 262 Registered Nurses who volunteered to take part in the study. Findings. The theory that emerged from this study provides nurses with a way of articulating their understanding of intuition and their perceptions of its use in nursing practice. Conclusions. Intuition is not some mystical power that appears from nowhere, with no rational explanation or basis. The findings from this study show that it is a product of the synergy that occurs as a result of the interaction of a number of factors.

Aim: To explore the similarities and differences in the nursing practice in nutritional care between a residential aged care setting and a hospital setting. Background: Despite being preventable and treatable, undernutrition remains a problem for many older people in residential aged care and hospital settings. Nurses have a crucial role in assisting people who are unable to eat independently and are uniquely positioned to implement solutions that will lead to better nutritional care. Design: During 2007-2010, an action research study was conducted, underpinned by the principles of the participatory world view to address undernutrition in a residential aged care setting and a hospital setting. Methods: The multimethod approach of data and between-method triangulation were used to collect and analyse qualitative non-participant observations and action research group data. Non-participant observations and action research group data were qualitatively analysed using the Analytic Hierarchy. Findings: How nurses chose to participate in the provision of nutritional care and assert their autonomy when changing practice to nutritional care affected the quality of the resident/patient mealtime experience. Operational efficiency influenced the choices that nurses made about the type of intervention to implement to improve nursing practice in nutritional care. Nurses required management approval to change practice in nutritional care. Conclusion: The reasons for undernutrition are multifactorial and more research is needed to investigate the organizational structures and processes that affect the delivery of nutritional care across role functions, how these affect the continuity of care and the nurses' role in defining the culture around resident/patient mealtimes. Refereed/Peer-reviewed

Background: Intravenous antibiotics are the cornerstone of treatment for patients with cystic fibrosis (CF). Midlines are a type of vascular access device (VAD) used exclusively in one treatment facility within Australia, most other centres use peripherally inserted central catheters (PICCs). Conclusions: Midlines may be an alternative to PICCs for adult CF patients although further research is required with a larger sample size to enable definitive conclusions. Design: Retrospective observational. Methods: Medical records and hospital reports were used to record rates of adverse events and unexpected removal of VADs. The primary outcome was a composite measure of adverse events (catheter-related blood stream infection, deep vein thrombosis, occlusion, pain, infiltration, bleeding, phlebitis, catheter leakage and dislodgement) and whether the VAD was removed unexpectedly. Objective: To ascertain the safety and efficacy of midlines for CF patients receiving intravenous antibiotics. Participants: Adult patients with a diagnosis of CF, who had a PICC or midline inserted for the commencement of antibiotic therapy during the period 2004-2010 to treat a respiratory exacerbation. Results: There were 231 midlines and 97 PICCs inserted into 64 patients (39 male and 25 female; age range 18-47 years old). Presented as per 1000 VAD days, patients with PICCs and midlines had similar rates of adverse events (14 and 11 adverse events per 1000 VAD days, respectively). Unexpected removal was higher for patients with midlines (6.90 per 1000 VAD days) than for PICCs (2.89 per 1000 VAD days). Incident rate ratios (IRRs) showed that patients with midlines and PICCs had similar rates of adverse events (IRR 1.18, P = 0.617, CI 0.62-2.22) although the removal rate of patients with midlines was twice that of patients with PICCs (IRR 2.24, P = 0.079, CI 0.91-5.56). As an absolute risk there were only 4.09 more cases of removal for patients with midlines per 1000 VAD days than those with PICCs. Setting: A large, major metropolitan teaching hospital in Adelaide, South Australia. Refereed/Peer-reviewed

Summary Introduction Evaluating and improving a model of nursing care is a fundamental part of clinical practice improvement. While Australian nurses are showing increasing interest in improving models of care delivery, more research is needed that addresses and articulates the processes attendant upon evaluating, re-designing and implementing improvements to the provision of nursing care. Providing nurses with an open opportunity to plan, act, observe and reflect on their practice promotes successful partnerships between academics and clinicians. Aim The aim of this study was to evaluate and improve the model of nursing care delivery to patients in a general surgical ward using participatory action research. Method Researchers conducted non-participant observations ( n = 9) of two hours duration across the 24 h period. Focus groups ( n = 3) were used to share non-participant observation data with staff, providing them with an opportunity to reflect on their practice and explore possible solutions. Data was collected in 2008–2009. Results Two main problem areas were identified as impeding the nurses’ ability to provide care to patients: (i) practices and behaviours of nurses and (ii) infrastructure and physical layout of the ward. An overview of issues within each problem area is presented. Conclusion Shifting the focus of task-centred care towards a more patient-centred care approach, results directly in improvements in resource utilisation, improved cost-effectiveness and job satisfaction for nursing staff. New ways of thinking about nursing processes and systems, workflow design and skill allocation will guide hospital administrators and managers in the effective and efficient allocation of nursing work in similar settings.

To improve nutritional care and the mealtime experience of older people in a residential aged care setting by assisting nurses to create change to their practice and to the mealtime environment.Despite being preventable and treatable, inadequate nutrition remains a problem for many older people in residential aged care and tertiary health care settings. Nevertheless, many organisations are uniquely positioned to implement solutions that will lead to better care.The study used a qualitative, action research approach, grounded in the participatory worldview.The multimethod approach of data and between-method triangulation were chosen to assist in understanding the multidimensional issues associated with resident mealtimes and the provision of nutritional care. The collection of non-participant observations was informed by aspects of the Developmental Research Sequence. Action group meetings and non-participant observations were qualitatively analysed using the Analytic Hierarchy.Protected Mealtimes was tailored for the residential aged care unit. The most significant change involved the transformation of system processes by creating the space in nurses' busy schedules and thus reclaiming time for nurses to reconnect with nutritional care. Fixed role boundaries were made flexible by assisting individuals to understand and extend their roles in nutritional care. Most importantly, sustainability of Protected Mealtimes was achieved and long-term changes around nutritional care continued to be resident focused.This study demonstrates that lasting changes to nursing practice in nutritional care can be achieved by applying the principles of a participatory worldview and action research.CHANGE is challenging to achieve in complex health care organisations. This study bridges the gap between theory and practice and has shown that nurses can create change by employing a participatory worldview and action research as part of their toolkit for problem solving.

Midline catheters have many advantages for chronically ill patients needing up to six weeks intravenous therapy and medications, and when inserted in a sterile environment and correctly monitored and maintained, have a significantly lower association of infection and thrombus than previously suggested. Furthermore, there is a reduction in central collateral vessel formation from incursions into the superior vena cava, associated with peripherally inserted central catheters. Midline use was examined in a cystic fibrosis control group. Lines were checked daily until removal. All midline catheter tips were sent for culture on removal and data from 42 midlines placed in 2006 were retrieved from the hospital scientist for analysis. Twenty-seven inpatients with cystic fibrosis were identified and informed of the trial and possible risks of midline use. Outcome variables included infection and thrombus rates. On conclusion of the trial, data demonstrated both zero infection and thrombus rates in the study patient population. Midline catheters were monitored for a further 12 months following conclusion of the trial and infection rates continued to be below 1% and thrombus rates lower than 2%. In the specified group, the parameters of use for midlines fit with international cystic fibrosis intravenous antibiotic protocols currently adhered to. The study has begun to generate evidence to inform clinical practice, improve patient outcomes and supports the role of the specialist nurse in implementing midlines for cystic fibrosis patients. Refereed/Peer-reviewed

Mental heath nurses recognise the importance of professional boundaries and therapeutic relationships and understand that clinical supervision is an important component to good clinical practice and their ongoing professional development. This qualitative constructivist grounded theory research has uncovered a potential risk in contemporary mental health clinical practice, where the desire for expedient answers may compromise the outcome of formal structured supervision. The notion of a new concept ‘superficial supervision’ and its implications for formal structured supervision are explored.

Design: An exploratory qualitative study. Findings: the parents described a 'paradoxical' parenting style where they were trying to parent using two diametrically opposed unsustainable options. For example, they described trying to hold their subsequent child emotionally close but aloof at the same time. Key conclusions and implications for practice: The results from this study indicate that the impact of a loss of an infant has far-reaching consequences on subsequent parenting. Support and early intervention at the time of the stillbirth and subsequent pregnancy are likely to be useful. However, further research is required to determine the extent to which early intervention can alter the tendency towards bereaved parents adopting a paradoxical parenting style. The impact of this style on mental health and the emotional health and well-being of the next born child/ren after perinatal loss should also be further examined. Objective: To gain an in-depth understanding of the parenting experiences of bereaved parents in the years following an infant death. Participants: A purposive sample of 13 bereaved parents (10 mothers and three fathers) was used. Parents who had accessed the support services offered by two bereavement support agencies were recruited. Participants were asked to describe their experiences of raising their subsequent child. Interviews were conducted when the next born child was at least three years of age. Setting: Semi-structured interview in the participants' homes. Data were collected over a five-month period in 2008 and analysed using thematic analysis. Refereed/Peer-reviewed

An immense body of literature on the effects of hypertension on perinatal morbidity and mortality exists, but only a handful of studies have reported adverse outcomes associated with low maternal blood pressure during pregnancy. This study aimed to investigate if there is an increased risk of fetal loss associated with hypotension during pregnancy. A matched case-control study of stillbirth and maternal blood pressure was conducted in which maternal blood pressures for a total of 124 pregnancies culminating in stillbirth were compared with maternal blood pressures in 243 (matched) pregnancies resulting in a liveborn infant. Women whose diastolic blood pressures fell in a borderline range (60 to 70 mm Hg) were consistently at greater risk of stillbirth relative to normotensive pregnancies. Women who had three or more mean arterial pressure valuesor = 83 mm Hg during the course of their pregnancy were at nearly twice the risk of stillbirth (odds ratio 1.78; 95% confidence interval [CI] 1.06 to 2.99; P = 0.03). Systolic hypotension was not significantly associated with stillbirth, but proportionately more control women were noted to have systolic hypertension (SBPor = 130 mmHg) than cases, and the adjusted odds of stillbirth in women who were hypertensive at either their first or last antenatal visit or whose antenatal average SBP wasor = 130 mm Hg were all very close to 0.4 (95% CI 0.37 to 0.43; P = 0.02 to 0.03) relative to normotensives. We concluded that maternal hypotension, particularly borderline hypotension, may be a contributory risk factor for stillbirth. Women with hypertension in pregnancy may now be at a decreased risk of stillbirth as a result of the close care and treatment they receive.

Aim. This paper describes the findings of a descriptive study about what nurses do at mealtimes in relation to monitoring/assisting the eating practices of older patients in an acute care facility.Background. The prevalence of under nutrition is known to be high in hospitalized older patients and insufficient dietary intake is regarded as a major cause. However, most of the research tends to concentrate on the nursing home setting. Little is known about the situation in acute care facilities.Methods. Two medical wards participated in the study. Ward 1 had introduced a change of nurses' meal break time and ward 2 continued with normal practice. Convenience sampling was used. Fifty nurses and 48 patients were observed at different mealtimes during two weeks. Four nurses and four patients who were observed were also interviewed. Data were analysed using descriptive statistics and thematic analysis.Results. Kitchen staff delivered all meals and collected the majority of the meal trays. Older patients did not receive enough assistance during mealtimes. Interruptions happened frequently and social interaction was neglected. About one-third of patients observed left more than two-third of their meals.Conclusion. Nutrition issues appeared to receive less priority in the ward than other nursing care activities and nurses' assistance was generally insufficient and not provided in a timely manner.Relevance to clinical practice. Findings highlight the deficiency in practice that should suggest to nurses that they examine their practice and put into place strategies to ensure older patients are properly/adequately hydrated and receive sufficient nutrient intake.

Evidenced-based nursing is seen as the future of nursing but the real world in which practice occurs is limiting the possibilities for change. The practice of post-operative (PO) vital sign collection in the general ward setting is described as an example of the complexities that surround practice. Despite the ongoing work around evidenced-based practice, elements of nursing practice remain based on tradition. Routines and rituals are driving care rather than clinical judgement. The complexities of practice limit the possibilities for change. These complexities include the systems in which nurses' practice, the fear of medico-legal repercussions, and the sense of security that rituals provide. This paper discusses these themes including the barriers to change and the implications for practice. The development of evidenced-based practice is only one component of the solution to the provision of best practice. Care is required to ensure that the evidenced-based movement does not lead to recipe book care rather than patient centred practice.

The purpose of this study was to explore the memories of patients who had a short-term admission to the ICU, with a particular focus on dreams, nightmares and confusion. Descriptive data were collected from a target sample of 50 participants, by means of a questionnaire. Following this, eight patients who had completed and returned the questionnaire and had reported hallucinations, dreams or confusion participated in open-ended, semi-structured interviews. Analysis of the data generated by the questionnaire revealed that the most common memories of ICU were anxiety, pain, thirst and nausea. Nightmares, hallucinations and confusion were also common and were reported to be highly distressing. The transcribed interviews were subjected to a thematic analysis. The themes that emerged were, reality and unreality, blackness and colour, powerlessness and purpose, and death. Participants described horrifying paranoid delusions. It is proposed that constant reassurance and explaining every day ICU happenings may assist patients to understand what they are experiencing and loved ones may provide an important link with reality.

Patient surveillance during the postoperative period has traditionally consisted of the collection of routine and regulated vital signs, supported by observations of other aspects of a patient's recovery. The purpose of this research was to determine if the frequent collection of postoperative vital signs assisted in detecting postoperative complications in the first 24 hours after a patient has returned to the ward setting. The study involved: (1) a survey of policy documents; (2) observations of postoperative nursing care; and (3) an audit of medical records. Major findings revealed that vital signs are collected based on tradition and are collected routinely, and there may not be a relationship between vital-signs collection and the occurrence or detection of complications.

Background. Traditionally, the purpose of routine postoperative surveillance has been to detect postoperative complications. The literature reports well-documented, procedure-specific postoperative complication rates. However, there are no reports detailing the prevalence of postoperative complications in general surgical ward settings, where nurses care for patients following a variety of surgical procedures.Aims. This paper reports an audit of the frequency and type of postoperative complications in a general surgical population occurring in the first 24 hours postoperatively.Methods. A patient record audit was undertaken for all postoperative patients who returned to two general surgical wards. This was conducted sequentially, involving a 4 week data collection phase in each participating ward during 2001.Results. The audit sample comprised 144 patient records with an average patient age of 54 years. Statistically significant results included the rate of postoperative nausea and vomiting of 37.5% (n = 54), and 17% (n = 25) of patients experiencing another 'clinical event'.Limitations. The findings reflect only those complications recorded/documented in postoperative patients' records, and cannot be generalized beyond the sample and setting.Conclusions. Postoperative patients cared for on general surgical wards experienced a high level of nausea and vomiting, while the occurrence of life-threatening complications was small.

Evidence-based nursing is the current fashion. It is being touted as the mechanism to achieve best practice in the clinical setting. But while evidence-based practice (EBP) is being presented in the literature, discussed at nursing practice forums, and evidence-based centres of excellence have developed, there seems to be very little impact in the practice that nurses deliver on a daily basis. The case in point is the collection of vital signs. While not historically a nursing skill, over the last 60 years it has become an integral component of practice in the postoperative general surgical setting. The evidence to support these practices is scant. Policies and text purport traditional routine-regulated practice without substantive evidence to support their claims. These policies are being used to control rather than support EBP. In conjunction with the traditional practice of vital sign collection and the culture of the clinical settings, the policies are limiting opportunities for clinicians to make individual decisions about care delivery based on the unique needs of each patient. Rather than focusing on EBP as the solution to the development of best practice, is it not time to change the focus to real strategies that will assist in achieving best practice? These include the creation of rigorous relevant evidence, the valuing of clinical expertise and the changing of the cultures in which nurses develop and practice.