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Walsh, K., Moss, C., Lawless, J., McKelvie, R., & Duncan, L. (2008). Puzzling practice: A strategy for working with clinical practice issues. International Journal of Law and Psychiatry, 14(2), 94–100.
Abstract: The authors share the evolution of innovative ways to explore, 'unpack' and re-frame clinical issues that exist in everyday practice. The elements of these processes, which they call 'puzzling practice', and the techniques associated with them, were delineated over a two year period by the authors using action theory based processes. The authors have evolved several different frameworks for 'puzzling practice' which they draw on and use in their practice development work and in research practice. This paper pays attention to a particular form of puzzling practice that they found to be useful in assisting individual clinicians and teams to explore and find workable solutions to practice issues. In this example 'puzzling practice' uses seven different elements; naming the issue; puzzling the issue; testing the puzzle; exploring the heart of out practice; formulating the puzzle question; visualising the future; and generating new strategies for action. Each of the elements is illustrated by the story and the key foundations and ideas behind each element is explored.
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Rose, L., Nelson, S., Johnston, L., & Presneill, J. J. (2008). Workforce profile, organisation structure and role responsibility for ventilation and weaning practices in Australia and New Zealand intensive care units. Journal of Clinical Nursing, 17(8), 1035–1043.
Abstract: The aim of this research is to provide an analysis of the scope of nursing practice and inter-professional role responsibility for ventilatory decision-making in Australian and New Zealand intensive care units (ICU). Self-administered questionnaires were sent to nurse managers of eligible ICUs within Australia and New Zealand. Survey responses were available from 54/180 ICUs. The majority (71%) were located within metropolitan areas and categorised as a tertiary level ICU (50%). The mean number of nurses employed per ICU bed was 4.7 in Australia and 4.2 in New Zealand, with 69% (IQR: 47-80%) of nurses holding a postgraduate specialty qualification. All units reported a 1:1 nurse-to-patient ratio for ventilated patients with 71% reporting a 1:2 nurse-to-patient ratio for non- ventilated patients. Key ventilator decisions, including assessment of weaning and extubation readiness, were reported as predominantly made by nurses and doctors in collaboration. Overall, nurses described high levels of autonomy and influence in ventilator decision-making. Decisions to change ventilator settings, including FiO(2) (91%, 95% CI: 80-97), ventilator rate (65%, 95% CI: 51-77) and pressure support adjustment (57%, 95% CI: 43-71), were made independently by nurses. The authors conclude that the results of the survey suggest that, within the Australian and New Zealand context, nurses participate actively in ventilation and weaning decisions. In addition, they suggest, the results support an association between the education profile and skill-mix of nurses and the level of collaborative practice in ICU.
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Pirret, A. M. (2007). The level of knowledge of respiratory physiology articulated by intensive care nurses to provide rationale for their clinical decision-making. Intensive & Critical Care Nursing, 23(3), 145–155.
Abstract: The objective of this paper is to outline a study firstly, assessing ICU nurses' ability in articulating respiratory physiology to provide rationale for their clinical decision-making and secondly, the barriers that limit the articulation of this knowledge. Using an evaluation methodology, multiple methods were employed to collect data from 27 ICU nurses who had completed an ICU education programme and were working in one of two tertiary ICUs in New Zealand. Quantitative analysis showed that nurses articulated a low to medium level of knowledge of respiratory physiology. Thematic analysis identified the barriers limiting this use of respiratory physiology as being inadequate coverage of concepts in some ICU programmes; limited discussion of concepts in clinical practice; lack of clinical support; lack of individual professional responsibility; nurses' high reliance on intuitive knowledge; lack of collaborative practice; availability of medical expertise; and the limitations of clinical guidelines and protocols. These issues need to be addressed if nurses' articulation of respiratory physiology to provide rationale for their clinical decision-making is to be improved.
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Ardagh, M., Wells, E., Cooper, K., Lyons, R., Patterson, R., & O'Donovan, P. (2002). Effect of a rapid assessment clinic on the waiting time to be seen by a doctor and the time spent in the department, for patients presenting to an urban emergency department: A controlled prospective trial. Access is free to articles older than 6 months, and abstracts., 115(1157).
Abstract: The aim of this study was to test the hypothesis that triaging certain emergency department patients through a rapid assessment clinic (RAC) improves the waiting times, and times in the department, for all patients presenting to the emergency department. For ten weeks an additional nurse and doctor were rostered. On the odd weeks, these two staff ran a RAC and on even weeks, they did not, but simply joined the other medical and nursing staff, managing patients in the traditional way. During the five weeks of the RAC clinic a total of 2263 patients attended the emergency department, and 361 of these were referred to the RAC clinic. During the five control weeks a total of 2204 patients attended the emergency department. There was no significant difference in the distribution across triage categories between the RAC and non-RAC periods. The researchers found that the rapid management of patients with problems which do not require prolonged assessment or decision making, is beneficial not only to those patients, but also to other patients sharing the same, limited resources.
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