Minimum practice standards for Australian graduate

Minimum practice standards for Australian graduate emergency nursing programs: An exploratory, sequential

mixed-methods study.

By

Tamsin Patricia Jones

RN, BN (Hons), BSc (Health Promotion), Grad Dip Critical Care, MHPE, FCENA

A thesis submitted in fulfilment of the requirements for the degree of Doctor of

Philosophy

Sydney Nursing School

The University of Sydney

2021

ii

Statement of Originality

This thesis is an account of original research undertaken from 2015 to 2020 while I

was a student at Griffith University and The University of Sydney. I have been primarily

responsible for the design, data collection, data analysis, and reporting of the

research. Given the nature of a higher research degree, this work was undertaken with

the assistance of others, who are duly acknowledged. To the best of my knowledge all

references to other published work contained in this thesis are correct, and no part of

the thesis has been submitted for any other degree.

Tamsin Jones

iii

Acknowledgements

Completing this thesis has been a challenging, yet rewarding experience. There

are so many wonderful people that have supported me throughout this journey. I am

truly grateful for the support I have received, and would like to make some key

acknowledgements.

I am so incredibly grateful to my wonderful supervisors Professor Ramon Shaban

and Professor Kate Curtis. Your unwavering guidance, patience and feedback

throughout this study has been incredible. You are both truly inspiring and I have

learnt so much from you both. I would also like to acknowledge Professor Debra

Creedy who initially commenced the supervision journey with me.

To my incredibly supportive, always loving husband Mark. Thank you for your

patience and constant belief in me and my ability. You have always been interested in

what I was doing and where things were at. You propped me up when, at times, the

juggle of our lives just seemed a bit hard. Thank you for always being there.

To my three children, Tom, Jack and Clementine. You have given me so much

love, so many cuddles, and great distractions. Whilst you’re all a bit young now to

understand, my hope is that from this you will grow up believing you can achieve your

goals. You each have wonderful little personalities that show you are kind,

compassionate and determined. I hope these characteristics remain with you always.

To my parents, but in particular my mum Mary. I truly can’t thank you enough

for coming down from the country, often weeks at a time, to help with caring for our

family whilst I was immersed in data or writing. You have always been a rock, and you

didn’t let a pandemic get in the way (not even our Victorian arm). You have always

supported me with any pursuit I have wanted to achieve. You truly are one of life’s

gems; a selfless and beautifully kind woman.

My colleagues and friends have provided me with constant encouragement,

wisdom and much needed laughter. Thank you for our coffee dates, debrief sessions

and laughs; you have kept me sane.

iv

Thank you to the College of Emergency Nursing Australasia (CENA) for

supporting this research through the distribution of the Delphi surveys and the New

Investigator Research Grant (2018).

Thank you to all the participants who contributed to the various phases of this

study.

To the Skellern Family Foundation for their generous scholarship. What a

wonderful gift this has been, and the reason I have had protected time to complete

my PhD.

I wish to acknowledge Dr Floriana Badalotti from Artelingua, who edited my thesis

in accordance with Standards D and E of the Australian Standards for Editing Practice.

v

Table of Contents

Statement of Originality .......................................................................................... ii

Acknowledgements ................................................................................................ iii

List of Tables ........................................................................................................... ix

List of Figures .......................................................................................................... x

Authorship Attribution Statements ......................................................................... xi

Abstract ................................................................................................................ xiii

List of Abbreviations ..............................................................................................xvi

Glossary of Terms ................................................................................................ xviii

Publications related to thesis ................................................................................ xxii

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

vi

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

vii

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

viii

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

ix

List of Tables

Table 1.1 Distinct elements of emergency nursing work defined by the CENA .............. 5

Table 2.1 Summary of international comparison of practice and competency standards from updated literature search (2015-2020) ................................................ 34

Table 2.2 Summary of domains across international practice and competency standards from updated literature search (2015-2020) ................................ 35

Table 2.3 Specialty areas of nursing & midwifery in Australia ....................................... 39

Table 3.1 Research approaches to the connection, relationship and inference with data. ............................................................................................................... 43

Table 3.2 Mixed-methods research designs ................................................................... 46

Table 5.1 Demographic details of Round One and Round Two respondents ................ 93

Table 5.2 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

x

List of Figures

Figure 1.1 Common areas of care in the emergency department ................................... 3

Figure 1.2 Progression of clinical areas through the emergency department................. 8

Figure 2.1 Screening process and search outcomes for updated integrative review .... 33

Figure 3.1 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

xi

Authorship Attribution Statements

Professor Ramon Shaban and Professor Kate Curtis formed the higher degree

supervisory team. Professor Debra Creedy was a member of the higher degree

supervisory team whilst the thesis author was a part-time PhD student at Griffith

University 2015-2017. Published manuscripts form part of the higher degree award of

Doctor of Philosophy undertaken by Tamsin Jones.

The following outlines the published and submitted manuscripts embedded in this

thesis and authorship attribution statements indicating my contributions of the thesis

and published works.

• Chapter 2, Section 2.3 of this thesis contains Publication 1:

Jones, T., Shaban, RZ., Creedy, DK. (2015). Practice standards for emergency

nursing: An international review. Australas Emerg Nurs J. 18(5): 190-203. doi:

10.1016/j.aenj.2015.08.002

I designed this study with the co-authors, analysed and interpreted the data,

wrote the drafts and led the preparation and submission of the manuscript.

• Chapter 4 Section 4.2 of this thesis contains Publication 2:

Jones, T., Curtis, K., Shaban, RZ. (2020). The academic and professional features of

Australian graduate emergency nursing programs: A national study. Australas

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.

https://doi.org/10.1016/j.auec.2020.02.003

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.

xiv

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

xv

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).


“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).


“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).


“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).

xxi

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:


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



implement, evaluate and refer

care




• Triage



delivery

• Safe discharge of patients



implement, evaluate and refer

care




• Triage



delivery

• Facilitate safe and effective

discharge processes


Communication • Communicates effectively in all

areas of practice

• Communicates effectively and

professionally in all areas of

practice



practice

• De-escalates potential or actual

aggressive/confrontational

situations and assists those less

experienced in managing such

situations



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


nursing care

• Collaborates with patient and


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:


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

68

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).

72

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

89

completion of their tertiary emergency nursing qualification. The purpose of this study

was to generate consensus-based practice standards for graduate emergency nursing

programs in Australia.

5.2.3. Method

5.2.3.1. Study design

A two-round modified Delphi method was used for this study. The Delphi

technique is a well-established approach for determining consensus amongst experts

(Asselin & Harper, 2014; Cole et al., 2013; Keeney, 2011). Three survey rounds are

often reported as an appropriate number of iterations to achieve consensus amongst

Delphi literature. The first round being an exploratory or scoping phase (Keeney, 2011)

was informed by existing preliminary research (Jones et al., 2020a; Jones et al., 2015)

to generate the initial survey statements and create a ‘modified Delphi’ (Trevelyan &

Robinson, 2015; Varndell et al., 2020).

This survey was divided into four sections: (i) demographics, (ii) graduate

emergency nursing course entry requirements, (iii) graduate attributes on completion,

and (iv) clinical care capabilities. To enhance utility of the survey, graduate attributes

on completion were divided further into seven domains and clinical care capabilities

were divided into ten categories. Participants were able to provide additional

comments and statements via open-ended responses for each of the graduate

attribute domains and clinical care capability categories across both Delphi rounds.

The initial survey was piloted with a panel of eight, consisting of nurse

academics and expert emergency nurses. Feedback was provided regarding face and

content validity, reliability and feasibility. Based on the feedback minor editing and

word changes occurred, survey progress completion bars were added, and additional

operational definitions were provided throughout the survey.

5.2.3.2. Sample and recruitment

Convenience sampling and snowballing were used with the aim of establishing a

heterogenous panel of emergency nurses, inclusive of the various roles within

90

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).

91

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%)

94

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.

95

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%)

96

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

97

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

98

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

99

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


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

100

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

101

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

102

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

103

Mental health 94.9

Oncological emergencies 92.6

Ophthalmology 90.4

Poisoning/Toxicology 94.9

Rash 91.9

Sexual Assault 89.0

Vascular Emergencies 91.9

5.2.5. Discussion

The findings from this study have generated the evidence to inform the first set

of practice standards for Australian gradate emergency nursing programs. Previous

studies have identified the importance of emergency nursing practice standards (Jones

et al., 2015). The absence of practice standards specifically developed for graduate

emergency nursing programs has led to variation in graduate attributes which has

implications for patient safety and workforce planning (Jones et al., 2020a), and

evidenced the need for such standards to be established.

Previous research findings were used to inform the development of the first

round of Delphi questions (Jones et al., 2020a; Jones et al., 2015), and consensus was

readily established across three key areas: course entry requirements; graduate

attributes; and clinical care capabilities. The high levels of agreement demonstrate the

importance emergency nurses place on entry requirements, attributes and clinical

capabilities, and this consensus is not role dependent. Nurses working in clinical,

management and education positions were united in their responses and expectations

of graduate emergency nursing programs.

Prior clinical experience in an emergency care setting is required before nurses

enrol in graduate emergency nursing studies. Additionally, nurses undertaking these

studies need to be working between 0.5 and 0.8 FTE in an emergency care

environment. Working whilst studying is stressful, particularly for those with primary

care responsibilities (Ng et al., 2016), but the application of new theory in the context

of the student’s emergency care environment is required to develop and maintain safe

practice (Hickman et al., 2018). Some report that hours of employment can have a

104

negative influence on student performance and clinical care (Pitt, Powis, Levett-Jones,

& Hunter, 2012), however by articulating expectations of prior experience and hours

of employment ensures that minimum entry requirements are clear, and a foundation

for prior experience and employment is established. Mandating hours does not inhibit

strategies that can be implemented to support students.

Establishing specific graduate attributes and clinical care capabilities for

graduate emergency nursing programs provides a framework to guide graduate

emergency nursing education. The attributes and capabilities are designed to align

with unit(s)/subject(s) of graduate emergency nursing specialisation, which are most

commonly completed at a graduate certificate level. The establishment of these

standards is not about developing competency, but about providing clear capabilities

of graduates in the context of their clinical practice environment to achieve safe

patient care (Cashin et al., 2017; O'Connell et al., 2014a). Graduate attributes and

clinical care capabilities communicate the expectations of early career emergency

nurses to employers, education providers and clinicians (Cashin et al., 2017). The

reported attributes and capabilities reflect the current opinions of a heterogenous

sample of emergency nurses. The dynamic nature of healthcare and emergency

nursing means that the graduate attributes and clinical care capabilities will require

regular review and update, to reflect contemporary graduate emergency nursing

practice.

These practice standards have been developed relevant to the Australian

context, however internationally, emergency nursing colleges and associations could

potentially use these standards to inform the development and enhancement of

graduate emergency nursing programs, or adopt similar processes for the

establishment of country specific graduate emergency nursing standards. Additionally,

the graduate attributes and clinical care capabilities provide an evidence-based

scaffold that can be used to inform advanced emergency nursing education and

practice roles (O’Connell & Gardner, 2012). To embed these standards in graduate

emergency nursing programs and future clinical practice, it is recommended that a

framework for Australian graduate emergency nursing programs be established and

disseminated.

105

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.

106

Chapter 6. Discussion

6.1. Introduction

In this chapter, the findings from each phase of this exploratory sequential

mixed-methods study are integrated and synthesised to address the aim of this

research. The graduate emergency nursing practice standards established from this

body of research are examined relative to the existing literature. The graduate

attributes and clinical care capabilities are explained and the specific workforce

considerations for graduate emergency nursing programs will be discussed.

Methodological reflections of this research are also addressed in this chapter.

6.2. Study outcome and implications

This research established evidence-based minimum practice standards for

Australian graduate emergency nursing programs. A summary of each study and the

sequential integration of findings is presented in Figure 6.1. Three key elements have

been identified from this research that have implications for graduate emergency

nursing education, the emergency nursing workforce and the patients under their

care:

1. Graduate attributes for graduate emergency nursing programs have been

established.

2. Expected areas of clinical care capabilities for graduate emergency nursing

programs have been determined.

3. Workforce considerations are required prior to nurses applying for and

undertaking a graduate emergency nursing program.

107

Figure 6.1 Summary of sequential integration of studies to establish minimum practice standards for graduate emergency nursing programs.

OUTCOME OF EXPLORATORY SEQUENTIAL MIXED-METHODS STUDY

Evidence-based minimum practice standards for Australian graduate emergency

nursing programs established

STUDY THREE Aim: To generate consensus amongst the Australian emergency nursing profession regarding practice standards for graduate emergency nursing programs Study Three Outcome: Established evidence to generate practice standards for Australian graduate emergency nursing programs. This was inclusive of graduate attributes, clinical care capabilities and workforce considerations

STUDY TWO Aim: To determine the academic and professional profile of Australian graduate emergency nursing programs Study Two Outcome: Design and characteristics of graduate emergency nursing programs centre around eight categories

STUDY ONE Aim: To identify and analyse existing emergency nursing practice/competency standards Study One Outcome: Practice and competency standards are used internationally to guide emergency nursing practice across nine common domains

Examine practice and competency standards used to guide emergency nursing practice.

108

6.3. Minimum practice standards for graduate emergency nursing programs

This study has generated the first evidence-based minimum practice standards

for Australian graduate emergency nursing programs. Until now, there have been no

minimum practice standards that state the expected graduate attributes or clinical

care capabilities specific to Australian graduate emergency nursing programs. The

minimum practice standards for Australian graduate emergency nursing programs are

presented in Table 6.1. Implementation of the practice standards by tertiary education

providers will enable graduate emergency nurse to demonstrate all attributes on

completion of their program. Clinical care capabilities are listed in Table 6.2, which

provide structure and clarity for graduate attribute 7.8 Demonstrate clinical care

capabilities in the context of the emergency care environment. These have been stated

to ensure there is consistency and a shared understanding of the expectations of

clinical care capabilities across Australian graduate emergency nursing programs.

These contemporary, evidence-based practice standards for graduate

emergency nursing programs were established across a heterogenous sample of

emergency nurses. This is an important consideration as practice standards reflective

of contemporary professional values and experience increase confidence in the

generated outcomes and their relevance and application in emergency nursing

practice; particularly, standards designed to inform graduate education and clinical

practice (Gill et al., 2014; Gill et al., 2015; O'Connell et al., 2014a).

Study Two, which examined the academic and professional characteristics of

Australian graduate emergency nursing programs, demonstrated that there were a

number of inconsistencies across graduate attributes and clinical care capabilities,

which have implications for workforce planning and the delivery of safe patient care

(Jones et al., 2020a). Graduates need to demonstrate informed practice on completion

of their graduate emergency nursing program by incorporating multiple sources of

knowledge to inform and rationalise the care they deliver in the context of their

emergency care environment (Baid & Hargreaves, 2015). The established minimum

practice standards for Australian graduate emergency nursing programs provide

expectations for the graduate emergency nurse, clinicians, managers, and academics,

109

and thus create clarity for what is expected in the delivery of safe patient care by

students.

Table 6.1 Minimum practice standards for Australian graduate emergency nursing programs

1. Communication

1.1 Communicate effectively with the patient, their family and support people

1.2 Effectively communicate assessment findings and management plans with

patient, their family and support people

1.3 Effectively communicate with colleagues to plan, deliver and evaluate care

1.4 Provide clear, concise and informative handovers

1.5 Provide structured, concise and informative documentation

2. Safe and Quality Patient Care

2.1 Identify and report unsafe or inappropriate practice

2.2 Manage critical incidences and stressful situations

2.3 Demonstrate safe and effective use of technology and biomedical

equipment

2.4 Promote a caring environment for the patient and significant others

2.5 Involve the patient in the decisions about their care

2.6 Advocate for the patient

2.7 Establish rapport with patients, families and support people

3. Research and Quality Improvement

3.1 Critically evaluate and apply nursing research to emergency patient care

3.2 Identify and suggest areas for practice or policy change

3.3 Support the development of quality improvement within the emergency care

environment

3.4 Support the development of research within the emergency care

environment

4. Ethics and Legal

4.1 Maintain patient privacy and confidentiality

4.2 Function within an ethical framework

4.3 Practice according to all relevant legislation and standards of practice

5. Teamwork and Leadership

110

5.1 Work within their own scope of practice

5.2 Perform effectively as a team member

5.3 Collaborate with colleagues, including the multidisciplinary team, to bring

about best patient outcomes

5.4 Recognise and manage own stress

5.5 Provide support for colleagues when caring for challenging patient and or

family needs

5.6 Effectively lead a team to provide safe, quality patient care

5.7 Act as a role model for nurses and other health professionals

5.8 Supervise and delegate the delivery of patient care to others

5.9 Demonstrate preparedness and response for major incidents and disasters

6. Professional Development

6.1 Maintain their own ongoing professional development

6.2 Contribute to the professional development of colleagues

6.3 Promote the profile of emergency nursing

7. Clinical Practice and Expertise

7.1 Provide appropriate and timely assessments of the undiagnosed patient

7.2 Effectively prioritise patient care needs

7.3 Determine, monitor and implement appropriate assessment and

management strategies for multiple undifferentiated patients

7.4 Transport complex patients throughout the healthcare environment

7.5 Provide appropriate discharge care including referrals and education

materials

7.6 Anticipate, assess and manage the care of the deteriorating patient across

the lifespan

7.7 Safely work at triage

7.8 Demonstrate clinical care capabilities in the context of the emergency care

environment

The following clinical care capabilities are areas where students are required to

apply their knowledge of advanced pathophysiology, assessment and management

strategies for conditions in the emergency care setting (Table 6.2). These are minimum

expectations of graduates.

111

Table 6.2 Clinical care capabilities of emergency nurses on completion of graduate emergency nursing programs

1. Neurological Clinical Care Capabilities

1.1 Altered conscious states, inclusive of causative conditions causing such as:

meningitis, seizures, stroke, subarachnoid haemorrhage, and raised

intracranial pressure

2. Cardiovascular Clinical Care Capabilities

2.1 Acute coronary syndromes

2.2 Advanced ECG interpretation and arrhythmia management

2.3 Advanced Life Support

2.4 Aortic Aneurysms and non-ischaemic cardiac conditions

2.5 Heart Failure and associated complications

2.6 Insertion of intravenous cannula

2.7 Invasive haemodynamic monitoring

3. Respiratory

3.1 Acute exacerbations, and emergency presentations, of respiratory

conditions such as: asthma: chronic obstructive pulmonary disease (COPD),

pneumonia, pulmonary embolism

3.2 Advanced airway management across the lifespan

3.3 Arterial Blood gas result interpretation

3.4 Chest X-ray interpretation requirements

3.5 Invasive and non-invasive ventilation across the lifespan

4. Kidney, Hepatic & GIT

4.1 Acute Kidney Injury (AKI) and Chronic Kidney disease (CKD)

4.2 Acute pancreatitis

4.3 Biliary tract disease

4.4 Complications associated with liver cirrhosis

4.5 Testicular torsion

5. Endocrine

5.1 Diabetic Ketoacidosis (DKA)

5.2 Hyperglycaemic Hyperosmolar Syndrome (HHS)

5.3 Thyroid dysfunction and associated conditions

6. Shock

112

6.1 Cardiogenic, distributive, hypovolaemic and obstructive shock

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

113

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).

114

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

115

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

116

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.

117

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

118

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


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

119

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

References

Aitken, L., Currey, J., Marshall, A., & Elliott, D. (2008). Discrimination of educational outcomes between differing levels of critical care programmes by selected stakeholders in Australia: A mixed-method approach. Intensive and Critical Care Nursing, 24(2), 68-77. doi:10.1016/j.iccn.2007.09.001

Anderson, N., Slark, J., Faasse, K., & Gott, M. (2019). Paramedic student confidence, concerns, learning and experience with resuscitation decision-making and patient death: A pilot survey. Australasian Emergency Care, 22(3), 156-161. doi:10.1016/j.auec.2019.07.001

Aranda, S., & Yates, P. (2009). A National Professional Development Framework for Cancer Nursing (2nd ed.). Canberra: EdCaN.

Asselin, M., & Harper, M. (2014). Revisiting the Delphi Technique: Implications for Nursing Professional Development. J Nurses Prof Dev, 30(1), 11-15. doi:10.1097/01.NND.0000434028.30432.34

Australasian College for Emergency Medicine. (2012). Statement on the Delineation of Emergency Departments. West Melbourne: ACEM.

Australasian College for Emergency Medicine. (2014). Emergency Department Design Guidelines. West Melbourne: ACEM.

Australasian College for Emergency Medicine. (2019a). Emergency Department Overcrowding Position Statement. West Melbourne: ACEM.

Australasian College for Emergency Medicine. (2019b). Policy on Standard Terminology (P02) (ACEM Ed.). West Melbourne.

Australasian College for Emergency Medicine. (2020). Acess Block Position Statement S27. West Melbourne: ACEM.

Australasian Rehabilitation Nurses' Association. (2004). Rehabilitation Nursing Competency Standards for Registered Nurses. Eltham: ARNA.

Australian College of Children and Young People's Nurses. (2016). Standards of Practice for Children and Young People's Nurses (ACCYPN Ed.).

Australian College of Cosmetic Surgery. (2015). Professional Practice Standards and Scope of Practice for Aesthetic Nursing Practice in Australia (ACCS Ed.).

Australian College of Critical Care Nurses. (2015). Practice Standards for Specialist Critical Care Nurses (3rd ed.): ACCCN.

Australian College of Mental Health Nurses. (2018). Mental Health Practice Standards for Nurses in Australian General Practice 2018. Canberra: ACMHN.

Australian College of Neonatal Nurses. (2019). Standards for Practice (4th ed.): ACNN.

Australian College of Perioperative Nurses. (2020). Standards for Perioperative Nursing in Australia (16 ed.): ACORN.

131

Australian Commision on Safety and Quality in Health Care. (2018). Colonoscopy Clinical Care Standard. Sydney: ACSQHC.

Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards (2nd ed.). Sydney, NSW: ACSQHC.

Australian Diabetes Educators Association. (2017). National Competencies for Credentialled Diabetes Educators (ADEA). Canberra: ADEA.

Australian Education Network. (2015). Study Nursing Courses in Australia. Retrieved from http://www.australianuniversities.com.au/courses/australia/study/nursing/campus/c/d/all-nursing/

Australian Health Practitioner Registration Agency. (2017). Who We Are. Retrieved from https://www.ahpra.gov.au/About-AHPRA/Who-We-Are.aspx

Australian Institute of Health and Welfare. (2014). Australian Hospital Statistics 2013-2014 - emergency department care. Canberra: AIHW.

Australian Institute of Health and Welfare. (2018). Emergency department care 2017-18: Australian hospital Statistics. Health services series no. 89. Cat. no HSE 216. Canberra: AIHW.

Australian Institute of Health and Welfare. (2020). Emergency department care 2018-2019. Canberra: AIHW.

Australian Nursing & Midwifery Federation. (2016). Nursing Specialty: ANMF.

Australian Nursing and Midwifery Accreditation Council. (2014). Midwife Accreditation Standards. Canberra: ANMAC.

Australian Nursing and Midwifery Accreditation Council. (2015). Nurse Practitioner Accreditation Standards. Canberra: ANMAC.

Australian Nursing and Midwifery Accreditation Council. (2017). Enrolled Nurse Accreditation Standards (ANMAC Ed.). Canberra: ANMAC.

Australian Nursing and Midwifery Accreditation Council. (2019). Registered Nurse Accreditation Standards 2019. Canberra: ANMCAC.

Australian Qualifications Framework Council. (2012). Graduate: An Explanation. Retrieved from http://www.aqf.edu.au/wp-content/uploads/2013/06/Graduate-Explanation.pdf

Australian Qualifications Framework Council. (2013a). AQF specification for the Graduate Certificate. Retrieved from https://www.aqf.edu.au/sites/aqf/files/graduate-explanation.pdf

Australian Qualifications Framework Council. (2013b). Australian Qualifications Framework (2nd ed.): AQF.

Bagnasco, A., Tubino, B., Piccotti, E., Rosa, F., Aleo, G., Di Pietro, P., & Sasso, L. (2013). Identifying and correcting communication failures among health professionals working in the Emergency Department. Int. Emerg. Nurs, 21(3), 168-172. doi:10.1016/j.ienj.2012.07.005

http://www.australianuniversities.com.au/courses/australia/study/nursing/campus/c/d/all-nursing/

http://www.australianuniversities.com.au/courses/australia/study/nursing/campus/c/d/all-nursing/

https://www.ahpra.gov.au/About-AHPRA/Who-We-Are.aspx

http://www.aqf.edu.au/wp-content/uploads/2013/06/Graduate-Explanation.pdf

http://www.aqf.edu.au/wp-content/uploads/2013/06/Graduate-Explanation.pdf

https://www.aqf.edu.au/sites/aqf/files/graduate-explanation.pdf

132

Bagnasco, A., Zanini, M., Hayter, M., Catania, G., & Sasso, L. (2020). COVID 19—A message from Italy to the global nursing community. J Adv Nurs. doi:10.1111/jan.14407

Baid, H., & Hargreaves, J. (2015). Quality and safety: reflection on the implications for critical care nursing education. Nurs Crit Care, 20(4), 174-182. doi:10.1111/nicc.12182

Baker, T., & Dawson, S. (2013). What small rural emergency departments do: A systematic review of observational studies. Aust. J. Rural Health, 21, 254-261. doi:10.1111/ajr.12046

Baker, T., & Dawson, S. (2014). Small rural emergency services still manage acutely unwell patients: A cross-sectional study. EMA, 26, 131-138. doi:10.1111/1742-6723.12229

Barnhill, D., McKillop, A., & Aspinall, C. (2012). The Impact of Postgraduate Education on Registered Nurses Working in Acute Care. Nurs Prax NZ, 28(2), 27-36.

Baxter, R., & Evardsson, D. (2018). Impact of a critical care postgraduate certificate course on nurses' self-reported competence and confidence: A quasi-experimental study. Nurse Educ Today, 65, 156-161. doi:10.1016/j.nedt.2018.03.004

Benner, P. (1982). From Novice to Expert. American Journal of Nursing, 82(3), 402-407.

Biesta, G. (2015). Pragmatism and the Philosophical Foundations of Mixed Methods Research 1. In A. Tashakkori & C. Teddlie (Eds.), Mixed Methods in Social & Behavioural Research (pp. pp 95-118). Thousand Oaks: SAGE publications, Inc.

Bishop, F. (2015). Using mixed methods research designs in health psychology: An illustrated discussion from a pragmastist perspective. Br J Health Psychol, 20, 5-20. doi:10.1111/bjhp.12122

Bolin, T., Peck, D., Moore, C., & Ward-Smith, P. (2011). Competency and educational requirements: perspective of the rural emergency nurse. J Emerg Nurs, 37(1), 96-99. doi:10.1016/j.jen.2010.06.022

Bouchoucha, S., Wikander, L., & Wilkin, C. (2013). Assessment of simulated clinical skills and distance students: can we do it better? Nurse Educ Today, 33(9), 944-948. doi:10.1016/j.nedt.2012.11.00

Bowen, G. A. (2009). Document Analysis as a Qualitative Research Method. Qual. Res. J, 9(2), 27-40. doi:10.3316/qrj0902027

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. qual. Res. Psychol, 3(2), 77-101. doi:10.1191/1478088706qp063oa

Burns, S. (2011). Prediciting asademic progression for student registered nurse anesthetists. AANA J, 79(3), 193-201.

Callaghan, A., Kinsman, L., Cooper, S., & Radomski, N. (2017). The factors that influence junior doctors’ capacity to recognise, respond and manage patient deterioration in an acute ward setting: An integrative review. Aust Crit Care, 30(4), 197-209. doi:10.1016/j.aucc.2016.09.004

133

Callander, E. J., & Schofield, D. J. (2011). Emergency Department Workforce Models: What the literature can tell us. Emerg Med Australas, 23(1), 84-94. doi:10.1111/j.1742-6723.2010.01378.x

Campo, T., Comer, A., Evans, D. D., Kincaid, K., Norton, L., Ramirez, E. G., . . . Wilbeck, J. (2018). Practice Standards for the Emergency Nurse Practitioner Specialty. Adv Emerg Nurs J, 40(4), 240-245. doi:10.1097/TME.0000000000000209

Canadian Nurses Association. (2014). Emergency Nursing Core Competencies. Retrieved from http://nena.ca/w/wp-content/uploads/2014/11/NENA-Core-Competencies.pdf

Cashin, A., Buckley, T., Donoghue, J., Heartfield, M., Bryce, J., Cox, D., . . . Dunn, S. (2015). Development of the Nurse Practitioner Standards for Practice Australia. Policy, Polit Nurs Pract, 16(1-2), 27-37. doi:10.1177/1527154415584233

Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckely, T., Cox, D., . . . Fisher, M. (2017). Standards for practice for registered nurses in Australia. Collegian, 24, 255-266. doi:10.1016/j.colegn.2016.03.002

Castner, J., Grinslade, S., Guay, J., Hettinger, A. Z., Seo, J. Y., & Boris, L. (2013). Registered nurse scope of practice and ED complaint-specific protocols. J Emerg Nurs, 39(5), 467-473.e463. doi:10.1016/j.jen.2013.02.009

Chamberlain, D., Pollock, W., & Fulbrook, P. (2018). ACCCN Workforce Standards for Intensive Care Nursing: Systematic and evidence review, development, and appraisal. Aust Crit Care, 31, 292-302.

Chief Nursing and Midwifery Office. (2020). Specialising - information for nurses and midwives. Retrieved from Western Australia: https://ww2.health.wa.gov.au/Careers/Occupations/Nursing-and-midwifery/Specialising-information-for-nurses-and-midwives

Clough, B. (2020). On International Nurses Day, coronavirus means nurses are finally being noticed for their difficult work. ABC News. Retrieved from https://www.abc.net.au/news/2020-05-12/coronavirus-nurses-healthcare-professionals-frontline-workers/12235768

Cole, Z., Donohoe, H., & Stellefson, M. (2013). Internet-Based Delphi Research: Case Based Discussion. Environ Manage, 51(3), 511-523. doi:10.1007/s00267-012-0005-5

College of Emergency Nurses New Zealand. (2007). CENNZ Standards of Practice. Retrieved from http://www.nzno.org.nz/Portals/0/Docs/Groups/College%20of%20Emergency%20Nurses/2011-07-12%20Standards%20of%20practice%202007%20May%20(2).pdf

College of Emergency Nursing Australasia. (2008). Position Statement: Definiton of an Emergency Service. Surrey Hills, Victoria.

College of Emergency Nursing Australasia. (2014). Practice Standards for the Emergency Nursing Specialist. AENJ, 17(2), 77-90. doi:10.1016/j.aenj.2014.02.001

http://nena.ca/w/wp-content/uploads/2014/11/NENA-Core-Competencies.pdf


https://ww2.health.wa.gov.au/Careers/Occupations/Nursing-and-midwifery/Specialising-information-for-nurses-and-midwives

https://ww2.health.wa.gov.au/Careers/Occupations/Nursing-and-midwifery/Specialising-information-for-nurses-and-midwives

https://www.abc.net.au/news/2020-05-12/coronavirus-nurses-healthcare-professionals-frontline-workers/12235768

https://www.abc.net.au/news/2020-05-12/coronavirus-nurses-healthcare-professionals-frontline-workers/12235768

http://www.nzno.org.nz/Portals/0/Docs/Groups/College%20of%20Emergency%20Nurses/2011-07-12%20Standards%20of%20practice%202007%20May%20(2).pdf



134

College of Emergency Nursing Australasia. (2015). Triage and the Australasian Triage Scale. Hobart: CENA.

Considine, J., Curtis, K., Shaban, R., & Fry, M. (2018). Consensus-based clinical research priorities for emergency nursing in Australia. Australas Emerg Care, 21, 43-50. doi:10.1016/j.auec.2018.03.001

Continence Nurses Society Australia. (2017). Practice standards for Nurse Continence Specialists. (C. N. S. Australia Ed. 2nd ed.). Melbourne.

Cooper, S. J., Porter, J., & Endacott, R. (2011). Mixed methods research: a design for emergency care research? Emerg Med J, 28, 682-685. doi:10.1136/emj2010.096321

Cotterill-Walker, S. M. (2012). Where is the evidence that master's level nursing education makes a difference to patient care? A literature review. Nurse Educ Today, 32(1), 57-64. doi:10.1016/j.nedt.2011.02.001

Council of Deans of Nursing and Midwifery (Australia & New Zealand). (2017). Membership - Schools of Nursing and Midwifery. Retrieved from http://www.cdnm.edu.au/membership.html

Cowley-Evans, J. (2012). "Being managed to nurse". Emergency Nurse New Zealand, Spring, 6-9.

CRANAplus. (2016). Professional standards of remote practice: Nursing and Midwifery: CRANAplus.

Crawford, K., Morphet, J., Jones, T., Innes, K., Griffiths, D., & Williams, A. (2014). Initiatives to reduce overcrowding and access block in Australian emergency departments: A literature review. Collegian, 21(4), 359-366. doi:10.1016/j.colegn.2013.09.005

Creswell, J., & Plano Clark, V. (2011). Designing and Conducting Mixed Methods Research (2nd ed.). California: Sage Publications.

Critical Appraisal Skills Program. (2013). 10 questions to help you make sense of a review. Retrieved from http://media.wix.com/ugd/dded87_a02ff2e3445f4952992d5a96ca562576.pdf

Cross, R., Morphet, J., & Miller, C. (2018). Emergency nursing students' and nurse educators' perception of care delivery: A comparison study of self-assessment ratings`. Int Emerg Nurs, 41, 31-37. doi:10.1016/j.ienj.2018.05.006

Currie, J., & Crouch, R. (2008). How far is too far? Exploring the perceptions of the professions on their current and future roles in emergency care. Emerg Med J, 25(6), 335-339. doi:10.1136/emj.2007.047332

Curry, L. (2015). Mixed methods in health sciences research : a practical primer. Los Angeles: SAGE.

Curtin, M., & Fossey, E. (2007). Appraising the trustworthiness of qualitative studies: Guidelines for occupational therapists. Aust. Occup. Ther. J, 54, 88-94. doi:10.1111/j.1440-1630.2007.00661.x

http://www.cdnm.edu.au/membership.html

http://media.wix.com/ugd/dded87_a02ff2e3445f4952992d5a96ca562576.pdf

135

Curtis, K., Munroe, B., Van, C., & Elphick, T.-L. (2020). The implementation and usability of HIRAID, a structured approach to emergency nursing assessment. Australas Emerg Care., 23(1), 62-70. doi:10.1016/j.auec.2019.10.001

Curtis, K., & Wiseman, T. (2008). Back to basics—Essential nursing care in the ED: Part One. Australasian Emergency Nursing Journal, 11(1), 49-53. Retrieved from http://www.sciencedirect.com/science/article/pii/S1574626707002649. doi:http://dx.doi.org/10.1016/j.aenj.2007.11.004

Darcy Associates. (2015). Review of Postgraduate Nursing and Midwfiery Education in Victoria. Melbourne: Darcy Associates.

Davidson, J. E., Bloomberg, D., & Burnell, L. (2007). Scope creep: when nursing practice moves beyond traditional boundaries: an evidence-based example using procedural sedation. Crit Care Nurs Q, 30(3), 219-232. doi:10.1097/01.CNQ.0000278922.21821.52

DeGrande, H., Liu, F., Greene, P., & Stankus, J. (2018). The experiences of new graduate nurses hired and retained in adult intensive care units. Intensive & Critical Care Nursing, 49, 72-78. doi:10.1016/j.iccn.2018.08.005

Deloitte Access Economics. (2016). Cost of delivery of higher education. : Australian Department of Education and Training.

Diamond, I. R., Grant, R. C., Feldman, B. M., Pencharz, P. B., Ling, S. C., Moore, A. M., & Wales, P. W. (2014). Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol, 67(4), 401-409. doi:10.1016/j.jclinepi.2013.12.002

Dick, W. (2003). Anglo-American vs. Franco-German Emergency Medical Services System. Prehosp Disaster Med, 18(1), 29-37. doi:10.1017/S1049023X00000650

Dimond, B. (1995). The scope of professional practice and the accident and emergency nurse. Accid Emerg Nurs, 3(2), 105-107. doi:10.1016/0965-2302(95)90095-0

Donohoe, H., Stellefson, M., & Tennant, B. (2012). Advantages and Limitations of the e-Delphi Technique: Implications for Health Education Researchers. Am J Health Educ, 43(1), 38-46. doi:10.1080/19325037.2012.10599216

Doody, O., & Noonan, M. (2013). Preparing and conducting interviews to collect data. Nurse Res, 20(5), 28-32. doi:10.7748/nr2013.05.20.5.28.e327

Drennan, J. (2012). Masters in nursing degrees: an evaluation of management and leadership outcomes using a retrospective pre-test design. J Nurs Manag, 20(1), 102-112. doi:10.1111/j.1365-2834.2011.01346.x

Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Appl Nurs Res, 24(4), 244-255. doi:10.1016/j.apnr.2009.12.004

Eatlock, J., Clarke, M., Picton, C., & Young, T. (2015). Meeting the four-hour deadline in an A&E department. J Health Organ Manag, 25(6), 606-624. doi:10/1108/14777261111178510

http://www.sciencedirect.com/science/article/pii/S1574626707002649

http://dx.doi.org/10.1016/j.aenj.2007.11.004

136

Edmonds, L., Cashin, A., & Heartfield, M. (2013). Comparison of Australian specialty standards with registered nurse standards. Int Nurs Rev, 63, 162-179.

El-Banna, M., Briggs, L., Sagady Leslie, M., Athey, E., Pericak, A., Falk, N., & Greene, J. (2015). Does Prior RN Clinical Experience Predict Academic Success in Graduate Nurse Practitioner Programs? J Nurs Educ, 54(5). doi:10.3928/01484834-20150417-05

Emergency Nurses Association. (2008). Emergency Nursing Core Curriculum, 6th Edition: Elsevier.

Emergency Nurses Association. (2011). Emergency Nursing Scope and Standards of Practice, 2011 Edition. Des Plaines: ENA.

Emergency Nurses Association. (2017). Emergency Nursing Scope and Standards of Practice (ENA Ed. 2nd ed.). Des Plaines.

Emergency Nurses Association. (2018). Emergency Nursing: Core curriculum (7th ed.). St Louis, Missouri: Elsevier.

Estabrooks, CA, Midodzi, W., Cummings, G., Ricker, K., & Giovannetti, P. (2005). The Impact of Hospital Nursing Characteristics on 30-Day Mortality. Nursing Research, 54(2), 74-84.

European Society for emergency Nursing. (2017). Minimum standards for nurses working in Emergency Departments: EuSEN board.

Evans, C., & Donnelly, M. (2018). Deterred by debt? Young people, schools and the escalating cost of UK higher education. J Youth Stud, 21(9), 1267-1282. doi:10.1080/13676261.2018.1461815

Evans, L., & Kohl, D. (2014). Mission Impossible? Educating an Emergency Nurse. J Emerg Nurs, 40(3), 253-256. doi:10.1016/j.jen.2013.03.004

Faculty of Emergency Nursing. (2014). Comptency Framework - Member. Retrieved from http://www.fen.uk.com/member.html

Faculty of Emergency Nursing. (2019). Clinical Competency Framework, Member Level. Retrieved from https://fen.uk.com/competency-framework/

Fair Work Australia. (2012). Victorian Hospitals' Industrial Association (AG2012/9133). Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) enterprise agreement 2012-2016 (F. W. Australia, Trans.): FWA.

Fetters, M., Curry, L., & Creswell, J. (2013). Achieving Integration in Mixed Methods Designs - Principles and Practices. Health Serv Res, 48(6), 2134-2156. doi:10.1111/1475-6773.12117

Fetters, M., & Molina-Azorin, J. (2017). The Journal of Mixed Methods Research Starts a New Decade: The Mixed Methods research Integration Trilogy and Its Dimensions. J . Mix. Methods Res, 11(3), 291-307. doi:10.1177/1558689817714066

Fitzpatrick, J., Campo, T., & Gacki-Smith, J. (2014). Emergency Care Nurses: Certification, Empowerment, and Work-Related Variables. J Emerg Nurs, 40(2), e37-43. doi:10.1016/j.jen.2013.01.021

http://www.fen.uk.com/member.html

https://fen.uk.com/competency-framework/

137

Fitzpatrick, J., Campo, T., Graham, G., & Lavandero, R. (2010). Certification, empowerment, and intent to leave current position and the professional among critical care nurses. Am J Crit Care, 19(3), 218-226. doi:10.4037/ajcc2010442

Francis, J., Johnston, M., Robertson, C., Glidewell, L., Entwistle, E., Eccles, M., & Grimshaw, J. (2010). What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health, 25(10), 1229-1245. doi:10.1080/08870440903194015

Fry, M. (2008). Overview of emergency nursing in Australiasia. Int Emerg Nurs, 16, 280-286. doi:10.1016/j.ienj.2208.01.003

Fry, M., & MacGregor, C. (2014). Confidence and impact on clinical decision-making and behaviour in the emergency department. Australas Emerg Nurs J, 17(3), 91-97. doi:10.1016/j.aenj.2014.03.003

Fry, M., Shaban, R., & Considine, J. (2019). Emergency Nursing in Australia and New Zealand. In K. Curtis, C. Ramsden, R. Shaban, M. Fry, & J. Considine (Eds.), Emergency and Trauma Care for nurses and paramedics (pp. 3-16). Chatswood, NSW: Elsevier.

Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol, 13(1). doi:10.1186/1471-2288-13-117

Gerard, S. O., Kazer, M. W., Babington, L., & Quell, T. T. (2014). Past, Present, and Future Trends of Master's Education in Nursing. J Prof Nurs., 30(4), 326-332. doi:10.1016/j.profnurs.2014.01.005

Gill, F., Leslie, G., Grech, C., Boldy, D., & Latour, J. (2014). Developing and Testing the Standard of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT) for Critical Care Nursing Practice. J Contin Educ Nurs, 45(7), 312-320. doi:10.3928/00220124-20140620-02

Gill, F., Leslie, G., Grech, C., Boldy, D., & Latour, J. (2015). Development of Australian clinical practice outcome standards for graduates of critical care nurse education. J Clin Nurs, 24(3-4), 486-499. doi:10.1111/jocn.12631

Gill, F., Leslie, G., Grech, C., & Latour, J. (2012). A review of critical care nursing staffing, education and practice standards. Aust Crit Care, 25(4), 224-237. doi:10.1016/j.aucc.2011.12.056

Gill, F., Leslie, G., Grech, C., & Latour, J. (2013a). Health consumers' experiences in Australian critical care units: postgraduate nurse education implications. Nurs Crit Care, 18(2), 93-102. doi:10.1111/j.1478-5153.2012.00543.x

Gill, F., Leslie, G., Grech, C., & Latour, J. (2013b). Using a web-based survey tool to undertake a Delphi study: Application for nurse education research. Nurse Educ Today, 33(11), 1322-1328. doi:10.1016/j.nedt.2013.02.016

Gill, F., Leslie, G., Grech, C., & Latour, J. (2015). An analysis of Australian graduate critical care nurse education. Collegian, 22, 71-81. Retrieved from

138

http://www.sciencedirect.com/science/article/pii/S1322769613001236. doi:10.1016/j.colegn.2013.11.006

Glogowska, M. (2010). Paradigms, pragmatism and possibilities: mixed-methods research in speech and language therapy. Int J Lang Commun Disord, 46(3), 251-260. doi:10.3109/13682822.2010.507614

Glynn, P., & Silva, S. (2013). Meeting the needs of new graduate in the emergency department: A qualitative study evaluating a new graduate intership program. J Emerg Nurs, 39(2), 173-178. doi:10.1016/j.jen.2011.10.007

Goodwin, V., McMaster, R., Hyde, S., Appleby, M., & Fletcher, T. (2019). Qualitative evaluation of a postgraduate course in mental health nursing. Nurse Educ Pract, 36, 40-46. doi:10.1016/j.nepr.2019.02.015

Graham, B., Endacott, R., Smith, J., & Latour, J. (2019). 'They do not care how much you know until they know how much you care': a qualitative meta-synthesis of patient experience in the emergency department. Emerg Med J, 36, 355-363. doi:10.1136/emermed-2018-208156

Graham, B., & Smith, J. (2015). Understanding team, interpersonal and situational factors is essential for routine communication with patients in the emergency department (ED): A scoping literature review and formation of the 'T.IP.S' conceptual framework. J Commun Healthc, 9(3), 210-222. doi:10.1080/17538068.2016.1192370

Grant, J., Mitchell, C., & Cutherbertson, L. (2017). National Standards of Practice for Maternal, Child and Family Health Nursing Practice In Australia. Adelaide: Flinders Press

Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiro Med, 5(3), 101-117. doi:10.1016/s0899-3467(07)60142-6

Greene, J. (2015). Preserving distinctings within the multimethod and mixed methods merger. In S. Hesse-Biber & R. Johnson (Eds.), The Oxford handbook of multimethid and mixed methods research inquiry (pp. 606-615). New York, NY: Oxford University Press.

Griffith University. (2016). Research Ethics Manual - Privacy and confidentiality in human research Booklet 23. Office for Research

Grover, E., Porter, J., & Morphet, J. (2017). An exploration of emergency nurses' perceptions, attitudes and experiences of teamwork in the emergency department. Australas Emerg Nurs J, 20(2), 92-97. doi:10.1016/j.aenj.2017.01.003

Guba, E. G. (1981). Criteria for Assessing the Trustworthiness of Naturalistic Inquiries. Educational Communcation and Technology, 29(2), 75-91. Retrieved from https://www.jstor.org/stable/30219811.

Gullick, J., Lin, F., Massey, D., Wilson, L., Greenwood, M., Skylas, K., . . . Gill, F. (2019). Structures, processes and outcomes of specialist critical care nurse education:

http://www.sciencedirect.com/science/article/pii/S1322769613001236

https://www.jstor.org/stable/30219811

139

An integrative review. Aust Crit Care, 32(4), 331-345. doi:doi:10.1016/j.aucc.2018.09.007

Hackett, A., & Strickland, K. (2018). Using the framework approach to analyse qualitative data: a worked example. Nurse Res, 26(2), 8-13. doi:10.7748/nr.2018.e1580

Halcomb, E., Stephens, M., Bryce, J., Foley, E., & Ashley, C. (2017). The development of professional practice standards for Australian general practice nurses. J Adv Nurs, 73(8), 1958-1969. doi:10.1111/jan.13274

Halcomb, E., & Hickman, L. (2015). Mixed methods research. Nurs Stand, 29(32), 41-47. doi:10.7748/ns.29.32.41.e8858

Hall, J. N. (2013). Pragmatism, Evidence, and Mixed Methods Evaluation. New Dir Eval, 2013(138), 15-26. doi:10.1002/ev.20054

Harris, P., Taylor, R., Minor, B., Elliott, V., Fernandez, M., O'Neal, L., . . . Duda, S. (2019). The REDCap consortium: Building an international community of software platform partners. J Biomed Inform, 95. doi:10.1016/j.jbi.2019.103208

Harris, P., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 42(2), 377-381. doi:10.1016/j.jbi.2008.08.010

Hasson, F., & Keeney, S. (2011). Enhancing rigour in the Delphi technique research. Technolo Forecast Soc Change, 78(9), 1695-1704. doi:10.1016/j.techfore.2011.04.005

Heal, C., D'Souza, K., Banks, J., Malau-Aduli, B., Turner, R., & Smith, J. (2018). A snapshot of current Objective Structured Clinical Examination (OSCE) practice at Australian medical schools. Med Teach, 41(4), 441-447. doi:10.1080/0142159X.2018.1487547

Health Workforce Australia. (2014). Australia's Future Health Workforce - Nurses Detailed. Canberra: Department of Health.

Helms, C., Gardner, A., & McInnes, E. (2016). Consensus on an Australian Nurse practitioner specialty framework using Delphi methodology: results form the CLLEVER 2 study. J Adv Nurs, 73(2), 433-447. doi:10.1111/jan.13109

Hendricks, J., Mooney, D., Crosby, D., & Forrester, K. (1996a). Education in emergency nursing: a new beginning. Part 2. Accid Emerg Nurs, 4(3), 156-159. doi:10.1016/s0965-2302(96)90064-8

Hendricks, J., Mooney, D., Crosby, D., & Forrester, K. (1996b). Education in emergency nursing: A new beginning. Part I. Accid Emerg Nurs, 4(2), 78-81. doi:10.1016/s0965-2302(96)90007-7

Henrik, A., & Kerstin, N. (2009). Questioning Nursing Competences in Emergency Health Care. J Emerg Nurs, 35(4), 305-311. doi:10.1016/j.jen.2008.06.015

140

Hermann, R., Long, E., & Trotta, R. (2019). Improving Patients' Experiences Communcating With Nurses and Providers in the Emergency Department J Emerg Nurs, 45(5), 523-530. doi:10.1016/j.jen.2018.12.001

Hickman, L. D., DiGiacomo, M., Phillips, J., Rao, A., Newton, P. J., Jackson, D., & Ferguson, C. (2018). Improving evidence-based practice in postgraduate nursing programs: A systematic review: Bridging the evidence practice gap (BRIDGE project). Nurse Educ Today, 63, 69-75. doi:10.1016/j.nedt.2018.01.015

Homer, C. S. E., Passant, L., Kildea, S., Pincombe, J., Thorogood, C., Leap, N., & Brodie, P. M. (2007). The development of national competency standards for the midwife in Australia. Midwifery, 23(4), 350-360. doi:10.1016/j.midw.2006.03.008

Howard, P., & Papa, A. (2012). Future-of-Nursing Report: The Impact on Emergency Nursing. J Emerg Nurs, 38(6), 549-552. doi:10.1016/j.jen.2012.08.001

Hsieh, H., & Shannon, S. (2005). Three Approaches to Qualitative Content Analysis Qual. Health Res, 15, 1277-1288. doi:10.1177/1049732305276687

IBM Corporation. (2019). IBM SPSS Statistics for Windows, Version 26.0. New York: Armonk.

Ilangakoon, C., Jones, T., Innes, K., & Morphet, J. (2020). Caring for deteriorating paediatric patients in the emergency department: A mixed-method study. Australas Emerg Care, In Press. doi:10.1016/j.auec.2020.07.006

Jeffrey, C., Mitchell, M., Henderson, A., Lenthall, S., Knight, S., Glover, P., . . . Groves, M. (2014). The value of best-practice guidlines for OSCEs in a postgraduate program in an Australian remove area setting. Rural and Remote Health, 14(3), 2469. doi:10.22605/RRH2469

Jiang, J., Zeng, L., Kue, J., Li, H., Shi, Y., & Chen, C. (2018). Effective teaching behaviors in the emergency department: A qualitative study with Millennial nursing students in Shanghai. Nurse Educ Today, 61, 220-224. doi:10.1016/j.nedt.2017.12.007

Johnson, F., Best, W., Beckley, F., Maxim, J., & Beeke, S. (2017). Identifying mechanisms of change in a coversation therapy for aphasia using behaviour change theory and qualitative methods. Int J Lang Commun Disord, 52(3), 374-387. doi:10.1111/1460-6984.12279

Johnson, R., Onwuegbuzie, A., & Turner, L. (2007). Toward a Definition of Mixed Methods Research. J . Mix. Methods Res, 1(2), 112-133. doi:10.1177/1558689806298224

Jones, T., Curtis, K., & Shaban, R. (2020a). Academic and professional characteristics of Australian graduate emergency nursing programs: A national study. Australas Emerg Care, In press. doi:10.1016/j.auec.2020.02.003

Jones, T., Curtis, K., Shaban, RZ. (2020b). Practice Expectations of Australian Graduate Emergency Nursing Programs: A Delphi Study. Manuscript accepted for publication.

141

Jones, T., Shaban, R., & Creedy, D. (2015). Practice standards for emergency nursing: An international review. Australas Emerg Nurs J, 18(4), 190-203. doi:10.1016/j.aenj.2015.08.002

Källberg, AS., Ehrenberg, A., Florin, J., Östergren, J., & Göransson, K. E. (2017). Physicians’ and nurses’ perceptions of patient safety risks in the emergency department. Int Emerg Nurs, 33, 14-19. doi:10.1016/j.ienj.2017.01.002

Keeney, S. (2011). The Delphi technique in nursing and health research. Chichester, West Sussex: Wiley-Blackwell.

Kennedy, B., Curtis, K., & Waters, D. (2014). The personality of emergency nurses: Is it unique? Australas Emerg Nurs J, 17(4), 139-145. doi:10.1016/j.aenj.2014.07.002

Kidd, T., Kenny, A., & Meehan-Andrews, T. (2012). The experience of general nurses in rural Australian emergency departments. Nurse Educ Pract, 12(1), 11-15. doi:10.1016/j.nepr.2011.05.001

Kiernan, M. D., & Hill, M. (2018). Framework analysis: a whole paradigm approach. Qual. Res. J, 18(3), 248-261. doi:10.1108/QRJ-D-17-00008

Lapierre, A., Lefebvre, H., & Gauvin-Lepage, J. (2019). Factors Affecting Interprofessional Teamwork in Emeregncy Department are of Polytrauma Patients: Results of an Exploratory Study. Journal of Trauma nursing, 26(6), 312-322. doi:10.1097/JTN.0000000000000469

Lasater, K. (2011). Clinical judgement: The last frontier for evaluation. Nurse Educ Pract, 11(2), 86-92. doi:10.1016/j.nepr.2010.11.013

Lenthal, S., Wakerman, J., Opie, T., Dollard, M., Dunn, S., Knight, S., . . . Watson, C. (2009). What stresses remote area nurses? Current knowledge and future action. Aust J Rural Health, 17(4), 208-213. doi:10.1111/j.1440-1584.2009.01073.x

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. California: Sage Publications.

Lothian, J., Jolley, D., Curtis, A., Currell, A., Cameron, P., Stoelwinder, J., & McNeil, J. (2011). The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015. MJA, 194(11), 574-578. doi: 10.5694/j.1326-5377.2011.tb03107.x

Lyneham, J., Parkinson, C., & Denholm, C. (2008a). Explicating Benner's concept of expert practice: Intuition in emergency nursing. J Adv Nurs, 64(4), 380-387. doi:10.1111/j.1365-2648.2008.04799.x

Lyneham, J., Parkinson, C., & Denholm, C. (2008b). Intuition in emergency nursing: A phenomenological study. Int J Nurs Pract, 14(2), 101-108. doi:10.1111/j.1440-172X.2008.00672.x

Mackavey, C., & Cron, S. (2019). Innovative strategies: Increased engagement and synthesis in online advanced practice nursing education. Nurse Educ Today, 76, 85-88. doi:10.1016/j.nedt.2019.01.010

142

Maringe, F. (2006). University and course choice: Implications for positioning, recruitment and marketing. Int. J. Educ. Manag, 20(6), 446-479. doi:10.1108/09513540610683711

Marshall, A. P., Currey, J., Aitken, L. M., & Elliott, D. (2007). Key stakeholders' expectations of educational outcomes from Australian critical care nursing courses: A Delphi study. Australian Critical Care, 20(3), 89-99. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-34547126906&partnerID=40&md5=dc69978f83201e6a458251a0b3e6ef2b. doi:10.1016/j.aucc.2007.05.001

McCarthy, G., Cornally, N., Mahoney, C. O., White, G., & Weathers, E. (2013). Emergency nurses: Procedures performed and competence in practice. International Emergency Nursing, 21(1), 50-57. doi:10.1016/j.ienj.2012.01.003

McClelland, H. (2012). Editorial - The Future of Nursing for Emergency Care. Int Emerg Nurs, 20(2), 49-50. doi:10.1016/j.ienj.2012.02.003

McClelland, M., Lazar, D., Sears, V., Wilson, M., Siegel, B., & Pines, J. (2011). The Past, Present, and Future of Urgent Matters: Lessons Learned from a Decade of Emergency Department Flow Improvement. Acad Emerg Med, 18(12), 1392-1399. doi:10.1111/j.1553-2712.2011.01229.x

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. J Clin Epidemiol, 62(10), 1006-1012. doi:10.1016/j.jclinepi.2009.06.005

Morgan, D. L. (2007). Paradigms Lost and Pragmatism Regained: Methodological Implications of Combining Qualitative and Quantitative Methods. J . Mix. Methods Res, 1(1), 48-76. doi:10.1177/2345678906292462

Morphet, J., Considine, J., & McKenna, L. (2011). Transition to specialty practice programs in emergency nursing - A review of the literature. Australas Emerg Nurs J, 14(1), 45-49. doi:10.1016/j.aenj.2010.11.001

Morphet, J., Kent, B., Plummer, V., & Considine, J. (2016a). Profiling nursing resources in Australian emergency departments. Australas Emerg Nurs J, 19(1), 1-10. doi:10.1016/j.aenj.2015.12.002

Morphet, J., Kent, B., Plummer, V., & Considine, J. (2016b). Transition to Specialty Practice Program characteristics and professional development outcomes. Nurse Educ Today, 44, 109-115. doi:10.1016/j.nedt.2016.05.017

Morphet, J., Plummer, V., Kent, B., & Considine, J. (2017). A framework for transistion to specialty practice programmes. J Adv Nurs, 73(8), 1970-1981. doi:10.1111/jan.13279

Morphet, J., Kent, B., Plummer, V., & Considine, J. (2015). The effect of Transition to Specialty Practice programs on Australian emergency nurses' professional development, recruitment and retention. Australas Emerg Nurs J, 18, 204-211. doi:dx.doi.org/10.1016/j.aenj.2015.08.001

Morse, J. (2015). Critical Analysis of Strategies for Determining Rigor in Qualitative Inquiry. Qual. Health Res, 25(9), 1212-1222. doi:10.1177/1049732315588501

http://www.scopus.com/inward/record.url?eid=2-s2.0-34547126906&partnerID=40&md5=dc69978f83201e6a458251a0b3e6ef2b

http://www.scopus.com/inward/record.url?eid=2-s2.0-34547126906&partnerID=40&md5=dc69978f83201e6a458251a0b3e6ef2b

143

Munroe, B., Curtis, K., Buckely, T., Lewis, M., & Atkins, L. (2018). Optimising implmementation of a patient-assessment framework for emergency nurses: A mixed-method study. J Clin Nurs, 269-286. doi:10.1111/jocn.13932

Munroe, B., Curtis, K., Murphy, M., Strachan, L., & Buckely, T. (2015). HIRAID: An evidence-informed emergency nursing assessment framework. Australas Emerg Nurs J, 18(2), 83-97. doi:10.1016/j.aenj.2015.02.001

Nagle, C., McDonald, S., Morrow, J., Kruger, G., Cramer, R., Couch, S., . . . Heartfield, M. (2019). Informing the development midwivery standards for practice: A literature review for policy development. Midwifery, 76, 8-20. doi:10.1016/j.midw.2019.05.007

National Emergency Nurses Association. (2014). Emergency Nursing Core Competencies. Retrieved from http://nena.ca/w/wp-content/uploads/2014/11/NENA-Core-Competencies.pdf

National Emergency Nurses Association. (2018). Emergency Nursing Scope and Standards of Canadian Practice (NENA Ed. 6th Edition ed.).

National Health and Medical Research Council. (2018). National Statement on Ethical Conduct in Human research 2007 (Updated 2018). Canberra: The Australian Research Council and Universities Australia

National Nursing & Nursing Education Taskforce. (2006). A National Specialisation Framework For Nursing And Midwifery. Melbourne: Department of Human Services.

Nayna Schwerdtle, P., Connell, C., Lee, S., Plummer, V., Russo, P., Endacott, R., & Kuhn, L. (2020). Nurse Expertise: A Critical Resource in the COVID-19 Pandemic Response Ann Glob Health, 86(1), 1-5. doi:10.5334/aogh.2898

Neville, C., Eley, D., Hangan, C., Weir, J., Quinn, J., & Meehan, T. (2010). Standards of Practice for Australian Menthal Health Nurses: 2010 (P. Marks Ed.). Canberra, ACT: Australian College of Mental Health Nurses.

Neville, C., Hangan, C., Eley, D., Quinn, J., & Weir, J. (2008). Mental health nursing standards for Australia: A review of current literature. Int J Ment Health Nurs, 17(2), 138-146. doi:10.1111/j.1447-0349.2008.00522.x

Ng, L., Eley, R., & Tuckett, A. (2016). Exploring factors affecting registered nurses' pursuit of postgraduate education in Australia. Nurse Health Sci, 18(4), 435-441. doi:10.1111/nhs.12289

Niemczyk, N., Cutts, A., & Perlman, D. (2018). Prior Work and Educational Experience Are Not Associated With Successful Completion of a Master's-Level, Distance Education Midwifery Program. J Midwifery Womens Health, 63(2), 161-167. doi:doi:10.1111/jmwh.12716

Nixon, V. (2008). Identification of the development needs for the emergency care nursing workforce. Int Emerg Nurs, 16(1), 14-22. doi:10.1016/j.ienj.2007.10.001



144

Noon, A. J. (2014). The cognitive processes underpinning clinical decision in triage assessment: A theoretical conundrum? Int Emerg Nurs, 22(1), 40-46. doi:10.1016/j.ienj.2013.01.003

Norton, A., & Cherastidtham, I. (2015). University fees: what students pay in deregulated markets: Grattan Institute.

Nursing and Midwifery Board Australia. (2014). Nurse practitioner standards for practice. Retrieved from http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

Nursing and Midwifery Board Australia. (2016a). Fact sheet - Advanced nursing practice and specialty areas within nursing. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/fact-sheet-advanced-nursing-practice-and-specialty-areas.aspx

Nursing and Midwifery Board Australia. (2016b). Registered nurses standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Nursing and Midwifery Board Australia. (2018). Midwife standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/Midwife-standards-for-practice.aspx

Nursing and Midwifery Board of Australia. (2006). National competency standards for the registered nurse. Melbourne: NMBA.

O'Connell, J., Gardner, G., & Coyer, F. (2014a). Beyond competencies: using a capability framework in developing practice standards fro advanced practice nursing. J. Adv. Nurs, 70(12), 2728-2735. doi:10.1111/jan.12475

O'Connell, J., Gardner, G., & Coyer, F. (2014b). Profiling Emergency Nurse Practitioner Service. An Interpretive Study. Adv Emerg Nurs J, 36(3), 279-290. doi:10.1097/TME.0000000000000030

O’Connell, J., & Gardner, G. (2012). Development of clinical competencies for emergency nurse practitioners: A pilot study. Australas Emerg Nurs J, 15(4), 195-201. doi:10.1016/j.aenj.2012.10.004

Ochieng, P. A. (2009). An Analysis of the strengths and limitations of qualitative research paradigms. Probl. Educ. 21st Century, 13, 13-18.

Ortega, K., Burns, S., Hussey, L., Schmidt, J., & Austin, P. (2013). Prediciting Success in Nurse Anesthesia Programs: An Evidence-Based Review of Admission Criteria. AANA J, 81(3), 183-189.

Ostaszkiewicz, J., Thompson, J., & Watt, E. (2019). A national project to develop and validate practice standards for Australian nurse continence specialists. ANZCJ, 25(1), 16-21.

Østerås, N., Gulbrandsen, P., Garratt, A., Benth, J. Š., Dahl, F. A., Natvig, B., & Brage, S. (2008). A randomised comparison of a four- and a five-point scale version of

http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/fact-sheet-advanced-nursing-practice-and-specialty-areas.aspx



https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx



https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/Midwife-standards-for-practice.aspx

https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/Midwife-standards-for-practice.aspx

145

the Norwegian Function Assessment Scale. Health Qual Life Outcomes, 6(1), 14. doi:10.1186/1477-7525-6-14

Pallant, J. (2016). SPSS Survival Manual: a step by step guide to data analysis using SPSS (6th ed.). Melbourne: Allen & Unwin.

Palliative Care Australia. (2018). National Palliative Care Standards (P. C. Australia Ed. 5th ed.).

Parkinson, S., Eatough, V., Holmes, J., Stapley, E., & Midgley, N. (2016). Framework analysis: a worked example of a study exploring young people’s experiences of depression. qual. Res. Psychol, 13(2), 109-129. doi:10.1080/14780887.2015.1119228

Penz, K., Stewart, N., Karunanayake, C., Kosteniuk, J., & MacLeod, M. (2019). Competence and confidence in rural and remote nursing practice: A structural equation modelling analysis of national data J Clin Nurs, 28, 1664-1679. doi:10.1111/jocn.14772

Perry, A. (2013). The Clinical Nurse Leader: Improving Outcomes and Efficacy in the Emergency Department. J Emerg Nurs, 39(4), 334-339. doi:10.1016/j.jen.2011.10.001

Pitt, V., Powis, D., Levett-Jones, T., & Hunter, S. (2012). Factors influencing nursing students' academic and clinical performance and attrition: An integrative literature review. Nurse Educ Today, 32(8), 903-913. doi:10.1016/j.nedt.2012.04.011

Pool, I. A., Poell, R. F., Berings, M. G. M. C., & ten Cate, O. (2016). Motives and activities for continuing professional development: An exploration of their relationships by integrating literature and interview data. Nurse Educ Today, 38, 22-28. doi:10.1016/j.nedt.2016.01.004

Potter, C. (2006). To what extent do nurses and physicians working within the emergency department experience burnout: A review of the literature. Australas Emerg Nurs J, 9, 57-64. doi:10.1016/j.aenj.2006.03.006

Proehl, J., & Hoyt, S. (2015). Keeping It Real: Advocating for Patients and Nurses. Adv Emerg Nurs J, 37(3), 147-148. doi:10.1097/TME.0000000000000072

Pugh, D., Hamstra, S., Wood, T., Humphrey-Murto, S., Touchie, C., Yudkowsky, R., & Bordage, G. (2015). A procedural skills OSCE: assessing technical and non-technical skills of internal medicine residents. Adv in Health Sci Educ, 20, 85-100. doi:10.1007/s10459-014-9512-x

Rautiainen, E., & Vallimies-Patomäki, M. (2016). A review of the organization, regulation, and financing practices of postgraduate education in clinical nursing in 12 European countries. Nurse Educ Today, 36, 96-104. doi:10.1016/j.nedt.2015.08.004

Redley, B., Botti, M., Wood, B., & Bucknall, T. (2017). Interprofessional communication supporting clinical handover in emergency departments: An observation study. Australas Emerg Nurs J, 20, 122-130. doi:10.1016/j.aenj.2017.05.003

146

Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. London: Routledge.

Ritchie, J., Spencer, L., & O'Connor, W. (2003). Carrying out Qualitative Analysis. London: SAGE Publications.

Rose, L., & Gerdtz, M. (2007). Invasive ventilation in the emergency department: Part 2: Implications for patient safety. Australasian Emergency Nursing Journal, 10(1), 26-29. doi:10.1016/j.aenj.2006.10.002

Rose, L., & Gerdtz, M. F. (2009). Mechanical ventilation in Australian emergency departments: survey of workforce profile, nursing role responsibility, and education. Australasian Emergency Nursing Journal, 12(2), 38-43. doi:10.1016/j.aenj.2009.01.003

Rowley, J. (2012). Conducting research interviews. Manag. Res. Rev, 35(3/4), 260-271. doi:10.1108/01409171211210154

Rubio-Navarro, A., Jose Garcia-Capilla, D., Jose Torralba-Madrid, M., & Rutty, J. (2019). Ethical, legal and professional accountability in emeregncy nursing practice: An ethnographic observational study. Int Emerg Nurs, 46, 100777. doi:10.1016/j.ienj.2019.05.003

Rubio-Navarro, A., Jose Garcia-Capilla, D., Jose Torralba-Madrid, M., & Rutty, J. (2020). Accountability issues in an English emergency department: A nursing perspective. Int Emerg Nurs, 51, 100881. doi:10.1016/j.ienj.2020.100881

Sayers, J., DiGiacomo, M., & Davidson, P. (2011). The nurse educator role in the acute care setting in Australia: important but poorly described. Aust J Adv Nurs, 28(4), 44-52.

Sbaih, L. (1995). To do or not to do: use of the Scope of Professional Practice in accident and emergency work. Accid Emerg Nurs, 3(1), 7-13. doi:10.1016/0965-2302(95)90053-5

Sbaih, L. (1997). Becoming an A & E nurse. Accident & Emergency Nursing, 5(4), 193-197. doi:10.1016/s0965-2302(97)90028-x

Schneider, Z., Whitehead, D., LoBiondo-Wood, G., & Haber, J. (2016). Nursing and midwifery research: methods and appraisal for evidence-based practice (5th ed.). Chatswood; NSW: Elsevier.

Schull, M., Guttmann, A., Leaver, C., Vermeulen, M., Hatcher, C., Rowe, B., . . . Anderson, G. (2011). Prioritizing perfomrance measurement for emergency department care: sconsensus on evidence-based quality of care indicators. CJEM, 13(5), 300-309. doi:10.2310/8000.2011.110334

Schwandt, T. A., Lincoln, Y. S., & Guba, E. G. (2007). Judging interpretations: But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. Educ. Psychol, 2007(114), 11-25. doi:10.1002/ev.223

Scott, H. (2004). Should nurses in emergency care have practice boundaries? Br J Nurs, 13(1), 4-4. doi:10.12968/bjon.2004.13.1.11975

Silverman, D. (2011). Interpreting Qualitative Data (4th ed.). London: Sage.

147

Smith, J., & Firth, J. (2011). Qualitative data analysis: the framework approach. Nurs Res, 18(2), 52-62. doi:10.7748/nr2011.01.18.2.52.c8284

Snyder, A., Keeling, A., & Razionale, C. (2006). From "First Aid Rooms" to advanced practice nursing: A glimpse into the history of emergency nursing. Adv Emerg Nurs J, 28(3), 198-209. doi:10.1097/01261775-200607000-00006

Sole, G., Claydon, L., Hendrick, P., Hagberg, J., Jonsson, J., & Harland, T. (2012). Employers' perspectives of competences and attributes of physiotherapy graduates: an exploratory qualitative study. New Zealand Journal of Physiotheraphy, 40(3), 123-127.

Sullivan, C., Staib, A., Griffin, B., Bell, A., & Scott, I. (2016a). The Four Hour Rule: The National Emergency Access Target in Australia. Time to Review. Systematic Literature Review Appendix A. Aust Health Rev, 40(3), 319-323. doi:10.1071/AH15071_AC

Sullivan, C., Staib, A., Khanna, S., Good, N., Boyle, J., Cattell, R., . . . Scott, I. (2016b). The National emergency Access Target (NEAT) and the 4-hour rule: time to review the target. Med J Aust, 204(9). doi:10.5694/mja15.01177

Sullivan, E., Hegney, D., & Frances, K. (2012). Victorian rural emergency care - a case for advancing nursing practice. Int J Nurs Pract, 18(3), 226-232. doi:10.1111/j.1440-172X.2012.02021

Szekeres, J. (2010). Sustaining student numberes in the competitive marketplace. J. High. Educ. Policy. Manag, 32(5), 429-439. doi:10.1080/1360080X.2010.511116

Tashakkori, A., & Teddlie, C. (1998). Mixed methodology: Combining qualitative and quantitative approaches. Thousand Oaks, CA: Sage.

Taylor, B., & Francis, K. (2013). Qualitative Research in the Health Sciences: Methodologies, methods and proccesses. Oxon, UK: Routledge.

Teddlie, C., & Tashakkori, A. (2009). Foundations of Mixed Methods Research. Los Angeles: Sage.

Tertiary Education Quality and Standards Agency. (2015). Higher Education Standards Fraemwork (Threshold Standards) 2015 - TEQSA Contextual Overview (A. Government Ed. Vol. Version 1.1). Canberra: Australian Government.

The Australian Nurse Teachers' Society. (2010). Australian Nurse Teacher Professional Practice Standards: ANTS.

The University of Sydney. (2014). Research Data Management Policy 2014.

The University of Sydney. (2018). Research Code of Conduct 2013. Sydney.

Thompson, C., Williams, K., Morris, D., Quinsey, K., Bird, S., Kobel, C., . . . Masso, M. (2014). HWA Expanded Scopes of Practice Program Evaluation: Nurses in the Emergency Department Sub-Project - Final Report. University of Wollongong: Centre for Health Service Development, Australian Health Services Research Institute.

148

Timmings, R. W. (2006). Rural and Isolated Practice Registered Nurse (RIPRN) -- emergency nurses of the Queensland 'bush'. Australas Emerg Nurs J, 9(1), 29-34. doi:10.1016/j.aenj.2006.01.001

Toronto, C. (2017). Considerations when conducting e-Delphi research: a case study. Nurs Res, 25(1), 10-15. doi:10.7748/nr.2017.e1498

Trevelyan, E., & Robinson, N. (2015). Delphi methodology in health research: how to do it? J. Integr. Med, 7(4), 423-428. doi:doi.org/10.1016/j.eujim.2015.07.002

Valdez, A. M. (2009). So much to learn, so little time: Educational priorities for the future of emergency nursing. Adv Emerg Nurs J, 31(4), 337-353. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-73849101878&partnerID=40&md5=3408cf1829cb059e921bfb0f600ecaad. doi:10.1097/TME.0b013e3181bcb571

Vanderspank-Wright, B., Lalonde, M., Smith, C., Wong, S., & Bentaz, J. (2019). New Graduate Nurse Transition Into the Intensive Care Unit: Qualitative Insights From a Longitudinal Study - Part 1. Res Theory Nurs Pract, 33(4), 428-444. doi:10.1891/1541.6577.33.4.428

Varndell, W., Fry, M., Lutze, M., & Elliot, D. (2020). Use of the Dephi method to generate guidance in emergency nursing practice: A systematic review. Int. Emerg. Nurs, In Press. doi:10.1016/j.ienj.2020.100867

Victorian Government. (2015). Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Act 2015 (C. P. Counsel, Trans.). In 003 (pp. 68).

Victorian Government. (2019). Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Amendment Act 2019. Retrieved from: https://content.legislation.vic.gov.au/sites/default/files/61fd645b-ff4f-3131-a61d-0032eaf538b4_19-001aa%20authorised.pdf

Walker-Cillo, G. A., & Harding, A. (2013). The Art of Remediation in Professional Emergency Nursing Practice. Adv Emerg Nurs J, 35(2), 129-142. doi:10.1097/TME.0b013e31828dc4b2

Wangensteen, S., Finnbakk, E., Adolfsson, A., Kristjansdottir, G., Roodbol, P., Ward, H., & Fagerström, L. (2018). Postgraduate nurses' self-assessment of clinical competence and need for further training. A European cross-sectional survey. Nurse Educ Pract, 62, 101-106. doi:10.1016/j.nedt.2017.12.020

Ward, D., Furber, C., Tierney, S., & Swallow, V. (2013). Using Framework Analysis in nursing research: A worked example. J. Adv. Nurs, 69(11), 2423-2431. doi:10.1111/jan.12127

Ward, M. (2012). National School Nursing Professional Practice Standards (2nd ed.): VSN.

White, K., Macfarlane, H., Hoffmann, B., Sirvas-Brown, H., Hines, K., Rolley, J., & Grahan, S. (2018). Consensus Statement of Standards for Interventional Cardiovascular Nursing Practice. Heart, Lung Circ, 27, 535-551. doi:10.1016/j.hlc.2017.10.022

http://www.scopus.com/inward/record.url?eid=2-s2.0-73849101878&partnerID=40&md5=3408cf1829cb059e921bfb0f600ecaad

http://www.scopus.com/inward/record.url?eid=2-s2.0-73849101878&partnerID=40&md5=3408cf1829cb059e921bfb0f600ecaad

149

Williams, S., & Crouch, R. (2006). Emergency department patient classificaiton systems: A systematic review. Accid Emerg Nurs, 14, 160-170. doi:10.1016/j.aaen.2006.06.002

Wounds Australia. (2016). Standards for Wound Prevention and Management (3rd Edition ed.). Osbrone Park, WA: Cambridge Media.

150

Appendix 1: Ethics Approval Email for Study Two

151

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?

152

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


Professor Kate Curtis, School of Nursing, The University of Sydney,

New South Wales


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

mailto:[email protected]



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

or [email protected].

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.”

http://www.griffith.edu.au/about-griffith/plans-publications/griffith-university-privacy-plan

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


Supervisors: Professor Ramon Shaban Marie Bashir Institute for

Infectious Diseases & Biosecurity, Westmead Institute for Medical

Research, NSW, 2145


Professor Kate Curtis, School of Nursing, The University of Sydney,

New South Wales


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

[email protected]

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


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

[email protected]

(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


☐ Other specialist qualification (Please specify)


4. What is your highest qualification in emergency nursing

☐Graduate Certificate

☐Graduate Diploma

☐Masters

☐PhD

☐ Other (please specify)


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)


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


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


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


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


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


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


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


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


regarding the theme of: Research and Quality Improvement

Theme: Ethics and Law


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


regarding the theme of: Ethics and Law

Theme: Teamwork and Leadership


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


regarding the theme of: Teamwork and Leadership

Theme: Professional development


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


regarding the theme of: Professional Development

Theme: Clinical practice and expertise


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


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


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



Acute Kidney Injury (AKI)

Acute Pancreatitis

Biliary tract disease

Chronic Kidney Disease (CKD)

Complications associated with liver cirrhosis

Testicular torsion


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


Shock

Cardiogenic shock

Distributive shock

Hypovolaemic Shock

Obstructive shock


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


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


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


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


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


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)


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


186

Emergency Nursing Course requirements

Our 2019 review of all graduate emergency nursing courses in Australia showed there are 14 tertiary emergency nursing courses offered by Australian universities. Each of these courses is unique with distinct academic and professional characteristics. These courses vary in entry requirements, prior experience and the hours of full time equivalent (FTE) that students are required to work in an emergency care setting. We seek your professional opinions on a range of academic and professional characteristics of graduate emergency nursing courses. You will notice that this survey is mostly the same as round 1. This is intentional. The purpose is to generate consensus amongst emergency nurses with regards to graduate emergency nursing attributes and expectations.

10. In my professional opinion nurses wanting to undertake graduate studies in

emergency nursing should have prior acute care clinical experience as a registered nurse:

☐ Yes

☐ No

☐ Other Comment/Explanation for decision:

11. In my professional opinion nurses wanting to undertake graduate studies in

emergency nursing should have prior clinical experience as a registered nurse in the:

☐ Emergency Department

☐ Emergency care setting

☐ Acute care setting

☐ Prior clinical experience Is not required

☐ Other


12. I believe nurses completing graduate studies in emergency nursing should be working the following minimum Full Time Equivalent (FTE) clinical practice hours in an approved emergency care environment:

☐ 0.8 FTE

☐ 0.6 FTE

☐ 0.5 FTE

☐ There should be no mandated hours of clinical practice Comment/Explanation for decision:

Our review also showed that a number of courses will not allow nurses working in a Level 1 emergency department or a remote emergency care clinic to enrol in their graduate emergency nursing course, unless the student is able to complete a rotation in a Level 3 or Level 4 emergency department. Please indicate your agreement with the statements below. These statements relate to students completing graduate emergency nursing studies.

187

13. In my professional opinion, nurses working in rural and remote areas or Level 1 emergency departments, with no exposure to a Level 3 or Level 4 emergency department, should be able to undertake graduate emergency nursing courses:

☐ Yes

☐ No


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


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


☐ 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


☐ Other


188

In the following "Graduate Expectations" section we ask you to indicate your level of agreement with the statements below. The level of agreement ranges from Strongly Agree, to Strongly Disagree. For each of the following statements, please consider your clinical practice expectations of a nurse who has just completed their graduate certificate studies in emergency nursing

Please feel free to add any additional explanations, comments or practice expectations.

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

Graduate Expectations: Communication On completion of the graduate emergency nursing course the graduate will be able to:

1 Communicate effectively with the patient, their family and support people, considering factors such as cognitive impairment, level of health literacy, culture and ethnicity

2 Effectively communicate with patients, families and support people regarding assessment findings and management plans

3 Effectively communications with colleagues, including the multidisciplinary team, to plan, deliver and evaluate care

4 Provide clear, concise and informative handovers

5 Provide structured, concise and informative documentation

Optional: additional explanations, comments or practice expectations regarding the theme of communication

Graduate Expectations: Delivery of safe and quality patient care On completion of the graduate emergency nursing course the graduate will be able to:

6 Identify and report unsafe or inappropriate practice

7 Manage critical incidences and stressful situations

8 Demonstrate safe and effective use of technology and biomedical equipment

9 Promote a caring environment for the patient and significant others

10 Involve the patient in the decisions about their care

11 Advocate for the patient

189

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

12 Establish rapport with patients, families and support people

Optional: additional explanations, comments or practice expectations regarding the theme of: Delivery of safe and quality patient care

Theme: Research and Quality Improvement On completion of the graduate emergency nursing program the graduate will be able to:

14 Critically evaluate and apply nursing research to emergency patient care

15 Identify and suggest areas for practice or policy change

16 Support the development of quality improvement within the emergency care environment

17 Support the development of research within the emergency care environment

Optional: additional explanations, comments or practice expectations regarding the theme of: Research and Quality Improvement

Theme: Ethics and Law On completion of the graduate emergency nursing program the graduate will be able to:

18 Maintain patient privacy and confidentiality

19 Function within an ethical framework

20 Practice according to all relevant legislation and standards of practice

Optional: additional explanations, comments or practice expectations regarding the theme of: Ethics and Law

Theme: Teamwork and Leadership On completion of the graduate emergency nursing program the graduate will be able to:

21 Work within their own scope of practice

22 Performs effectively as a team member

23 Collaborate with colleagues, including the multidisciplinary team, to bring about best patient outcomes

24 Recognise and manage own stress

190

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

25 Provide support for colleagues when caring for challenging patient and or family needs

26 Effectively leads a team to provide safe, quality patient care

27 Act as a role model for nurses and other health professionals

28 Supervise and delegate the delivery of patient care to others

29 Demonstrate preparedness and response for major incidents and disasters

30 Lead a team in caring for the at-risk patient

Optional: additional explanations, comments or practice expectations regarding the theme of: Teamwork and Leadership

Theme: Professional development On completion of the graduate emergency nursing program the graduate will be able to:

31 Maintain their own ongoing professional development

32 Contribute to the professional development of colleagues

33 Promote the profile of emergency nursing

Optional: additional explanations, comments or practice expectations regarding the theme of: Professional Development

Theme: Clinical practice and expertise On completion of the graduate emergency nursing program the graduate will be able to:

34 Provide appropriate and timely assessments of the undiagnosed patient

35 Effectively prioritise patient care needs

36 Determine, monitor and implement appropriate assessment and management strategies for multiple undifferentiated patients

37 Transport complex patients throughout the healthcare environment

38 Provide appropriate discharge care including referrals and education materials

39 Anticipate, assess and manage the care of the deteriorating patient across the lifespan

40 Safely work at triage

191

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

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


Cardiovascular

Acute coronary syndromes

Advanced ECG interpretation

Advanced Life Support (ALS)

Aortic Aneurysms

Arrhythmias

Heart Failure

Insertion of intravenous cannula (IVC)

192

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

Invasive haemodynamic monitoring

Non-ischaemic cardiac conditions

Vasoactive infusions


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



Acute Kidney Injury (AKI)

Acute Pancreatitis

Biliary tract disease

Chronic Kidney Disease (CKD)

Complications associated with liver cirrhosis

Testicular torsion


Endocrine

Diabetic Ketoacidosis (DKA)

Hyperglycaemic Hyperosmolar Syndrome (HHS)

193

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

Thyroid dysfunction and associated conditions


Shock

Cardiogenic shock

Distributive shock

Hypovolaemic Shock

Obstructive shock


Trauma and Injury

Abdominal Injury

Application of Philadelphia collar

Burns / Thermal Injury

Chest Injury

Musculoskeletal Injury

Spinal cord injury

Submersion injury

Traumatic head injury


Obstetrics

Bleeding in pregnancy

Hypertensive disorders of pregnancy


Paediatrics

Advanced Paediatric Life Support

Bronchiolitis

Calculate IV fluid replacement requirements (for example resuscitation, dehydration, maintenance)

Croup

194

No. Statement

Stro

ngl

y A

gre

e

Agr

ee

Ne

ith

er

Agr

ee

or

Dis

agre

e

Dis

agre

e

Stro

ngl

y

Dis

agre

e

Epiglottis

Gastroenteritis

Neonatal resuscitation

Seriously ill child


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


195

Appendix 14: Confirmation of manuscript acceptance to Nurse

Education Today