Wayne Varndell

Background: Disaster events that overwhelm health system capacity often require the deployment of nurses from non‐critical care clinical areas to supplement the specialist intensive care workforce. However, the role of deployed registered nurses in intensive care is poorly defined and without clear role boundaries, experienced intensive care nurses often bear disproportionate supervisory burdens, and deployed staff may assume clinical responsibilities for which they are inadequately prepared. Developing a scope of practice for deployed nurses is essential for safe, effective surge responses. Aim: To achieve expert consensus on the scope of practice of deployed registered nurses in a surged intensive care unit. Study Design: A Real‐Time Delphi study was conducted using a web‐based platform. A 65‐item survey was administered to a panel of experienced Australian intensive care nurses and educators with expertise in training and/or supervising nurses deployed to intensive care during surge events. Participants rated activities that could potentially be undertaken by deployed registered nurses in a surged intensive care setting using a 5‐point Likert scale across two dimensions: appropriateness for delegation and importance within a tiered nursing model. Consensus was defined a priori as ≥ 70% agreement. Free‐text comments were analysed thematically. Results: Fifteen expert panellists completed the survey. Of the 69 items assessed, 33 reached consensus and were retained as constituting the scope of practice for registered nurses deployed to intensive care. Consensus items spanned neurological observation, basic cardiovascular monitoring, gastrointestinal care, fluid balance documentation, and essential nursing cares. No consensus was reached for mechanical ventilation, non‐invasive ventilation or renal replacement therapy. Conclusions: This study resulted in a consensus‐derived scope of practice for deployed registered nurses in a surged intensive care. The findings establish clear role boundaries to support safe, tiered nursing care during future surge events and provide a foundation for developing targeted upskilling programs. Relevance to Clinical Practice: The findings offer intensive care clinicians, educators, and health services a practical foundation for planning surge nursing models before surge events occur. Clearer role delineation may also reduce uncertainty for deployed nurses and lessen the supervisory burden on experienced intensive care staff.

Aim: The aim of this research was to investigate the clinical use of nitrous oxide among Australian nurses and midwives, assess their pharmacological knowledge of the gas, determine their awareness of its environmental effects and evaluate their broader attitudes toward climate change. Background: Balancing clinical efficacy with environmental sustainability is an emerging priority in acute pain management. While nitrous oxide offers rapid, reversible analgesia, its substantial ecological footprint as a greenhouse gas cannot be ignored. Nurses and midwives are well‐positioned to drive sustainable analgesic practices, yet their current utilisation and awareness of these environmental impacts require further investigation. Design: A cross‐sectional survey of nurses and midwives practising in Australia. Method: Australian nurses and midwives who have administered nitrous oxide as part of patient management were invited to complete a 62‐item survey. Quantitative data were analysed using descriptive statistics and qualitative responses were thematically analysed. Results: Responses from 446 respondents were analysed. Pharmacological knowledge of nitrous oxide was low (median 28.6%), as was awareness of its environmental impact (median 28.6%). Respondents aged 40 and under had lower awareness of nitrous oxide's impact on climate (28.6% vs. 42.9%). Climate change beliefs and intentions were high (both 80.0%). Awareness of nitrous oxide's environmental impact explained 79% of variance in climate change belief ( F = 35.211). Conclusion: Administration of nitrous oxide by nurses and midwives in Australia for acute pain management occurs across diverse healthcare settings. However, significant knowledge gaps regarding its pharmacological properties and environmental impact highlight an urgent need for targeted education, clinical guidance and sustainable practice initiatives. Addressing these gaps will empower clinicians to balance patient comfort with environmental stewardship, supporting healthcare delivery that is both high quality and ecologically responsible. Implications for the Profession and/or Patient Care: This study highlights a critical gap in knowledge regarding both the pharmacology and environmental impact of nitrous oxide among Australian nurses and midwives. While nitrous oxide remains a valued, safe option for acute pain management, addressing its significant ecological footprint requires bridging this knowledge gap through education, clear clinical guidance and sustainable practice initiatives. Effective pain management must balance patient comfort and clinical safety with environmental stewardship to deliver clinically effective, ecologically responsible care. Impact: This study investigated the clinical utilisation of nitrous oxide for acute pain management among Australian nurses and midwives, while evaluating their pharmacological knowledge and awareness of its environmental implications. Despite strong climate change commitments, nurses and midwives face a significant knowledge‐practice gap regarding nitrous oxide, showing limited understanding of both its pharmacology and its severe environmental impact. Reporting Method: In reporting the results, we have used the Checklist for Reporting of Survey Studies (CROSS). Patient or Public Contribution: No patient or public contribution.

Urinary catheterisation is an important aspect of patient care yet commonly causes discomfort or pain. Current international guidelines recommend water‐based sterile lubricant during catheterisation of women, whereas local anaesthetic gel (e.g., lignocaine gel) is advocated in men, potentially highlighting a gender bias in clinical care. The purpose of this systematic literature review was to evaluate the effectiveness of 2% lignocaine gel compared to water‐based lubricant in reducing pain during urethral catheterisation of women. A systematic search using key terms and their alternate spellings was used to identify relevant studies. Studies were included that examined the use of 2% lignocaine during urethral catheterisation of women. This review searched Cochrane Library, Cumulated Index in Nursing and Allied Health Literature (CINAHL), Emcare Nursing and Allied Health Database, Excerota Medica Database (EMBASE), Maternity and Infant Care Database, MEDLINE, OVID, ProQuest, PubMed and SCOPUS. In addition, clinical trial and systematic review registries were also searched from inception to May 2025. A total of 2030 studies were identified and screened. Three randomised controlled studies involving 214 female participants were included in this review. Pooled results indicated a statistically significant difference in favour of 2% lignocaine gel compared to water‐based lubricant during urethral catheterisation in women (mean difference −10.81, 95% CI: −15.81 to −5.35). The application of 2% lignocaine gel is more effective in reducing catheterisation‐associated pain in women compared to water‐based lubricant. Current clinical guidelines suggest the use of a water‐based lubricant for women, but an anaesthetic‐based lubricant for men. The belief that women do not require local anaesthesia before catheterisation may be influenced by historical perspectives and warrants further investigation.

Aim: The aim of this study was to examine the perceptions and experiences of emergency nurses managing acute pain in critically ill patients. Design: Qualitative descriptive study. Method: Non‐participant observations ( n = 46, 157 h across 10 shifts) and semi‐structured interviews ( n = 30) were conducted at two Australian metropolitan emergency departments from November to December 2020. Transcribed data were analysed using reflexive thematic analysis. Results: The qualitative analysis yielded three main themes and eight subthemes: (i) being in the resuscitation area in which participants detail learning to work in the resuscitation area; influences in managing critically ill patients and confidence in acute pain management; (ii) prioritising pain management identified the challenges in optimising pain management and balancing departmental demands; and (iii) between being and doing and how nurse–patient interactions and care behaviours impacted on optimising pain management and comfort in the resuscitation area. Conclusion: Emergency nurses were primarily responsible for the continuity of patient care and optimisation of pain control for critically ill patients. Confidence in managing acute pain in critically ill patients was variable. While nurses actively sought ways to provide a reassuring presence and comfort to critically ill patients, this was limited by unpredictable workloads, availability of staff and communication challenges. Implications for the Profession and/or Patient Care: These study findings may assist in the development of policy and formal education of emergency nurses transitioning into the resuscitation area and the management of acute pain in critically ill patients. Impact: Pain is under‐assessed and managed in critically ill patients, and this could stem from emergency nurses' practices. The findings could inform interventions to enhance pain management and practices. Patient or Public Contribution: No patient or public contribution. Reporting Method: This study adhered to the COREQ criteria.

Aim: The aim of this study was to (i) identify barriers and enablers and (ii) inform mitigating or strengthening strategies for implementing nurse‐initiated care protocols at scale in emergency departments (EDs).Design: Embedded mixed methods.Methods: The study included four clusters with a total 29 EDs in NSW, Australia. Concurrent quantitative and qualitative data were collected via electronic nursing and medical staff surveys and analysed. Barriers and enablers to implementation were identified and mapped to the domains of the Theoretical Domains Framework (TDF). Selection of intervention functions and behaviour change techniques (BCTs) enabled development of implementation strategies.Results: In total, 847 responses from nursing and medical staff (43%) reported four enablers for use and implementation: (i) knowing or being able to learn to use simple nurse‐initiated care; (ii) protocols help staff remember care; (iii) carefully considered education programme with protected time to attend training; and (iv) benefits of nurse‐initiated care. Nine barriers were identified: (i) lack of knowledge; (ii) lack of skills to initiate complex care (paediatric patients, high‐risk medications and imaging); (iii) risk for inappropriate care from influence of cognitive bias on decision‐making; (iv) punitive re‐enforcement; (v) protocols that are too limited, complex or lack clarity; (vi) perceived lack of support from medical or management; (vii) perception that tasks are outside nursing role; (viii) concern nurse‐initiated care may increase the already high workload of medical and nursing staff; and (ix) context. The barriers and enablers were mapped to nine TDF domains, five intervention functions and 18 BCTs informing implementation using strategies, including an education programme, pre‐existing videos, audit and feedback, clinical champions and an implementation plan.Conclusion: A rigorous, systematic process generated a multifaceted implementation strategy for optimising nurse‐initiated care in rural, regional and metropolitan EDs.Implications: Staff wanted safe interventions that did not lead to increased workload. Staff also wanted support from management and medical teams. Common barriers included a lack of knowledge and skill in advanced practice. Clinicians and policymakers can consider these barriers and enablers globally when implementing in the ED and other high‐acuity areas. Successful strategies targeting barriers to advanced practice by emergency nurses can be addressed at the local, state and national levels.Impact: Implementation of new clinical practices in the ED is complex and presents challenges. Key barriers and enablers, including those related to initiating care and workloads in the ED were identified in this study. This research broadly impacts ED staff and policymakers globally.Reporting Method: Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR‐RHS).Patient or Public Contribution: Site senior nurse researchers for each cluster worked closely with site stakeholders, including local consumer groups. Consumer councils were engaged at all the sites. Site visits by the research nurses have been an important strategy for discussing the study with key stakeholders.Trial Registration: Australian and New Zealand Clinical Trial: ACTRN12622001480774p

Objective To determine the relationship between point-of-care beta-hydroxybutyrate (BHB) concentration and outcomes in adult patients without diabetes admitted through ED. Methods This was a prospective study from 10 March to 2 July 2021. Admitted patients without diabetes had capillary BHB sampled in ED. Outcomes of length-of-stay (LOS), composite mortality/ICU admission rates and clinical severity scores (Quick Sepsis Organ Failure Assessment score/National Early Warning Score [qSOFA/NEWS]) were measured. BHB was assessed as a continuous variable and between those with BHB above and equal to 1.0 mmol/L and those below 1.0 mmol/L. Results A total of 311 patients were included from 2377 admissions. Median length-of-stay was 4.1 days (IQR 2.1-9.8), 18 (5.8%) died and 37 (11.8%) were admitted to ICU. Median BHB was 0.2 mmol/L (IQR 0.1-0.4). Twenty-five patients had BHB >= 1.0 mmol/L and five were >3.0 mmol/L. There was no significant difference in median LOS for patients with BHB >= 1.0 mmol/L compared to non-ketotic patients, 5.3 days (IQR 2.2-7.5) versus 4.1 days, respectively (IQR 2.0-9.8) (P = 0.69). BHB did not correlate with LOS (Spearman rho = 0.116, 95% confidence interval: 0.006-0.223). qSOFA and NEWS also did not differ between these cohorts. For those 25 patients with BHB >= 1.0 mmol/L, an infective/inflammatory diagnosis was present in 11 (44%), at least 2 days of fasting in 10 (40%) and ethanol intake >40 g within 48 h in 4 (16%). Conclusions Routine BHB measurement in patients without diabetes does not add to clinical bedside assessment and use should be limited to when required to confirm a clinical impression.

Introduction: Emergency department (ED) overcrowding is a global problem and a threat to the quality and safety of emergency care. Providing timely and safe emergency care therein is challenging. To address this in New South Wales (NSW), Australia, the Emergency nurse Protocol Initiating Care—Sydney Triage to Admission Risk Tool (EPIC-START) was developed. EPIC-START is a model of care incorporating EPIC protocols, the START patient admission prediction tool, and a clinical deterioration tool to support ED flow, timely care, and patient safety. The aim of this study is to evaluate the impact of EPIC-START implementation across 30 EDs on patient, implementation, and health service outcomes. Methods and analysis: This study protocol adopts an effectiveness-implementation hybrid design (Med Care 50: 217-226, 2012) and uses a stepped–wedge cluster randomised control trial of EPIC-START, including uptake and sustainability, within 30 EDs across four NSW local health districts spanning rural, regional, and metropolitan settings. Each cluster will be randomised independently of the research team to 1 of 4 dates until all EDs have been exposed to the intervention. Quantitative and qualitative evaluations will be conducted on data from medical records and routinely collected data, and patient, nursing, and medical staff pre- and post-surveys. Ethics and dissemination: Ethical approval for the research was received from the Sydney Local Health District Research Ethics Committee (Reference Number 2022/ETH01940) on 14 December 2022. Trial registration: Australian and New Zealand Clinical trial, ACTRN12622001480774p. Registered on 27 October 2022.

Objective: To determine whether blood culture contamination (BCC) rates could be decreased in the ED by an educational programme.Methods: Educational intervention focusing on a 1‐min venepuncture cleaning time and providing a larger chlorhexidine alcohol swab. BCC rates were examined retrospectively 12‐month pre‐, and 9‐month post‐intervention.Results: Six thousand nine hundred and fifty‐three blood cultures were collected over the study period. The BCC rate was 2.4% pre‐intervention versus 1.8% post‐intervention, with no significant difference in BCC rates (Z‐score = 1.862, P = 0.063).Conclusion: This educational intervention focusing on skin clean time did not significantly decrease BCC rates in a setting of an already low (<3%) BCC rate.