Patient experiences of alcohol specialist nurse interventions in a general hospital, and onwards care pathways.

AIMS: To provide insight into patient experiences of a general hospital-based alcohol specialist nurse intervention during alcohol detoxification, experiences of alcohol specialist nurse hospital-based follow-up appointments (Pathway A) as well as the experiences of patients who did not have access to this additional help post detoxification (Pathway B). DESIGN: A longitudinal qualitative study. METHODS: A thematic analysis of semi-structured interviews (2016-2017) with 24 patient participants (N = 12 in each pathway; purposive selection) 1-4 weeks post-detoxification and at 3 and 6 months, to identify patient experiences of these interventions. RESULTS: Participants gave accounts of how 'empathic' and 'straight talking' interactions with alcohol specialist nurses during detoxification helped them to 'open up' and orient towards change. After detoxification follow-up, outpatient appointments in the hospital setting were seen as supporting change in early recovery and engagement with a wider range of services. Those with no access to nurse follow-up described experiencing a 'void' in available help. Participants in both groups described barriers to engagement with community alcohol services, peer groups and access to help for mild-moderate mental health problems. CONCLUSION: Patient accounts indicate alcohol specialist nurse interventions during and after unplanned detoxification in a hospital setting can help orient patients towards change and support early recovery. IMPACT: Providing alcohol specialist nurse interventions in general hospitals offers one route to initiating recovery in alcohol-dependent patients. This has potential to improve the lives of those affected and to reduce related demands on hospital services, but further research is needed.

The long-term effects of prolonged intensive care stay postcardiac surgery.

OBJECTIVES: Short-term outcomes for those with a prolonged length of stay (LOS) in intensive care (ITU) following cardiac surgery are poor, with higher rates of in-hospital mortality and morbidity. Consequently, discharge from hospital has been considered the key measure of success. However, there has been a shift towards long-term outcomes, functional recovery and quality of life (QoL) as measures of surgical quality. The aim of this review is to compare and critique the findings of multiple studies to determine the long-term effects of prolonged ITU stay postcardiac surgery. METHODS: A computerized literature search of CINAHL, EMBASE and Google Scholar databases, based on keywords "long-term effects," "prolonged ITU stay," "cardiac surgery," with rigorous CASP critique was undertaken. RESULTS: The search yielded 12 papers meeting the inclusion criteria, with eight retrospective and four prospective studies. Eight of these 12 papers identified inferior long-term survival or higher mortality rates for those who had prolonged LOS in ITU in comparison to "normal" LOS or a control. The greatest burden of mortality was 6 months to 1 year postdischarge. Three papers found that quality of life was adversely affected or worse for those who had experienced prolonged LOS in ITU. CONCLUSIONS: Further research is required to provide better quality evidence into QoL, following prolonged stay in ICU postcardiac surgery. The evidence reviewed suggests that the risk of mortality in this demographic of patients is higher, especially within the first year and, therefore, more frequent medical surveillance of these patients is recommended.

Challenges faced by nurses in managing pain in a critical care setting.

AIM: To explore nurses' challenges in managing pain among ill patients in critical care. BACKGROUND: Pain can lead to many adverse medical consequences and providing pain relief is central to caring for ill patients. Effective pain management is vital since studies show patients admitted to critical care units still suffer from significant levels of acute pain. The effective delivery of care in clinical areas remains a challenge for nurses involved with care which is dynamic and constantly changing in critically ill. DESIGN: Qualitative prospective exploratory design. METHODS: This study employed semi structured interviews with nurses, using critical incident technique. Twenty-one nurses were selected from critical care settings from a large acute teaching health care trust in the UK. A critical incident interview guide was constructed from the literature and used to elicit responses. RESULTS: Framework analysis showed that nurses perceived four main challenges in managing pain namely lack of clinical guidelines, lack of structured pain assessment tool, limited autonomy in decision making and the patient's condition itself. CONCLUSIONS: Nurses' decision making and pain management can influence the quality of care given to critically ill patients. It is important to overcome the clinical problems that are faced when dealing with pain experience. RELEVANCE TO CLINICAL PRACTICE: There is a need for nursing education on pain management. Providing up to date and practical strategies may help to reduce nurses' challenges in managing pain among critically ill patients. Broader autonomy and effective decision making can be seen as beneficial for the nurses besides having a clearer and structured pain management guidelines.

Exploring factors that influence success when introducing "The Safewards Model" to an acute adolescent ward: A qualitative study of staff perceptions.

PROBLEM: The Safewards' model identifies factors that can lead to conflict and addresses these factors, using ten interventions, within inpatient mental health wards aiming to reduce "conflict and containment." The Department of Health (2014) and Care Quality Commission (2017) supported the use of Safewards to reduce restrictive practice across all mental health settings in the UK, but its application to adolescent mental health remains relatively unexplored. This study therefore aims to address the research question: "What are the factors influencing the success of ten Safewards' interventions when implemented onto an acute adolescent ward?" METHODS: Eight healthcare assistants and two nurses who had attended Safewards' training participated in semi-structured interviews four months after Safewards was introduced to an acute adolescent ward. The interviews were transcribed verbatim and analyzed using thematic analysis. Data analysis was conducted inductively by developing data-driven themes. FINDINGS: Many of the factors influencing Safewards' success in adolescent mental health (e.g., acuity; dependence on nonregular staffing; lack of leadership and operating procedures) paralleled the evidence found in adult services. CONCLUSIONS: This study contributes new information by implementing "mutual help" and "calm down" principles with adolescents, as well as discussing barriers of operational procedures and benefits of patient involvement.

Moving our care home: A qualitative study of the views and experiences of residents, relatives and staff.

INTRODUCTION: Involuntary relocation when care homes close can be detrimental to residents' health and well-being and is associated with increased mortality. There is little formal evidence to support whether planning can mitigate the impact of such moves. This study aimed to understand the experiences of a whole care home relocation where staff and residents relocated together using existing published guidance. METHODS: A longitudinal qualitative research study using individual face-to-face semi-structured interviews was conducted between August 2018 and August 2019. Baseline interviews were conducted 6-8 weeks after relocation with follow-up interviews 10-12 months later. Interviews were recorded, transcribed and analysed using framework analysis. RESULTS: 27 interviews were conducted; 19 baseline interviews (4 residents, 7 family members, 8 staff) and 8 follow-up interviews (2 residents, 2 family members, 4 staff). Participants' feelings about the relocation were mixed: some reported apprehension before the move but others excitement. Residents and families felt variably involved in planning the move, whereas staff expressed lack of involvement. Time, family support and continuity of care helped participants settle in. The new environment shaped participants' experiences and abilities to adjust, especially the lack of a homely feeling with the new home, the larger size and changes in staff organisation and management. CONCLUSIONS: Despite implementation of existing guidance, relocation was still challenging for residents, staff and family members. Future relocations should increase involvement of staff in the planning and design of the home; offer continuous support to those involved; and ensure continuity of care and management style.

Prospective cohort study of mental health during imprisonment.

BACKGROUND: Mental illness is common among prisoners, but little evidence exists regarding changes in symptoms in custody over time. AIMS: To investigate the prevalence and predictors of psychiatric symptoms among prisoners during early custody. METHOD: In a prospective cohort study, 3079 prisoners were screened for mental illness within 3 days of reception. To establish baseline diagnoses and symptoms, 980 prisoners were interviewed; all remaining in custody were followed up 1 month and 2 months later. RESULTS: Symptom prevalence was highest during the first week of custody. Prevalence showed a linear decline among men and convicted prisoners, but not women or remand prisoners. It decreased among prisoners with depression, but not among prisoners with other mental illnesses. CONCLUSIONS: Overall, imprisonment did not exacerbate psychiatric symptoms, although differences in group responses were observed. Continued discussion regarding non-custodial alternatives for vulnerable groups and increased support for all during early custody are recommended.

Inequity in provision of and access to health visiting postnatal depression services.

AIM: This paper is a report of a study of equity in the provision of a public health nursing postnatal depression service. BACKGROUND: Postnatal depression is a global public health concern. Health visitors are nurses involved in the early detection and treatment of postnatal depression. However, research has revealed that all women are not assessed for postnatal depression particularly women in minority ethnic groups. METHODS: A case study was conducted involving 21 observations of health visitors visiting postnatal women, interviews with 20 health visitors, 6 managers, 12 English women, 9 Bangladeshi women and 3 other personnel. Data were collected between 2003 and 2005 and analysis was completed in 2008. FINDINGS: The organization had a policy to create equitable postnatal depression services, but practitioners were not clear whether it was to be implemented, and it did not address the needs of a diverse population. All health visitors received specialized training and were consequently expected to assess and treat all women. The training based on the policy had not equipped health visitors with knowledge and skills to assess and treat women in minority ethnic groups. CONCLUSION: While a policy was in place, equity in care was not achieved. An analysis of women's needs is recommended prior to policy development and policy implementation should be planned. To achieve equity, training should include knowledge and skills for cultural competency. Research is needed to illuminate the characteristics of equitable nursing services.

Staff-student relationships and their impact on nursing students' belongingness and learning.

AIM: This paper is a report of selected findings from a study exploring the relationship between belongingness and placement experiences of preregistration nursing students. BACKGROUND: Staff-student relationships are an important influence on students' experiences of belongingness and their clinical learning. The need to belong is universal and pervasive, exerting a powerful influence on thought processes, emotions, behaviour, health and happiness. People deprived of belongingness are more likely to experience diminished self-esteem, increased stress and anxiety, depression and a decrease in general well-being. Nursing students' motivation and capacity to learn, self-concept, confidence, the extent to which they are willing to question or conform to poor practice and their future career decisions are influenced by the extent to which they experience belongingness. METHOD: During 2006, 18 third year students from two Australian universities and one United Kingdom university participated in in-depth semi-structured interviews. Data were analysed thematically. FINDINGS: Participants described placement experiences spanning a continuum from those promoting a high degree of belongingness to those provoking intense feelings of alienation. Staff-student relationships (including receptiveness, inclusion/exclusion, legitimization of the student role, recognition and appreciation, challenge and support) were the most important influence on students' sense of belonging and learning. Similarities between sites were remarkable, despite the differences in healthcare and higher education systems. CONCLUSION: Staff-student relationships are key to students' experience of belongingness. Understanding the types of interactions and behaviours that facilitate or impede students' belongingness and learning are essential to the creation of positive clinical experiences.

The ascent to competence conceptual framework: an outcome of a study of belongingness.

AIM: This paper presents qualitative findings from a study that explored nursing students' experience of belongingness when undertaking clinical placements. The aim is to locate the professional and practical implications of the research within an Ascent to Competence conceptual framework. BACKGROUND: The need to belong exerts a powerful influence on cognitive processes, emotional patterns, behavioural responses, health and well-being and failure to satisfy this need can have devastating consequences. The literature suggests that diminished belongingness may impede students' motivation for learning and influence the degree to which they are willing to conform rather than adopt a questioning approach to clinical practice. DESIGN: A mixed methods, cross national, multi-site case study approach was adopted with third-year preregistration nursing students from three universities (two in Australia and one in England) participating; 362 in the quantitative phase and 18 in the qualitative phase. FINDINGS: Qualitative findings demonstrated that, although the primary purpose of clinical education is to facilitate students' progress towards the attainment of competence, the realisation of this goal is impacted by a wide range of individual, interpersonal, contextual and organisational factors which can be conceptualised hierarchically. By this structuring it is possible to see how belongingness is a crucial precursor to students' learning and success. CONCLUSION: The framework demonstrates that students progress to a stage where attainment of competence is possible only after their previous needs for safety and security, belongingness, healthy self-concept and learning have been met. RELEVANCE TO CLINICAL PRACTICE: The future of the nursing profession depends upon the development of confident, competent professionals with a healthy self-concept and a commitment to patient-centred care and self-directed learning. This paper demonstrates that the realisation of this goal is strongly influenced by the extent to which students' clinical placement experiences promote and enhance their sense of belonging.

Development and psychometric testing of the Belongingness Scale-Clinical Placement Experience: an international comparative study.

AIM: This paper reports the development and psychometric testing of the Belongingness Scale-Clinical Placement Experience, an instrument designed to measure the extent to which nursing students experience belongingness related to their clinical placements. BACKGROUND: The need to belong is a global concept that exerts a powerful influence on cognitive processes, emotional patterns, behavioural responses, health and well-being. Diminished belongingness impedes students' motivation to learn. Measuring belongingness specific to the clinical environment and comparing different cohorts requires valid and reliable instruments. METHOD: Scales for measuring belongingness were identified following a critical review of the literature. From these a new 34-item instrument was developed. During 2006 the instrument was tested with students (n = 362) from two Australian universities and one university in the south of England. Principal component analysis with varimax rotation was used to determine construct validity and Cronbach's coefficient alpha determined the scale's internal consistency reliability. RESULTS: Differences in belongingness scores were statistically significant, with the British cohort scoring higher than either of the Australian sites. The scale demonstrated high internal consistency (alpha 0.92). Principal component analysis yielded a three-component structure termed Esteem, Connectedness and Efficacy and each subscale demonstrated high internal consistency: 0.9; 0.82; 0.8 respectively. CONCLUSION: The scale was reliable and valid for the three cohorts. Results indicated that the instrument is capable of differentiating between respondents and cohorts. Further research in different contexts would be valuable in taking this work forward.

Mentorship in contemporary practice: the experiences of nursing students and practice mentors.

AIM: This paper explores the role of the mentor in contemporary nursing practice in the UK. It presents findings from a recent study which investigated the impact of a locality-based nursing education initiative on students, practice mentors and academic staff and draws on another study, conducted in the same setting and two Australian sites, to examine the perceptions of nursing students and mentors. BACKGROUND: Within nursing, mentorship is integral to students' clinical placement experiences and has attracted increasing interest among researchers. Despite a plethora of studies focussing on mentoring and its nature and application within the practice setting, limited attention has been paid to the extent to which guidelines provided by regulatory bodies for nursing inform and influence the practice of mentoring in contemporary health-care settings. DESIGN: The study used a two-phased design with data on mentorship being focussed on the second phase. METHOD: Data were collected using an online survey questionnaire of pre-qualifying students and a postal questionnaire for practice mentors. FINDINGS: The findings highlight the importance of mentorship for prequalifying students and emphasise the need to provide mentors with adequate preparation and support. They confirm previous research, but also highlight improvements in bridging the gap between rhetoric and reality for mentorship. Results are further strengthened when compared with those of the second study. CONCLUSIONS: Findings provide new evidence of a narrowing of the gap between the theory and practice of mentoring and for the continuing implementation of national standards to clarify the roles and responsibilities of the mentor. They also suggest the benefits of developing such standards in countries with similar systems of support for nursing students. RELEVANCE TO CLINICAL PRACTICE: Mentorship is pivotal to students' clinical experiences and is instrumental in preparing them for their role as confident and competent practitioners.

Shifting the focus: sequential methods of analysis with qualitative data.

The purpose of this article is to illustrate both the processes of data analysis and the methodological development involved in adopting the sequential use of two data analysis methods applied to the same data set. Understanding of the phenomena of interest was sought through examining both the content and the form of nurses' accounts of practice experiences. Initially, a method of thematic content analysis was applied to understand what the nurses said about their experiences. The core theme of nurses' change agency derived from this analysis was examined further through a method of narrative analysis. In the second analysis, the focus was shifted to how the nurses accounted for their experiences. The innovative use of iterative, sequential methods of analysis revealed greater complexity and depth of understanding of the phenomena than would have been achieved with one method alone.

Belongingness: A critique of the concept and implications for nursing education.

Clinical experience is recognised as central to nursing education. Quality clinical placements across a range of venues are vital to the development of competent and confident professionals. However there is evidence, both empirical and anecdotal, suggesting that nursing students' clinical placement experiences are often fraught with problems. These problems are long standing and multi-dimensional. For many students clinical placements are typified by feelings of alienation and a lack of belongingness. This paper proposes that the problematic nature of clinical placements may be better understood through the lens of 'belongingness'. A critical review of selected studies drawn from the psychological and social science literature provides insight and useful direction for a more focused review of the nursing literature. The potential relationships between belongingness, nursing students, and their clinical placement experiences are then exemplified by excerpts taken from the nursing literature (including unpublished material). Finally, an ongoing study that seeks to address the paucity of empirical research in this area is highlighted.

Belongingness: a montage of nursing students' stories of their clinical placement experiences.

The psychological and social sciences literature is replete with assertions that human beings are fundamentally and pervasively motivated by the need to belong. This paper reports on some of the findings from the qualitative phase of a mixed-method, multi-site study that explored nursing students' experience of belongingness while on clinical placements. Students from Australia and the United Kingdom were interviewed to identify factors that impact upon and are consequences of belongingness. A montage of participants' stories is used to illustrate some of the key features of clinical workplaces that are conducive to the development of belongingness. Contextual factors and interpersonal dynamics were seen to have a significant bearing on students' experiences. Clinical leaders/managers who were welcoming, accepting and supportive, and nursing staff who were inclusive and encouraging, facilitated students' perception of being valued and respected as members of the nursing team. Additionally, the provision of consistent, quality mentorship was identified as important to students' feelings of connectedness and fit. The experience of belongingness, in turn, enhanced students' potential for learning and influenced their future career decisions. Alternatively, alienation resulted from unreceptive and unwelcoming clinical environments and from the dissonance created when students' personal and professional values did not articulate with those evident in practice environments. Consequently, distress, detachment and disengagement occurred and students' capacity and motivation for learning was negatively impacted.

Clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland; a qualitative study.

BACKGROUND: A preceptorship model of clinical teaching was introduced to support the new all-graduate nurse education programme in Ireland in 2002. Little is known about how this model impacts upon the pedagogical practices of the preceptor or student learning in clinical practice leading to question what constitutes effective teaching and learning in clinical practice at undergraduate level. AIM: This study aimed to explore the clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland and identify when best practice, based on current theoretical professional and educational principles occurred. METHOD: A qualitative research study of a purposively selected sample of 13 students and 13 preceptors, working together in four clinical areas in one hospital in Ireland. Methods were semi-structured interviews, analysed thematically, complemented by documentary analysis relating to the teaching and assessment of the students. Ethical approval was gained from the hospital's Ethics Committee. FINDINGS: Preceptor-student contact time within an empowering student-preceptor learning relationship was the foundation of effective teaching and learning and assessment. Dialoguing and talking through practice enhanced the students' knowledge and understanding, while the ability of the preceptor to ask higher order questions promoted the students' clinical reasoning and problem solving skills. Insufficient time to teach, and an over reliance on students' ability to participate in and contribute to practice with minimal guidance were found to negatively impact students' learning. CONCLUSIONS & IMPLICATIONS: Concepts such as cognitive apprenticeship, scaffolding and learning in communities of practice can be helpful in understanding the processes entailed in preceptorship. Preceptors need extensive educational preparation and support to ensure they have the pedagogical competencies necessary to provide the cognitive teaching techniques that foster professional performance and clinical reasoning. National competency based standards for preceptor preparation should be developed.

Experiences of service user and carer participation in health care education.

The agenda of involving service users and their carers more meaningfully in the development, delivery and evaluation of professional education in health is gaining in importance. The paper reports on a symposium which presented three diverse initiatives, established within a school of nursing and midwifery in the United Kingdom. These represent different approaches and attempts to engage service users and in some instances carers more fully in professional education aimed at developing mental health practitioners. Each is presented as achieving movement on a continuum of participation from service users as passive recipients to service users as collaborators and co-researchers. The paper concludes with a discussion of the lessons to be learnt which will hopefully stimulate service user involvement on a wider basis.

Exploring the experiences of teenagers with cochlear implants.

OBJECTIVES: Teenage cochlear implant users' perceptions of deafness, surgery, fitting of the device and life as a cochlear implant wearer were explored in order to gain a more comprehensive understanding of teenagers' experiences of living with the device. METHODS: Semi-structured in-depth interviews were undertaken and analysed using thematic analysis. Ten teenagers aged 14-16 years with at least one cochlear implant were interviewed. RESULTS: Seven teenagers experienced great pre-operative anxiety and two reported significant post-operative pain. Four of the teenagers described a mismatch between their expectations and the disappointing reality of adjusting to the device. However, all the teenagers reported an enhanced sense of well-being as a result of being able to interact more easily with their world around them. The teenagers differed in the extent to which they identified with the hearing and deaf world. DISCUSSION: Despite the early challenges, over time the teenagers experienced many functional and psychosocial benefits. Most felt their lives were now easier as a result of the cochlear implant(s). They described complex, flexible identities. CONCLUSIONS: By giving prominence to the teenagers' voices this study has added new knowledge concerning their experience of surgery. The findings also more fully revealed the challenges of adjusting to the device and the impact of having a cochlear implant on the teenagers' identities. Clinical recommendations are made to address the gaps in service highlighted by these findings.

Service user involvement in giving mental health students feedback on placement: A participatory action research study.

BACKGROUND: Although the drive to engage service users in service delivery, research and education has mainstream acceptance, it is not easy to achieve meaningful involvement. The contribution that could potentially be made by users whilst accessing services is often overlooked. OBJECTIVES AND PARTICIPANTS: This study involved stakeholders (mentors, service users and a lecturer) working together to design, evaluate and refine a system enabling students to seek feedback from service users. The feedback concerned mental health students' interpersonal skills and occurred whilst on practice placement. This research aimed to explore the experiences of those concerned when nine students attempted to learn from rather than about service users. DESIGN: A 2-year study, encompassing five cycles of participatory action research (PAR). SETTING: A small island community in the British Isles, adopting UK standards for pre-registration nurse education. METHODS: Data came from interviews with service users and mentors and a series of reflective group discussions with students who volunteered to try out the feedback mechanism. The deliberations of the PAR stakeholder group informed the research cycles and added to the data, which were subject to thematic analysis. FINDINGS: Findings indicated that service users volunteering to give feedback had unanimously positive experiences. Students' experience lay on a continuum: those with a stronger sense of self were more willing and able to ask for feedback than less confident students. Cultural adjustment to the role change needed was challenging, requiring self-awareness and courage. Over time, all students achieved deep learning and, for some, learning appeared transformative. CONCLUSION: Although contextual, the study concluded that the feedback initiative encouraged the development of more equitable relationships, in which mental health nurses respected the expertise of service users. This potentially benefits student development, recovery-orientated practice, service users and HEIs searching for meaningful ways to involve service users in learning and formative assessment.

Virtual interactive practice: utilizing healthcare information systems to contextualize the skills associated with clinical decision making within nurse education.

This paper reports on a Virtual Interactive Practice (VIP) project that has the potential to revolutionise the educational delivery and learning of clinical skills complementing "real" practice. The focus is currently on nurse learning but the principles could equally be applied to multi and inter-professional learning and clinical decision-making. This project represents a new model to enhance clinical skill acquisition and clinical reasoning using a structured competency base. Integral to this is a strong partnership between education and practice utilising "real" live and recorded anonymised patient data from a critical care clinical information system (CIS) within a large district general hospital to structure scenarios fostering problem-based learning. This educational practice interface enables the synthesis of clinical data using virtual technology and sophisticated scenario-based simulation within a skills laboratory. The aim is to enhance the more ad hoc system of learning within conventional practice placements. Early findings suggest that VIP enhances practice providing a safe but challenging learning experience with the benefit of instant performance feedback to students.