Reflections on strategic nurse leadership

This paper sets out some personal reflections by the Chief Nursing Officer for Wales on the challenges facing nurses and midwives as they undertake strategic leadership roles in NHS organisations. The paper looks at the national approach taken in Wales where behavioural competencies for executive nurse directors have been implemented. It considers the implications of the breadth of responsibilities executive nurse directors have and the importance of developing and supporting middle grade nurse managers and clinical directors. It concludes by looking at who is responsible for care within an organisation.     

Evaluation of a modified emergency surgical acuity score in predicting operative and non-operative mortality and morbidity in an acute surgical unit

Background

Emergency general surgery (EGS) patients have an increased risk of mortality and morbidity compared to other surgical patients. Limited risk assessment tools exist for use in both operative and non-operative EGS patients. We assessed the accuracy of a modified Emergency Surgical Acuity Score (mESAS) in EGS patients at our institution.

Methods

A retrospective cohort study from an acute surgical unit at a tertiary referral hospital was performed. Primary endpoints assessed included death before discharge, length of stay (LOS) >5 days and unplanned readmission within 28 days. Operative and non-operative patients were analysed separately. Validation was performed using the area under the receiver operating characteristic (AUROC), Brier score and Hosmer-Lemeshow test.

Results

A total of 1763 admissions between March 2018 and June 2021 were included for analysis. The mESAS was an accurate predictor of both death before discharge (AUROC 0.979, Brier score 0.007, Hosmer–Lemeshow P = 0.981) and LOS >5 days (0.787, 0.104, and 0.253, respectively). The mESAS was less accurate in predicting readmission within 28 days (0.639, 0.040, and 0.887, respectively). The mESAS retained its predictive ability for death before discharge and LOS >5 days in the split cohort analysis.

Conclusion

This study is the first to validate a modified ESAS in a non-operatively managed EGS population internationally and the first to validate the mESAS in Australia. The mESAS accurately predicts death before discharge and prolonged LOS for all EGS patients, providing a highly useful tool for surgeons and EGS units worldwide.     

Double barrelled uro-colostomy versus Ileal conduit for urinary diversion following pelvic exenteration: a single centre experience

Introduction

The ideal method for urinary diversion following total pelvic exenteration (TPE) remains unclear. This study compares the outcomes of double-barrelled uro-colostomy (DBUC) and ileal conduit (IC) in a single Australian centre.

Methods

All consecutive patients who underwent pelvic exenteration with the formation of either a DBUC or an IC between 2008 and November 2022 were identified from the prospective database from the Royal Adelaide Hospital and St. Andrews Hospital. Demographic, operative characteristics, general perioperative, long-term urological and other relevant surgical complications were compared via univariate analyses.

Results

Of 135 patients undergoing exenteration, 39 patients were eligible for inclusion: 16 patients with a DBUC, and 23 patients with an IC. More patients in the DBUC group had previous radiotherapy (93.8% vs. 65.2%, P = 0.056) and flap pelvic reconstruction (93.7% vs. 45.5%, P = 0.002). The rate of ureteric stricture trended higher in the DBUC group (25.0% vs. 8.7%, P = 0.21), but in contrast, urine leak (6.3% vs. 8.7%, P>0.999), urosepsis (43.8% vs. 60.9%, P = 0.29), anastomotic leak (0.0% vs. 4.3%, P>0.999), and stomal complications requiring repair (6.3% vs. 13.0%, P = 0.63) trended lower. These differences were not statistically significant. Rates of grade III or greater complications were similar; however, no patients in the DBUC group died within 30-days or had grade IV complications requiring ICU admission compared with two deaths and one grade IV complication in the IC group.

Conclusion

DBUC is a safe alternative to IC for urinary diversion following TPE, with potentially fewer complications. Quality of life and patient-reported outcomes are required.     

The engagement of older people living with chronic lung disease in a peer support community-based exercise programme: A qualitative study

Background

Chronic lung disease is a common and complex condition. Pulmonary rehabilitation programmes—either hospital-based or in the community are recommended in evidence-based clinical practice guidelines.

Aim

To explore the experience of older people with chronic lung disease involved in a peer support community-based exercise maintenance programme.

Design and Method

Participants were a part of the Lungs in Action programme run in a local community leisure centre through Lung Foundation Australia. All the programme participants (n = 25) were invited by an independent person through email and/or letter to participate in the study and provided with a participant information and consent form. Participants who returned consent forms were scheduled for group interviews. Participants were recruited over a 2-week period between 30 August and 13 September 2022. We conducted qualitative group interviews using a semi-structured interview guide to explore the experiences of older people living with chronic lung disease. Data were analysed using reflexive thematic analysis.

Results

A total of 14 participants (eight female and six male) aged between 64 and 86 years were interviewed. Three themes emerged from the data: motivation, authentic social engagement, and sustainable achievement. Motivation stemmed from the participants' perceived health benefits, and from the trainers' motivation and encouragement. Participants discussed how sharing experiences created an environment of trust and understanding, fun and friendship. Social engagement and creating authentic relationships were key aspects raised by participants. Feeling more confident in themselves and being able to accomplish physical tasks, making activities of daily living more manageable featured highly in participants' responses.

Discussion and Conclusion

Community-based peer support exercise groups enable environments for people with chronic lung disease to maintain physical fitness, and to connect with others to form friendships and have fun.