The black and white and shades of grey of boundary violations.

Using a Constructivist Grounded Theory approach (Charmaz, 2006), this research examined the social construct of the "professional boundary" necessary in mental health therapeutic work and the problem of professional boundary violations in the therapeutic relationship. Thirteen mental health clinicians from various professional disciplines commonly found in mental health clinical practice responded to three specific questions designed to gain an understanding about how clinicians gauge the differences between minor and serious boundary violations. The three questions facilitated further exploration of boundary violations specifically to explore the difficulties of determining what is and what is not considered a boundary violation often resulting in polarised views or "black and white" descriptions and opinions. However many shades of grey were also revealed during the interviews. Almost all participants rated intimacy or sexual contact with a client or an ex-client as being a serious boundary violation, on the other hand there was a great deal of variety in the examples offered as minor boundary violations. Whilst the "Black" is clearly defined by clinicians in this research, the "White" only seemed to create more "Grey" areas, with descriptions of behaviours that fell into the Grey area being more difficult to define.

Undernutrition in older people in Australia.

Despite being preventable and treatable, undernutrition remains a problem for many older people in tertiary healthcare settings. Nurses have a crucial role in assisting people who are unable to eat independently and are uniquely positioned to implement solutions that will lead to better nutritional care. However, what is known about the management of undernutrition is not informing nursing practice. This study used action research, underpinned by the 'participatory world view', to address the theory-practice gap. Data and between-method triangulation were used to collect and analyse qualitative non-participant observations and action research group data. Set Up Ready For Dining (SURFD) was developed and implemented by nurses to improve patient mealtimes. Findings show that nursing practice in nutritional care is influenced by technique within the healthcare context that emphasises operational efficiency, and by the choices that nurses made around being the patient advocate during mealtimes.

Nursing practice in nutritional care: a comparison between a residential aged care setting and a hospital setting.

AIM: To explore the similarities and differences in the nursing practice in nutritional care between a residential aged care setting and a hospital setting. BACKGROUND: Despite being preventable and treatable, undernutrition remains a problem for many older people in residential aged care and hospital settings. Nurses have a crucial role in assisting people who are unable to eat independently and are uniquely positioned to implement solutions that will lead to better nutritional care. DESIGN: During 2007-2010, an action research study was conducted, underpinned by the principles of the participatory world view to address undernutrition in a residential aged care setting and a hospital setting. METHODS: The multimethod approach of data and between-method triangulation were used to collect and analyse qualitative non-participant observations and action research group data. Non-participant observations and action research group data were qualitatively analysed using the Analytic Hierarchy. FINDINGS: How nurses chose to participate in the provision of nutritional care and assert their autonomy when changing practice to nutritional care affected the quality of the resident/patient mealtime experience. Operational efficiency influenced the choices that nurses made about the type of intervention to implement to improve nursing practice in nutritional care. Nurses required management approval to change practice in nutritional care. CONCLUSION: The reasons for undernutrition are multifactorial and more research is needed to investigate the organizational structures and processes that affect the delivery of nutritional care across role functions, how these affect the continuity of care and the nurses' role in defining the culture around resident/patient mealtimes.

Evaluating and improving a model of nursing care delivery: a process of partnership.

INTRODUCTION: Evaluating and improving a model of nursing care is a fundamental part of clinical practice improvement. While Australian nurses are showing increasing interest in improving models of care delivery, more research is needed that addresses and articulates the processes attendant upon evaluating, re-designing and implementing improvements to the provision of nursing care. Providing nurses with an open opportunity to plan, act, observe and reflect on their practice promotes successful partnerships between academics and clinicians. AIM: The aim of this study was to evaluate and improve the model of nursing care delivery to patients in a general surgical ward using participatory action research. METHOD: Researchers conducted non-participant observations (n = 9) of two hours duration across the 24 h period. Focus groups (n = 3) were used to share non-participant observation data with staff, providing them with an opportunity to reflect on their practice and explore possible solutions. Data was collected in 2008-2009. RESULTS: Two main problem areas were identified as impeding the nurses' ability to provide care to patients: (i) practices and behaviours of nurses and (ii) infrastructure and physical layout of the ward. An overview of issues within each problem area is presented. CONCLUSION: Shifting the focus of task-centred care towards a more patient-centred care approach, results directly in improvements in resource utilisation, improved cost-effectiveness and job satisfaction for nursing staff. New ways of thinking about nursing processes and systems, workflow design and skill allocation will guide hospital administrators and managers in the effective and efficient allocation of nursing work in similar settings.

Reclaiming time for nursing practice in nutritional care: outcomes of implementing Protected Mealtimes in a residential aged care setting.

AIMS: To improve nutritional care and the mealtime experience of older people in a residential aged care setting by assisting nurses to create change to their practice and to the mealtime environment. BACKGROUND: Despite being preventable and treatable, inadequate nutrition remains a problem for many older people in residential aged care and tertiary health care settings. Nevertheless, many organisations are uniquely positioned to implement solutions that will lead to better care. DESIGN: The study used a qualitative, action research approach, grounded in the participatory worldview. METHODS: The multimethod approach of data and between-method triangulation were chosen to assist in understanding the multidimensional issues associated with resident mealtimes and the provision of nutritional care. The collection of non-participant observations was informed by aspects of the Developmental Research Sequence. Action group meetings and non-participant observations were qualitatively analysed using the Analytic Hierarchy. RESULTS: Protected Mealtimes was tailored for the residential aged care unit. The most significant change involved the transformation of system processes by creating the space in nurses' busy schedules and thus reclaiming time for nurses to reconnect with nutritional care. Fixed role boundaries were made flexible by assisting individuals to understand and extend their roles in nutritional care. Most importantly, sustainability of Protected Mealtimes was achieved and long-term changes around nutritional care continued to be resident focused. CONCLUSIONS: This study demonstrates that lasting changes to nursing practice in nutritional care can be achieved by applying the principles of a participatory worldview and action research. RELEVANCE TO CLINICAL PRACTICE: CHANGE is challenging to achieve in complex health care organisations. This study bridges the gap between theory and practice and has shown that nurses can create change by employing a participatory worldview and action research as part of their toolkit for problem solving.

'They follow the wants and needs of an institution': Midwives' views of water immersion.

BACKGROUND: A midwife's ability to fully support women's autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman's agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. OBJECTIVES: A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. METHODS: Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. FINDINGS: Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife's ability to offer and the woman's decision to use water immersion under the themes 'the reality of the system', 'the authoritative 'others'' and 'the pseudo decision-makers'. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. CONCLUSIONS: The insight gained from examining midwives' views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.

Superficial supervision: are we placing clinicians and clients at risk?

Mental heath nurses recognise the importance of professional boundaries and therapeutic relationships and understand that clinical supervision is an important component to good clinical practice and their ongoing professional development. This qualitative constructivist grounded theory research has uncovered a potential risk in contemporary mental health clinical practice, where the desire for expedient answers may compromise the outcome of formal structured supervision. The notion of a new concept 'superficial supervision' and its implications for formal structured supervision are explored.

Placental position and late stillbirth: a case-control study.

AIMS AND OBJECTIVES: The aim of this study was to determine whether there is a relationship between placental position and stillbirth with the objective of establishing if placental position impacted on stillbirth risk. BACKGROUND: Whilst there has been extensive research on low placental implantation because of the importance of detecting placenta praevia, little research has been undertaken on other aspects of placental position and possible impact on pregnancy outcome. DESIGN: A matched case-control study of stillbirth and placental position was conducted using case-notes from two tertiary obstetric referral centres. METHODS: Notes were retrospectively examined and Placental position as documented in the case-notes at the routine mid-trimester (20 week) ultrasound was identified. Placental position for a total of 124 pregnancies culminating in stillbirth was compared with placental position in 243 (matched) pregnancies resulting in a live born baby. RESULTS: Women who had a posterior located placenta were statistically more likely to suffer a stillbirth than women who had a placenta in any other position OR 1.64 (95%CI 1.02-2.65 p = 0.04). CONCLUSION: Posterior located placenta may be a contributory risk factor for stillbirth. Further research is warranted. Implications for practice. Nurses and midwives should be aware of this potential risk factor to monitor foetal well-being closely.

Water immersion policies and guidelines: How are they informed?

BACKGROUND: Water immersion for labour and birth is consistently challenged as a practice lacking support from high quality evidence. Despite this, the option is available to Australian women. Practitioners are guided by policies and guidelines however, given the research paucity, questions surround the way in which water immersion policies and guidelines are informed. AIMS: The aims of the study were to determine how water immersion policies and/or guidelines are informed and to what extent the policy/guideline facilitates the option of water immersion for labour and birth with respect to women's choice and autonomy. METHODS: Phase two of a three phase mixed methods study used critical, post structural interpretive interactionism to examine the process of development and implementation of water immersion policies and guidelines from informant's experience. Semi-structured interviews were conducted with 12 Australian participants. FINDINGS: Participants highlighted that the lack of randomised controlled trials had resulted in other forms of evidence being drawn upon to inform water immersion policies and guidelines. This was influenced in part by individual interpretations of evidence with medical views taking precedence. This sometimes resulted in policy and guideline documents that were restrictive with this impacting on women's ability to access the option. CONCLUSION: Perceived limitations of research and the subsequent translation of this perceived paucity of evidence into policies and guidelines, has impacted on women's ability to exercise choice and autonomy with respect to water immersion and indeed, on the professional autonomy of practitioners who wish to facilitate it.

Practitioner accreditation for the practice of water immersion during labour and birth: Results from a mixed methods study.

BACKGROUND: Water immersion for labour and birth is an option that is increasingly favoured by women. Australian water immersion policies and guidelines commonly specify that practitioners, such as midwives, must undertake further education and training to become accredited. METHOD: A three-phase mixed methods approach was used. Phase one used critical discourse analysis to determine who or what informs policies and guidelines related to water immersion for labour and/or birth. Phase two examined policy and guideline informants' experiences of the development of policies/guidelines, whilst phase three surveyed Australian midwives' views and experiences of water immersion and their use of and/or involvement in the development of policies and guidelines. FINDINGS: Practitioner accreditation for the facilitation of water immersion was a common finding across all phases of the study. An examination of policies and guidelines found that practitioners, namely midwives, were required to meet additional training requirements to facilitate water immersion. Participants of phases two and three identified and discussed accreditation as a significant challenge to the option of water immersion, particularly where there were inconsistencies across documents and in the interpretation of their content. CONCLUSION: The need for practitioners to be accredited to facilitate water immersion was identified as a major barrier to availability and therefore, women's ability to access the option. Given these findings, the need for accreditation should be challenged.

Pathways to increasing the use of psychosocial care with hospitalized children.

Trauma-informed care or psychosocial care can prevent or reduce the long-term impacts of hospitalization on children and their families, but few hospital staff members receive formal training in the optimal delivery of this care. This study aimed to (a) identify predictors of staff knowledge, confidence, use, and barriers regarding psychosocial care, and investigate whether these differed by profession; (b) identify pathways to increasing the use of psychosocial care; and (c) understand the association between psychosocial care and staff stress and burnout. Surveys were conducted with staff members (N = 180) within a large pediatric hospital. Questions were based on those used in similar research, and stress and burnout were assessed using the Professional Quality of Life scale. The study found that although all staff members reported using psychosocial care, only 27.2% had received training in these skills. There were no substantial differences in knowledge, confidence, and use of psychosocial care between different professions (medical, nursing, allied health, and administration staff), although nursing staff members reported a higher number of barriers to using psychosocial care. Training was indirectly associated with greater use via greater confidence and greater knowledge. Low confidence and a higher number of barriers were associated with staff burnout, and greater skill use and a higher number of barriers were associated with staff stress. Overall, these findings suggest that training that improves confidence and knowledge may support staff to deliver psychosocial care, with potential benefits for staff well-being. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trauma-informed care in practice: Observed use of psychosocial care practices with children and families in a large pediatric hospital.

Hospitalization for illness or injury can be experienced by children and their families as traumatic, which can impede recovery and lead to ongoing problems. The provision of quality trauma-informed or psychosocial care by hospital staff may mitigate trauma-related problems; however, there is great variability in the use of psychosocial care practices. Most previous research is based on self-report data and focuses primarily on nurses and physicians. The current study aimed to investigate the use of psychosocial care practices among a range of staff in a large urban pediatric hospital, using observations and interviews. A coding matrix of practices and a set of interview questions were developed based on previous research. Participants included 18 direct care hospital staff and 10 patients. Trained observers observed 13 staff and 10 patients, and coded instances of psychosocial care; 17 staff participated in interviews. A large number of instances of psychosocial care were observed but there was substantial variability in overall use and the use of individual practices. Interviewed staff reported many benefits of psychosocial care for patients and staff, although there were some costs, including emotional fatigue. Contrary to current evidence, most staff reported they rely on visible triggers of distress or need before providing psychosocial care. Future research could investigate the optimal ratio of psychosocial to physical care practices, taking into account patient feedback and psychosocial and medical outcomes. To improve the consistency of psychosocial care, training could incorporate the practice examples documented here, include staff self-care, and encourage informal avenues of learning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Nursing practice and oral fluid intake of older people with dementia.

AIM: This paper describes the findings of a descriptive study about what nurses do to ensure that older people with dementia have adequate hydration. BACKGROUND: Frail nursing home residents, particularly those who cannot accurately communicate their thirst as a result of Alzheimer's disease and who depend on nursing staff for their fluid intake, are at risk of dehydration. While the interventions that promote nutrition in older people with dementia are documented, the specific interventions for improving oral hydration in older people with dementia remain poorly studied and understood. DESIGN: Observational study. METHODS: Ten care workers and seven residents were observed for the types of behavioural nursing interventions and assistance provided to residents when promoting oral fluid intake. Observational data were compared with resident-care plans to determine whether what was carried out by care workers was consistent with what was being documented. RESULTS: Care workers provided a wide variety of behavioural interventions to the residents when promoting oral fluid intake. The resident-care plans did not sufficiently represent the specific interventions implemented by care workers. CONCLUSIONS: A more rigorous approach is required in defining the specific behavioural interactions practised by care workers, which promote oral fluid intake in older people with dementia. Nurses determined the content of care documented in care plans, yet they were not the predominant implementers of that care. Care plans need to be accurate in terms of the specific nursing actions that respond to the level of assistance required by the resident, both behaviourally and physically. RELEVANCE TO CLINICAL PRACTICE: Sound knowledge and reflective practices should be implemented by care workers of the nursing interventions that promote adequate oral fluid intake. Care plans should serve a dual purpose and facilitate communication between staff members and provide sufficient flexibility to allow for the contribution of novel ways in which to promote oral fluid intake while also being educative.

The complexity of pain in aged care.

Older people living in residential aged care often experience complex persistent pain because of the presence of multiple comorbidities and geriatric syndrome. Complex persistent pain is associated with physical, psychological and emotional burdens. All of these factors can result in existential suffering. Current pain management in aged care is targeted at passive strategies. More consideration needs to be given to how assessment and management of pain in this population can be improved, using a biopsychosocial model, to decrease unnecessary suffering.

Australian midwives views and experiences of practice and politics related to water immersion for labour and birth: A web based survey.

BACKGROUND: There is little published research that has examined practitioners' views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. AIMS: The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. METHODS: Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. FINDINGS: Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women's informed choice. CONCLUSION: Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. ETHICAL CONSIDERATIONS: The Human Research Ethics Committee of the University of South Australia approved the research.

A critical analysis of Australian policies and guidelines for water immersion during labour and birth.

BACKGROUND: Accessibility of water immersion for labour and/or birth is often dependent on the care provider and also the policies/guidelines that underpin practice. With little high quality research about the safety and practicality of water immersion, particularly for birth, policies/guidelines informing the practice may lack the evidence necessary to ensure practitioner confidence surrounding the option thereby limiting accessibility and women's autonomy. AIM: The aims of the study were to determine how water immersion policies and/or guidelines are informed, who interprets the evidence to inform policies/guidelines and to what extent the policy/guideline facilitates the option for labour and birth. METHOD: Phase one of a three-phase mixed-methods study critically analysed 25 Australian water immersion policies/guidelines using critical discourse analysis. FINDINGS: Policies/guidelines pertaining to the practice of water immersion reflect subjective opinions and views of the current literature base in favour of the risk-focused obstetric and biomedical discursive practices. Written with hegemonic influence, policies and guidelines impact on the autonomy of both women and practitioners. CONCLUSION: Policies and guidelines pertaining to water immersion, particularly for birth reflect opinion and varied interpretations of the current literature base. A degree of hegemonic influence was noted prompting recommendations for future maternity care policy and guidelines'. ETHICAL CONSIDERATIONS: The Human Research Ethics Committee of the University of South Australia approved the research.

Comparing safety climate for nurses working in operating theatres, critical care and ward areas in the UK: a mixed methods study.

OBJECTIVES: The main aim of the study was to explore the potential sources of variation and understand the meaning of safety climate for nursing practice in acute hospital settings in the UK. DESIGN: A sequential mixed methods design included a cross-sectional survey using the Safety Climate Questionnaire (SCQ) and thematic analysis of focus group discussions. Confirmatory factor analysis (CFA) was used to validate the factor structure of the SCQ. Factor scores were compared between nurses working in operating theatres, critical care and ward areas. Results from the survey and the thematic analysis were then compared and synthesised. SETTING: A London University. PARTICIPANTS: 319 registered nurses working in acute hospital settings completed the SCQ and a further 23 nurses participated in focus groups. RESULTS: CFA indicated that there was a good model fit on some criteria (χ2=1683.699, df=824, p<0.001; χ2/df=2.04; root mean square error of approximation=0.058) but a less acceptable fit on comparative fit index which is 0.804. There was a statistically significant difference between clinical specialisms in management commitment (F (4,266)=4.66, p=0.001). Nurses working in operating theatres had lower scores compared with ward areas and they also reported negative perceptions about management in their focus group. There was significant variation in scores for communication across clinical specialism (F (4,266)=2.62, p=0.035) but none of the pairwise comparisons achieved statistical significance. Thematic analysis identified themes of human factors, clinical management and protecting patients. The system and the human side of caring was identified as a meta-theme. CONCLUSIONS: The results suggest that the SCQ has some utility but requires further exploration. The findings indicate that safety in nursing practice is a complex interaction between safety systems and the social and interpersonal aspects of clinical practice.

The history of nursing services and education in Sri Lanka and the effects on developing professionalism.

Understanding the evolution of nursing in a country provides perspective on the origins of current successes and dilemmas and enables the development of strategies and plans for future trends in the profession. This article explores the evolution of nursing services and education in Sri Lanka and the effects on developing professionalism in nursing. Internet database searches, personal communication, and published and unpublished literature and reports were reviewed to obtain historical information on nursing services and education in Sri Lanka. The Sri Lankan health system is reviewed, and the establishment of Western medicine in Sri Lanka and its effects on developing institutionalized nursing education is presented, with a focus on the evolution of nursing education. Major challenges for the nursing profession in Sri Lanka are discussed, and some recommendations are shared.

'Fishing with the dead'--recall of memories from the ICU.

The purpose of this study was to explore the memories of patients who had a short-term admission to the ICU, with a particular focus on dreams, nightmares and confusion. Descriptive data were collected from a target sample of 50 participants, by means of a questionnaire. Following this, eight patients who had completed and returned the questionnaire and had reported hallucinations, dreams or confusion participated in open-ended, semi-structured interviews. Analysis of the data generated by the questionnaire revealed that the most common memories of ICU were anxiety, pain, thirst and nausea. Nightmares, hallucinations and confusion were also common and were reported to be highly distressing. The transcribed interviews were subjected to a thematic analysis. The themes that emerged were, reality and unreality, blackness and colour, powerlessness and purpose, and death. Participants described horrifying paranoid delusions. It is proposed that constant reassurance and explaining every day ICU happenings may assist patients to understand what they are experiencing and loved ones may provide an important link with reality.

Tradition, rituals, and standards, in a realm of evidenced based nursing care.

Evidenced-based nursing is seen as the future of nursing but the real world in which practice occurs is limiting the possibilities for change. The practice of post-operative (PO) vital sign collection in the general ward setting is described as an example of the complexities that surround practice. Despite the ongoing work around evidenced-based practice, elements of nursing practice remain based on tradition. Routines and rituals are driving care rather than clinical judgement. The complexities of practice limit the possibilities for change. These complexities include the systems in which nurses' practice, the fear of medico-legal repercussions, and the sense of security that rituals provide. This paper discusses these themes including the barriers to change and the implications for practice. The development of evidenced-based practice is only one component of the solution to the provision of best practice. Care is required to ensure that the evidenced-based movement does not lead to recipe book care rather than patient centred practice.