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.
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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
Conference Presentations .................................................................................... xxiii
Grants and Scholarships ....................................................................................... xxiv
Chapter 1. Background .......................................................................................... 1
1.1. Introduction...................................................................................................... 1
1.2. Background ....................................................................................................... 1
1.2.1. Emergency healthcare environment ...................................................... 2
1.2.2. Contemporary emergency nursing practice ........................................... 4
1.2.3. Emergency nursing education ................................................................ 6
1.2.4. Standards and Governance for emergency nursing education .............. 8
1.2.5. Funding for education in Australian tertiary graduate programs ........ 10
1.2.6. Workforce influencing patient safety ................................................... 11
1.3. Gap in knowledge ........................................................................................... 12
1.4. Thesis aim and research questions ................................................................ 12
1.5. Significance of this study ................................................................................ 13
1.6. Position of the thesis author .......................................................................... 13
1.7. Summary and overview of the thesis ............................................................. 14
Chapter 2. Literature Review ............................................................................... 16
2.1. Introduction.................................................................................................... 16
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
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2.4.1. Results of the updated literature review.............................................. 32
2.5. Practice standard development in Australian specialty nursing.................... 38
2.6. Summary ........................................................................................................ 41
Chapter 3. Methodology and Methods ................................................................ 42
3.1. Introduction.................................................................................................... 42
3.2. Philosophical paradigm: Pragmatism ............................................................. 42
3.3. Mixed-methods .............................................................................................. 44
3.4. Study aim ........................................................................................................ 45
3.4.1. Research questions ............................................................................... 45
3.5. Study design: Exploratory sequential design ................................................. 45
3.6. Human research ethical considerations ......................................................... 48
3.6.1. Research merit and integrity ................................................................ 49
3.6.2. Justice.................................................................................................... 49
3.6.3. Beneficence........................................................................................... 49
3.6.4. Respect .................................................................................................. 49
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
3.8.1. Phase 1: Document Analysis ................................................................. 51
3.8.2. Phase 2: Semi-structured interviews with key informants .................. 55
3.8.3. Integration of findings .......................................................................... 61
3.8.4. Data saturation ..................................................................................... 61
3.8.5. Trustworthiness .................................................................................... 61
3.9. Study 3: Stakeholder analysis of graduate emergency nursing practice standards ................................................................................................................... 62
3.9.1. Delphi .................................................................................................... 62
3.9.2. Rigour .................................................................................................... 71
3.10. Data integration .......................................................................................... 72
3.11. Data storage ............................................................................................... 73
3.12. Summary ..................................................................................................... 74
Chapter 4. Results of Study 2 Analysis of Australian Graduate Emergency Nursing Programs…….. ........................................................................................................ 75
4.1. Introduction.................................................................................................... 75
4.2. Publication 2: Academic and professional characteristics of Australian graduate emergency nursing programs. ................................................................... 75
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4.3. Summary ........................................................................................................ 84
Chapter 5. Results of Study 3 Practice Expectations of Australian Graduate Emergency Nursing Programs ................................................................................ 85
5.1. Introduction.................................................................................................... 85
5.2. Publication 3: Practice Expectations of Australian Graduate Emergency Nursing Programs: A Delphi Study. ........................................................................... 85
5.2.1. Abstract ................................................................................................. 85
5.2.2. Background ........................................................................................... 86
5.2.3. Method ................................................................................................. 89
5.2.4. Results ................................................................................................... 92
5.2.5. Discussion ........................................................................................... 103
5.2.6. Conclusion ........................................................................................... 105
5.3. Summary ...................................................................................................... 105
Chapter 6. Discussion ........................................................................................ 106
6.1. Introduction.................................................................................................. 106
6.2. Study outcome and implications .................................................................. 106
6.3. Minimum practice standards for graduate emergency nursing programs .. 108
6.3.1. Graduate attributes ............................................................................ 112
6.4. Application to graduate emergency nursing programs ............................... 118
6.4.1. Prior experience .................................................................................. 118
6.4.2. Clinical exposure and the relevance to program admission .............. 119
6.4.3. Working in the ED whilst studying ...................................................... 121
6.5. Methodological reflection ............................................................................ 122
6.6. Summary ...................................................................................................... 123
Chapter 7. Conclusion and Recommendations ................................................... 125
7.1. Introduction.................................................................................................. 125
7.2. Recommendations ....................................................................................... 125
7.2.1. Recommendations for policy .............................................................. 125
7.2.2. Recommendations for practice .......................................................... 125
7.2.3. Recommendations for education ....................................................... 126
7.2.4. Recommendations for research ......................................................... 127
7.2.5. Recommendations for the profession ................................................ 128
7.3. Conclusion .................................................................................................... 128
References........................................................................................................... 130
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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 13: Delphi Round 2 Refined Statements ................................................ 184
Appendix 14: Confirmation of manuscript submission to Nurse Education Today.. 195
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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 5.2 Graduate Emergency Nursing Course Entry Requirements ........................... 95
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
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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 3.1 Exploratory sequential design ....................................................................... 47
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
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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
Emerg Care. 23: 173-180. doi: 10.1016/j.auec.2020.02.003
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 5 Section 5.2 of this thesis contains Publication 3:
Jones, T., Curtis, K., Shaban, RZ. (2020b). Practice Expectations of Australian
Graduate Emergency Nursing Programs: A Delphi Study. Manuscript accepted for
publication in Nurse Education Today Feb 2nd 2021.
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.
xii
Supervisor Confirmation
As supervisors of for the candidature upon which this thesis is based, we can
confirm that the authorship attribution statements above are correct.
Supervisor Name: Professor Ramon Z. Shaban
Signature:
Date: 24/11/2020
Supervisor Name: Professor Kate Curtis
Signature:
Date: 24/11/2020
xiii
Abstract
Background
A skilled emergency nursing workforce is needed to provide high quality and
safe healthcare to patients in the emergency care environment. Graduate emergency
nursing education programs, often referred to as postgraduate programs, are
essential in establishing a nursing workforce that has the required theoretical
knowledge and clinical skills to work in this dynamic environment. Little is known
about graduate emergency nursing programs in Australia. There are no minimum
practice standards for graduate emergency nursing programs in Australia, and thus
there is variation in graduate attributes and clinical expectations of nurses on
completion of graduate emergency nursing qualifications.
Aim
The aim of this study was to develop minimum practice standards for graduate
emergency nursing programs in Australia.
Methods
An exploratory sequential mixed-methods design comprising of three
interconnected studies was used to answer the research aim. Study One is a
comparative and integrative review of international emergency nursing practice
standards. Study Two is an embedded mixed-methods analysis of the academic and
professional characteristics of Australian graduate emergency nursing programs,
including a document analysis and in-depth interviews of course coordinators. Study
Three is a modified two-round Delphi method of Australian emergency nurses to
generate consensus amongst Australian emergency nurses with regards to graduate
emergency nursing course entry requirements, graduate expectations and clinical care
capabilities.
Results
This study established evidence-based minimum practice standards for Australian
graduate emergency nursing programs through three interconnected studies.
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Study One found that emergency nursing practice and competency standards
exist internationally. There are numerous differences across the six sets of
international emergency nursing practice and competency standards, which are
influenced by the level and experience of the emergency nurses to whom they apply.
Nine domains of analysis were identified, and some similarities across these domains
exist: clinical expertise; communication; environment and resources; leadership; legal;
professional development; professional ethics; research and quality; teamwork.
Study Two identified that graduate emergency nursing programs in Australia
are mostly delivered at a graduate certificate level. While all programs required
students to be a registered nurse, prior experience was not consistently required, and
employment requirements during course completion were also variable. All programs
required students to complete a clinical assessment; however, these varied in number
and structure, and students working in rural and remote emergency care
environments were often required to complete rotations in Level 3 or Level 4 EDs to
facilitate clinical exposure and aid the completion of clinical assessments. The majority
of programs were designed to provide education for emergency nurses who were
commencing their emergency specialist nurse career.
The findings from Study Three, and sequential integration of Study One and
Study Two, generated the evidence to establish minimum practice standards for
Australian graduate emergency nursing programs. These standards have been
informed by the emergency nursing profession across seven graduate attribute
domains: communication; safe and quality patient care; research and quality
improvement; ethics and legal; teamwork and leadership; professional development;
and clinical practice expertise. Within the domain of clinical expertise is the attribute
that requires students to demonstrate clinical care capabilities. These have been
defined by the profession and centre around ten categories: neurological;
cardiovascular; respiratory; kidney hepatic & gastrointestinal; endocrine; shock;
obstetrics; trauma and injury; paediatrics; and other.
Moreover, through this research graduate attributes for graduate emergency
nursing programs have been established, the expected areas of clinical care
capabilities for graduate emergency nursing programs have been determined, and
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workforce considerations for nurses undertaking graduate emergency nursing
programs have been identified.
Conclusion
This original research has generated evidence-based minimum practice
standards for Australian graduate emergency nursing programs. These standards
detail the professional practice expectations of graduates. The practice standards
present a guide for higher education to anchor their graduate emergency nursing
curricula. Consistent and transparent expectations inform clinical practice, which
ultimately leads to safer delivery of informed patient care, and improves workforce
planning.
xvi
List of Abbreviations
ACEM Australian College for Emergency Medicine
ACT Australian Capital Territory
AHPRA Australian Health Practitioner Regulation Agency
AIHW Australian Institute of Health and Welfare
ANMAC Australian Nursing & Midwifery Accreditation Council
AQF Australian Qualifications Framework
BN Bachelor of Nursing
CENA College of Emergency Nursing Australasia
CENNZ College of Emergency Nurses New Zealand
CNC Clinical Nurse Consultant
CNE Clinical Nurse Educator
CNS Clinical Nurse Specialist
CSP Commonwealth-Supported Place
ECG Electrocardiograph
ED Emergency Department
ENA Emergency Nurses Association (United States)
EuSEN European Society for emergency Nursing
FEN Faculty of Emergency Nursing (United Kingdom)
FTE Full Time Equivalent
HES Higher Education Standards
HREC Human Research and Ethics Committee
xvii
HWA Health Workforce Australia
KPI Key Performance Indicator
LMS Learning Management System
MDT Multidisciplinary Team
NEAT National Emergency Access Target
NENA National Emergency Nurses Association (Canada)
NHMRC National Health and Medical Research Council
NM Nurse Manager
NMBA Nursing and Midwifery Board of Australia
NSQHS National Safety and Quality Health Service
OSCE Objective Structured Clinical Examination
PG Postgraduate
PI Primary Investigator
PICF Participant Information and Consent Form
PIS Participant Information Statement
RN Registered Nurse
RTO Registered Training Organisation
SOP Scope of Practice
TEQSA Tertiary Education Quality and Standards Agency
TNCC Trauma Nursing Core Course
TSPP Transition to Specialty Practice Program
UK United Kingdom
USA United States of America
xviii
Glossary of Terms
Access block
“The situation where patients who have been admitted and need a hospital bed are
delayed from leaving the emergency department because of lack of inpatient bed
capacity” (Australasian College for Emergency Medicine, 2020, p. 1).
Clinical progression
The progression of emergency nurses caring for patients in low acuity areas with
minor illness or injury, to caring for patients in high acuity areas with critical illness
or injury (Morphet, Kent, Plummer, & Considine, 2015).
Clinical education
Education that is provided in the clinical environment. Clinical education in
emergency nursing is provided in the emergency care environment.
Capability standard
A combination of skills, knowledge, values, flexibility and confidence. Individuals can
critically reflect, manage change and move beyond competency (Aranda & Yates,
2009; O'Connell, Gardner, & Coyer, 2014a).
Clinical Nurse Educator
A Clinical Nurse Educator (CNE) facilitates education and professional development
in the clinical practice environment. A CNE is a registered nurse; any additional
qualifications are organisation-specific. A CNE in the ED is also responsible for the
management of graduate nursing education within the ED (Sayers, DiGiacomo, &
Davidson, 2011).
Competency standard
The integrated application of specific knowledge, skills and attributes (Edmonds,
Cashin, & Heartfield, 2013).
xix
Critical illness / Critically unwell patient
A critically unwell patient or patient with a critical illness is in an unstable clinical
state or at risk of clinical deterioration. Their illness or injury is potentially life-
threatening, and thus they often require invasive interventions such as: invasive
haemodynamic monitoring; vasoactive infusions; endotracheal intubation;
mechanical ventilation (Australian College of Critical Care Nurses, 2015).
Emergency Care Environment
A clinical environment that cares for patients requiring emergency care. Examples of
these are: the emergency department, an emergency clinic in a rural or remote
area, the Royal Flying Doctors service.
Emergency Department
“An emergency department (ED) is a dedicated hospital-based facility specifically
designed and staffed to provide 24-hour emergency care. An Emergency
Department must be part of an integrated health delivery system within a hospital”
(Australasian College for Emergency Medicine, 2019b, p. 5).
Full time equivalent (FTE)
The percentage of a 40-hour working week (full time); for example, 0.4 FTE is 16
hours per week.
Graduate program/ Graduate studies
Graduate studies in this thesis refers to tertiary education that is beyond a Bachelor
qualification. These programs are delivered at an AQF Level 8 (graduate certificate
and diploma) and Level 9 (Masters). These programs aim to prepare students for
specialist or advanced practice (Australian Qualifications Framework Council,
2013a).
Informed practice
It extends beyond evidence-based practice and incorporates the “intentional
process to understand the various types of knowledge and sources of knowledge
behind the rationales for clinical decisions” (Baid & Hargreaves, 2015, p. 176).
xx
Level 1 Emergency Department
“An ED that provides emergency care within a designated area of a remote or rural
hospital. It is the minimum level of service that can be defined as an Emergency
Department” (Australasian College for Emergency Medicine, 2012, p. 2).
Level 2 Emergency Department
“An ED that is part of a secondary hospital with capabilities to manage some
complex cases, and would offer some sub-specialty services” (Australasian College
for Emergency Medicine, 2012, p. 3).
Level 3 Emergency Department
“An ED that is part of a major regional, metropolitan or urban hospital with
capabilities to manage most complex cases and have some sub-specialty services”
(Australasian College for Emergency Medicine, 2012, p. 5).
Level 4 Emergency Department
“Emergency Departments at this level are part of a large, multifunctional quaternary
or major referral hospital with capabilities to manage a wide range of complex
conditions, and that offer a significant level of sub-specialty services” (Australasian
College for Emergency Medicine, 2012, p. 6).
National Emergency Access Target (NEAT)
“The NEAT is a public hospital time-based target that relates to a patient’s length of
stay in the ED. The aim is that 90% of patients who presents to the ED will physically
leave within four hours: the patient is admitted, discharged or referred to another
hospital” (Australasian College for Emergency Medicine, 2019b, p. 10).
Overcrowding
“The situation where ED function is reduced because the number of patients
exceeds its physical and/or staffing capacity” (Australasian College for Emergency
Medicine, 2019a, p. 1).
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Practice Standard
Practice standards guide a clinician’s practice, and inform performance, attributes
and expected outcomes. These are the minimum requirements for a registered
nurse to practice (Campo et al., 2018; Jones, Shaban, & Creedy, 2015, p. 192;
Neville, Hangan, Eley, Quinn, & Weir, 2008).
Postgraduate
Postgraduate is a term often used interchangeably with graduate. It refers to a
student who is undertaking or has completed tertiary studies that exceed the
Bachelor qualification. The AQF recommend that the term ‘graduate’ is used instead
of postgraduate (Australian Qualifications Framework Council, 2012).
Triage
“A process of assessment of a patient on arrival to the ED to determine the priority
for medical care based on the clinical urgency of their presenting condition”
(College of Emergency Nursing Australasia, 2015, p. 1).
xxii
Publications related to thesis
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
2. Jones, T., Curtis, K., Shaban, RZ. (2020a). The academic and professional features of
Australian graduate emergency nursing programs: A national study. Australas Emerg
Care. 23: 173-180. doi: 10.1016/j.auec.2020.02.003
3. Jones, T., Curtis, K., Shaban, RZ. (2020b). Practice expectations of Australian graduate
emergency nursing programs: A Delphi study. Manuscript accepted for publication.
xxiii
Conference Presentations
Jones, T., Creedy, DK & Shaban, RZ. (11-13 October, 2017). Communication of graduate
emergency nursing programs. Oral paper presented at the International Conference
for Emergency Nurses Australasia, Sydney, Australia.
Jones, T., Curtis, K & Shaban, RZ. (16-18, October, 2019). The Academic and Professional
features of Australian post-graduate emergency nursing programs. Oral paper
presented at the International Conference for Emergency Nurses Australasia,
Adelaide, Australia
xxiv
Grants and Scholarships
• College of Emergency Nursing Australasia (CENA). New Investigator Research Grant
(2018): Minimum Practice Standards for Australian Graduate Emergency Nursing
Programs - Awarded $4,000.
• Skellern Family Foundation Scholarship (2018). The University of Sydney Susan Wakil
School of Nursing and Midwifery - Awarded $30,000 per annum until submission.
1
Chapter 1. Background
1.1. Introduction
This thesis, which includes several peer-reviewed publications, presents the
results of a study that aimed to establish minimum practice standards for Australian
graduate emergency nursing programs. International practice and competency
standards for emergency nursing have been critiqued and their relevance to graduate
emergency nursing programs considered. Academic and professional characteristics of
Australian graduate emergency nursing programs have been identified, and practice
standards for graduate emergency nursing programs have been established.
This chapter provides the background to the study. The nature of the profession
and practice of emergency nursing are explored. The emergency healthcare
environment, particularly the emergency department (ED), emergency nursing and
education for emergency nurses are explored as context for this research. The warrant
for this research, namely the evidence gap in relation to the sufficiency of graduate
emergency nursing education courses for beginner emergency nurses, is established
and the need for national graduate emergency nursing practice standards is
documented. The aims and significance of this research are addressed, and the thesis
author’s position is described. A summary of the thesis structure is presented at the
end of this chapter, including the location of peer-reviewed publications included in
this thesis.
1.2. Background
In this section the emergency care environment and emergency nursing, which
give context to the clinical practice environment and care requirements of emergency
nurses, are described. The education of emergency nurses is explored, including the
regulatory bodies and standards that currently influence the delivery of emergency
nursing education, in addition to factors that influence students completing graduate
studies. Patient safety implications associated with a skilled emergency nursing
workforce are also discussed.
2
1.2.1. Emergency healthcare environment
The context of emergency healthcare environments in Australia is vast, from
rural and remote settings where healthcare centres have emergency treatment rooms
and reduced resources (Baker & Dawson, 2013), to quaternary-level emergency
departments (EDs) with access to specialist treatment services and extensive
resuscitative care equipment (Australasian College for Emergency Medicine, 2012).
Despite these variations, the nature of patient presentations is similar (Baker &
Dawson, 2014). Patients who present seeking emergency care are typically
undiagnosed and have the potential to rapidly deteriorate if appropriate assessment
and management strategies are not implemented. Patients presenting for emergency
care need to be triaged, assessed, have provisional care implemented based on their
provisional diagnosis, and conclude with patients dispositioned to the most
appropriate setting based on their care requirements (Australasian College for
Emergency Medicine, 2014). The age of patients extends across the lifespan and the
illness and injuries experienced do not discriminate based on geographical location
(Baker & Dawson, 2014).
Emergency departments are discrete clinical areas; they have the highest
interface with patients seeking emergency care (Australasian College for Emergency
Medicine, 2012) and are the primary place of employment for nurses who identify as
emergency nursing specialists (Morphet, Kent, Plummer & Considine, 2016a). The ED
is busy, dynamic and unpredictable (Fry, Shaban, & Considine, 2019), and the service
demand on Australian public emergency departments continues to increase
(Australian Institute of Health and Welfare, 2018). Over the past five years (2014-
2019) patient presentations to Australian public hospital emergency departments
have risen to over 8.3 million, an increase of 12% (Australian Institute of Health and
Welfare, 2020). A number of factors are thought to contribute to this increase in
demand, such as an aging population, increasing general practitioner fees, and
accessibility to care (Crawford et al., 2014).
Increasing patient presentations frequently creates challenges for EDs, such as
overcrowding; this in turn can impact the delivery of patient care (Crawford et al.,
3
2014; Duffield et al., 2011). Despite such challenges, Australian EDs are expected to
meet the National Emergency Access Target (NEAT) (Sullivan, Staib, Griffin, Bell &
Scott, 2016a). The NEAT stipulates that 90% of patients should have left the ED within
4 hours, which includes hospital admission, transfers to another health service or
discharge. The NEAT has resulted in some Australian EDs reviewing and modifying
their approach to patient flow, although the premise of timely care delivery remains
consistent (Sullivan et al., 2016b).
In Australia, ED’s are located in metropolitan, rural and regional areas, and their
capacity and capability are defined by the four-level Australasian College for
Emergency Medicine (ACEM) Framework (Australasian College for Emergency
Medicine, 2012). Formally designated Australian EDs must operate within a hospital.
They must be designed so that patients who are critically unwell and require
resuscitative or advanced emergency care can be directed to a dedicated area of the
ED to receive this specialist care. Laboratory, radiology and blood product services
must be accessible 24 hours a day, along with 24-hour access to retrieval services and
specialist advice. Nursing staff must be on site 24 hours a day and medical staff must
be within 10 minutes of the ED at all times (Australasian College for Emergency
Medicine, 2012, 2014; College of Emergency Nursing Australasia, 2008). As the level of
the emergency department increases, so do the expected ED design and care
requirements, but all EDs are structured so that patients are allocated to clinical areas
for care based on their acuity, as represented in Figure 1.1.
Figure 1.1 Common areas of care in the emergency department Adapted from: Morphet, Plummer, Kent, and Considine (2017, p. 1973)
Triage
Assess and prioritse all patients presenting to the ED
Minor illness/injury
(General cubicles/fast track)
Lowest patient acuity
Moderate illness/injury
(Monitored cubicles)
Patients with increased complexity
Critical illness/ injury
(Resuscitation cubicles)
Complex patients
4
1.2.2. Contemporary emergency nursing practice
Emergency nurses and their practice is unique (Kennedy, Curtis, & Waters,
2014). A recent study in a large Australian ED examined the personality profile of
emergency nurses. They identified that emergency nurses enjoyed fast-paced
environments and were effective in stressful situations, while also being able to
converse easily with strangers in kind, friendly and helpful ways. Emergency nurses go
above and beyond to assist others, but remained humble, wanting to celebrate the
success of others as opposed to individual accolades (Kennedy et al., 2014).
Emergency nurses require a wide-range of basic and advanced skills to manage
the complexities that emerge in EDs (Fry et al., 2019; Howard & Papa, 2012; Kennedy
et al., 2014; Sbaih, 1997). This has been particularly notable during the COVID-19
global pandemic, which was declared on 11th March 2020. The global COVID-19
pandemic has raised the profile of emergency nursing, illustrating the complexities of
care delivery and of the emergency nursing practice environment (Bagnasco, Zanini,
Hayter, Catania, & Sasso, 2020; Clough, 2020; Nayna Schwerdtle et al., 2020).
Advanced assessment skills are required when caring for patients in the emergency
department as they almost always present with an unknown diagnosis (Curtis,
Munroe, Van, & Elphick, 2020; Fry et al., 2019). The interpretation of these
assessment findings influences decisions relating to patient care, the clinical care
location of patients and the advanced clinical skills needed of nursing staff working in
the ED (Munroe, Curtis, Buckely, Lewis, & Atkins, 2018). The uniqueness of emergency
nursing in Australia extends beyond the hospital setting, as emergency nurses may
work in rural and remote areas of the country which can be isolated environments
with limited staff, facilities, and education. These clinicians need to assess and manage
patient complaints in the clinical context in which they work. The patient diagnosis is
often unknown, it may be life-threatening, and there is the potential for patient
deterioration (Baker & Dawson, 2013, 2014; Lenthal et al., 2009; Sullivan, Hegney &
Frances, 2012). Emergency nurses are required to adapt to rapidly changing and
evolving situations, and again the COVID-19 global pandemic has evidenced this.
Emergency nurses were required to rapidly prepare the emergency care environment
and critical care workforce for the anticipated burden on emergency services (Nayna
5
Schwerdtle et al., 2020). This was achieved whilst significant limitations in the
movement and gathering of citizens and residents across Australia were experienced.
In Australia the College of Emergency Nursing Australasia (CENA) has
established practice standards for specialist emergency nurses, which were published
in 2014. The CENA Practice Standards for the Emergency Nursing Specialist outline the
expected performance criteria across nine domains for an expert emergency nurse
specialist, with the intent of articulating best practice. These domains are clinical
expertise, communication, teamwork, resources & environment, professional
development, leadership, legal, professional ethics, and research & quality
improvement (College of Emergency Nursing Australasia, 2014). The CENA defines an
emergency nurse specialist as “a registered nurse who has significant experience in
the emergency practice setting” (College of Emergency Nursing Australasia, 2014, p.
79), however what constitutes significant experience is not defined (College of
Emergency Nursing Australasia, 2014). In addition to providing guidance for practice,
the document has clear elements of emergency nursing that may be considered as
distinguishing features of emergency nursing. These features are collectively not
required of nurses working in other environments, as outlined in Table 1.1.
Table 1.1 Distinct elements of emergency nursing work defined by the CENA
• Triage assessment and prioritisation
• Symptom-based assessment to develop differential diagnosis and treatment
pathways
• Knowledge, skills and competencies to instigate and maintain the care of
patients in an everchanging environment with competing pressures
• Ability to change approach to accommodate the individual physical and
psychosocial dynamics of patients
• Emergency management of minor injuries
• Accurate and timely nursing assessment of undiagnosed and unstable
patients for signs of deterioration to enhance best patient outcomes
• Coordinated, cooperative and multidisciplinary emergency teamwork
6
• Trauma team preparedness and response
• Disaster and major incident preparedness and response
• Coordinate efficient patient flow and disposition
• Manage diverse discharges and referrals for multiple patients
• Participation in and development of emergency-based research and
knowledge to inform evidence-based practice and clinical tools
• Evaluation of performance against specific emergency key performance
indicators (KPI)
• Use of technology that includes diagnostic and life sustaining equipment
Modified from: College of Emergency Nursing Australasia (2014, pp. 80-81)
While these practice standards and elements provide a framework for expert
emergency nurses, their relevance to, and application by, novice emergency nurses
remains unclear. The CENA Practice Standards for the Emergency Nursing Specialist
align with Benner’s expert level of practice (Benner, 1982; Lyneham, Parkinson, &
Denholm, 2008a). Benner’s novice to expert model, based on Dreyfus’ Model of Skill
Acquisition, continues to be utilised to articulate proficiency in nursing practice across
five levels: novice, advanced beginner, competent, proficient and expert (Benner,
1982). In the absence of graduate emergency nursing practice standards, it is unclear
to what level of proficiency nurses with recent graduate-level qualifications in
emergency nursing would align.
1.2.3. Emergency nursing education
Education for emergency nurses is essential to safely deliver quality of care.
Education ranges from informal hospital facilitated orientation and Transition to
Specialty Practice Programs (TSPPs) to formalised graduate tertiary education
(Morphet, Kent, Plummer & Considine, 2016b). Transition to Specialty Practice
Programs are frequently delivered by individual healthcare networks and are designed
to prepare the novice emergency nurse to safely work in the emergency department,
and thus participants are not expected to care for patients who are critically unwell.
The availability of education programs is heavily influenced by resources, particularly
those that require the support and expertise of experienced emergency nursing staff,
7
but is not well discussed in the literature. Recently Australian emergency nursing
TSPPs have been examined, reporting an inconsistency between attributes and
outcomes of participants on completion of these programs (Morphet et al., 2016b).
These programs are often seen as a foundation or scaffold for nurses who progress to
graduate studies in emergency nursing; however, they are not accessible to all nurses
working in emergency care environments (Morphet, Considine & McKenna, 2011;
Morphet, Kent, Plummer & Considine, 2015).
Specialist emergency nursing education programs were developed in Australia to
facilitate theoretical understanding and proficient clinical practice, supporting the
practitioner to become competent in the emergency care environment (Baxter &
Evardsson, 2018; Fry et al., 2019; Lyneham et al., 2008a; Walker-Cillo & Harding,
2013). These programs were initially localised to individual hospitals and established
according to the clinical demands and needs of the local ED environment (Fry et al.,
2019; Hendricks, Mooney, Crosby, & Forrester, 1996b). The transfer of pre-
registration nurse education to the tertiary sector saw a shift in post-registration
emergency nursing programs being delivered in the tertiary environment. A number of
programs were initially delivered under the umbrella of ‘critical care’, however as the
independent specialisations of emergency medicine and subsequently emergency
nursing became recognised, so did the acknowledgement and delivery of specialist
emergency nursing education. It is unclear from the literature how graduate
emergency nursing curricula in Australia are developed and there is currently no
documented consensus relating to what the core graduate attributes and clinical care
capabilities are. While one Australian university published their approach to graduate
emergency nursing curriculum development, the extent to which other tertiary
facilities have adapted this approach is unknown (Hendricks, Mooney, Crosby, &
Forrester, 1996a; Hendricks et al., 1996b).
Access to tertiary education has become increasingly accessible due to changes
in mode of delivery, with online education becoming increasingly popular (Mackavey
& Cron, 2019); nevertheless, the impact this has had on graduate emergency nursing
education is unknown. The benefits of graduate education are both individual and
professional. Studies have detailed that completion of graduate education in nursing
8
specialties leads to safer patient care through enhanced patient assessment, critical
thinking and problem-solving skills (Barnhill, McKillop, & Aspinall, 2012; Baxter &
Evardsson, 2018; Cotterill-Walker, 2012; Ng, Eley, Tuckett, 2016). The practice
environment of the ED is an important consideration in the application of graduate
emergency nursing education and the clinical progression of emergency nurses.
Nurses working in an emergency department are generally transitioned through areas
of the emergency department based on theoretical and practical preparation
combined with experience and qualifications (Figure 1.2) (Morphet et al., 2016b;
Morphet et al., 2017). As the acuity of the patient increases, so does the complexity of
critical thinking and clinical skills required of emergency nurses to deliver patient care.
Hence, the expected attributes of nurses who graduate with post-registration
qualifications in emergency nursing need to be defined. Equally, the educational
preparation of nurses to safely and adequately care for patients in these clinical areas
is an important consideration.
Figure 1.2 Progression of clinical areas through the emergency department Adapted from: Morphet et al. (2017, p. 1973)
1.2.4. Standards and Governance for emergency nursing education
In Australia, the Australian Health Practitioner Regulation Agency (AHPRA) is the
professional regulating agency for nurses and works with the Nursing and Midwifery
Board Australia (NMBA), who establish the professional standards, guidelines and
codes of practice that inform the minimum requirements for the registration of nurses
and midwives (Australian Health Practitioner Registration Agency, 2017). The NMBA
influences the attributes, competencies, and effectively the curriculum of pre-
Minor illness/injury
Lowest patient acuity
Moderate illness/ injury
Patients with increased complexity
Critical illness/ injury
Complex patients
Triage
Expediently assess and prioritse all
patients
9
registration nursing courses, to reflect the registration requirements of nurses. Nurses
who complete graduate programs in emergency nursing must continue to practice
within the NMBA standards as is required by all nurses registered with the AHPRA,
however there are no specific standards that reflect the increase in clinical care
capabilities (Nursing and Midwifery Board Australia, 2016b) .
Since the integration of nurse education in the tertiary sector, there has been a
proliferation of postgraduate and specialist nursing courses. The Australian
Qualifications Framework (AQF) was introduced in 1995 and is the policy used to
inform the development of regulated qualifications guiding learning outcomes and
duration of study. The second edition of the AQF (2011) brought about greater clarity
and consistency for each level, enabling international comparability and transferability
of qualifications. There are 14 qualification types across 10 taxonomic levels that span
across the secondary, vocational and tertiary education sectors in Australia. The
learning outcomes for each of the levels guides the expected knowledge, skills and
application of learning. Graduate certificates and graduate diplomas are delivered at
an AQF level 8, whilst masters qualifications are delivered at AQF level 9. This
framework provides guidance for graduate emergency education providers; however,
the specialist knowledge, skills and application are open to individual interpretation
(Australian Qualifications Framework Council, 2013b).
The Tertiary Education Quality and Standards Agency (TEQSA) independently
regulates the quality of Australian higher education, providing standards that promote
student needs whilst minimising risk. The Higher Education Standards (HES)
Framework (2015) are standards that higher education providers must meet. The
seven domains in the HES Framework include student participation and attainment;
learning environments; teaching; research and research training; institutional quality
assurance; governance and accountability and representation; and information and
information management. All domains must be applied when developing graduate
programs and are reviewed every seven years (Tertiary Education Quality and
Standards Agency, 2015) .
The Australian Nursing & Midwifery Accreditation Council (ANMAC) is the
independent body responsible for developing accreditation standards and ensuring
10
that nursing and midwifery education providers meet these standards when delivering
their programs. The ANMAC standards must be met by nursing and midwifery
education providers where nursing and midwifery registration is required on
completion of enrolled nurse, registered nurse, registered midwife and nurse
practitioner education programs (Australian Nursing and Midwifery Accreditation
Council, 2014, 2015, 2017, 2019). Specialist emergency nurses do not require
additional registration beyond general nursing registration. Thus, ANMAC does not
have a role in the overview and accreditation of specialist emergency nursing
programs and graduate attributes.
Whilst all of the above mentioned governing and regulatory bodies (excluding
ANMAC) might indirectly influence graduate emergency nursing programs, be it
standards for registration (NMBA), policies for course development (AQF) or standards
to regulate the higher education sector (TEQSA), none of these bodies directly
influences the attributes and minimum practice standards required for graduate
emergency nursing specialist education. The NMBA has determined that the
regulation of nursing specialties is a matter for the specialist nursing colleges
themselves (Nursing and Midwifery Board Australia, 2016a).
1.2.5. Funding for education in Australian tertiary graduate programs
The cost of tertiary education is considerable and is reported to be an inhibiting
factor for students considering graduate nursing education (Ng et al., 2016) . This
concern is not isolated to Australian graduate studies, but experienced in developed
countries such as the United Kingdom and United States of America (Evans &
Donnelly, 2018; Norton & Cherastidtham, 2015). The cost of graduate studies extends
beyond course fees, particularly if travel costs are involved in attending classes.
Commonwealth-Supported Places (CSP) is an Australian Government initiative
that reduces the fees for domestic students. Essentially the Australian Government
contributes money to selected courses and students are required to pay the
outstanding amount. The allocation process for CSP funded programs in graduate
education is not clearly advertised and reasons for restricted places are not disclosed.
In Australia fee help schemes are available for graduate study that essentially act as a
11
deferred student loan with a reduced interest rate (Norton & Cherastidtham, 2015).
Scholarships are another source of funding to facilitate education; however, they are
limited, can be university-dependent, and the criteria for selection can encourage or
inhibit applications (Darcy Associates, 2015). With projected shortfalls in the nursing
workforce, and in particular the emergency nursing workforce (Health Workforce
Australia, 2014), strategies to engage and support nurses to enhance their education
and ultimately the delivery of patient care are essential.
1.2.6. Workforce influencing patient safety
Nursing is the largest health profession in Australia and continues to have
projected workforce shortages. It is proposed that by 2030 there will be a shortfall of
123,000 nurses, with a projected undersupply of 10,500 critical care and emergency
sector nurses for this same period (Health Workforce Australia, 2014). Emergency
department staffing requirements are not mandated by the Commonwealth and thus
each state may determine their own needs. The Victorian Government has led the
mandating of nursing and midwifery ratios through the Safer Patient Care Act (2015)
(Victorian Government, 2015), with recent amendments improving the safety of
patient care in the ED occurring in 2019 (Victorian Government, 2019). This Act
requires EDs to have one nurse staffed for every resuscitation bed in addition to one
nurse for every three beds in the ED, and stipulates the minimum triage nurse and in-
charge requirements based on the ED size. Nurses working in triage, resuscitation and
in-charge require additional education to underpin their delivery of care, as these
clinical areas have advanced care needs informed by critical decision-making and
evidence-based prioritisation. Nurses working in these high acuity areas act as an early
alarm, managing and escalating the care needs of patients that are potentially life-
saving (Noon, 2014). However, despite increased education requirements of staff
working in these areas, it has been reported that only one third of emergency nurses
have graduate qualifications in emergency nursing (Morphet et al., 2016a). Specialist
education in emergency nursing contributes to the skilled workforce and is essential to
achieve the National Safety and Quality in Healthcare Service (NSQHS) Standards,
ultimately improving patient care (Australian Commission on Safety and Quality in
Health Care, 2017; Callander & Schofield, 2011; Cotterill-Walker, 2012; Cross,
12
Morphet, & Miller, 2018; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti,
2005).
1.3. Gap in knowledge
Graduate education, historically referred to as postgraduate education, is
tertiary education that is beyond a Bachelor qualification. These programs are
delivered at an AQF Level 8 (graduate certificate and diploma) and Level 9 (masters)
(Australian Qualifications Framework Council, 2013a). Graduate education in
emergency nursing was established to facilitate theoretical knowledge, clinical skills
and proficient clinical practice (Baxter & Evardsson, 2018; Fry et al., 2019; Gerard,
Kazer, Babington, & Quell, 2014; Gill, Leslie, Grech, & Latour, 2015; Lyneham et al.,
2008a; Walker-Cillo & Harding, 2013). Emergency nurses need specialist graduate
education to safely care for patients, particularly high acuity areas such as
resuscitation, trauma and triage. As the acuity of the patient increases, so does the
complexity of critical thinking and clinical skills required of emergency nurses to
deliver safe patient care. Emergency nurses undertake graduate education to enhance
their knowledge, critical thinking and clinical decision-making skills in the emergency
care environment, particularly when caring for the critically unwell patient (Baxter &
Evardsson, 2018; Morphet et al.,2016b; Morphet et al., 2017). The educational
preparation of nurses to safely and adequately care for patients in these clinical areas
is an important consideration. However, the expected attributes of nurses who
complete graduate studies in emergency nursing education and their clinical care
capability is unknown. There are currently no minimum practice standards for
Australian graduate emergency nursing programs. This thesis intends to address this.
1.4. Thesis aim and research questions
The aim of this exploratory, sequential mixed-methods study was to establish
minimum practice standards for Australian graduate emergency nursing programs.
Three research questions underpin this research aim, as follows:
13
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)
1.5. Significance of this study
The clinical stability of patients, number of patient presentations and available
bed access can vary for any given shift. These fluctuations impact the skill mix and
nursing staff required on each shift, and consequently the educational preparedness
that is required of the ED nursing team to deliver safe, effective and timely patient
care in uncertain conditions (Cowley-Evans, 2012; Fair Work Australia, 2012; Morphet
et al., 2015; Valdez, 2009).
The projected shortfall of 10,500 critical care and emergency sector nurses in
Australia by 2030 is concerning (Health Workforce Australia, 2014) . The expected
level of education and qualifications for these emergency nurses is unclear, and thus
the effects of this shortfall may be greater than anticipated if there is a protracted
process for further education. Defining the expected graduate attributes of
emergency programs is an important process in achieving widespread understanding
of individual knowledge, clinical capabilities, and expected clinical practice outcomes
enabling consistent expectations, safe practice and better patient care (Gill et al.,
2012).
1.6. Position of the thesis author
I have worked in the emergency department as a nurse for over 15 years. This
thesis was driven by my experience as an emergency nurse educator and my role with
the recruitment of nurses to the emergency department who held a graduate
qualification with emergency nursing specialisation. Qualifications generate
expectations, however those expectations are often influenced by the clinical practice
14
environment and experience with individual tertiary providers, instead of familiarity
with specific graduate attributes from education providers. I have repeatedly
observed assumptions of staff capabilities based on qualification lead to unsafe
practice and potentially contribute to adverse patient outcomes. Conversely, I have
observed staff with graduate qualifications not being recognised for their prior
learning, knowledge and qualification.
Additionally, I have worked in international emergency departments, mostly low-
income countries, where post-registration emergency nursing education is not a
tertiary qualification, and in some countries where it does not exist. Education of
nurses working in emergency care environments is often informal and not
transferable. I would love to be able to support the establishment of graduate-level
emergency nursing programs internationally, but to provide this level of support and
guidance I need to better understand graduate emergency nursing education in
Australia, and establish practice standards for graduate emergency nursing education
for the Australian context. The research process in addition to the research outcome
may provide a useful platform to review international graduate emergency nursing
education.
1.7. Summary and overview of the thesis
An overview of emergency care, emergency nursing and emergency nursing
education has been presented in this chapter. Emerging from this discussion is the
significant impact the projected workforce shortages of emergency nurses could
potentially have on the quality and safety of patient care. The exploration in this
chapter highlighted that to support the delivery of quality and safe patient care,
emergency nursing education at the graduate level requires clarification and practice
outcomes to facilitate the appropriate development and delivery of programs to meet
the needs of patients and the workforce.
This thesis consists of seven chapters. Chapter One has presented the context of
this study. The emergency care environment, in particular the emergency department
has been explained. Emergency nursing and the educational requirements for
15
emergency nurses to safely care for their patients have been described. The barriers
to graduate education and emergency nursing workforce concerns have been
outlined. The evidence gap, significance of the research and research aims have been
presented.
Chapter Two includes the first publication embedded in this thesis. This
publication is an integrative literature review that examined the Australian and
international practice and competency standards for emergency nurses (Jones,
Shaban, & Creedy, 2015) . An updated review of the literature was conducted, to
identify any additional or updated international practice or competency standards for
emergency nurses. Literature exploring practice standard development for Australian
nursing specialties was also reviewed and summarised.
Chapter Three describes and justifies the exploratory sequential mixed-methods
design, the theoretical stance of pragmatism, and the methods and research tools
used in the context of this study. The ethical considerations are also presented in this
chapter.
The results of this study are presented in Chapter Four and Chapter Five. The
academic and professional characteristics of graduate emergency nursing programs
are presented in Chapter Four, Publication 2 (Jones, Curtis, & Shaban, 2020a). The
verbatim manuscript submitted for Publication 3 is located in Chapter Five. This is a
summary of outcomes from Study Three which examined the practice expectations of
Australian graduate emergency nursing programs (Jones, Curtis, & Shaban, 2020b).
Chapter Six presents the minimum practice standards for graduate emergency
nursing programs. This discussion chapter provides an explanation of the results from
this exploratory sequential study relevant to the literature. The methodological
reflections from this body of research are also described.
The final chapter of this thesis, Chapter Seven, concludes this study and
contains recommendations for practice and future research.
16
Chapter 2. Literature Review
2.1. Introduction
In this chapter the available literature relating to practice and competency
standards for emergency nursing is critically reviewed. The guiding questions for this
literature review are presented, followed by a summary of the integrative review. The
integrative review was published in the peer-reviewed Australasian Emergency
Nursing Journal in 2015 and is embedded in this chapter. An updated review of the
literature is presented, and analyses new and updated international practice and
competency standards for emergency nursing. Following the integrative review,
approaches to specialist nursing practice standard development in Australia are
discussed.
The aim of this review was to identify and synthesise the available evidence
surrounding graduate emergency nursing program practice standards. The research
questions that guided this review were:
1. What professional practice and competency standards for emergency nursing
exist globally?
2. What are the similarities and differences between international emergency
nursing practice and competency standards?
3. What academic and professional characteristics of Australian graduate emergency
nursing programs are evident in the literature?
4. What professional practice standards underpin graduate emergency nursing
programs across Australia?
5. What methods have been used to establish practice standards for nursing
specialities in Australia?
2.2. Literature review overview
The integrative review presents the findings of Study One. The purpose of the
integrative literature review was to determine what contributions have been made to
17
international practice standards in emergency nursing. This work involved a
comparative analysis of international emergency nursing practice and competency
standards, and examined how these standards apply to expected attributes of a
professional on completion of graduate studies in emergency nursing. Whilst a
systematic approach was applied to the literature search, there were very few peer-
reviewed publications that answered the literature review questions. Subsequent
searching of grey literature, including international emergency association websites
and publications linked to their associations, was conducted. This integrative review
enabled the context of the broader issue to be explored in the absence of published
literature (Green, Johnson, & Adams, 2006). A structured and consistent approach was
used to review each of the documents and is described in the embedded publication.
The methods and findings from this integrative review are presented and discussed.
Academic and professional characteristics of Australian graduate emergency
nursing programs have not been published, nor are there published standards for
Australian graduate emergency nursing programs. Practice and competency standard
development in nursing has occurred for many specialities in Australia. These
standards have contributed to the articulation of expectations and practice
requirements of nurses working in these specialties. The body of evidence and
understanding regarding approaches to practice standard development are explored
and inform the methods chosen to complete this research and answer the research
questions for Study Two and Study Three.
2.3. Publication 1: Practice standards for emergency nursing: An
international review
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
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(Australian Institute of Health and Welfare, 2014; Bolin, Peck, Moore, & Ward-Smith, 2011; Castner et al., 2013; Critical Appraisal
Skills Program, 2013; Currie & Crouch, 2008; Curtis & Wiseman, 2008; Davidson, Bloomberg, & Burnell, 2007; Dick, 2003; Dimond,
1995; Eatlock, Clarke, Picton, & Young, 2015; Emergency Nurses Association, 2008, 2011; L. Evans & Kohl, 2014; Fitzpatrick,
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
requires membership
NENA members
Standards aimed for: Emergency nurses Emergency Nurses Emergency nurses, examined at
three levels of assessment –
associate, member and fellow
Emergency nurses
35
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
(Australian Nursing & Midwifery Federation, 2016).
The National Nursing and Nursing Education Taskforce (N3ET) identified 18
nursing and midwifery specialties in their National Specialisation Framework for
Nursing and Midwifery Report (2006) (National Nursing & Nursing Education
Taskforce, 2006). Since this publication, the Chief Nursing and Midwifery Office in
Western Australian have reported 29 areas of nursing specialty (Chief Nursing and
Midwifery Office, 2020). Table 2.3 presents the specialty areas identified in these two
reports.
Table 2.3 Specialty areas of nursing & midwifery in Australia
Burns Medical nursing Palliative care
Cardiology Health Care Planning &
Management
Paediatric care
Community Health Infection control Perioperative
Continence Intensive care Plastic surgery
Critical Care Management Rehabilitation
40
Diabetes education Mental health Remote area nursing
Dialysis Midwifery Renal care
Education Neonatal intensive care Research
Emergency Neurological Rural nursing
Family Health Nurse practitioner School nurse
Gastroenterology Occupational health Surgical nursing
Gerontology / aged care Oncology / Haematology Wound management
(Chief Nursing and Midwifery Office, 2020; National Nursing & Nursing Education Taskforce, 2006)
Practice or competency standards are located on the websites of Australian
specialist nursing professional bodies for 22 nursing specialties (Aranda & Yates, 2009;
Australasian Rehabilitation Nurses' Association, 2004; Australian College of Children
and Young People's Nurses, 2016; Australian College of Cosmetic Surgery, 2015;
Australian College of Critical Care Nurses, 2015; Australian College of Neonatal Nurses,
2019; Australian College of Perioperative Nurses, 2020; Australian Commision on
Safety and Quality in Health Care, 2018; Australian Diabetes Educators Association,
2017; College of Emergency Nursing Australasia, 2014; Continence Nurses Society
Australia, 2017; CRANAplus, 2016; Grant, Mitchell, & Cutherbertson, 2017; Halcomb,
Stephens, Bryce, Foley, & Ashley, 2017; Neville et al., 2010; Nursing and Midwifery
Board Australia, 2014, 2018; Palliative Care Australia, 2018; The Australian Nurse
Teachers' Society, 2010; Ward, 2012; White et al., 2018; Wounds Australia, 2016).
However, there is limited published evidence on how these specialist standards have
been developed. Review of literature (Australian College of Mental Health Nurses,
2018; Cashin et al., 2015; Cashin et al., 2017; Gill, Leslie, Grech, Boldy, & Latour, 2015;
Nagle et al., 2019; Ostaszkiewicz, Thompson, & Watt, 2019), qualitative consultation
with key stakeholders (Cashin et al., 2015; Cashin et al., 2017; Gill et al., 2015;
Halcomb et al., 2017), observation (Cashin et al., 2017), and survey (Australian College
of Mental Health Nurses, 2018; Cashin et al., 2017; Gill et al., 2015; Halcomb et al.,
2017) are processes researchers have applied when developing specialty nursing
practice standards in Australia.
Despite there being a paucity of published research regarding the development
of Australian nursing specialty practice and competency standards, publications from
41
the AusDACE study provide a clear guide to practice standard development for
graduates of Australian critical care education (Gill, Leslie, Grech, Boldy, & Latour,
2014; Gill et al., 2015; Gill et al., 2012; Gill, Leslie, Grech, & Latour, 2013b). This
rigorous and evidence-based mixed-methods research used review of the literature
(Gill et al., 2012), interviews and focus groups to engage and consult with key
stakeholders including course convenors and consumers (Gill, Leslie, Grech, & Latour,
2013a; Gill et al., 2015) and a three round Delphi survey (Gill et al., 2013b). The
authors integrated findings generated the SPECT tool (Gill et al., 2014) and practice
outcomes for graduate critical care nurses (Gill et al., 2015). Similar methods should
be considered in the development of Australian practice standards for graduate
emergency nursing programs.
2.6. Summary
A comprehensive review of the literature relating to international emergency
nursing practice and competency standards has been presented in this chapter. As
identified above, six international emergency nursing bodies have developed practice
or competency standards relevant to emergency nursing in their country of practice.
Across the six sets of standards consistent similarities were identified in all nine
domains: (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.
Published literature relating to specialty nursing practice standard development
in Australia is limited. Reported findings present multiple methods such as literature
review, consultation with key stakeholders, observation, and survey. Practice
standards for graduate critical care nurse education have been published, however
practice standards for graduate emergency nursing programs do not exist. This
identified gap demonstrates the need for further research and practice standard
development. The following chapter presents the methodology and methods used in
this research.
42
Chapter 3. Methodology and Methods
3.1. Introduction
This chapter describes an overview of the methodology and methods used to
address the research questions for this mixed-methods study. It describes the
philosophical assumption of pragmatism, and how this informs the approach and
development of this body of research. Exploratory sequential mixed-methods design is
explained, and the three methods used to explore the minimum practice standards for
emergency nursing graduates are justified and discussed, namely document analysis,
key informant interviews, and Delphi.
3.2. Philosophical paradigm: Pragmatism
The worldview that researchers assume can influence the way in which research
is conducted. Purists will view research from their own ontological and
epistemological beliefs, which inform the methods used to answer their research
question. Historically researchers who come from a positivist grand theory employ
quantitative approaches to their research question. They believe that research should
be conducted objectively and free from judgement or influence by the researcher
(Teddlie & Tashakkori, 2009) whereas those who view research with an interpretivist
or critical inquiry worldview will utilise qualitative methods and see the researcher as
an integral part of the research process (Morgan, 2007) .
It is often argued that the qualitative and quantitative research are distinct and
discrete methods and that the paradigms that guide the selection of methods do not
interconnect. Mixed-methods research challenges this philosophy, whereby rather
than ontological and epistemological assumptions, it is the research question that
guides the approach to the research and the appropriate selection of methods (Biesta,
2015; Creswell & Plano Clark, 2011; Morgan, 2007; Teddlie & Tashakkori, 2009).
Pragmatism has long been ingrained in theory with Charles Pierce, William
James and John Dewey being considered pioneers for the development and
43
understanding of this philosophical approach. Through triangulation of opposing views
and processes in qualitative and quantitative research, each method is accepted and
recognised for their own merit (Biesta, 2015; Bishop, 2015; Creswell & Plano Clark,
2011; Glogowska, 2010; Hall, 2013; Morgan, 2007; Teddlie & Tashakkori, 2009).
Pragmatism is problem-centred, works within the real world and current issues, and is
based on fact whilst considering the influences of the natural world of human subjects
(Creswell & Plano Clark, 2011; Morgan, 2007; Teddlie & Tashakkori, 2009).
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
Australian graduate emergency nursing
programs?
Phase 1: Data collection & Analysis:
Document Analysis of Australian University
websites and their graduate emergency
nursing programs
Phase 2: Data Collection & Analysis:
Key Informant interviewswith graduate emergency nursing course convenors
Study 3
quant
Research Question: What professional practice standards should underpin
graduate emergency nursing
programs/courses across Australia?
Data Collection & Analysis:
Two round Delphi to determine attributes and
clinical practice expectations for
graduate emergency nursing program
graduates
Integration
Integration & synthesis
of
ALL data to establish minimum practice
standards for Australian graduate
emergency nursing
programs
49
and risk mitigation related to the individual studies for this research are explained
later in this chapter.
3.6.1. Research merit and integrity
Research merit and integrity is required to ensure that there is benefit from the
research being conducted. For this to be achieved the research study needs to be
based on the current evidence, be developed using sound and appropriate methods
that are respectful of participants, involve a team with appropriate experience and
qualifications, and disseminate findings appropriately (NHMRC, 2018).
3.6.2. Justice
Justice in research is maintained by ensuring that there is an appropriate
selection of participants who do not experience inappropriate burden and that
benefits are distributed fairly. The outcomes from the research should be readily
available to participants in a timely way (NHMRC, 2018).
3.6.3. Beneficence
During research the benefits of the research should exceed any potential risks
that participants may experience. The research project must be conducted in a way
that minimises potential risks and communicates them clearly to participants. In the
event that the research is found to be causing more harm than possible benefit, then
it needs to be paused to ensure its careful consideration and whether discontinuation
or modification of the project are necessary (NHMRC, 2018).
3.6.4. Respect
The contribution of research participants is invaluable. It is their participation
that facilitates the investigation and understanding of posed questions in research and
this must be respected by maintaining the above values of merit and integrity, justice
and beneficence. Additionally, privacy, confidentiality, autonomy and cultural safety
must be preserved (NHMRC, 2018).
50
3.7. Study 1: Comparative analysis of emergency nursing practice standards
An integrative review of the international literature on practice and competency
standards for the graduate emergency nurse was conducted and has been presented
in the review of the literature, Section 2.3. This paper “presents a comparative
analysis of available international practice and competency standards for the
emergency nurse” (Jones et al., 2015, p. 192). Findings of the initial review identified
five domains of similarity in the analysed standards, including: (i) clinical expertise; (ii)
communication; (iii) teamwork; (iv) resources and environment; and (v) legal (Jones et
al., 2015). The updated literature established that there are nine domains of similarity
with the addition of leadership, research and quality, professional ethics and
professional development. The CENA Practice Standards for the Emergency Nursing
Specialist are a suitable framework to inform the development of graduate emergency
nursing standards (College of Emergency Nursing Australasia, 2014), but they have
been developed for the expert emergency nurse. This study demonstrated that
“further research is required to determine the expected practice standards and
outcomes of the graduate emergency nurse to govern clinical practice and safe patient
care” (Jones et al., 2015, p. 201).
3.8. Study 2: Analysis of Australian graduate-level emergency nursing
programs
Researchers use qualitative data collection and analysis methods when they
want to understand and explore the meaning of the research question, and are
actively involved in the research process (Ochieng, 2009; Schneider, Whitehead,
LoBiondo-Wood, & Haber, 2016). The techniques used for data collection and data
analysis vary depending on the philosophical assumptions, aim of the research and
research questions. Quantitative data collection and analysis approaches are used
when the researcher wants to objectively quantify answers to the research problem.
Study Two was an embedded, sequential mixed-methods study, using elements of
both quantitative and qualitative research methods. There were two discrete methods
of data collection for this study, with Phase 1 (document analysis) informing the
51
development of Phase 2 (key informant interviews).
The purpose of this study was to characterise graduate emergency nursing
programs in Australia and to subsequently inform the development of questions for
the quantitative phase in Study Three, a two-round Delphi. It was important to
identify what information was publicly disseminated to consumers via web, and then
contextualise this further and generate meaning by conducting key informant
interviews. The findings from both phases were integrated, which enabled
characterisation of Australian graduate emergency nursing programs. The section
below will provide a detailed description of the data collection methods and analysis
approaches used to complete Study Two. Ethics approval was gained for Study Two
from Griffith University Human Research Ethics Committee (GU: 2017/292) (Appendix
1).
3.8.1. Phase 1: Document Analysis
The purpose of the document analysis was to determine what was known in the
public domain about graduate emergency nursing programs in the tertiary education
setting. The sections below present the justification for the document analysis, sample
strategy, ethical considerations, data collection and analysis approaches.
3.8.1.1. Justification of method
Tertiary education providers primarily disseminate information relating to their
potential courses through various platforms, including face-to-face discussions,
leaflets and websites. The accessibility of web-based material makes this platform
preferable and easier for consumers to use (Mackavey & Cron, 2019; Maringe, 2006),
as time and location are not an issue. Thus the information displayed by universities
on their website is important as it communicates with consumers about their
programs and can influence students’ decision of whether they will study at that
particular tertiary institution (Szekeres, 2010). Details relating to graduate emergency
nursing programs, in particular learning outcomes, assessments, clinical practice
requirements, fees, and mode of learning, are ideally available for students and other
stakeholders to facilitate informed decision-making and questions relating to tertiary
programs (Mackavey & Cron, 2019; Szekeres, 2010).
52
The researcher wanted to explore what was publicly known regarding graduate
programs in emergency nursing. Systematically reviewing and analysing ‘background
material’ (Silverman, 2011) from university websites established a greater
understanding and generated knowledge of graduate emergency nursing programs,
and thus informed the development of the interview questions (Bowen, 2009). The
order for document analysis does vary depending on the research questions. For this
embedded mixed-method study, document analysis was the first point of data
collection; however it often occurs after an initial research phase to triangulate the
data that has been analysed (Bowen, 2009).
The advantages of document analysis are well reported. This method is less
time-consuming as the documents are readily available and not dependent on
participant involvement. It is unobtrusive as participants are not needed, and the
reduction in time and consumables reduces costs associated with research (Bowen,
2009).
Its limitations are also evident. Documents are produced for a purpose that is
not related to the research, and thus information is not always present or is
insufficient in detail. The information publicly presented on the university websites
was unable to be sourced through other avenues. Insufficient detail or incomplete
documentation can suggest biased selection, as organisations publish what they want
consumers to know, but it is also reflective of their marketing teams (Maringe, 2006).
The answer to these questions cannot be determined without passing judgement
(Bowen, 2009). Additionally, the information on websites needs to be updated
regularly, and thus the information is potentially out of date. Therefore, timing the
document analysis prior to interviews enabled the researcher to clarify, confirm and
expand on this in the next phase of data collection (Bowen, 2009).
3.8.1.2. Ethical considerations
As stated in Section 3.6 low-risk ethics approval from Griffith University Human
Research Ethics Committee (GU: 2017/292) was received for Study Two (Appendix 1).
Consent to access and critique publicly available information from individual
universities was not required as this information was openly accessible to all with
53
internet capabilities. De-identified material was analysed, and anonymity was
maintained.
3.8.1.3. Population
All Australian national graduate emergency nursing programs were identified
using the Council of Deans of Nursing and Midwifery (Australia & New Zealand) (2017)
website, which lists Bachelor of Nursing and Midwifery education providers in
Australia and New Zealand. The Australian Education Network (2015) website was also
used as this site provides a record of all tertiary education providers in Australia. The
inclusion criteria for Study Two were generated in consideration of the research aim
and question (Schneider et al., 2016).
The inclusion criteria for this study were:
• Australian tertiary education provider
• Delivered at least one graduate emergency specialisation unit aimed to prepare
the student to care for patients in the emergency department
The exclusion criteria were:
• Where qualifications did not demonstrate a clear unit of specialisation for
emergency nursing.
• Non-tertiary education providers, such as Registered Training Organisations
(RTOs). This was to ensure that the qualifications being examined were delivered
by the same type of educational body and therefore subject to the same
regulations.
Manual exploration of university websites identified from the Council of Deans
(Australia and New Zealand) and the Australian Education Network found 36 bachelor
of nursing (BN) programs being delivered at the time of data collection. Each of these
nursing and midwifery websites were then examined to identify graduate nursing
programs. The inclusion and exclusion criteria were applied and revealed that at the
time of data collection (June – September 2017) there were 16 universities that
delivered graduate programs that resulted in emergency nursing specialist
qualifications.
54
3.8.1.4. Data collection
Prior to the sample being identified, a data collection template was developed
(Appendix 2). This template was a series of questions centred around eight categories
for program characterisation, and was developed based on the research question and
experience of the research team. The categories were: (i) demographics, (ii) course
enrolment, (iii) fee arrangements, (iv) graduate outcomes, (v) course content, (vi)
course delivery, (vii) assessments and (viii) clinical practice requirements. It was
important that the same questions were asked of the data for consistency. Once the
sample was determined the template was piloted on three university websites. This
allowed for the identification of any additional questions not identified during the
initial development (Bowen, 2009). No modifications were required following the pilot
phase, however the category of ‘other’ was made available in the data collection tool
should any information retrieved from the websites be considered potentially
important yet not answer a specific question within the collection tool.
The template for data collection was applied to all 16 universities and entered
into a Microsoft Excel TM spreadsheet under each of the questions. On completion of
the data entry the responses were read in their entirety to ensure there were no
transcription errors. Scheduling of university website updates is not date-dependent,
and thus it was important that data was true and correct at the time of collection, as
revisiting the website at a later stage may reveal different data. Data was true and
correct for September 2017.
3.8.1.5. Data analysis – Content Analysis
Data analysis was an iterative process where documents were read, re-read,
interpreted and analysed using directed content analysis (Bowen, 2009; Hsieh &
Shannon, 2005). The data collection template served as a pre-determined coding
framework as specific data was extracted into established categories. Frequencies for
each question were determined and gaps where data was not available were
identified. When interpreting the organised content, the researcher considered the
subjectivity of the bias from website authors. During this deductive process the
researcher mapped data directly linked to the research question, whilst also looking
55
for patterns within the data for meaning and to inform questions for the key
informant interviews (Hsieh & Shannon, 2005) .
Whilst it is argued that this deductive content analysis reduces the richness of
the data, it is appropriate where specific detailed analysis is required. There was a
unidirectional relationship between the data and what was presented on the
websites, and discourse analysis was not required. No inherent bias was observed
(Bowen, 2009; Hsieh & Shannon, 2005). On completion, all analysed data were
reviewed by the research team, and the questions applied to the document analysis
were revised for the key informant interviews.
3.8.2. Phase 2: Semi-structured interviews with key informants
The purpose of these in-depth interviews was to further understand the findings
from the document analysis, to provide additional context and to contribute data
where absent or unclear information was identified in phase one (Schneider et al.,
2016). The sections below present the justification of method, population and
recruitment strategy, ethical considerations, data collection and analysis approaches.
3.8.2.1 Justification of method
Interviews are widely used in qualitative research as they explore and gain
deeper understanding and insight of the research questions (Doody & Noonan, 2013;
Rowley, 2012; Schneider et al., 2016). Data from the document analysis indicated a
number of areas within the graduate emergency nursing programs that required
further investigation. Exploration of document analysis outcomes with the key
informants minimised bias as the researcher was not making judgement on findings
that may have been unclear, whilst providing more depth and meaning to the
document analysis results (Doody & Noonan, 2013; Taylor & Francis, 2013).
Participants were termed key informants, as they were identified as individuals who
had significant knowledge and insight in graduate emergency nursing programs and
held a role within the university that was reflective of this (Taylor & Francis, 2013).
Semi-structured interviews were used as they provided both structure and
freedom for the researcher. The structure of the interview guide ensured that the
56
aims of the research question were addressed and that consistency was achieved with
each key informant interview. The open-ended format of these questions provided a
guide and therefore the researcher had freedom to explore issues and areas within
the dialogue that were spontaneously identified (Doody & Noonan, 2013).
A limitation of the semi-structured interview is that novice researchers may not
identify areas to explore during the interview and for the most part remain true to the
interview guide. This limits the interviews’ scope and intention, and thus depth and
richness of the data may be reduced (Doody & Noonan, 2013; Rowley, 2012).
3.8.2.2 Ethical considerations
As stated in Section 3.6, low-risk ethics approval from Griffith University Human
Research Ethics Committee (GU: 2017/292) was received (Appendix 1). Approval was
obtained from the respective university heads of schools for nursing and midwifery to
contact convenors of graduate emergency nursing programs within the tertiary
institution, or an appropriately appointed person. All participants were provided with
a participant information consent form (PICF) and questions answered as required
(Appendix 3). Participants were aware that there was no perceived harm or
discomfort for this study, and they were free to withdraw from the research at any
stage. Written or verbal consent was obtained prior to interviews. If verbal consent
was provided, this was recorded and transcribed. De-identified data were analysed
and anonymity of universities and participants was maintained.
3.8.2.3 Population and recruitment
Section 3.8.1.3 explains the identification process for the document analysis and
these universities were contacted for phase two of data collection. Heads of schools of
nursing and midwifery in addition to key informants were identified from university
websites. Individual emails were sent to heads of school for nursing and midwifery at
each university (n=16) identified in the document analysis. This purpose of this email
was to request permission to contact the coordinator of their graduate emergency
nursing program, or a member of staff they believed to be appropriate. Repeat emails
were sent to heads of school one month after the initial email if correspondence had
not been received. Replies were received from all heads of school (n=15) and an
57
executive assistant (n=1). Two universities declined involvement as their graduate
emergency nursing programs were no longer offered, and therefore they did not
believe their involvement in the study was relevant. A school approval process was
required by one tertiary institution, however despite follow up emails, ongoing
correspondence ceased and thus it was considered that permission was not granted
(Schneider et al., 2016).
Key informants, as confirmed by heads of school, were emailed (n=13) and the
recruitment and data collection process took 10 months. This lengthy duration was
attributable to illness, leave and staff workloads, hence leading to the postponing of
interviews. Additionally, two key informants declined to participate as they did not
believe they were in an appropriate position to provide accurate responses, therefore
new key informants needed to be determined and approved by the corresponding
head of school.
3.8.2.4 Data collection
Interviews were conducted by the researcher and guided by 22 open-ended
questions (Appendix 4). They were carried out via telephone as participants were
geographically dispersed across all states of Australia. The researcher explained the
interview process to participants prior to the commencement of the interview, which
included the purpose of the interview, the proposed duration of 30-45 minutes, and
confirmation that participants approved audio recording of the interview. It is believed
that discussing the steps with the participant as well as reaffirming confidentiality and
anonymity builds trust between the researcher and the interviewee (Doody &
Noonan, 2013) whilst adhering to ethical principles.
The researcher took notes throughout the interview. Despite some researchers
reporting that the taking of notes during interviews can be distracting for the
researcher as key ideas for deeper exploration are missed (Doody & Noonan, 2013;
Rowley, 2012), note-taking is considered an effective strategy for engagement and
building rapport with the participant, as well as seeking clarity about and
understanding of statements made throughout interviews (Schneider et al., 2016).
Interviews were transcribed and responses de-identified prior to data analysis.
58
3.8.2.5 Data Analysis – Framework Analysis
Framework analysis was initially developed for social research, however there
has been increasing use in the healthcare context (Gale, Heath, Cameron, Rashid, &
Redwood, 2013; Kiernan & Hill, 2018; Parkinson, Eatough, Holmes, Stapley, & Midgley,
2016; Smith & Firth, 2011; Ward, Furber, Tierney, & Swallow, 2013). Framework
analysis provides a systematic, rigorous and transparent approach to the analysis of
qualitative data by utilising five clear stages that support the researcher in the
organisation and analysis of data: familiarisation, developing a thematic framework,
indexing, charting, mapping, and interpretation (Figure 3.3). Whilst the researcher
progresses through each of the stages systematically, there is a reflexive component
whereby the researcher can move back and forth between the stages as new themes
and subthemes emerge (Hackett & Strickland, 2018; Kiernan & Hill, 2018; Ritchie &
Spencer, 1994). This reflexive and iterative process is made clear through a recorded
and transparent audit trail (Gale et al., 2013; Kiernan & Hill, 2018; Parkinson et al.,
2016; Smith & Firth, 2011; Ward et al., 2013).
Figure 3.3 Summary of 5 steps of Framework Analysis applied to Phase 2 (Johnson, Best, Beckley, Maxim, & Beeke, 2017)
Stage 1 - Familiarisation
This initial step of the analysis was important. It is here that the primary
investigator (PI) became familiar with the interviews and was immersed in the data. By
• Transcripts
• Audiotapes
1. Familiarsiation with data
• Descriptive themes and subthemes of data
2. Developing a thematic framework • Application of
thematic framework to transcripts
3.Indexing
• Extract data from transcripts
• Place quotes/evidence in matrix spreadsheet
4. Charting• Compare and
interrogate data
• Confirm themes
5. Mapping & Interpretation
59
listening to the interview recordings, reading the interview transcripts and studying
the interview notes, the PI became familiar with the whole data set, enabling the
identification of recurring themes and key ideas (Ritchie & Spencer, 1994; Ward et al.,
2013). The PI made notes in the margin of the transcript throughout this process and
thoughts, themes and recurring issues were recorded (Gale et al., 2013). Members of
the research team also immersed themselves in a selected sample of data and
provided their themes, thoughts and concerns. These notes were reviewed by the PI
for consideration.
Stage 2 - Developing a thematic framework
A thematic framework, which is also referred to as an index, was generated by
the PI, who reviewed and compared the themes, thoughts and concerns identified
during the familiarisation stage (Hackett & Strickland, 2018; Ritchie, Spencer, &
O'Connor, 2003). During this review the PI continually referred to the research aim
and the key topics from the interview guide. This maintained alignment to the original
research question whilst being transparent with the data analysis (Ritchie et al., 2003).
Subthemes that emerged were noted and informed the development of the initial
headings, and thus of the thematic framework (Braun & Clarke, 2006; Ritchie et al.,
2003). Within the initial themes, the heading ‘other’ was included; this was to ensure
that any data considered important was not overlooked, nor did the research team try
and ‘fit’ this data into a code where it did not implicitly align (thus the term indexing is
used as opposed to coding) (Parkinson et al., 2016; Ritchie et al., 2003). Once the
initial version of the thematic framework was developed it was applied to three
transcripts, which enabled refinement and conceptualisation of subthemes. Each
sentence was carefully read and notes were recorded to ensure the thought process
and analysis of the data by the PI was explicit (Hackett & Strickland, 2018; Kiernan &
Hill, 2018).
Stage 3 - Indexing
During the indexing stage the thematic framework that was piloted and revised
during stage two was systematically applied to all transcripts (Appendix 5). Qualitative
60
research encourages the subjective voice to be expressed, however to improve
trustworthiness the notes made by the PI ensured transparency of thinking was
evident (Ward et al., Gale et al., 2013; Ritchie et al., 2003; 2013). Transcripts were
indexed using the thematic framework and clearly recorded. In qualitative research,
judgements are made; however, because the PI collected the data and was immersed
in the data set, misconceptions were avoided because the PI was familiar with the
content. By applying the framework to all of the data, judgements and assumptions
are transparent (Hackett & Strickland, 2018; Ritchie et al., 2003).
Stage 4 - Charting
Volumes of interview transcripts were summarised, organised and ‘charted’
during this stage. The PI systematically went through each of the transcripts and
reviewed each of the assigned codes and the corresponding subtheme. Data was
abstracted and summarised by the PI and inserted into the matrix spreadsheet in
Microsoft Excel TM whilst retaining the language and context (Ritchie et al., 2003). All
text inserted into the matrix was annotated with the transcript line number to aid
location of data and maintain transparency of the audit trail (Gale et al., 2013; Ritchie
& Spencer, 1994).
Stage 5 - Mapping & Interpretation
This final stage involved the PI reviewing the whole data set. The PI referred to
the original aims and objectives of the study prior to reviewing the charted matrix.
When examining the matrix, the PI consulted notes and summaries within the matrix
to ensure the context and meaning were accurately captured. The PI completed this
process, with the collaboration of the research team to discuss the findings, provide
provoking questions and to unpack the PI’s thought process as connections between
the data were established (Parkinson et al., 2016; Ritchie et al., 2003). Patterns and
associations between the themes and subthemes were explored and interrogated,
and questions that arose were examined and discussed with the research team. This
step was important to characterise graduate emergency nursing education in Australia
and the influencing factors (Gale et al., 2013; Ritchie & Spencer, 1994). Themes and
61
sub-themes were compared and checked against original data sets to ensure that the
recording was accurate and contextual.
3.8.3. Integration of findings
The findings from Phase 1 were integrated with the findings from Phase 2. The
two phases of data collection and analysis were not compared against each other, but
were merged to understand and characterise Australian graduate emergency nursing
programs. It is recommended that when qualitative and quantitative data are merged,
yet remain thematically connected, a weaving approach for integration is used
(Fetters, Curry, & Creswell, 2013). The researchers moved through both data sets to
generate meaning from the data and answer the research question.
3.8.4. Data saturation
Data saturation is traditionally associated with grounded theory, referring to the
point where no new data is found and therefore no other data sources are required.
Data saturation is an important consideration; however its relevance and application
in theoretical interviews where predefined theory is known has been unclear (Francis
et al., 2010). As proposed by Francis et al. (2010), principles of data saturation do not
apply to these interviews, because the end point of sampling was directly linked to the
number of eligible participants. The researcher was not seeking to develop a theory
but understand the characteristics for Australian graduate emergency nursing
programs at the time of data collection (Francis et al., 2010; Schneider et al., 2016). It
was anticipated that variation would occur between participant responses, and this
variability was welcomed as it provided further evidence of inconsistencies between
programs and graduate attributes.
3.8.5. Trustworthiness
Trustworthiness was maintained by applying Lincoln and Guba’s (1985) criteria
of credibility, transferability, dependability and confirmability. Credibility was
established as key informants were experts and knowledgeable in the area of
graduate emergency nursing education. The informants voluntarily participated in the
interview, notes were made throughout the interview to aid with clarifying questions,
62
and results were member-checked. The use of both document analysis and key
informant interviews contributed to the triangulation of data, and all members of the
research team discussed and compared their findings (Curtin & Fossey, 2007; Guba,
1981; Lincoln & Guba, 1985).
Transferability was achieved through a national review of graduate emergency
nursing, with 13 out of 14 potential universities participating in the interviews and
thus the population is appropriately described. The findings reflect Australian
graduate emergency nursing programs across Australia, as presented in Chapter Four
(Schwandt, Lincoln, & Guba, 2007).
Dependability is achieved as the method is clearly detailed in this chapter and
could be repeated in future; thus, consistency was achieved. A clear record of the
document analysis and interview data has been maintained, and framework analysis
provided a detailed audit trail (Guba, 1981; Morse, 2015).
Confirmability is preserved as the researcher maintained an objective position
throughout the interviews and allowed the participants to freely speak. Data was
analysed by the primary researcher and reviewed by the research team to minimise
bias. Framework analysis provided a clear audit trail of analysis. Notes recorded and
questions that arose during the interviews have been kept as a reflexive record (Curtin
& Fossey, 2007; Guba, 1981; Morse, 2015).
3.9. Study 3: Stakeholder analysis of graduate emergency nursing practice
standards
3.9.1. Delphi
The Delphi technique was established in 1944 as a tool to forecast the use of
technology during warfare. Since inception it has evolved and been modified,
maintaining the premise that “group opinion is more valid than individual” (Keeney,
2011, p. 16). As a research method the Delphi technique has been adopted by various
disciplines and has gained recognition in nursing and health research (Asselin &
Harper, 2014), where it has commonly been used for priority setting and generation of
63
consensus (Keeney, 2011). The sections below present the justification of method,
sample and recruitment strategy, ethical consideration, data collection and analysis
approaches for the Delphi.
3.9.1.1. Justification of method
The Delphi is based on survey design that consists of two or more rounds of
data collection to systematically generate consensus amongst a selected panel of
experts (Cole, Donohoe, & Stellefson, 2013; Keeney, 2011). The Delphi differs from
traditional surveys as it is likened to a survey focus group instead of finding
generalisability among a defined population group in a single survey (Cole et al.,
2013). First, an assembled group of experts are given a series of questions on a topic
where there is limited information or agreement; data is analysed, feedback is
provided, and the expert panel review the questions derived from the feedback and
analysis over multiple rounds. This iterative process generates a consensus amongst
experts, as opposed to generalising findings from a single survey data set. Opposing
values can be incorporated, with feedback from participants determining the
consensus of such opinions (Cole et al., 2013; Donohoe, Stellefson, & Tennant, 2012;
Keeney, 2011). There is no absolute definition or guideline for how to implement a
Delphi, which is often a criticism of this process (Cole et al., 2013; Donohoe et al.,
2012; Keeney, 2011).
Enhancing technology, particularly the internet, has seen a shift from paper-
based Delphi studies to electronic ones (e-Delphi). A major strength of the e-Delphi is
it has an even greater capacity to reach expert panel members that are geographically
dispersed and increase the speed at which data is collected and subsequent phases
distributed (Donohoe et al., 2012). In the context of this mixed-method study,
generating a national consensus of an expert panel who are members of a
geographically dispersed profession is achievable through electronic distribution.
Figure 3.4 provides an overview of a two-round Delphi approach.
A strength of the e-Delphi is that it is inexpensive as there are minimal
consumable costs in its distribution. Expert panel members are not required to be
face-to-face and are able to complete the multiple Delphi rounds at their own
64
convenience. Subject bias is also minimised as strong opinions of participants or
strong personalities are not able to influence the data during this anonymous process,
as participants are not face-to-face (Asselin & Harper, 2014; Cole et al., 2013).
Anonymity is a benefit of surveys as it is thought that responders are more likely to
contribute opinions that are reflective of their thoughts, as they are free from
judgement or pressure (Keeney, 2011).
Figure 3.4 Two-round Delphi process Adapted from: Cole et al. (2013, p. 517)
Survey methodology is often considered challenging and the Delphi is exposed
to similar limitations. Response rates to the surveys can be low, and this is
experienced in Delphi as experts are required to respond to two or more rounds of
Research Question /
Problem
• Well defined research question
Establish Expert Panel
•Defined expert panel selection criteria
•Recruit potential participants/panel members
•Filter responses and identify participants
Delphi
Round one:
•Distribute round one survey link with instructions via email
•Collect round one responses
•Analyse responses and produce summary report
•Integrate responses into next round and develop round two survey
Delphi
Round Two
•Distribute round two survey link and circulate round one summary report by email
•Monitor attrition rate
•Analyse responses and assess convergence
•Terminate Delphi and prepare final report
Analysis and Final report
•Analysis of results
•Prepare Delphi results summary and final consensus statement
•Distribute final report
•Apply consensus judgement to initial problem
65
survey questions. Additionally, using electronic approaches for survey dissemination
may have challenges in reaching participants due to blocks in email accounts that may
terminate the email or send the email to their ‘junk’ or ‘spam’ box. The attrition of
each survey round in the Delphi, in particular the final round, is a criticism, and is why
many researchers now limit the number of rounds to three (Asselin & Harper, 2014;
Keeney, 2011). Keeping participants engaged by feeling like they are partners within
the study through the provision of feedback is also considered a strategy to address
this (Cole et al., 2013).
Another criticism of the Delphi is the notion of ‘expert panel’. It is proposed that
the absence of guidelines for the Delphi, and the breadth of what can be deemed an
expert, may result in the omission of consumer views or other opinions (Asselin &
Harper, 2014; Diamond et al., 2014). The size of the expert panel also lacks definition.
Although it is argued that a large panel size can improve reliability and reduce error,
what constitutes ‘large’ is not clearly stated. Clear inclusion and exclusion criteria that
are considered in direct consult with the research question and justified, however, can
minimise expert panel ambiguity (Diamond et al., 2014; Hasson & Keeney, 2011). The
inclusion criteria, stated below in Section 3.9.1.2, explain this in the context of this
study and justifies how the expert panel were determined.
3.9.1.2. Sample and recruitment
In order to establish minimum practice standards for graduates of emergency
nursing programs in Australia, a heterogeneous expert panel of emergency nurses was
desired. Convenience sampling was used for this study as a specific cohort of
participants was required to form the expert panel (Schneider et al., 2016). As noted
in Section 1.2.1 and 1.2.2, the roles and clinical practice environments for Australian
emergency nursing are broad and geographically dispersed, thus it was important that
the expert panel reflected the opinions of this population. Clear delineation of
participants was needed to increase rigour and representative consensus (Asselin &
Harper, 2014). Not only was geographical dispersion of panel participants desired, but
the panel needed to be inclusive of the variety of practice roles within emergency
nursing.
66
The researcher originally considered graduate qualifications in emergency
nursing as an inclusion criterion. However, there are no mandated requirements for
graduate emergency nursing qualifications in Australia, and consequently it was
possible emergency nurses working in senior roles may not have a graduate
qualification in emergency nursing. Therefore, graduate qualifications were not added
as an isolated inclusion criterion.
The inclusion criteria for this study were nurses who identified as an emergency
nurse, and those who were currently working, or had previously worked, in an
emergency care environment. Conversely, the exclusion criteria for this study were
nurses who did not identify as an emergency nurse, and those who had never worked
in an emergency care environment.
The College of Emergency Nursing Australia (CENA) was contacted to facilitate
the dissemination of the Delphi survey. The CENA has more than 1500 members and is
the peak professional body for emergency nursing in Australasia. Their capability of
contacting emergency nurses through their database was therefore desirable, and
reduced potential ethical conflict as anonymity of participants was maintained, since
the researcher did not have access to participants’ email addresses. The CENA also
uses social media platforms of Facebook, Instagram and Twitter to disseminate
approved research studies. Once approval from the CENA was granted (Appendix 7),
an email was forwarded to the administrator for circulation to all members (Appendix
8). The email included the Participant Information Statement (PIS) and an email to be
sent to participants with a link to the online survey. A clear explanation was provided
to ensure participants were aware of the requirements of the Delphi and that
subsequent rounds of survey would follow. Snowballing of participants was
encouraged, with CENA members encouraged to forward the email and share social
media communication with emergency nursing colleagues who may be interested in
participating in this study.
The size of an expert panel for a Delphi is debated in the literature and is not
always clearly articulated. A primary concern of large panels is the potential for
dilution of panel expertise, in contrast to the favourable argument that large panels
increase the heterogeneity of the expert group (Asselin & Harper, 2014; Diamond et
67
al., 2014; Donohoe et al., 2012; Keeney, 2011; Toronto, 2017). The research team
agreed that the likely response rate of CENA members for Round One of the Delphi
would be 10%, and therefore approximately 140 respondents. This number of
participants was likely to yield appropriate heterogeneity amongst emergency nurses.
Attrition in subsequent rounds of the Delphi was also anticipated and thus 140
respondents provided an appropriate buffer for this (Asselin & Harper, 2014; Keeney,
2011).
3.9.1.3. Ethical considerations for Delphi
Low-risk ethics approval from The University of Sydney Human Research Ethics
Committee (HREC) approval number 2019/771 (Appendix 6) was granted. A PIS,
including the timeline for each data collection round, was provided to all participants
(Appendix 9) prior to the first Delphi round (Asselin & Harper, 2014). The PIS was
embedded into the unique URL survey link, being the landing page for participants.
Participants were required to indicate they had read the PIS and agreed to participate
in the study prior to commencing the survey. Completion of the survey was
considered consent. There was no perceived harm or discomfort for participants.
Confidentiality was maintained as no identifiable data was collected. Distributed
feedback was representative of the group responses, not of individual ones. Surveys
disseminated for Round Two of the Delphi received ethics approval from The
University of Sydney HREC prior to distribution, as per HREC requirements (Appendix
11).
The research team were all active members within the CENA and emergency
nursing. It was likely that many participants knew one or more of the research team.
However, the research team did not have access to any participant information and
were not distributing the online surveys, therefore issues relating to power and
coercion were unlikely. Participants were emailed via the CENA secretariat and
therefore contact was not made by the research team.
3.9.1.4. Data collection
A two-round Delphi was implemented for data collection. This survey was
piloted with a panel of eight people. The pilot panel included expert emergency nurses
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and academics. The panel were asked to review and answer all survey questions, and
provide feedback concerning face and content validity, feasibility and reliability. In
addition to minor editing and word changes, members of the pilot panel provided
feedback regarding the inclusion of survey progress completion bars and navigation
panels, which were manually added into REDCap, a secure web-based survey tool that
has an easy and interactive interface, with appropriate coding. Given the length of the
survey, the pilot panel believed that progress bars were an important inclusion as it
would provide participants with an indicator of how far they had progressed through
the survey. A limitation of REDCap is the termination of the survey if the browser back
button is used. The pilot panel thought the addition of navigation panels may reduce
the incidence of survey termination amongst participants, as they allowed participants
to move forward and backwards throughout each section of the survey. Another
recommendation of the pilot panel was the inclusion of operational definitions for
participants. Definitions were provided throughout the survey when terminologies
were first used, however to minimise the need to navigate backwards for definition
clarification, ‘hover’ definitions were added. This process created bold coloured blue
words, and when participants ‘hovered’ over these words using their mouse or finger
depending on the electronic device, definitions were provided. This was achieved with
manual coding in REDCap.
Round One questionnaire development was generated from the results of the
key informant interviews, document analysis and literature review, and refined
following the pilot outcome. The first round is generally considered a scoping phase,
whereby participants provide answers to open-ended questions; however, the
findings from Study Two informed the survey development. This approach to a first
round of Delphi questions is often referred to as a ‘modified Delphi’ (Keeney, 2011).
Demographics, graduate emergency nursing course entry requirements, graduate
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
survey responses (Asselin & Harper, 2014; Keeney, 2011).
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3.10. Data integration
Integration of qualitative and quantitative data and synthesis of results is a key
component of mixed-methods (Teddlie & Tashakkori, 2009) . The sequential design of
this mixed-methods study involved integration of results at a number of points. The
findings from the integrative literature review were used to inform the questions
applied in the document analysis; in Study Two, the results from the document
analysis were used to develop the questions asked of key informants. As noted in
Section 3.8.3, results from these two phases of data collection were then integrated
with a weaving approach (Fetters et al., 2013). The outcomes from Study Two were
used to generate questions and statements distributed in the first round of Study
Three, using a modified Delphi. Results from Study Three were then used to establish
minimum practice standards for graduate emergency nursing programs (Creswell &
Plano Clark, 2011).
Fetters and Molina-Azorin (2017) refer to the to the integration trilogy in mixed-
methods research, which is illustrated in Figure 3.6. Integration occurred throughout
the study, from conceptualisation of the research aims and questions, to philosophical
assumptions, methodological design and selected methods. Abductive reasoning was
used to explore and explain how the quantitative results expanded and generalised
the qualitative findings (Fetters & Molina-Azorin, 2017; Greene, 2015). Generation of
the first practice standards for Australian graduate emergency nursing programs
required integration of all relevant findings from each study.
73
Figure 3.6 Mixed-Methods Research Integration Trilogy (Fetters & Molina-Azorin, 2017, p. 292)
3.11. Data storage
Data were stored in accordance with Griffith University and The University of
Sydney policies. Data from the document analysis were entered into a Microsoft Excel
TM spreadsheet. Interviews were transcribed verbatim and emailed to the primary
researcher in a word document. Delphi survey data were collected using Research
Electronic Data Capture (REDCap) and downloaded in CSV format.
During analysis, data were stored on the researcher’s Okta Verify password-
protected computer in a locked office in a locked building. Audio tapes from the semi-
structured interviews and the interview transcripts were kept in the same office in a
locked filing cabinet. On completion, data storage occurred through the Research Data
Store (RDS) at the University of Sydney.
All metadata related to this research, including study protocols and data
collection instruments, were saved on the University of Sydney server, with final
versions also kept with data saved in the RDS. Ethical and privacy data collected, such
as consent forms, were de-identified, with no personal information.
74
On completion of the project data were archived, 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 (The University of Sydney, 2014).
3.12. Summary
This chapter has presented an overview of the mixed-methods exploratory
sequential design for this research. The philosophical assumptions of pragmatism have
been explained and its influence on data collection and analysis. The methods for each
study were outlined with discussion regarding ethical considerations, sample,
recruitment, data collection and analysis provided. The integration process for this
research was described. The findings from Study Two are reported in the next chapter,
Chapter Four.
75
Chapter 4. Results of Study 2
Analysis of Australian Graduate Emergency Nursing Programs
4.1. Introduction
This chapter presents the findings from the analysis of Australian graduate-
level emergency nursing programs. These findings derive from peer-reviewed
Publication 2, which presents the academic and professional characteristics of
Australian graduate emergency nursing programs (Jones et al., 2020a).
4.2. Publication 2: Academic and professional characteristics of Australian
graduate emergency nursing programs.
Publication 2 presents the findings from Study Two, an analysis of Australian
graduate emergency nursing programs. This publication is the accepted manuscript by
the Journal, with the full reference:
Jones, T., Curtis, K., Shaban, RZ. (2020a). Academic and professional characteristics of
Australian graduate emergency nursing programs. Australas Emerg Care. 23: 173-180.
doi: 10.1016/j.auec.2020.02.003
76
77
78
79
80
81
82
83
(Aitken, Currey, Marshall, & Elliott, 2008; Bouchoucha, Wikander, & Wilkin, 2013; Chamberlain, Pollock, & Fulbrook, 2018; Deloitte
Access Economics, 2016; Fry & MacGregor, 2014; Marshall, Currey, Aitken, & Elliott, 2007; Munroe, Curtis, Murphy, Strachan, &
Buckely, 2015; Penz, Stewart, Karunanayake, Kosteniuk, & MacLeod, 2019; Varndell, Fry, Lutze, & Elliot, 2020; Wangensteen et al.,
2018)
84
4.3. Summary
In this chapter the findings from the analysis of Australian graduate emergency
nursing programs were presented. The methods used in this study included both
document analysis and key informant interviews. The academic and professional
characteristics of these programs were summarised into eight categories: (i) course
entry, (ii) fee arrangements, (iii) volume of learning, (iv) mode of program delivery, (v)
clinical assessments, (vi) employment requirements, (vii) expectations of the graduate,
and (viii) influence of healthcare employers and professional engagement. The
following chapter, Chapter Five, will present results from Study Three.
85
Chapter 5. Results of Study 3
Practice Expectations of Australian Graduate Emergency Nursing
Programs
5.1. Introduction
This chapter presents the findings from stakeholder analysis of graduate
emergency nursing practice standards. These findings are presented from an accepted
manuscript (Jones et al., 2020b). Publication 3 will report the practice expectations of
Australian graduate emergency nursing programs.
5.2. Publication 3: Practice Expectations of Australian Graduate Emergency
Nursing Programs: A Delphi Study.
Publication 3 presents the findings from Study Three: stakeholder analysis of
graduate emergency nursing practice standards. The findings are presented verbatim
from the manuscript that has been accepted by Nurse Education Today on 2nd
February 2021 (Appendix 14). The manuscript is presented in Word version and
formatted for thesis consistency. Figures and tables have been re-numbered and
references re-located from the paper to the reference list at the end of the thesis.
5.2.1. Abstract
Background: Practice standards in nursing provide minimum expectations to enable
the provision of high quality and safe care. There are currently no practice standards
for post-registration graduate emergency nursing programs in Australia, leading to
variation in graduate attributes and clinical expectations on completion of their
program.
Objectives: The aim of this study was to establish consensus-based practice standards
for graduate emergency nursing programs in Australia.
Design: Delphi approach.
86
Participants: Australian nurses who identified as an emergency nurse and currently
worked, or previously worked, in an emergency care environment.
Methods: A modified two-round Delphi method was used. The survey was divided
into four sections of data collection, including demographics, graduate emergency
nursing course entry requirements, graduate expectations, and clinical care
capabilities. Data were analysed using descriptive statistics including calculation of
content validity index (CVI).
Results: There were 204 respondents in Round One and 153 respondents in Round
Two. Respondents agreed that nurses wanting to undertake graduate studies in
emergency nursing require prior experience in the emergency care environment and
should be working a minimum of 0.5 full time equivalent (FTE) whilst completing their
studies. Thirty-nine statements presented under graduate attributes achieved a CVI
of > 0.8. All 70 clinical care capability statements presented in Round Two achieved a
CVI of > 0.8.
Conclusion: This study generated the evidence to establish minimum practice
standards for Australian graduate emergency nursing programs. The standards centre
around three key areas: graduate entry requirements, graduate attributes and clinical
care capabilities. The standards provide a clear guide for employers, educators and
clinicians, and inform capabilities for early career emergency nurses.
Key words: Practices standards, emergency nursing, Delphi, graduate education,
nursing education, graduate attributes, clinical care capability
5.2.2. Background
Practice standards in nursing are in general terms regulated and used by
governing nursing bodies to inform professional expectations, attributes and
performance. They may be used to inform guidelines, curriculum, and performance
assessments for nurses, whilst allowing flexibility and variation with in a safe and
ethical framework (Edmonds et al., 2013; O'Connell et al., 2014a). Practice standards
for specialty areas in nursing articulate the comprehensive role of specialist nurses,
and inform expectations with regards to safe and ethical practice (Edmonds et al.,
87
2013; Jones et al., 2020a; Jones et al., 2015). Emergency nursing is an internationally
recognised specialty, and practice and competency standards for emergency nurses
have been developed by professional emergency nursing bodies globally including:
College of Emergency Nurses New Zealand, College of Emergency Nursing Australasia,
Emergency Nurses Association, European Society for emergency Nursing, Faculty of
Emergency Nursing, and the National Emergency Nurses Association (Jones et al.,
2015).
In Australia registered nurse standards for practice are regulated at a national
level and inform practice expectations for all registered nurses, including those in
specialty practice (Nursing and Midwifery Board Australia, 2016a). Specialist nurses
have a different scope of practice relevant to the context of their clinical practice
environment and thus the development of regulated standards for specialist areas of
nursing has been considered (National Nursing & Nursing Education Taskforce, 2006).
However, the Specialist registration for the nursing profession project (2016)
determined that there was no perceived improvement in patient safety or outcomes
by regulating specialty areas of nursing practice. A recommendation from this
Australian project was for professional colleges and associations to develop practice
standards for their relevant specialty area of nursing practice (Nursing and Midwifery
Board Australia, 2016a). In Australia emergency nursing practice standards are not
regulated by nursing registration, and thus the application of practice standards for
emergency nurses across differing levels of educational preparation, is likely to vary
based on interpretation and utility (Jones et al., 2020a; Jones et al., 2015; Nursing and
Midwifery Board Australia, 2016a).
The COVID-19 global pandemic has raised the profile of emergency nursing,
demonstrating the complexities of care and emergency nursing practice environment
(Bagnasco et al., 2020; Clough, 2020; Nayna Schwerdtle et al., 2020). Emergency
nurses care for patients with low acuity presentations, through to the critically unwell
requiring complex and life-saving care across the age spectrum. The breadth of
emergency nursing clinical capabilities required to care for these patients highlights
the importance of suitably trained nursing staff working in the emergency care
environment (Fry et al., 2019). Internationally the educational preparation for
88
emergency nurses varies as do the emergency nursing practice standards applied in
this specialist field (Emergency Nurses Association, 2018; Jiang et al., 2018; Jones et
al., 2015; Rautiainen & Vallimies-Patomäki, 2016).
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
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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
92
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
presented.
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5.2.4.2. Graduate emergency nursing course entry requirements
Agreement amongst the respondents was high that prior clinical experience was
necessary for nurses wanting to undertake a graduate qualification in emergency
nursing (n=136, 88.9%), with the ED (n=73, 48%) or the emergency care environment
(n=45, 29.6%) being the preferred location. Respondents agreed that potential
students from rural and remote areas should be able to complete graduate emergency
nursing qualifications without a mandatory rotation to a metropolitan ED (n=100,
65.8%). The majority of respondents (n= 135, 88.2%) believe participants should be
working between 0.5 and 0.8 full time equivalent (FTE) in the emergency care
environment whilst completing their graduate emergency nursing program. A
common justification for employment whilst completing the course was ‘exposure’
and ‘consolidation’, as indicated by one comment “It is vital for the graduate to
correlate knowledge with practice at the time of study” (nurse 124, nurse manager).
Participants also agreed that rotations to other emergency nursing clinical practice
environments is ideal but not required for graduate emergency nursing programs.
Table 5.2 Graduate Emergency Nursing Course Entry Requirements
Variable Round Two result
Prior clinical experience as a registered nurse required Yes – 136 (88.9%)
No – 15 (9.8%)
Other – 2 (1.3%)
Location of prior clinical experience as a registered
nurse
ED (73 (48%)
Emergency Care (29.6%)
Acute Care – 27 (17.8%)
Not required – 2 (1.3%)
Other 5 (3.3%)
Minimum FTE requirements in an approved emergency
care environment 0.8 – 45 (29.4%)
0.6 – 59 (38.6%)
0.5 – 31 (20.3)
No mandated hours – 18
(11.8%)
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Rural and Remote students can undertake a graduate
emergency nursing qualification
Yes – 100 (65.8%)
No – 40 (26.3%)
Other – 12 (7.9%)
Students working in a paediatric only ED should be
required to rotate to an adult only or mixed (adult and
paediatric) ED
Yes – 52 (34%)
No – 4 (2.6%)
Ideal but not required -
93 (60.8%)
Other – 4 (2.6%)
Students working in an adult only ED should be
required to rotate to a paediatric only or mixed (adult
and paediatric) ED
Yes – 57 (37.3%)
No – 10 (6.5%)
Ideal but not required –
80 (52.3%)
Other – 6 (3.9%)
5.2.4.3. Graduate attributes on completion
Forty-two statements were presented for agreement in section three of the
survey. Statements were divided into seven domains: communication; safe and quality
patient care; ethics and law; professional development; research and quality
improvement; teamwork and leadership; and clinical practise expertise. In Round One,
three statements yielded a CVI of < 0.8 and were eliminated from Round Two of the
Delphi. Based on the qualitative comments in Round One, one statement was added
to the communication domain for Round Two. A total of 40 statements were
presented in Round Two of the Delphi, with 39 statements yielding a CVI of > 0.8. Four
domains had a very high level of agreement with a CVI of > 0.90 across all statements,
namely communication, safe and quality patient care, ethics and law, and professional
development (see Table 3). A possible explanation for the high level of agreement is
evidenced in the qualitative comments “these are skills expected of an RN however a
graduate emergency nurse would be expected to apply them in an emergency care
context” (nurse 6, academic).
Research and quality improvement, teamwork and leadership, and clinical
practice expertise had one or more statements that yielded a CVI of <0.86 but > 0.8.
Qualitative responses referred to these domains being areas for ongoing learning
“Many of these traits and motivations do tend to come out in the year following
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completion of postgrad” (nurse 10, academic) and “I feel the grad cert [graduate
certificate] can give the nurse the tools, however a lot of skills are developed on the job
and through mentorship” (nurse 173, nurse educator). The domain of teamwork and
leadership had one statement with a CVI of < 0.8 and thus it has been removed from
the graduate attributes. The Cronbach alpha was calculated for each domain with
values in Round One ranging from 0.772 to 0.0.975, and from 0.720 to 0.971 in Round
Two.
Table 5.3 Attributes of graduate emergency nurses on completion of their graduate program
Communication Round Two CVI
Communicate effectively with the patient, their family and
support people
97.8
Effectively communicate assessment findings and
management plans with patient, their family and support
people
97.8
Effectively communications with colleagues to plan, deliver
and evaluate care
97.8
Provide clear, concise and informative handovers 97.8
Provide structured, concise and informative documentation 98.6
Safe and quality patient care
Identify and report unsafe or inappropriate practice 98.6
Manage critical incidences and stressful situations 89.9
Demonstrate safe and effective use of technology and
biomedical equipment
94.2
Promote a caring environment for the patient and significant
others
96.4
Involve the patient in the decisions about their care 97.8
Advocate for the patient 97.1
Establish rapport with patients, families and support people 97.1
Research and Quality Improvement
Critically evaluate and apply nursing research to emergency
patient care 94.2
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Identify and suggest areas for practice or policy change 86.3
Support the development of quality improvement within the
emergency care environment 93.5
Support the development of research within the emergency
care environment 85.6
Ethics and Legal
Maintain patient privacy and confidentiality 95.7
Function within an ethical framework 97.1
Practice according to all relevant legislation and standards of
practice
96.4
Teamwork and Leadership
Work within their own scope of practice 97.8
Performs effectively as a team member 96.4
Collaborate with colleagues, including the multidisciplinary
team, to bring about best patient outcomes
97.1
Recognise and manage own stress 94.2
Provide support for colleagues when caring for challenging
patient and or family needs
93.5
Effectively leads a team to provide safe, quality patient care 84.9
Act as a role model for nurses and other health professionals 96.4
Supervise and delegate the delivery of patient care to others 87.1
Demonstrate preparedness and response for major incidents
and disasters
80.6
Professional Development
Maintain their own ongoing professional development 99.3
Contribute to the professional development of colleagues 92.8
Promote the profile of emergency nursing 92.8
Clinical Practice and Expertise
Provide appropriate and timely assessments of the
undiagnosed patient
96.4
Effectively prioritise patient care needs 96.4
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Determine, monitor and implement appropriate assessment
and management strategies for multiple undifferentiated
patients
92.8
Transport complex patients throughout the healthcare
environment
93.5
Provide appropriate discharge care including referrals and
education materials
94.2
Anticipate, assess and manage the care of the deteriorating
patient across the lifespan
95.7
Safely work at triage 86.3
5.2.4.4. Clinical Care Capabilities on completion
The final section of the survey sought consensus about the clinical care areas
that students are required to apply their knowledge of advanced pathophysiology,
assessment and management strategies for conditions in the emergency care setting.
This section was divided into ten categories for agreement: neurological;
cardiovascular; respiratory; kidney hepatic & gastrointestinal; endocrine; shock;
obstetrics; trauma and injury; paediatrics; and other.
In Round One 82 clinical care capabilities were presented to for agreement, and
12 statements yielded a CVI of < 0.8 and thus eliminated from Round Two of the
Delphi. A total of 70 clinical care capabilities were presented for agreement in Round
Two with all statements yielding a CVI of > 0.8. Table 4 summarises the expected
clinical care capabilities of students who complete graduate emergency nursing
programs. The Cronbach alpha was calculated for each category with values in Round
One ranging from 0.813 to 0.988, and from 0.854 to 0.989 in Round Two. Table 4
summarises the expected clinical care capabilities of students who complete graduate
emergency nursing programs.
Qualitative comments provided justification for the high levels of agreement
“postgraduate students should be able to identify the clinical indicators, red flags and
pathways of escalation for these presentations” (nurse 140, nurse educator), and
acknowledged that clinical capability is necessary however confidence may take time
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to develop “they should be capable of managing these patients but confidence will
come with experience” (nurse 149, RN).
However, some qualitative comments identified concerns with listing conditions,
and emphasised the importance of clinical context for the application of theory into
practice, as evidenced by the two comments below:
“Need to take into consideration of where they are employed and relevant
exposure to the above. Should have the knowledge to obtain an appropriate
history and assessment, recognise the potential diagnosis, escalate
appropriately and manage accordingly, within their scope of practice at the
place of their employment.” (nurse 104, nurse manager)
“Dependent of course on their location…[sic]...change your perception to
develop capacity to become a lifelong learner, a reflexive practitioner who
can identify what they need to upskill and when they need to upskill” (nurse
156, academic).
Table 5.4 Recommended clinical care capabilities of graduates on completion of their graduate emergency nursing program
Neurological Clinical Care Capabilities Round Two CVI
Altered conscious states, 97.1
Meningitis 93.4
Raised ICP 94.1
Seizures 97.8
Stroke 97.1
Subarachnoid haemorrhage 95.6
Cardiovascular Clinical Care Capabilities
Acute coronary syndromes 97.1
Advanced ECG interpretation and arrhythmia management 88.2
Advanced Life Support 94.9
Aortic Aneurysms 93.4
Arrhythmias 96.3
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Heart Failure 96.3
Insertion of intravenous cannula 95.6
Invasive haemodynamic monitoring 95.6
Non-ischaemic cardiac conditions 97.1
Vasoactive infusions 96.3
Respiratory
Acute COPD 98.5
Acute Pulmonary Oedema (APO) 97.1
Advanced airway 91.9
Advanced mechanical ventilation (adult) 90.4
Arterial Blood Gas Analysis 95.6
Asthma 97.8
Chest X-ray Interpretation 85.3
Invasive Mechanical ventilation across the lifespan 89.0
Non-invasive positive pressure ventilation (NIPPV) 92.6
Pneumonia 97.8
Pulmonary Embolism 97.8
Kidney, Hepatic & GIT
Acute Kidney Injury 95.6
Acute Pancreatitis 97.1
Biliary tract disease 94.9
Chronic Kidney Disease (CKD) 94.1
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
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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.
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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,
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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.
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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
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6.1 Cardiogenic, distributive, hypovolaemic and obstructive shock
6.2 Vasoactive infusions
7. Trauma and Injury
7.1 Abdominal, Chest, Head, Musculoskeletal, Spinal Injury
7.2 Burns/ Thermal injury
7.3 Submersion injury
8. Obstetrics
8.1 Complications associated with pregnancy
9. Paediatrics
9.1 Advanced paediatric and neonatal resuscitation
9.2 Calculation of IV fluid replacement requirements
9.3 Paediatric respiratory conditions such as: asthma, bronchiolitis, croup and
epiglottitis
9.4 Gastroenteritis
9.5 Seriously ill child
10. Other
10.1 Drug and alcohol
10.2 Ear Nose Throat (ENT) emergencies
10.3 Hypo/Hyperthermia
10.4 Infectious diseases
10.5 Legal issues and forensics
10.6 Mental health
10.7 Oncological emergencies
10.8 Ophthalmology
10.9 Poisoning/Toxicology
10.10 Rash
10.11 Sexual Assault
10.12 Vascular Emergencies
6.3.1. Graduate attributes
This study established evidence-based graduate attributes for emergency
nursing programs across seven domains: (i) communication; (ii) safe and quality
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patient care; (iii) research and quality improvement; (iv) ethics and legal; (v) teamwork
and leadership; (vi) professional development; and (vii) clinical practice expertise.
6.3.1.1. Communication
Communicating for Safety is one of the standards in the National Safety and
Quality Health Service (NSQHS) standards (Australian Commission on Safety and
Quality in Health Care, 2017). Study One, an analysis of international emergency
nursing practice and competency standards, and Study Three, a Delphi study that
established evidence to generate the minimum practice standards for Australian
graduate emergency nursing programs, demonstrated the importance of emergency
nurses having strong communication skills. The value placed on effective
communication by the practicing profession demonstrates the veracity of the results
and the extent to which emergency nurses are aligned with the NQSHCS.
Communication in emergency nursing can be challenging (Graham & Smith, 2015).
Patients and significant others are often stressed, as the cause for ED presentation is
unknown. Nurses are required to keep relevant healthcare professionals, the patient,
and significant others informed of waiting times, assessment findings, management
plans and evaluation of implemented care (Graham, Endacott, Smith, & Latour, 2019;
Hermann, Long, & Trotta, 2019), and they do so for multiple patients across the
illness/injury trajectory. For the critically unwell, time-critical conversations about
patient care need to be succinct, transparent and empathetic (Graham et al., 2019).
Where sentinel adverse events occur in emergency care, poor communication is a key
contributing factor, and often within the multidisciplinary team, particularly during
patient handover (Redley, Botti, Wood, & Bucknall, 2017), patient transfer, and
discharge (Bagnasco et al., 2013). Interpersonal and informational communication are
perceived by patients and their significant others as key attributes of emergency
nurses, with humanism, reassurance, assertiveness and explaining having a strong
influence on the patient experience in the emergency care environment (Graham et
al., 2019; Hermann et al., 2019).
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6.3.1.2. Safe and quality patient care
Harm minimisation and quality care are the premise of the NSQHS standards,
and the emergency nursing profession strongly value these attributes (Australian
Commission on Safety and Quality in Health Care, 2017). Graduates of emergency
nursing programs are potential leaders in the specialisation of emergency nursing and
are required to model safe and quality patient care, which includes appropriate
escalation and management of stressful or unsafe situations and patient advocacy.
The emergency care environment is laden with uncertainty and risk of error, which is
further exacerbated during times of access block, overcrowding, workforce and
equipment shortages (Källberg, Ehrenberg, Florin, Östergren, & Göransson, 2017;
Redley et al., 2017). As noted in Study Two, the complexities of the emergency care
environment are often explored in graduate emergency nursing education. However,
it is important that there are graduate attributes that can be applied in the context of
the emergency care environment to re-enforce the expectations of quality and safe
patient care practices.
6.3.1.3. Research and quality improvement
The findings of Study Two, which examined the academic and professional
characteristics of Australian graduate emergency nursing programs, revealed that the
level of graduate program entry influences the depth of research and quality
improvement attributes of graduates. The majority of graduate emergency nursing
programs are taught at an AQF Level 8 (graduate certificate), and only some at an AQF
Level 9 (Masters). Nurses who complete an emergency nursing program delivered at a
graduate certificate level (AQF 8) must be able to critically evaluate practice and use
appropriate evidence to inform their delivery of care (Australian Qualifications
Framework Council, 2013b). Results from Study Three asserted the importance of
research and quality improvement in the attributes of emergency nursing program
graduates. Graduates should not be afraid of challenging practice in the emergency
care environment, as it is from these critical questions that graduates of tertiary
programs may support the achievement of better patient outcomes through practice
change and quality improvement (Proehl & Hoyt, 2015). Academics, educators and
clinicians should give consideration to the established research priorities for
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emergency nursing in Australia (Considine et al., 2018). Utilising these consensus-
based priorities that focus on professional issues, patient safety, care of vulnerable
populations and health care systems (Considine et al., 2018) amplifies the role of
emergency nurses, particularly those with graduate qualifications, in supporting the
development of research and quality improvement in emergency care.
6.3.1.4. Ethics and legal
All registered nurses in Australia must practice in accordance with the Registered
Nurse Standards of Practice (Nursing and Midwifery Board Australia, 2016b) and
relevant NMBA codes and guidelines. Whilst there is flexibility within the NMBA
standards to support scope expansion of emergency nurses (Nursing and Midwifery
Board Australia, 2016a, 2016b), legal and ethical adherence must be stated in the
emergency nursing graduate attributes to mitigate confusion. The evidence-based
minimum practice standards for Australian graduate emergency nursing programs
detail the expected graduate attributes and clinical capabilities areas where the
nurses’ scope of practice may expand within the flexibility of the Registered Nurse
Standards of Practice. To support the expansion of practice scope, these graduate
emergency nursing standards need to be taken into consideration by the individual,
academics, clinicians and managers. The individual nurse must be accountable for
their practice that is aligned with relevant legal, professional and ethical standards
(Rubio-Navarro, Jose Garcia-Capilla, Jose Torralba-Madrid, & Rutty, 2019, 2020).
6.3.1.5. Teamwork and leadership
Study Three results determined that teamwork and leadership are important
attributes for graduates of emergency nursing programs, and respondents indicated
that graduates are emerging leaders. This is consistent with findings of Study Two, as
participants reported graduates are not expert practitioners but are at the beginning
of their emergency nursing specialist journey. Nurses make up the greatest proportion
of the emergency department workforce; hence, the importance of teamwork and
leadership is reflected in the developed graduate attributes and is consistent with
other findings (Grover, Porter, & Morphet, 2017; Lapierre, Lefebvre, & Gauvin-Lepage,
2019). When considering the transferability of teamwork, it is important to
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contextualise this to the emergency care environment and consider barriers and
enablers of teamwork. Individual, relational, processual, organisational and contextual
factors all contribute to teamwork in emergency and trauma settings, and can impact
patient outcomes (Lapierre et al., 2019). Nursing and medical staff in Australia must
work collaboratively to assess, treat and discharge multiple patients from the
emergency department within four hours to achieve the NEAT (Sullivan et al., 2016a;
Sullivan et al., 2016b). The challenges of effective teamwork increases with the
complexity of patient care needs, for example caring for patients experiencing acute
behavioural issues, or patients who are critically unwell requiring life-saving care
(Lapierre et al., 2019). In these critical situations, effective leadership skills are also
essential to achieve best outcomes for patients and staff. It is with exposure and
experience that teamwork and leadership skills are developed, which highlights the
importance of students working whilst completing their graduate emergency nursing
studies. On completion of graduate programs, emergency nurses need to have
developed effective teamwork and leadership skills that can be role modelled to less
experienced nurses commencing their emergency nursing career. The skills of
teamwork and leadership continue to develop well beyond the graduate qualification
(Cotterill-Walker, 2012; Drennan, 2012).
6.3.1.6. Professional development
The findings from Study One revealed there is increasing importance placed on
the acquisition of graduate qualifications in emergency nursing by professional bodies.
Results from Study Two and Three highlight that graduate education aims to establish
skills for lifelong learning and personal and professional growth (Cotterill-Walker,
2012). Increasing the qualifications and skill mix within the emergency nursing
workforce contributes to improved patient safety and delivery of care; however, only
one third of nurses working in an emergency department hold graduate qualifications
(Morphet et al., 2016a). Graduates of emergency nursing programs are a resource in
the emergency care environment, as their expanded knowledge and practice
capabilities can support both junior and senior staff (Cotterill-Walker, 2012; Goodwin,
McMaster, Hyde, Appleby, & Fletcher, 2019; Pool, Poell, Berings, & ten Cate, 2016)
and promote the profile of emergency nursing.
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6.3.1.7. Clinical practice expertise
Clinical practice and expertise were considered important by the Australian
emergency nursing profession in this study. Graduates of tertiary emergency nursing
programs must demonstrate sound clinical judgement skills (Lasater, 2011) in dynamic
emergency care environments and across the illness trajectory and life span. The
profession has defined clinical care capabilities and established that on completion of
graduate emergency nursing programs, nurses should be safely working as triage
nurses. As noted in Section 1.2.2, triage is considered a distinct element of emergency
nursing (College of Emergency Nursing Australasia, 2014). Findings from Study Two
identified differences in triage clinical practice requirements on commencement and
completion of graduate emergency nursing studies. The findings from Study Three
illustrate uniform expectations of safe triage practice from graduates on completion of
their program.
Graduates of tertiary emergency nursing programs must apply knowledge of
advanced pathophysiology, assessment and management strategies across clinical
care capabilities (Table 6.2). These defined evidence-based capabilities are not
intended to be prescriptive, but provide a platform to anchor expected practice in the
context of a students’ emergency care environment. The extensive list of clinical care
capabilities highlights the breadth of skills, knowledge, values, flexibility and
confidence that are required of emergency nurses in their delivery of patient care
(Baid & Hargreaves, 2015) and centre across 10 categories: (i) neurological; (ii)
cardiovascular; (iii) respiratory; (iv) kidney hepatic & gastrointestinal; (v) endocrine;
(vi) shock; (vii) obstetrics; (viii) trauma and injury; (ix) paediatrics; and (x) other. Until
now, graduate emergency education has been driven by healthcare providers and
course convenors, and, as established in Study Two, there has been absence of
standardisation which has been developed for other nursing specialisations such as
critical care (Gill et al., 2015) and emergency nurse practitioner education (O'Connell,
Gardner, & Coyer, 2014b). As identified in Study Two, there was variation across a
number of clinical care capabilities, so having defined expectations of clinical practice
mitigates confusion for stakeholders. Whilst it is not expected that two programs will
be the same, students need to know what is expected of them and need to have
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confidence that their education will prepare them to provide contemporary
emergency care that is safe, but also transferable to other emergency care
environments. Equally, managers and patients need to know that graduates are
capable and safe in their practice.
6.4. Application to graduate emergency nursing programs
The establishment of practice standards for Australian graduate emergency
nursing programs will provide structure for graduate education providers to anchor
their teaching. The Australian Nursing and Midwifery Accreditation Council (ANMAC)
provides accreditation standards for all registered nurse, registered midwife, enrolled
nurse and nurse practitioner programs. All programs must evidence how they meet
these standards, which ultimately influences the development of curriculum
(Australian Nursing and Midwifery Accreditation Council, 2014, 2015, 2017, 2019). The
minimum practice standards for Australian graduate emergency nursing programs
that were established from this study are not the basis for program accreditation,
however utilisation of these standards will inform program development with the aim
of preparing students to care for patients across an illness trajectory, from mild and
moderate to critical illness or injury; inclusive of working at triage (Jones et al., 2020b).
Findings from Study Two showed there were a number of inconsistencies across
Australian graduate emergency nursing programs with regards to (i) prior experience;
(ii) clinical exposure and relevance to program admission; and (iii) working in the ED
whilst studying. Evidence from Study Three addressed these three inconsistences, and
established expectations of the profession with regards to application to graduate
emergency nursing programs.
6.4.1. Prior experience
Findings from Study Two found that the majority of Australian graduate
emergency nursing programs (71%, n=10) do not require future students to have
worked in the ED prior to undertaking their graduate studies (Jones et al., 2020a).
However, the emergency nursing profession in Study Three contradicted this finding
from Study Two, as 78% (n= 118) believed future graduate emergency nursing
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students must have prior emergency nursing experience before commencing their
study (Jones et al., 2020b). The effect of prior experience in graduate education is not
well examined, with studies often focussing on grade point average (GPA) as a
determinant of success (Niemczyk, Cutts, & Perlman, 2018; Ortega, Burns, Hussey,
Schmidt, & Austin, 2013). Studies that have explored the effect of prior clinical
experience and the relationship with academic success, have concluded that there is
no significant relationship between academic performance and clinical experience
(Burns, 2011; El-Banna et al., 2015; Niemczyk et al., 2018). One American study
reported an inverse relationship with years of experience and GPA, concluding that a
student’s GPA decreased for each year of critical care nursing experience (Burns,
2011). However, given the variation in types of assessment that may contribute to a
GPA, it is inconclusive if prior experience contributes to improved performance and
safe delivery of patient care in the clinical practice environment.
Studies exploring the experience of newly registered nurses working in ED and
ICU express the importance of lengthy orientation programs, between 12-24 weeks, to
develop knowledge and skills for working in these critical care environments, and
consistent and effective preceptorship during this time to develop safe practice
(DeGrande, Liu, Greene, & Stankus, 2018; Glynn & Silva, 2013). Prior experience in the
emergency care environment before commencing graduate studies is important, as it
enables the nurse to become familiar with their clinical environment, establish
expectations of care and establish rapport with team members (Baid & Hargreaves,
2015; Vanderspank-Wright, Lalonde, Smith, Wong, & Bentaz, 2019). Establishing a safe
and familiar working environment aids in mitigating additional challenges that may be
experienced during graduate study.
6.4.2. Clinical exposure and the relevance to program admission
Findings in Study Two, which examined the academic and professional
characteristics of Australian graduate emergency nursing programs, highlighted that
the type of emergency care environment is an influencing factor for graduate
emergency nursing program entry (Jones et al., 2020a). A number of graduate
emergency nursing programs only accepted students from rural and remote areas if
120
the student was able to complete a rotation in a Level 3 or Level 4 emergency
department, arguing that exposure to critically unwell patients was limited and
therefore students were unable to achieve their assessments. Results from Study
Three affirm that rotations should not be a requirement for students completing
graduate emergency nursing programs. Kidd, Kenny, and Meehan-Andrews (2012)
assert that rural nurses working in emergency care do not see benefit in rotations to
metropolitan EDs as the responsibility of decision-making by emergency nursing staff
in rural areas is more complex that in the metropolitan setting. This does not detract
from the challenges related to exposure of patient presentations, but if strong
foundations are developed by the student then knowledge, skills, critical thinking, and
clinical judgement can be systematically applied to all patients in their emergency care
context (Baid & Hargreaves, 2015).
The issue of clinical exposure is not isolated to rural and remote students.
Nurses working in adult only or paediatric only emergency departments will have
limited exposure to patients across the lifespan (Ilangakoon, Jones, Innes, & Morphet,
2020). The emergency environment is dynamic and subsequent age and acuity of
patient presentations are unpredictable. Participants in Study Three determined that
whilst rotations are ideal and may enhance variation in patient exposure for students,
they should not be a requirement (Jones et al., 2020b). Given the ‘unknown’ patient
population in the ED, rotations do not necessarily solve concerns relating to exposure.
The unknown patient presentation is what often contributes to reduced confidence in
emergency nursing clinicians, and thus structured and consistent education that can
be applied in the context of the clinicians environment is important (Kidd et al., 2012).
Pre-registration literature demonstrated the importance of clinical exposure to
support healthcare professionals develop confidence and competence in patient care
(Anderson, Slark, Faasse, & Gott, 2019; Callaghan, Kinsman, Cooper, & Radomski,
2017; Sole et al., 2012); the same is required in graduate emergency nursing
programs. Education strategies that facilitate critical thinking, the delivery of informed
care and the ongoing demonstration of graduate attributes and clinical care
capabilities on completion of their graduate program need to be considered (Baid &
Hargreaves, 2015), not mandated clinical rotations.
121
Where challenges relating to patient exposure may inhibit the completion of a
clinical assessment tasks that centre around clinical care capabilities, such as care of
paediatric patients in an adult only emergency department, course coordinators need
to develop appropriate assessments to ensure graduate attributes and clinical care
capabilities can be achieved. Objective structured clinical examinations (OSCE) have
been used in medicine, allied health and nursing (Heal et al., 2018; Jeffrey et al., 2014;
Pugh et al., 2015) and are a possible solution for this potential dilemma. Logistics
regarding standardisation of assessors and location of assessments would need to be
explored (Pugh et al., 2015).
6.4.3. Working in the ED whilst studying
Graduate emergency programs require students to apply theory into the clinical
practice environment. It was evident from the findings of Study Two that minimum full
time equivalent (FTE) hours were inconsistent amongst programs, with some
programs not requiring employment in the emergency care environment whilst
studying. There are a number of barriers to nurses completing graduate studies in
emergency nursing. This is particularly relevant for nurses with additional
responsibilities such as being a primary carer, where work in the clinical environment,
study and primary care commitments increase levels of stress (Ng et al., 2016).
However, emergency nursing is a clinical specialisation and students undertaking
graduate studies in this specialty need to demonstrate safe, ethical and informed
practice. There is an absence of literature that evidences the clinical practice hours
required to achieve safe and informed care during graduate emergency nursing
programs. Recently, Gullick et al. (2019) report that 18 hours of clinical practice per
week are mandated in the UK during graduate critical care education, while expert
emergency nurses in Australia agreed in Study Three that graduate emergency nursing
students require continuous employment at a minimum of 0.5 FTE to develop
proficiency in caring for patients across the age and acuity spectrum in the context of
their emergency care environment.
122
6.5. Methodological reflection
This study has generated the first set of Australian graduate emergency nursing
practice standards, which will aid workforce planning by nursing management,
establish support needs of clinical educators, inform academics in graduate
emergency nursing program development, and importantly inform practice standards
to ensure the safe delivery of care. The use of an exploratory sequential mixed-
methods design guided an in-depth understanding of international emergency nursing
practice standards and Australian graduate emergency nursing programs. This meant
that data from each phase was used to inform the study design and data collection of
the subsequent phase. Findings from the analysis of international emergency nursing
practice and competency standards informed the development of the document
analysis tool. Findings from the document analysis informed the development of the
question guide for key informant interview. Finally, findings from the document
analysis and key informant interviews informed the first round of the Delphi
questionnaire. This rigorous and ethical process facilitated the established minimum
practice standards for Australian graduate emergency nursing programs.
There was high level of engagement from key informants in Study Two: 13 of a
possible 14 informants provided evidence that was representative of graduate
emergency education in Australia, which established trustworthiness in this phase.
The pilot phase of the Delphi survey established face and content validity, as well as
reliability in the first round of the survey (Hasson & Keeney, 2011; Keeney, 2011;
Schneider et al., 2016).
There are limitations to this study. CENA is the peak professional body for
emergency nurses, however not all emergency nurses practising in Australia are
members. Members of CENA are often those engaged in the profession, and therefore
results may not reflect the opinion of all emergency nurses. Equally, whilst at least 204
emergency nurses across all Australian states and territories responded the Delphi
survey, there were few nurses from rural and remote areas. It is unclear if this is
because there are fewer emergency nurses working in these areas, if CENA
membership is low amongst this cohort, or if potential participants were not engaged
123
in the study. Therefore, the established findings with regards to expectations of rural
and remote nurses undertaking graduate emergency nursing programs may not reflect
the opinions of this cohort.
Another limitation was not all CENA members received Delphi survey emails,
due to internet firewalling in many government health services. However, the use of
snowballing and social media distribution of the study by CENA assisted to overcome
this limitation.
The established graduate practice standards are for the Australian emergency
nursing context, therefore generalisability of findings to an international context may
have some limitations. However, rigorous research methods were used, and therefore
international emergency nursing bodies may like to adopt these processes, or use the
established practice standards as a platform for graduate emergency nursing
education development.
Study Two was limited to the use of publicly available information on university
websites. Confidentiality inhibited key informants from sharing documents related to
their graduate emergency nursing programs. Program documents may have provided
objective evidence as opposed to the potential subjective bias of key informant.
Finally, COVID-19 has brought about significant changes to both the tertiary
education sector and the emergency care practice environment. The education of
graduate emergency nurses, and subsequent graduate attributes and clinical care
capabilities, will be influenced by this pandemic. However, the final round of data
collection did occur during the height of the first wave of the COVID-19 pandemic in
Australia, so there is some COVID-19 context in the established practice standards.
6.6. Summary
The findings from this exploratory sequential mixed-methods study have
informed the development of the first Australian graduate emergency nursing
program practice standards. These evidence-based standards reflect the
contemporary values and experience of the Australian emergency nursing profession
with regards to graduate attributes and clinical care capabilities. Additionally, the
124
findings have established workforce considerations to inform application to graduate
emergency nursing programs. Specific workforce considerations relate to prior
experience, clinical exposure and the relevance on program admission, and working in
the ED whilst studying. The minimum practice standards for graduate emergency
nursing programs provide a guide for clinicians, managers, educators and academics in
relation to practice expectations, which ultimately inform patient safety and
workforce planning. The following chapter, Chapter Seven, is the final chapter in this
thesis and will present recommendations for future practice and conclude the study.
125
Chapter 7. Conclusion and Recommendations
7.1. Introduction
This final chapter presents the recommendations from this exploratory
sequential mixed-methods research. Ten recommendations are presented across five
areas: (i) policy, (ii) practice, (iii) education, (iv) future research, (v) profession. These
recommendations relate to the minimum practice standards for Australian graduate
emergency nursing programs that have been established through this research. The
chapter ends with a conclusion of this study.
7.2. Recommendations
7.2.1. Recommendations for policy
Recommendation One: Consideration and endorsement of the minimum practice
standards for Australian graduate emergency nursing programs by the College of
Emergency Nursing Australasia (CENA)
The Australian College of Emergency Medicine (ACEM) has long been engaged
and involved in the establishment of graduate emergency medicine training. It is
recommended that CENA, the peak professional body for emergency nurses in
Australasia, be engaged in graduate emergency nursing education through
endorsement of these standards. These endorsed standards could be utilised by CENA
to regulate graduate emergency nursing programs. The minimum practice standards
for Australian graduate emergency nursing programs should be made publicly
available on the CENA website, increasing their availability and utility.
7.2.2. Recommendations for practice
Recommendation Two: Prior experience in the emergency care environment is
required before applying for graduate studies in emergency nursing.
Prior experience aids assimilation into the workplace, including familiarity with
processes and resources and expectations of care (Baid & Hargreaves, 2015;
126
Vanderspank-Wright et al., 2019). It is therefore recommended that nurses wanting
to undertake graduate studies in emergency nursing have clinical practice experience
in the emergency care environment before submitting their application. This will
reduce environmental challenges that may be experienced by nurses during their
emergency nursing graduate program.
Recommendation Three: Graduate emergency nursing students are working in their
clinical practice environment
To facilitate theory to practice translation, as well as confidence and
competence in the delivery of safe emergency nursing care, it is necessary for
graduate students to have concurrent employment. It is recommended that students
are working a minimum of 0.5 FTE in the emergency care environment. To
demonstrate the minimum practice standards, graduate emergency nursing students
need to receive feedback and opportunities to reflect on their clinical practice;
concurrent employment facilitates these learning opportunities.
Recommendation Four: Nurses completing graduate emergency nursing programs
are not required to complete mandatory clinical rotations
It is recommended that nurses working in rural or remote emergency care
environments, and nurses working in adult only or paediatric only emergency
departments should not be required to complete mandatory rotations during their
program of study. Any rotation completed by a student should be optional. Education
strategies will need to be established to support these students apply infrequently
observed clinical concepts in the context of their environment.
7.2.3. Recommendations for education
Recommendation Five: Higher education providers implement the minimum
practice standards for Australian graduate emergency nursing programs
This study recommends that higher education providers implement the
minimum practice standards for Australian graduate emergency nursing programs.
The use of these standards will inform the development of programs and the
assessments of students. It is suggested that programs that do not currently address
127
the seven graduate attribute domains and ten clinical care capability categories
modify their programs to enhance patient safety and workforce consistency of
graduates.
Recommendation Six: Graduate emergency nursing programs incorporate clinical
assessments in the emergency environment across the duration of the program
Clinical care capability assessments should be designed so that students
demonstrate safe, ethical and informed practice in all clinical practice areas of
progression. Clinical assessments should extend across the duration of the program to
ensure graduates demonstrate graduate practice standards on completion of their
emergency nursing program. Alternate assessment strategies, such as Objective
Structured Clinical Examination (OSCE), will need to be developed within the graduate
emergency nursing program to support students who may have limited capacity to
demonstrate their clinical care capability in the clinical practice environment.
7.2.4. Recommendations for research
Recommendation Seven: Future research partners with consumers
Partnering with Consumers is a standard of the NSQHS, and therefore it is
recommended that the voice of patients and significant others is observed. It is
suggested that consumers review and provide comment on the minimum practice
standards for Australian Graduate emergency nursing programs.
Recommendation Eight: Future research to evaluate the perception,
implementation, and impact of the graduate emergency nursing practice standards
It is recommended that research is conducted to evaluate the perception,
implementation, and the impact of the minimum practice standards. Investigation into
the perceptions of students, clinicians, educators, managers and academics is
suggested. Future studies examining the influence of prior experience and concurrent
employment on observed minimum practice standards of graduates is recommended.
Exploration of barriers and enablers to practice standard implementation is also
advised. The evaluation of impact may be through recruitment and retention of
graduate qualified emergency nurses in the emergency department. Additionally,
128
review of clinical outcomes such as key performance indicators and clinical risk in the
emergency care environment is proposed.
Recommendation Nine: Future research examines barriers and enablers of nurses
undertaking graduate emergency nursing education
We need an educated emergency nursing workforce that is capable of delivering
safe and informed care in the context of their emergency care environment. It is
therefore recommended that following implementation of these standards, there is
future research examining the experience, barriers and enablers of nurses undertaking
graduate emergency nursing programs from all emergency care environments.
7.2.5. Recommendations for the profession
Recommendation Ten: Practice standards are updated every five years
It is recommended the minimum practice standards for graduate emergency
nursing programs are reviewed and updated every five years. Engagement and input
are to be sought from the emergency nursing profession during this process to ensure
the standards align with contemporary emergency nursing practice.
7.3. Conclusion
This exploratory sequential mixed-methods study has generated new
knowledge about Australian graduate emergency nursing programs. The findings from
this study have generated minimum practice standards for Australian graduate
emergency nursing programs. These standards have been established by the
emergency nursing profession across seven graduate attribute domains: (i)
communication; (ii) safe and quality patient care; (iii) research and quality
improvement; (iv) ethics and legal; (v) teamwork and leadership; (vi) professional
development; and (vii) clinical practise expertise. Within the domain of clinical
expertise ten categories of clinical care capabilities have been defined: (i) neurological;
(ii) cardiovascular; (iii) respiratory; (iv) kidney hepatic & gastrointestinal; (v) endocrine;
(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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Appendix 1: Ethics Approval Email for Study Two
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Appendix 2: Questions applied to document analysis
Category Questions
Demographics • In which state is the course provider?
Course Enrolment
• What is the title of the program that students enrol in (i.e. masters of advanced nursing / graduate certificate of emergency nursing)?
• What is the duration of the program (program students enrol in)?
• What are the alternative exits for the overarching program?
• Can the student study part-time?
• What are the entry requirements for the overarching program?
• What are the admission requirements for the emergency nursing specialisation?
• What is the duration of the emergency nursing specialisation (i.e. if students enrol in a master’s program)
• Is emergency nursing specialisation available to international students?
• What needs to completed/ achieved for the student to receive the emergency nursing qualification?
Fee arrangement
• Is CSP available?
• Are scholarships available? If yes, what type of scholarships?
Graduate outcomes
• What are the graduate outcomes for the emergency nursing program?
• What are the graduate outcomes for the overarching program (if applicable)
Course content
• What topics are covered in the graduate emergency nursing program?
• Are there links to the CENA practice standards?
Course delivery
• How many units must be completed to achieve the emergency nursing qualification?
• What are the titles of these units?
• What are the duration of these units? (i.e. semester, trimester, year-long)
• What is the mode of delivery for the emergency nursing program?
Assessments • How many assessments for each unit?
• What are the types of assessments students complete?
Clinical Practice requirements
• Does the student need to be working in an emergency care environment to complete the program?
• If yes, how many hours per week?
• What support does the student require from their workplace for the emergency nursing program?
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Appendix 3: Participant Information Consent Form Study Two,
Key Informant Interviews
Study Title: Minimum Practice Standards for Graduate Emergency
Nursing Programs
INFORMATION SHEET
Researchers: Student Researcher: Tamsin Jones, PhD Candidate, School of Nursing,
The University of Sydney, New South Wales
Email: [email protected]
Supervisors: Professor Ramon Shaban Marie Bashir Institute for
Infectious Diseases & Biosecurity, Westmead Institute for Medical
Research, NSW, 2145
Email: [email protected]
Professor Kate Curtis, School of Nursing, The University of Sydney,
New South Wales
Email: [email protected]
Why is the research being conducted?
Increasing demand and patient acuity in emergency departments have prompted the need for
specialist-trained nurses to deliver an advanced level of care. Nurses who choose to work in
the emergency department often complete graduate education to ensure advanced care is
safely and competently delivered.
Several universities in Australia deliver graduate programs in emergency nursing, however course
content, graduate practice outcomes and clinical assessment requirements for emergency nursing
graduates vary across universities. Uniform minimum standards for the Australian graduate
emergency nurse are absent. This project aims to develop practice standards for the emergency
nursing graduate.
This study is being undertaken as part of a PhD research project by Tamsin Jones. This study has
been approved by the Griffith University Human Research Ethics Committee GU: 2017/292.
What you will be asked to do
Your participation is voluntary. If you choose to take part you will be asked to participate in one
telephone interview, of approximately 30 minutes, at a time convenient to you. The purpose of the
interview is to clarify your postgraduate emergency nursing program course structure, the clinical
153
practice environments, graduate outcomes, course delivery methods and assessment strategies.
With your permission the interviews will be audiotaped and subsequently transcribed.
The expected benefits of the research
This study intends to develop minimum practice standards for emergency nursing graduates.
Standardisation may improve the quality of patient care, assist with workforce recruitment and aid
potential emergency nursing students with program selection.
Risks to you
The purpose of this study is to identify common themes relating to course content, practice
outcomes and clinical assessment methods in emergency nursing university programs. There
is no foreseeable harm to participants.
Your confidentiality
Confidentiality is incredibly important to us. All data collected will remain confidential and will be
de-identified. Your university or individual information will not be identifiable in any published
materials. Codes will be assigned to maintain confidentiality when transcribing interviews.
Anonymity will be maintained in all publications and reporting. The information you provide will
only be accessed the student researcher, Tamsin Jones, or by the PhD supervisors, Professor Ramon
Shaban and Professor Kate Curtis.
Data will be stored on a password-protected computer in the locked office of the principal
investigator. All printed documents and audiotapes will be stored in a locked filing cabinet in
the locked office of the principal investigator. All data relating to this research project will be
kept for 5 years before being disposed.
Questions / further information
If you have any questions or concerns relating to the research please contact the principal
investigator Tamsin Jones via email [email protected] or via phone 0410669758.
The ethical conduct of this research
Griffith University conducts research in accordance with the National Statement on Ethical Conduct
in Human Research. If potential participants have any concerns or complaints about the ethical
conduct of the research project they should contact the Manager, Research Ethics on 07 3735 4375
Feedback to you
At the end of this study you can be sent a document of the findings. It is expected that Study Two
will be completed in October 2018.
Dissemination of results
The results from this research will be published in the PhD thesis for Ms Tamsin Jones. Results may
also be disseminated through conference presentations and via academic journals. A summary
report will be provided to the Council of Deans of Nursing and Midwifery (Australia and New
Zealand) for dissemination to Heads of Nursing and Midwifery.
154
Privacy Statement
“The conduct of this research involves the collection, of your identified personal information. The
information collected is confidential and will not be disclosed to third parties without your consent,
except to meet government, legal or other regulatory authority requirements. A de-identified copy
of this data may be used for other research purposes. However, your anonymity will at all times be
safeguarded. For further information consult the University’s Privacy Plan at
http://www.griffith.edu.au/about-griffith/plans-publications/griffith-university-privacy-plan or
telephone (07) 3735 4375.”
155
Study Title: Minimum Practice Standards for Graduate Emergency Nursing
Programs
CONSENT FORM
Research
Team
Student Researcher: Tamsin Jones, PhD Candidate, School of Nursing,
The University of Sydney, New South Wales
Email: [email protected]
Supervisors: Professor Ramon Shaban Marie Bashir Institute for
Infectious Diseases & Biosecurity, Westmead Institute for Medical
Research, NSW, 2145
Email: [email protected]
Professor Kate Curtis, School of Nursing, The University of Sydney,
New South Wales
Email: [email protected]
By signing below, I confirm that I have read and understood the information package and in
particular have noted that:
• I understand that my involvement in this research will include one audiotaped telephone
interview of approximately 30 minutes at a time convenient to me;
• I have had any questions answered to my satisfaction;
• I understand the risks involved;
• I understand that there will be no direct benefit to me from my participation in this
research;
• I understand that my participation in this research is voluntary;
• I understand that if I have any additional questions I can contact the research team;
• I understand that I am free to withdraw at any time, without explanation or penalty;
• I understand that I can contact the Manager, Research Ethics, at Griffith University Human
Research Ethics Committee on 3735 4375 (or [email protected]) if I have
any concerns about the ethical conduct of the project; and
• I agree to participate in the project.
Name
Signature
Date
156
Verbal consent process
By agreeing to participate, you will be confirming that:
• You understand what participation in this research entails –
o One audiotaped telephone interview
o The purpose of the interview is to clarify your postgraduate emergency nursing
program course structure, the clinical practice environments, graduate outcomes,
course delivery methods and assessment strategies
o The interview will be at a time convenient to you
o The interview will be approximately 30 minutes duration
• You have had any questions answered to your satisfaction;
• You understand that if you have any additional questions you can contact the
research team;
• You understand that your participation is voluntary and that you are free to
withdraw at any time, without explanation or penalty; and
• You understand that you can contact the Manager, Research Ethics, at Griffith
University Human Research Ethics Committee on 3735 4375 (or research-
[email protected]) if you have any concerns about the ethical conduct of the
project.
Privacy Statement
“The conduct of this research involves the collection, access and/or use of your identified personal
information. The information collected is confidential and will not be disclosed to third parties
without your consent, except to meet government, legal or other regulatory authority
requirements. A de-identified copy of this data may be used for other research purposes. However,
your anonymity will at all times be safeguarded. For further information consult the University’s
Privacy Plan at http://www.griffith.edu.au/about-griffith/plans-publications/griffith-university-
privacy-plan or telephone (07) 3735 4375.”
Verbal Consent Details:
Date :
Time:
Participant Name:
Had read to him/her the participant information verbal consent script.
They confirmed they understood the nature of the research and their participation and
agreed to proceed with the interview.
157
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/
diploma 1.5. Acceptance of international students
2. Teaching Approach 1.1 Flexible 1.2 Online 1.3 Blended 1.4 Face-to-Face
3. Workload 1.5 Hours per semester/week 1.6 Number of units delivered
4. Assessment 4.1 Written 4.2 Exam / Quiz 4.3 Clinical
5. Fee Arrangements 1.7 CSP 1.8 Scholarships 1.9 Employer contribution 1.10 Fees 1.11 Access to funding limiting recruitment
6. Graduate attributes and expectations
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.
https://redcap.sydney.edu.au/surveys/?s=JW3YAWKXYR
163
Should you have any questions about this study please contact Tamsin Jones at
If you believe that your fellow emergency nursing colleagues, past and present, would
like to participate in this project please feel free to share this email with them.
Thank you for considering this invitation
Tamsin Jones
164
Appendix 9: Participant Information Sheet
Professor Ramon Shaban
Susan Wakil School of Nursing of Nursing and Midwifery
Faculty of Medicine and Health University of Sydney
M02A – 88 Mallet Street, Building A NSW 2006 AUSTRALIA
Telephone: +61 2 8627 3117 Email: [email protected]
PARTICIPANT INFORMATION SHEET
Research Study
Minimum Practice Standards for Australian Graduate Emergency
Nursing Programs
(MiEMERG Nurse)
(1) What is this study about?
You are invited to take part in a research study which aims to develop minimum
standards for graduate emergency nursing programs in Australia. The aim of this
project is to provide evidence for the development of practice standards for
graduate emergency nursing programs.
You have been invited to participate in this study because you are an emergency nurse.
This Participant Information Statement tells you about the research study. Knowing
what is involved will help you decide if you want to take part in the research. Please
read this sheet carefully and ask questions about anything that you don’t understand
or want to know more about.
Participation in this research study is voluntary.
By giving your consent to take part in this study you are telling us that you:
✓ Understand what you have read.
✓ Agree to take part in the research study as outlined below.
✓ Agree to the use of information as described.
You are able to download a copy of this Participant Information Statement to keep.
(2) Who is running the study?
The study is being carried as out by the following researchers:
165
• Tamsin Jones, Student Researcher, PhD Candidate, Susan Wakil School of Nursing &
Midwifery, The University of Sydney, NSW
• Professor Ramon Shaban, Supervisor, Susan Wakil School of Nursing & Midwifery, The
University of Sydney, NSW and Marie Bashir Institute for Infectious Diseases &
Biosecurity, Westmead Institute for Medical Research, NSW
• Professor Kate Curtis, Supervisor, Susan Wakil School of Nursing & Midwifery, The
University of Sydney, NSW
Student Declaration
Tamsin Jones is conducting this study as the basis for the degree of Doctor of Philosophy
at The University of Sydney. This will take place under the supervision of Professor
Ramon Shaban and Professor Kate Curtis.
Funding Declaration
This PhD research is being funded by the Skellern Family Foundation Scholarship, The
University of Sydney.
(3) What will the study involve for me?
This study involves the completion of three web-based surveys using REDCap.
To complete the first survey, simply click on the link provided or copy it into your
internet browser
https://redcap.sydney.edu.au/surveys/?s=JW3YAWKXYR
The results of this first survey will be analysed before the second survey is developed.
The findings of each survey will be sent to you along with a new link to the next survey.
This will be repeated until three rounds are complete. This survey is confidential.
For your convenience, each survey round will be open for a period of two weeks,
allowing you time to complete the questions at a time, place and pace suitable to you.
There will be a four week break between survey arounds to enable the analysis of
results and development of the subsequent survey.
(4) How much of my time will the study take?
It is expected that the first survey will take approximately 20-30 minutes to complete,
however all subsequent surveys will take approximately 15 minutes of your time.
(5) Who can take part in the study?
You were chosen to take part in this study because of your knowledge about emergency
nursing and the provision of care. You have been identified through your membership
166
with the College of Emergency Nursing Australasia (CENA), or through dissemination to
you by a CENA member.
(6) Do I have to be in the study? Can I withdraw from the study once I've started?
Being in this study is completely voluntary and you do not have to take part. Your
decision whether to participate will not affect your current or future relationship with
the researchers or anyone else at The University of Sydney or the College of Emergency
Nursing Australasia (CENA).
Submitting your completed questionnaire is an indication of your consent to participate
in the study. You can withdraw your responses any time before you have submitted the
questionnaire. Once you have submitted it, your responses cannot be withdrawn
because they are anonymous and therefore we will not be able to tell which one is yours.
(7) Are there any risks or costs associated with being in the study?
Aside from giving up your time, we do not expect that there will be any risks or costs
associated with taking part in this study.
(8) Are there any benefits associated with being in the study?
This study intends to determine the minimum practice standards for Australian
graduate emergency nursing programs. A shared and agreed understanding of these
standards may help to guide the development of emergency nursing curriculum and
create a shared vision of expectations for graduates which may inform clinical practice,
improve patient safety, and aid workforce planning.
(9) What will happen to information about me that is collected during the study?
Data is collected using the REDCap software. The survey data is anonymous and will be
kept strictly confidential. This software provides the highest level of password
encrypted data security. Once extracted from REDCap data will be stored as per the
University of Sydney’s data management guidelines. Secure password-protected
servers will be used to store the encrypted data. Only the research team will have access
to this information. Study findings may be published, but you will not be individually
identifiable in these publications. The data collected will be used to develop a thesis for
a Doctor of Philosophy.
(10) Can I tell other people about the study?
Yes, you are welcome to tell other people about the study and share the URL link.
(11) What if I would like further information about the study?
167
When you have read this information, Tamsin Jones will be available to discuss it with
you further and answer any questions you may have. If you would like to know more at
any stage during the study, please feel free to contact Tamsin, PhD Candidate, via email
(12) Will I be told the results of the study?
As stated above, the interim survey results will be provided to participants four weeks
after the closure of each survey round, providing participants with insight into the
responses provided by their peers. The data will be analysed and discussed in more
detail as part of a University of Sydney Doctoral Thesis, and as such intend to be shared
with the emergency nurses through publication and conference presentations.
(13) What if I have a complaint or any concerns about the study?
Research involving humans in Australia is reviewed by an independent group of people
called a Human Research Ethics Committee (HREC). The ethical aspects of this study
have been approved by the HREC of The University of Sydney [2019/771]. As part of this
process, we have agreed to carry out the study according to the National Statement on
Ethical Conduct in Human Research (2007). This statement has been developed to
protect people who agree to take part in research studies.
If you are concerned about the way this study is being conducted or you wish to make
a complaint to someone independent from the study, please contact the university
using the details outlined below. Please quote the study title and protocol number.
The Manager, Ethics Administration, University of Sydney:
• Telephone: +61 2 8627 8176 Email: [email protected]
• Fax: +61 2 8627 8177 (Facsimile)
This information sheet is for you to keep
168
Appendix 10: Delphi Round One Questions
Delphi questions for Round Two
To help you to participate in this study we would like to provide you with some
definitions of key terms and words that we use.
The aim of this study is to establish graduate emergency nurse practice standards for
emergency nurses practicing in Australia. The word graduate is used throughout this survey.
In this study the word graduate is defined as a person who has been awarded a qualification
by an authorised issuing organisation, in this instance a nursing degree at a university, and is
entering, or has recently entered, professional practice as an emergency nurse. When you see
graduate we want you think of it as you would the word postgraduate. In this survey we are
not referring to nurses who have recently graduated from their pre-registration nursing
courses and are completing a graduate year. We are referring to nurses who are completing a
tertiary-delivered qualification specialising in emergency nursing.
This definition reflects the requirements of the Australian Qualifications Framework
(AQF). Moreover, the AQF advises that:
In common language usage, graduate and postgraduate are synonymous and both connote a
stage after graduation. In Australia and internationally, there is no consistent usage of either
term. The term postgraduate often is used in the education sector, particularly in higher
education. The usage tends to be applied to Bachelor and post-Bachelor Degrees. This usage
implies that the Bachelor Degree necessarily proceeds and is a pre-requisite for higher level
qualifications. In contrast, modern qualification systems are based on taxonomically defined
levels that allow for a multiplicity of pathways. The AQF has adopted the term graduate in
favour of postgraduate. The term graduate in the AQF is used for all qualification types in
describing the learning outcomes to be achieved and applied to a person who has been
awarded any AQF qualification. Graduate also is used in the title of the AQF qualification
types: Graduate Certificate and Graduate Diploma. Substitution of the term postgraduate in
AQF qualification titles is not permitted.
When thinking about graduate certificates or graduate diplomas in emergency nursing, these
qualification types qualify individuals to apply a body of knowledge in a range of contexts to
undertake highly skilled work, and as a pathway for further learning.
By checking this box, I confirm that I have read the Participant Information Statement (PIS)
and that I give my consent freely to participate in this study ☐
Demographics
1. How many years have you worked as a registered nurse? (free text/numbers)
169
2. How many years have you worked in the emergency department/emergency care setting
as a registered nurse? (free text/numbers)
3. Do you have a graduate qualification in emergency nursing?
☐ Yes
(Skip logic to question 4)
☐ No
(Skip logic to question 5)
☐ Other specialist qualification (Please specify)
(Skip logic to question 5)
4. What is your highest qualification in emergency nursing
☐Graduate Certificate
☐Graduate Diploma
☐Masters
☐PhD
☐ Other (please specify)
(Skip logic to question 6)
5. If you have not undertaken a graduate qualification in emergency nursing, what has
inhibited/stopped you from completing this? (please select as many relevant options)
☐ Cost
☐ Time
☐ No interest
☐ No need
☐ Insufficient workplace support
☐ Travel requirements
☐ Other (please provide detail)
6. What is your age in years as of the 31st December 2019? (free text/numbers)
7. In what state or territory do you primarily work (Please select one)?
☐ ACT
☐ NSW
☐ NT
☐ QLD
☐ SA
☐ TAS
☐ VIC
☐ WA
☐ OTHER (please specify)
170
8. In what type of emergency department or emergency care setting do/did you mostly
practice as a registered nurse as per the Australasian College of 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)
9. 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)
10. Which of the following best describes your current role (Please select as many as
applicable)?
☐ Academic
☐ Associate Nurse Manager
☐ Clinical nurse consultant
☐ Clinical nurse specialist / Registered Nurse Level 2/ Clinical Nurse / Nurse 3
☐ 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)?
☐ Academic
☐ Associate Nurse Manager
☐ Clinical nurse consultant
☐ Clinical nurse specialist / Registered Nurse Level 2/ Clinical Nurse / Nurse 3
☐ Coordinator of Nursing
☐ Nurse Educator / clinical coach / clinical support nurse
☐ Nurse Manager
☐ Nurse Practitioner
☐Registered nurse
☐ Research Nurse
☐ Other (please describe)
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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.
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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:
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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
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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
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No. Statement
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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
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No. Statement
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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
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No. Statement
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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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No. Statement
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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)
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No. Statement
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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
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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
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Appendix 14: Confirmation of manuscript acceptance to Nurse
Education Today