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Associate Professor Margaret Fry

Biography

Associate Professor Margaret Fry has worked in critical care areas (intensive and emergency) for over 20 years and has been judged by my peers as highly credible. She has been recognised by peers with awards that include St George Hospital Nurse of the Year (2001) and Australasian Emergency Nurse of the Year (2005).Margaret is an authorised Nurse Practitioner and her theoretical knowledge extends to the development and implementation of nurse practitioner models of service. Margaret is viewed as a clinical leader with the National Institute of Clinical Studies.

Associate Professor Fry has an extensive track record in implementing and enabling changes in policy and practice throughout New South Wales and other jurisdictions. A/Profs Fry has a strong research background in the field of advanced nursing practice, extended nursing roles and pain management, with vast experience of new models of care. Margaret’s publication and conference track record demonstrates a strong theoretical understanding and appreciation of quantitative and qualitative research methods.

Professional

NSW Ministerial Emergency Care Taskforce
Emergecy care Insititute
NSW health Studer steering committee
National Institute of Clinical Studies Emergency Community of Care Steering Committe

Image of Margaret Fry
Adjunct Professor, Faculty of Health
Bachelor of Applied Science (Nursing), Education (Adult Education), PhD
 

Research Interests

Emergency care
Nurse practitioner
Advanced practice
Pain management
Methodology qualitative

Can supervise: Yes
Registered at Level 2 Research areas Critical / Acute Care Delphi Technique Ethnography Nursing Education and Practice Survey Methods

Nurse practitioner
Critical care
Advanced assessment
Research subjects undergraduate and post graduate

Chapters

Fry, M. 2007, 'Overview of Emergency Nursing in Australasia' in Curtis, K., Ramsden, C. & Friendship, J. (eds), Emergency & Trauma Nursing, Mosby Australia, Sydney, pp. 2-8.
Fry, M. 2007, 'Triage' in Curtis, K., Ramsden, C. & Friendship, J. (eds), Emergency & Trauma Nursing, Mosby Australia, Sydney, pp. 84-91.
Homer, C.S. & Fry, M. 2007, 'Gynaecological emergencies' in Curtis, K., Ramsden, C. & Friendship, J. (eds), Emergency & Trauma Nursing, Mosby Australia, Sydney, pp. 502-515.

Conferences

Baldwin, R.J., Duffield, C.M., Fry, M., Roche, M.A., Stasa, H. & Solman, A. 2013, 'What does a Clinical Nurse Consultant do', ACCCN NSW and ICCMU conference, Australian Critical Care Nurses Association, Sycney, pp. 1-1.
The research collected both quantitative and qualitative data to examine what CNCs do in their current roles It examined role and functions what CNCs did how they went about their jobs how they spent their time was focused more broadly than duties or tasks did not attempt to measure outcomes or validate claims The instrument developed has now been used in three studies into nurses with advance practice roles
Fry, M., Bennett, S. & Huckson, S. 2010, 'Emergency Department pain management practices: An Australian audit', Emergency Department pain management practices: An Australian audit, Royal College of Nursing, London.
Emergency Department pain management practices: An Australian audit RCN International Nursing Research Conference, taking place at the Sage, Newcastle Gateshead, North of England, UK on 11-13 May 2010.
Varndell, W. & Fry, M. 2010, 'Measuring patient dependency in an Australian Adult Emergency Department (2nd prize for best presentation)', 8th International Conference for Emergency Nurses, College of Emergency Nursing Australasia, Australia.
lazar, S., Chapman, N., Lassere, M., Fry, M. & Chong, B. 2009, 'Understanding Hospital Physicians Perspectives and Attitudes towards the Implementation of Venous Thrombosis Prophylaxis', Annual Scientific Haematology Conference.
Understanding Hospital Physicians Perspectives and Attitudes towards the Implementation of Venous Thrombosis Prophylaxis Steven Lazar1, Nicola Chapman1,2, Marissa Lassere1,2, Margaret Fry2,3, Beng Chong1,Annual Scientific Haematology Conference

Journal articles

Wise, S., Fry, M., Duffield, C., Roche, M. & Buchanan, J. 2014, 'Ratios and nurse staffing: The vexed case of emergency departments.', Australas Emerg Nurs J.
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Within Australia nursing unions are pursuing mandated nurse-patient ratios to safeguard patient outcomes and protect their members in healthcare systems where demand perpetually exceeds supply. Establishing ratios for an emergency department is more contentious than for hospital wards. The study's aim was to estimate average staffing levels, skill mix and patient presentations in all New South Wales (NSW) Emergency Departments (EDs).
Varndell, W., Elliott, D. & Fry, M. 2014, 'The validity, reliability, responsiveness and applicability of observation sedation-scoring instruments for use with adult patients in the emergency department: A systematic literature review.', Australas Emerg Nurs J.
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This paper reports a systematic literature review examining the range of published observational sedation-scoring instruments available in the assessment, monitoring and titration of continuous intravenous sedation to critically ill adult patients in the Emergency Department, and the extent to which validity, reliability, responsiveness and applicability of the instruments has been addressed.
Fry, M., Gallagher, R.D., Chenoweth, L. & Stein-Parbury, J. 2014, 'Nurses' experiences and expectations of family and carers of older patients in the emergency department', International Emergency Nursing, vol. 22, no. 1, pp. 31-36.
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Background: Older people are often accompanied by family/carers to the emergency department (ED). Few studies investigate nurses experiences of interacting with these family/carers.
Elliott, D., McKinley, S., Perry, L., Duffield, C., Iedema, R., Gallagher, R., Fry, M., Roche, M. & Allen, E. 2014, 'Clinical utility of an observation and response chart with human factors design characteristics and a track and trigger system: study protocol for a two-phase multisite multiple-methods design.', JMIR Res Protoc, vol. 3, no. 3, p. e40.
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Clinical deterioration of adult patients in acute medical-surgical wards continues to occur, despite a range of systems and processes designed to minimize this risk. In Australia, a standardized template for adult observation charts using human factors design principles and decision-support characteristics was developed to improve the detection of and response to abnormal vital signs.
Gallagher, R.D., Fry, M., Chenoweth, L., Gallagher, P. & Stein-Parbury, J. 2014, 'Emergency nurses perceptions and experiences of providing care for older people', Nursing and Health Sciences, vol. Online.
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Emergency department nurses are challenged to provide safe, quality care to older people; however, nurses' perceptions of their role and experiences are seldom investigated. This focus-group study investigated emergency department nurses' perceptions and experiences of caring for older people, using four focus groups of nurses with a minimum three months' experience in the emergency department and a demographic survey. Data were thematically analyzed.
Wise, S., Fry, M., Duffield, C.M., Roche, M.A. & Buchanan, J. 2014, 'Ratios and nurse staffing: The vexed case ofemergency departments', Australasian Emergency Nursing Journal, vol. IN PRESS.
Within Australia nursing unions are pursuing mandated nursepatient ratios tosafeguard patient outcomes and protect their members in healthcare systems where demandperpetually exceeds supply. Establishing ratios for an emergency department is more con-tentious than for hospital wards. The studys aim was to estimate average staffing levels, skillmix and patient presentations in all New South Wales (NSW) Emergency Departments (EDs).
Fry, M., Arendts, G., Chenoweth, L. & MacGregor, C. 2014, 'Cognitive impairment is a risk factor for delayed analgesia in older people with long bone fracture: a multicenterexploratory study', International Psychogeriatrics, vol. InPress.
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Background: Older people who present to the emergency department (ED) often experience a significant delay to analgesia. This study compares the time to analgesia for cognitively impaired and cognitively intact older people diagnosed with a long bone fracture.
Fry, M., Duffield, C., Baldwin, R., Roche, M., Stasa, H. & Solman, A. 2013, 'Development of a tool to describe the role of the clinical nurse consultant in Australia', JOURNAL OF CLINICAL NURSING, vol. 22, no. 11-12, pp. 1531-1538.
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Fry, M., Horvat, L., Roche, M., Fong, J. & Plowes, J. 2013, 'A four month prospective descriptive exploratory study of patients receiving antibiotics in one Emergency Department', INTERNATIONAL EMERGENCY NURSING, vol. 21, no. 3, pp. 163-167.
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Baldwin, R., Duffield, C.M., Fry, M., Roche, M., Stasa, H. & Solman, A. 2013, 'The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study', INTERNATIONAL JOURNAL OF NURSING STUDIES, vol. 50, no. 3, pp. 326-334.
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Fry, M., MacGregor, C., Ruperto, K., Jarrett, K., Wheeler, J., Fong, J. & Fetchet, W. 2013, 'Nursing praxis, compassionate caring and interpersonal relations: An observational study', Australian Emergency Nursing Journal, vol. 16, no. 2, pp. 37-44.
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Background: The Clinical Initiative Nurse (CIN) is a role that requires experienced emergency nurses to assess, initiate diagnostic tests, treat and manage a range of patient conditions. The CIN role is focused on the waiting room and to 'communicate the
Roche, M., Duffield, C., Wise, S., Baldwin, R., Fry, M. & Solman, A. 2013, 'Domains of practice and Advanced Practice Nursing in Australia', NURSING & HEALTH SCIENCES, vol. 15, no. 4, pp. 497-503.
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Varndell, W., MacGregor, C., Gallagher, R. & Fry, M. 2013, 'Measuring patient dependency--performance of the Jones Dependency Tool in an Australian emergency department.', Australas Emerg Nurs J, vol. 16, no. 2, pp. 64-72.
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The emergency department (ED) is a dynamic environment, in which a high volume of undifferentiated patients with varying levels of urgency must be assessed and treated in a timely manner, primarily by nurses. Nurses not only provide initial but also continuing care for all patients presenting to the ED. Predicting the number of nurses required and the ideal ratio of nursing staff to patients presenting is complex. Current methods of predicting ED nursing workforce fail to reflect the severity and variability of illness/injury or case mix. In addition, they exclude the realities of patients have different nursing requirements, that patient stability changes frequently and that issues such as patient surge (sudden high volumes of presentations) do occur. The aim of this study was to examine the potential for using the Jones Dependency Tool (JDT) for determining patient dependency in the Australian context.
Merrick, E.T., Duffield, C.M., Baldwin, R.J. & Fry, M. 2012, 'Nursing in general practice: organizational possibilities for decision latitude, created skill, social support and identity derived from role', Journal of Advanced Nursing, vol. 68, no. 3, pp. 614-624.
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Abstract Aim. This article is a report of a study to describe the factors that support organizational opportunities for practice nurse decision-making and skill development for nurses employed in general practice in New South Wales, Australia. Background. Corresponding to the availability of subsidies from the Australian universal health insurer (Medicare), there has been an increase in the number of nurses employed in general practice. Currently, there is no Australian evidence as to the organizational possibilities for these practice nurses to make decisions, develop their own skills and abilities, derive identity from their role or how their role is influenced by social support. Methods. Over a 8-month period in 2008 practice, nurses employed in general practice in the State of New South Wales were invited to complete a 26-item selfadministered online questionnaire utilizing constructs from Karaseks (1998) Job Content Questionnaire (valid n = 160). Results. Confirmatory Factor Analysis indicated that all scales demonstrated acceptable levels of internal consistency. Sequential regression models revealed that social support exerts a weak influence on decision latitude (R2 = 007); the addition of self-identity through work significantly improved the predictive ability of the model (R2 = 016). Social support and self-identity through work exerted a negative influence on created skill (R2 = 0347), whereas social support was effective in predicting self-identity through work (R2 = 0148). Conclusions. Collegial and supervisory support in the work environment predicts organizational possibilities for practice nurse decision-making.
Clarke, E., Diers, D., Kunisch, J., Duffield, C., Thoms, D., Hawes, S., Stasa, H. & Fry, M. 2012, 'Strengthening the nursing and midwifery unit manager role: an interim programme evaluation.', J Nurs Manag, vol. 20, no. 1, pp. 120-129.
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An interim evaluation was conducted on the professional development components of the New South Wales (NSW) Health 'take the lead' ('ttl') programme, an initiative aimed at enhancing nursing/midwifery unit managers' (N/MUM) skills.
Wheeler, J., Davis, D., Fry, M., Brodie, P. & Homer, C.S.E. 2012, 'Is Asian ethnicity an independent risk factor for severe perineal trauma in childbirth? A systematic review of the literature', Women and Birth, vol. 25, no. 3, pp. 107-113.
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Objective: To undertake a systematic review of the literature to determine whether Asian ethnicity is an independent risk factor for severe perineal trauma in childbirth. Method: Ovid Medline, CINAHL, and Cochrane databases published in English were used to identify appropriate research articles from 2000 to 2010, using relevant terms in a variety of combinations. All articles included in this systematic review were assessed using the Critical Appraisal Skills Programme (CASP) 'making sense of evidence' tools. Findings: Asian ethnicity does not appear to be a risk factor for severe perineal trauma for women living in Asia. In contrast, studies conducted in some Western countries have identified Asian ethnicity as a risk factor for severe perineal trauma. It is unknown why (in some situations) Asian women are more vulnerable to this birth complication. The lack of an international standard definition for the term Asian further undermines clarification of this issue. Nevertheless, there is an urgent need to explore why Asian women are reported to be significantly at risk for severe perineal trauma in some Western countries. Conclusion: Current research on this topic is confusing and conflicting. Further research is urgently required to explore why Asian women are at risk for severe perineal trauma in some birth settings. 2011 Australian College of Midwives.
Merrick, E.T., Duffield, C.M., Baldwin, R.J., Fry, M. & Stasa, H. 2012, 'Expanding the role of practice nurses in Australia', Contemporary Nurse, vol. 41, no. 1, pp. 133-140.
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Like other countries, Australia is looking to reforms in the primary health care sector to meet the growing demand for care. Expansion of the role of practice nurses (PNs) is one way in which this demand may be met. To date the Federal Australian government has played a significant role in encouraging growth in the PN worforce. If the PNs tend to be GP directed, with little autonomy, care must be taken to consider whether to expand existing scopes of practice.
Fry, M. 2012, 'An ethnography: Understanding emergency nursing practice belief systems', International Emergency Nursing, vol. 20, no. 3, pp. 120-125.
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Background: Further insight is needed to better understand how beliefs impact on contemporary Australian Emergency Department (ED) triage nursing practice. Specifically, how do cultural notions drive beliefs that give shape to nursing practice? Methods: Ethnography was the methodological framework used to explore triage practice. A purposeful sample of 10 Triage Nurses across four EDs was selected. Two hundred hours of nonparticipant observation were collected. Results: Beliefs were identified that gave meaning to triage nursing behaviour and action. Belief 1: Respecting space and privacy; Belief 2: Taking control and responsibility; Belief 3: Patients should not arrive with expectations; Belief 4: Do not ask for a bed; Belief 5: Expect a level playing field; Belief 6: No benefit from having a referral letter; Belief 7: Do not waste time. When a belief was engaged Triage Nurses implemented a range of practices, which were culturally oriented and at times at odds with patient expectations and care.
Fry, M., Hearn, J. & McLaughlin, T. 2012, 'Pre-hospital pain management patterns and triage nurse documentation.', Int Emerg Nurs, vol. 20, no. 2, pp. 83-87.
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Little is known about the public's preferences for pain management prior to attending an Emergency Department (ED). Therefore, the aim of the study was to explore (i) triage documentation of pre-hospital analgesic patterns for patients presenting in pain; (ii) patient documented explanations for not self administering an analgesic in the pre-hospital setting; (iii) triage nurse documentation of pain descriptors and or pain scores; and (iv) the disposition of ED patients presenting in pain.
Fry, M., Horvat, L., Roche, M.A., Fong, J. & Plowes, J. 2012, 'The prevalence and triage characteristics of patients presenting with infection to one tertiary referral hospital', Australasian Emergency Nursing Journal, vol. 15, pp. 127-132.
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Globally, severe infection and or sepsis is a problem that is costing billions of dollars, using hundreds of hospital beds, and often results in patient death. Any infection can potentially develop a sepsis health trajectory if left unrecognised and unmanaged. We conducted a 12 month retrospective descriptive exploratory study. Our research explored the prevalence and triage characteristics of patients presenting with infection to one tertiary referral hospital. Electronic medical records were reviewed to identify patients that had a primary diagnosis related to infection. The study identified that 16% (n = 7756) of adult presentations had a discharge diagnosis related to infection. A significant difference (X2 = 297.83, df = 4, p .001) in Triage Code allocation for the infection group was identified compared with the non-infection patient group. Thirty-nine percent (n = 3027) of patients with infections were admitted to hospital. Of the patients (n = 1930; 4%) admitted to a critical care area, 6% (n = 122) had a primary diagnosis related to infection. Of the ED deaths (n = 81), 12% (n = 10) had a primary diagnosis related to infection.
Fry, M., Ruperto, K., Jarrett, K., Wheeler, J., Fong, J. & Fetchett, W. 2012, 'Managing the wait: Clinical initiative nurses' perceptions of an extended practice role', Australian Journal of emergency nursing, vol. 15, no. 4, pp. 202-210.
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Introduction: The Clinical Initiative Nurse (CIN) is a role that requires experienced emergency nurses to assess, initiate diagnostic tests and treat and manage a range of patient conditions. In 2010, the New South Wales Ministry of Health redefined the focus of the CIN role to be on waiting room patients. The new CIN role was now focused on the waiting room and to communicate the wait, initiate diagnostics and or treatment and follow-up for waiting room patients. While new models of care are often introduced the perceptions of those undertaking the roles are often absent from evaluation. We aimed to explore emergency nurses perceptions of the extended practice role known as the Clinical Initiative Nurse.
Lutze, M., Ratchford, A. & Fry, M. 2011, 'A review of the Transitional Emergency Nurse Practitioner', Australian Emergency Nursing Journal, vol. 14, pp. 226-231.
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Introduction: A retrospective exploratory study was conducted to (i) explore the practice patterns of a Transitional Emergency Nurse Practitioner (TENP) working across two urban Emergency Departments (ED); (ii) identify the demographic characteristics of the TENP patient cohort; and (iii) identify if TENP patients were appropriately and timely managed. Method: The study was conducted across two hospital sites over two consecutive years for a 3-month period. Data collection occurred during the months of December through to February. TENP patients were identified by hospital electronic medical record and were then grouped into a model that included 'Fast Track' or 'See and Treat' cohort. The cohorts were then analysed for diagnostic groups, age, sex, length of stay, triage category, and re-presentations. Results: The TENP worked a total of 600 h (Site 1 252 h; Site 2 348 h) across the study period. The TENP managed a total of 481 patients (262 Site 1; 220 Site 2) during the study period. The majority of patients (412; 84%) were managed in the 'See and Treat' cohort (Site 1 246, 94%; Site 2 166, 75%) and 70 patients (16%) were managed in the 'Fast Track' cohort (Site 1 16, 4%; Site 2 54, 25%). The median length of stay for TENP managed patients was 143 min, with 96% of patients leaving the ED in less than 8 h. There were no TENP unplanned representations at either site. The TENP managed more male patients across both sites. The majority (75%) of patients the TENP managed had musculoskeletal and/or wound conditions or injuries.
Fry, M., Fong, J., Asha, S. & Arendts, G. 2011, 'A 12-month evaluation of the impact of Transitional Emergency Nurse Practitioners in one metropolitan Emergency Department', Australian Journal of emergency nursing, vol. 14, no. 1, pp. 4-8.
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Objective To meet increasing work demand, the NSW government funded Transitional Emergency Nurse Practitioner (TENP) roles which would work within a Nurse Practitioner (NP) framework. The role provided opportunity for experienced nurses to, develop advanced practice skills, manage a range of patient conditions and injuries. Therefore, the aims of this study were to: (i) describe patient demographics and conditions managed within the TENP model; (ii) examine the efficiency and safety of TENP management; and (iii) evaluate the impact of the TENP role on the delivery of emergency services. Design A 12-month prospective observational study was conducted to evaluate the implementation of a TENP model. Setting A 550 bed University Referral Hospital St George Hospital providing around 50,000 admissions and 770,000 outpatient treatments annually to a catchment population of 250,000. Subjects Patients presenting with minor injuries and illnesses to one metropolitan emergency department (ED). The majority of patients seen were in triage categories 3, 4 and 5.
Nugus, P., Holdgate, A., Fry, M., Forero, R., McCarthy, S. & Braithwaite, J. 2011, 'Work Pressure and Patient Flow Management in the Emergency Department: Findings From an Ethnographic Study', Academic Emergency Medicine, vol. 18, no. 10, pp. 1045-1052.
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Objectives: In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency d
Fry, M., Bennett, S. & Huckson, S. 2011, 'An Australian Audit of ED Pain Management Patterns', Journal of emergency nursing, vol. 37, no. 3, pp. 269-274.
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Introduction: Timely and appropriate pain management is an important quality indicator of ED performance. Emergency health care workers are well positioned to become active leaders and innovatively responsive in reducing human suffering. A pain management audit was conducted to determine Australia practice patterns. Methods: A 12-month retrospective descriptive cohort audit was undertaken. Through the randomization process a medical record audit tool was completed for each record identified. Ethical approval for the study was obtained. Results: Seventy-four hospitals agreed to conduct the audit, 36 (48%) provided data. The total number of patient notes reviewed was 2,066. Ninety-five percent (1,966) of patients arrived by ambulance. Of the patients (n=547; 56.4%) with a documented triage pain score the majority arrived in severe pain (n=300; 41.3%). Of the total number of patients (1,966) documented arriving in pain 1,473 (74.9%) received an analgesic. Six hundred and forty-four (32.7%) patients received an opioid. From time of emergency department arrival, the median time for analgesic administration was 70 minutes (IQR 58 minutes to 92 minutes). Twenty-five emergency departments (69.4%) had pain management policies that enabled nurses to initiate a pharmacological analgesia without medical consultation. Discussion: The Australian pain management audit highlighted current practices and potential areas for further research. While the audit demonstrated that nurse initiated pain management interventions promoted better analgesic response, greater consistency of triage pain assessment, code allocation, and documentation of pain scores may go some way to improving the timeliness of analgesia.
Fry, M. 2011, 'Literature review of the impact of nurse practitioners in critical care services', Nursing in Critical Care, vol. 16, no. 2, pp. 58-66.
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Aims: The comprehensive review sought to examine the impact of Critical Care Nurse Practitioner models, roles, activities and outcomes. Method: The Medical Literature Analyses and Retrieval (MEDLINE), The Cumulative Index of Nursing and Allied Health Literature (CINAHL); PubMED; PROQUEST; ScienceDirect; and the Cochrane database were accessed for the review. Alternative search engines were also included. The search was conducted with the key words: critical care, intensive care, acute, adult, paediatric, trauma, disease management programs, disease management, case management, neonatal, cardiology, neurological, retrieval, transfer and combined with Nurse Practitioner. From the identified 1048 articles 47 studies were considered relevant. Results: Internationally, Critical Care Nurse Practitioners were located in all intensive care areas and services including post intensive care discharge follow-up, intensive care patient retrieval and transfers and follow-up outpatient services. The role focussed on direct patient management, assessment, diagnosis, monitoring and procedural activities. Critical Care Nurse Practitioners improved patient flow and clinical outcomes by reducing patient complication, morbidity and mortality rates. Studies also demonstrated positive financial outcomes with reduced intensive care unit length of stay, hospital length of stay and (re)admission rates. Conclusions: Internationally, Critical Care Nurse Practitioners are demonstrating substantial positive patient, service and nursing outcomes. Critical Care Nurse Practitioner models were cost effective, appropriate and efficient in the delivery of critical care services.
Duffield, C.M., Gardner, G., Chang, A.M., Fry, M. & Stasa, H. 2011, 'National regulation in Australia: A time for standardisation in roles and titles', COLLEGIAN, vol. 18, no. 2, pp. 45-49.
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Chapman, N., Lazar, S., Fry, M., Lassere, M. & Chong, B.H. 2011, 'Clinicians adopting evidence based guidelines: a case study with thromboprophylaxis', BMC Health Services Research, vol. 11, pp. 240-250.
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Background: Venous Thromboembolism (VTE) is a cause of hospital mortality and managing its morbidity is associated with significant expenditure. Uptake of evidenced based guideline recommendations intended to prevent VTE in hospital settings is sub-optimal. This study was conducted to explore clinicians' attitudes and the clinical environment in which they work to understand their reluctance to adopt VTE prophylaxis guidelines. Methods: Between February and November 2009, 40 hospital employed doctors from 2 Australian metropolitan hospitals were interviewed in depth. Qualitative data were analysed according to thematic methodology. Results: Analysis of interviews revealed that barriers to evidence based practice include i) the fragmented system of care delivery where multiple members of teams and multiple teams are responsible for each patient's care, and in the case of VTE, where everyone shares responsibility and no-one in particular is responsible; ii) the culture of practice where team practice is tailored to that of the team head, and where medicine is considered an 'art' in which guidelines should be adapted to each patient rather than applied universally. Interviewees recommend clear allocation of responsibility and reminders to counteract VTE risk assessment being overlooked. Conclusions: Senior clinicians are the key enablers for practice change. They will need to be convinced that guideline compliance adds value to their patient care. Then with the support of systems in the organisation designed to minimize the effects of care fragmentation, they will drive practice changes in their teams. We believe that evidence based practice is only possible with a coordinated program that addresses individual, cultural and organisational constraints.
Fry, M. 2011, 'A systematic review of the impact of afterhours care models on emergency departments, ambulance and general practice services', Australasian Emergency Nursing Journal, vol. 14, pp. 217-225.
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Introduction: The aim of the systematic review was to examine (i) the impact of afterhours primary care models on ED, ambulance services and or general practitioners and (ii) the effectiveness of these services (afterhours) on nurse practitioners and/or the medical doctors delivery of care. Method: Articles were assessed using the Critical Appraisal Skills Programme (CASP) making sense of evidence tools and covered the period from 1970 to 2011. The data sources searched were: Cumulative Index to Nursing and Allied Health literature, Medline, EMBASE, The Cochrane Database of Systematic Reviews, PubMed, Science Direct and Proquest. Results: A total of 2268 were retrieved and 419 studies were identified. Eighty-seven studies were found to be relevant. Nine countries are represented in the data. There were few relevant Randomised Controlled Trials (n = 5). The evidence was largely based on quasi experimental (time series), before and after or comparative studies. Studies were usually set within a single hospital or community setting with heterogeneous samples, short sample periods, and or measured a single outcome such as patient satisfaction. Conclusions: Six models were identified from the review which highlighted evidence that afterhour care models can reduce GP workload and to a lesser extent ED and ambulance services. Potentially these models could ease acute care work load, improve access across the vast geographical distances of Australia.
Fry, M. & Rogers, T.F. 2009, 'The Transitional Emergency Nurse Practitioner role: Implementation study and preliminary evaluation', Australian Emergency Nursing Journal, vol. 12, no. 2, pp. 32-37.
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Summary Background: An implementation study was undertaken to develop and employ Transitional Emergency Nurse Practitioners (TENPs) to address increased service demands. The TENP role was to be a new advanced practice role, which was based on a Nurse Practitioner (NP) framework. The implementation study provided a roadmap for the introduction of the new nursing role. The implementation study aimed to i) develop an integrated and supported Transitional Emergency Nurse Practitioner role; ii) provide a framework for practice and knowledge development; and, iii) undertake a six month preliminary evaluation of TENP work performance. Methods: The study describes the communication strategy, the consultative process for role definition, education, ongoing support structures and assessment and feedback mechanisms embedded in the implementation process. In addition, a six month mixed method preliminary evaluation was undertaken as part of the implementation plan. The preliminary evaluation included review of TENP managed patient groups; peer audit of TENP documentation; a senior emergency physician survey of TENP work performance; and, review of TENP investigations and referrals. Results: TENPs managed the care of, or were involved with, 2730 patients (10%) of which 68% (n = 1987) were in the See and Treat group and 32% (n = 721) were in the Collaborative (742) and Consultative (22) groups. TENPs managed an average of 20 patients per 15 hour work day. Work performance evaluation identified the role was safe and efficient and that staff supported the new role.
Fry, M. & Ruperto, K. 2009, 'A 12 month retrospective study of airway management practices', International Emergency Nursing, vol. 17, no. 2, pp. 108-112.
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Introduction Australian emergency nurses have a primary role in advanced airway management. Consequently, they need to be competent in, and have a systematic approach to, airway preparation, management and rescue. Aim The aims of the study were to (i) identify all patients undergoing endotracheal intubations in the emergency department; (ii) describe patient characteristics, diagnosis and disposition; and, (iii) review the introduction of an advanced airway management algorithm and difficult airway equipment tray. Methods A 12 month retrospective study was undertaken (1/1/2006 to 31/12/2006) of all patients requiring oral endotracheal intubation. A survey was conducted to determine nursing confidence and practice with intubation and the benefit of introducing an advanced airway management algorithm and a preassembled difficult airway equipment tray. Results Two hundred and fifty three patients required intubation during the study. The age ranged from neonates/infants to 98 years. Emergency nurses felt confident in assisting with endotracheal intubation and regularly encountered airway rescue situations. The pre-assembled difficult airway equipment and airway management algorithm led to improved confidence and practice. Conclusion Endotracheal intubation is a regular ED intervention. Emergency nurses need to have knowledge of airway management and rescue. A developed airway management algorithm and difficult airway equipment tray improved nursing confidence, expertise and response time in advanced airway interventions.
Fry, M. 2009, 'Barriers and facilitators for successful after hours care model implementation: Reducing ED utilisation', Australasian Emergency Nursing Journal, vol. 12, no. 4, pp. 137-144.
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A systematic review examined the barriers and facilitators influencing the success and sustainability of after hours care models on acute care utilisation. Extensive research had been undertaken in many countries, particularly in the United Kingdom, The United States of America, Ireland, Canada, Denmark, Sweden, and to a lesser degree Australia. The literature covered the period from 19702008. The evidence demonstrated a positive impact on acute service utilisation patterns. There were few relevant randomised control trials. The evidence was largely based on quasi experimental (time series), before and after or comparative studies. Study results often noted barriers and facilitators for model success and sustainability. The relevant literature was largely international, so results may need to be interpreted in a considered way given geographical, cultural and social differences. This said the findings are relevant to the Australian context.
Fry, M. 2008, 'Overview of emergency nursing in Australasia', International Emergency Nursing, vol. 16, no. 4, pp. 280-286.
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Emergency nursing practice has been shaped by many factors. These factors include advances in resuscitation and technology, recognition of emergency as a specialty practice, increased consumer expectation, increased number of patient presentations and changing case mix. These factors and the growing demand on the healthcare system have increased the complexity and demands experienced in emergency nursing. The current focus on emergency care provides an opportunity for nurses to collectively drive the healthcare agenda, management focus, policy direction and research agenda.
Arendts, G., Stevens, M. & Fry, M. 2008, 'Topical anaesthesia and intravenous cannulation success in paediatric patients: a randomized double-blinded trial', British Journal of Anaesthesia, vol. 100, no. 4, pp. 521-524.
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Background: It is not known whether the choice of topical anaesthetic influences the likelihood of successful i.v. cannulation in the paediatric population. The null hypothesis of this study was that no difference exists in the initial success rate of cannulation between two commonly used topical anaesthetics. Methods: A randomized double-blind trial conducted on patients between the age of 12 months and 12 yr presenting to a tertiary hospital emergency department. Patients requiring cannulation were randomized to either 4% amethocaine gel (AnGEL) or 5% lidocaine and prilocaine in a 1:1 emulsion (EMLA). The primary endpoint was success of initial attempt at i.v. cannulation. Results: One hundred and seventy-seven patients were analysed of 203 enrolled. The success rate of AnGEL (73/97, 75%) and EMLA (59/80, 74%) did not significantly differ ({chi}21 0.05, P=0.82). Conclusions: No difference exists in the cannulation success rates between the two anaesthetics. The choice of topical anaesthetic in paediatric cannulation should be based on other factors such as cost, time to anaesthesia, efficacy of the agent, and adverse effect profile.
Nugus, P., Braithwaite, R., Holdgate, A., Travaglia, S., McCarthy, S., Fry, M. & Daly, B. 2007, 'The impact of clinical knowledge, structure and interaction in the patient pathway: The organisational journey of emergency clinicians', Academic Emergency Medicine, vol. 14, no. 4, pp. 97-98.
abstract
Holdgate, A., Morris, J., Fry, M. & Zecevic, M. 2007, 'Accuracy of triage nurses in predicting patient disposition', Emergency Medicine Australasia, vol. 19, pp. 341-345.
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Increasing demand to reduce patient waiting times and improve patient flow has led to the introduction of a number of strategies such as fast track and patient streaming. The triage nurse is primarily responsible for identifying suitable patients, based on prediction of likely admission or discharge. The aim of the present study was to explore the accuracy with which triage nurses predict patient disposition.
Dwyer, D., Fry, M., Sommerville, A. & Holdgate, A. 2006, 'Randomized, single blinded control trial comparing haemolysis rate between two cannula aspiration techniques', Emergency Medicine Australasia, vol. 18, pp. 484-487.
Objective: Blood aspiration through i.v. cannulae is a common ED sampling method. It is, however, associated with increased haemolysis rates when compared with direct venipuncture. Our ED utilizes two common methods of sampling through cannulae. The aim of the present study was to examine the haemolysis rates for these two techniques. Methods: A randomized, single blinded prospective study was performed. From a convenience sample patients were randomized to either `Method one (blood taken directly from cannula hub) or `Method two (blood taken using an Interlink device through cannula cap). For each group patient demographics, clinical information and haemolysis were analysed. ?<sup>2</sup>-analysis and a multivariate logistic regression model were applied to determine significant relationships. Results: A total of 1390 patients were enrolled, 694 had blood collected by `Method one and 696 by `Method two, with haemolysis rates of 6.5% and 7.2%, respectively. Univariate analysis showed ease of aspiration to be the only variable to have a strong association with haemolysis ( P < 0.0001). After allowing for ease of aspiration the technique used did not significantly affect haemolysis rate ( P = 0.7). Conclusions: The rate of haemolysis is unrelated to the technique of blood aspiration. However, haemolysis rates increase significantly with perceived difficulty of blood draw.
Arendts, G. & Fry, M. 2006, 'Factors Associated With Delay to Opiate Analgesia in Emergency Departments', The Journal of Pain, vol. 7, no. 9, pp. 682-686.
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Patients presenting to an emergency department (ED) with painful conditions continue to experience significant delay to analgesia. It remains unclear whether demographic and clinical factors are associated with this outcome. The objectives of this study were to determine 1) the proportion of patients that require parenteral opiate analgesia for pain in an ED and who receive the opiate in less than 60 minutes; and 2) whether any factors are predictive for the first dose of analgesia being delayed beyond 60 minutes. A retrospective cohort study with descriptive and comparative data analysis was conducted. Over a 3-month period, the medical record of every patient receiving parenteral opiates in a tertiary emergency department was reviewed and analyzed. Of 857 patients, 451 (52.6%) received analgesia in less then 60 minutes. Multiple demographic and clinical factors are associated with statistically significant delay to analgesia, including age, triage code, seniority of treating doctor, diagnosis, and disposition from the ED.
Fry, M. & Stainton, S.C. 2005, 'An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes', Accident and Emergency Nursing, vol. 13, no. 4, pp. 214-219.
The role of the triage nurse has emerged in response to growing community demand for a more accessible and efficient emergency department (ED) service. The focus of triage research has been on measuring outcomes and improving the delivery of emergency care. This has meant that the context of care, and triage processes and practices have remained concealed. Thus, little evidence about the role and ways to prepare nurses for this role is available. The aim of this study was to provide insight and understanding needed to educate and support the triage nursing role in Australian EDs.
Fry, M. & Jones, K. 2005, 'The clinical initiative nurse: Extending the role of the emergency nurse, who benefits?', Australasian Emergency Nursing Journal, vol. 8, no. 1, pp. 9-12.
Introduction and aim: In 2002, the New South Wales (NSW) Government provided funding to implement a new emergency nursing role, the clinical initiative nurse (CIN), that would target waiting patients. The aims of this study were to evaluate the impact of the clinical initiative nurse role and to identify the areas for change in the role. Methodology: The evaluation of the CIN role included data obtained from the Emergency Department Information System (EDIS) and a 22-item questionnaire examining role function, professional practice and role satisfaction. Results: There were 55 emergency nurses in the CIN role. CINs triaged 4793 patients and undertook 22,912 episodes of patient care on 9366 patients. The questionnaire response rate was 68% (n = 26). Sixteen (62%) nurses perceived that the role offered greater opportunity for clinical and professional advancement, while 10 (38%) did not. Twenty-three (88%) reported the need for additional clinical guidelines to assist in understanding the role function and independence and 11 (42%) reported the need to extend the scope of CIN practices, while 15 (58%) did not. All CINs perceived the need to have a dedicated orientation program for the role.
Fry, M. & Rhodes-Sutton, A. 2005, 'A retrospective chart review of adult mortality characteristics of patients presenting to a principal tertiary emergency department', Accident and Emergency Nursing, vol. 13, no. 2, pp. 122-125.
Aim: To determine the incidence of death after arrival to one metropolitan emergency department (ED) for each triage code, day of arrival, diagnosis and length of stay. Method: A 12-month retrospective chart review was conducted in a 550 bed principal referral hospital of all patients that presented to the ED and subsequently died. The ED annual attendance rate for the study year was 46,017 patients. The data collected included patient demographics, diagnosis, triage code, length of stay and ward disposition. The data are expressed as proportions, percentages, frequencies or the statistic chi-square ([chisquare]). The proportion of ED deaths also examined included those patients admitted through the ED to a ward area. Results: The ED mortality rate for the study period was 1.3% (n = 595). One hundred and twenty-three patients (21%) died in the unit, while 472 (79%) were admitted through the ED to a ward area. The total annual hospital mortality rate was 1.7% (n = 790). The mean age of patients that died was 76 years. Of ED deaths, 329 (55%) were male and 266 (45%) female. Triage code 1 (60%) was allocated more commonly to patients that died in the ED compared with triage code 3 (46%) for ED-Ward deaths. Conclusions: Examination of ED mortality rate provides a deeper understanding of service utilisation and nursing staff work performance. Triage codes are beneficial in evaluating ED services, casemix, policies and quality assurance activities, but the application of this indicator to in-patient services appears limited.
Fry, M. & Brunero, S. 2004, 'The characteristics and outcomes of mental health patients presenting to an emergency department over a twelve month period.', Australian Emergency Nursing Journal, vol. 7, no. 2, pp. 21-25.
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The number of mental health consumers presenting to the emergency department (ED) over the last five years has been increasing because of mainstreaming. The aims of this paper are to: (i) describe the characteristics of mental health patient presentations to our ED; (ii) examine the distribution of triage code allocations; and (iii) identify the outcomes of ED mental health patients.
Fry, M., Ajami, A. & Borg, A. 2004, 'Bringing relevant information to diverse groups about emergency department services: The 'BRIDGE' Project.', Australian Emergency Nursing Journal, vol. 7, no. 1, pp. 19-22.
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Emergency departments (EDs) need to engage with the community to ensure fairer access to health resources. A particularly vulnerable group in the general community are people from non English speaking backgrounds (NESB). The ED at St George Hospital in Sydney developed an innovative project aimed at bringing relevant information to diverse groups about community services and EDs. This became known as the BRIDGE project. The project involved a diverse group of stakeholders from the community, the area health service and the hospital. As an education program it sought to inform our local NESB community about health care choices. Part of the program involved the development of a video, which has been produced in six different languages. We believe a community better informed about health care services will improve personal health care decision-making and resource utilisation.
Fry, M., Ryan, J. & Alexander, N. 2004, 'A Prospective Study of Nurse Initiated Panadeine Forte: Expanding Pain Management in the ED', Accident and Emergency Nursing, vol. 12, no. 3, pp. 136-140.
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ntroduction. This study describes an innovative pain management strategy that aimed to improve the efficiency and effectiveness of timely analgesia for those patients in moderate pain and who experienced significant delay prior to medical assessment. Method. A 12-week prospective exploratory study was conducted to evaluate the introduction of a triage nurse initiated schedule 4 drug. A panadeine forte policy was developed and a data tool formulated to evaluate the effectiveness and frequency of nurse initiated panadeine forte.
Fry, M., Thompson, J. & Chan, A. 2004, 'Patients Regularly Leave Emergency Departments Before Medical Assessment: A Study of Did Not Wait Patients, Medical Profile and Outcome Characteristics.', Australian Emergency Nursing Journal, vol. 6, no. 2, pp. 21-26.
In 2001 New South Wales Health reported an increase in the number of patients who did not wait for treatment in emergency departments. Because so little was known about this group of patients a study was conducted to indentify: (1) the characteristics and reasons for patients leaving prior to medical assessment; (2) patients' illnesses or conditions, urgency code and nature of ED encounter; and (3) DNW patient outcomes. A 13 question telephone survey was conducted which focused on the presenting complaint, waiting times, staff communication and patient outcomes. During the three-month study, 64% of eligible patients were contacted. The reasons they gave for leaving were largely because of the time delay in being seen, but some left because their condition resolved or they felt too ill to stay or they received treatment or reassurance from the triage nurse. A small number of patients left because of safety concerns in the waiting room, because they had other commitments or because staff were rude. Some patients left to go to other facilities; almost 70% of patients sought medical attention within 24 hours of leaving the ED. The endemic problem of overcrowding is placing demands on EDs to review and reform service delivery. While the study was conducted in a tertiary referral centre this ED is characteristic of most others across Australia. Outcome analysis of this vulnerable group is required.
Fry, M. & Holdgate, A. 2002, 'Nurse initiated intravenous mrophine in the emergency department:efficacy,rate of adverse events and impact on time to analgesia', Emergency Medicine Australasia, vol. 14, no. 3, pp. 249-254.
Objectives: The objectives of this study were: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia. Methods: A prospective convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses. Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min. Demographic, diagnostic and waiting time data were also recorded.
Fry, M. & Burr, G. 2001, 'Using a survey tool to explore the processes underpinning the triage role: A pilot study.', Australian Emergency Nursing Journal, vol. 4, no. 11, pp. 27-31.
Fry, M. & Burr, G. 2001, 'Current triage practice and influences affecting clinical decision making in emergency departments in NSW, Australia', Australian Emergency Nursing Journal, vol. 9, no. 4, pp. 227-234.
Fry, M. 2001, 'Expanding the triage nurses role in the emergency department how will this influence practice?', nursing achievements, vol. 1, no. 2, pp. 26-29.
Fry, M. 2001, 'Triage nurses can safely, accurately and appropriately order x-rays for patient's with isolated distal limb injuries: A 12 month ED study', Journal of emergency nursing, vol. 27, no. 1, pp. 17-22.
Fry, M. & Burr, G. 2001, 'Using a survey tool to explore the processes underpinning the triage role: A pilot study', Australian Emergency Nursing Journal, vol. 4, no. 1, pp. 27-31.
A triage survey tool, was developed using the Delphi technique and piloted by thirty triage nurses across New South Wales (NSW). While the essential task of the triage nurse is to determine the patient's medical urgency this position frequently involves complex clinical decision-making, the fast tracking of patients and the initiation of investigations. The available literature has not adequately explored the processes underpinning neither triage practice nor the nature of clinical decisions made by triage nurses throughout New South Wales. This survey tool aims to capture current triage processes and the influences that impact upon the role so as to develop a better understanding of triage practice in both the rural and metropolitan settings.
Fry, M. & Saunders, D. 2000, 'Letter to the president', Australian Emergency Nursing Journal, vol. 3, no. 1, pp. 4-4.
Fry, M. & Holdgate, A. 2000, 'The safety of nurse initiated narcotics in the emergency department",', Nursing Matters, vol. 1, no. 1, pp. 25-25.
Fry, M. & Kenny, C. 2000, 'Ventilators in the ED: the ABC', Australian Emergency Nursing Journal, vol. 3, no. 1, pp. 6-10.
The increasing workload experienced by emergency departments and the difficulties with transferring patients out of the ED has meant emergency departments are caring for patients longer. Many of these patients are acutely ill and often these patients are requiring advanced airway management and ventilation. In caring for the ventilated patient the emergency nurse needs to have an understanding of the different types of respiratory failure, the common types of ventilators and the different types of ventilation modes available. The ventilated patient requires specialised care and the emergency nurse must be knowledgeable in the theory and practice of ventilation. To ensure the ventilated patient's safety the emergency nurse needs to be comfortable with the type of ventilator they are using in their department and proficient in the appropriate monitoring of patients on ventilators, and astute in detecting ventilator emergencies.
Ahern, M. & Fry, M. 1999, 'Right ventricular infarction', nursing achievements, vol. 1, no. 1, pp. 47-52.
Fry, M., Holdgate, A., Baird, L., Silk, J. & Ahern, M. 1999, 'An emergency department's analysis of pain management patterns', Australian Emergency Nursing Journal, vol. 2, no. 3, pp. 31-36.
Fry, M., Jackson, S. & McAlpine, A. 1999, 'The advanced clinical nurse a new model of practise: meeting the challenge of peak activity periods', Australian Emergency Nursing Journal, vol. 2, no. 3, pp. 26-28.
Fry, M. 1999, 'Emergency nursing here today: what about tomorrow', Australian Emergency Nursing Journal, vol. 2, no. 2, pp. 9-9.
Fry, M. & Taylor, A. 1998, 'Tetanus the silent killer', Australian critical care, vol. 11, no. 3, pp. 82-85.
Hollis, G. & Fry, M. 1998, 'Non invasive calf blood pressure measurement is not useful in the adult patient in the emergency department', Emergency Medicine Australasia, vol. 10, no. 3, pp. 276-277.
Shardlow, W. & Fry, M. 1998, 'Crossing the barriers: shifting to trauma nursing on demand', Australian Critical Care, vol. 11, no. 2, pp. 59-60.
Fry, M. & McAlpine, A. 1998, 'Bridging the gap international nursing consultancy the lived experience', Australian Emergency Nursing Journal, vol. 1, no. 5, pp. 22-23.
Fry, M., Ekholm, J. & Farrington, C. 1996, 'Innovative research projects meeting the needs of the elderly patients within the ED', Australian Emergency Nursing Journal, vol. 1, no. 1, pp. 42-45.