A review of critical care nursing staffing, education and practice standards

Implementation and utilisation of Australian critical care practice standards: What do we know?

BACKGROUND

The Australian College of Critical Care Nurses published the third edition of practice standards (PSs) for specialist critical care nurses in 2015. Higher-education providers currently use these standards to inform critical care curricula; however, how critical care nurses perceive and use PSs in clinical practice is unknown.

OBJECTIVES

The objective of this study was to explore critical care nurses' perceptions about the Australian College of Critical Care Nurses PS for specialty critical care nursing, to understand how the PSs are used in clinical practice, and what opportunities exist to support their implementation.

METHODS

An exploratory qualitative descriptive design was used. A purposive sampling strategy was used, with 12 critical care specialist nurses consenting to participate in semistructured interviews. The interviews were recorded and transcribed verbatim. Transcripts were analysed thematically using an inductive coding approach.

FINDINGS

Three main themes were identified: (i) lack of awareness of the PS; (ii) minimal to no utilisation of the PS in clinical practice and the challenges contributing to this; and (iii) improving the implementation and utilisation of the PS in clinical practice.

CONCLUSIONS

There is a significant lack of awareness and utilisation of the PS in clinical practice. To overcome this, increasing recognition, endorsement, and valuation of the PSs to stakeholders at an individual, health service, and legislative level are suggested. Further research is required to establish relevance of the PS in clinical practice and understand how clinicians use the PS to promote and develop critical care nursing.

Critical care nursing policy, practice, and research priorities: An international cross-sectional study

PURPOSE

To examine the status of critical care nursing internationally, assess the impact of the COVID-19 pandemic, and identify research priorities by surveying professional critical care nursing organizations (CCNOs) worldwide.

DESIGN

A descriptive survey methodology was used. This study is the sixth worldwide quadrennial review to assess international critical care nursing needs and provide evidence to inform critical care nursing policy, practice and research priorities globally.

METHODS

The sixth World Federation of Critical Care Nurses survey of CCNOs was emailed to potential participants from countries with CCNOs or known critical care nurse leaders. Data were collected online using Survey Monkey™. Responses were entered into SPSS version 28 software (IBM Corp.) and analyzed by geographical region and national wealth group.

FINDINGS

Ninety-nine national representative respondents participated in the survey (70.7% response rate). The most important issues identified were working conditions, teamwork, staffing levels, formal practice guidelines, wages, and access to quality education programs. The top five CCNO services that were of most importance were providing national conferences, local conferences, workshops and education forums, practice standards and guidelines, and professional representation. Important pandemic-related services and activities provided by CCNOs included addressing emotional and mental well-being of nurses, providing guidance related to nurse staffing/workforce needs, assisting to coordinate efforts to obtain personal protective equipment supplies, serving as a country liaison with the World Health Organization's COVID-19 response activities, and assisting in the development and implementation of policies regarding standards of care. The most important contributions expected from the World Federation of Critical Care Nurses were standards for professional practice, standards for clinical practice, website resources, professional representation, and providing online education and training materials. The top five research priority areas were: stress levels (inclusive of burnout, emotional exhaustion and compassion fatigue); critical care nursing shortage, skill mix and workforce planning; recruitment, retention, turnover, working conditions; critical care nursing education and patient outcomes; and adverse events, staffing levels, patient outcomes.

CONCLUSIONS

The results highlight priority areas for critical care nursing internationally. The COVID-19 pandemic impacted critical care nurses as direct care providers. As a result, addressing the ongoing needs of critical care nurses remains a priority area of focus. The results also highlight important policy and research priorities for critical care nursing globally. Results of this survey should be incorporated into strategic action plans at the national and international levels.

CLINICAL RELEVANCE

Issues of importance to critical care nurses including research and policy priorities during and following COVID-19 are now clarified through this survey. The impact and importance that COVID-19 has had on critical care nurses and their preferences and priorities are provided. Clear guidance to leaders and policy makers on where critical care nurses would like to see greater focus and attention to help strengthen the contribution of critical care nursing practice to the global healthcare agenda.

Nurses' motivations and desired learning outcomes of postgraduate critical care studies: A descriptive exploratory study

BACKGROUND

Education guidelines and professional practice standards inform the design of postgraduate critical care nursing curricula to develop safety and quality competencies for high-quality care in complex environments. Alignment between nurses' motivations for undertaking postgraduate critical care education, and intended course learning outcomes, may impact students' success and satisfaction with programs.

OBJECTIVES

The objectives of this study were to explore nurses' motivations and desired learning outcomes on commencement of a postgraduate critical care course and determine how these align with safety and quality professional attributes.

METHODS

In this exploratory descriptive study, qualitative data were extracted from survey responses of four cohorts of students enrolled in a graduate certificate-level critical care course between 2013 and 2016 (N = 390, 93%), at one Australian university. Summative qualitative content analysis was used to code and quantify textual content followed by synthesis to identify themes and subthemes.

RESULTS

Five themes of motivations were identified: (i) Knowledge development; (ii) Skill development, (iii) Personal outcomes, (iv) Personal professional behaviours, and (v) Interpersonal professional behaviours. Most frequently, students' motivations and desired learning outcomes included 'Understanding' (329 participants [84%], 652 references), 'Development of technical skills' (241 participants [62%], 384 references), 'Development of confidence' (178 participants [46%], 220 references), and 'Career progression' (149 participants [38%], 168 references). Less frequent were motivations related to safety and quality competencies including teamwork, communication, reflective practice, and research skills.

CONCLUSION

Findings suggest students' motivations to undertake postgraduate studies most often related to acquisition of new knowledge and technical skills. Desired skills and behaviours were consistent with many, but not all, of the key course outcomes and attributes specified by health professional education guidelines and nurses' professional practice standards. Understanding the differences between students' motivations and desired safety- and quality-related course learning outcomes informs course orientation, teaching activities, and student support to optimise achievement of essential learning outcomes.

A qualitative study of reinforcement workers' perceptions and experiences of working in intensive care during the COVID-19 pandemic: A PsyCOVID-ICU substudy

PURPOSE

During the COVID pandemic, many hospitals had to mobilize reinforcement healthcare workers, especially in intensive care (ICUs). We investigated the perceptions and experiences of reinforcement workers deployed to ICUs, and the impact of deployment on their personal and professional lives.

METHODS

For this qualitative study, a random sample of 30 reinforcement workers was drawn from 4 centres participating in the larger PsyCOVID-ICU study. Individual semi-structured interviews were held, recorded, transcribed and analyzed by thematic analysis.

RESULTS

Thirty interviews were performed from April to May 2021 (22 nurses, 2 anesthesiology nurses, 6 nurses' aides). Average age was 36.8±9.5 years; 7 participants had no ICU experience. Four major themes emerged, namely: (1) Difficulties with integration, especially for those with no ICU experience; (2) lack of training; (3) difficulties with management, notably a feeling of insufficient communication; (4) Mental distress relating to the unusual work and fear of contaminating their entourage.

CONCLUSION

Healthcare workers deployed as reinforcements to ICUs at the height of the pandemic had a unique experience of the crisis, and identified important gaps in organisation and preparation. They also suffered from a marked lack of training, given the stakes in the management of critically ill patients in the ICU.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Workforce management and patient outcomes in the intensive care unit during the COVID-19 pandemic and beyond: a discursive paper

AIMS

To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.

BACKGROUND

In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.

DESIGN

Discursive paper.

FINDINGS

Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.

CONCLUSION

COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.

RELEVANCE TO CLINICAL PRACTICE

Objective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

The Fifth International Survey of Critical Care Nursing Organizations: Implications for Policy

Purpose

To examine the activities, concerns, and expectations of critical care nurses and professional critical care nursing organizations worldwide.

Design

A descriptive survey methodology was used. This study is the fifth worldwide quadrennial review of its type to monitor variations in critical care nursing needs and provide robust evidence to inform policy related to critical care nursing practice.

Methods

The fifth World Federation of Critical Care Nurses international survey of critical care nursing organizations was emailed to potential participants from countries with critical care nursing organizations or known critical care nurse leaders. Data were collected online. Responses were entered into SPSS version 23 software (IBM Corp., Armonk, NY, USA) and analyzed by geographical region and national wealth group.

Findings

Eighty‐two national representative respondents participated in the survey, of whom two thirds (n = 56, 68%) had an established critical care nursing organization in their country. The five most important issues identified were working conditions, teamwork, staffing levels, the need for formal practice guidelines and competencies, and wages. The top five critical care nursing organization services that were considered to be of most importance were professional representation, as well as provision of workshops and education forums, national conferences, practice standards and guidelines, and local conferences. The most important contributions expected from the World Federation of Critical Care Nurses were standards for clinical practice and professional practice, international conferences, professional representation, and study and education grants.

Conclusions

The results highlight priority areas for critical care nursing and reinforce the need to address factors that can inform critical care nursing policy and practice. Results of this survey should be incorporated into strategic action plans at the national and international levels.

Clinical Relevance

Nursing leaders, policymakers, and other interested stakeholders should consider these findings when planning critical care workforce requirements. Interested parties should work collaboratively to inform recommendations for further policy and action.

Nurse staffing in large general hospitals in China: an observational study

BACKGROUND

The appropriate staffing of nurses not only reflects the situation of nursing management of human resource, but also is related to the nursing quality in hospitals. This study investigated the staffing of nurses in large general hospitals in China.

METHODS

In this study, a database established by the National Centre for Nursing Care Quality Control, which conducted a national survey of the staffing of nurses in China mainland in 2017, was analysed. The time-point survey data of 20 375 departments in 668 large general hospitals in China were obtained, including the information of nurses and patients during the day (10:00 am) and at night (10:00 pm). Then, the staffing of nurses was evaluated by calculating the nurse to patient ratio (the average number of patients assigned to a nurse, NTP ratio). The Kruskal-Wallis test was performed to compare the NTP ratios during the day and at night among different regions and departments.

RESULTS

In large general hospitals, a nurse takes care of eight patients (NTP ratio = 1:8.0) during the day and 23 patients at night (NTP ratio = 1:23) on average. There were significant differences between day and night. In terms of different regions, a nurse in the hospitals in the western region takes care of 7.8 patients during the day (NTP ratio = 1:7.8) on average, and the nursing resource in the western region is more adequate than that in the eastern (1:8.0) and central (1:8.0) regions. At night, the eastern region has a higher level of NTP (1:23.0). In terms of departments, a nurse working in the ICU takes care of two patients during the day (NTP ratio = 1:2.0) and 2.9 patients at night (NTP ratio = 1:2.9). The level of NTP in the oncology department is relatively higher: 9.3 during the day and 34.0 at night. Other departments including internal medicine, surgery, obstetrics and gynaecology, paediatrics, and geriatrics have NTP ratios of 1:7-8 during the day and 1:18-25 at night.

CONCLUSIONS

In China, the nurse staffing of large general hospitals has some regional and departmental patterns. The low level of nurse staffing at night may be a problem worthy of attention; the Chinese government needs to establish standards for different periods and departments to improve efficiency and quality of nursing.

The Critical Care Resuscitation Unit Transfers More Patients From Emergency Departments Faster and Is Associated With Improved Outcomes

BACKGROUND

Transfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes.

OBJECTIVES

We hypothesized that an innovative Critical Care Resuscitation Unit (CCRU) would be associated with improved outcomes by reducing transfer times to a quaternary care center and times to interventions for ED patients with critical illnesses.

METHODS

This pre-post analysis compared 3 groups of patients: a CCRU group (patients transferred to the CCRU during its first year [July 2013 to June 2014]), a 2011-Control group (patients transferred to any ICU between July 2011 and June 2012), and a 2013-Control group (patients transferred to other ICUs between July 2013 and June 2014). The primary outcome was time from transfer request to ICU arrival. Secondary outcomes were the interval between ICU arrival to the operating room and in-hospital mortality.

RESULTS

We analyzed 1565 patients (644 in the CCRU, 574 in the 2011-Control, and 347 in 2013-Control groups). The median time from transfer request to ICU arrival for CCRU patients was 108 min (interquartile range [IQR] 74-166 min) compared with 158 min (IQR 111-252 min) for the 2011-Control and 185 min (IQR 122-283 min) for the 2013-Control groups (p < 0.01). The median arrival-to-urgent operation for the CCRU group was 220 min (IQR 120-429 min) versus 439 min (IQR 290-645 min) and 356 min (IQR 268-575 min; p < 0.026) for the 2011-Control and 2013-Control groups, respectively. After adjustment with clinical factors, transfer to the CCRU was associated with lower mortality (odds ratio 0.64 [95% confidence interval 0.44-0.93], p = 0.019) in multivariable logistic regression.

CONCLUSION

The CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.

A two phase study to revise the Australian Practice Standards for Specialist Critical Care Nurses

BACKGROUND

Observational work to develop the ACCCN Competency Standards was undertaken more than 20 years ago. Since then the landscape of critical care nursing as a specialty has changed and it is not known if the Competency Standards reflected contemporary practice.

OBJECTIVES

To revise the ACCCN Competency Standards for Specialist Critical Care Nurses to ensure they continue to meet the needs of critical care nurses and reflect current practice.

METHODS

A two-phased project was undertaken. In Phase I focus groups were held in all states. Thematic analysis was conducted using two techniques. The standards were revised based on the main themes. Phase II consisted of an eDelphi technique. A national panel of critical care nurses responded to three survey rounds using a 7 point likert-type scale to indicate their level of agreement with the revised standards. A 70% agreement level for each statement was determined a priori.

RESULTS

Phase I: 12 focus groups (79 participants) were conducted. Phase II: A panel of specialist critical care nurses (research, management, clinical practice and education) responded to round 1 (n=64), round 2 (n=56), and round 3 (n=40). Fifteen practice standards with elements and performance criteria were grouped into four domains (professional practice, provision and coordination of care, critical thinking and analysis, collaboration and leadership). The revised Practice Standards for Specialist Critical Care Nurses build upon and are additional to the Nursing & Midwifery Board of Australia National Competency Standards for Registered Nurses. The standards reflect contemporary critical care nurse practices using an expanded range of technologies to care for complex critically ill patients across the lifespan in diverse settings.

CONCLUSION

The national study has resulted in the 3rd edition of the Practice Standards for Specialist Critical Care Nurses. There was input from stakeholders and agreement that the revised standards capture contemporary Australian critical care nursing practice.

Basic Competence of Intensive Care Unit Nurses: Cross-Sectional Survey Study

Critical care patients benefit from the attention of nursing personnel with a high competence level. The aim of the study was to describe and evaluate the self-assessed basic competence of intensive care unit nurses and related factors. A cross-sectional survey design was used. A basic competence scale (Intensive and Critical Care Nursing Competence Scale version 1, Likert scale 1-5, 1 = poor and 5 = excellent) was employed among Finnish intensive care unit nurses (n = 431). Intensive care unit nurses' self-assessed basic competence was good (mean 4.19, SD 0.40). The attitude and value base of basic competence was excellent whereas experience base was the poorest compared to the knowledge base and skill base of intensive and critical care nursing. The strongest factor explaining nurses' basic competence was their experience of autonomy in nursing care (F value 60.85, β 0.11, SE 0.01, and P ≤ 0.0001). Clinical competence was self-rated as good. Nurses gave their highest competence self-ratings for ICU patient care according to the principles of nursing care. The ICU nurses also self-rated their professional competence as good. Collaboration was self-rated as the best competence. In basic and continuing education and professional self-development discussions it is meaningful to consider and find solutions for how to improve nurses' experienced autonomy in nursing.

Critical care nursing organizations and activities: a fourth worldwide review

AIM

To examine the activities and concerns of critical care nurses and professional critical care nursing organizations around the world and to identify expectations held of nursing leaders and policy makers to help address their concerns.

BACKGROUND

This study is the fourth worldwide review of its type. Previous surveys were undertaken in 2001, 2005 and 2009.

METHODS

An online descriptive survey was emailed to 88 potential participants from countries with critical care nursing organizations or known critical care nursing leaders. Responses were downloaded into Survey Monkey™ (Version 22) and analysed by geographical region and income level.

RESULTS

Fifty-nine respondents from 58 countries completed the questionnaire, of whom 43 had critical care nursing organizations established in their countries and 29 were members of the World Federation of Critical Care Nurses. The services provided by the organizations to be of most value were national conferences, website, professional representation, and practice standards and guidelines. Professional policies had been developed by some organizations on workforce, education and practice, while almost half provided their members with either a newsletter or journal. Collectively, the most important issues for critical care nurses were working conditions, provision of formal practice guidelines and competencies, staffing levels and access to quality education programmes.

CONCLUSIONS

Important issues continue to challenge the specialty of critical care nursing as new developments, priorities, clinical issues and other global events and influences impact critical care nursing worldwide.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This study will help guide nursing leaders and policy makers to address the needs of critical care nurses and their patients. Collaborative approaches between the specialty, nursing leaders and health policy advisors will assist to inform appropriate change in areas recommended for further action.

Developing and Testing the Standard of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT) for Critical Care Nursing Practice

BACKGROUND

Nurses working in critical care often undertake specialty education. There are no uniform practice outcomes for critical care programs, and consumer input to practice standards has been lacking.

METHODS

A structured multiphase project was undertaken to develop practice standards and an assessment tool informed by critical care nursing stakeholders as well as patients and families-the Standards of Practice and Evaluation of Critical-Care-Nursing Tool (SPECT).

RESULTS

Testing of the SPECT revealed adequate content validity index (CVI), domain CVI (range, 0.772 to 0.887), and statement CVI (range, 0.66 to 1.00). Reliability was adequate in terms of internal consistency (Cronbach's α > 0.864) and test-retest Spearman rank correlation (range, 0.772 to 0.887); intra-rater kappa agreement was significant for 102 of 104 statements with moderate agreement for 94.2% of statements.

CONCLUSION

The SPECT appears to have clinical feasibility, preliminary validity and reliability, and provides a clear definition for the expected practice level for graduates of a critical care education program.

An electronic delphi study to establish pediatric intensive care nursing research priorities in twenty European countries*

OBJECTIVES

To identify and to establish research priorities for pediatric intensive care nursing science across Europe.

DESIGN

A modified three-round electronic Delphi technique was applied. Questionnaires were translated into seven different languages.

SETTING

European PICUs.

PARTICIPANTS

The participants included pediatric intensive care clinical nurses, managers, educators, and researchers. In round 1, the qualitative responses were analyzed by content analysis and a list of research statements and domains was generated. In rounds 2 and 3, the statements were ranked on a scale of one to six (not important to most important). Mean scores and SDs were calculated for rounds 2 and 3.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Round 1 started with 90 participants, with round 3 completed by 64 (71%). The seven highest ranking statements (≥ 5.0 mean score) were related to end-of-life care, decision making around forgoing and sustaining treatment, prevention of pain, education and competencies for pediatric intensive care nurses, reducing healthcare-associated infections, identifying appropriate nurse staffing levels, and implementing evidence into nursing practice. Nine research domains were prioritized, and these were as follows: 1) clinical nursing care practices, 2) pain and sedation, 3) quality and safety, 4) respiratory and mechanical ventilation, 5) child- and family-centered care, 6) ethics, 7) professional issues in nursing, 8) hemodynamcis and resuscitation, and 9) trauma and neurocritical care.

CONCLUSIONS

The results of this study inform the European Society of Pediatric and Neonatal Intensive Care's nursing research agenda in the future. The results allow nurse researchers within Europe to encourage collaborative initiatives for nursing research.

Health consumers' experiences in Australian critical care units: postgraduate nurse education implications

AIM

To explore critical care patients and families experiences and seek their input into nurses' postgraduate educational preparation and practice.

BACKGROUND

There is an inconsistency in the expected standard of practice to 'qualify' Australian critical care nurses. There has also been a lack of health consumer input in the development of postgraduate course curriculum and content.

METHOD

Following institutional ethics committee approval, purposive sampling was used to select participants for focus groups and individual interviews who had experienced intensive care or coronary care.

FINDINGS

Seventeen participants provided data which created two main thematic categories; the role of the critical care nurse and; minimum practice standards for postgraduate critical care course graduates. Both physical patient care and socio-emotional support of patients and family were identified as important for the critical care nurse role. The level of socio-emotional support provided by nurses was reported to be inconsistent. Components of socio-emotional support included communication, people skills, facilitating family presence and advocacy. These components were reflected in participants' concepts of minimum practice standards for postgraduate critical care course graduates; talking and listening skills, relating to and dealing with stressed people, individualizing care and patient and family advocacy.

CONCLUSION

Health consumers' views emphasize that socio-emotional skills and behaviours need to be explicitly described in postgraduate critical care nursing course curricula and instruments developed to consistently assess these core competencies.

Using a web-based survey tool to undertake a Delphi study: application for nurse education research

BACKGROUND

The Internet is increasingly being used as a data collection medium to access research participants. This paper reports on the experience and value of using web-survey software to conduct an eDelphi study to develop Australian critical care course graduate practice standards.

METHODS

The eDelphi technique used involved the iterative process of administering three rounds of surveys to a national expert panel. The survey was developed online using SurveyMonkey. Panel members responded to statements using one rating scale for round one and two scales for rounds two and three. Text boxes for panel comments were provided.

COLLECTING DATA AND PROVIDING FEEDBACK

For each round, the SurveyMonkey's email tool was used to distribute an individualized email invitation containing the survey web link. The distribution of panel responses, individual responses and a summary of comments were emailed to panel members. Stacked bar charts representing the distribution of responses were generated using the SurveyMonkey software. Panel response rates remained greater than 85% over all rounds.

DISCUSSION

An online survey provided numerous advantages over traditional survey approaches including high quality data collection, ease and speed of survey administration, direct communication with the panel and rapid collation of feedback allowing data collection to be undertaken in 12 weeks. Only minor challenges were experienced using the technology. Ethical issues, specific to using the Internet to conduct research and external hosting of web-based software, lacked formal guidance.

CONCLUSIONS

High response rates and an increased level of data quality were achieved in this study using web-survey software and the process was efficient and user-friendly. However, when considering online survey software, it is important to match the research design with the computer capabilities of participants and recognize that ethical review guidelines and processes have not yet kept pace with online research practices.