from the editor - heather dawson-byrne · from the editor - heather dawson-byrne nursing measures...

Australian Journal of Advanced Nursing 2000 Volume 18 Number 15

EDITORIAL

FROM THE EDITOR - Heather Dawson-Byrne

NURSING MEASURES PROVIDING POSITVE OUTCOMES FOR THE NEWBORN

W hile midwifery education in Australia is thefocus of intense debate both from within andoutside the field of midwifery (Byrne P 2000)

practitioners and researchers continue endeavouring todevelop ways of improving the care for both the mother andnewborn For centuries this has been the focus of midwivesand the year 2000 is no different Confinement may be inhospitals at home or in birthing centres regardless themidwife puts the health and wellbeing of the child andmother as the prime reason for practice

In the guest editorial Professor Rhonda Griffithdiscusses the effects economic rationalism has had on thefunding and practice of nursing including midwiferypractice

The themed papers in this issue of The AustralianJournal of Advanced Nursing focus on nursing measuresaimed at increasing positive outcomes for the newborn

Caroline Homer Gregory Davis Peter Petocz and LesleyBarclay compared obstetric outcomes primarily caesareansection rates of low-risk women presenting in spontaneouslabour to the birth centre with those attending the hospitalrsquosconventional labour ward This study showed no significantdifference suggesting that contrary to popular belief thesite of birthing does not effect clinical outcomes

Along a similar theme the second paper authored byMargaret Cooke Richard Mattick and Elizabeth Campbelldescribes the adoption of a lsquostop smokingrsquo program inantenatal clinics The lsquostop smokingrsquo program wasspecifically designed to be implemented by antenatal clinicswith the aim of discovering what did or did not influence

clinic managers decision to adopt the program Notunexpectedly the intensity of program disseminationpositively effected the program up-take rates However andperhaps more importantly reasons for not using theprogram included insufficient time available to run theprogram lack of support from fellow colleagues inabilityto provide follow-up staff turnover and poor access andstorage of the program materials

In the original papers section Marie Gertz and TraceyBucknall report on research conducted in Australianemergency rooms to investigate triage nurses decision-making and describe their scope of practice The studyrevealed a marked variability in education for triage nurseswith over half stating that no unit-based specific triageeducation was provided These findings provide guidancefor education and triage practice

The fourth paper lsquoThe role of the psychiatric consultant-liaison nurse in the general hospitalrsquo by Julie Sharrock andBrenda Happell examines the effect this role has on clientsnow that lsquomainstreamingrsquo of psychiatric clients is the normin Australia

The final article by Wendy Day discusses the use ofmassage for clients with cardiac pain and the positive effectthis may have on clients following an acute cardiac event

REFERENCESByrne P 2000 The South Australian Nurse Practitioners project A midwifersquosperspective on a new initiative Collegian 7(3)37-39


GUEST EDITORIAL

6

Readers of this Journal who were practicing prior tothe late 1980rsquos will remember when theeffectiveness of health care was assessed against

the processes of care delivery and patientclientsatisfaction with services That changed dramatically inthe early 1990rsquos when funders of health services inAustralia (government at State and Commonwealth level)began to assess the efficacy of services in terms of dollars spent Health planners and administrators are now occupied by schemes designed to maximise health outcomes for users of services while containing thecost of care

Value for money has become the issue with variationsin cost being closely monitored by administrators (Hindleand Newman 1996) reforms being linked to costs ratherthan clinical discovery (Bessler and Ellies 1995 Duckett1996) and the corporatisation of health facilities (Whiteand Collyer 1997)

The health needs priorities and options of Australiansare changing for a variety of reasons including

increasing prevalence of chronic disease particularlyrelated to an aging society that requires ongoing careacross agencies

continuing reduction in hospital length of stay and theexpanding role of non-inpatient and ambulatoryservices

pressures for improved productivity and efficiency inthe delivery of health care

increasing dependence on technology

The Commonwealth Government has responded bytaking a strategic approach to the design and funding ofservices Six priority areas were identified (publichospitals pharmaceutical non-inpatient medical specialistand diagnostic services primary health and communitycare small rural communities and mental health) and anintegrated approach to services was adopted (NationalHealth Strategy 1991) An integrated health system was tobe achieved through

incentives for best practice

incentives for productivity and efficiency

scope for sustainability and flexibility

service models which encourage continuity of care

selective use of market and competitive pressures

equity in distribution of health resources

devolution of administration and service delivery(National Health Strategy 1991)

This was to be the blue print for health reform inAustralia and to support it a new vocabulary emerged thatincluded case management best practice guidelinesfunderprovider split diagnosis related groups (DRGs)and more recently access block

Describing the model and enabling factors was a startbut the real conundrum is for the service administratorsand clinicians who have the task of bringing togetherservices dealing with incentive programs restructuringservices and developing relationships between providersto achieve the goals for continuity of care

How is the model working at the point of care Therehave been some long overdue reforms and somefrustrations

Incentives for Best Practice

Accountability is fundamental to professional practiceand peer review quality management and clinicalprotocols have been introduced as the key to achievingbest practice That was a positive move The qualityinitiatives have been supported by financial andorganisational incentives also considered to be bestpractice

Incentives have produced positive and negativeoutcomes the interpretation depends on priorities andagendas and is not regarded consistently throughoutorganisations Funding patterns and priorities continue tobe a stimulus to review practice and initiate lsquoinnovationrsquoand no individual associated with health including usersof the health system are exempt from the consequencesThe theory-practice gap widens as financial incentivesovertake clinical imperatives Consequently hospitalwards are less effective for teaching purposesInterestingly some incentives donrsquot generate best practice

Within health there are markedly different financialincentives according to the care environment Forexample private medical practitioners receive incentivesaccording to the number of patients they see Overservicing is not unknown However in the public hospitalsystem the opposite is the case and in fact there areadditional marginal costs associated with attractingpatients Demand on accident and emergency departmentsis an example and hospitals have addressed the increasing

GUEST EDITORIAL - Rhonda Griffiths

Professor Rhonda Griffiths is the Director South Western Sydney Centre for Applied Nursing Research LiverpoolHospital Sydney Australia

lsquoTHEYrsquo SAY ITrsquoS THE BEST HEALTH SYSTEM IN THE WORLD


GUEST EDITORIAL

demands by encouraging non-emergency patients to see ageneral practitioner The effect is to shift the cost of care

Fundamental planks of best practice are still to be put inplace A major system weakness that discourages anintegrated approach and best practice is lack of fundingacross organisations and little scope for moving acrossepisodes of care the principles of managed care have someway to go before that model is adopted in Australia (Duckett1996) The NSW Government has recently announced 3year funding cycles which will enable Area Health Servicesto plan expenditure over that period (NSW Health Council2000) However funding for services continues toemphasise single organisations or specific service episodes

Incentives for productivity and efficiency

Demand for health services is increasing and in themajority of cases growth in demand is met throughefficiency and productivity savings within existing servicesClinical review mechanisms have been developed toenhance and emphasise evaluation of effectiveness ofdifferent types of interventions The emphasis is onproviding lower cost substitutes for higher cost servicesThat is not always bad if managed intelligently for exampleearly obstetric discharge programs

Service models to encourage continuity of care

Clinicians confirm that the goal of continuity of care hasnot been realised partly due to the funding proceduresThere are numerous separate Commonwealth and Stateprograms delivering primary and community care often tothe same target groups Rural communities also haveexpressed concern about lack of access to services andinability to develop services that reflect their needs andresources where economies of scale are required todemonstrate viable and sustainable services (TrickettTitulaer and Bhatia 1997)

The idea of integrated services is very sensible the ironyis that neither Medicare nor other funding arrangementsencourage integration In fact methods of payment actuallyencourage a highly specialised and segmented healthservice (National Health Strategy)

Selective use of market and competitive pressure

Market mechanisms are widely regarded as important forimproving consumer responsiveness and efficiencyHowever in health consumer choice is restricted andconsumers have limited ability to review data describing theeffectiveness and consequences of particular servicesUniversal health insurance and bulk billing means that thecost of services has little impact upon consumer choice

Equity in distribution of health resources

Area Health Services in NSW receive funding accordingto a Resource Distribution Formula based on geographicand demographic variables in addition to functions such asresearch and teaching Equity in health does not imply all

Australians will have access to all services in their localarea The purchaser-provider split was introduced in NewZealand as one strategy to ensure all residents would haveaffordable access to a range of core health services (Ashton1997) That model could positively influence equity by separating the demand side (funder) from the supply side (provider) however in New Zealand it is not seen as along term strategy rather a precursor to managed care(Ashton 1997)

CONCLUSION

Health is a complex system one in which hardlyanything is as it seems

Area Health Services purchase services from localsources to meet their requirements based on type andquantity of service and location Purchasers reorganiseservices based on their priorities frequently with the viewof introducing an element of rationing or substituting acostly service for a less costly alternative

Nurses are the public face of the health system and inthat position take much of the criticism that should moreaccurately be aimed at Government and Area HealthServices We continue to be excluded from priority settingparticularly at the local level and therefore continue to reactto directives which at times are in conflict with ourprofessional philosophy and personal priorities for jobsatisfaction and fulfilment

Is it any wonder that an experienced registered nurse isbecoming a rare find in wards Health Departments andnurse registering authorities have expressed concern at thedeclining number of students enrolling in nursing programsand the increasing number of experienced nurses leavingthe profession The reasons are multifactorial however Ibelieve a review of the impact of current policy on nursingservices would be worthwhile

REFERENCESAshton T 1995 The purchaser-provider split in New Zealand The story so farAustralian Health Review 18(1)43-60

Bessler JS Ellies M 1995 Values and value-avision for the Australian healthcare system Australian Health Review 18(3)6-17

Cromwell D and Mays L 1998 Waiting list statistics as performanceindicators Observations on their use in hospital management Australian HealthReview 21(4)15-26

Duckett S 1996 The new market in health care Prospects for managed care inAustralia Australian Health Review 19(2)7-22

Hindle D and Newman J 1996 Hospital input price indices in Australia Arethey worth the effort Australian Health Review 19(3)28-39

National Health Strategy 1991 The Australian Health Jigsaw Integration ofHealth Care Delivery Issues Paper No 1 Treble Press Sydney

NSW Health Council 2000 A Better Health System for NSW Better healthCentre-Publications Watehouse Sydney

Trickett P Titulaer I and Bhatia K 1997 Rural remote and metropolitan areahealth differentials A summary of preliminary findings Australian HealthReview 20(4)128-137

White K and Collyer F 1997 To market To market Corporatisationprivatisation and hospital costs Australian Health Review 20(2)13-25


BIRTH CENTRE OR LABOUR WARD A COMPARISON OF THE CLINICALOUTCOMES OF LOW-RISK WOMEN IN A NSW HOSPITAL

RESEARCH PAPER

ABSTRACT

A number of birth centres were established in NewSouth Wales as a result of the Shearman Report (NSWHealth Department 1989) The objective of this studywas to compare the obstetric outcomes primarilycaesarean section rates of low-risk women presentingin spontaneous labour to the birth centre with thoseattending the hospitalrsquos conventional labour ward Thestudy showed that there was no significant differencein the caesarean section rate between the groups (35in the birth centre and 43 in the labour ward) Wesuggest that the site of birthing does not affect clinicaloutcomes for low-risk women at this hospital Theseresults are relevant to contemporary clinical practiceas they question the basis upon which birth centreshave been popularised that is the medicalisation ofbirth in conventional labour wards increasesintervention rates

INTRODUCTION

T he Shearman Report on Obstetric Services in NewSouth Wales (NSW Health Department 1989)recommended the establishment of low-risk

lsquohome-likersquo delivery areas or birth centres where womencould receive continuity of care from midwives throughtheir pregnancy labour and delivery This plus consumeractivism from womenrsquos groups led to the development ofa number of birth centres in New South Wales The recentAustralian Federal Governmentrsquos Report into ChildbirthProcedures was also very supportive of birth centres andrecommended the continuation and expansion of birthcentre services in the public health system (SenateCommunity Affairs Reference Committee 1999)

The philosophy behind a birth centre is to provide low-risk pregnant women with care in a non-clinicalenvironment with as little intervention as possible in thenormal progress of labour In Australia however mostwomen of low-risk status give birth in hospital labourwards In 1995 only 32 of NSW births occurred inbirth centres (Taylor and Pym 1996) As a result moresalaried midwives work in hospital labour wardscompared to birth centres

Excellent obstetric and neonatal outcomes havepreviously been reported in women delivering in birthcentres with low intervention rates (Stern et al 1992)equivalent neonatal results (Biro and Lumley 1991) andincreased maternal satisfaction when compared withroutine maternity care in hospital-based labour wards

Caroline Homer CM MN is a Senior Research Midwife at theMidwifery Practice and Research Centre Sydney Australia

Gregory Davis MD FRANZCOG is a Staff Specialist in theDepartment of Womenrsquos Health St George Hospital SydneyAustralia

Peter Petocz PhD is a Senior Lecturer in the School ofMathematical Sciences University of Technology SydneyAustralia

Lesley Barclay CM PhD is a Professor in the MidwiferyPractice and Research Centre Sydney and the Family HealthResearch Unit South Eastern Sydney Area Health Service andthe Faculty of Nursing University of Technology SydneyAustralia

Accepted for publication January 2000

Deborah Matha CM RN is a Midwifery Unit Manager in theDepartment of Womenrsquos Health St George Hospital SydneyAustralia

Michael Chapman MD FRANZCOG is Professor in theDepartment of Womenrsquos Health St George Hospital Sydneyand the University of New South Wales Sydney Australia

ACKNOWLEDEGMENTS

This study was partially funded by an internal grant from the Faculty

of Nursing Midwifery and Health University of Technology Sydney Thankyou to Maralyn Rowley from Victoria University Wellington New Zealand

for her advice on an early study proposal and the data collection tool

Thanks also to the staff of the Clinical Information Department at St GeorgeHospital for assistance with collecting the medical records and selecting the

labour ward group

KEYWORDS birth centres caesarean section low-risk

9Australian Journal of Advanced Nursing 2000 Volume 18 Number 1

(Waldenstroumlm and Nilsson 1997 Waldenstroumlm andNilsson 1993) The last reported Australian comparativestudy of a birth centre and labour ward was conducted in 1986 and reported that the obstetric outcomes forwomen admitted to the birth centre were generally better than for those admitted to the labour ward althoughthese differences were not statistically significant (Martins et al 1987)

This paper reports on a retrospective cohort studyconducted at St George Hospital where the outcomes ofwomen going into spontaneous labour in the birth centrewere compared with those of similar women whopresented to the labour ward The clinical endpoints wererates of caesarean section and assisted vaginal delivery

Setting

Approximately 2500 births occur each year either inthe birth centre or labour ward at St George Hospital inSydney The birth centre was purpose-built and opened in1991 It is situated 50 metres from the labour ward andcontains two birthing rooms each with a double bed and aspa bath Basic neonatal resuscitation equipment isimmediately available although concealed Women aretransferred to the labour ward in order to receive electronicfoetal monitoring intravenous infusions or epiduralanalgesia Women who wish to attend the birth centre arereferred by general practitioners and accepted for care ifthey are deemed to be at low-risk according to strictcriteria Antenatal intrapartum and postpartum care areprovided by midwives and care continues in the birthcentre unless medical or obstetric complicationsnecessitate review by an obstetrician andor subsequenttransfer to the labour ward

METHOD

Prior to commencement the study was approved by theEthics Committees of the South Eastern Sydney AreaHealth Service (Southern Section) and the University ofTechnology Sydney Data was collected retrospectivelyfor the calendar year 1995 Women suitable for inclusionin the study were public patients presenting in spontaneouslabour after a pregnancy free of medical or obstetriccomplications with a singleton vertex presentationbetween 37 and 42 weeks gestation

Three hundred and sixty-seven women presented inlabour to the birth centre in 1995 and all were included inthe sample Medical records were retrieved for thesewomen and data collected by a researcher (CH)experienced in data collection The labour ward samplewas identified by obtaining a computer-generated randomselection of women who presented in labour to the labourward in 1995 Women were excluded if they had beenbooked for the birth centre and transferred out due tocomplications or had been admitted antenatally for

medical or pregnancy-related complications The medicalrecords of 632 women were reviewed Of these 265women did not fulfill the low-risk criteria and wereexcluded to obtain the final labour ward sample of 367 The most common reasons for exclusion wereinduction of labour (19) private insurance (15)elective caesarean section (12) pre-eclampsia (8) andpreterm delivery (7)

Analysis

Data were entered into a database using Epi-Infosoftware and transferred into a SPSS statistical packagefor the purposes of analysis Analysis was performed on anintention to treat basis that is the women who presentedto the birth centre were analysed as such even if theytransferred to the labour ward during their labour

Studentrsquos t test was used for continuous variables andcategorical data were analysed using the chi-squaredstatistic All tests were two-tailed and significance wasregarded as P lt 005

RESULTS

Demographics

The women from the birth centre and the labour wardwere of similar mean age (28 years in the birth centre and275 years in the labour ward) and parity with morewomen in the birth centre group from an English speakingbackground (Table 1)

Transfers from birth centre to labour ward

Of the 367 women who commenced labouring in thebirth centre 111 (30) were transferred during labour tothe labour ward The principal reasons for transfer wereslow progress in labour (39) request for epiduralanalgesia (16) meconium staining of the liquor (14)and foetal distress (12)

Mode of delivery

There were no differences in mode of delivery betweenthe two birth groups with the overall caesarean section

RESEARCH PAPER

Birth centre Labour ward n=367 n=367

English 304 (828) 155 (422)Chinese 3 (08) 63 (172)Arabic 17 (46) 68 (185)Other 43 (118) 81 (221)

X23 =150 p=0001

Table 1 The primary language spoken by women labouring in the birth centre and labour ward

(Values are given as n () and the chi-squared statistic is applied to the table)


rate being 4 and the instrumental delivery rate 119(Table 2) Twenty-two of the 312 nulliparous women hada caesarean section (7) compared with 7 of the 422multiparous women (17)

The most common reason for an assisted delivery(caesarean section or instrumental vaginal delivery) wasfailure to progress in labour Significantly more women inthe labour ward group had an assisted delivery for foetaldistress (24 of 65 assisted births [369]) than in the birthcentre group (10 of 51 assisted births [196] [(21 =414P = 004])

Electronic foetal monitoring was significantly morelikely to be used in the labour ward group (53 versus24 plt0001) Electronic foetal monitoring was definedas the use of continuous cardiotocography for a significantpart of the labour and delivery

Analgesia in labour

Women in the birth centre group were significantly lesslikely to use analgesia in labour More than half thewomen (53) from the birth centre did not receiveanalgesia compared with only 21 from the labour ward(plt0001) More women who presented to the labour wardused epidural anaesthesia (196) than those whopresented to the birth centre (155) Other forms ofanalgesia included nitrous oxide inhalation and narcoticinjection

Perineal outcomes

After controlling for parity women in the birth centregroup were more likely to have an intact perineum (36)than those in the labour ward (27) Women in the labourward group were more likely to have an episiotomy (17)than in the birth centre (13) however these differenceswere not statistically significant

Neonatal outcomes

All infants were liveborn and Apgar scores at fiveminutes were similar between the two groups There were

no five minute Apgar scores less than 4 in either groupOne neonatal death occurred an infant from the labourward group with a severe congenital abnormality who diedon day 10 after being transferred to a level three neonatalnursery

DISCUSSION

While this is a small non-randomised study the resultshave implications for clinical practice and the organisationof maternity services at this hospital and in similar centresMore women from English speaking backgrounds chose toattend the birth centre than the labour ward Culturalpreferences may account for this difference but it couldalso be related to a dearth of information about birthcentres in other languages Research conducted in Sydneyin the late 1980rsquos also reported an imbalance in theprimary language of those seeking birth centre ascompared to labour ward care (Martins et al 1987) Birthcentres may not be an attractive option to all women andthis should be considered when the planning andintroduction of maternity services is undertaken It is alsoimportant to ensure that language does not act as a barrierto birth centre access

Women who presented to our birth centre in labour hada low emergency caesarean section rate Birth centres inAustralia (Stern et al 1992) the United States (Rooks et al1989) and Sweden (Waldenstroumlm and Nilsson 1997) havereported comparable caesarean section rates reflecting thelow-risk nature of this group of women

When this project was planned it was thought that theemergency caesarean section rate in women of similar riskstatus would be higher in the conventional labour wardThis proved not to be the case suggesting that the labourward can achieve similarly low operative delivery rates Inthe only randomised controlled trial of comprehensivebirth centre care (Waldenstroumlm and Nilsson 1997) therewere also no significant differences in the caesareansection rates between birth centre and standard care In ourstudy the only difference in caesarean section rate wasbetween nulliparous and multiparous women which wasnot unexpected

Caesarean section rates are an important outcome in theprovision of maternity services with significantimplications for women in terms of physical as well aspsychological health An association has been foundbetween emergency caesarean section and subsequentmaternal psychological problems (Fisher et al 1997Boyce and Todd 1992) Research in Queensland (Creedy1999) has also identified a strong correlation betweenobstetric interventions (including caesarean section) andpost-traumatic stress disorder Caesarean sections alsoimpact on health services in terms of costs For examplein the United Kingdom it has been estimated that each 1

RESEARCH PAPER

10

Birth centre Labour ward Total n=367 n=367 n=734

normal vaginal 316 (861) 302 (823) 618 (842)delivery

caesarean section 13 (35) 16 (43) 29 (4)

instrumental delivery 38 (104) 49 (134) 87 (119)

X2

5 =35 p=062

Table 2 Mode of delivery of women commencing labour in the birth centre and labour ward



increase in caesarean section rate costs the National HealthService an additional pound5 million (Anonymous 1997)

We believe women attend a birth centre as they feel thatthis will mean their chance of experiencing a normal birthis higher Our study and others would suggest that this isnot true Birth centres can offer a home-like atmosphere anon-intervent ionist women-centred philosophy andusually continuity of midwifery care However webelieve that the philosophy in conventional labour wards ismoving towards that of a birth centre in terms of meetingwomenrsquos needs and avoiding unnecessary intervention

Significantly more women in the birth centre group didnot require any analgesia during labour This may reflectthe self-selection bias inherent in this study that is womenwho wanted a lsquonaturalrsquo labour and birth were more likelyto choose to attend the birth centre Similar proportions ofwomen from the two groups used epidural analgesiaEarlier research in low-risk primparous women hasreported mean epidural rates of 53 (Hewson et al 1985)and more recently 28 (Williams et al 1998)Randomised trials of continuity of midwifery care for low-risk women have reported epidural rates ranging from 16 to 32 (MacVicar et al 1993 Flint et al 1989 Turnbullet al 1996) The Birth Centre Trial in Sweden reportedrates of 12 and 15 in the birth centre and standard caregroups respectively (Waldenstroumlm and Nilsson 1997) Ouroverall rate of 175 reflects the low-risk status of thewomen and the philosophy of both the birth centre and thelabour ward

During labour almost one third of women in our studytransferred from the birth centre to the labour ward Thistransfer rate is higher than others reported for example19 in the Swedish (Waldenstroumlm and Nilsson 1997) andAustralian (Stern et al 1992) studies and 12 in the UnitedStates (Rooks et al 1989) Possibly this is related to theclose proximity of the birth centre to the labour wardwhich made intrapartum transfer easier to arrange thanfrom a free-standing or external centre Also as the birthcentre and the labour ward were part of one maternity unitbirth centre midwives were able to follow many of thetransferred women which may result in a lower thresholdfor transfer than in other institutions

More women in the labour ward group had an assisteddelivery for foetal distress than those commencing labourin the birth centre The reason for this is unclear howeverit is possibly related to the easy accessibility to and thesubsequent increased use of electronic foetal monitoringwith a resulting increase in the diagnosis of foetal distressin the labour ward group

Perinatal mortality is a primary concern in theprovision of maternity care however because of the low-risk nature of the women in our cohort an impossiblylarge sample would be necessary to determine statistically

and clinically significant differences between the birthcentre and labour ward groups Our study did not havesufficient power to detect significant differences inperinatal mortality Previous descriptive studies of birthcentres in Australia and the United States have reportedperinatal mortality rates of between 089 and 13 per 1000births in women commencing labour in a birth centre(Stern et al 1992) The Swedish study (Waldenstroumlm andNilsson 1997) however raised concerns about an excess ofperinatal deaths in their birth centre group (09 versus02) and recommended further research into the safety ofbirth centres be conducted

It was not possible to conduct our study as arandomised controlled trial as the birth centre has beenestablished for six years and women and clinicians wereopposed to such a trial Our study was also not designed toexamine the reasons why women choose birth centre carenor the impact that this environment had over theirbirthing experience and level of satisfaction While weacknowledge the importance and significance of thesefactors they were outside the scope of this project

CONCLUSION

This study suggests that appropriate care of low-riskwomen can result in excellent outcomes wherever labouris conducted This study has implications for midwiferyand maternity service provision in the Australian contextConventional labour wards where the majority of low-riskwomen receive intrapartum care can achieve favourableoutcomes and women need to be reassured that lowcaesarean section rates are possible in both birth centresand labour wards

In the future when we plan the provision of maternityservices in Australia we may need to decide whether toincrease the number of birth centres or to redesignconventional labour wards to make them more like birthcentres Our study has shown that a conventional settingcan achieve excellent outcomes We also know that birthcentres are available to only a small proportion of womenand are usually oversubscribed Perhaps then some of theanswers lie in reorganising our maternity services so thatall women can have access to a lsquobirth centre philosophyrsquo ifthey choose

RESEARCH PAPER

11


Anonymous 1997 What is the right number of caesarean sections [editorial]Lancet 349(9055)815

Biro MA and Lumley J 1991 The safety of team midwifery The first decadeof the Monash Birth Centre Medical Journal of Australia 155(7)478-480

Boyce P M and Todd A L 1992 Increased risk of postnatal depression afteremergency caesarean section Medical Journal of Australia 157(3)172-174

Creedy D 1999 Birthing and the development of trauma symptoms Incidenceand contributing factors Unpublished doctoral dissertation Brisbane GriffithUniversity

Fisher J Astbury J and Smith A 1997 Adverse psychological impact ofoperative obstetric interventions A prospective longitudinal study Australianand New Zealand Journal of Psychiatry 31(5)728-738

Flint C Poulengeris P and Grant A 1989 The lsquoKnow Your Midwifersquo scheme- a randomised trial of continuity of care by a team of midwives Midwifery5(1)11-16

Hewson D Bennett A Holloday S and Booker E 1985 Childbirth inSydney teaching hospitals A study of low-risk primiparous womenCommunity Health Studies 9(3)195-201

MacVicar J Dobbie G Owen-Johnstone L Jagger C Hopkins M andKennedy J 1993 Simulated home delivery in hospital A randomisedcontrolled trial British Journal of Obstetrics and Gynaecology 100(4)316-323

Martins JM Greenwell J Linder-Pelz S and Webster MA 1987Evaluation of outcomes Deliveries at the birth centre and traditional setting atthe Royal Hospital for Women Sydney Sydney NSW Department of Health

NSW Health Department 1989 Final report of the ministerial task force onobstetric services in NSW The Shearman Report Sydney NSW Department ofHealth

Rooks J P Weatherby N L Ernst E K M Stapleton S Rosen D andRosenfield A 1989 Outcomes of care in birth centres The National BirthCentre Study New England Journal of Medicine 321(26)1804-1811

Senate Community Affairs Reference Committee 1999 Rocking the cradle Areport into childbirth procedures Canberra Commonwealth of Australia

Stern C Permezel M Petterson C Lawson J Eggers T and Kloss M1992 The Royal Womenrsquos Hospital Family Birth Centre The first 10 yearsreviewed Australian and New Zealand Journal of Obstetrics and Gynaecology32(4)291-296

Taylor L and Pym M 1996 New South Wales Midwives Data Collection1995 Sydney NSW Health Department

Turnbull D Holmes A Shields N Cheyne H Twaddle S Gilmour W HMcGinley M Reid M Johnstone I Geer I McIlwaine G and Lunan CB 1996 Randomised controlled trial of efficacy of midwife-managed careLancet 348(9022)213-218

Waldenstroumlm U and Nilsson C A 1993 Womenrsquos satisfaction with BirthCentre care A randomised controlled trial Birth 21(1)3-13

Waldenstroumlm U and Nilsson C A 1997 The Stockholm birth centre trialMaternal and infant outcome British Journal of Obstetrics and Gynaecology104(4)410-418

Williams F L Florey C V Ogston S A Patel N B Howie P W andTindall V R 1998 UK study of intrapartum care for low-risk primigravidasA survey of interventions Journal of Epidemiology and Community Health52(8)494-500

RESEARCH PAPER

REFERENCES


ABSTRACT

This paper reports the dissemination by the CancerEducation Research Program (CERP) of a previouslytested smoking cessation program called lsquoFresh startrsquoto 23 antenatal clinics The program was specificallydesigned for use by staff in antenatal clinics The aimof the study was to investigate the factors thatinfluenced midwifery managersrsquo adoption of theprogram Clinics were randomly assigned to groupsthat received the program by simple dissemination(mail-out) or intensive dissemination (a mail-out pluspersonal contact with midwifery facilitators) A casehistory approach was used to investigate the variableswhich influenced a midwifery managerrsquos decision toadopt the program The results indicated that intensivedissemination improved program adoption and thatprogram components were selected to fit the physicaland social context within antenatal clinics Managersbelieved the main barriers to the implementation of theprogram were the negative reactions of clientsinsufficient time available for smoking cessationinterventions lack of support from professionalcolleagues inability to provide follow-up to clientsstaff turnover and poor access and storage ofmaterials

INTRODUCTION

number of smoking cessation interventions (ieadvice education self-help material andcognitive-behavioural strategies to quit) have

been developed and tested for use in primary andsecondary health-care settings (Mattick and Baillie 1992)Randomised controlled trials indicate that the use of briefinterventions have a small but significant effect onsmoking quit-rates in both general and pregnantpopulations (Walsh and Redman 1993 Lumley 1992Baillie et al 1994) The lsquoFresh startrsquo smoking cessationprogram has been specifically designed for use during theantenatal period and has a 9 difference in validatedsmoking cessation when compared with usual care (Walsh1994)

Experimental trials investigating the effectiveness ofsmoking cessation programs are often tested in only one ortwo institutions Experimental trials require rigorouscompliance with program protocols therefore they areoften unable to adequately describe the factors whichinfluence adoption and implementation of the program byorganisations and clinicians (Susser 1995 Norman et al1990 Halvorsen et al 1993 Edmundson et al 1994)Experimental trials do not allow the investigation offactors (for example uptake of programs and programfidelity) which can influence the program outcomes whenthey are disseminated to a large number of institutions(Steckler et al 1992 Walsh et al 1990 Wiggers andSanson-Fisher 1994 Sanson-Fisher and Campbell 1994)Bauman et al (1991) states there is little guidance on howbest to disseminate and implement programs whenenvironmental conditions differ (eg experience of staffnumber of resources client populations) because there hasbeen inadequate research about the dissemination ofprograms These authors further suggest there is a need toidentify program and contextual factors necessary andsufficient for a desired outcome

Margaret Cooke SRN CM PhD is a researcher at the FamilyHealth Research Unit St George Hospital Kogarah New SouthWales Australia

Richard P Mattick PhD is an Associate Professor at theNational Drug and Alcohol Research Centre University of NSWSydney Australia

Elizabeth Campbell PhD is an Evaluation Officer at the HealthPromotion Hunter Centre for Health Advancement WallsendNew South Wales Australia


ACKNOWLEDGEMENTSThe research was a collaborative project by The New South Wales EducationResearch Program (NSW Cancer Council University of Newcastle) and theNational Drug and Alcohol Research Centre (University of New South Wales)It was supported by a grant received by Newcastle University from the PublicHealth Research and Development Committee awarded to Raoul WalshSelina Redman Maxwell Brinsmead and Maralyn Rowley and a PhDscholarship from the Drug and Alcohol Directorate NSW Department ofHealth The authors would like to thank Professor Lesley Barclay for editorialassistance The lsquoFresh startrsquo program was originally developed and tested byRaoul Walsh Hunter Centre for Health Advancement Wallsend NSW

A DESCRIPTION OF THE ADOPTION OF THE lsquoFRESH STARTrsquo SMOKINGCESSATION PROGRAM BY ANTENATAL CLINIC MANAGERS

RESEARCH PAPER

KEY WORDS antenatal smoking cessation program management take-up case history

A


The Cancer Education Research Program (CERP)disseminated the lsquoFresh startrsquo smoking cessation programto 23 antenatal clinics in NSW Australia The objectives ofthe project were to examine the relative effectiveness ofthe tested program using two methods of dissemination(simple and intensive) This paper describes thedissemination process and the adoption of the program byantenatal clinic managers Dissemination is the plannedand active diffusion of a new idea to a social system(Basch et al 1986) Rogersrsquo Diffusion of Innovation modelsuggests that the dissemination process can be described infive stages (Rogers 1995) These stages are knowledgepersuasion decision to adopt implementation andconfirmation Dissemination failure can occur at any ofthese stages and the model implies that different strategiesmay be required to promote dissemination during eachphase (Scott and Bruce 1994 Parcel et al 1990 Orlandi1987) This study describes the factors that influence amanagerrsquos decision to adopt the lsquoFresh startrsquo program

Several authors state that understanding the processassociated with health promotion programs is as necessaryas investigating the outcomes of such programs (Dolan-Mullen et al 1995 Portnoy et al 1989 Susser 1995)Information about the interaction between the context themechanism of delivery and the program is necessary todetermine the practicality and flexibility of the programand the generalisability of the outcomes (Susser 1995)This study aims to describe the lsquoFresh startrsquo smokingcessation program and its mechanism of dissemination Italso aims to gain some understanding of the range ofvariables which impact on program dissemination and amanagerrsquos adoption decision in different organisationalcontexts

A descriptive case history approach is used in this studyto explore the process of program dissemination tohospital antenatal clinics Case histories which aredescriptive rather than predictive in nature are useful forgenerating hypotheses and appropriate for this studybecause of the early stage of development ofdissemination research (Portnoy et al 1989) A case historyapproach is also appropriate due to the methodologicalissues inherent in studies investigating large complexsocial units It is difficult to obtain a sample of sufficientsize to carry out statistical analyses with adequate powerto test the effect of the large number of organisational andindividual variables (Dolan-Mullen 1995 Susser 1995)

Study aims

The principal objective of the research was to examinethe relative effectiveness of a tested smoking cessationeducation program using two methods of disseminationThis paper examines the dissemination process during theadoption phase of dissemination The specific aims are todescribe the adoption of the program by clinic managersthe factors which influence a managerrsquos decision to adopt

the program the perceived processes necessary forprogram implementation and the perceived barriers toimplementation

METHOD

The lsquoFresh startrsquo smoking cessation program wasdeveloped and disseminated by the Cancer EducationResearch Program (CERP) to 23 hospital antenatal clinicsA description of the design research materials and themethods used to disseminate the program will bepresented followed by the procedure used to evaluate theadoption of the program

Design

The research design was a randomised-controlled trialof the dissemination of a smoking cessation program usingtwo methods of dissemination (Simple and Intensive)This paper is a descriptive study of the adoption of theprogram by clinic managers three months postdissemination

Research materials

The lsquoFresh startrsquo smoking cessation program ismultifaceted and has components for policy developmenttraining of clinicians resources for smoking cessationintervention and program evaluation The smokingintervention component of the lsquoFresh startrsquo program hasbeen tested in a randomised controlled trial and found tobe effective (Walsh 1994) The program attempts toprovide smoking clients with a repetitive message aboutsmoking cessation through a variety of sources writtenvisual and interpersonal The interventions are designed totake a minimum amount of staff time (approximately 10minutes) and allow for flexibility according to the day-to-day demands of the clinic All hospitals received materialsto trial the program and could request more if requiredThese materials consisted of a training video and staff flipchart for staff a quit-kit video and stickers for clientsdetails about sample policy and computerised feedbackresources

Staff training video a 20-minute video that describeda seven-step approach which could be tailored to anindividual client needs These steps ranged from askingthe client about her smoking patterns to arrangement offollow-up dependent on the clientrsquos decision

Staff flip chart a chart used by staff to facilitatediscussion about smoking so that smoking cessationmessages could be reinforced and barriers to smokingcessation addressed with clients

Client stickers labels which provided informationabout smoking status and smoking cessation interventionsoffered to a client and which were designed to fit onantenatal records

RESEARCH PAPER

14


Client quit-kit consisted of written materials whichwere offered to clients These included the lsquoSmoking andPregnancyrsquo pamphlet (Quit Smoking and Pregnancy1993) a self help quit booklet lsquoExtra help to quit for goodrsquo(Quit Extra help to quit for life 1993) and a quitdeclaration These provided information about the effectsof smoking during pregnancy and strategies that could beused by the client to quit smoking

Client video a 15 minute video (Walsh 1994a) whichwas directed towards pregnant smokers and providedsimilar information to the quit kit but in a visual form Thevideo could be shown to groups or loaned to individualclients

Sample policy detailed the agreed role of clinic staffregarding detection treatment and follow-up of pregnantwomen who smoke Best practice recommendations weredescribed according to the readiness of clients to quitsmoking Policy formation was an important step toestablishing positive staff attitudes and practices tosmoking cessation and the sample policy could bemodified to best fit the context of the clinic

Computerised feedback a computer programdesigned to monitor smoking cessation intervention wasavailable for a duration of two weeks to those clinicsselected for intensive dissemination of the program

Clients used a touch screen computer to provideinformation about smoking status and smoking cessationintervention provided by the clinic Computerisedfeedback was only offered to the Intensive disseminationclinics because this component required negotiation andtraining which could not be executed via simple mail-out

Sample selection

All hospitals in NSW where there were greater than500 birthsyear were asked to participate in the trialTwenty-three hospitals agreed to participate after ethicsapproval by the area health service Two additionalhospitals did not participate because of a delay in ethicsapproval The 23 clinics were stratified according to clinicsize (number of births) and the proportion of smokingclients Hospitals were then randomly allocated to eitherthe simple or intensive dissemination groups The resultsof a previously conducted pre-dissemination survey(Cooke et al 1998) indicated that the disseminationgroups did not appear to differ in the number of bedsnumber of births number of clinic staff length ofappointment times type of decision-making staffperceptions of barriers to smoking cessation educationclinic size proportion of smokers current smokingcessation education (SCE) practice or barrier scores forproviding smoking cessation education (see Table 1)

RESEARCH PAPER

15

Variable Range Simple Intensive Significantdissemination dissemination differenceMean (sd) Mean (sd)n=12 n=11

Average no bedshospital 90-903 352 (296) 334 (227) ns

Average no birthshospital 818-4697 2508 (1207) 2089 (1098) ns

Average no clinic staffday 3-13 7 (2) 7 (2) ns

Average time for medical antenatal appointment 10-15 mins 121 (25) 114 (23 ns

Average time for midwifery antenatal appointment 10 -30 mins 179 (54) 145 (35) ns

Average staff rating for centralised decision-making 6-30 184 (20) 177 (22) ns

Average staff score for barriers to smoking cessation 11-42 248 (63) 251 (64) ns

Frequency of hospitals by type of hospital n = 12 n = 11

Tertiary 2 2

Regional referral 3 3

Teaching referral 2 3

District 5 3

Frequency of hospital with SCE policy 2 1

Frequency of hospitals with midwifery clinics 10 7

Table 1 Means and frequencies of variables by dissemination group


Dissemination methods

Two methods of dissemination were used to distributethe program (simple and intensive)

Simple Dissemination (SD) Twelve clinics were sentthe lsquoFresh startrsquo program components via a simple mail-out The covering letter was addressed to the antenatalclinic manager This letter gave information about the risksassociated with smoking during pregnancy theeffectiveness of brief interventions and how the lsquoFreshstartrsquo program could be used to overcome the barriers tosmoking cessation It provided a brief description of thevarious components offered in this program and how theyshould be used It also discussed the availability ofmaterials for clients who were unable to speak or readEnglish SD Clinics were given enough materials to trialthe program and a contact number should they desire morematerials to continue the program All materials wereprovided free of charge The computerised feedback wasthe only program component not offered to the SD clinics

Intensive Dissemination (ID) n = 11 For this group amail-out was facilitated by personal contact withmidwifery facilitators The ID clinics were also providedwith specific feedback from a pre-dissemination surveyabout the proportion of clients who were smokers and thelevel of smoking cessation intervention that was providedin the clinic Future evaluation of the program was offeredvia computerised feedback

The ID clinics were supplied with the name andphotograph of a midwife who would contact them withinseven days of receiving the package The role of thesemidwives was to persuade managers to adopt the programThey were also available to provide training and supportfor the program and to discuss any difficulties associatedwith the implementation of the program The midwiferyfacilitators were trained in the use of the lsquoFresh startrsquoprogram Clinics could contact the midwives at any timeThe midwives were able to provide materials as well asresources (such as video machines computers) necessaryto run the program

Evaluation procedure

Evaluation was undertaken by a) midwifery facilitatorswho kept a logbook on all contacts with the clinics b) astructured interview with clinic managers three monthsafter introduction of the program and c) the use of theMoore and Benbasat attribute scale (Moore and Benbasat1991) which measured each managerrsquos perception of theprogram

Logbook The midwifery facilitators kept logbooks ofall contacts with clinics The type of contact length ofcontact and a summary of the interaction betweenfacilitator and clinic were recorded

Interview Three months after the lsquoFresh startrsquoprogram had been disseminated 23 antenatal clinicmanagers were contacted by phone and asked about theirawareness and adoption of specific program componentsA structured interview schedule with some open-endedquestions was used to collect data The managers wereasked their reasons for adoptingnot adopting specificcomponents their plan for implementing the program andpotential barriers to implementing the program

The Moore and Benbasat attribute scale (1991) wasused to obtain the managers perceptions of the programWhilst this instrument was originally developed to studythe adoption and diffusion of information technologyMoore and Benbasat state that it could be modified toinvestigate other types of innovations (Moore andBenbasat 1991) This scale has been recommended for useby Rogers and is consistent with his ideas about influentialinnovation characteristics (Rogers 1995) The brief 25item version of the scale was reworded to improve facevalidity and piloted using 10 midwifery managers whowere sent the smoking cessation program but were notassociated with the dissemination The scale had itemswhich measured a managerrsquos perceptions of the relativeadvantage of the program compatibility with clinicroutines ease of use visibility of the program to othersdemonstrability of program outcomes ability to trial theprogram impact on professional status and degree towhich program use was voluntary Qualitative andquantitative analysis of the data was carried out usingcontent analysis and simple descriptive statistics todescribe the dissemination and adoption of the program

RESULTS

The results will describe the differences between thevarious dissemination methods (SD and IS) The findingswill be described in relation to the research aims whichwere the adoption of the program by clinic managers thefactors that influence a managerrsquos decision to adopt theprogram the perceived processes necessary for programimplementation and the perceived barriers againstimplementation

The dissemination process differences between SDand ID clinics

The facilitation of the program by midwives in theIntensive Dissemination clinics increased the level ofcontact with the change agency After the initial mail-outof the program only three out of twelve midwiferymanagers in the Simple Dissemination (SD) clinics hadcontacted CERP These managers requested more quit-kits flip charts and client videos Phone contact with thesethree clinics ranged between 5-35 minutes

RESEARCH PAPER

16


Phone contact and personal visits for the IntensiveDissemination (ID) clinics were usually initiated byCERP The ID clinics were contacted by phone 4-9 timesby the midwifery facilitators The duration of the calls wasbetween 12-95 minutes These calls were used to providefurther information about the program persuade themanagers to adopt the program obtain a firm decision toadopt the program and negotiate training sessions All buttwo clinics in the ID group had at least one personal visitfrom CERP midwifery facilitators These two clinicmanagers refused training as they believed that theprogram was self-explanatory Three of the ID clinics hadmore than one visit from the facilitators The visits wereprimarily used by midwifery facilitators to provideinformation about the program to managers and providetraining to clinic staff The average time for each visit wasapproximately 60 minutes

Program adoption

Of the 23 antenatal clinics 17 (4) reported adopting allof the program components 48 (11) were adopting partsof the program 17 (4) were planning to adopt the programand 17 (4) were not using or planning to use the programThe reported adoption of the program by clinic managerswas cross-checked with each facilitatorrsquos logbooks and thenumber of materials supplied to the clinics by CERP Therewas consistency for 16 of the 23 clinics Three clinics withdiscrepant findings appeared to be adopting (managers hadrequested and been provided with large numbers of programmaterials) even though the managers reported not adoptingthose components All these hospitals were in the ID groupID clinics may have been under some pressure fromfacilitators to accept program components Four hospitals(SD n=2 and ID n=2) reported they were adopting theprogram although they had not ordered extra componentsSeveral of these clinics stated they had other sources for thesmoking cessation quit kits

Significantly more of the six components of the lsquoFreshstartrsquo program were adopted by the ID group than by theSD group (See Table 2 - Adoption score)

The majority of clinics adopted the training video quit-kits client video and flip chart and perceived theseprogram components to be useful Overall clinics wereless likely to adopt the labelling stickers or the samplepolicy

Factors influencing adoption

Reasons for program adoption On average most ofthe managers rated the quality of the program as high (M= 73 sd 17 range 1-10) with eight of the managersspontaneously commenting on the lsquogoodrsquo quality of theprogram However the managersrsquo perceptions of attributes(Moore and Benbasat 1991) of the lsquoFresh startrsquo programdid not appear to differ due to the method of dissemination(See Table 2 -Attribute score)

Reasons given for adopting the program in order offrequency cited were to decrease the number of smokersthe quality of the program to improve womenrsquos healthstatus the availability of the program the unfulfilled needfor a smoking cessation program and to assist researchManagers who were planning to use the program but didnot have the complete authority to adopt the programstated that adoption was delayed due to the need to gainapproval from medical personnel Other managers whowere planning to use the program had difficulty organisingand providing staff with information and training for theprogram

Reasons for non-adoption of the program Therewere four managers who did not adopt the program Ofthese managers one had not received the program andthree managers reported clinic disruptions due to staffturnover and workload For example one clinic was in the

RESEARCH PAPER

17

Variables Mean Sd n 95 CI t p

TINT1

Intensive group 460 146 12 -100 - 135 31 nsSimple group 442 72 8Attribute score

2

Intensive group 6067 593 12 -1009 - 285 -118 nsSimple group 6429 730 7Adoption score

3

Intensive group 833 345 12 44 - 823 234 03Simple group 400 487 8

Note TINT1 = The mean number of types of smoking interventions used by staff in each antenatal clinic prior to dissemination This measurewas obtained from a pre-dissemination survey of all ANC staff in the participating clinics Attribute score2 = the addition of the sub-scale scores from the Attribute scale Adoption score3 = the number of program components adopted or planning to be adopted Components not being adopted were given a scoreof 0 planning to be adopted were given a score of 1 and components already adoptedimplemented were given a score of 2 n = number ofANC clinics in each group 95 CI = the 95 confidence interval of the difference between the means ns = not significant at = 05

Table 2 Mean differences between intensive and simple dissemination groups for TINT1 Attribute score2 and Adoption score3


RESEARCH PAPER

process of closing its maternity service and the manager hadchanged twice since the program had been disseminatedThe other clinic had a new manager and the third had a dailyrotation of midwives who required extensive orientation tothe clinic Two of these managers also expressed doubtsabout the effectiveness of smoking cessation duringpregnancy and the third was a smoker who believed it wasthe doctorsrsquo role to address drug use during pregnancy Thenon-adopters were aware that the program existed but onlyone was motivatedable to review and evaluate the program

There was a difference in the type and number ofcomponents adopted by the clinics and the reasons given foradoptingnot adopting them For example the flip chart wasbelieved to be a useful reminder to staff by severalmanagers but others believed it to be time-consuming andtoo lsquoclinicalrsquo to use with clients The stickers wereperceived to be useful by only a minority of the managersand two managers in the SD group believed labelling wouldhave negative consequences The sample policy was neitherpositively nor negatively rated by any of the managersAlso the client video was perceived by one manager to betoo confronting while another manager rated it as excellentbecause it did not lsquosanitisersquo the risks associated withsmoking

Furthermore the physical context within the clinicsinfluenced the adoption of some components For instancethe client video was perceived to be of limited use in threeclinic situations in crowded and noisy clinics in clinicswhere clients controlled the TV and in clinics which had novideo fixtures The quit-kits and client videos were alsoperceived to be of limited use in clinics with a highproportion of non-English speaking clients

Essential implementation processes

The managers indicated that important processes forprogram implementation included informing thestakeholders training program evaluation and structuralchanges They believed that it was necessary for hospitaladministrators to be accepting of the program Thisoccurred primarily through CERP gaining ethics approvalfor the research trial Nevertheless several of the midwiferymanagers also stressed the need to inform or gain approvalfor the program from both the nursing and the medicalsupervisors of the clinic Midwifery staff and to a lesserextent medical staff were informed of the program duringusual ward meetings or on an informal basis in smallerclinics Staff generally participated in discussions about theprogram and decisions to use the program except in oneinstance when the manager decreed the use of the program

The managers believed training was necessary to changestaff behaviour and attitudes For example somerespondents stated lsquostaff find it hard to get a woman to seta quit date as they are used to telling a woman to cut downrsquoTraining involved staff (mainly midwives) viewing the

training video in groups during an inservice sessionarranged by the midwifery facilitators (in the case of the IDclinics) or by the manager or midwifery educators (in theSD clinics) In a few clinics new staff were informed of theprogram during orientation

Several managers also perceived program evaluationwas important for the maintenance of the program beyondthe trial period These managers believed their supervisorswould require evidence that the program was effectiveThey also believed that their clinic would not be able toevaluate the program without the evaluation resourcesoffered by CERP

Finally managers from two clinics said that the programrequired structural changes within the clinic One clinicobtained extra staff to conduct the initial antenatal history tocope with the increased time associated with the use of theprogram The other referred interested clients to a clinicwhere staff who specialised in management of drug use inpregnancy were available This was done due to timeconstraints within the clinic

Implementation barriers

Open-ended questions were used to elicit the actual orpotential barriers associated with the implementation andadministration of the program These were categorised andTable 3 provides the number of participants who identifiedbarriers There was no difference in the total number ofbarriers identified by SD and ID clinics

The negative attitudes or reactions of a smoker to the

program were the most commonly cited barrier to programimplementation It was believed that clients would ignoreadvice given by clinicians and that this would haveconsequences for the patientclinician relationship Theprogram was also believed to be inappropriate for smokerswho could not speak English

The time involved with either using the program or intraining staff was also seen as a barrier to implementing theprogram by approximately half the participants Even thosemanagers who believed the program did not entail extra

Table 3 Frequency of ANC managers who reported barriers to theimplementation of the lsquoFresh startrsquo smoking cessation program

Barriers to implementation Frequency reported(n = 23)

Client behaviour 12Time 11Medical role 9Follow up failure 8Staff turnover 7Staff attitude 7Accessstorage of materials 4Staff training 4Cost 2Distance 1


RESEARCH PAPER

time were concerned about the availability of time tocarry out interventions in a busy clinic As one participantsaid lsquoif it is really busy it adds 10-15 minutes and if theclient is refusing to listenthis is not necessarily extratime as we covered it (smoking) anyway there is just notenough time to do everythingrsquo The managers estimatedthat the time needed to provide smoking cessationinterventions to smokers ranged between five to twenty-five minutes Furthermore although both ID and SDmanagers found it difficult to arrange time for inservicetraining the additional persuasion the ID managersreceived from midwifery facilitators meant that stafftraining was more likely to be organised in ID clinics thanin SD clinics

Another problem perceived by managers was thedifficulty in achieving the involvement of medical staff inthe program Medical staff did not usually attend wardmeetings or clinic training sessions This perception wassupported by the midwifery facilitators from CERPMidwifery staff had no control or authority over thebehaviour of medical staff Senior medical staff weresometimes believed to be unsupportive of the program andjunior medical staff were transient members of staff Therewas a common perception among the midwiferymanagers that medical staff did not believe smokingintervention was part of their medical role Thesestatements are typical of the comments made lsquoI donrsquot thinkthe medical staff will be actively involved particularly theVMOsrsquo and lsquoDoctors tend to call midwives to do smokingcessation because they donrsquot see it as their rolersquo TheCERP midwifery facilitators also believed that the doctorspreferred to have doctors to train them in the program

Lack of follow-up due to poor involvement of medicalstaff was perceived to be a barrier to the programMidwives began the program with clients at the initialhistory-taking visit but subsequent clinic visits werefrequently carried out by medical staff and the managersbelieved follow-up of smoking cessation intervention wasminimal This was particularly true when subsequent careoccurred outside the antenatal clinics for example duringshared care with general practitioners As one participantsaid lsquomedical staff are not supportive and there is aproblem with follow-up because of thisrsquo

Staff turnover although only mentioned by sevenparticipants appears to be a significant barrier to theimplementation of the program All of the clinics whichdid not adopt the program commented on the barrier dueto staff turnover Staff turnover was the only reason givenfor non-adoption by two of these clinics Associated withstaff turnover issues is the need to continually train staffand the time involved in doing this As one managercommented lsquowe have new students every three weeksyou have to reiterate it (the program) to them (students)five or six timesrsquo Another difficulty with training in larger

hospitals was getting the staff together in one place fortraining sessions

Finally a few of the participants saw that access andstorage of program materials future costs of the programand distance from the change agency were seen aspotential or real barriers to implementing the programTwo managers also commented on the need to modify theprogram to suit their clinic This could potentially decreasethe fidelity and effectiveness of the program

DISCUSSION

This study describes the lsquoFresh startrsquo smokingcessation program and the methods used by CERP todisseminate the program to 23 antenatal clinics Itdescribes the adoption process and explores some of thecomplex interactions between the program thedissemination method and the social context The findingsindicate that adoption of the program varies due to themethod used to disseminate the program Intensivedissemination clinics adopted more program componentsthan simple dissemination clinics Although the method ofdissemination did not influence a managerrsquos perception ofthe program individual beliefs of managers and thecontext within the clinic appeared to influence theadoption of the program and the selection of specificcomponents to be used by staff

A limitation of the study is that only a small number ofclinics were involved in the research The range ofvariables that influenced adoption within these clinics wasdiverse For this reason this study can only present someof the factors which may influence adoption and cannotfully determine the relative importance of these factors tothe outcomes of dissemination There may also have beensome lsquopressurersquo on managers in the ID clinics tolsquooverstatersquo their adoption of the program due to thepersuasion from CERP facilitators to use the programNevertheless the three general areas that seem toinfluence program adoption are dissemination methodprogram characteristics and social context Awareness ofthese areas and their relation to each other may assist inthe future design and dissemination of programs (Normanet al 1990)

Dissemination method

Intensive interpersonal contact with programfacilitators and the additional time training skill andmaterial resources supplied by the facilitators in the IDclinics increased the number of program componentswhich were adopted when compared with simpledissemination (SD) However simple dissemination andincreased availability of program materials seems to besufficient to increase awareness and encourage at leastpartial adoption of the program by clinics It remains to be


seen whether the number of components adoptedinfluences the implementation and the cost-effectivenessof the program

It is difficult to form any firm conclusions about thecauses of adoption failure as only a small number ofclinics failed to adopt the program Nevertheless simpledissemination resulted in adoption failure in one clinicbecause there was no follow-up of the mail-out to checkthat clinics had received the program This adoptionfailure could be addressed by improving the simpledissemination procedure A routine follow-up of allclinics two or three months after the initial disseminationmay increase adoption of the program

The intensive dissemination involved the use ofmidwifery facilitators A small proportion of midwiferymanagers believed that the program would not beeffective Similar to other research studies managers withnegative attitudes towards smoking cessationinterventions were less likely either to adopt the programor to support its use by other staff members (Saunders andFoulds 1992 Bruce and Burnette 1991) Interpersonalcontact with facilitators compared with written materialsonly did not improve the perceptions midwifery managershad about the program (Rogers 1995) Although intensivedissemination increased the number of componentsadopted by managers this does not appear due to thechanging of managersrsquo attitudes but may have improvedthe accessibility and availability of the programcomponents

The program characteristics

Adoption of the program appeared to be facilitatedbecause the managers were able to select componentsperceived from the variety of program components asmost suitable for their clinic There was wide variation inthe program components that were adopted andimplemented by clinic managers Several factorsassociated with the clinic environment appeared toinfluence their adoption decisions These were theattitudes of the managers client characteristics(particularly language) and the physical setting andresources of the clinic

The components which were least likely to beimplemented were the stickers (which recorded smokingstatus and treatment) and the sample policy Bauman andcolleagues suggest that lack of program fidelity may haveimplications for the implementation and maintenance ofthe program (Bauman et al 1991) Stickers on clients notesmake the program more visible and act as cues forclinicians to provide intervention and follow-up Severalstudies indicate that cues improve the effectiveness ofsmoking cessation interventions (Lindsay and Wilson1994 Kottke et al 1994) Furthermore use of the stickersmay increase the ability of the clinic to evaluate program

implementation and its effectiveness The managers in thisstudy suggest program evaluation is critical for programmaintenance and this is supported by other research(Kottke et al 1994 Rogers 1995)

The other component which was generally not adoptedby the clinics was the policy for smoking cessationintervention Policy development has been found to beassociated with increased levels of smoking cessationwithin hospitals (Cooke et al 1996) The managerssuggested there were two factors that influenced the non-adoption of policy development Firstly the program wasperceived as a research trial and the managers werereluctant to commence policy development procedureswithout evidence of the programrsquos effectiveness Policydevelopment within hospitals also involved severalorganisational levels and professions The managersbelieved policy adoption required a substantial amount oftime and effort It may be that policy adoption requiresmore time and should occur later in the disseminationprocess While changes to the program may influence thefidelity and effectiveness of the program when a clinicwas flexible enough to allow these changes programadoption was enhanced (Bauman et al 1991)

Social context

Program adoption was facilitated when managers wereable to make necessary changes to the social setting suchas organising training increasing staffing and changingclinic structure This supports the assertion thatorganisational change is often necessary for theimplementation of health education programs (Rogers1995) It also indicates that the degree of flexibility withinthe social context is an important factor in thedissemination process (Dolan-Mullen et al 1995 Rogers1995) The ability of organisations to adapt to change isbelieved to be influenced by the complexity and nature ofcommunication networks with organisations (Rogers1995)

The social context of the clinics also may havehindered program dissemination Although the lsquoFreshstartrsquo program was believed to be relatively advantageousit was also perceived to have some negative consequencesAlmost half the managers believed that the program wouldhave a negative effect on the patientclinician relationshipand that there were significant time and resource costsassociated with its implementation Negative attitudes andlack of time are frequently cited barriers to healthpromotion adoption and these perceptions will need to beaddressed if successful implementation and maintenanceof the program is to occur (Wender 1993)

In addition to the social context situational constraintsof the clinics such as the staff turnover problems withfollow-up the proportion of non-English speaking clientsthe clinicrsquos physical environment and distance from the

RESEARCH PAPER

20


change agency were believed to be barriers to programadoption The barriers to the program were specific to eachclinic and need to be addressed by clinic staff duringimplementation planning Mechanisms and strategies toidentify and overcome barriers to program implementationin each organisation should be part of the disseminationprocess

Finally some midwifery managers appeared to lack theauthority to influence people who have a key role inprogram adoption and implementation such as medicalstaff and hospital administrators The managers generallybelieved medical staff were either unsupportive of theprogram or disinterested Whether this perception isaccurate or not it is likely to have acted as a barrier toprogram dissemination to medical staff and should beaddressed in future dissemination efforts

CONCLUSION

Evaluation during the early phases of dissemination canhighlight factors that may facilitate or hinder adoptionAdoption is facilitated by the intensive interpersonaldissemination program flexibility managerial supportand adaptability of the clinic But lack of program fidelityand situational barriers to program implementation are ofconcern The effect of these factors on the implementationand the eventual outcomes of the program will be exploredin future papers investigating the dissemination of thelsquoFresh startrsquo program

The barriers to the dissemination of a smokingcessation program are specific to each clinic A processwhich could be used to identify and address potentialbarriers to adoption and implementation should be acomponent of any health promotion program

REFERENCESBaillie AJ Mattick RP Hall W Webster P 1994 Meta-analytic review ofthe efficacy of smoking cessation interventions Drug and Alcohol Review13157-170

Basch C Eveland J Potnoy B 1986 Diffusion systems for education andlearning about health Family and Community Health 9(2)1-26

Bauman L Stein R Ireys H 1991 Reinventing fidelity The transfer ofsocial technology among settings American Journal of CommunityPsychology 19(4)619-639

Bruce N Burnette S 1991 Prevention of lifestyle related disease Generalpractitionersrsquo views about their role effectiveness and resources FamilyPractice 8(4)373-379

Cooke M Mattick R Barclay L 1996 Predictors of brief smokingintervention in a midwifery setting Addiction 91(11)1715-1725

Cooke M Mattick RP Campbell E 1998 The influence of individual andorganisational factors on the smoking intervention practices of staff in 20antenatal clinics Drug and Alcohol Review 1(2)179-189

Dolan-Mullen P Evans D Forster J Gottlieb N Kreuter M Moon ROrsquoRourke T Strecher V 1995 Settings as an important dimension in healtheducationpromotion policy programs and research Health EducationQuarterly 22(3)329-345

Edmundson EW Luton SC McGraw SA Kelder SH Layman AKSmyth MH Bachman KJ Pedersen SA Stone EJ 1994 CATCHClassroom process evaluation in a multi-centre trial Health EducationQuarterly (Supplement) 2S27-S50

Halvorsen HW Cohen SJ Brekke KL McClatchey MW Cohen MM1993 Process evaluation of a system (Partners for Prevention) for prevention-orientated primary care Evaluation and the Health Professions 16(1)96-105

Kottke TE Solberg LI Brekke ML Conn SA Maxwell P BrekkeMJ 1994 Doctors helping smokers Development of a clinic-based smokingintervention system In NIH Publication No 94-3693 Smoking and tobaccocontrol Monograph 5 - Tobacco and the clinician Intervention for medicaland dental practice United States Department of Health and Human ServicesRockville MD National Institute of Health pp69-91

Lindsay EA Wilson DM 1994 Effects of training family physicians in acomprehensive smoking cessation intervention In NIH Publication No 94-3693 Smoking and tobacco control Monograph 5 - Tobacco and the clinicianIntervention for medical and dental practice United States Department ofHealth and Human Services Rockville MD National Institute of Health USpp48-68

Lumley J 1992 Strategies for reducing smoking in pregnancy In EnkinMW Keirse MJ Renfrew MJ Neilson JP (eds) Pregnancy andchildbirth module Cochrane database of systematic reviews - Review no03312 2 October Oxford England

Mattick R Baillie A 1992 An outline for approaches to smoking cessationMonograph Series No19 Australian Government Publishing ServiceCanberra

Moore GC Benbasat I 1991 Development of an instrument to measure theperceptions of adopting an information technology innovation InformationSystems Research 2(3)192-222

Norman SA Greenberg R Marconi K Novelli W Felix M SchechterC Stolley P Stunkard A 1990 A process evaluation of a two-yearcommunity cardiovascular risk reduction program What was done and whoknew about it Health Education Research 5(1)87-97

Orlandi M 1987 Promoting health and preventing disease in health caresettings Preventive Medicine 16119-130

Parcel G Perry C Taylor W 1990 Beyond demonstration Diffusion ofhealth promotion innovations In Bracht N (ed) Health promotion atcommunity level London Sage

Portnoy B Anderson M Erikson MP 1989 Application of diffusion theoryto health promotion research Family and Community Health 12(3)63-71

Quit 1993 Extra Help to Quit for Good Melbourne Victorian Smoking andHealth Program

Quit 1993 Smoking and Pregnancy Melbourne Victorian Smoking andHealth program

Rogers E 1995 Diffusion of innovations 4th edn New York Free Press

Sanson-Fisher R Campbell E 1994 Health research in Australia Its role inachieving the goals and targets Health Promotion Journal of Australia4(3)28-33

Saunders JB Foulds K 1992 Brief and early intervention Experience fromstudies of harmful drinking Australia and New Zealand Journal of Medicine22224-230

Scott S Bruce R 1994 Determinants of innovative behaviour A path modelof individual innovation in the workplace Academy of ManagementJournal37(3)580-607

Steckler A Goodman R McLeroy K Davis S Koch G 1992 Measuringthe diffusion of innovative health promotion programs American Journal ofHealth Promotion 6(3)214-224

Walsh R 1994b Smoking Cessation in Pregnancy PhD dissertationDiscipline of Behavioural Science in Relation to Medicine NewcastleUniversity Newcastle Australia

Walsh R Redman S 1993 Smoking cessation in pregnancy Do effectiveprogrammes exist Health Promotion International 8(2)11-127

Walsh R Redman S and Brinsmead M 1990 Smoking intervention duringpregnancy The global war 7th World Conference on Tobacco and HealthWHO and Health Perth Australia

Wender RC 1993 Cancer screening and prevention in primary care Cancer721093-1099

Wiggers JH Sanson-Fisher R 1994 Smoking cessation Behavior Change11(3)167-176

RESEARCH PAPER

21


NURSING Bits Bytes+ON-LINE ALCHEMY - PREVENTING GOLD BEING TURNED INTO LEADDr Rod Sims

T he shift to technology-based and on-line learning has beenmatched by more focus on learners and learning throughstudent-centred approaches to curriculum development

As tertiary educational institutions rely more on the on-linedelivery and access of their courses there can be acorresponding increase in expectations on the independent andoften geographically isolated learner to use those materialseffectively This article argues that to make these resourcesvaluable to the user requires the skills of an alchemist asproducing materials for on-line consumption is not aboutcreating nice-looking digital paper but of harnessing the magicthat on-line environments can provide through employing newmethods of information and visual communication

Are you enchanted every time you use your Internet browser tojourney through the world of digital information - or are youfaced with a maze of flashing images too many buttons and acomplicated network of links It is these contrasting images ofthe enchanted and disenchanted user (Rose 1999) thatprompted the need to reassess what is presented on computerdisplays to better understand how the vast amounts ofinformation can be accessed and interpreted effectivelyAlthough the Internet continues to be lauded as the next greateconomy research projects are highlighting the problems thatindividuals can have with the extensive array of informationbeing made available electronically and the demands ofemployers for that information to be retrieved in a timely andmanageable fashion

For example a recent research project conducted throughSouthern Cross University NSW investigated the phenomenonof interactivity by metaphorically placing it on stage andauditioning it for the role of human-computer communicationThe research participants were the adjudicators for the auditionand the research data presented a new set of variables by whichthe interaction between human computer and information mightbe considered These variables present the means for enhancinginteractivity in the context of human-computer communicationand are a necessary focus for those involved in web-development by

Reducing interactive interference ~ ensuring that multimedia components do not interfere or interrupt theuserrsquos interpretation with the content

Establishing interactive balance ~ creating an environmentin which the user is able to watch explore navigatebecome involved and manipulate content without beingdistracted by non-essential information

Creating environments where users are in control ~ too often we assume that having access to options equates to control over the environment ensuring the user has adequate information to be in control of their informationneeds is critical for all human-computer communications

Enabling interactive negotiation between designer and user~ conceptualising the user as someone who is workingwith the designer of the content and not the computer as presenter of content will allow that user to negotiate how to access and retrieve the content - rather than beingforced to cater for another persons ideas of what is best

Allowing the user to be an actor rather than being a passiveonlooker to streams of images ~ the user has a right toactively participate in an interactive experience

The on-going success of human-computer communication willbe through interactivity as a manifestation of communicationbetween the designer and the user If designers can develop theirideas into a performance such that the user is integrated withthat illusion of being on stage then the magic and engagementso eagerly sought after might well be realised And this is thechallenge for the on-line developer - to become an alchemistwho transforms content into a form with which the user trulyinteracts

REFERENCES

Rose E 1999 Deconstructing interactivity in educational computing Educational

Technology 39(1)43-49

Dr Rod Sims is Associate Professor in the School of Multimediaand Information Technology at Southern Cross University CoffsHarbour Australia With an extensive career in computerseducation teaching and learning spanning over 25 years heremains passionate about realising effective relationshipsbetween computers and people


CYBERNURSE-General SitesPaul Kogler

wwwthegovernmentcomozschool

Canrsquot seem to find your old school photos Need to find anembarrassing photo for a colleaguersquos 40th birthday This siteclaims to have a comprehensive database of nearly everyschool photo taken in Australian schools They guarantee tohave at-least 98 of all Australian studentsrsquo photos in theirdatabase

wwwrosesonlycomau

You get to work and open your diary only to discover thattoday is your anniversary thatrsquos ok Just log ontorosesonlycomau order an arrangement and recover instyle Rosesonlycomau has a large selection ofarrangements coming in many different styles colours andaccessory options at very reasonable prices They guaranteesame day delivery

wwwolympicscomeng

The official site of the Sydney 2000 Olympics games Forthose who have not already had enough this site offers goodinformation for both domestic and international visitors

wwwhealthpostscomau

Healthpostscomau has a comprehensive listing of medicaljob vacancies appropriate for those associated with thehealth profession Positions can be applied for via this sitesimilarly one can advertise a position throughhealthpostscomau

wwwaflcomauhomedefaulthtm

AFL - Need I say more For all the scores news previewsevents and footy tips this place is it

wwwrleaguecom

Who captained Canterbury in the 1988 grand final whenBalmain won 24-12 Find out here All the latest scores andnews from around the world are available here

wwwa2zcomau

A site designed for those with better things to do on aSaturday than go shopping A site that allows you to browseand order everything that you would normally expect to findat your local Coles Supermarket Most major brands areavailable from a wide variety of departments The site is userfriendly competitively priced with a high convenience factorbut most products are only available in bulk

wwwwhitepagescomau

Most will have already discovered this extremely useful sitebut for those who have not it provides instant access to allwhite pages in Australia

BITS AND BYTES

A coalition of 18 major American nursing and health careorganizations including the Honor Society of Nursing SigmaTheta Tau International the American Organization of NurseExecutives the American Hospital Association and the AmericanRed Cross - have launch a new Web site wwwnursesourceorg

The site features information about the nationrsquos nursing shortageand how NHT is addressing the problem

The coalition is organizing a national media campaign to recruit more nurses According to the Bureau of Labor Statistics employment opportunities for registered nurses willgrow more rapidly than all other US occupations through 2008Despite this accelerating demand nursing school enrollmentshave declined for five consecutive years leading to a growingnursing shortage

The new Web site is designed to help close this gap Nursingprofessionals will be able to use the site to research thousandsof health care careers and job opportunities

VitalCareerscom an Internet company focused on careercontent for health care employers and professionals has signedon as a major sponsor of the Nurses for a Healthier Tomorrowcampaign and also developed the Web site VitalCareerscomprovides an exclusive community for professionals who registertheir profiles to receive access to information about clinical andnon-clinical health careers

The site is linked to an interactive health careers job-bankdatabase operated by VitalCareerscom allowing Internet usersto search for career opportunities nationally

NURSES FOR A HEALTHIER TOMORROW (NHT)





wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT

A survey of 172 Australian triage nurses wasundertaken to describe their scope of practiceeducational background and to explore the self-reported influences perceived to impact on theirdecision-making

The survey results reveal variability in the educationalrequirements for nurses to triage Indeed over half ofthe nurses who participated in the study worked inemergency departments that provided no specifiedunit-based triage education Additionally substantialinter-respondent variations in nursesrsquo self-reportedparticipation in a range of decisions to expediteemergency care were identified Analysis revealedsignificant associations between demographiccharacteristics of the triage service levels of nurseautonomy and the nursesrsquo self-reported participationin a number of triage decisions

The findings of this study have implications foremergency nurse education and the development andevaluation of triage practice guidelines

INTRODUCTION

T riage is a process of prioritising patients whoattend an emergency department (Handysides1996) In Australia registered nurses assign a

triage code using the National Triage Scale (NTS) Thisscale requires the nurse to allocate the patient into one offive categories according to how long they should wait formedical care Two types of triage decisions have beendescribed in the literature (Australian CommonwealthDepartment of Health and Family Services 1997 Geraciand Geraci 1994 Purnell 1991 Purnell 1995) Primarytriage decisions relate to initial patient assessmentdetermining patient acuity administering first aid anddeciding patient dispositions Secondary triage decisionsare concerned with the initiation of nursing interventionsin order to expedite emergency management (AustralianCommonwealth Department of Health and FamilyServices 1997)

The qualities of decisions made by nurses with regardto the primary triage role have important implications forpatient outcomes (Manchester Triage Group 1997) Forthe patient a poor triage decision may result in a delay inlife or limb-saving interventions andor permanentdisability However a number of authors have suggestedthat triage nurses frequently make secondary decisions toinitiate nursing interventions aimed at expeditingemergency care (Gerdtz and Bucknall 1999 Purnell1995) Indeed interventions provided by triage nurseswhile the patient is waiting for medical assessment mayimpact upon patient outcomes (Parris et al 1997 Purnell1995)

Triage Primary roles and secondary roles

The triage nursesrsquo primary role is to allocate a triagecode The triage code reflects the patientrsquos clinical needand precedes medical diagnosis (CommonwealthDepartment of Health and Family Services 1997) While

Marie Gerdtz BN AandECert GradDip Adult Ed and Training is a PhD candidate at the School of Postgraduate NursingUniversity of Melbourne and a Clinical Nurse EducatorEmergency Care Centre St Vincentrsquos Public HospitalMelbourne Australia

Tracey Bucknall BN IntCareCert GradDip Advanced NursingPhD is a Senior Lecturer at the School of PostgraduateNursing University of Melbourne Australia

Accepted for publication April 2000

ACKNOWLEDGEMENT The authors wish to acknowledge the support of the Emergency NursesrsquoAssociation of Victoria Inc and thank the nurses who filled out thequestionnaire

AUSTRALIAN TRIAGE NURSESrsquo DECISION-MAKING AND SCOPE OF PRACTICE

KEYWORDS self-reporting survey decision-making triage nurses

the complexity of the decision to allocate a triage code iswell recognised (Cioffi 1998 Corcoran et al 1988 Gerdtzand Bucknall 1999) there remains a paucity of research inthe published literature regarding other decisions related tothe primary triage role These include nursesrsquo decisions onpatient dispositions and referring non-urgent patients toother health providers

Secondary decisions made by triage nursesrsquo have beendescribed in terms of individual tasks such as ordering X-rays for patients with limb injuries (Lee et al 1996Macleod and Freeland 1992 Parris et al 1997) or thecollection of blood for laboratory tests (Purnell 1991) InPurnellrsquos (1991) survey of 185 emergency departments inthe United States twelve tasks frequently performed bytriage nurses were identified

Building on the work of Purnell (1991) Geraci andGeraci (1994) conducted a 72-hour observational study ofthe triage nursesrsquo role in one emergency department Theyidentified a list of tasks performed by triage nurses for 466patients In addition to the scope of tasks performed bytriage nurses both North American authors discuss anumber of factors that may influence nursesrsquo participationin performing these tasks These factors include thephysical facilities provided at triage the level of autonomytriage nurses have to make decisions and thecharacteristics of triage nurses including their educationalbackground and level of experience

In Australia Standen and Dilley (1998) have reportedvariability in both the educational preparation of triagenurses and various aspects of the triage role Howeverlittle has been discovered about the complex patient nurseand organisational variables that influence triage nursesrsquodecision-making in practice These issues represent aserious gap in the knowledge required for the developmentof practice-based triage education

The task environment

Clinical reasoning comprises a psycho-dynamicrelationship between the human problem-solver and thetask environment (Fonteyn 1995) In their seminal workElstein et al (1978) described the hypothetico-deductivemodel of decision-making used by physicians from aninformation-processing standpoint The hypothetico-deductive model describes decision-making as aninteractive process of data collection hypothesisgeneration cue interpretation and hypothesis evaluation(Elstein and Bordage 1988) Within the information-processing paradigm clinical decisions are studied incontext of practice (Dowie and Elstein 1998) Lyneham(1998) researched emergency nursesrsquo decision-makingusing a modified grounded theory approach and concludedthat the hypothetico-deductive model was used by nurseswhen conducting initial patient assessments

Indeed a commonly used method applied to the studyof triage nursesrsquo decision-making involves the use ofsimulated patient scenarios (for example see Dilley andStanden 1998 Jelinek and Little 1996) Simulated patientscenarios however fail to take into account that as with alldecisions the triage decision is socially constructed(Edwards 1998) It is argued that contextual factors withinthe task environment such as time limitations stress andsocial interactions cannot be replicated when simulateddecisions are made (Thomas et al 1989) For these reasonsseveral authors (Bucknall 1996 Watson 1994) haveadvocated a triangulation approach to the design ofdecision research in nursing combining multiple methodsto address a range of questions (Greenwood 1998)

This paper reports on one part of a major researchprogram aimed at developing a comprehensive descriptionof triage nursesrsquo decision-making The purpose of thisexploratory study was three-fold first to describe thescope of clinical decisions made by triage nurses secondto describe levels of experience education and specialtraining required for nurses to perform the triage role andthird to examine the self reported influences which areperceived to impact upon triage nursesrsquo decision-makingin practice

RESEARCH AIMS

The aims of this study were to

Describe the level of appointment experience and educational background of triage nurses in the state of Victoria Australia

Describe the incidence of decision-making reported bythe triage nurses surveyed with regard to eighteen clinical decisions drawn from triage practice

Describe the level of autonomy triage nursesrsquo report tohave in relation to eighteen clinical decisions drawn from practice

Explore the relationship between demographic characteristics of the triage services and triage nursesrsquoparticipation in decision-making

Explore the relationship between triage nursesrsquo levels of autonomy and their reported participation in decision-making

METHOD

A descriptive exploratory method was chosen toaddress the research aims This method was selected tofacilitate both an initial description of the taskenvironment and an exploration of the scope andfrequency of decision tasks undertaken in practiceBeanland et al (1999) identify descriptiveexploratory


RESEARCH PAPER


survey studies as an effective research method insearching for information about the characteristics ofsubjects groups or organisations and the frequency of aphenomenonrsquos occurrence

Sample

Following ethics approval the Council of theEmergency Nurses Association of Victoria Incorporated(ENA Vic Inc) approved the study and provided access toits membership database All ENA members (285)received a letter of explanation and an invitation toparticipate in the study the questionnaire and a reply paidenvelope

Questionnaire

A self-reporting questionnaire was developed to collectinformation regarding the nursesrsquo clinical decision-makingat triage and their demographic characteristics Thisapproach was selected as the most suitable method of datacollection as a large sample was necessary in order todescribe the nursesrsquo scope of practice in a variety ofsettings The survey approach also avoided the difficulttask of accessing multiple sites that may have only smallnumbers of nurses performing the triage role

Validity

The content validity of the instrument was supported bya literature review and pilot study The pilot questionnairewas administered to ten triage nurses Feedback wasobtained regarding the scope of responses offered and theclarity of questions asked A number of revisions weremade prior to the questionnaire being distributed Thequestionnaire was divided into two sections

Section one comprised of questions on demographiccharacteristics which were informed by the work ofPurnell (1991) and included the type of emergency facility(generalist or specialist) the number of hours worked andthe nursesrsquo qualifications

Section two comprised of questions concerningeighteen skilled tasks performed by the triage nurse Theapproach to questioning was based on a recent study ofcritical care nursesrsquo clinical decisions (Bucknall andThomas 1995) The skilled triage tasks chosen forinclusion in this study were identified in the work ofPurnell (1991 1995) and Geraci and Geraci (1994) andwere selected to represent a range of triage activities ofvarying complexity For each of the eighteen tasksexpressed as a triage decision participants were requiredto answer three questions The first question requiredparticipants to indicate the level of autonomy they have intheir work place to make the decision A five-point Likert-type scale was employed to grade the response Theresponse categories were represented along the scalepoints as lsquoguided by the triage assessment of each

individualrsquo lsquodirected by departmental protocol orguidelinesrsquo lsquorequires a doctorsrsquo orderrsquo (neutral category)lsquonot performed due to resource limitationsrsquo and lsquonotpermittedrsquo The second question asked the participant tostate the frequency with which they made the decisionsidentified A six-point Likert-type scale was employedwith the points of the scale

1 lsquoneverrsquo

2 lsquoat least once per yearrsquo

3 lsquoat least once per monthrsquo

4 lsquoat least once per weekrsquo

5 lsquoat least once per triage shiftrsquo

6 lsquoseveral times per triage shiftrsquo

In order to determine the scope of triage decision-making the final question required participants to identifylsquoany triage decisions they made on a regular basis withoutmedical supervisionrsquo that had not been listed

Analysis

Descriptive and inferential statistics were utilised toexamine the nursesrsquo responses to each of the eighteenlisted decisions Content analysis was used to exploreother decisions the nursesrsquo reported to have made in thetriage area without medical supervision

Data analysis was performed using Statistical Packagefor Social Sciences For the purpose of analysis thedecision data cells were collapsed to yield three categoriesto describe frequency frequent decisions included thosemade several times per shift daily or weekly infrequentdecisions were those reported to be made monthly oryearly and never were those decisions never madePearsonrsquos Chi-square test was used to examine therelationship between the frequency with which the nursesreported making each of the listed decisions and theindependent variables identified Fishers Exact Test wasutilised when the expected frequency within cells of thecontingency table was small

In analysing associations between nursesrsquo levels ofautonomy and their participation in decision-making thedecision data cells were collapsed to yield two nominalcategories independent nursesrsquo able to make thedecisions based upon their own assessment andor byusing protocols or guidelines and contingent nursesrsquo ableto make the decision by obtaining a doctors order Nurseswho reported being unable to make the decision either dueto resource limitations or who were not permitted to makethe decision at triage were excluded from this section ofanalysis

RESULTS

RESEARCH PAPER


Demographics

The convenience sample of 285 emergency nursesaccessed for this study represents 227 of Victorianemergency nurses (Victorian Government Department ofHuman Services and Division 1999) A response rate of6807 (n=194) was achieved A small number ofrespondents were excluded from the study because theywere not currently practicing triage (n=23) A total of 172returned questionnaires were subject to analysis

Thirty-seven separate emergency departments wererepresented in the sample identified by cross checkingpostcodes with the Victorian Department of Health andCommunity Services listing public and private hospitals(Victorian Department of Human Services 1999) Thedemographic characteristics of the sample are outlined inTable 1

Incidence of decision-making

The self-reported incidence of decision-making for theprimary triage role revealed high percentages of decision-making in all of the decisions listed In particulardecisions to evaluate vital signs and to splint an injuredlimb were frequently made by the majority of nursesTable 2 shows a detailed presentation of the reportedfrequency of decision-making for each of the primarytriage decisions listed The nursesrsquo reported frequency ofdecision-making for the secondary triage role revealed agreater degree of inter-respondent variation than thedecisions related to the primary triage role

Table 3 summarises the overall incidence of decision-making with regard to the secondary triage role Over halfof the nurses reported frequent participation in decisions toperform a urinalysis utilise pulse oximetry perform bloodglucose monitoring and order an X-ray for an isolated limbinjury

The results of the content analysis provide a descriptionof decisions other than the eighteen listed in the surveythat the nursesrsquo reported to be making in the triage areawithout medical supervision The data was examined andcoded according to seven themes that emerged from thenursesrsquo comments The main theme was triage referral(32) which involved a number of subcategories thesewere accessing psychiatric liaison services (116) drugand alcohol detoxification services (34) and facilitatingaccess to specialist medical services (52) Other majorthemes included administering analgesia (47)administering first aid (156) activating emergencyresponses (47) conducting focused physicalassessments (81) and directing ongoing nursingmanagement (122)

RESEARCH PAPER

27

Table 1 Demographic characteristics of the study sample (n=172)

Variable n Mean SD

LocationRuralremote 48 279

designated triage nurse 29 604

no designated triage nurse 19 296

Metropolitan 124 721designated triage nurse 116 935


Patient presentationslt10000 15 87

10000-30000 61 355gt30000 86 500

Type of emergency serviceGeneralist 128 744

Adult only 34 198

Specialist 10 58

Hospital typePublic 160 930

Private 12 70

Appointment levelRegistered Nurse 40 233

Clinical Nurse Specialist 59 343Associate Charge Nurse 73 424ChargeNurseother

Education LevelRegistered Nurse without 73 424emergencyor critical care qualification

Registered Nurse with 99 576certificate or Graduate Diploma in critical care or emergency nursing

Educational requirements specific to triageTriage orientation (lt 1 week) 65 378

Triage preceptorship (gt 1 week) 23 134

No unit-based education 84 552specified to triage

ExperienceYears as a Registered Nurse 1363 787

Years as an Emergency Nurse 858 569Hours worked per fortnight 5872 1960in emergency area

Hours worked per fortnight 1851 1294at triage


RESEARCH PAPER

Table 2 Nursesrsquo self-reported frequency of decision-making regarding the primary triage role (n=172)

Reported frequency of decision-making

Decisions Frequently Infrequently Never No resourceNot permitted

To evaluate vital signs 959 12 06 24(complete set or single parameter)To splint an injured limb 918 76 0 06

To re-evaluate a patient 812 153 18 18in the waiting area

To refer a non-urgent 749 53 06 193(NTS 5 ) patient to a general practitioner

To consult with an 776 93 56 75inpatient unit

Key

Frequent = several times per shift once per shift once per week

Infrequent = once per month once per year

Never = the decision is never made

No resourcenot permitted = decision cannot be made due to resource limitations or nurses are not permitted to make the decision

Table 3 Nursesrsquo self-reported frequency of decision-making regarding the secondary triage role (n=172)


Decisions Frequent Infrequent Never No resourceNot permitted

To perform a urinalysis 924 41 06 30

To utilise pulse oximetry 819 47 29 105

To perform a blood 731 175 06 88glucose measurement

To administer paracetamol 714 136 79 12to a febrile childTo order an X-ray 546 55 117 283(for an isolated limb injury)

To perform a Plaster of Paris 467 132 72 329check

To administer oxygen therapy 438 107 41 414at triage

To initiate oral re-hydration 541 226 113 12therapy in a child

To administer nebulised 339 109 73 479medicationTo initiate an electrocardiograph 302 136 47 514

To collect venous blood 276 192 122 410for laboratory studies

To initiate intravenous 243 70 89 597cannulation

Key






RESEARCH PAPER

Levels of autonomy

Of the nurses surveyed 473 made the mandatorydecision to allocate a triage code based on their ownassessment in all cases 7 were directed by protocols orguidelines in all cases and 456 made the decision toallocate a triage code based upon a combination of theirown assessment with some specified chief complaintsdirected by protocols or guidelines In Table 4 the level ofautonomy for decisions linked with the primary triage roleare presented

Analysis of nursesrsquo reported levels of autonomy for thesecondary triage role revealed a greater degree of inter-respondent variability than the primary role Table 5outlines the level of autonomy for decisions linked withthe secondary triage role

Triage nursesrsquo self-reported levels of autonomy werefound to be significantly linked to increased frequency ofdecision-making in six of the decisions listed Thedecisions shown in Table 6 are those which weresignificantly more likely to be made by nurses in the

Table 4 Triage nurses self-reported levels of autonomy for primary triage decisions (n=172)

Decision Level of Autonomy

Own assessment Protocol Guideline Doctorsrsquo order No resourceNot permitted

To evaluate vital signs 929 41 0 29(either a complete set or a single parameter)

To splint an injured limb 917 71 0 12To re-evaluate a patient 906 58 06 29in the waiting area

To refer a non-urgent (NTS 5) 610 140 12 238patient to a General Practitioner

To consult with an inpatient unit 639 139 150 72

Table 5 Triage nurses self-reported incidence of autonomy for secondary triage decisions (n=172)





To perform a blood glucose 843 47 12 99measurementTo administer paracetamol to a 348 255 326 81febrile child

To order an X-ray (for an isolated 70 205 392 332limb injury




To administer nebulised 236 124 176 567medicationTo initiate an 413 36 30 520electrocardiograph

To collect venous blood 178 59 333 428for labratory studies



independent group (able to make the decisions based upon

their own assessment andor by using protocols or

guidelines) than those in the contingent group (able to

make the decision by obtaining a doctorrsquos order)

Frequency of triage nursesrsquo decision-making anddemographic characteristics

The decision to perform vital signs perform a

urinalysis and refer a non-urgent (NTS 5) patient to a

general practitioner could not be subject to chi square

analysis due to the skewed distribution of frequencies

within the contingency table

Nurses who worked in rural or remote areas reportedincreased participation in decision-making compared withnursesrsquo working in metropolitan settings in three of thedecisions listed These included the decision to collectblood for laboratory studies (x2=686 p=0032) insert anintravenous cannula (x2=931 p= 0009) and perform anelectrocardiograph (x2=858 p=0003)

Nursesrsquo who worked in emergency departments whichtreated more than 30000 patients annually reportedincreased participation in decision-making whencompared with nurses working in departments treating10000-30000 patients annually and those working indepartments treating less than 10000 patients annually for

RESEARCH PAPER

Table 6 Triage nurses self-reported decision-making frequency significantly linked to level of autonomy

Decision Frequency Level of Autonomy

Independent Contingent Totals x 2 p

To perform an electrocardiograph(n=79)Frequent 49 1 50 770 002Infrequent 20 2 22Never 5 2 7

To perform a Plaster of Paris check(n=110)Frequent 65 12 77 3078 lt001Infrequent 14 7 21Never 1 11 12

To collect venous blood forlaboratory studies(n=70)Frequent 26 14 40 1008 lt001Infrequent 8 22 30To consult with an inpatient unit(n=149)Frequent 115 10 125 4585 lt001Infrequent 12 3 15Never 1 8 9

To administer nebulised medication(n=86)Frequent 44 12 56 1427 001Infrequent 14 4 18Never 3 9 12

To administer paracetamol to a febrile child(n=130)Frequent 77 23 100 2820 lt001Infrequent 7 12 19Never 1 10 11

To commence oral rehydrationtherapy for a child(n=102)Frequent 60 12 72 641 001Infrequent 18 12 30

Noteplt005 Chi Squaren=Nurses able to make the decision without direct medical supervision in the triange area guided by their own assessment directed by protocol or guidelines or byobtaining a Doctorsrsquo order independant=decision made guided by own assessment or decision assisted by protocol or guidelinecontingent=decision requires a Doctors order


two of the decisions listed These included the decision toadminister paracetamol to a febrile child (x2=762p=002) and to splint an injured limb (x2=1275p=0002)

Four decisions were found to be significantly morelikely to be made by nurses working in general emergencysettings than adult settings and by nurses working inadult settings than in specialist emergency settings Thesedecisions included the decision to perform a Plaster ofParis check (x2=1265 p=0013) the decision to performa blood glucose measurement (x2=1375 p=0001) thedecision to perform an electrocardiograph (x2=1291p=0012) and the decision to collect blood for laboratorystudies (x2=933 p=0009)

Due to the small number of nurses working in privateemergency departments (69) no comparisons weremade regarding these nursesrsquo participation in decision-making compared to public sector nurses

DISCUSSION

The most important feature of the survey results is thedegree of variability identified in the level of educationand training required for nurses to perform the triage roleOver half of the nurses who participated in this studyworked in emergency departments that provided nospecific unit-based triage education (Table 1) Thisresearch builds upon the work of Standen and Dilley(1998) who also identified inconsistency in the training oftriage nurses working in Victorian public hospitals

Notwithstanding this result an important finding of thestudy was the number of triage nurses who reportedfrequent and independent participation in a range ofcomplex diagnostic and management decisions Forexample decisions to commence oral rehydration therapyin a child (Table 2) and to order diagnostic tests such as x-rays (Table 3) Both of these decisions involve aconsiderable degree of risk at triage because they are madein the face of an undifferentiated illness or injury and arenot informed by extensive physiological data For examplethe triage nursesrsquo decision to commence oral rehydrationtherapy in a child requires the nurse to not only diagnosedehydration but to rule out surgical causes ofgastrointestinal symptoms Despite its complexity thisdecision was reported to be independently made by overhalf of the nurses in the study (Table 5) A further exampleis the triage nursesrsquo decision to order an X-ray for anisolated limb injury Of the nurses surveyed over onequarter reported independently making this decision inpractice (Table 5) This diagnostic decision requires thenurse to first establish the provisional diagnosis offracture second screen the patient regarding thepotentially harmful effects of radiation and third useradiological terminology to specify the nature and extentof x-rays required

A further notable finding from this study was thefrequency with which many of the nurses reported makingthe decision to refer a non-urgent patient to a generalpractitioner (Table 2) Of the nurses surveyed over twothirds reported independently making this decision inpractice (Table 4) In addition to the risks alreadydiscussed this decision poses some specific legal risks forthe triage nurse George (1983) has suggested that anexamination conducted in the triage environment may fallbelow acceptable nursing standards in terms of obtainingadequate clinical data on which to base a referral decisionAdditionally Gerdtz and Bucknall (1999) have identifiedno established convention within Australia regarding howinformation is communicated from the referring nurse tothe receiving health care provider

The risks taken by nurses in making these decisions isfurther compounded because they are made in anenvironment of limited resource where time and availabledata regarding the patients condition may be limited orambiguous (Gerdtz and Bucknall 1999) Phillips (1987)described such decisions in the context of critical carenursing as lsquohotrsquo because they frequently involve timeconstraints and often place the nursesrsquo professionalreputation and self-esteem lsquoon the linersquo (Bucknall 1996Phillips 1987)

A further noteworthy finding of this study was the highlevel of conformity regarding nursesrsquo participation inprimary triage decisions and the considerable degree ofvariability regarding their participation in secondarydecision-making Primary triage decisions were uniformlyreported by participants to be frequently made in practice(Table 2) This is possibly because primary decisions arelargely diagnostic in nature and culminate in themandatory allocation of a triage code Similarly nursesrsquodecisions to refer a non-urgent patient to a generalpractitioner or conduct a reassessment also involvedmaking a judgement regarding patient acuity Importantlyprimary decisions made by triage nurses appeared torequire little in the way of equipment and resource As aresult nursesrsquo participation in these decisions was notfound to be influenced by the environmental variablesexplored

In contrast to the uniform participation reported forprimary triage decision-making this study identified aconsiderable level of variability in nursesrsquo reportedparticipation in secondary triage decisions (Table 3)Many secondary triage decisions require time space andspecific equipment Indeed a number of demographicresource and organisational factors identified in this studyappear to influence nursesrsquo participation in the secondarytriage role

First the significant associations identified betweennursesrsquo participation in decision-making related tosecondary triage decisions and hospital location are likelyto be the result of differences in the triage role in rural and

RESEARCH PAPER

31


metropolitan locations It is interesting to note that nearlyone third of nurses working in rural or remote locationsworked in departments without a designated triage nurseThe combination of decisions significantly more likely tobe made by nurses working in rural and remote areas thanthose working in metropolitan emergency departmentssupports this argument Decisions to perform anelectrocardiograph insert an intravenous cannula andcollect blood for laboratory studies are usually related incombination with the assessment of chest pain It ispossible that nurses in rural and remote areas may beworking as sole practitioners These nurses may not onlyperform the triage role but also provide ongoingemergency care In metropolitan locations the interfacebetween the triage nursesrsquo decision-making and furthernursing assessment is likely to be structured to minimisethe duration of time spent with the designated triage nurseIf a patient is judged to be of high acuity rapid transferinto the emergency treatment area usually occurs

Second the significant associations identified in thisstudy between increased participation in decision-makingand the type of emergency service are likely to be due to acombination of resource factors and differences relatingto illness and injury patterns in children as well as theobvious behaviour differences Decisions to collect bloodfor laboratory studies or glucose measurement or toperform an electrocardiograph are less likely to be madeon a child in the triage area because children generallyrequire more time for procedures and usually involve theassistance of another nurse

The significant association between nursesrsquo self-reported levels of autonomy and increased participation indecision-making for six of the ten secondary decisionsexamined is not a surprising result (Table 6) The presenceof protocols or guidelines may increase nursesrsquoparticipation in decision-making because they provideorganisational endorsement for nurses to initiate certaininterventions

Limitations

Participants may have under or over-estimated theirparticipation in decision-making Additionally some ofthe issues raised around autonomy in this paper may relateto the nursesrsquo view of what constitutes a triage decisionThis may have influenced nursesrsquo reports of theirparticipation

CONCLUSION

The findings of this research reveal that many triagenursesrsquo work in organisations that provide no specifictriage education Despite this result many of the nurseswho took part in the current study reported frequentparticipation in a range of complex diagnosticmanagement and referral decisions These findings

highlight the need for evaluation of existing practiceguidelines and education programs

The current study identified high levels of conformityrelated to nurses self-reported participation in the primarytriage role This result implies first that primary triagedecisions are closely linked to andor inform mandatorycode allocation and second that the demographic andorganisational characteristics of the task environment havelittle impact on the frequency with which nurses makeprimary triage decisions These findings highlight the needfor observational research into triage nursesrsquo decision-making Future studies should seek to explore contextualinfluences on nursesrsquo decision-making in the naturalenvironment

The variability reported by the nurses in performingsecondary triage decisions and the significant associationsidentified between decision frequency demographiccharacteristics of the triage service and levels of nurseautonomy suggest that nursesrsquo participation in thesecondary triage role is influenced by both the physicaland organisational structure of the task environment Inlight of this finding future research must also involveexploration of the effect of nurse-initiated interventions attriage and the impact of these interventions on patientoutcomes

REFERENCESAustralian Commonwealth Department of Health and Family Services and TheAustralian College of Emergency Medicine 1997 Australian National TriageScale A user manual Canberra Australian Government Publishing Service

Beanland C Schneider Z LoBiondo-Wood G and Haber J 1999 Nursingresearch Methods critical appraisal and utilisation Edited by James B FirstAustralian Ed Artarmon NSW Mosby Publishers Australia

Bucknall TK 1996 Clinical decision-making in critical care nursing practiceDecisions processes and influences Doctoral dissertation La TrobeUniversity Melbourne

Bucknall TK and Thomas S 1995 Clinical decision-making in critical careAustralian Journal of Advanced Nursing 13(2)10-17

Cioffi J 1998 Decision-making by emergency nurses in triage assessmentsAccident and Emergency Nursing 6184-191

Corcoran S Narayan S and Moreland H 1988 lsquoThinking aloudrsquo as astrategy to improve decision-making Heart and Lung 17 (5)463-468

Dilley S and Standen P 1998 Victorian Nurses demonstrate concordance inthe application of the National Triage Scale Emergency Medicine 1012-18

Edwards B 1998 Seeing is believing - picture building A key component oftelephone triage Journal of Clinical Nursing 751-57

Elstein A S and Bordage G 1988 Psychology of Clinical Reasoning InDowie J and Elstein A (eds) Professional Judgement CambridgeCambridge University Press

Fonteyn M E 1995 Clinical reasoning in nursing Clinical reasoning in thehealth professions Oxford Butterworth Heinemann

George J E 1983 Triage risks Journal of Emergency Nursing 9(2)112-113

Geraci EB and Geraci TA 1994 An observational study of the emergencytriage role in a managed care facility Journal of Emergency Nursing20(3)189-203

Gerdtz MF and Bucknall TK 1999 Why we do the things we do Applyingclinical decision-making frameworks to triage practice Accident andEmergency Nursing 750-57

Greenwood J 1998 Theoretical approaches to the study of nursesrsquo clinicalreasoning Contemporary Nurse 7(3)110-116

Handysides G 1996 Triage in Emergency Practice St Louis Mosby-YearBook Inc

RESEARCH PAPER


Jelinek GA and Little M 1996 Inter-rater reliability of the National TriageScale over 11500 simulated cases Emergency Medicine 8226-230

Lee KM Wong TW Chan R Lau CC Fu YK and Fung KH 1996Accuracy and efficiency of X-ray requests initiated by triage nurses in anaccident and emergency department Accident and Emergency Nursing4(4)179-181

Lyneham J 1998 The process of decision-making by emergency nursesAustralian Journal of Advanced Nursing 16(2)7-14

Macleod AJ and Freeland P 1992 Should nurses be allowed to request X-rays in an accident and emergency department Archives of EmergencyMedicine 9(1)19-22

Manchester Triage Group 1997 Emergency Triage Mackway-Jones K (ed)London BMJ Publishing Group

Parris W McCarthy S and Richardson S 1997 Do triage nurse-initiated X-rays for limb injuries reduce patient transit time Accident and EmergencyNursing 514-15

Phillips LR 1987 Critical points in decision-making In Hannah KJReimer M Mills WC and Letourneau S (eds) Clinical judgement anddecision-making The future with nursing diagnosisNew York John Wiley and Sons

Purnell L 1991 A survey of emergency department triage in 185 hospitalsPhysical facilities fast-track systems patient classification systems waitingtimes and qualification training and skills of triage personnel Journal ofEmergency Nursing 17(6)402-407

Purnell L 1995 Reducing waiting time in Emergency Department TriageNursing Management 26(9)64-66

Standen P and Dilly S 1998 A review of triage nursing practice andexperience in Victorian public hospitals Emergency Medicine 9301-305

Thomas SWearing A and Bennett M 1989 Clinical decision-making fornurses and health professionals Sydney Harcourt Brace Jovanovich

Victorian Department of Health and Community Services 1995 EmergencyServices Enhancement Program Victoria Acute Health Services

Victorian Department of Human Services and Public Health and DevelopmentDivision 1999 Nurse Labour Force Projections Victoria 1998-2009Melbourne

Victorian Department of Human Services 1999 Victorian Public HospitalLists httpwwwdhsvicgovauahslistshtm

Watson SJ 1994 An exploratory study into a methodology for theexamination of decision-making by nurses in the clinical area Journal ofAdvanced Nursing 20351-360

RESEARCH PAPER

33


ABSTRACT

The mainstreaming of psych iatr ic serv ices hasincreased the amount of contact nurses have withclients experiencing mental health problems within thegeneral hospital env ironment A rev iew of theliterature suggests that general nurses find themselveslacking in the skills confidence and knowledge to careadequately for these patients The aim of this paper isto discuss the potential contribution of the psychiatricconsultation-liaison nurse in addressing such problemsin order to improve health outcomes for patientsexperiencing mental health problems While a numberof positions for Psych iatr ic Consu ltation-LiaisonNurses are being created throughout Australia there isa paucity of literature relating to the development ofth is important role This paper is intended tocontribute to the advancement of a body of knowledgein this area

INTRODUCTION

T he launch of the National Mental Health Policy(Australian Health Ministers 1992) provided thestimulus for fundamental changes to psychiatric

services delivery within the Australian health systemCentral to these reforms is the concept of mainstreamingMainstreaming refers to the shift from traditionalpsychiatric institutions as the basis of care for people withmental health problems to the integration and co-locationof these services into the mainstream general healthsystem It is envisaged that by reducing the isolation andstand-alone nature of psychiatric services clients willhave increased access to quality general health careservices (Australian Health Ministers 1992) As a directconsequence of mainstreaming a larger number of clientsexperiencing mental health problems are now being caredfor within the general hospital environment ThePsychiatric Consultation-Liaison Nurse (PCLN) has acrucial role in providing knowledge enhancing skills andbeing supportive of nurses providing care for these clients

This paper will examine some of the problems incurredin the realisation of the goals of the National MentalHealth Policy (Australian Health Ministers 1992) withparticular focus upon nursing care issues The discussionwill include the incidence of mental health problemsamong general hospital patients the ability and confidenceof nurses in general hospitals to provide for this clientpopulation the concept of consultation-liaison (C-L)psychiatry the role of the Psychiatric Consultation-Liaison Nurse (PCLN) and the importance of this role forimproved health outcomes for patients

SCHOLARLY PAPER

34

THE ROLE OF THE PSYCHIATRIC CONSULTATION-LIAISON NURSE IN THEGENERAL HOSPITAL

Julie Sharrock RN PsychCert CritCareCert BEd isPsychiatric Nurse Consultation Liason Nurse HonoraryResearch Fellow Centre for Psychiatric Nursing Research andPractice School of Postgraduate Nursing The University ofMelbourne Australia

Brenda Happell RN BA(Hons) DipEd PhD is AssociateProfessor Director Centre for Psychiatric Nursing Researchand Practice School of Postgraduate Nursing The Universityof Melbourne Australia


KEYWORDS psychiatric nursing consultation liaison general hospitals mental health


MENTAL HEALTH PROBLEMS IN THEGENERAL HOSPITAL

An implication arising from mainstreaming is thatgeneral hospitals are having more contact with psychiatricservices and their clients This places a responsibility ongeneral hospitals to ensure that their services areaccessible and responsive to this group of patients and thatstaff are equipped with the knowledge and skills needed toprovide quality care that meets their needs The Australianhealth system also needs to ensure that people with mentalhealth problems are not subjected to the stigma and otherforms of discrimination associated with service deliveryprior to mainstreaming

While mainstreaming may have increased thefrequency contact with patients with mental healthproblems is not a new phenomenon for general hospitalsIndeed physical and mental health problems can occur ingeneral hospital patients (Mayou and Sharpe 1991)according to whether they

1 occur simultaneously either co-existing by chance or being precipitated by a common causesuch as a major life event

2 are a complication of a physical problem or

3 are the cause of a physical problem

Grouping mental health problems in this way is helpfulbut does not provide a clear definition of a mental healthproblem The presence of a diagnosed psychiatric disordercan be considered a defining characteristic of a mentalhealth problem However this definition is limiting asthere are patients who present with psychologicalproblems who are considered likely to benefit from someform of psychological intervention but whose symptomsare not severe enough or cannot be classified neatly intocurrent psychiatric diagnostic categories (Mayou andSharpe 1991) Sub-clinical depression or severe anxiety inresponse to physical illness behavioural disturbance suchas aggression and treatment difficulties such as poorcompliance are a few clinical examples that demonstratethis issue The absence of a definition of mental healthproblem means that accurately determining the incidenceof mental health problems in general hospital patients hasbeen difficult Results vary depending on the definitions ofmental health problem used and the population examined(Mayou and Sharpe 1991) Nevertheless a number ofstudies demonstrate that a significant percentage ofpatients in general health care settings experience mentalhealth problems

In the general hospital setting patients with physicalillness have been found to have higher rates of psychiatricdisorder than the general community (Gelder et al 1996)It has been reported that approximately 25 of the generalpopulation are likely to suffer from emotional orpsychological disturbance and that approximately afurther 15 suffer from a diagnosed psychiatric disorder

(Mental Health Consumer Outcomes Task Force 1991)Clarke et al (1991) examined a sample of medical andsurgical admissions to a major metropolitan teachinghospital in Melbourne and estimated that 30 of theirsample of patients had lsquosignificant psychiatric morbiditythat warranted attentionrsquo (primarily depression andanxiety) Gomez (in Tunmore 1997) suggests theprevalence of psychiatric morbidity is between 30 and65 in medical inpatients

The nature of psychiatric morbidity varies Affectiveand adjustment disorders are common in the elderly andalcohol problems more common in young men admittedfor medical care (Gelder et al 1996) Organic mentaldisorders are more frequent in geriatric units and alcoholproblems more frequent in liver units (Mayou and Hawton1986) Up to 45 of new referrals to outpatients clinics forphysical treatment have no diagnosis ascribed that canexplain the patientsrsquo physical symptoms While aproportion of these patients eventually have a physicaldiagnosis made the remainder are likely to have apsychological explanation made of their symptoms(Mayou and Hawton 1986) Presentations to generalhospitals for treatment of deliberate self-poisoningaccount for approximately 10 of medical admissions inAustralia (Henderson et al 1993) Patients who attemptsuicide constitute 3-5 of all admissions to majorintensive care units in Melbourne (Bailey 1998)

ARE NURSES IN GENERAL HOSPITALS EQUIPPED TOPROVIDE CARE FOR CLIENTS WITH MENTAL HEALTHPROBLEMS

The role of nurses in the recognition of mental healthproblems and subsequent care of the patient isundoubtedly significant As the largest professional healthcare group that provides the greatest amount of direct andindirect care to patients their contribution to the provisionof optimal care is enormous However local researchevidence indicates that the problems and needs of peoplewith mental health problems are poorly assessed andunderstood by nurses Critical care nurses studied inMelbourne indicated that they believed they were poorlyprepared to care for patients with mental health problems(Bailey 1998) General nurses indicated that they did notenjoy caring for people with eating disordersschizophrenia or those who deliberately self-harmed as aresult of a mental health problem (Fleming and Szmukler1992)

Emergency nurses have also been found to questiontheir role in caring for patients with mental healthproblems and it has been claimed that they do not see it aspart of their lsquorealrsquo work (Gillette et al 1996) A lack ofresources and difficulty accessing psychiatric expertisehas also been identified as compounding nursesrsquo ability tomeet the mental health needs of patients who present to theemergency department (Gillette et al 1996) and theintensive care unit (Bailey 1998) Feelings of fear and

SCHOLARLY PAPER

35


powerlessness and an acknowledgment of the increasedlength of time required to care for people with mentalhealth problems frequently resulted in these nursesavoiding patients with mental health problems (Gillette etal 1996)

The nature of the mental health problems themselvesfurther perpetuates this situation Patients with mentalhealth problems admitted to a general hospital may engagein behaviour that is not in keeping with the lsquosick rolersquoconsequently they are likely to be stereotyped andnegatively labelled Negative labelling results in adverseconsequences for the patient including perpetuation ofproblem behaviours and the occasional application ofextreme measures to control such behaviour (Trexler1996)

It is important to clarify that the existing researchstudies have examined discrete areas of interest such asnursesrsquo experiences with particular disorders or sets ofsymptoms (Bailey 1998 1994 Fleming and Szmukler1992) or specific settings (Bailey 1998 Gillette et al 1996Bailey 1994) There are no studies that have examined thesubjective experience of caring for people with mentalhealth problems in the general health care setting from theperspective of those nurses who provide the careAlthough one might expect to find similarities suchresearch should be conducted as a matter of urgency

The existence of negative attitudes towards patientswith mental health problems among general hospitalnursing staff is problematic for a profession whichchampions holism as a central tenet to guide and direct itsphilosophy and practice Holistic care is the facilitation ofhealth collaboratively with the patient considering thephysical psychological social spiritual and culturaldomains (Newbeck 1986 Blattner 1981) It acknowledgesthe interdependence of the mind the body and the spiritIn contrast to this it is suggested that nurses working ingeneral hospitals primarily focus on physical care andtasks and feel less skilled to attend to the psycho-socialneeds of their patients (Gillette and Bucknell 1996 Swanand MacVicar 1990 Whitehead and Mayou 1989 Wilson-Barnett 1978) Nurses working in a general hospital maytherefore find it challenging and difficult when faced withpatients who require input that is not physical in natureWhile such negativity continues the goals of the NationalMental Health Policy (1992) will not be able to be fullyrealised

The changes to nursing registration contained in theVictorian Nurses Act (1993) were substantially influencedby a commitment to the principles of holistic careComprehensive undergraduate nursing education whichhad already been adopted in most other States of Australiawas long considered the vehicle through which graduatesof nursing programs would emerge as skilled inpsychosocial as well as physical care The graduate of thecomprehensive program was envisaged to be sufficiently

skilled to function at the level of beginning practice in allhealth care areas including psychiatry (College ofNursing Australia et al 1989) It might therefore beexpected that as more graduates emerge from theseprograms they will be sufficiently skilled andknowledgable to provide such care in a competent andnon-judgemental manner

An examination of the changes made to the psychiatricnursing component of undergraduate nursing curriculathroughout Victoria following the introduction of theNurses Act (1993) would however shed significant doubton such a view A review of curricula throughout Victoria(Happell 1998) indicates that the majority of Victorianuniversities did not alter the psychiatric component of theprograms at all following legislative change It is clear thatfuture comprehensive nurses would have substantialvariation in the amount of exposure to the theory andpractice of psychiatric nursing encountered during theirundergraduate program The review by Happell (1998)revealed the compulsory component of psychiatric nursingto be between 0 and 174 of total curriculum hours withthe large majority of programs being below the 10 markIt is therefore not possible to be confident that thesegraduates will be sufficiently skilled knowledgable andconfident to provide holistic nursing care to clientsexperiencing mental health problems across a broad rangeof health care settings

CONSULTATION-LIAISON PSYCHIATRY DEFINED

The problem of knowledge deficit is of course notunique to nursing The development of Consultation-Liaison (C-L) Psychiatry was a direct response to theacknowledgment of the deficits of general health careprofessionals in providing care to clients with mentalhealth problems within the general health care system C-L psychiatry was defined by the Department of Health andCommunity Services (now the department of HumanServices as)

a service provided to patients who are admitted to ageneral hospital for a non-psychiatric condition but whomay exhibit symptoms of a psychiatric condition andwhose case may be enhanced by the expertise of healthworkers with mental health care training This service isprovided either through direct consultation with thepatient or indirectly through support education andadvice to other health professional responsible for the careand treatment of the patient (Dept of Health andCommunity Service 1996 p9)

In keeping with Victorian Government policydirections (Dept of Health and Community Service 1996)the delivery of C-L services via multi-disciplinary teamsand in particular the inclusion of nurses is advocated(Dept of Health and Community Service 1996) Thispresents a stark contrast to a 19911992 survey ofAustralian and New Zealand teaching hospitals which

SCHOLARLY PAPER

36


found that 77 of the C-L psychiatry staff were medicalwith varying degrees of input from nurses psychologistssocial workers and occupational therapists (Smith et al1994) C-L Psychiatry teams in Victoria have tended toremain medically dominated with psychiatric registrarsforming the lsquobackbonersquo of the service (Dept of Health andCommunity Service 1996)

PSYCHIATRIC CONSULTATION-LIAISON NURSING

In relation to psychiatric nursing practice thedevelopment of this sub-specialty originated in NorthAmerica in the 1960s and was influenced by movestoward holistic and patient-centred nursing care (Robinson1982) To varying degrees nurses in Australia areestablishing themselves as a key component of C-LPsychiatry teams (Smith et al 1994) albeit after theirNorth American (Robinson 1991) and British colleagues(Tunmore 1997)

The inclusion of psychiatric nurses as part of the C-Lteam is crucial The North American experiencedemonstrates that nurses contribute to the team in a waythat is significantly different but complementary to themedical staff (Robinson 1987) While the C-L psychiatristis primarily called upon to give an opinion in cases oflsquodiagnosis uncertaintyrsquo C-L nurses are more likely to beasked to assist with patients suffering depression anxietyor displaying a disturbance in behaviour In keeping withthe medical model psychiatrists focus on assessmentdiagnosis and treatment they rarely suggest nursing careor provide other forms of support to nursing staff On theother hand nurses who are appropriately skilledknowledgable and experienced are able to provide suchknowledge advice and support from a specifically nursingperspective

The PCLN assists the primary care nurses to develop aplan of care that may or may not include the PCLN workingdirectly with the patient (Robinson 1987) The focus is onguiding and supporting the primary care team by providinginformation assistance and education (Robinson 1982Tunmore 1990a 1990b) The PCLN endeavours tostrengthen the teamsrsquoexisting skills in mental health nursingas well as facilitate the development of new skillsHowever the objective of the medical and nursing staff ismutual that of improved patient care (Robinson 1987)

C-L psychiatry is based on an understanding of humanbeings from a biopsychosocial perspective and anunderstanding that diagnosis treatment and prevention ofillness incorporates these domains (Smith 1993) Utilisingthe consultation process C-L psychiatry teams apply theirspecialist skills in psychiatry and mental health to assistgeneral health care teams in the provision of mental healthcare to their patients Commonly C-L teams are basedwithin general hospitals and provide consultations togeneral or specialist medical and surgical teams (Lipowski1991)

The PCLN provides consultation primarily (but notexclusively) to nurses working in general health caresettings The PCLN may work directly with patients andtheir families in providing mental health nursingassessment and intervention (Robinson 1987) Howeverthe PCLN works more often with nursing staff assistingthem to develop a care plan that incorporates mental healthconcepts in order to meet the needs of patients The PCLNacts as a resource to the staff on mental health issuesprovides supportive formal and informal education andacts as a link between general and mental health servicesThe PCLN also works with general health care nursingstaff in the development of policies and processes inrelation to mental health issues (Tunmore 1997) Becausethe PCLN works closely with the nursing staff she isparticularly interested in the reactions that nurses have topatients with mental health problems and how thesereactions effect the relationship between the patient andnursing staff (Tunmore 1997)

IMPROVED OUTCOMES FOR PATIENTS WITH MENTALHEALTH PROBLEMS

The key in determining the value or otherwise ofPCLNs primarily concerns whether or not assistance withpatient care provided to general hospital staff by the C-Lteam makes any difference to the quality of care deliveredIn the terms of our current environment improved qualityof care means shorter length of stay decreasedreadmission rates decreased morbidity and mortality andimproved patient satisfaction While the literatureindicates that this has been notoriously difficult todemonstrate some inroads are being made (Fleming andSzmukler 1992 Strain et al 1991 Schubert et al 1989Fulop et al 1987 Mumford and Schlesinger 1987 Pincus1984 Levitan and Kornfield 1981) These studiesprimarily demonstrate a decrease in length of stay and theassociated costs with C-L intervention

However as Mumford and Schlesinger caution

Although cost benefits may be realized throughthe operation of a C-L psychiatry service suchquantifiable benefits represent only one yield of theservice and should not eclipse the value of relievedsuffering expansion of skills and competencies instudents and residents or the acquisition of newknowledge A financial orientation should notconstitute the sole rationale for such a service(1987 p360)

Effectiveness of PCLN interventions and the impact ofthe role on quality of patient care have been largelyanecdotal One study estimated that cost savings of$65000 were achieved by a PCLN over an 8-monthperiod through the provision of family therapy to 10families in a 250-bed community hospital in ConnecticutUSA (Ragaisis 1996) In a qualitative study Roberts(1998) interviewed the nursing staff of a haematology

SCHOLARLY PAPER

37


ward in Britain where PCLN services were provided on aregular basis The nurses valued the PCLNrsquos availabilityand accessibility and appreciated the specialised expertiseand skills in counselling that the PCLN offeredAssessment of patientsrsquo reactions to illness input intomanaging mental health problems of patients facilitatingskill development in the nursing staff and assisting nursesin development of the nurse-patient relationship werespecifically identified as significant contributions made bythe PCLN Similar themes emerged from a consultee(primarily nursing staff) satisfaction survey conductedover a three-month period on 75 requests for consultationby a PCLN in a general hospital Accessibility andresponsiveness were again identified as highly valuedaspects of the service and in addition the assistanceprovided by the PCLN in the development of patient careplans was appreciated The staff gave particularly positivefeedback for referrals where the PCLN was involved as aprimary therapist in the care of the patient and hisherfamily (Newton and Wilson 1990)

Unfortunately there has been little attempt to evaluatethe potential role of the PCLN in Australia One exceptionto this has been a significant and recent research projectundertaken by Victorian nurses the lsquoEvaluation ofPsychiatric Nurse Consultancy (PNCC) in EmergencyDepartments Projectrsquo (Gillette et al 1996) This projectplaced two skilled psychiatric nurses in the EmergencyDepartments of two public hospitals in Melbourne Thenurses undertook a consultancy role similar to the PCLNrole This report demonstrated a number of positiveoutcomes including decreased length of stay for mentalhealth consumers in the Emergency Department Mostnotable was an increased satisfaction with care on the partof clients some evidence that aggression was managedmore effectively and an increased confidence in thenursing staff when working with clients with mental healthneeds It is important to note that a number of EmergencyDepartments in Victoria have psychiatric nurses providingconsultancy services similar to the service developed inthis project The PNCC project is an example where thework of psychiatric nurses is shown to contribute in apositive way to the care of general hospital patients

In order to evaluate the input psychiatric nurses asconsultants can have on the care of patients with mentalhealth problems in non-psychiatric settings similar studiesto the PNCC Project need to be undertakenDocumentation of Australian and New Zealandexperiences of psychiatric nurse consultancy within theliterature in this area is sparse even though it is known tothe authors that there are a number of nurses working inthis area across these countries Although it makes sensethat this type of consultancy can contribute in a positiveway to health outcomes evaluation studies from theperspective of patients relatives and staff must beundertaken as a matter of urgency

CONCLUSION

Psychiatric nurse consultancy is a developing area forpsychiatric nursing The role of the PsychiatricConsultation-Liaison Nurse is one that offers psychiatricnurses an opportunity within the general hospital setting toimprove the quality of attention to the psychological andpsychiatric needs of patients (Tunmore 1990b) Themainstreaming of psychiatric services within the generalhealth care system has increased the need for nurses to beequipped with the skills and knowledge required toprovide optimum care to clients experiencing mentalhealth problems Research findings although limitedsuggest that nurses do not consider themselves sufficientlyprepared to provide care to this clientele The role of thePCLN therefore has the potential to assist the staff ingeneral hospital in contributing to care in a manner that isconsistent with National Mental Health Policy (AustralianHealth Ministers 1992)

Consultation Liaison Psychiatry is to some degree anestablished sub-specialty of psychiatry Nurses arebeginning to join their medical colleagues but thedevelopment of the PCLN role particularly in Australia isin its infancy The skills and knowledge that psychiatricnurses have to offer the C-L Psychiatry service differ fromthose of their medical colleagues but are complementaryGiven that nurses form the greater percentage of generalhospital staff psychiatric nurses are well placed to assisttheir nursing colleagues in the care of patients with mentalhealth problems Preliminary evidence demonstrates thatthis input can have a significant influence on the quality ofhealth outcomes for patients Further local research anddocumentation within the literature needs to occur so thatmeaningful debate and role development can occur withinAustralia

REFERENCESAustralian Health Ministers 1992 National Mental Health Policy CanberraAustralian Government Publishing Service

Bailey S 1994 Critical care nursesrsquo and doctorsrsquo attitudes to parasuicidepatients The Australian Journal of Advanced Nursing 11(3)11-17

Bailey SR 1998 An exploration of critical care nursesrsquo and doctorsrsquo attitudestowards psychiatric patients Australian Journal of Advanced Nursing 15(3)8-14

Blattner B 1981 Holistic Nursing Englewood Cliffs Prentice Hall

Clarke DM Minas H and Stuart GW 1991 The prevalence of psychiatricmorbidity in general hospital inpatients Australian and New Zealand Journalof Psychiatry 25322-9

College of Nursing Australia Australian Nursing Federation FlorenceNightingale Committee Australia and New South Wales College of Nursing1989 Nursing Targets (Review of the Goals in Nursing Education) CanberraRoyal College of Nursing Australia

Department of Health and Community Services 1995 Victoriarsquos mental healthservice A framework for service delivery Psychiatric Services DivisionVictorian Government Department of Health and Community Services

Fleming J and Szmukler GI 1992 Attitudes of medical professionalstowards patients with eating disorders Australian and New Zealand Journal ofPsychiatry 26436-443

SCHOLARLY PAPER

38


Fulop G Strain JJ Vita J Lyons JS and Hammer JS 1987 Impact ofpsychiatric comorbidity on length of stay for medicalsurgical patients Apreliminary report American Journal of Psychiatry 144(7)878-82

Gelder M Gath D Mayou R and Cowen P 1996 Oxford textbook ofpsychiatry 3rd edn Oxford Oxford University press

Gillette J Bucknell M and Meegan E 1996 Evaluation of psychiatric nurseconsultancy in emergency departments project Royal Melbourne Institute ofTechnology Bundoora Victoria Faculty of Nursing

Gillette J and Bucknell M 1996 Transforming emergency departmentculture The impact of the psychiatric nurse consultant In Culture and caringCaring and culture Australian and New Zealand College of Mental HealthNurses 22nd annual conference Auckland Australian and New ZealandCollege of Mental Health Nurses Inc

Happell B 1998 The implications of legislative change on the future ofpsychiatric nursing in Victoria Australian and New Zealand Journal ofPsychiatry 32229-34

Henderson A Wright M and Pond SM 1993 Experience with 732 acuteoverdose patients admitted to an intensive care unit over six years The MedicalJournal of Australia 15828-30

Levitan SJ and Kornfield DS 1981 Clinical and cost benefits of liaisonpsychiatry American Journal of Psychiatry 138(6)790-3

Lipowski ZJ Consultation-liaison psychiatry In Judd FK Burrows GDand Lipsitt DR (eds) 1991 Handbook of studies on general hospitalpsychiatry Amsterdam Elseviier Science Publishers BV

Mayou R and Hawton K 1986 Psychiatric disorder in the general hospitalBritish Journal of Psychiatry 149172-190

Mayou R and Sharpe M Psychiatric problems in the general hospital In FKJudd GD Burrows and DR Lipsitt (eds) 1991 Handbook of studies ongeneral hospital psychiatry Amsterdam Elseviier Science Publishers BV

Mental Health Consumer Outcomes Task Force 1991 Mental health statementof rights and responsibilities Canberra Australian Government PublishingService

Mumford E and Schlesinger HJ 1987 Assessing consumer benefit costoffset as an incidental effect of psychotherapy General Hospital Psychiatry9360-3

Newbeck I 1986 The whole works Nursing Times 82(30)48-49

Newton L and Wilson KG 1990 Consultee satisfaction with a psychiatricconsultation-liaison nursing service Archives of Psychiatric Nursing 4(4)264-70

Nurses Act 1993 Melbourne Government Printer for the State of Victoria

Pincus HA 1984 Making a case for consultation-liaison psychiatry Issues incost-effective analysis General Hospital Psychiatry 6173-9

Psychiatric Services Division Victorian Government Department of Health andCommunity Services 1996 Review of consultation-liaison services inVictorian hospitals Victorian Government Department of Health andCommunity Services

Ragaisis KM 1996 The psychiatric consultation-liaison nurse and medicalfamily therapy Clinical Nurse Specialist 10(1)50-6

Roberts D 1998 Nursesrsquo perceptions of the role of liaison mental health nurseNursing Times 94(43)56-7

Robinson L 1982 Psychiatric liaison nursing 1962-1982 A review and updateof the literature General Hospital Psychiatry 4139-145

Robinson L 1987 Psychiatric consultation liaison nursing and psychiatricconsultation liaison doctoring Similarities and differences Archives ofPsychiatric Nursing 1(2)73-80

Robinson L Psychiatric consultation-liaison nursing In Judd FK BurrowsGD and Lipsitt DR (eds) 1991 Handbook of studies on general hospitalpsychiatry Amsterdam Elseviier Science Publishers BV

Schubert DSP Billowitz A Gabinet L and Friedson W 1989 Effect ofliaison psychiatry on attitudes toward psychiatry rate of consultation andpsychosocial documentation General Hospital Psychiatry 1177-87

Smith GC 1993 From psychosomatic medicine to consultation-liaisonpsychiatry The Medical Journal of Australia 159(6)745-749

Smith GC Ellis PM Carr VJ Ashley WK Chesterman HM Kelly BSkerritt PW and Wright M 1994 Staffing and funding of consultation-liaisonpsychiatry services in Australia and New Zealand Australian and New ZealandJournal of Psychiatry 28398-404

Strain JJ Lyons JS Hammer JS Fahs M Lebovits A Paddison PLSnyder S Strauss E Burton R Nuber G Abernathy T Sacks H NordlieJ and Sacks C 1991 Cost offset from psychiatric consultation-liaisonintervention with elderly hip fracture patients American Journal of Psychiatry148(8)1044-9

Swan J and MacVicar B 1990 Breaking down the barriers Nursing Times86(34)26-29

Trexler JC 1996 Reformation of deviance labeling theory for nursing ImageJournal of Nursing Scholarship 28(2)131-135

Tunmore R 1997 Mental health liaison and consultation Nursing Standard11(50)46-53

Tunmore R 1990a The consultation liaison nurse Nursing 4(3)31-4

Tunmore R 1990b Setting the pace Nursing Times 86(34)29-32

Whitehead L and Mayou R 1989 Care of the mind Nursing Times85(45)49-50

Wilson-Barnett J 1978 In hospital Patientsrsquo feelings and opinions NursingTimes 74(8)29-32

SCHOLARLY PAPER

39


ABSTRACT

The experience of car diac chest pain is alwaystraumatic and stressfu l for patients The availableliterature suggests that although nurses place a lot ofimportance on cardiac patients being pain free it isapparent this is often not achieved Research anddocumented case studies suggest that relaxation canplay an important role in the treatm ent and preventionof this distressing symptom (Tiernan 1994 Altice andJamison 1989 Guzzetta 1989) Nurses caring forpatients with chest pain need to look beyond medicalmanagement and begin to challenge nursing practiceto help patients deal effectiv ely with chest pain in a waythat meets each indiv idualrsquos needs This articlediscusses ways in which relaxation when used as an adjunct to medical therapies can be a usefu l nursingmanagement tool for effectiv ely reliev ing cardiac pain

INTRODUCTION

I magine a pain in your chest so severe that you feel asif you are going to die It is difficult to breathe youare terrified feel out of control and anxious Chest

pain is the initial symptom of many life threateningdisease processes such as myocardial infarctionpulmonary embolism and aortic aneurysm It is a warningsign of actual or potential injury to a structure within thethoracic cavity (Falloon and Roques 1997) Chest pain is adevastating symptom can have a permanent impact on thepatientrsquos life including negative psychological effectwhich is on the sufferer On a cognitive level the patientrsquosperception of pain is of critical importance Pain isolatescoronary patients because it limits their normal activitiesof daily living causing fear of routine tasks potentiallydecreasing confidence and self-esteem It can disruptthought and overwhelm the sufferer (OrsquoConner 1995) It issuggested that the rapid relief of cardiac chest pain canhelp to minimise or alleviate its impact reducing fear andanxiety (Lappin 1998) The reduction of fear and anxietycan also aid in the reduction of cardiac chest pain and it issuggested that this can be achieved through interventionssuch as relaxation (Miller and Perry 1990)

Although many nurses may regard medical treatmentsas the immediate or usual method of relieving paininterventions for chest pain should not be limited topharmacology A broad range of nursing interventionssuch as relaxation techniques verbal and non-verbalreassurance distraction repositioning and enhancementof the placebo effect through the use of positivestatements may assist with the relief of pain (Altice andJamison 1989) It is extremely important that the patient isaccurately and promptly assessed prior to thecommencement of relaxation therapy so that the patientcan be provided with accurate rapid and appropriatemedical treatment for the underlying cause of the pain(Thompson 1989)

This article discusses the benefits of relaxation therapyand specific relaxation strategies in chest painmanagement Relaxation is defined by Guzzetta andDossey (1992 p100) as lsquothe absence of physical mental

Wendy Day RCompN BN MA candidate is a Lecturer in theFaculty of Nursing at the Universal College of LearningManawatu Polytechnic Palmerston North New Zealand


RELAXATION A NURSING THERAPY TO HELP RELIEVE CARDIAC CHEST PAIN

SCHOLARY PAPER

KEY WORDS cardiac pain chest pain patient experience symptoms nursing management


SCHOLARY PAPER

and emotional tensionrsquo and by McCaffery et al (1994p168) as lsquoa state of relative freedom from both anxiety andskeletal muscle tension a quietening or calming of themind and musclesrsquo

LITERATURE REVIEW

There is a significant amount of literature relating to themedical and nursing assessment differentiation andtreatment of chest pain Jacavone and Dostal (1992) foundthat nurses placed considerable importance on relievingpatientsrsquo chest pain thus partially or totally relieving thecausative ischaemic process They also identified thatnurses were taught that relief of a patientrsquos chest pain wasextremely important and should be one of the aims of careNurses then shared this knowledge with their patientsAvailable literature suggests that despite the apparentimportance if relieving pain it is often inadequatelyreported or treated

Many studies have documented the issues associatedwith accurate interpretation of patientrsquos chest pain and theeffectiveness of nursing and medical interventionsThompson et al (1993) compared the interpretation of painintensity between patients and the nurses caring for themThese authors found that pain interpretation was quitesimilar but nursing management of pain was ofteninconsistent and inadequate OrsquoConner (1995) studiedpatientsrsquo and nursesrsquo ratings of chest pain and discoveredthat nurses underestimated pain severity in up to fortypercent of cases especially if the pain was severe

Willetts (1989) suggests that under-treatment of chestpain is related to nursesrsquo misconceptions about addictionpoor knowledge of drug action and duration and fear ofrespiratory depression Eighty percent of the cardiacpatients in Willettrsquos survey said their pain never reallydisappeared during their stay in the Coronary Care Unit(CCU) and forty percent of patients said anxiety abouttheir condition increased because of the chest pain

Schwartz and Keller (1993) examined the experienceand reporting of chest pain The patients who participatedin this study experienced uncertainty in response to chestpain and expected to have some continued pain Ruston(1998) looked at experiences of myocardial infarction andthe actions patients took as a response to their experiencesThey found delays in patientsrsquo reporting of pain wereinfluenced by the idea that some continued chest pain wasnormal and expected a belief that health careprofessionals were somehow able to detect pain and thefeelings of uncertainty that accompanied the painexperience Mackintosh (1994) and Rowe (1996)identified that poor communication between doctorsnurses and patients can result in patients delaying thereporting of chest pain

Miller et al (1998) suggest that patients who are able tocommunicate appreciate health care professionals whospend time with them are attentive and listen Caunt(1992) suggested that other variables which influence themanagement of pain include having a calm restfulenvironment the teaching of relaxation the ability ofpatients to carry out a relaxation method the ability tounderstand the reason for the pain and the importance ofreporting pain

The Lifestyle Heart Trial investigated whether mobilepatients with existing cardiac conditions could bemotivated to make comprehensive lifestyle changes andwhether or not these changes would result in a reductionof coronary atherosclerosis The results of this trialsuggested a correlation between comprehensive lifestylechanges and a reduction in coronary atherosclerosis Thelifestyle changes included stress management such asstretching progressive relaxation breathing exercisesmeditation and visualisation (Ornish et al 1998 Ornish1991) These results indicate that relaxation may play animportant role in the treatment and prevention of coronaryatherosclerosis

Holden (1992) demonstrated the application ofpsychological approaches to pain management by usingrelaxation breathing exercises and taped sounds to help aseriously ill patient cope with anxiety attacks Guzzetta(1989) discovered relaxation and music therapy reducedstress and lowered the incidence of cardiac complicationsin patients with a presumptive diagnosis of myocardialinfarction Miller and Perry (1990) found that deepbreathing relaxation techniques used in postoperativecoronary bypass patients resulted in significant decreasesin blood pressure pulse rate and respiratory rate Fromthe available literature it is apparent that nurses need tofind effective ways of encouraging the reporting of chestpain and of assisting the patient to gain adequate relief ofthe pain

DISCUSSION

Consider a situation where a few days after a patientsuffers a heart attack the pain returns to the patientrsquos chestand left arm The patient rings the call bell to get help Thenurse arrives and on assessment finds that the patient haschest pain rated at seven out of ten on a pain scale andappears anxious The nurse commences cardiacmonitoring performs an electrocardiograph (ECG) andgives the patient some nitrolingual spray and a Diazepamtablet then leaves the patient alone with their painAlthough the medical management and pharmacologicaltreatment of chest pain is of critical importance there arenursing measures that can be used to complement medicaltreatments With accurate assessment and recognition ofanxiety these nursing measures can result in more rapid


effective pain relief and an associated reduction in theneed for anti-anxiety drugs

Cardiac chest pain usually occurs as a result of theoxygen demand of the heart muscle exceeding the oxygensupply due to decreased coronary circulation It is arecognised symptom of coronary artery disease orcoronary artery spasm Cardiovascular disease or systemicillnesses which result in an inability to increasemyocardial oxygen supply to meet demand may alsocause chest pain Medical management of this pain usuallyinvolves the use of nitrates to dilate the coronary arteriesand narcotics to reduce pain and decrease myocardialoxygen demand (Isselbacher et al 1994 Guzzetta andDossey 1992)

Episodes of acute pain are often accompanied by somedegree of fear anxiety or depression The presence ofthese emotional reactions increases the bodyrsquossympathetic responses by raising levels of endogenouscatecholamines noradrenalin and norepinephrinecausing an increase in myocardial oxygen demandincreased ischaemic pain and possibly an increase inarrhythmias It is generally thought that the greater thepersonrsquos anxiety the greater their experience of pain willbe (Pedley 1996 Mackintosh 1994 Thompson 1989Benson 1975)

The patientrsquos perception of chest pain is of greatimportance It affects how the patient copes with the painand how relief is obtained and for this reason apsychological approach to pain relief may be useful(Lappin 1998) Such approaches to pain managementattempt to alter the patientrsquos perception of pain andprovide alternative behaviour patterns for dealing with thatpain (Cornock 1996)

The relaxation response has been documented as a wayof reducing pain According to Benson et al (1974 p37)lsquothe relaxation response appears to be an integratedhypothalamic response resulting in a generalised decreasein sympathetic nervous system activityrsquo and possibly anincrease in parasympathetic activity Oxygen consumptiondecreases and both pulse and respiration rates have alsobeen found to decrease Benson (1982 Benson et al 1977)suggest that the relaxation response may be ofpreventative and therapeutic value when treating illnesseswhich are exacerbated by prolonged stress for examplehypertension It is possible to elicit the relaxation responsethrough a variety of relaxation techniques (Benson 1982)

Relaxation may be considered a nursing therapy whichhas been found to decrease anxiety and enhance pain reliefand that can be applied in almost any setting (Pedley 1996Altice and Jamison 1989) Factors that affect theindividualrsquos ability to participate in relaxation therapyinclude age health state fear medication belief systemscultural factors and willingness to participate (McCafferyet al 1994 Guzzetta and Dossey 1992)

Relaxation offers potential benefit for people in painbecause of the relationship between muscle tension painand anxiety Relaxation skills allow the individual to focusinward evoke inner calm and control awareness andlinear time It is an acquired skill that needs to be taughtprior to episodes of pain to be effective (Guzzetta andDossey 1992) This can be achieved within a coronary careward by providing regular relaxation sessions The ward inwhich the author worked achieved this by conducting anoptional relaxation session every Wednesday afternoonduring the normal patient rest period

Relaxation therapy has been shown to offer a variety ofbenefits including aiding sleep strengthening the nurse-patient relationship improving problem-solvingminimising the detrimental effects of continued orrepeated episodes of pain reducing pain increasingconfidence and decreasing fatigue It may providedistraction from pain and increase the effectiveness ofother pain relief measures Relaxation may help to makepain more tolerable and decrease fear or distress(McCaffery et al 1994) It is important to note thatrelaxation therapy is not a substitute for cardiacassessment or medical interventions but may be a usefuladjunct in the management of cardiac pain

Teaching relaxation

Before teaching relaxation it is important that thepatient is assessed for readiness to learn Relaxationtechniques require patient cooperation and participationtherefore it is important that the patient understands howand why relaxation would benefit them (Pedley 1996Tiernan 1994) They should choose the method or strategyof relaxation with which they feel most comfortable Oncethe patientrsquos willingness to learn has been established anda relaxation strategy chosen a quiet and comfortableenvironment should be arranged (Guzzetta and Dossey1992)

Guzzetta and Dossey (1992) suggest that strategies forteaching relaxation should include breathing exercisesrepetition of autogenic phrases progressive musclerelaxation and body scanning Relaxation imagery is alsoa useful relaxation method Imagery is defined by Tiernan(1994 p48) as lsquo the perception of a mental representationof realityrsquo Using images the patient is able to respond tounconscious physiologic processes Guided imagery canbe useful and usually follows the relaxation exercise(Carroll and Bowsher 1995 Guzzetta and Dossey 1992)

Other useful relaxation strategies include biofeedbackthe use of prayer meditation drawing images listening tomusic and the invoking of the relaxation response throughpassive concentration and the slow repetition of a singleword on exhalation for 15 to 20 minutes (Cornock 1996Carroll and Bowsher 1995 McCaffery et al 1994Guzzetta and Dossey 1992 Guzzetta 1989)

SCHOLARLY PAPER

42


A variety of relaxation imagery exercises can be usedby patients with chest pain It is important to check whatthe patient feels comfortable with and likes to do Thereare many relaxation techniques that take varied of amountsof time The following technique is recommended byMcCaffery et al (1994)

1 Breathe in deeply and clench your fists

2 Breathe out and go as limp as a rag doll

3 Start yawning

These steps should be repeated until the patient is relaxed

(McCaffery 1994)

Music and relaxation tapes can also be useful inrelaxation imagery To incorporate this into the ward orunit environment it would be necessary to develop a tapelibrary and have several cassette players with headphonesWhen using music as part of a relaxation strategy thepatient and not the nurse should select the music (Guzzettaand Dossey 1992 McCaffery 1979)

The author has used both progressive muscle relaxationand relaxation imagery in her nursing practice to helprelieve pain and anxiety among patients with acuteepisodes of chest pain The author has found them to beeffective in reducing fear and assisting with the relief ofthis pain The authorrsquos experience indicates that mostpatients are willing to learn and try these techniques whenthe nurse is prepared to take the time to support themGiving patients education in relaxation techniquesprovides them with skills they can use to reduce pain andgive them some control over what is happening to them

RECOMMENDATIONS

Patients suffering from cardiac chest pain occurring asa result of decreased oxygen supply to the heart musclemay benefit from the use of relaxation to elicit therelaxation response (Benson et al 1977) The LifestyleHeart Trial research (Ornish 1991 Ornish et al 1998) alsoindicates that cardiac patients benefit from lifestylechanges that include the reduction of stress through the useof relaxation strategies

To achieve this nurses need to acquire the skillsnecessary to teach and facilitate relaxation and theknowledge of how relaxation strategies can be used toelicit the relaxation response The author suggests thatrelaxation strategies should be taught to nurses atundergraduate level or during initial training this occurs tosome extent in some current nursing education programsbut needs a more focused approach

Patients should be taught and encouraged to practicerelaxation techniques with which they feel comfortableRegular relaxation sessions should be set up within the

coronary care ward at a time when the patients can attendthese sessions without interruption Patients should beinformed of the benefits and encouraged to attendregularly so that they develop relaxation skills to use athome More than one session per week would bebeneficial Further research into the effects of relaxationon relief and prevention of chest pain should beundertaken

CONCLUSION

The available literature suggests that nurses need tolook for ways to enhance pain relief for patients sufferingfrom cardiac chest pain Research related to both medicalscience and nursing science supports the use of relaxationas an adjunct to pain management Although it may not bepossible to use relaxation effectively on initial admissionbecause relaxation techniques need to be learnt andpracticed relaxation has many potential benefits to thepatient in pain

Relaxation could be used as a tool to aid in thedevelopment of good communication patterns and trustingtherapeutic relationships between the nurse and patientNurses need to have an understanding of relaxationstrategies and their applications to be able to applyrelaxation strategies as a means of reducing the pain anddistress of cardiac patients To achieve the goal ofreducing cardiac patientsrsquo chest pain and associatedanxiety all nursing staff in the coronary care area shouldlearn and be able to teach and facilitate a variety ofrelaxation strategies

REFERENCESAltice NF and Jamison GB 1989 Interventions to facilitate painmanagement in myocardial infarction Journal of Cardiovascular Nursing3(4)49-56

Benson H Beary JF and Carol MP 1974 The relaxation responsePsychiatry 37(1)37-46

Benson H 1975 The relaxation response New York William Morrow andCompany

Benson H Kotch J B and Crassweller K D 1977 The relaxation responseMedical Clinics of North America 61(4)929-938

Benson H 1982 The relaxation response History physiological basis andclinical usefulness Acta Medica Scandinavica (suppl) 660231-237

Carroll D and Bowsher B 1995 Pain Management and Nursing CareOxford Butterworth-Heinemann

Caunt JE 1992 The changing role of coronary care nurses Intensive andCritical Care Nursing 882-93

Cornock MA1996 Psychological approaches to cardiac pain NursingStandard 11(12)34-38

Falloon EM and Roques J 1997 Acute chest pain AACN Clinical Issues8(3)383-397

Guzzetta CE 1989 Effects of relaxation and music therapy on patients in acoronary care unit with presumptive acute infarction Heart and Lung18(6)609-616

Guzzetta CE and Dossey B 1992 Cardiovascular nursing Holistic practiceSt Louis Mosby Yearbook

Holden T 1992 Dialogues with excellence Seeing Joan through AmericanJournal of Nursing 92(12)26-30

SCHOLARLY PAPER

43


Isselbacher KJ Braunwald E Wilson JD Martin JB and Kasper DL1994 Harrisonrsquos Principles of Internal Medicine (13th Ed) USA McGrawHill Inc

Jacavone J and Dostal M 1992 A descriptive study of nursing judgement inthe assessment and management of cardiac pain Advances in Nursing Science15(1)54-63

Lappin M 1998 Constructive management of cardiac pain In Carter B (ed)Perspectives on pain Mapping the territory London Arnold

Mackintosh C 1994 Non-reporting of cardiac pain Nursing Times 90(13)36-39

McCaffery M 1979 Nursing Management of the Patient with Pain 2nd edPhiladelphia JB Lippincott

McCaffery M Beebe A and Latham J (Ed)1994 Pain Clinical ManualFor Nurses (UK ed) Mosby Times Mirror International

Miller EH Nordquist DA Doran KA Ahern CK and Karsten YMC1998 Inter-regional health care Patient stories and chart reviews ClinicalNurse Specialist 12(1)15-21

Miller KM and Perry P A 1990 Relaxation technique and post-operativepatients undergoing cardiac surgery Heart and Lung 19(2)136-146

OrsquoConner L 1995 Pain assessment by patients and nurses Intensive andCritical Care Nursing 11 (5)283-292

Ornish D 1991 Can you prevent - and reverse-CAD Patient Care 25(16)25-30 35-36

Ornish D Scherwitz LW Billings JH Gould KL Merritt TA SparlerS Armstrong WT Ports TA Kirkeeide RL Hogeboom C and Brand R1998 Intensive lifestyle changes for the reversal of coronary heart diseaseJournal of the American Heart Association (JAMA) 280(23)2001-2007

Pedley H 1996 The nursersquos role in pain assessment and management in acoronary care unit Intensive and Critical Care Nursing 12254-260

Rowe R 1996 Reasons for pre-hospital delays in reporting of chest painNursing Times 92(18)40-42

Ruston A Clayton J and Calnan M 1998 Patientsrsquo actions during theircardiac event Qualitative study exploring differences and modifiable factorsBritish Medical Journal 316 (7137)1060-1064

Schwartz JM and Keller C1993 Variables affecting the reporting of painfollowing an acute myocardial infarction Applied Nursing Research 6(1)13-18

Thompson C 1989 The nursing assessment of the patient with cardiac pain onthe coronary care unit Intensive Care Nursing 5(4)147-154

Thompson DR Webster RA and Sutton TW1993 Coronary care unitpatientsrsquo and nursesrsquo ratings of intensity of ischaemic chest pain Intensive andCritical Care Nursing 1083-88

Tiernan BJ 1994 Relaxation and guided imagery in critical care CriticalCare Nursing October 47-51

Willetts K 1989 Assessing cardiac pain Nursing Times 85(47)52-54

SCHOLARLY PAPER

44


EVENTS AT HOME AND OVERSEAS

AUSTRALIA

SEPTEMBER 2000

September 25-27 2000 - Adelaide

International Forensic Nursing Conference Every nurseis a forensic nurse at some time Inquiries ph +61 8 8201 5095 fax +61 8276 1602 email sonconfflinderseduau

OCTOBER 2000

October 1-3 2000 - Darwin

Fifty years of enrolled nursing Our gold millenniumInquiries Kylie Mulhall ph +61 8 8981 1875 email conventioncatalystsnorgatecomau

October 3-7 2000 - Canberra

35th Annual Conference of the Australian PsychologicalSociety Ltd The brain games The meeting of the mindsInquiries ph +61 (3) 9663 6166 fax +61 (3) 9663 6177 emailconferpsychsocietycomau Website httpwwwpsychsocietycomau

October 15-18 2000 - Melbourne

13th Aged and Community Services Australia NationalConference amp Trade Exhibition Ageing boldly 2000Inquiries The Meeting Planners Pty Ltd 108 Church StHawthorn VIC 3122 email agedcaremeetingplannerscomau

October 18-20 2000 - Perth

Geriaction Inc National Conference 2000 Dare to ageChallenging the boundaries Inquiries ph +61 8 9332 2900 fax +61 8 9332 2911 email promacopromacocomau

October 19 2000 - Canberra

7th Australian and New Zealand Paediatric and NeonatalIntensive Care Conference Inquiries ConferenceLogistics ph +61 2 6281 6624 fax +61 2 6285 1336email conferenceconlogcomau


25th Australian and New Zealand Annual ScientificMeeting on Intensive Care Inquiries ConferenceLogistics ph +61 2 6281 6624 fax +61 2 6285 1336email conferenceconlogcomau Websitehttpwwwanzicascomauasm

NOVEMBER 2000

November 1-4 2000 - Melbourne

International Emergency Nurses Conference Inquiries+61 3 9820 9115 email aaen2000mcigroupcomWebsite httpmcigroupcomemergnursehtm


Aged care housing summit Australiarsquos fastest growingproperty development market Inquiries ph +61 39529 4314 fax +61 3 9510 4733

November 25-29 - Melbourne

4th World Stroke Conference Inquiries ConferenceSecretariat ICMS ph +61 (3) 9682 0244 fax +61 (3) 9682 0288

MARCH 2001

March 4-7 2001 - Canberra

6th National Rural Health Conference Good health -Good country Inquiries ph +61 2 6285 4660 fax +61 2 6285 4670 email conferenceruralhealthorgau

March 8-9 2001 - Noosa Queensland

1st MaterMercy National Nursing ConferenceBalancing care and costs Inquiries ph 1800 061 660fax +61 2 6282 3565 email confrcnaorgau Websitewwwrcnaorgau

MAY 2001

May 9-11 2001 - Sydney

Royal College of Nursing Australia National Convention2001 Inquiries 1800 061 660 fax +61 2 6282 3565email confrcnaorgau Website wwwrcnaorgau

NOVEMBER 2OO1

November 14-16 2001 - Sydney

4th International Neonatal Nursing Conference 2001Excellence knows no boundaries Inquiries 1800 061 660 fax +61 2 6282 3565 email confrcnaorgau Website wwwrcnaorgau

OVERSEAS

JUNE 2001

June 10-15 2001 - Copenhagen

ICN 22nd Quadrennial Congress NursingA new era foraction Call for papers deadline for abstracts - June 12000 Inquiries ph +45 4492 4492 fax +45 4492 5050email icndiscongresscom

JUNE 2002

June 30-July 5 2000 - Oslo Norway

18th International Cancer Congress Sharing newknowledge strengthening the team Inquiries ph +41 22809 18 70 fax +41 22 809 18 74 emailcongrexcongrexch

INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL

BIRTH CENTRE OR LABOUR WARD A COMPARISON OF THE CLINICAL OUTCOMES OF LOW-RISK WOMEN IN A NSW HOSPITAL

A DESCRIPTION OF THE ADOPTION OF THE lsquoFRESH STARTrsquo SMOKING CESSATION PROGRAM BY ANTENATAL CLINIC MANAGERS


THE ROLE OF THE PSYCHIATRIC CONSULTATION-LIAISON NURSE IN THE GENERAL HOSPITAL



NURSING Bits+ Bytes


GUEST EDITORIAL

6

Readers of this Journal who were practicing prior tothe late 1980rsquos will remember when theeffectiveness of health care was assessed against

the processes of care delivery and patientclientsatisfaction with services That changed dramatically inthe early 1990rsquos when funders of health services inAustralia (government at State and Commonwealth level)began to assess the efficacy of services in terms of dollars spent Health planners and administrators are now occupied by schemes designed to maximise health outcomes for users of services while containing thecost of care

Value for money has become the issue with variationsin cost being closely monitored by administrators (Hindleand Newman 1996) reforms being linked to costs ratherthan clinical discovery (Bessler and Ellies 1995 Duckett1996) and the corporatisation of health facilities (Whiteand Collyer 1997)

The health needs priorities and options of Australiansare changing for a variety of reasons including

increasing prevalence of chronic disease particularlyrelated to an aging society that requires ongoing careacross agencies

continuing reduction in hospital length of stay and theexpanding role of non-inpatient and ambulatoryservices

pressures for improved productivity and efficiency inthe delivery of health care

increasing dependence on technology

The Commonwealth Government has responded bytaking a strategic approach to the design and funding ofservices Six priority areas were identified (publichospitals pharmaceutical non-inpatient medical specialistand diagnostic services primary health and communitycare small rural communities and mental health) and anintegrated approach to services was adopted (NationalHealth Strategy 1991) An integrated health system was tobe achieved through

incentives for best practice

incentives for productivity and efficiency

scope for sustainability and flexibility

service models which encourage continuity of care

selective use of market and competitive pressures

equity in distribution of health resources

devolution of administration and service delivery(National Health Strategy 1991)

This was to be the blue print for health reform inAustralia and to support it a new vocabulary emerged thatincluded case management best practice guidelinesfunderprovider split diagnosis related groups (DRGs)and more recently access block

Describing the model and enabling factors was a startbut the real conundrum is for the service administratorsand clinicians who have the task of bringing togetherservices dealing with incentive programs restructuringservices and developing relationships between providersto achieve the goals for continuity of care

How is the model working at the point of care Therehave been some long overdue reforms and somefrustrations

Incentives for Best Practice

Accountability is fundamental to professional practiceand peer review quality management and clinicalprotocols have been introduced as the key to achievingbest practice That was a positive move The qualityinitiatives have been supported by financial andorganisational incentives also considered to be bestpractice

Incentives have produced positive and negativeoutcomes the interpretation depends on priorities andagendas and is not regarded consistently throughoutorganisations Funding patterns and priorities continue tobe a stimulus to review practice and initiate lsquoinnovationrsquoand no individual associated with health including usersof the health system are exempt from the consequencesThe theory-practice gap widens as financial incentivesovertake clinical imperatives Consequently hospitalwards are less effective for teaching purposesInterestingly some incentives donrsquot generate best practice

Within health there are markedly different financialincentives according to the care environment Forexample private medical practitioners receive incentivesaccording to the number of patients they see Overservicing is not unknown However in the public hospitalsystem the opposite is the case and in fact there areadditional marginal costs associated with attractingpatients Demand on accident and emergency departmentsis an example and hospitals have addressed the increasing

GUEST EDITORIAL - Rhonda Griffiths

Professor Rhonda Griffiths is the Director South Western Sydney Centre for Applied Nursing Research LiverpoolHospital Sydney Australia

lsquoTHEYrsquo SAY ITrsquoS THE BEST HEALTH SYSTEM IN THE WORLD


GUEST EDITORIAL













CONCLUSION
















RESEARCH PAPER

ABSTRACT


INTRODUCTION












ACKNOWLEDEGMENTS





labour ward group





Setting


METHOD




Analysis



RESULTS

Demographics




Mode of delivery


RESEARCH PAPER



X23 =150 p=0001







Analgesia in labour


Perineal outcomes


Neonatal outcomes



DISCUSSION





RESEARCH PAPER

10





X2

5 =35 p=062












CONCLUSION



RESEARCH PAPER

11




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


GUEST EDITORIAL













CONCLUSION
















RESEARCH PAPER

ABSTRACT


INTRODUCTION












ACKNOWLEDEGMENTS





labour ward group





Setting


METHOD




Analysis



RESULTS

Demographics




Mode of delivery


RESEARCH PAPER



X23 =150 p=0001







Analgesia in labour


Perineal outcomes


Neonatal outcomes



DISCUSSION





RESEARCH PAPER

10





X2

5 =35 p=062












CONCLUSION



RESEARCH PAPER

11




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes



RESEARCH PAPER

ABSTRACT


INTRODUCTION












ACKNOWLEDEGMENTS





labour ward group





Setting


METHOD




Analysis



RESULTS

Demographics




Mode of delivery


RESEARCH PAPER



X23 =150 p=0001







Analgesia in labour


Perineal outcomes


Neonatal outcomes



DISCUSSION





RESEARCH PAPER

10





X2

5 =35 p=062












CONCLUSION



RESEARCH PAPER

11




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes




Setting


METHOD




Analysis



RESULTS

Demographics




Mode of delivery


RESEARCH PAPER



X23 =150 p=0001







Analgesia in labour


Perineal outcomes


Neonatal outcomes



DISCUSSION





RESEARCH PAPER

10





X2

5 =35 p=062












CONCLUSION



RESEARCH PAPER

11




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





Analgesia in labour


Perineal outcomes


Neonatal outcomes



DISCUSSION





RESEARCH PAPER

10





X2

5 =35 p=062












CONCLUSION



RESEARCH PAPER

11




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes










CONCLUSION



RESEARCH PAPER

11




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes




















RESEARCH PAPER

REFERENCES


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


ABSTRACT


INTRODUCTION










RESEARCH PAPER


A





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





Study aims



METHOD


Design


Research materials





RESEARCH PAPER

14







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes







Sample selection


RESEARCH PAPER

15










Tertiary 2 2



District 5 3















RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes












RESULTS




RESEARCH PAPER

16



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes



Program adoption








RESEARCH PAPER

17


TINT1


2


3





RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


RESEARCH PAPER



















RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


RESEARCH PAPER







DISCUSSION














Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes










Social context




RESEARCH PAPER

20




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes




CONCLUSION

































RESEARCH PAPER

21













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes













REFERENCES








wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES












wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





wwwrosesonlycomau


wwwolympicscomeng


wwwhealthpostscomau




wwwrleaguecom


wwwa2zcomau


wwwwhitepagescomau


BITS AND BYTES









RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


RESEARCH PAPER

ABSTRACT




INTRODUCTION




















RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes









RESEARCH AIMS







METHOD



RESEARCH PAPER



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes



Sample


Questionnaire


Validity





1 lsquoneverrsquo







Analysis




RESULTS

RESEARCH PAPER


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


Demographics







RESEARCH PAPER

27


Variable n Mean SD







10000-30000 61 355gt30000 86 500


Adult only 34 198

Specialist 10 58


Private 12 70












RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


RESEARCH PAPER








Key


















Key






RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


RESEARCH PAPER

Levels of autonomy





































RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes














RESEARCH PAPER















DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





DISCUSSION








RESEARCH PAPER

31





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





Limitations


CONCLUSION




















RESEARCH PAPER

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes

















RESEARCH PAPER

33


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


ABSTRACT


INTRODUCTION




SCHOLARLY PAPER

34




















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes















SCHOLARLY PAPER

35













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes













SCHOLARLY PAPER

36














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes














SCHOLARLY PAPER

37





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





CONCLUSION











SCHOLARLY PAPER

38



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes



































SCHOLARLY PAPER

39


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


ABSTRACT


INTRODUCTION








SCHOLARY PAPER



SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes


SCHOLARY PAPER


LITERATURE REVIEW








DISCUSSION











Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes










Teaching relaxation




SCHOLARLY PAPER

42





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





3 Start yawning


(McCaffery 1994)



RECOMMENDATIONS





CONCLUSION















SCHOLARLY PAPER

43





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes





















SCHOLARLY PAPER

44



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes



AUSTRALIA

SEPTEMBER 2000



OCTOBER 2000













NOVEMBER 2000







MARCH 2001





MAY 2001



NOVEMBER 2OO1



OVERSEAS

JUNE 2001



JUNE 2002



INFORMATION FORUM

45

FROM THE EDITOR

GUEST EDITORIAL







NURSING Bits+ Bytes

from the editor - heather dawson-byrne · from the editor - heather dawson-byrne nursing measures...

Documents