Using consensus methods to develop clinical practice guidelines for intensive care: The Intensive Care Collaborative project

BACKGROUND: Clinical practices or procedures based on the best available evidence are an essential resource within an intensive care unit (ICU). Maintaining the currency of a local clinical practice manual is challenging however, particularly in relation to the time required, other workload pressures and the availability of staff with relevant skills to interrogate the literature. The aim of the Intensive Care Collaborative (ICC) project was to use the synergism of group processes to develop state-based clinical guidelines for six common intensive care practices - eye care, oral care, endotracheal tube management, suctioning, arterial line management, and central venous catheter (CVC) management. METHODS: Participants were 55 senior nurse clinicians from all nine area health services in NSW, seven academic facilitators, and staff from the Intensive Care Coordination and Monitoring Unit (ICCMU). A range of approaches were used to develop the six clinical practice guidelines (CPG) and related systematic literature reviews, including a preparatory educational seminar for participants, formation of working groups of clinicians, with subsequent teleconferences, e-mail and online forums to identify the scope of each guideline and review the literature. A consensus development conference (CDC) was conducted to finalise the reviews with a nominal group technique (NGT) used to develop recommendations for practice. External Validation Panels (EVP) verified the recommendations in each clinical practice guideline. Group voting was undertaken using a Likert scale (1-3 disagree, 4-6 neutral, 7-9 agree) with consensus agreement set as a median of at least seven. RESULTS: Eighty-three recommendations for practice were developed for the six Clinical Practice Guidelines; 50% were based on research literature evidence (23% with high levels of evidence). The balance were based on consensus opinion of the panel members. Only five recommendations were not validated by external validation. CONCLUSION: This project has demonstrated a method for guideline development that is robust, incorporating evidence from research and clinical expertise utilising an objective egalitarian framework.     

Musculoskeletal symptoms in New South Wales dentists

This study describes the prevalence and distribution of symptoms of musculoskeletal disorders occurring in New South Wales dentists and investigates the relationship between these symptoms and work practices.
Four hundred and forty two members of the Australian Dental Association (New South Wales Branch), were randomly selected and sent questionnaires. Eighty per cent (n=355) responded. No significant differences in reported symptoms were found when considering age, experience, handedness, operating position or period of working without a break.
Eighty-two per cent of the respondents reported experiencing one or more musculoskeletal symptoms during the previous month. Sixty-four per cent of the sample reported suffering pain (the majority reported back pain) and 58 per cent headaches. Most severe symptoms reported were pain (39%) and headaches (25%). Those in the youngest age category of less than 35 years (26%), were significantly more likely to have headaches (X² 4df p<0.05). Female dentists were more likely to rate the severity of their most severe symptom higher (X² 1df p<0.05), and to report more frequent pain (X² 2df p<0.05) and headaches (X² 2df p<0.05).
Those practising four-handed dentistry were significantly more likely to be in the 35–44 age range (X² 4df p<0.01), to work for longer periods before taking a 10-minute break (X² 5df p<0.05) and to report frequent pain (X² 2df p<0.05).
The results support the findings of previous studies conducted overseas but additional information about musculoskeletal symptoms in this occuptional group has been identified.     

Traumatic brain injury: An integrated clinical case presentation and literature review: Part I: Assessment and initial management

Holistic nursing care of critically ill patients continues to be a challenge for all levels of critical care clinicians. Patients with multi-system dysfunction in particular, present complicated clinical challenges that demand care based on sound knowledge and understanding of physiological, psychosocial and spiritual needs. Experiential learning through exposure to a range of patient presentations enables incremental development of professional practice and excellence in nursing care. Case study learning enhances understanding through application of theory to practice in complex clinical presentations.

This two-part paper outlines the assessment, interventions and outcome of a person who sustained multiple trauma including severe traumatic brain injury (TBI). Part I explores assessment and initial management from pre-hospital care through to the Emergency Department (ED) and operating theatre. Part II describes the intensive care period as an integral component of the continuum of care. Key issues in the case are presented sequentially with relevant literature integrated and applied to clinical progress, focussing on the complex physiological, psychosocial, spiritual and environmental needs of the patient and his family. The purpose of the paper is to therefore provide a comprehensive learning resource for critical care nurses, particularly for those beginning their practice.     

Nursing students' perceptions of difficult or challenging clinical situations

This study examined students' perceptions of difficult or challenging clinical situations and how facilitators assisted students in relation to these specific situations Responses to open-ended questions from first-year nursing students before and after a series of hospital and community nursing practice placements were analysed The findings suggest that students do find certain clinical situations difficult or challenging and that facilitators can greatly assist students to effectively deal with these through specific teaching strategies     

How to make the right choice: a new model for the selection interview

The problems encountered when selecting new members of staff in the higher education setting are those universal in any type of organization. Nursing faculties, however, have an even greater difficulty in selecting appropriate staff owing to the diversity of both clinical and academic backgrounds of applicants. The organization is therefore stimulated and challenged in its ability to select the right employee for the job. The literature tends to support the use of group decision making in selection and the function of the group in the interview setting is to evaluate the applicant's prior learning against desirable characteristics. From an analysis of the literature, criteria relating to desirable employee characteristics for nurse academics have been developed. The author has identified a new model to use in assisting the selection panel in predicting the right person for the job.     

An application of nursing faculty practice: clinical camps

The incorporation of clinical practice into nursing faculty role expectations has triggered much debate. Despite the urge for the incorporation of practice into faculty roles, past research has demonstrated that the majority of faculties do not in fact include clinical practice. Reasons given for the failure of nurse academics to practice include lack of time, the failure of academia to value the practice, and the failure to include the practice as criteria for tenure and promotion. For faculty practice to occur it has been argued that clinical practice needs to be more a matter of individual intent: adaptable, and creative. Clinical camps provide potential opportunities for clinical practice for faculties. These camps, it is argued, offer the possibility of clinical teaching, promotion of collegial relationships between faculty and health care agencies, development of positive faculty-student relationships, and a valuable research site. For this reason, it is argued that clinical camps be considered a viable venue for faculty practice.