Minimum practice standards for Australian graduate emergency nursing programs: An exploratory, sequential mixed-methods study. By Tamsin Patricia Jones RN, BN (Hons), BSc (Health Promotion), Grad Dip Critical Care, MHPE, FCENA A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Sydney Nursing School The University of Sydney 2021
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Minimum practice standards for Australian graduate emergency nursing programs: An exploratory, sequential
mixed-methods study.
By
Tamsin Patricia Jones
RN, BN (Hons), BSc (Health Promotion), Grad Dip Critical Care, MHPE, FCENA
A thesis submitted in fulfilment of the requirements for the degree of Doctor of
Philosophy
Sydney Nursing School
The University of Sydney
2021
ii
Statement of Originality
This thesis is an account of original research undertaken from 2015 to 2020 while I
was a student at Griffith University and The University of Sydney. I have been primarily
responsible for the design, data collection, data analysis, and reporting of the
research. Given the nature of a higher research degree, this work was undertaken with
the assistance of others, who are duly acknowledged. To the best of my knowledge all
references to other published work contained in this thesis are correct, and no part of
the thesis has been submitted for any other degree.
Tamsin Jones
iii
Acknowledgements
Completing this thesis has been a challenging, yet rewarding experience. There
are so many wonderful people that have supported me throughout this journey. I am
truly grateful for the support I have received, and would like to make some key
acknowledgements.
I am so incredibly grateful to my wonderful supervisors Professor Ramon Shaban
and Professor Kate Curtis. Your unwavering guidance, patience and feedback
throughout this study has been incredible. You are both truly inspiring and I have
learnt so much from you both. I would also like to acknowledge Professor Debra
Creedy who initially commenced the supervision journey with me.
To my incredibly supportive, always loving husband Mark. Thank you for your
patience and constant belief in me and my ability. You have always been interested in
what I was doing and where things were at. You propped me up when, at times, the
juggle of our lives just seemed a bit hard. Thank you for always being there.
To my three children, Tom, Jack and Clementine. You have given me so much
love, so many cuddles, and great distractions. Whilst you’re all a bit young now to
understand, my hope is that from this you will grow up believing you can achieve your
goals. You each have wonderful little personalities that show you are kind,
compassionate and determined. I hope these characteristics remain with you always.
To my parents, but in particular my mum Mary. I truly can’t thank you enough
for coming down from the country, often weeks at a time, to help with caring for our
family whilst I was immersed in data or writing. You have always been a rock, and you
didn’t let a pandemic get in the way (not even our Victorian arm). You have always
supported me with any pursuit I have wanted to achieve. You truly are one of life’s
gems; a selfless and beautifully kind woman.
My colleagues and friends have provided me with constant encouragement,
wisdom and much needed laughter. Thank you for our coffee dates, debrief sessions
and laughs; you have kept me sane.
iv
Thank you to the College of Emergency Nursing Australasia (CENA) for
supporting this research through the distribution of the Delphi surveys and the New
Investigator Research Grant (2018).
Thank you to all the participants who contributed to the various phases of this
study.
To the Skellern Family Foundation for their generous scholarship. What a
wonderful gift this has been, and the reason I have had protected time to complete
my PhD.
I wish to acknowledge Dr Floriana Badalotti from Artelingua, who edited my thesis
in accordance with Standards D and E of the Australian Standards for Editing Practice.
v
Table of Contents
Statement of Originality .......................................................................................... ii
Acknowledgements ................................................................................................ iii
List of Tables ........................................................................................................... ix
List of Figures .......................................................................................................... x
Authorship Attribution Statements ......................................................................... xi
Abstract ................................................................................................................ xiii
List of Abbreviations ..............................................................................................xvi
Glossary of Terms ................................................................................................ xviii
Publications related to thesis ................................................................................ xxii
2.2. Literature review overview ............................................................................ 16
2.3. Publication 1: Practice standards for emergency nursing: An international review …… .................................................................................................................. 17
2.4. Update of Integrative Review: Practice Standards for Emergency Nursing (2015-2020) ............................................................................................................... 32
vi
2.4.1. Results of the updated literature review.............................................. 32
2.5. Practice standard development in Australian specialty nursing.................... 38
3.7. Study 1: Comparative analysis of emergency nursing practice standards .... 50
3.8. Study 2: Analysis of Australian graduate-level emergency nursing programs .. ........................................................................................................................ 50
3.9. Study 3: Stakeholder analysis of graduate emergency nursing practice standards ................................................................................................................... 62
Chapter 4. Results of Study 2 Analysis of Australian Graduate Emergency Nursing Programs…….. ........................................................................................................ 75
4.2. Publication 2: Academic and professional characteristics of Australian graduate emergency nursing programs. ................................................................... 75
Chapter 5. Results of Study 3 Practice Expectations of Australian Graduate Emergency Nursing Programs ................................................................................ 85
5.2. Publication 3: Practice Expectations of Australian Graduate Emergency Nursing Programs: A Delphi Study. ........................................................................... 85
Appendix 1: Ethics Approval Email for Study Two ................................................. 150
Appendix 2: Questions applied to document analysis ........................................... 151
Appendix 3: Participant Information Consent Form Study Two, Key Informant Interviews ........................................................................................................... 152
Appendix 4: Study Two semi-structured interview guide for key informant interviews ............................................................................................................................ 157
Appendix 5: Indexing Framework Used for Key Informant Interviews ................... 158
Appendix 6: Ethics Approval Letter Study Three ................................................... 159
Appendix 7: Approval letter from CENA for Study Three ....................................... 161
Appendix 8: Email sent to CENA members for participation in round 1 of Delphi .. 162
Appendix 9: Participant Information Sheet ........................................................... 164
Appendix 10: Delphi Round One Questions .......................................................... 168
Appendix 11: Ethics approval for Round Two Delphi............................................. 182
Appendix 12: Research Data Management Plan ................................................... 183
Appendix 14: Confirmation of manuscript submission to Nurse Education Today.. 195
ix
List of Tables
Table 1.1 Distinct elements of emergency nursing work defined by the CENA .............. 5
Table 2.1 Summary of international comparison of practice and competency standards from updated literature search (2015-2020) ................................................ 34
Table 2.2 Summary of domains across international practice and competency standards from updated literature search (2015-2020) ................................ 35
Table 2.3 Specialty areas of nursing & midwifery in Australia ....................................... 39
Table 3.1 Research approaches to the connection, relationship and inference with data. ............................................................................................................... 43
Table 3.2 Mixed-methods research designs ................................................................... 46
Table 5.1 Demographic details of Round One and Round Two respondents ................ 93
Table 5.3 Attributes of graduate emergency nurses on completion of their graduate program.......................................................................................................... 97
Table 5.4 Recommended clinical care capabilities of graduates on completion of their graduate emergency nursing program ........................................................ 100
Table 6.1 Minimum practice standards for Australian graduate emergency nursing programs ...................................................................................................... 109
Table 6.2 Clinical care capabilities of emergency nurses on completion of graduate emergency nursing programs ...................................................................... 111
x
List of Figures
Figure 1.1 Common areas of care in the emergency department ................................... 3
Figure 1.2 Progression of clinical areas through the emergency department................. 8
Figure 2.1 Screening process and search outcomes for updated integrative review .... 33
Figure 3.2 Exploratory sequential design for the establishment of minimum practice standards for Australian graduate emergency nursing programs ................. 48
Figure 3.3 Summary of 5 steps of Framework Analysis applied to Phase 2 ................... 58
Figure 3.4 Two-round Delphi process ............................................................................ 64
Figure 3.5 Delphi data collection process for Study 3 to determine consensus-based practice standards for Australian graduate emergency nursing programs ... 70
Figure 3.6 Mixed-Methods Research Integration Trilogy .............................................. 73
Figure 5.1. Data collection and analysis process for Delphi study to determine consensus-based practice standards for Australian graduate emergency nursing programs ........................................................................................... 92
Figure 6.1 Summary of sequential integration of studies to establish minimum practice standards for graduate emergency nursing programs. ............................... 107
xi
Authorship Attribution Statements
Professor Ramon Shaban and Professor Kate Curtis formed the higher degree
supervisory team. Professor Debra Creedy was a member of the higher degree
supervisory team whilst the thesis author was a part-time PhD student at Griffith
University 2015-2017. Published manuscripts form part of the higher degree award of
Doctor of Philosophy undertaken by Tamsin Jones.
The following outlines the published and submitted manuscripts embedded in this
thesis and authorship attribution statements indicating my contributions of the thesis
and published works.
• Chapter 2, Section 2.3 of this thesis contains Publication 1:
Jones, T., Shaban, RZ., Creedy, DK. (2015). Practice standards for emergency
nursing: An international review. Australas Emerg Nurs J. 18(5): 190-203. doi:
10.1016/j.aenj.2015.08.002
I designed this study with the co-authors, analysed and interpreted the data,
wrote the drafts and led the preparation and submission of the manuscript.
• Chapter 4 Section 4.2 of this thesis contains Publication 2:
Jones, T., Curtis, K., Shaban, RZ. (2020). The academic and professional features of
Australian graduate emergency nursing programs: A national study. Australas
Campo, & Gacki-Smith, 2014; Fitzpatrick, Campo, Graham, & Lavandero, 2010; Fry, 2008; Henrik & Kerstin, 2009; Homer et al.,
2007; Lothian et al., 2011; Lyneham, Parkinson, & Denholm, 2008b; McCarthy, Cornally, Mahoney, White, & Weathers, 2013; H.
McClelland, 2012; M. McClelland et al., 2011; Moher, Liberati, Tetzlaff, & Altman, 2009; Nixon, 2008; Nursing and Midwifery
Board Australia, 2014; Nursing and Midwifery Board of Australia, 2006; Perry, 2013; Potter, 2006; Rose & Gerdtz, 2007; Rose &
Gerdtz, 2009; Sbaih, 1995; Schull et al., 2011; Scott, 2004; Snyder, Keeling, & Razionale, 2006; Thompson et al., 2014; Timmings,
2006; Williams & Crouch, 2006)
32
2.4. Update of Integrative Review: Practice Standards for Emergency
Nursing (2015-2020)
A search for any additional or updated emergency nursing practice or
competency standards since the original integrative review was conducted. The search
dates were from January 2015 to June 2020. The purpose was to identify any new
standards that would contribute to understanding emergency nursing practice
standards. The same electronic databases and search terms were used from the
original integrative review. Manual searches in Google, along with international
emergency nursing websites, were also conducted. Figure 2.1 summarises the search
outcomes and screening processes.
2.4.1. Results of the updated literature review
The search yielded 1542 articles. Following the removal of duplicates, 1311 titles
and abstracts were screened. 19 full text references were reviewed, including four
documents found through manual searches. Four documents met the inclusion criteria
for review. These documents were all discovered from the manual search and were
not publications in peer-reviewed journals. Two emergency nursing standards were
updated from the original integrative review (Emergency Nurses Association, 2017;
Faculty of Emergency Nursing, 2019); one set of practice standards were not available
for the integrative review, and thus the competency standards were originally
analysed (National Emergency Nurses Association, 2018), and one new set of
standards were developed following the original review (European Society for
emergency Nursing, 2017). It is important to note that all four standards refer to
emergency nurses being required to apply the standards to all patients across the life
span, who may have undiagnosed and complex care needs, and may be critically
unwell. They also address that emergency nurses care for the physical, psychological,
social, cultural and spiritual care needs for patients and their significant others. A
summary of the four standards is provided in Table 2.1, and all standards were
analysed using the domains of analysis used in the original integrative review which
are presented in Table 2.2.
33
Figure 2.1 Screening process and search outcomes for updated integrative review
INC
LUD
ED
ELIG
IBIL
ITY
SC
REE
NIN
G
Total (n = 1542)
Removal of duplicates (n = 231)
Screening of records by titles and abstracts
(n = 1311)
Records excluded Title: (n = 1262)
Abstract: (n = 30)
Full text records assessed for eligibility (n = 19)
Full texts records excluded (n = 13)
Articles by thesis author excluded
(n = 2)
(n = )
IDEN
TIFI
CA
TIO
N
MEDLINE (n = 2)
CINAHL (n = 72)
EMBASE (n = 593)
Hand searched material (n = 4)
SCOPUS (n = 871)
Final records for review (n = 4)
34
Table 2.1 Summary of international comparison of practice and competency standards from updated literature search (2015-2020)
ENA = Emergency Nurses Association; EuSEN = European Society for emergency Nursing; FEN = Faculty of Emergency Nursing; NENA = Canadian Nurses Association
ENA [USA] EuSEN [Europe] FEN [UK] NENA [Canada]
Standard type: Standards of Practice with
competencies
Competencies Competency Framework Standards of Practice
Title: Emergency Nursing – Scope
and Standards of Practice
Emergency Department Nurse
Competencies
FEN Competency Framework Emergency Nursing Scope and
Standards of Canadian Practice
Standards developed
by:
The ENA Emergency Nursing
Scope and Standards of
Practice Revision Work Team
2016
European Society for
emergency Nursing
“Emergency Nurses for use by
emergency nurses”
National Emergency Nurses
Association
Emergency nursing
input
Yes Not stated Yes Not Stated
Edition: 2nd Not stated Not stated 6th
Review Date: 2017 2017 2019 2018
Next review: Not stated Not stated Not stated Not Stated
Number of domains or
competencies
20 domains 8 domains 4 domains applied to nine sets
of competencies
12 domains
National Governing
Body for Emergency
Nurses
Nursing regulatory bodies in 50
states of the USA
Individual countries within the
European Union
The Nursing and Midwifery
Council
Regulatory bodies in 12
individual provinces or
territories of Canada
Accessibility Available for purchase Available for anyone online Public, additional detail
Table 2.2 Summary of domains across international practice and competency standards from updated literature search (2015-2020)
DOMAINS ENA [USA] EuSEN [Europe] FEN [UK] NENA [Canada]
Clinical
Expertise
• Assess, analyse, plan, prioritise,
implement, coordinate and
evaluate, refer care
• Respond appropriately to the
deteriorating patient, or patient
at risk of deterioration
• Triage
• Integrate health promotion and
education strategies into care
delivery
• Advocate for patient
• Assess, initiate, prioritise,
escalate, evaluate and refer care
• Early detection of deterioration
and appropriate escalation
• Triage
• Advocate for patient
• Assess, analyse, plan, prioritise,
implement, evaluate and refer
care
• Respond appropriately to the
deteriorating patient, or patient
at risk of deterioration
• Triage
• Integrate health promotion and
education strategies into care
delivery
• Safe discharge of patients
• Advocate for patient
• Assess, analyse, plan, prioritise,
implement, evaluate and refer
care
• Respond appropriately to the
deteriorating patient, or patient
at risk of deterioration
• Triage
• Integrate health promotion and
education strategies into care
delivery
• Facilitate safe and effective
discharge processes
• Advocate for patient
Communication • Communicates effectively in all
areas of practice
• Communicates effectively and
professionally in all areas of
practice
• Communicates effectively and
professionally in all areas of
practice
• De-escalates potential or actual
aggressive/confrontational
situations and assists those less
experienced in managing such
situations
• Communicates effectively and
professionally in all areas of
practice
Teamwork • Collaborates with patient and
key stakeholders in delivery of
nursing care
• Works effectively, collaboratively
and professionally within the
multi-disciplinary team
• Collaborates with patient and
key stakeholders in delivery of
nursing care
• Collaborates with patient and
key stakeholders in delivery of
nursing care
Resources &
Environment
• Utilises appropriate resources to
plan, provide and sustain
evidence-based nursing services
• Effective use of a wide range of
equipment for care delivery
• Emergency and disaster
recognition and response
• Effective deployment, use and
evaluation of monitoring
equipment, including teaching
• Ensures equipment necessary for
safe patient care are available
and in working order
36
that are safe, effective and
fiscally responsible
• Practices in an environmentally
safe and healthy manner
other staff how to use this
equipment
Professional
Development
• Actively maintains currency and
competency of professional and
practice
• Promotes professional
development
• Maintains professional portfolio
• Provides mentorship
• Evaluates one’s own and others’
nursing practice
• Achieved or working towards a
postgraduate qualification in
Emergency Nursing
• Maintains professional portfolio
• Promotes the profile of
emergency nursing
• Actively seeks feedback
• Maintains [a] personal
development plan and actively
manage professional
development
• Reflects on practice
• Maintains a professional
portfolio
• Provides preceptorship and
mentorship
• Demonstrates emotional
resilience
• Maintains professional
competency based on provincial
governing bodies
• Maintains personal and
professional development and
lifelong learning
• Provides preceptorship and
mentorship
• Fosters a professional image of
nursing
Leadership • Leads within the emergency care
setting and the emergency
profession
• Proactively manages patient flow
• Can access and implement
relevant departmental and
organisational policies and
procedures
• Applies principles of leadership
and negotiation
• Functions as team leader in an
emergency situation
• Modifies personal behaviour to
contribute to or manage crisis
situations.
• Supervises team members and
delegate care
• Manages actual or potential
violent incidents safely
• Maintains safety for colleagues,
patients, significant others and
themselves
Legal • Adheres to professional scope
and standards of practice
• Practice according to regulatory
requirements for licensure
• Works within scope of practice
• Applies clinical governance and
risk management strategies
• Practices and applies legal
principles, standards and
• Practices within the scope of
practice established by current
legislation and federal, provincial
or territorial and municipal laws
and regulatory bodies
37
ENA = Emergency Nurses Association; EuSEN = European Society for emergency Nursing; FEN = Faculty of Emergency Nursing; NENA = Canadian Nurses Association
(Emergency Nurses Association, 2017; European Society for emergency Nursing, 2017; Faculty of Emergency Nursing, 2019; National Emergency Nurses Association, 2018)
guidance provided by relevant
professional governing body
Professional
Ethics
• Practices ethically
• Applies cultural diversity and
inclusion principles in their
practice
• Professionally accountable • Role model, practices care and
develops guidelines according to
ethical principles
• Provides care based on the Code
of Ethics for Nursing. and/or the
provincial association or
provincial order, and
institutional policies and
procedures
Research &
Quality
• Integrates evidence and research
findings into practice
• Endorses a climate of research,
scientific and clinical inquiry
• Contributes to quality nursing
practice
• Engages in and facilitate
research and quality
improvement for emergency
nursing
• Promotes a research culture in
emergency nursing
• Contributes to the development
of audit, governance activities,
practice, protocols, procedures,
policies and guidelines, and
research
• Engages in research in the
practice setting
• Facilitates research in the
practice setting
• Adheres to ethics that govern
research
38
The findings from the updated literature review demonstrate there are
similarities across all nine domains of analysis: (i) clinical expertise; (ii) communication;
(iii) environment and resources; (iv) leadership; (v) legal; (vi) professional
development; (vii) professional ethics; (viii) research and quality; (ix) teamwork. The
original integrative review showed five domains of similarity, with the updated review
adding leadership, research and quality, professional ethics and professional
development. The results highlight the importance of standards being reviewed, as
two of these documents are new editions of previous standards (Emergency Nurses
Association, 2017; Faculty of Emergency Nursing, 2019). Additionally, they show the
importance of collaboration and the public availability of practice standards. The first
edition of the European Society for emergency Nursing competency standards
acknowledges the use of the CENA practice standards for the Emergency Nursing
Specialist (College of Emergency Nursing Australasia, 2014) and the NENA emergency
nursing core competencies (National Emergency Nurses Association, 2014) in their
development. No standards reviewed in the updated literature review were aimed at
graduate emergency nursing programs, which further highlights the absence of such
standards, demonstrating a clear gap in the literature and the need for the
development of practice standards for graduate emergency nursing programs.
2.5. Practice standard development in Australian specialty nursing
Practice standards for specialty areas in nursing articulate the comprehensive
role of these specialist clinicians, and inform expectations with regards to safe and
ethical clinical practice (Edmonds et al., 2013). The presented findings from the above
literature review demonstrate that international practice standards (College of
Emergency Nurses New Zealand, 2007; College of Emergency Nursing Australasia,
2014; Emergency Nurses Association, 2017; National Emergency Nurses Association,
2018) and competency standards (Canadian Nurses Association, 2014; European
Society for emergency Nursing, 2017; Faculty of Emergency Nursing, 2014; National
Emergency Nurses Association, 2014) for the specialisation of emergency nursing
exist. These practice standards have all been established by the relevant professional
emergency nursing bodies, they have not been developed by nursing regulation
39
bodies. In Australia, the NMBA reviewed the need for regulated specialist practice
standards for Australian nurses in their Specialist registration for the nursing
profession project (2014) (Nursing and Midwifery Board Australia, 2016a). A key
finding from this review was that there was insufficient evidence to demonstrate the
impact that such standards would have on patient outcomes, and therefore they did
not support the regulation of specialty nursing practice (Nursing and Midwifery Board
Australia, 2016a). The justification was that flexibility within the Registered Nurses
Standards for Practice (Nursing and Midwifery Board Australia, 2016b) was considered
sufficient to cover the extension of practice that is often required in nursing
specialties. The recommendation from the NMBA was that standards for nursing
specialties should be developed by individual specialist nursing professional bodies
(Nursing and Midwifery Board Australia, 2016a). The Australian Nursing and Midwifery
Federation (ANMF) supported the need for the development of specialty nursing
practice standards by professional bodies, emphasising that they need to align with
the overall purpose, function and ethical standards of the nursing profession
Morgan (2007) summarises three core elements of the opposing paradigm views
and demonstrates how pragmatism sits within these (Table 3.1). The pragmatic
connection between theory and data is an abductive process. It is considered fluid-
like, where the researcher moves in and out of both inductive and deductive
reasoning throughout the research process to inform inferences about the findings.
Pragmatism challenges the concept of the researcher being purely objective or
subjective in research. Pragmatism asserts that the researcher is inter-subjective, as
they are not incommensurate with an ‘all or nothing’ assumption. Transferability is
also an important consideration in pragmatism, as the findings from mixed-methods
research are applied to other settings, which challenges the purist assumptions that
inferences are only contextual or generalisable (Morgan, 2007).
Table 3.1 Research approaches to the connection, relationship and inference with data.
Qualitative Approach
Quantitative Approach
Pragmatic Approach
Connection of theory and data
Induction Deduction Abduction
Relationship to research process
Subjectivity Objectivity Inter-subjectivity
Inference from data
Context Generality Transferability
(Morgan, 2007, p. 71)
44
3.3. Mixed-methods
Mixed-methods research is believed to have been formalised by Campbell and
Fiske in 1959 (Johnson, Onwuegbuzie, & Turner, 2007). Since its inception, mixed-
methods research has gained momentum as researchers combine both quantitative
and qualitative research methods to explore and answer research questions with
greater depth and understanding, and is considered the third approach to research
(Johnson et al., 2007; Teddlie & Tashakkori, 2009). Its use in the healthcare
environment and in educational research continues to increase, which is thought to be
related to the multifactorial dimensions and complexity of human subjects that
characterise these two areas (Glogowska, 2010).
The research question remains the focus when developing a program of
research for mixed-methods studies, and thus the researcher utilises the strengths of
quantitative and qualitative methods. Mixed-methods research is often used where a
research problem is complex and one design would insufficiently answer the research
questions, thus the multiple methods are required. The researcher must be clear
about the role of both the qualitative and quantitative approaches, the rationale for
their use in answering the study aim, and research questions and the order in which
they are conducted (Curry, 2015) . The sequence of data collection, relationship
between analysed results, and integration of data is an important consideration and
justification for when a simultaneous or sequential design is required (Curry, 2015;
Halcomb & Hickman, 2015).
In this study, it was necessary to determine what emergency nursing practice
standards are available internationally, and determine their relevance to graduate
emergency nursing programs. It was necessary to understand the current Australian
context of graduate emergency nursing studies to inform and subsequently explore a
consensus about graduate-level emergency nurse practice standards. A mixed-
methods design was adopted as it enabled an integration of both qualitative and
quantitative research methods for deeper understanding (Creswell & Plano Clark,
2011; Teddlie & Tashakkori, 2009). Graduate specialty practice nursing education
research is often complex with limited evidence, and thus requires rigorous
45
exploration using a combination of qualitative and quantitative data to substantiate
and validate the evidence generated (Cooper, Porter, & Endacott, 2011; Creswell &
Plano Clark, 2011; Tashakkori & Teddlie, 1998).
3.4. Study aim
The overall aim of this study was to establish minimum practice standards for
graduate emergency nursing programs. The generation of these specific practice
standards for nurses who have completed graduate-level post-registration studies
specialising in emergency nursing will ideally improve workforce expectations and
patient safety.
3.4.1. Research questions
The research questions that guided the phases of this study are:
1. What professional practice and competency standards for emergency nursing
exist globally? (Study 1)
2. What are the academic and professional characteristics of Australian graduate
emergency nursing programs? (Study 2)
3. What professional practice standards should underpin graduate emergency
nursing programs across Australia? (Study 3)
3.5. Study design: Exploratory sequential design
As explained in Section 3.3, mixed-methods research utilises both qualitative
and quantitative approaches. Depending on the structure of the mixed-methods, the
qualitative or quantitative methods will have a stronger influence in the exploration
and development of the study design, and thus answering of the research questions.
Careful consideration is required of the research questions, which subsequently
determines which of the six core mixed-methods designs is selected, as illustrated in
Table 3.2.
46
Table 3.2 Mixed-methods research designs
Research Design
Description
Convergent parallel design
• Concurrent quantitative and qualitative data collection and analysis
• Compares results during interpretation for convergence and divergence
Explanatory sequential design
• Quantitative data collection and analysis is followed by qualitative data collection and analysis
• Qualitative findings are used to help explain the quantitative results
Exploratory sequential design
• Qualitative data collection and analysis is followed by quantitative data collection and analysis
• Quantitative findings are used to build on the initial qualitative results
Embedded design
• Quantitative or qualitative data collection and analysis occurs. A qualitative or quantitative component of data collection is embedded into the design to strengthen the research design
Transformative design
• The concurrent or sequential collection of quantitative and qualitative data is conducted within a transformative theoretical framework
Multiphase design
• Combines sequential and concurrent approaches over multiple phases
• Common in large scale research, particularly evaluative
(Creswell & Plano Clark, 2011, p. 73)
Exploratory sequential design uses a series of studies that begins with qualitative
data collection. It is preferred by researchers when little is known of the research
question, as rich data from the qualitative data collection phase can be used to inform
the development of the quantitative data collection tool, as illustrated in Figure 3.1
(Creswell & Plano Clark, 2011).
47
Figure 3.1 Exploratory sequential design (Creswell & Plano Clark, 2011)
The exploratory sequential design was selected for this research, as it enabled
the researcher to explore and understand the current position of graduate emergency
nursing programs across Australia through qualitative data collection. There is a
paucity of literature relating to graduate emergency nursing attributes or graduate
emergency nursing programs, and therefore a qualitative phase was required to
better understand this (Creswell & Plano Clark, 2011). A comparative analysis of
available international emergency nursing practice and competency standards was
carried out and informed the development of the document analysis, which then
informed the development of the key informant interview questions. The analysis
from this embedded mixed-methods study was subsequently used to develop the
Delphi. Each stage of data collection needed to occur in isolation, with the findings
informing the development of the next phase of data collection, as illustrated in Figure
3.2 (Creswell & Plano Clark, 2011; Curry, 2015).
48
Figure 3.2 Exploratory sequential design for the establishment of minimum practice standards for Australian graduate emergency nursing programs
3.6. Human research ethical considerations
This body of research was conducted in accordance with the National Statement
on Ethical Conduct in Human Research 2007 (2018), Griffith University Research Ethics
Manual (Griffith University, 2016) and The University of Sydney Research Code of
Conduct (2013) (The University of Sydney, 2018). Ethics approval was received for
Study Two from Griffith University HREC (Appendix 1) and for Study Three from The
University of Sydney (Appendix 6). Ethics was submitted to different universities for
different studies based on the University of PhD enrolment at the time of data
collection. The studies were designed with due attention and application of the ethical
values and principles of: research merit and integrity, justice, beneficence and respect
(National Health and Medical Research Council (NHMRC), 2018). Specific application
Study 1
QUAL
Research Question:
What professional practice and competency standards for emergency
nursing exist globally?
Data Collection & Analysis:
Integrative literature review.
Comparative analysis of global practice and
competency standards for emergency nursing
Study 2
QUAL
Research Question:
What are the academic and professional characteristics of
expectations and clinical care capabilities were the four key areas of data collection.
Participants could provide open-ended answers to any questions where they wanted
to contribute more data relating to the area being examined. Open-ended questions
created an opportunity for thoughts and opinions of the expert panel to be captured.
Non-identifiable demographic data was collected in section one of the survey, such as
69
highest level of education qualification, role, state or territory of work and years of
experience. In section two of the survey, participants were asked to provide their
agreement to statements relating to clinical practice requirements for graduate
emergency nursing programs. Responses to the statements in section three “graduate
expectations” and four “clinical care capabilities” of the survey were measured against
a 5-point Likert scale (1 = Strongly agree; 2 = Agree; 3= Neither agree or disagree; 4
Disagree; 5 Strongly Disagree. Likert scales are an ordinal measurement that enabled
the researcher to explore panel members’ beliefs and opinions about each statement
or question (Østerås et al., 2008).
The survey was administered via the CENA secretariat and sent to all CENA
members who were registered to receive research emails. Potential participants
received a unique URL for the tool via REDCap. The survey was open for three weeks
and two reminder emails were sent at the end of the first and second weeks to the
CENA membership. CENA also distributed the survey URL via their social media
platforms of Facebook, Instagram and Twitter.
On completion of the Round One survey, data was analysed and feedback was
distributed to participants by the CENA in conjunction with the second round of the
Delphi. Following ethics approval for the Round Two survey (Appendix 11), the CENA
members were emailed the second round of the Delphi and asked to rank their
agreement with refined statements and expectations of graduates against the 5-point
Likert scale. A unique URL for the second survey tool via REDCap was provided. The
Delphi data collection occurred occur over a total period of 14 weeks. Round One of
the Delphi was open for three weeks. Round Two data collection occurred during the
height of the first wave of COVID-19 in Australia which, as noted in Section 1.2.2, had
a significant impact on the emergency nursing workforce. To maximise data collection,
the Round Two survey was open for four and a half weeks. A summary of the data
collection process is represented below in Figure 3.5:
70
Figure 3.5 Delphi data collection process for Study 3 to determine consensus-based practice standards for Australian graduate emergency nursing programs
3.9.1.5. Data analysis
On completion of each survey round, data was downloaded from REDCap and
managed according to the Research Data Management Plan (RDMP) (Appendix 12) at
The University of Sydney. Open-ended comments in Round One were analysed using
qualitative content analysis. Directed content analysis was applied as existing
knowledge from prior research influenced the initial questions in the Delphi, and thus
informed the initial framework for data analysis (Hsieh & Shannon, 2005).
Data were analysed with descriptive statistics using Statistics Package for Social
Sciences (SPSS)TM (IBM Corporation, 2019). Frequencies, medians and interquartile
ranges were calculated to summarise the characteristics and outcomes of the data, in
addition to calculation of the content validity index (CVI). The CVI was calculated for
each statement in the ‘graduate expectations and clinical capabilities’ sections by
identifying the number of respondents who ranked the statement with 1 (strongly
•Initial email sent by the CENA: 10/02/2020
•Follow up emails sent: 17/02/20 and 24/02/20
•Round One Delphi closed: 29/02/2020
Round One Delphi data collection
10/02/2020 -29/02/2020
•Round One data analysis completed
•Feedback summary completed
•COVID-19 global pandemic declared by WHO 11/03/20
•Round Two survey submitted to HREC for approval: 23/03/20
•Round Two HREC approval received 09/04/20
Round One Delphi analysis and HREC
approval
01/03/2020 -09/04/2020
•Round Two email sent with Round One feedback –16/04/20
•Follow up email sent – 04/05/20 and 14/05/20
•Round Two Delphi closed - 17/05/20
Round Two Delphi data collection
16/04/2020 -
17/05/2020
71
agree) or 2 (agree), divided by the total number of respondents. The research team
established levels of consensus: high, moderate and low (Considine, Curtis, Shaban, &
Fry, 2018), which were determined by analysing the levels of agreement. Whilst there
is ambiguity in the literature regarding the value of the CVI that should be applied to
the inclusion and removal of statements, there is agreement that a value greater than
80 or 85% is deemed highly relevant, 70-79% is thought to be relevant, and less than
70% is considered not relevant (Considine et al., 2018; Helms, Gardner, & McInnes,
2016). The research team agreed that a CVI of 90% would be considered extremely
relevant, above 80% relevant, and less than 80% not relevant. Statements that did not
achieve a CVI of 80% would be removed, and thus a reduced number of statements
would be distributed in Round Two. A CVI of 80% was chosen to ensure there was
greater agreement amongst the profession (Helms et al., 2016).
3.9.2. Rigour
The rigour of the Delphi was established during the piloting phase. The selected
group of eight emergency nursing experts and academic staff reviewed the first round
of the Delphi and assessed the content and face validity of the tool. The expert pilot
panel confirmed that the survey was clearly understood, correct terminology was used
and the research aims were measured. Reliability was confirmed by the panel
completing the survey and generated similar results (Hasson & Keeney, 2011;
Schneider et al., 2016). Internal consistency was determined for each round of the
Delphi survey. The Cronbach alpha coefficient was calculated for sections three and
four of the survey across both rounds (Pallant, 2016).
Consensus was established by the research team prior to dissemination of
Round One of the Delphi. Its rigour was further strengthened by the application of the
exclusion and inclusion criteria, which supported heterogeneity of panel members. A
clear audit trail was maintained by the researcher for the analysis of the qualitative
The move of pre-registration nursing education in Australia to the tertiary
environment in the 1990s reflects the professionalism of nursing (Fry et al., 2019).
Formal qualifications in Australia are regulated by the Australian Qualifications
Framework, which defines graduate as “ a person who has been awarded a
qualification by an authorised issuing organisation” (Australian Qualifications
Framework Council, 2012, p1). In Australia ‘graduate’ emergency nursing education,
sometimes colloquially or historically referred to as postgraduate education, is a
nationally regulated. Graduate nursing education extends beyond the Bachelor
qualification, and refers to tertiary qualifications inclusive of a graduate certificate,
graduate diploma, masters and doctoral studies. Most graduate emergency nursing
programs in Australia are delivered at the level of graduate certificate (Jones et al.,
2020a). The basis of national recognition is the Australian Qualifications Framework
(AQF) (Australian Qualifications Framework Council, 2013b) , which are not speciality
specific. Recent research has revealed that modified CENA Practice Standards for the
Emergency Nursing Specialist are used by the majority of emergency nursing graduate
programs in Australia, however because these standards are inconsistently modified
to meet the requirements of the individual program clinical expectations and graduate
attributes vary (Jones et al., 2020a). These standards were developed for expert
emergency nurses, and not for nurses graduating from specialist emergency education
(College of Emergency Nursing Australasia, 2014).
This paper reports the third study in an exploratory sequential mixed-methods
body of research (Jones et al., 2020a; Jones et al., 2015). Previous findings established
that there were differences in expectations of course entry requirements for
Australian graduate emergency nursing programs (Jones et al., 2020a). Specific areas
of variation related to the required hours of employment during graduate studies,
prior experience before undertaking a graduate emergency nursing program, and
mandated rotations for students in rural and remote areas. This study was developed
to address the inconsistency in attributes and expectations of graduates on
89
completion of their tertiary emergency nursing qualification. The purpose of this study
was to generate consensus-based practice standards for graduate emergency nursing
programs in Australia.
5.2.3. Method
5.2.3.1. Study design
A two-round modified Delphi method was used for this study. The Delphi
technique is a well-established approach for determining consensus amongst experts
(Asselin & Harper, 2014; Cole et al., 2013; Keeney, 2011). Three survey rounds are
often reported as an appropriate number of iterations to achieve consensus amongst
Delphi literature. The first round being an exploratory or scoping phase (Keeney, 2011)
was informed by existing preliminary research (Jones et al., 2020a; Jones et al., 2015)
to generate the initial survey statements and create a ‘modified Delphi’ (Trevelyan &
Robinson, 2015; Varndell et al., 2020).
This survey was divided into four sections: (i) demographics, (ii) graduate
emergency nursing course entry requirements, (iii) graduate attributes on completion,
and (iv) clinical care capabilities. To enhance utility of the survey, graduate attributes
on completion were divided further into seven domains and clinical care capabilities
were divided into ten categories. Participants were able to provide additional
comments and statements via open-ended responses for each of the graduate
attribute domains and clinical care capability categories across both Delphi rounds.
The initial survey was piloted with a panel of eight, consisting of nurse
academics and expert emergency nurses. Feedback was provided regarding face and
content validity, reliability and feasibility. Based on the feedback minor editing and
word changes occurred, survey progress completion bars were added, and additional
operational definitions were provided throughout the survey.
5.2.3.2. Sample and recruitment
Convenience sampling and snowballing were used with the aim of establishing a
heterogenous panel of emergency nurses, inclusive of the various roles within
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emergency nursing and geographical dispersion (Schneider et al., 2016; Trevelyan &
Robinson, 2015). Participants were recruited through the College of Emergency
Nursing Australasia (CENA), the peak professional body for emergency nurses in
Australasia, who have a membership base in excess of 1500. CENA used several
platforms to disseminate the survey URL, including direct email to CENA members and
social media. Snowballing also occurred, with participants sharing CENA social media
advertisements for the study with their peers, and re-distribution of the research
email (Schneider et al., 2016). Follow up emails and social media posts were
administered by the CENA. Nurses who identified as an emergency nurse, and
currently worked or previously worked in an emergency care environment were
eligible to participate. Emergency care encompasses clinical environments where
patients required emergency care for example: the emergency department, an
emergency clinic in a rural or remote area, or the royal flying doctors service. The
team originally considered graduate qualifications in emergency nursing as an
inclusion criterion, however in the absence of mandated qualification requirements
for nurses working in emergency care (Morphet et al., 2016a), it was possible that
nurses working in senior roles, or with years of emergency nursing experience, may
have been excluded.
The size of an expert panel is often debated. Large panels are considered to
dilute expertise, whilst increasing heterogeneity of panels is considered more
achievable with larger panel sizes (Asselin & Harper, 2014; Diamond et al., 2014;
Donohoe et al., 2012; Keeney, 2011; Toronto, 2017). The research team agreed that
an initial response rate of 10% of CENA members would yield approximately 140
respondents, and represent heterogeneity amongst emergency nurses. Attrition in
Delphi methods is also anticipated with each survey iteration, and thus a panel size of
140 provided an appropriate buffer for this (Asselin & Harper, 2014; Keeney, 2011).
5.2.3.3. Ethical considerations
This study was conducted in accordance with to the National Statement on the
Conduct of Human Research by the Australian National Health and Medical Research
Council, and the protocol approved by the University Human Research Ethics
Committee (reference number 2019/771).
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5.2.3.4. Data collection and analysis
Two rounds of data collection occurred between February 2020 and May 2020,
which was during the height of the first wave of COVID-19 in Australia. The COVID-19
global pandemic was declared on 11th March 2020, with significant limitations in the
movement and gathering of citizens and residents across Australia soon after this
announcement. Emergency nurses were required to rapidly prepare the emergency
care environment for the anticipated burden on emergency services (Nayna
Schwerdtle et al., 2020). Research Electronic Data Capture (REDCap) was the online
software used to capture and host each of the rounds of data (Harris et al., 2019;
Harris et al., 2009).
There were four distinct sections of survey data collection in Round One and
Round Two. In section one participants were asked to provide demographic
information that related to their age, clinical experience, academic qualifications,
primary area of practice and professional roles. The focus of section two was to
establish participant opinion of clinical practice requirements for nurses wanting to
undertake a graduate qualification in emergency nursing. As noted above, the
presented statements were informed by the findings from previous research. In
section three and four of the survey, participants were asked to rank their opinion
using a five-point Likert scale (1 = Strongly Agree, 2 = Agree, 3 = Neither Agree or
Disagree, 4 = Disagree, 5 = Strongly Disagree) for all presented statements. Based on
the teams previous research findings the domains and statements from the peer-
reviewed CENA Practice Standards for the Emergency Nursing Specialist (College of
Emergency Nursing Australasia, 2014) were presented to participants in section three:
graduate attributes (Jones et al., 2020a; Jones et al., 2015). Specific systems based
clinical care capabilities were presented to participants in section four, again informed
by the team’s previous research with regards to content that was identified in
Australian graduate emergency nursing programs (Jones et al., 2020a).
Descriptive statistics and content analysis were used to analyse data from Round
One and Two. Quantitative data was analysed using Statistics Package for Social
Sciences (SPSS)TM, with frequencies, median’s and interquartile ranges calculated and
the content validity index (CVI) was determined for each statement in section three
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and four of the survey. The research team established pre-determined levels of
consensus, and agreed that a CVI of 90% would be considered extremely relevant,
above 80% thought of as relevant, and less than 80% considered not relevant.
Statements that did not achieve a CVI of 80% would be removed, and thus a reduced
number of statements would be distributed in Round Two of data collection. A CVI of
80% was chosen to ensure there was greater agreement amongst the profession
(Helms et al., 2016). Internal consistency was determined in section three and four of
the survey by calculating the Cronbach alpha coefficient. Qualitative data to open-
ended responses were analysed using qualitative content analysis (Hsieh & Shannon,
2005). Generalised feedback from Round One analysis was provided to participants
with the dissemination of Round Two. Figure 1 provides a summary of the data
collection and analysis timeline.
Figure 5.1. Data collection and analysis process for Delphi study to determine consensus-based practice standards for Australian graduate emergency
nursing programs
5.2.4. Results
Data were collected between February and May 2020, with 204 respondents in
Round One and 153 respondents in Round Two of the Delphi.
5.2.4.1. Demographics
The characteristics of respondents were similar across the two rounds of data
collection and are presented in Table 1. The median age of respondents in Round One
Round 1
Data collection & analysis
• Round One survey distrubted by the CENA
• Round One survey closed 3 weeks post inital email
• Round One data analysis completed
• Round One feedback summary completed
Round 2
Data collection & analysis
• Round Two survey developed
• Round Two survey sent to HREC for approval
• Round Two survey distrubted by the CENA with round 1 feedback
• Round Two survey closed 4 weeks post initial email
93
was 39 (IQR 33-38) and Round Two was 41 (IQR 33-51). The majority of respondents
resided in in Victoria, New South Wales and Queensland. The median of years working
as an RN in the ED was 12 years for both Round One and Round Two, and 75% of
respondents had a graduate qualification in emergency nursing. Respondents were
able to indicate more than one current practice role if appropriate, and there was a
reasonable distribution across clinical, management and education. The majority of
participants practiced in a Level 3 (Urban District) or Level 4 (Major Referral) ED, that
treated both paediatric and adult patients (mixed ED) (Australasian College for
Emergency Medicine, 2012).
Table 5.1 Demographic details of Round One and Round Two respondents
Round One Round Two
Age (median, IQR) 39 (33-38) 41 (33-51)
Years working as a RN 15 16
Years working in ED 12 12
Current role Academic – 25 (12.3%)
CNC – 16 (7.8%)
CNS – 47 (23%)
NE – 47 (23%)
Nursing Management – 20
(9.8%)
NP – 9 (4.4%)
RN – 68 (33.3%)
Other – 11 (5.4%))
Academic – 14 (9.2%)
CNC – 10 (6.5%)
CNS – 29 (19%)
NE – 42 (27.5%)
Nursing Management– 23
(15.1%)
NP – 7 (4.6%)
RN – 49 (32%)
Other – 8 (5.3%)
State of employment ACT – 7 (3.4%)
NSW – 45 (22.1%)
NT – 5 (2.5%)
QLD 34 (16.7%)
SA – 14 (6.9%)
TAS - 11 (5.4%)
VIC – 64 (31.4%)
WA – 20 (9.8%)
OTHER – 3 (1.5%)
ACT – 3 (2%)
NSW – 53 (35.3%)
NT - 6 (3.9%)
QLD – 16 (10.5%)
SA – 13 (8.5%)
TAS - 5 (3.3%)
VIC - 41 (26.8%)
WA – 14 (9.2%)
OTHER – 1 (0.7%)
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Level of ED Level 4 ED -80 (39.8%)
Level 3 ED -61 (30.3%)
Level 2 ED – 38 (23.9%)
Level 1 ED – 9 (4.5%)
Remote Emergency Clinic –
2 (1%)
Other – 1 (0.5%)
Level 4 ED – 64 (42.1)
Level 3 ED – 36 (23.7%)
Level 2 ED – 35 (22.9%)
Level 1 ED – 13 (8.6%)
Remote Emergency Clinic - 0
Other – 4 (2.6%)
Clinical practice area ED (adult only) – 35 (17.2%)
ED (paediatric only) – 6
(3%)
Mixed ED – 147 (72.1%)
Rural / remote - 1 (0.5%)
Education sector – 12
(5.9%)
Other – 2 (1%)
ED (adult only) – 23 (15%)
ED (paediatric only) – 2
(1.3%)
Mixed ED – 115 (75.2%)
Rural / remote – 1 (0.7%)
Education sector – 10 (6.5%)
Other – 2 (1.3%)
Graduate
qualification in
emergency nursing
Yes – 152 (75.2%)
No – 25 (12.4%)
Other specialist
qualification - (25 (12.4%)
Yes – 117 (76.5%)
No – 16 (10.5%)
Other specialist qualification
– 20 (13.1%)
Highest level of
qualification
Grad Certificate – 59
(28.9%)
Grad Diploma – 37 (18.1%)
Masters - 53 (26%)
PhD – 9 (4.4%)
Other – 3 (1.5%)
Grad Certificate – 40
(26.3%)
Grad Diploma – 39 (25.7%)
Masters – 52 (34.2%)
PhD – 12 (7.9%)
Other 9 (5.9%)
CNC = Clinical Nurse Consultant, CNS = Clinical Nurse Specialist, NE = Nurse Educator, NP = Nurse Practitioner, RN = Registered Nurse; ACT = Australian Capital
Territory, NSW = New South Wales, NT = Northern Territory, QLD = Queensland, SA = South Australia, TAS = Tasmania, VIC = Victoria, WA = Western Australia,
Level 4 ED = major referral ED, Level 3 ED = urban district ED, Level 2 ED = Major regional/rural base ED, Level 1 ED = Rural Emergency Service
Findings from Round Two confirmed, clarified and strengthened the findings of
Round One with higher levels of agreement, and thus results from Round Two are
Complications associated with liver cirrhosis 95.6
Testicular torsion 95.6
Endocrine
Diabetic Ketoacidosis (DKA) 96.3
Hyperglycaemic Hyperosmolar Syndrome (HHS) 94.1
Thyroid dysfunction and associated conditions 94.9
Shock
Cardiogenic Shock 96.3
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Distributive Shock 97.8
Hypovolaemic Shock 97.8
Obstructive Shock 97.8
Trauma and Injury
Abdominal Injury 96.3
Application of Philadelphia Collar 91.9
Burns 97.1
Chest Injury 94.1
Musculoskeletal Injury 96.3
Spinal Cord Injury 95.6
Submersion Injury 93.4
Traumatic Brain Injury 95.6
Obstetrics
Bleeding in pregnancy 93.4
Hypertensive disorders of pregnancy 91.9
Paediatrics
Advanced Paediatric Life Support 83.8
Bronchiolitis 95.6
Calculate intravenous fluid replacement 91.2
Croup 95.6
Epiglottitis 91.9
Gastroenteritis 94.1
Neonatal Resuscitation 84.6
Seriously ill child 91.9
Other
Drug and alcohol 93.4
Ear Nose Throat (ENT) emergencies 92.6
Hypo/Hyperthermia 94.9
Infectious diseases 95.6
Legal issues and forensics 84.6
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Mental health 94.9
Oncological emergencies 92.6
Ophthalmology 90.4
Poisoning/Toxicology 94.9
Rash 91.9
Sexual Assault 89.0
Vascular Emergencies 91.9
5.2.5. Discussion
The findings from this study have generated the evidence to inform the first set
of practice standards for Australian gradate emergency nursing programs. Previous
studies have identified the importance of emergency nursing practice standards (Jones
et al., 2015). The absence of practice standards specifically developed for graduate
emergency nursing programs has led to variation in graduate attributes which has
implications for patient safety and workforce planning (Jones et al., 2020a), and
evidenced the need for such standards to be established.
Previous research findings were used to inform the development of the first
round of Delphi questions (Jones et al., 2020a; Jones et al., 2015), and consensus was
readily established across three key areas: course entry requirements; graduate
attributes; and clinical care capabilities. The high levels of agreement demonstrate the
importance emergency nurses place on entry requirements, attributes and clinical
capabilities, and this consensus is not role dependent. Nurses working in clinical,
management and education positions were united in their responses and expectations
of graduate emergency nursing programs.
Prior clinical experience in an emergency care setting is required before nurses
enrol in graduate emergency nursing studies. Additionally, nurses undertaking these
studies need to be working between 0.5 and 0.8 FTE in an emergency care
environment. Working whilst studying is stressful, particularly for those with primary
care responsibilities (Ng et al., 2016), but the application of new theory in the context
of the student’s emergency care environment is required to develop and maintain safe
practice (Hickman et al., 2018). Some report that hours of employment can have a
104
negative influence on student performance and clinical care (Pitt, Powis, Levett-Jones,
& Hunter, 2012), however by articulating expectations of prior experience and hours
of employment ensures that minimum entry requirements are clear, and a foundation
for prior experience and employment is established. Mandating hours does not inhibit
strategies that can be implemented to support students.
Establishing specific graduate attributes and clinical care capabilities for
graduate emergency nursing programs provides a framework to guide graduate
emergency nursing education. The attributes and capabilities are designed to align
with unit(s)/subject(s) of graduate emergency nursing specialisation, which are most
commonly completed at a graduate certificate level. The establishment of these
standards is not about developing competency, but about providing clear capabilities
of graduates in the context of their clinical practice environment to achieve safe
patient care (Cashin et al., 2017; O'Connell et al., 2014a). Graduate attributes and
clinical care capabilities communicate the expectations of early career emergency
nurses to employers, education providers and clinicians (Cashin et al., 2017). The
reported attributes and capabilities reflect the current opinions of a heterogenous
sample of emergency nurses. The dynamic nature of healthcare and emergency
nursing means that the graduate attributes and clinical care capabilities will require
regular review and update, to reflect contemporary graduate emergency nursing
practice.
These practice standards have been developed relevant to the Australian
context, however internationally, emergency nursing colleges and associations could
potentially use these standards to inform the development and enhancement of
graduate emergency nursing programs, or adopt similar processes for the
establishment of country specific graduate emergency nursing standards. Additionally,
the graduate attributes and clinical care capabilities provide an evidence-based
scaffold that can be used to inform advanced emergency nursing education and
practice roles (O’Connell & Gardner, 2012). To embed these standards in graduate
emergency nursing programs and future clinical practice, it is recommended that a
framework for Australian graduate emergency nursing programs be established and
disseminated.
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There are some limitations to this study. Email is an effective mode for Delphi
survey distribution, however due to health service internet blocks not all CENA
members received the participatory email. Whilst snowballing was encouraged, it’s
possible that some CENA members did not participate as they were unaware of the
study. To mitigate this, the survey was also distributed by some CENA members via
email and social media avenues A second limitation was that the timing of data
collection and the COVID-19 pandemic may have influenced response rates. In spite of
the COVID-19 pandemic, the survey response rate yielded a heterogenous sample of
more than 10% of the CENA membership.
5.2.6. Conclusion
This study has established the first set of Australian graduate emergency nursing
practice standards that centre around three key areas: graduate entry requirements,
graduate attributes and clinical care capabilities. These standards provide guidance to
employers, educators and clinicians on the practice requirements and capabilities of
graduate emergency nurses. They also inform graduate emergency and early career
emergency nurses of their practice requirements. Graduate emergency nursing
education programs within Australia should be anchored in these standards, they will
inform the development of emergency nurses nationally.
5.3. Summary
The results from this Delphi study have been presented in this chapter. This
study established consensus amongst the emergency nursing profession regarding
graduate emergency nursing program entry requirements, graduate attributes and
clinical care capabilities on program completion. The integrated discussion from Study
One, Two and Three occurs in Chapter Six. Minimum practice standards for graduate
emergency nursing programs are presented in the following chapter.
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Chapter 6. Discussion
6.1. Introduction
In this chapter, the findings from each phase of this exploratory sequential
mixed-methods study are integrated and synthesised to address the aim of this
research. The graduate emergency nursing practice standards established from this
body of research are examined relative to the existing literature. The graduate
attributes and clinical care capabilities are explained and the specific workforce
considerations for graduate emergency nursing programs will be discussed.
Methodological reflections of this research are also addressed in this chapter.
6.2. Study outcome and implications
This research established evidence-based minimum practice standards for
Australian graduate emergency nursing programs. A summary of each study and the
sequential integration of findings is presented in Figure 6.1. Three key elements have
been identified from this research that have implications for graduate emergency
nursing education, the emergency nursing workforce and the patients under their
care:
1. Graduate attributes for graduate emergency nursing programs have been
established.
2. Expected areas of clinical care capabilities for graduate emergency nursing
programs have been determined.
3. Workforce considerations are required prior to nurses applying for and
undertaking a graduate emergency nursing program.
107
Figure 6.1 Summary of sequential integration of studies to establish minimum practice standards for graduate emergency nursing programs.
OUTCOME OF EXPLORATORY SEQUENTIAL MIXED-METHODS STUDY
Evidence-based minimum practice standards for Australian graduate emergency
nursing programs established
STUDY THREE Aim: To generate consensus amongst the Australian emergency nursing profession regarding practice standards for graduate emergency nursing programs Study Three Outcome: Established evidence to generate practice standards for Australian graduate emergency nursing programs. This was inclusive of graduate attributes, clinical care capabilities and workforce considerations
STUDY TWO Aim: To determine the academic and professional profile of Australian graduate emergency nursing programs Study Two Outcome: Design and characteristics of graduate emergency nursing programs centre around eight categories
STUDY ONE Aim: To identify and analyse existing emergency nursing practice/competency standards Study One Outcome: Practice and competency standards are used internationally to guide emergency nursing practice across nine common domains
Examine practice and competency standards used to guide emergency nursing practice.
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6.3. Minimum practice standards for graduate emergency nursing programs
This study has generated the first evidence-based minimum practice standards
for Australian graduate emergency nursing programs. Until now, there have been no
minimum practice standards that state the expected graduate attributes or clinical
care capabilities specific to Australian graduate emergency nursing programs. The
minimum practice standards for Australian graduate emergency nursing programs are
presented in Table 6.1. Implementation of the practice standards by tertiary education
providers will enable graduate emergency nurse to demonstrate all attributes on
completion of their program. Clinical care capabilities are listed in Table 6.2, which
provide structure and clarity for graduate attribute 7.8 Demonstrate clinical care
capabilities in the context of the emergency care environment. These have been stated
to ensure there is consistency and a shared understanding of the expectations of
clinical care capabilities across Australian graduate emergency nursing programs.
These contemporary, evidence-based practice standards for graduate
emergency nursing programs were established across a heterogenous sample of
emergency nurses. This is an important consideration as practice standards reflective
of contemporary professional values and experience increase confidence in the
generated outcomes and their relevance and application in emergency nursing
practice; particularly, standards designed to inform graduate education and clinical
practice (Gill et al., 2014; Gill et al., 2015; O'Connell et al., 2014a).
Study Two, which examined the academic and professional characteristics of
Australian graduate emergency nursing programs, demonstrated that there were a
number of inconsistencies across graduate attributes and clinical care capabilities,
which have implications for workforce planning and the delivery of safe patient care
(Jones et al., 2020a). Graduates need to demonstrate informed practice on completion
of their graduate emergency nursing program by incorporating multiple sources of
knowledge to inform and rationalise the care they deliver in the context of their
emergency care environment (Baid & Hargreaves, 2015). The established minimum
practice standards for Australian graduate emergency nursing programs provide
expectations for the graduate emergency nurse, clinicians, managers, and academics,
109
and thus create clarity for what is expected in the delivery of safe patient care by
students.
Table 6.1 Minimum practice standards for Australian graduate emergency nursing programs
1. Communication
1.1 Communicate effectively with the patient, their family and support people
1.2 Effectively communicate assessment findings and management plans with
patient, their family and support people
1.3 Effectively communicate with colleagues to plan, deliver and evaluate care
1.4 Provide clear, concise and informative handovers
1.5 Provide structured, concise and informative documentation
2. Safe and Quality Patient Care
2.1 Identify and report unsafe or inappropriate practice
2.2 Manage critical incidences and stressful situations
2.3 Demonstrate safe and effective use of technology and biomedical
equipment
2.4 Promote a caring environment for the patient and significant others
2.5 Involve the patient in the decisions about their care
2.6 Advocate for the patient
2.7 Establish rapport with patients, families and support people
3. Research and Quality Improvement
3.1 Critically evaluate and apply nursing research to emergency patient care
3.2 Identify and suggest areas for practice or policy change
3.3 Support the development of quality improvement within the emergency care
environment
3.4 Support the development of research within the emergency care
environment
4. Ethics and Legal
4.1 Maintain patient privacy and confidentiality
4.2 Function within an ethical framework
4.3 Practice according to all relevant legislation and standards of practice
5. Teamwork and Leadership
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5.1 Work within their own scope of practice
5.2 Perform effectively as a team member
5.3 Collaborate with colleagues, including the multidisciplinary team, to bring
about best patient outcomes
5.4 Recognise and manage own stress
5.5 Provide support for colleagues when caring for challenging patient and or
family needs
5.6 Effectively lead a team to provide safe, quality patient care
5.7 Act as a role model for nurses and other health professionals
5.8 Supervise and delegate the delivery of patient care to others
5.9 Demonstrate preparedness and response for major incidents and disasters
6. Professional Development
6.1 Maintain their own ongoing professional development
6.2 Contribute to the professional development of colleagues
6.3 Promote the profile of emergency nursing
7. Clinical Practice and Expertise
7.1 Provide appropriate and timely assessments of the undiagnosed patient
7.2 Effectively prioritise patient care needs
7.3 Determine, monitor and implement appropriate assessment and
management strategies for multiple undifferentiated patients
7.4 Transport complex patients throughout the healthcare environment
7.5 Provide appropriate discharge care including referrals and education
materials
7.6 Anticipate, assess and manage the care of the deteriorating patient across
the lifespan
7.7 Safely work at triage
7.8 Demonstrate clinical care capabilities in the context of the emergency care
environment
The following clinical care capabilities are areas where students are required to
apply their knowledge of advanced pathophysiology, assessment and management
strategies for conditions in the emergency care setting (Table 6.2). These are minimum
expectations of graduates.
111
Table 6.2 Clinical care capabilities of emergency nurses on completion of graduate emergency nursing programs
1. Neurological Clinical Care Capabilities
1.1 Altered conscious states, inclusive of causative conditions causing such as:
meningitis, seizures, stroke, subarachnoid haemorrhage, and raised
intracranial pressure
2. Cardiovascular Clinical Care Capabilities
2.1 Acute coronary syndromes
2.2 Advanced ECG interpretation and arrhythmia management
2.3 Advanced Life Support
2.4 Aortic Aneurysms and non-ischaemic cardiac conditions
2.5 Heart Failure and associated complications
2.6 Insertion of intravenous cannula
2.7 Invasive haemodynamic monitoring
3. Respiratory
3.1 Acute exacerbations, and emergency presentations, of respiratory
conditions such as: asthma: chronic obstructive pulmonary disease (COPD),
pneumonia, pulmonary embolism
3.2 Advanced airway management across the lifespan
3.3 Arterial Blood gas result interpretation
3.4 Chest X-ray interpretation requirements
3.5 Invasive and non-invasive ventilation across the lifespan
4. Kidney, Hepatic & GIT
4.1 Acute Kidney Injury (AKI) and Chronic Kidney disease (CKD)
4.2 Acute pancreatitis
4.3 Biliary tract disease
4.4 Complications associated with liver cirrhosis
4.5 Testicular torsion
5. Endocrine
5.1 Diabetic Ketoacidosis (DKA)
5.2 Hyperglycaemic Hyperosmolar Syndrome (HHS)
5.3 Thyroid dysfunction and associated conditions
6. Shock
112
6.1 Cardiogenic, distributive, hypovolaemic and obstructive shock
(vi) shock; (vii) obstetrics; (viii) trauma and injury; (ix) paediatrics; and (x) other.
129
The minimum practice standards for Australian graduate emergency nursing
programs, if implemented, systematically aim to provide consistent expectation of
graduates. They present a guide for higher education to anchor their graduate
emergency nursing curriculum. Consistent and transparent expectations inform
clinical practice, which ultimately leads to safer delivery of informed patient care, and
improves workforce planning.
130
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Wangensteen, S., Finnbakk, E., Adolfsson, A., Kristjansdottir, G., Roodbol, P., Ward, H., & Fagerström, L. (2018). Postgraduate nurses' self-assessment of clinical competence and need for further training. A European cross-sectional survey. Nurse Educ Pract, 62, 101-106. doi:10.1016/j.nedt.2017.12.020
Ward, D., Furber, C., Tierney, S., & Swallow, V. (2013). Using Framework Analysis in nursing research: A worked example. J. Adv. Nurs, 69(11), 2423-2431. doi:10.1111/jan.12127
Ward, M. (2012). National School Nursing Professional Practice Standards (2nd ed.): VSN.
White, K., Macfarlane, H., Hoffmann, B., Sirvas-Brown, H., Hines, K., Rolley, J., & Grahan, S. (2018). Consensus Statement of Standards for Interventional Cardiovascular Nursing Practice. Heart, Lung Circ, 27, 535-551. doi:10.1016/j.hlc.2017.10.022
Appendix 4: Study Two semi-structured interview guide for key
informant interviews
1. Could you describe the proposed pathway for students completing graduate
studies in emergency nursing? (What program/course do students enrol in, and
how do they progress?)
2. Explain the process of application to the graduate emergency nursing program.
What are the alternative exits if masters enrolled?
3. Is the emergency nursing specialisation available for international students?
4. Describe the modes of learning that your program offers.
5. Given your mode of delivery, how does your program deliver the emergency
nursing content (i.e. tutorials, Google hangouts, lectures)?
6. What are the workload requirements per semester for the students?
7. Do you combine with any other specialist areas/disciplines? If so how, and which
ones?
8. What are the employment requirements for students wishing to complete the
emergency nursing specialisation?
9. What do you believe the attributes of the emergency nurse who completes your
program are? (What does the graduate look like in clinical practice?)
10. What do you see as the difference between the graduate certificate, graduate
diploma and masters of nursing?
11. From the websites I can see the following topics are covered XXXX. What other
topics does your program cover?
12. What other topics do you believe your program should cover?
13. Describe your approaches to assessment for your curriculum. How many
assessments per semester?
14. With clinical assessment, how do you prepare the assessors?
15. Outline who assesses the students and their level of training/qualification.
16. What are the clinical requirements of the program?
17. How do you bridge the gaps for students who may have limited clinical exposure
to some aspects of the curriculum (i.e. advanced mechanical ventilation)?
18. Do you have any healthcare employer or stakeholders? How does your program
work with stakeholders/healthcare employer partners?
19. How does the program link with the CENA?
20. What supportive funding sources are available for students (i.e.
scholarships/CSP)? How many are available? How do students apply?
21. What do you believe are the strengths of your program?
22. Do you have any documents that you would be willing to share to support the
national analysis of graduate emergency nursing programs?
158
Appendix 5: Indexing Framework Used for Key Informant
Interviews
1. Course Entry 1.1. Years of experience 1.2. Working in the ED/ Hours of employment 1.3. Prior learning (i.e. have to be working at triage, TSPP) 1.4. Mode of enrolment – masters or graduate cert/
1.12 Beginner/Novice practitioners (in specialty) 1.13 Advanced/Expert/Leader 1.14 Difference between masters, grad dip and grad cert 1.15 Linking with CENA practice standards
7. Stakeholder/Industry Engagement
1.16 Engagement in building relationships/meetings 1.17 Teaching of program 1.18 Assessments 1.19 Qualification of industry assessor / Training of
assessor / mentors 1.20 Course adapted to industry needs (Modifying course
assessments/content for industry setting/influence) 1.21 Review of program
8. Bridging Gap/Access to Learning
1.22 Online students 1.23 Rural and remote students/ non-tertiary 1.24 Preceptor/Mentor/Facilitator
9. Content/Topics 1.25 Paediatric vs Adult 1.26 Areas of focus for emergency 1.27 Absence – areas not covered 1.28 Combining with other specialties
10. Other
159
Appendix 6: Ethics Approval Letter Study Three
160
161
Appendix 7: Approval letter from CENA for Study Three
162
Appendix 8: Email sent to CENA members for participation in
round 1 of Delphi
Invitation to contribute to the development of National Practice Standards for
Graduate Emergency Programs
Dear CENA member,
You are invited to participate in a research project which aims to develop national
agreement on Practice Standards for Graduate Emergency Nursing Programs.
Throughout this survey you will see term ‘graduate’ will be used, for example graduate
program and graduate outcomes. When reading this term, we want you think of what
you might refer to as ‘postgraduate’. Whilst these terms are often used
interchangeably, the reason we are using graduate is because this term is reflective of
the requirements of the Australian Qualifications Framework (AQF). The development
of graduate emergency nursing standards will help to inform curriculum, assessment,
and create clearer expectations of graduates.
If you agree to participate in this research, we will ask you to complete three separate
web-based surveys. The first survey will take approximately 20-30 minutes to
complete. Each subsequent survey will take approximately 15 minutes to complete.
Your confidentiality will be maintained as we will not be able to identify you from the
information you provide. All data will be collected, analysed and stored as per the
University of Sydney Policy. CENA is disseminating the surveys, so the research team
do not have access to your details.
Ethics approval has been received by the Human Research and Ethics Committee at
The University of Sydney [2019/771]. Please read the participant information sheet if
you would like to know more about this project or are considering being involved in
this research. If you agree to participate, please click on the study URL below.
☐ Nurse Educator / clinical coach / clinical support nurse
☐ Nurse Manager
☐ Nurse Practitioner
☐Registered nurse
☐ Other (please describe)
Emergency Nursing Course requirements
Our 2019 review of all graduate emergency nursing courses in Australia showed there are 14
tertiary emergency nursing courses offered by Australian universities. Each of these courses is
unique with distinct academic and professional characteristics. These courses vary in entry
requirements, prior experience and the hours of full time equivalent (FTE) that students are
required to work in an emergency care setting. We seek your professional opinions on a range
of academic and professional characteristics of graduate emergency nursing courses.
All courses required students to be working in an emergency care setting, some required
students to be working a minimum of 0.6 FTE, others did not specify minimum hours. We seek
171
your professional opinions on a range of academic and professional characteristics of graduate
emergency nursing courses.
11. In my professional opinion nurses wanting to undertake graduate studies in emergency
nursing should have prior acute care clinical experience as a registered nurse:
☐ Yes
☐ No
☐ Other
Comment/Explanation for decision:
12. In my professional opinion nurses wanting to undertake graduate studies in emergency
nursing should have prior clinical experience as a registered nurse in the:
☐ Emergency Department
☐ Emergency care setting
☐ Acute care setting
☐ Prior clinical experience Is not required
☐ Other
Comment/Explanation for decision:
13. In my professional opinion nurses completing graduate studies in emergency nursing
should be working the following minimum Full Time Equivalent (FTE) clinical practice
hours in an approved emergency care environment:
☐ 1 FTE
☐ 0.9 FTE
☐ 0.8 FTE
☐ 0.7 FTE
☐ 0.6 FTE
☐ 0.5 FTE
☐ 0.4 FTE
☐ 0.3 FTE
☐ 0.2 FTE
☐ 0.1FTE
☐ There should be no mandated hours of clinical practice
Comment/Explanation for decision:
Our review also showed that a number of courses will not allow nurses working in a Level 1
emergency department or a remote emergency care clinic to enrol in their graduate
emergency nursing course, unless the student is able to complete a rotation in a Level 3 or
Level 4 emergency department. Please indicate your agreement with the statements
below. These statements relate to students completing graduate emergency nursing
172
studies.
14. In my professional opinion, nurses working in rural and remote areas or Level 1
emergency departments, with no exposure to a Level 3 or Level 4 emergency
department, should be able to undertake graduate emergency nursing courses:
☐ Yes
☐ No
☐ Other
Comment/Explanation for decision:
15. In my professional opinion, nurses working in a Level 3 or Level 4 emergency
department with no exposure to rural and remote areas should be required to complete
a rotation in a Level 1 emergency department or a remote emergency care clinic.
☐ Yes
☐ No
☐ Other
Comment/Explanation for decision:
16. In my professional opinion, nurses working in a Level 1 - 4 adult emergency department
should be required to complete a rotation in a Level 1 - 4 mixed (adult and paediatric) or
Level 1 - 4 paediatric emergency department
☐ Yes
☐ No
☐ Other
Comment/Explanation:
17. In my professional opinion nurses working in a Level 1 - 4 paediatric emergency
department should be required to complete a rotation in a Level 1 - 4 mixed (adult and
paediatric) or Level 1 - 4 adult emergency department:
☐ Yes
☐ No
☐ Other
Comment/Explanation:
173
In the following "Graduate Expectations" section we ask you to indicate your level of agreement with the statements below. The level of
agreement ranges from Strongly Agree, to Strongly Disagree. These statements have been developed from our prior research, particularly the
analysis of Australian graduate emergency nursing courses. You may notice that a number of these statements align to the CENA practice standards
for emergency nurses as many graduate courses have modified these standards to inform the development of their clinical practice assessments.
For each of the following statements, please consider your clinical practice expectations of a nurse who has just completed their graduate
certificate studies in emergency nursing.
We also invite you to add any explanations, comments or additional practice expectations.
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
Graduate Expectations: Communication
On completion of the graduate emergency nursing course the graduate will be able to:
1 Communicate effectively with the patient, their family and support people,
considering factors such as cognitive impairment, level of health literacy,
culture and ethnicity
2 Effectively communicate with patients, families and support people
regarding assessment findings and management plans
3 Effectively communications with colleagues, including the multidisciplinary
team, to plan, deliver and evaluate care
4 Provide clear, concise and informative handovers
Optional: additional explanations, comments or practice expectations
regarding the theme of communication
Graduate Expectations: Delivery of safe and quality patient care
On completion of the graduate emergency nursing course the graduate will be able to:
6 Identify and report unsafe or inappropriate practice
7 Manage critical incidences and stressful situations
174
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
8 Demonstrate safe and effective use of technology and biomedical
equipment
9 Promote a caring environment for the patient and significant others
10 Involve the patient in the decisions about their care
11 Advocate for the patient
12 Establish rapport with patients, families and support people
Optional: additional explanations, comments or practice expectations
regarding the theme of: Delivery of safe and quality patient care
Theme: Research and Quality Improvement
On completion of the graduate emergency nursing program the graduate will be able to:
14 Critically evaluate and apply nursing research to emergency patient care
15 Review and critique the evidence underpinning complex patient
interventions
16 Identify and suggest areas for practice or policy change
17 Support the development of quality improvement within the emergency
care environment
18 Support the development of research within the emergency care
environment
Optional: additional explanations, comments or practice expectations
regarding the theme of: Research and Quality Improvement
Theme: Ethics and Law
On completion of the graduate emergency nursing program the graduate will be able to:
19 Maintain patient privacy and confidentiality
20 Function within an ethical framework
175
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
21 Practice according to all relevant legislation and standards of practice
Optional: additional explanations, comments or practice expectations
regarding the theme of: Ethics and Law
Theme: Teamwork and Leadership
On completion of the graduate emergency nursing program the graduate will be able to:
22 Work within their own scope of practice
23 Performs effectively as a team member
24 Collaborate with colleagues, including the multidisciplinary team, to bring
about best patient outcomes
25 Recognise and manage own stress
26 Provide support for colleagues when caring for challenging patient and or
family needs
27 Effectively leads a team to provide safe, quality patient care
28 Act as a role model for nurses and other health professionals
29 Supervise and delegate the delivery of patient care to others
30 Demonstrate preparedness and response for major incidents and disasters
31 Lead a team in caring for the at-risk patient
32 Work as a Resource Nurse/In-Charge of a shift
Optional: additional explanations, comments or practice expectations
regarding the theme of: Teamwork and Leadership
Theme: Professional development
On completion of the graduate emergency nursing program the graduate will be able to:
33 Maintain their own ongoing professional development
34 Contribute to the professional development of colleagues
176
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
35 Promote the profile of emergency nursing
Optional: additional explanations, comments or practice expectations
regarding the theme of: Professional Development
Theme: Clinical practice and expertise
On completion of the graduate emergency nursing program the graduate will be able to:
36 Provide appropriate and timely assessments of the undiagnosed patient
37 Effectively prioritise patient care needs
38 Determine, monitor and implement appropriate assessment and
management strategies for multiple undifferentiated patients
39 Transport complex patients throughout the healthcare environment
40 Provide appropriate discharge care including referrals and education
materials
41 Anticipate, assess and manage the care of the deteriorating patient across
the lifespan
42 Identify and initiate discussions relating to organ donation
43 Safely work at triage
Optional: additional explanations, comments or practice expectations
regarding the theme of: Clinical practice and expertise
CLINICAL CARE CAPABILITY
Our analysis of Australian graduate emergency nursing courses identified a wide range of clinical conditions and skills taught to students.
Students are required to apply their knowledge of advanced pathophysiology, assessment and management strategies for these conditions in
the emergency care setting. Patients with these conditions may be critically unwell.
In this section we seek your level of agreement with the statements related to clinical care. Please feel free to add any other conditions or skills
you believe need to be taught in graduate emergency nursing courses.
177
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
On completion of the graduate emergency nursing course the graduate will be clinically capable to care for a patient with: able to care
for the patient with:
Neurological
Altered level of consciousness
Meningitis
Raised intracranial pressure
Seizures
Stroke
Subarachnoid haemorrhage
Optional: Please add any additional comments
Cardiovascular
Acute coronary syndromes
Advanced ECG interpretation
Advanced Life Support (ALS)
Aortic Aneurysms
Arrhythmias
Heart Failure
Insertion of intravenous cannula (IVC)
Invasive haemodynamic monitoring
Non-ischaemic cardiac conditions
Vasoactive infusions
Optional: Please add any additional comments
Respiratory
178
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
Acute exacerbation of chronic obstructive pulmonary disease (COPD)
Acute Pulmonary Oedema
Advanced airway management across the lifespan
Advanced mechanical ventilation (adult)
Advanced mechanical ventilation (paediatric)
Arterial Blood gas result interpretation
Asthma
Chest X-ray interpretation requirements
Collection of arterial blood gases
Invasive mechanical ventilation across the life span
Non-invasive positive pressure ventilation (NIPPV) across the lifespan
Pneumonia
Pulmonary Embolism
Tracheostomy
Optional: Please add any additional comments
Kidney, Hepatic & GIT
Acute Kidney Injury (AKI)
Acute Pancreatitis
Biliary tract disease
Chronic Kidney Disease (CKD)
Complications associated with liver cirrhosis
Testicular torsion
Optional: Please add any additional comments
Endocrine
179
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
Diabetic Ketoacidosis (DKA)
Hyperglycaemic Hyperosmolar Syndrome (HHS)
Thyroid dysfunction and associated conditions
Optional: Please add any additional comments
Shock
Cardiogenic shock
Distributive shock
Hypovolaemic Shock
Obstructive shock
Optional: Please add any additional comments
Trauma and Injury
Abdominal Injury
Application of Philadelphia collar
Burns / Thermal Injury
Chest Injury
Mass Casualty
Musculoskeletal Injury
Plastering
Spinal cord injury
Submersion injury
Suturing
Traumatic head injury
Optional: Please add any additional comments
Obstetrics
180
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
Bleeding in pregnancy
Emergent delivery of a baby
Hypertensive disorders of pregnancy
Optional: Please add any additional comments
Paediatrics
Advanced Paediatric Life Support
Bronchiolitis
Calculate IV fluid replacement requirements (for example resuscitation,
dehydration, maintenance)
Congenital paediatric conditions
Croup
Epiglottis
Gastroenteritis
Neonatal special care requirements
Neonatal resuscitation
Seriously ill child
Optional: Please add any additional comments
Other
Drug and alcohol
Ear Nose Throat (ENT) emergencies
Hypo/Hyperthermia
Infectious diseases
Legal issues and forensics
Mental health
181
No. Statement
Stro
ngl
y
Agr
ee
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
Oncological emergencies
Ophthalmology emergencies
Poisoning/Toxicology
Rash
Sexual Assault
Vascular Emergencies
Optional: Please add any additional comments
182
Appendix 11: Ethics approval for Round Two Delphi
183
Appendix 12: Research Data Management Plan
Project Name Minimum Practice Standards for Australian Graduate
Emergency Nursing Programs
Description Modified Delphi study to determine the expected
practice standards for Australian graduate emergency
nurses on completion of their program of study.
Lead Investigator Tamsin Jones
Faculty Faculty of Medicine and Health
Data Management
Notes
Data Survey data are to be collected using Research
Electronic Data Capture (REDCap). Data produced will be
numerical/ text, to be saved in CSV format when
downloaded from REDCap. Microsoft Excel used for
reading CSV files, SPSS to be used for analysis. Survey
data to be stored in Research Data Store (RDS) at The
University of Sydney.
Metadata related to the project include study protocol,
survey instruments, data dictionary. All metadata will be
saved on University of Sydney server with final versions
also kept with data saved in RDS. A README T(text)
document will keep record of all metadata in the RDS.
Ethical/ privacy: Survey data collected will be de-
identified, with no personal information. A unique study
ID will be created on completion of electronic survey.
Study will have ethical approval prior to
commencement.
Data will be archived on completion of project, with
access mediated or restricted to approved individuals.
Data will be stored for a minimum of 5 years, (minimum
retention for non-clinical research data) in accordance
with The University of Sydney Policy.
Data Management
Policy Exceptions
N/A
High performance
Computing (HPC)
N/A
Research Data
Storage
Classic (SMB)
184
Appendix 13: Delphi Round 2 Refined Statements
Demographics
1. How many years have you worked as a registered nurse? (free text/numbers)
2. How many years have you worked in the emergency department/emergency care setting as a registered nurse? (free text/numbers)
3. What is your highest qualification in nursing
☐Graduate Certificate
☐Graduate Diploma
☐Masters
☐PhD
☐ Other
4. Do you have a graduate qualification in emergency nursing?
☐ Yes
☐ No
☐ Other specialist qualification (Please specify)
5. What is your age in years as of the 31st December 2019? (free text/numbers)
6. In what state or territory do you primarily work (Please select one)?
☐ ACT
☐ NSW
☐ NT
☐ QLD
☐ SA
☐ TAS
☐ VIC
☐ WA
☐ OTHER (please specify)
185
7. In what type of emergency department or emergency care setting do/did you mostly practice as a registered nurse as per the Australasian College for Emergency Medicine definitions of emergency department (ED)?
☐ Level 4 Emergency Department / Major Referral Emergency Department
☐ Level 3 Emergency Department / Urban district Emergency Department
☐ Level 2 Emergency Department / Major Regional/ Rural Base Emergency Department
☐ Level 1 Emergency Department / Rural Emergency Service
☐ Remote Emergency Care Clinic
☐ Other (please describe)
8. Which of the following best describes your clinical practice area (the area you work most frequently) (Please select one)?
☐ Emergency department (adult only)
☐ Emergency department (paediatric only)
☐ Mixed Emergency department (adult & paediatric)
☐ Rural/remote emergency care clinic (not a Level 1-4 emergency department)
☐ Education sector (i.e. university)
☐ Other (please describe)
9. Which of the following best describes your current role (Please select as many as applicable)?
☐ Nurse Educator / clinical coach / clinical support nurse
☐ Nurse Manager
☐ Nurse Practitioner
☐Registered nurse
☐ Research Nurse
☐ Other (please describe)
186
Emergency Nursing Course requirements
Our 2019 review of all graduate emergency nursing courses in Australia showed there are 14 tertiary emergency nursing courses offered by Australian universities. Each of these courses is unique with distinct academic and professional characteristics. These courses vary in entry requirements, prior experience and the hours of full time equivalent (FTE) that students are required to work in an emergency care setting. We seek your professional opinions on a range of academic and professional characteristics of graduate emergency nursing courses. You will notice that this survey is mostly the same as round 1. This is intentional. The purpose is to generate consensus amongst emergency nurses with regards to graduate emergency nursing attributes and expectations.
10. In my professional opinion nurses wanting to undertake graduate studies in
emergency nursing should have prior acute care clinical experience as a registered nurse:
☐ Yes
☐ No
☐ Other Comment/Explanation for decision:
11. In my professional opinion nurses wanting to undertake graduate studies in
emergency nursing should have prior clinical experience as a registered nurse in the:
☐ Emergency Department
☐ Emergency care setting
☐ Acute care setting
☐ Prior clinical experience Is not required
☐ Other
Comment/Explanation for decision:
12. I believe nurses completing graduate studies in emergency nursing should be working the following minimum Full Time Equivalent (FTE) clinical practice hours in an approved emergency care environment:
☐ 0.8 FTE
☐ 0.6 FTE
☐ 0.5 FTE
☐ There should be no mandated hours of clinical practice Comment/Explanation for decision:
Our review also showed that a number of courses will not allow nurses working in a Level 1 emergency department or a remote emergency care clinic to enrol in their graduate emergency nursing course, unless the student is able to complete a rotation in a Level 3 or Level 4 emergency department. Please indicate your agreement with the statements below. These statements relate to students completing graduate emergency nursing studies.
187
13. In my professional opinion, nurses working in rural and remote areas or Level 1 emergency departments, with no exposure to a Level 3 or Level 4 emergency department, should be able to undertake graduate emergency nursing courses:
☐ Yes
☐ No
☐ Other Comment/Explanation for decision:
13. In my professional opinion, nurses working in a Level 3 or Level 4 emergency department with no exposure to rural and remote areas should be required to complete a rotation in a Level 1 emergency department or a remote emergency care clinic.
☐ Yes
☐ No
☐ A rotation to a Level 1 ED or remote emergency clinic would be beneficial, however this should not be a requirement of a graduate emergency nursing program
☐ Other Comment/Explanation for decision:
14. In my professional opinion, nurses working in a Level 1 - 4 adult emergency
department should be required to complete a rotation in a Level 1 - 4 mixed (adult and paediatric) or Level 1 - 4 paediatric emergency department
☐ Yes
☐ No
☐ A rotation to a Level 1 ED or remote emergency clinic would be beneficial, however this should not be a requirement of a graduate emergency nursing program
☐ Other Comment/Explanation:
15. In my professional opinion nurses working in a Level 1 - 4 paediatric emergency department should be required to complete a rotation in a Level 1 - 4 mixed (adult and paediatric) or Level 1 - 4 adult emergency department:
☐ Yes
☐ No
☐ A rotation to a Level 1 ED or remote emergency clinic would be beneficial, however this should not be a requirement of a graduate emergency nursing program
☐ Other
Comment/Explanation:
188
In the following "Graduate Expectations" section we ask you to indicate your level of agreement with the statements below. The level of agreement ranges from Strongly Agree, to Strongly Disagree. For each of the following statements, please consider your clinical practice expectations of a nurse who has just completed their graduate certificate studies in emergency nursing
Please feel free to add any additional explanations, comments or practice expectations.
No. Statement
Stro
ngl
y A
gre
e
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
Graduate Expectations: Communication On completion of the graduate emergency nursing course the graduate will be able to:
1 Communicate effectively with the patient, their family and support people, considering factors such as cognitive impairment, level of health literacy, culture and ethnicity
2 Effectively communicate with patients, families and support people regarding assessment findings and management plans
3 Effectively communications with colleagues, including the multidisciplinary team, to plan, deliver and evaluate care
4 Provide clear, concise and informative handovers
5 Provide structured, concise and informative documentation
Optional: additional explanations, comments or practice expectations regarding the theme of communication
Graduate Expectations: Delivery of safe and quality patient care On completion of the graduate emergency nursing course the graduate will be able to:
6 Identify and report unsafe or inappropriate practice
7 Manage critical incidences and stressful situations
8 Demonstrate safe and effective use of technology and biomedical equipment
9 Promote a caring environment for the patient and significant others
10 Involve the patient in the decisions about their care
11 Advocate for the patient
189
No. Statement
Stro
ngl
y A
gre
e
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
12 Establish rapport with patients, families and support people
Optional: additional explanations, comments or practice expectations regarding the theme of: Delivery of safe and quality patient care
Theme: Research and Quality Improvement On completion of the graduate emergency nursing program the graduate will be able to:
14 Critically evaluate and apply nursing research to emergency patient care
15 Identify and suggest areas for practice or policy change
16 Support the development of quality improvement within the emergency care environment
17 Support the development of research within the emergency care environment
Optional: additional explanations, comments or practice expectations regarding the theme of: Research and Quality Improvement
Theme: Ethics and Law On completion of the graduate emergency nursing program the graduate will be able to:
18 Maintain patient privacy and confidentiality
19 Function within an ethical framework
20 Practice according to all relevant legislation and standards of practice
Optional: additional explanations, comments or practice expectations regarding the theme of: Ethics and Law
Theme: Teamwork and Leadership On completion of the graduate emergency nursing program the graduate will be able to:
21 Work within their own scope of practice
22 Performs effectively as a team member
23 Collaborate with colleagues, including the multidisciplinary team, to bring about best patient outcomes
24 Recognise and manage own stress
190
No. Statement
Stro
ngl
y A
gre
e
Agr
ee
Ne
ith
er
Agr
ee
or
Dis
agre
e
Dis
agre
e
Stro
ngl
y
Dis
agre
e
25 Provide support for colleagues when caring for challenging patient and or family needs
26 Effectively leads a team to provide safe, quality patient care
27 Act as a role model for nurses and other health professionals
28 Supervise and delegate the delivery of patient care to others
29 Demonstrate preparedness and response for major incidents and disasters
30 Lead a team in caring for the at-risk patient
Optional: additional explanations, comments or practice expectations regarding the theme of: Teamwork and Leadership
Theme: Professional development On completion of the graduate emergency nursing program the graduate will be able to:
31 Maintain their own ongoing professional development
32 Contribute to the professional development of colleagues
33 Promote the profile of emergency nursing
Optional: additional explanations, comments or practice expectations regarding the theme of: Professional Development
Theme: Clinical practice and expertise On completion of the graduate emergency nursing program the graduate will be able to:
34 Provide appropriate and timely assessments of the undiagnosed patient
35 Effectively prioritise patient care needs
36 Determine, monitor and implement appropriate assessment and management strategies for multiple undifferentiated patients
37 Transport complex patients throughout the healthcare environment
38 Provide appropriate discharge care including referrals and education materials
39 Anticipate, assess and manage the care of the deteriorating patient across the lifespan
40 Safely work at triage
191
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Optional: additional explanations, comments or practice expectations regarding the theme of: Clinical practice and expertise
CLINICAL CARE CAPABILITY Our analysis of Australian graduate emergency nursing courses identified a wide range of clinical conditions and skills taught to students. Students are required to apply their knowledge of advanced pathophysiology, assessment and management strategies for these conditions in the emergency care setting. Patients with these conditions may be critically unwell.
In this section we seek your level of agreement with the statements related to clinical care. For each of the following statements, please consider your clinical practice expectations of a nurse who has just completed their graduate certificate studies in emergency nursing Please feel free to add any other conditions or skills you believe need to be taught in graduate emergency nursing courses.
On completion of the graduate emergency nursing course the graduate will be clinically capable to care for a patient with: able to care for the patient with:
Neurological
Altered level of consciousness
Meningitis
Raised intracranial pressure
Seizures
Stroke
Subarachnoid haemorrhage
Optional: Please add any additional comments
Cardiovascular
Acute coronary syndromes
Advanced ECG interpretation
Advanced Life Support (ALS)
Aortic Aneurysms
Arrhythmias
Heart Failure
Insertion of intravenous cannula (IVC)
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Invasive haemodynamic monitoring
Non-ischaemic cardiac conditions
Vasoactive infusions
Optional: Please add any additional comments
Respiratory
Acute exacerbation of chronic obstructive pulmonary disease (COPD)
Acute Pulmonary Oedema
Advanced airway management across the lifespan
Advanced mechanical ventilation (adult)
Arterial Blood gas result interpretation
Asthma
Chest X-ray interpretation requirements
Invasive mechanical ventilation across the life span
Non-invasive positive pressure ventilation (NIPPV) across the lifespan
Pneumonia
Pulmonary Embolism
Optional: Please add any additional comments
Kidney, Hepatic & GIT
Acute Kidney Injury (AKI)
Acute Pancreatitis
Biliary tract disease
Chronic Kidney Disease (CKD)
Complications associated with liver cirrhosis
Testicular torsion
Optional: Please add any additional comments
Endocrine
Diabetic Ketoacidosis (DKA)
Hyperglycaemic Hyperosmolar Syndrome (HHS)
193
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Thyroid dysfunction and associated conditions
Optional: Please add any additional comments
Shock
Cardiogenic shock
Distributive shock
Hypovolaemic Shock
Obstructive shock
Optional: Please add any additional comments
Trauma and Injury
Abdominal Injury
Application of Philadelphia collar
Burns / Thermal Injury
Chest Injury
Musculoskeletal Injury
Spinal cord injury
Submersion injury
Traumatic head injury
Optional: Please add any additional comments
Obstetrics
Bleeding in pregnancy
Hypertensive disorders of pregnancy
Optional: Please add any additional comments
Paediatrics
Advanced Paediatric Life Support
Bronchiolitis
Calculate IV fluid replacement requirements (for example resuscitation, dehydration, maintenance)
Croup
194
No. Statement
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Epiglottis
Gastroenteritis
Neonatal resuscitation
Seriously ill child
Optional: Please add any additional comments
Other
Drug and alcohol
Ear Nose Throat (ENT) emergencies
Hypo/Hyperthermia
Infectious diseases
Legal issues and forensics
Mental health
Oncological emergencies
Ophthalmology
Poisoning/Toxicology
Rash
Sexual Assault
Vascular Emergencies
Optional: Please add any additional comments
195
Appendix 14: Confirmation of manuscript acceptance to Nurse