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Background It is essential to evaluate the ways in which practice changes are implemented and received in and across contexts, identifying barriers and enablers, and mechanisms for enhancing success. Aim To provide insights into the experiences of clinicians in implementing a multifaceted bundled urinary catheter care intervention in four acute care hospitals in New South Wales, Australia. Methods The catheter care bundle was implemented using a pre- and postintervention study design. The intervention was implemented in all adult inpatient wards, emergency departments and operating theatres of four hospitals. The bundle consisted of an integrated set of evidence-based practices to assist clinicians in making better informed decisions related to catheter insertion, care and removal practices. Focus groups at each participating hospital evaluated the implementation processes from the clinicians' perspective, identifying barriers and enablers to successful implementation. Results Eight focus groups were held with 35 participants. Four key inter-related themes were identified: early and sustained engagement with key stakeholders; good planning but remaining flexible; managing the burden of practice change; and adopting and sustaining practice change. These themes capture and highlight the complexity and the challenges associated with implementation of the practice change across contexts and the project timeline. Conclusion It is imperative to understand the challenges associated with complex practice change and ways in which implementation can be optimised. This study identified barriers and enablers experienced by staff implementing the bundled intervention. The themes encapsulate factors central to success of practice change within the complex, multilayered healthcare environment. Relevance to clinical practice Key challenges highlight the need for forward planning, strategic engagement of key players, continuing monitoring and feedback together with adequate resourcing tailored to result in sustainable normalisation of the intervention over time. The COREQ checklist for qualitative studies has been used in reporting this study.

Empathy in healthcare benefits patients and healthcare providers. However, empathy decline is a recent trend within healthcare education. There is a paucity of literature that investigates the impact of volunteering on the empathy levels of undergraduate healthcare students. This scoping review explores the literature regarding empathy and volunteering for healthcare students.The Joanna Briggs Institute methodology for scoping reviews guided this study.The electronic databases MEDLINE, CINAHL, ProQuest, JBI, Cochrane, PubMed, PsychInfo, and PsychNurses were searched from January 2001 to August 2021. The original search was developed in MEDLINE and then adapted to the other databases.This scoping review used the Joanna Briggs Institute scoping review methodology. The search retrieved a total of 310 articles. Following deduplication, 271 articles were reviewed by title and abstract. Thirty articles were reviewed in full text with twelve articles meeting the criteria for inclusion. Included studies were assessed using the Mixed Methods Appraisal Tool (MMAT).Five qualitative, four quantitative and three mixed method studies were included. A variety of volunteering interventions for undergraduate healthcare students were identified from countries including the United States of America, Singapore, Australia, and Brazil. Thematic analysis identified that volunteer undergraduate healthcare students practiced and developed empathy, and experienced professional and personal development.Volunteering interventions were primarily in a service-learning modality within community health and palliative healthcare settings. Inconsistencies exist in empathy definitions and empirical empathy measurement. There is a need for more research that explores empathy development through volunteer activities in acute care settings.

Aims and objectives To identify the point prevalence of indwelling urinary catheters (IDCs) in adult inpatients in acute care hospitals, and to describe the indications for IDC insertion based on patient age, gender, specialty and hospital. Background Catheter-associated urinary tract infections (CAUTIs) are preventable healthcare-associated infections. IDC duration is the strongest predictor of CAUTI, and little is known about characteristics of patients who receive an IDC. Design Two single-day point prevalence surveys collected baseline patient data as part of a larger pre-post control-intervention study. Methods Surveys were conducted at four acute care hospitals in NSW, Australia, for all adult patients. Data collection included IDC presence, insertion details and urine culture collection. Point prevalence data were linked with electronically extracted patient demographic data. This study is presented in line with STROBE checklist (See Supplementary File 1). Result Data from 1,630 patients were analysed, with 196 patients (12%) identified as having an IDC on the survey dates. IDC prevalence rates were higher in males (13%) than in females (11%). Critical care had the highest rate of patients with IDCs (42%). Urine cultures were collected in 70 patients with an IDC (43%). Conclusions Findings indicated similar rates of IDC use in males and females, and there was no significant difference in age between patients with or without an IDC. However, indication for IDC varied by patient age and gender. High rates of urine culture collection may represent routine collection. Relevance to clinical practice IDC use is found across genders, all age groups and specialties. Nurses should be aware that any of their patients may have an IDC and be particularly aware of certain indications based on patient age and gender. Routine urine culture collection is not advised, and instead, nurses should be guided by clinical decision-making tools.

To provide information about the effectiveness of topical analgesic and local anesthetic agents for reducing pain associated with chronic leg ulcers.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After participating in this educational activity, the participant will:1. Distinguish adverse reactions to topical analgesics and local anesthetic agents.2. Evaluate the effectiveness of topical analgesics and local anesthetic agents for pain associated with chronic leg ulcers.3. Identify substances used as topical analgesics and local anesthetic agents and the application of those agents.To examine the evidence related to the effectiveness of topical analgesic and topical local anesthetic agents for reducing pain associated with chronic leg ulcers.A systematic search and review of the literature were undertaken using key search terms such as leg ulcers, topical anesthetics, topical analgesics, and pain. Six databases were electronically searched for articles published between January 1990 and August 2019.A total of 23 articles were identified that met the inclusion criteria. Data were extracted using content analysis. Most of the included studies were randomized controlled trials; however, the reported methodology for most of studies was poor, so the validity and reliability of the evidence are uncertain. Lidocaine/prilocaine cream, ibuprofen foam, and morphine gel were the most examined topical agents. Lidocaine/prilocaine cream significantly improved wound-related pain compared with all other studied agents. For topical analgesic agents, ibuprofen foam reduced chronic leg ulcer pain significantly, whereas morphine gel was ineffective.Lidocaine/prilocaine cream and ibuprofen foam are effective agents for reducing wound-related pain associated with chronic leg ulcers. Effective use of topical agents could reduce the need for systemic pain relief agents, mitigating potential adverse effects, while giving clinicians another treatment option to manage wound-related pain associated with chronic leg ulcers.To examine the evidence related to the effectiveness of topical analgesic and topical local anesthetic agents for reducing pain associated with chronic leg ulcers. A systematic search and review of the literature were undertaken using key search terms such as leg ulcers, topical anesthetics, topical analgesics, and pain. Six databases were electronically searched for articles published between January 1990 and August 2019. A total of 23 articles were identified that met the inclusion criteria. Data were extracted using content analysis. Most of the included studies were randomized controlled trials; however, the reported methodology for most of studies was poor, so the validity and reliability of the evidence are uncertain. Lidocaine/prilocaine cream, ibuprofen foam, and morphine gel were the most examined topical agents. Lidocaine/prilocaine cream significantly improved wound-related pain compared with all other studied agents. For topical analgesic agents, ibuprofen foam reduced chronic leg ulcer pain significantly, whereas morphine gel was ineffective. Lidocaine/prilocaine cream and ibuprofen foam are effective agents for reducing wound-related pain associated with chronic leg ulcers. Effective use of topical agents could reduce the need for systemic pain relief agents, mitigating potential adverse effects, while giving clinicians another treatment option to manage wound-related pain associated with chronic leg ulcers.

The Clinical Nurse Consultant (CNC) role emerged in New South Wales, Australia in 1986 as an advanced practice position. There is a growing body of literature seeking to articulate the multifaceted roles and responsibilities of the CNC within the Australian context. In this paper, we present a clinical case report that demonstrates how high risk medication administration errors via newly implemented syringe driver pumps, were identified and managed by a CNC. The CNC role was central in the identification of this series of medication errors that occurred across a number of hospitals, although these incidents could have been dismissed as human error. This report outlines the investigation, incident management process and subsequent release of a NSW state-wide Safety Alert. It also provides a discussion on the three key components for the successful management of a clinical incident investigation: leadership, teamwork and a ‘no blame' culture. The specific role of the CNC in this case report provides evidence that the role of the CNC is pivotal to patient safety.

© 2019 John Wiley & Sons Ltd Aims and objectives: This study aimed to reduce indwelling urinary catheter (IDC) use and duration through implementation of a multifaceted “bundled” care intervention. Background: Indwelling urinary catheters present a risk for patients through the potential development of catheter-associated urinary tract infection (CAUTI), with duration of IDC a key risk factor. Catheter-associated urinary tract infection is considered preventable yet accounts for over a third of all hospital-acquired infections. The most effective CAUTI reduction strategy is to avoid IDC use where ever possible and to remove the IDC as early as appropriate. Design: A cluster-controlled pre- and poststudy at a facility level with a phased intervention implementation approach. Methods: A multifaceted intervention involving a “No CAUTI” catheter care bundle was implemented, in 4 acute-care hospitals, 2 in metropolitan and 2 in rural locations, in New South Wales, Australia. Indwelling urinary catheter point prevalence and duration data were collected at the bedside on 1,630 adult inpatients at preintervention and 1,677 and 1,551 at 4 and 9 months postintervention. This study is presented in line with the StaRI checklist (see Appendix S1). Results: A nonsignificant trend towards reduction in IDC prevalence was identified, from 12% preintervention to 10% of all inpatients at 4 and 9 months. Variability in preintervention IDC prevalence existed across hospitals (8%–16%). Variability in reduction was evident across hospitals at 4 months (between −2% and 4%) and 9 months (between 0%–8%). Hospitals with higher preintervention prevalence showed larger decreases, up to 50% when preintervention prevalence was 16%. Indwelling urinary catheter duration increased as more of the short-term IDC placements were avoided. Conclusions: Implementation of a multifaceted intervention resulted in reduced IDC use in four acute-care hospitals in Australia. This result was not statistically significant but did reflect a positive trend of reduction. There was a significant reduction in short-term IDC use at 9 months postintervention. Relevance to clinical practice: Clinical nurse leaders can effectively implement change strategies that influence patient outcomes. Implementation of the evidence-based “No CAUTI” bundle increased awareness of appropriate indications and provided nurses with the tools to inform decision-making related to insertion and removal of IDCs in acute inpatient settings. Working in partnership with inpatients and the multidisciplinary team is essential in minimising acute-care IDC use.

IntroductionPhysical activity is recommended for improving health among people with common chronic conditions such as obesity, diabetes, hypertension, osteoarthritis and low mood. One approach to promote physical activity is via primary care exercise referral schemes (ERS). However, there is limited support for the effectiveness of ERS for increasing long-term physical activity and additional interventions are needed to help patients overcome barriers to ERS uptake and adherence.This study aims to determine whether augmenting usual ERS with web-based behavioural support, based on the LifeGuide platform, will increase long-term physical activity for patients with chronic physical and mental health conditions, and is cost-effective.Methods and analysisA multicentre parallel two-group randomised controlled trial with 1:1 individual allocation to usual ERS alone (control) or usual ERS plus web-based behavioural support (intervention) with parallel economic and mixed methods process evaluations. Participants are low active adults with obesity, diabetes, hypertension, osteoarthritis or a history of depression, referred to an ERS from primary care in the UK.The primary outcome measure is the number of minutes of moderate-to-vigorous physical activity (MVPA) in ≥10 min bouts measured by accelerometer over 1 week at 12 months.We plan to recruit 413 participants, with 88% power at a two-sided alpha of 5%, assuming 20% attrition, to demonstrate a between-group difference of 36–39 min of MVPA per week at 12 months. An improvement of this magnitude represents an important change in physical activity, particularly for inactive participants with chronic conditions.Ethics and disseminationApproved by North West Preston NHS Research Ethics Committee (15/NW/0347). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals.Results will be disseminated to ERS services, primary healthcare providers and trial participants.Trial registration numberISRCTN15644451; Pre-results.

Purpose The purpose of the study was to gain a better understanding of what severe hypoglycemia means to significant others. Methods Narrative inquiry methodology was utilized. In-depth interviews were conducted with 7 significant others of adults with type 1 diabetes about their experience with severe hypoglycemia. Interviews were recorded, transcribed verbatim, and then developed into narrated core stories through a process of selecting and organizing events and by describing the relationship among these events. This was followed by thematic analysis to reveal the shared narrative of significant others. Results Episodes of severe hypoglycemia were found to turn the participants’ lives upside down. The inability of the individual with diabetes to manage severe hypoglycemia required the significant other to detect and treat these episodes. The theme “managing disruption” captured how the significant others’ role shifted from one of background support to an active, primary role in severe hypoglycemia management. They became (1) the expert by arming themselves with knowledge and skills to assist with the severe hypoglycemia episodes, (2) the sentry by becoming more vigilant and prepared for these episodes, and (3) the protector of the person with diabetes by shielding him or her from the vulnerable position that the severe hypoglycemia episodes placed one in. Conclusions This study highlights the important role that significant others play in the management of severe hypoglycemia. It also emphasizes the need for health care professionals to provide appropriate education and support.

Background The physical, occupational, social and psychological impact of chronic leg ulcers (CLUs) on an individual is considerable. Wound-related pain (WRP), the most common symptom, is frequently reported as moderate to severe and mostly occurs at dressing change. WRP pain may not be alleviated by oral analgesics alone. Persistent poorly controlled leg ulcer pain can negatively impact wound healing and health-related quality of life (HRQoL). Methods A pilot, parallel group, non-blinded, randomised controlled trial was conducted in six procedure clinics located in a public community nursing service in New South Wales, Australia to evaluate eutectic mixture of local anaesthetics (EMLA®) on painful CLUs when used as a primary dressing. The primary objective was to assess feasibility by using pre-determined criteria: at least 80% recruitment rate, 80% retention rate and 80% adherence to the study protocol. Key eligibility criteria were that participants had a painful CLU no larger than 100 cm2, a numerical rating scale (NRS) wound-related pain intensity score equal to or greater than 4, low to moderate exudate, no contraindications to EMLA® and capacity to consent. One hundred and seven patients with painful CLUs were screened for eligibility; 56% (n = 60) were eligible and consented to participate in the study. Participants were randomly assigned to the intervention (n = 30) or control (n = 30) groups. The intervention group received a measured dose of the topical anaesthetic EMLA® 5% cream daily as a primary dressing for 4 weeks followed by usual wound management for a further 8 weeks. The control group received usual wound management. Participants and investigators were not blinded to the treatment. WRP was measured at every dressing change. Wound healing and HRQoL were measured at baseline, 4 and 12 weeks. Results Recruitment rate was lower than expected which likely meant patients were missed. Study retention rate was 90% (n = 54). Intervention fidelity was impacted by availability of resources and patient factors such as increased WRP. Conclusion This study identified that a larger randomised controlled trial investigating EMLA® applied as a primary dressing on painful chronic leg ulcers is feasible with modifications to the study protocol. Trial registration Australian New Zealand Clinical Trials Register: Registered 16 December, 2009

This study aimed to evaluate the effect of EMLA 5% cream applied to painful chronic leg ulcers (CLUs) as a primary dressing on wound healing and health-related quality of life (HRQoL). A pilot, parallel-group, nonblinded, randomized controlled trial was conducted in 6 community nursing procedure clinics in New South Wales, Australia. A total of 60 participants with painful CLUs of varied etiology were randomly assigned to the intervention (EMLA daily for 4 weeks as a primary dressing, followed by usual care) or usual care only. Wound size and HRQoL were measured at baseline, end of the intervention period (week 4), and week 12. At baseline, wound sizes were similar for both the intervention and control groups. During the intervention period, there was no significant difference in wound sizes between groups (intervention group: median (cm2) = 2.4, IQR = 1.3-12.7; control group: median (cm2) = 5.0, IQR = 2.5-9.9; P = .05). Mean HRQoL scores for all subscales at baseline and weeks 4 and 12 were similar between groups except for Wellbeing, which was significantly higher in the intervention group at the end of the 4-week intervention period (intervention group: mean = 52.41, SD = 24.50; control group: mean = 38.15, SD = 21.25; P = .03; d = 0.62). The trial findings suggest that daily applications of EMLA as a primary dressing do not inhibit wound healing and may improve patient well-being. Studies with larger samples are required to more comprehensively evaluate the impact of this treatment on wound healing and HRQoL.

To evaluate the effectiveness of the eutectic mixture of local anesthetics (EMLA; Aspen Pharmacare, St. Leonards, New South Wales, Australia) as a primary dressing on painful chronic leg ulcers.A pilot randomized controlled trial.The study was conducted across 6 community nursing procedure clinics located in a community nursing service in New South Wales, Australia.Sixty participants with painful chronic leg ulcers of varied etiology were recruited into the study.Participants were randomly assigned to an intervention (daily EMLA use for 4 weeks as a primary dressing) or a standard wound care group.The effectiveness of EMLA on wound-related pain intensity before, during, and after dressing change.Mean pain scores were similar between the 2 groups at baseline (P = .84). During dressing change, mean pain scores across the 4-week intervention period were significantly lower in the intervention compared with the control group (intervention group: mean, 3.39 [SD, 2.16]; control group: mean, 4.82 [SD, 2.27]; P = .02). Mean pain scores after dressing change were also significantly lower for the intervention group over the 4-week intervention period (intervention group: mean, 2.71 [SD, 1.94]; control group: mean, 3.92 [SD, 2.03]; P = .03).Data from this pilot study suggest that EMLA as a primary dressing may be effective in reducing chronic leg ulcer pain during and after dressing change and warrant further evaluation.

The Self-Directed Learning Readiness Scale for Nursing Education (SDLRSNE) was initially developed as an alternative to Guglielmino's [Guglielmino, L.M. 1977. Development of the Self-Directed Learning Readiness Scale. Unpublished Doctoral Dissertation, University of Georgia. Dissertation Abstracts International, vol. 38 (11a), p. 6467] Self-Directed Learning Readiness Scale. The aim of this study was to re-examine the factor structure of the subscales of the SDLRSNE and provide evidence of its validity. Data was collected using a cross-sectional survey of 227 first year undergraduate nursing students. To examine the factor structure of the SDLRSNE three one-factor congeneric models, each representing a different subscale, were tested with maximum likelihood confirmatory factor analysis. The model fit indices of the three one-factor congeneric models indicate that the resultant models fit the data well, providing support for the factorial validity of the SDLRSNE. Of the 40 items, 11 items had to be removed from the analyses as they failed to provide good fit with their subscales. Further research investigating the factor validity of the SDLRSNE is encouraged, specifically to examine the stability of the items across factors using multi-factor models.

SUMMARY A report outlining experience gained from the practice of introducing the buttonhole (BH) method of arteriovenous cannulation using the Biohole device, a polycarbonate sterile peg, to form the tunnel tracks. The author's findings are discussed informally and compared with current published literature to provide encouragement to nursing colleagues who are interested in introducing this method of needling, using the peg, into a typically busy haemodialysis unit.

Cannulation, and in particular, skilled cannulation is the cornerstone to preserving the arteriovenous fistula, the lifeline for a patient receiving long-term hemodialysis therapy. The buttonhole cannulation method has seen a huge revival in the 2000s, but it can sometimes prove challenging to implement successfully. This chapter discusses and describes the method of creating a buttonhole tract using the BioHole® device (a sterile polycarbonate peg), and describes the associated advantages and disadvantages. In a busy hemodialysis unit, use of the thumbtack-shaped 5-mm peg allows a fixed puncture route to be created quickly in just 7-14 days. The peg is placed at the site where the sharp puncture needle has just been removed by the designated primary cannulator. The peg remains in place until the next dialysis session when it is removed, the dialysis therapy completed as usual, and a new peg is inserted after hemostasis has been achieved. These steps are repeated for 1-2 weeks. Once the tunnel is formed, use of the peg is no longer needed and a blunt-ended puncture needle is inserted along the track each time. Buttonhole cannulation using the BioHole peg device offers advantages including reduced risk of needling complications and arteriovenous fistula failure, speedy transition to blunt needles, the tunnel track remaining narrow thus reducing the risk of developing an exit site infection, and suitability in difficult sites. Possible disadvantages are increased cost for purchase of the pegs during the track break-in period and potential complications such as discomfort, bleeding, and risk of infection. These risks/disadvantages minimize after the transition to blunt needles which in itself is a safer option than using sharp needles. As supported by KDOQI (2006) and the UK Renal Association (2011), adoption of the buttonhole method as the cannulation technique of choice is recommended in the majority of patients undergoing hemodialysis who have a native fistula.

Cannulation, and in particular, skilled cannulation is the cornerstone to preserving the arteriovenous fistula, the lifeline for a patient receiving long-term hemodialysis therapy. The buttonhole cannulation method has seen a huge revival in the 2000s, but it can sometimes prove challenging to implement successfully. This chapter discusses and describes the method of creating a buttonhole tract using the BioHole® device (a sterile polycarbonate peg), and describes the associated advantages and disadvantages. In a busy hemodialysis unit, use of the thumbtack-shaped 5-mm peg allows a fixed puncture route to be created quickly in just 7-14 days. The peg is placed at the site where the sharp puncture needle has just been removed by the designated primary cannulator. The peg remains in place until the next dialysis session when it is removed, the dialysis therapy completed as usual, and a new peg is inserted after hemostasis has been achieved. These steps are repeated for 1-2 weeks. Once the tunnel is formed, use of the peg is no longer needed and a blunt-ended puncture needle is inserted along the track each time. Buttonhole cannulation using the BioHole peg device offers advantages including reduced risk of needling complications and arteriovenous fistula failure, speedy transition to blunt needles, the tunnel track remaining narrow thus reducing the risk of developing an exit site infection, and suitability in difficult sites. Possible disadvantages are increased cost for purchase of the pegs during the track break-in period and potential complications such as discomfort, bleeding, and risk of infection. These risks/disadvantages minimize after the transition to blunt needles which in itself is a safer option than using sharp needles. As supported by KDOQI (2006) and the UK Renal Association (2011), adoption of the buttonhole method as the cannulation technique of choice is recommended in the majority of patients undergoing hemodialysis who have a native fistula.

CAH, a chronic condition with essentially life threatening aspects, is a frightening concept for families to come to terms with, even more so in the isolation of country areas. Having adequate knowledge and understanding is important in maintaining a sense of normality for these families and is an essential component to management both medically and within the family. The ultimate goal of this study was to improve patient access to education and support, and improve patient outcomes though increased knowledge and understanding. The principle aim of this study was to extend the education service we provide for our patients locally at specialist centres, to the patients who live in isolated regions of NSW and Australia wide. A comprehensive psychosocial education program (PEP) which was developed for patients and families with Congenital Adrenal Hyperplasia (CAH) and run at our local centre, was developed into an audiovisual format. In doing so, the program could be facilitated by one experienced health professional, therefore eliminating the need for a team of specialists to travel country areas, which is logistically difficult and considerably costly. Outreach services in NSW Australia, often provide only specialist medical care, with country families having only limited access to education, counselling and support services, that is routinely provided in metropolitan centres. In order to meet their needs the development of this innovative education program into an audiovisual format was planned and developed in order to provide an educational resource not only for patients and families, but also for clinicians. The PEP has been run 4 times with the program designed to cover the essential information required for families to know and understand the condition. Four 20 minutes sessions: What is CAH, Adolescent/Adult Issues, Psychosocial Issues and Sick Day Management, are followed by a 4 minute session on how to inject Hydrocortisone. The process of developing an audiovisual educational tool will be discussed and the essential factors which need to be considered, in developing such programs into an audiovisual format will be discussed in detail. This program is used in conjunction with the CAH Knowledge Questionnaire[1] (CAHKAQ) developed to evaluate our education process.

Patients living with chronic leg ulceration may frequently experience moderate to severe wound-related pain, which may not be alleviated by oral analgesics alone. Poorly controlled leg ulcer pain can prevent timely and effective wound management strategies being implemented, and increase wound healing times. Furthermore, patients with poorly controlled leg ulcer pain can experience continuous pain, which significantly affects quality of life. This case report introduces an innovative way of using the eutectic mixture of local anaesthetics (EMLA) 5% cream to reduce wound-related pain, reduce oral analgesic intake, and improve health-related quality of life for a patient with a painful, chronic lower leg ulcer.

Background Quality improvement strategies to increase and maintain the numbers of arteriovenous fistulas (AVFs) are a critical drive in enhancing the quality of care of patients receiving treatment with hemodialysis. How the AVF is needled is an important consideration in AVF survival; the ideal cannulation technique has not been established to date. Study Design Prospective randomized single-center trial. Setting & Participants Patients on maintenance hemodialysis therapy (N = 140). Intervention A 1-year intervention of buttonhole (constant site) or usual-practice (different site) cannulation. Outcomes Primary study outcome was AVF survival over 1 year, in which AVF failure was defined as an AVF no longer used for hemodialysis (also referred to as assisted patency). Secondary outcomes included primary patency, number of access interventions, bleeding time, infection rate, cannulation time and pain, and aneurysm formation. Results Demographic data were similar for both groups. The primary outcome measure of AVF survival at 1 year was statistically significantly increased in the buttonhole group (100% vs 86% with usual practice; P = 0.005, log-rank test). In the buttonhole group, there were fewer interventions (19% vs 39% in usual practice) and less existing aneurysm enlargement (23% vs 67% in usual practice). There were no bacteremia events in the buttonhole group and 2 in the usual-practice group (0.09/1,000 AVF days). There were no significant differences in bleeding times and lignocaine use between the 2 groups. Limitations A single-center study, lack of blinding. Conclusions In this study, AVF survival was significantly greater when using buttonhole cannulation. The buttonhole technique significantly decreased the need for access interventions and reduced existing aneurysm enlargement. Concerns of increased infection rates or prolonged bleeding times with the buttonhole technique were not seen in this study. The buttonhole technique should be considered the cannulation technique of choice for AVFs.

Background: Rapid and accurate testing of blood ketone levels (BKL) can assist in the assessment of insulin insufficiency and detection of diabetic ketoacidosis (DKA) in the acute care setting. We assessed the potential for introducing point of care measurement of BKL into an Australian emergency department. Methods: After providing informed consent, 72 patients (80 separate presentations) with insulin-requiring diabetes who presented to an emergency department with hyperglycaemia (capillary blood glucose level of ≥10.0. mmol/L) underwent testing for BKL at triage. Staff were guided by a protocol developed for interpretation of elevated BKL ≥ 1.0. mmol/L and subsequent actions. Urine ketones and arterial blood gas testing occurred as usual. Time to testing was recorded for all measures. Results: BKL testing occurred immediately in 91% of the presentations, whereas urine ketones and arterial blood gas testing was uncommon (24% and 15% respectively) and not immediate. Elevated BKL (≥1.0. mmol/L) occurred in 17% of presentations, of whom five were diagnosed with DKA within the Emergency Department. However, testing for BKL decreased over the duration of the study. Patients most frequently tested for BKL were younger (58.59 years) than patients who were not tested (79.5 years) (p= .011). Conclusions: Implementation of point of care BKL testing in the Emergency Department can assist in the detection of significant numbers of patients with insulin insufficiency, however, ongoing education and support is required to sustain the change in practice. © 2012.

Effective promotion of nursing as a career to high school students can potentially have a positive impact on the shortage of nurses. This study identified the perceptions of high school careers advisers of the Bachelor of Nursing program as a career choice, their perceptions of the attributes and characteristics necessary for nurses, and their perceptions of nurses' roles and responsibilities. These perceptions have not been previously identified in Australia and may not have been adequately considered in the planning of recruitment and retention strategies for nursing. The study findings suggest that careers advisers recognise the complexity of nursing practice in providing direct patient care and the range of attributes required for the registered nurse who provides this care. Careers advisers recognised that nursing had changed over the past ten years, although few perceived the roles and responsibilities of nurses to extend beyond activities related to patient care. There were few requests for information about nursing as a career from careers advisers and the findings indicates that they do not actively promote nursing as a career. This suggests that despite a range of initiatives to promote registered nursing as a career choice, careers advisers are not influencing significant numbers of school students to consider registered nursing as career.

Aims. The purpose of this study was to develop a validated Congenital Adrenal Hyperplasia Knowledge Assessment Questionnaire (CAHKAQ) that can be used to identify deficits in the knowledge of families living with CAH regarding the disease and its management. Background. Management of CAH requires good parental and/or patient knowledge and understanding of the disorder, and the action required when clinical problems arise. Effective education initiatives are important in helping families to manage the disorder. However, there are currently no established questionnaires available to assess the knowledge of CAH. Method. An extensive survey of the literature was conducted to develop a list of questions about CAH. The Delphi technique was used to develop and determine content validity of the CAHKAQ using a panel of 15 nursing and medical experts in endocrinology. The instrument was piloted to test for item variation, meaning and redundancy, and to determine instrument unidimensionality and internal consistency. The questionnaire was distributed to a convenience sample of family members (n = 98) of 36 children/adults with CAH recorded on the database of a large children's hospital endocrine clinic. Results. Three Delphi rounds were required to achieve final consensus for content validity. The resulting questionnaire contained 22 multiple-choice items and had a Flesch Reading Ease score of 67. Statistical analysis found the instrument to be internally consistent and unidimensional with a reported Cronbach's coefficient alpha of 0·67. Conclusion. The CAHKAQ is a valid and reliable questionnaire suitable for use in conjunction with education about CAH. Relevance to clinical practice. The CAHKAQ will be invaluable in assessing parental and patient knowledge and understanding of the disorder and identifying deficits that can be addressed through education. Further research is required to determine whether the underlying factors of the instrument are consistent with components of CAH knowledge.

The transition from student to an accountable health professional is a difficult time for the novice nurse and can result in significant anxiety, stress and poor socialisation into the nursing profession. A strategy applied at a major tertiary teaching hospital to address transitional issues for novice nurses is that of group debriefing sessions. This qualitative study used focus groups to explore the effectiveness of these debriefing sessions for new graduate nurses and trainee enrolled nurses. The results demonstrated that the sessions provided nurses with a supportive environment, access to peer support and a sense of belonging. This provided an opportunity to develop confidence in their nursing competence and improvement in interpersonal communication skills. Debriefing sessions are an effective psychosocial support mechanism that can ameliorate the 'reality shock' experienced by nurses in their first year of practice. Group debriefing is an important component in the transitional support process and should be used to complement other strategies to enhance the psychosocial experiences of novice nurses.