Humanistic caring, a nursing competency: modelling a metamorphosis from students to accomplished nurses.

BACKGROUND: Most nursing regulatory bodies expect nurses to learn to be humanistic and caring. However, the learning process and the developmental stages of this competency remain poorly documented in the nursing literature. METHODS: The study used interpretive phenomenology, and 26 participants (students and nurses) were individually interviewed. Benner's (1994) method was adapted and concretised into a five-phase phenomenological analysis to assist with intergroup comparisons. RESULTS: Critical milestones and developmental indicators were identified for each of the five stages of the 'humanistic caring' competency. Satisfaction and meaning at work seemed closely connected to the development of 'humanistic caring'. Links emerged between the development of 'humanistic caring' and three other competencies. CONCLUSIONS: Nurse educators might insist on the fact that 'humanistic caring' goes beyond nurse-patient communication and that it is integrated in nursing care. The findings highlight that nurses' working conditions should be improved in order to uphold humanistic caring after graduation.

Facilitating and hindering experiences to the development of humanistic caring in the academic and clinical settings: an interpretive phenomenological study with nursing students and nurses.

Objectives This paper reports on nursing students' and nurses' lived experiences mediating their development of humanistic caring. Methods Using interpretive phenomenology, 26 participants were individually interviewed. A five-stage phenomenological analysis based on Benner's (Benner, P. (1994). Interpretive phenomenology: Embodiment, caring, and ethics in health and illness. Thousand Oaks, CA: SAGE) method occurred simultaneously. Results The analysis highlighted that the development of humanistic caring is affected by role models and counterexamples, environments in which humanistic caring is exalted or trivialized, communication-related courses, patient storytelling, and work overload. Conclusions It might be valuable to raise the awareness of nurse educators about their opportunity in shaping the development of students' humanistic caring.

Factors influencing the practice of new graduate nurses: A focused ethnography of acute care settings.

AIM: To explore the influence of an acute care setting on competency deployment of new graduate nurses (NGNs) from a competency-based undergraduate programme. BACKGROUND: In the last 15 years, nursing education has shifted to competency-based education (CBE). Few studies have focused on how NGNs from these reformed programmes use the competencies they have developed. To be paradigmatically coherent with the nature of a competence, studies should also examine how context influences nursing practice and competency deployment. DESIGN: A focused ethnography of three acute care units from one academic hospital in Canada. METHODS: Purposive and snowball sampling strategies were used to recruit 19 participants: NGNs (n = 4), nurse preceptors (n = 2), clinical nurse specialists (n = 9) and nurse managers (n = 4). Data were collected through individual interviews, focus groups, observation and documentation. Data were analysed according to Roper and Shapira (Ethnography in nursing research. Thousand Oaks, CA: Sage Publications, 2000) ethnographic nursing analysis framework. RESULTS: Organisational and individual factors were identified as influencing NGNs' competency deployment. Organisational factors are orientation, stability, workload and the scientific culture of the unit. Personal factors have been linked to groups of professionals: for NGNs, personality and clinical placements during their initial education; for nurses working with NGNs, to be role models, to promote integration and to denounce bullying; and for other health professionals, to recognise nursing expertise. CONCLUSION: One way to smooth the transition from academic to clinical settings for NGNs is by offering transition or orientation programmes that will provide them with stability and a reduced workload, allowing them to progressively deploy their competencies. RELEVANCE TO CLINICAL PRACTICE: Organisational and individual factors influence how new graduate nurses deploy their competencies. Clinical educators and nurse managers can help new nurses by acting on these factors. This study conforms to the COREQ Research Reporting Guidelines for qualitative studies.

Psychometric analysis of the TRANSIT quality indicators for cardiovascular disease prevention in primary care.

OBJECTIVE: To assess a selection of psychometric properties of the TRANSIT indicators. DESIGN: Using medical records, indicators were documented retrospectively during the 14 months preceding the end of the TRANSIT study. SETTING: Primary care in Quebec, Canada. PARTICIPANTS: Indicators were documented in a random subsample (n = 123 patients) of the TRANSIT study population (n = 759). INTERVENTIONS: For every patient, the mean compliance to all indicators of a category (subscale score) and to the complete set of indicators (overall scale score) were established. To evaluate test-retest and inter-rater reliabilities, indicators were applied twice, two months apart, by the same evaluator and independently by different evaluators, respectively. To evaluate convergent validity, correlations between TRANSIT indicators, Burge et al. indicators and Institut national d'excellence en santé et en services sociaux (INESSS) indicators were examined. MAIN OUTCOME MEASURES: Test-retest reliability, inter-rater reliability, and convergent validity. RESULTS: Test-retest reliability, as measured by intraclass correlation coefficients (ICCs) was equal to 0.99 (0.99-0.99) for the overall scale score while inter-rater reliability was equal to 0.95 (0.93-0.97) for the overall scale score. Convergent validity, as measured by Pearson's correlation coefficients, was equal to 0.77 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to Burge et al. indicators and to 0.82 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to INESSS indicators. CONCLUSIONS: Reliability was excellent except for eleven indicators while convergent validity was strong except for domains related to the management of CVD risk factors.

Facilitating Implementation of Interprofessional Collaborative Practices Into Primary Care: A Trilogy of Driving Forces.

Implementing interprofessional collaborative practices in primary care is challenging, and research about its facilitating factors remains scarce. The goal of this participatory action research study was to better understand the driving forces during the early stage of the implementation process of a community-driven and patient-focused program in primary care titled "TRANSforming InTerprofessional cardiovascular disease prevention in primary care" (TRANSIT). Eight primary care clinics in Quebec, Canada, agreed to participate by creating and implementing an interprofessional facilitation team (IFT). Sixty-three participants volunteered to be part of an IFT, and 759 patients agreed to participate. We randomized six clinics into a supported facilitation ("supported") group, with an external facilitator (EF) and financial incentives for participants. We assigned two clinics to an unsupported facilitation ("unsupported") group, with no EF or financial incentives. After 3 months, we held one interview for the two EFs. After 6 months, we held eight focus groups with IFT members and another interview with each EF. The analyses revealed three key forces: (1) opportunity for dialogue through the IFT, (2) active role of the EF, and (3) change implementation budgets. Decision-makers designing implementation plans for interprofessional programs should ensure that these driving forces are activated. Further research should examine how these forces affect interprofessional practices and patient outcomes.

Integrating the Illness Beliefs Model in clinical practice: a Family Systems Nursing knowledge utilization model.

To promote the integration of Family Systems Nursing (FSN) in clinical practice, we need to better understand how nurses overcome the challenges of FSN knowledge utilization. A qualitative exploratory study was conducted with 32 practicing female nurses from hospital and community settings who had received FSN intervention training and skill development based on the Illness Beliefs Model and the Calgary Family Assessment and Intervention Models. The participants were interviewed about how they utilized FSN knowledge in their nursing practice. From the data analysis, a FSN Knowledge Utilization Model emerged that involves three major components: (a) nurses' beliefs in FSN and in their FSN skills, (b) nurses' knowledge utilization strategies to address the challenges of FSN practice, and (c) FSN positive outcomes. The FSN Knowledge Utilization Model describes a circular, incremental, and iterative process used by nurses to integrate FSN in daily nursing practice. Findings point to a need for re-evaluation of educational and management strategies in clinical settings for advancing the practice of FSN.

Reforming primary healthcare: from public policy to organizational change.

PURPOSE: Governments everywhere are implementing reform to improve primary care. However, the existence of a high degree of professional autonomy makes large-scale change difficult to achieve. The purpose of this paper is to elucidate the change dynamics and the involvement of professionals in a primary healthcare reform initiative carried out in the Canadian province of Quebec. DESIGN/METHODOLOGY/APPROACH: An empirical approach was used to investigate change processes from the inception of a public policy to the execution of changes in professional practices. The data were analysed from a multi-level, combined contextualist-processual perspective. Results are based on a longitudinal multiple-case study of five family medicine groups, which was informed by over 100 interviews, questionnaires, and documentary analysis. FINDINGS: The results illustrate the multiple processes observed with the introduction of planned large-scale change in primary care services. The analysis of change content revealed that similar post-change states concealed variations between groups in the scale of their respective changes. The analysis also demonstrated more precisely how change evolved through the introduction of "intermediate change" and how cycles of prescribed and emergent mechanisms distinctively drove change process and change content, from the emergence of the public policy to the change in primary care service delivery. RESEARCH LIMITATIONS/IMPLICATIONS: This research was conducted among a limited number of early policy adopters. However, given the international interest in turning to the medical profession to improve primary care, the results offer avenues for both policy development and implementation. PRACTICAL IMPLICATIONS: The findings offer practical insights for those studying and managing large-scale transformations. They provide a better understanding of how deliberate reforms coexist with professional autonomy through an intertwining of change content and processes. ORIGINALITY/VALUE: This research is one of few studies to examine a primary care reform from emergence to implementation using a longitudinal multi-level design.

Providing high-quality care in primary care settings: how to make trade-offs.

OBJECTIVE: To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care. DESIGN: Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices. SETTING: Three regions of Quebec. PARTICIPANTS: Health care professionals and staff of 5 PC practices. METHODS: Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed. MAIN FINDINGS: The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters. CONCLUSION: Irrespective of their models, PC practices' pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.

Scientific rigour and innovations in participatory action research investigating workplace learning in continuing interprofessional education.

The persistent theory-practice gap shows how challenging it can be for healthcare professionals to keep updating their practices. The continuing education challenges are partly explained by the tremendous stream of new discoveries in health and the epidemic of multi-morbid conditions. Participatory action research (PAR) is used in healthcare as a research approach that capitalizes on people's resources to better understand and enhance their professional practices. PAR thus can consolidate our knowledge on workplace learning in continuing interprofessional education while directly improving quality of care. However, PAR lacks clear scientific criteria to ensure the consistency between the investigators' methodology and philosophy, which jeopardize its credibility. This paper outlines the principles of rigour in PAR and describes the additions of a preliminary planning phase to Kemmis and McTaggart's PAR description as well as the use of the professional co-development group, an action-oriented data collection method. We believe that this will help PAR co-participants achieve improved scientific rigour and encourage more investigators to collaborate through this research approach contributing to the advancement of knowledge on workplace learning in continuing interprofessional education.

[Analysis of barriers to nursing intervention for families in mental health units, in light of Collerette's change model]. / Analyse des obstacles à l'intervention infirmière auprès des families dans les unités de soins de santé mentale à la lumière du modèle de changement de Collerette.

Accompanying loved ones suffering from a mental health problem on a daily basis is an experience that profoundly transforms the identity of families. Such families must often cope with feelings such as guilt and helplessness. The psychiatric hospitalisation of a family member suffering from mental illness hardly improves the situation. In this context, existing literature recognises the benefits of including family members involved in care, as much for the afflicted person as for family and the professionals involved. However, these families inevitably feel excluded from care and unrecognised in their role, leading to important consequences. This critical review of literature was meant to analyse the obstacles to practicing a family-oriented approach by nurses working in mental health units, in order to propose recommendations aiming at the transformation of present clinical practices in this regard. A systematic study of literature was carried out on the databases CINHAL, Psychlnfo and PubMed and the analysis of literature was realised based on the Theory of Change proposed by Collerette. The results demonstrate that confidentiality, lack of abilities and expertise in addition to certain organisational problems constitute the principal barriers to the practice of nursing interventions for families on a daily basis.

[A socioconstructivist and humanistic approach to continuing education nurses caring for people with complex needs]. / Une approche éducative socioconstructiviste et humaniste pour la formation continue des infirmières soignant des personnes ayant des besoins complexes.

In order to care for persons with complex needs, such as those living with a chronic illness and at risk for complications when hospitalized, nurses must possess multiple sorts of knowledge and skills. After a description of the prevalent schools of thought in pedagogy, the case is made for the use of narrative pedagogy - an educational approach based on nursing science research and congruent with the socio-constructivist and humanist schools of thought?in continuing professional development for nurses. Through the sharing of lived experiences from nurses, care recipients and their families, this educational approach fosters active listening, interpretation, questioning, and perspectival openness. It was tested with nurses caring for hospitalized older persons at risk of presenting signs of acute confusional state and found to be promising. Consequently, it is hoped that educators responsible for the continuing education of nurses in clinical settings will explore this novel educational option in order to adjust their teaching to the knowledge and experience of nurses and to the changing needs of care recipients.

[An evolutionist analysis of competence]. / Une analyse évolutionniste du concept de compétence.

For several years, many nursing education institutions have implemented the recommendations made in 2003 by the Institute of Medicine. Some have conducted a redesign of the structure of their program to integrate competency-based approach. What is a competence in this context? The purpose of this concept analysis is to clarify the meaning of the concept of competence from its recent use in nursing education. Rodgers' method of concept analysis was selected as it is relevant to explore this concept. A literature review in nursing was conducted from the CINAHL database. After analyzing the results, although no consensus appears in the literature, it seems that a competence could be defined as a formal action of systemic skills, contextualized and which is continuously developing. This definition differs from the behaviorist one sometimes used, where competences are synonymous with technical skills. To continue the development of this concept, it would be interesting to explore how it has evolved in other disciplines, such as education sciences or medicine.

[Supporting preceptor skills development with a forum discussion]. / Soutenir le développement des compétences de préceptrices a l'aide d'un forum de discussion.

The success of nursing students in clinical settings is significantly influenced by the nurse's preparation level of the preceptor's role. It is therefore essential to create and make available training activities that prepares and support the development of these skills in clinical settings. Among the significant benefits to participate in preceptorship training activities, the satisfaction of feeling better prepared and to share experiences with colleagues is well recognized. Thus, the online environment allows the creation of programs that encourage exchanges and discussions in addition to promote a social learning space. This article presents the implementation of an online training activity to support the development of preceptors skills in clinical settings with nursing students. The results of this clinical experience revealed several constraints to the involvement of nurses in this activity and enhanced the importance of an organizational partnership between the institution and the clinical environment to overcome these constraints.

[The development of clinical reasoning skills and leadership: personal factors and organizational factors]. / Le développement continu des compétences de raisonnement clinique et de leadership: facteurs personnels et facteurs organisationnels.

Continuing education of newly graduated nurses (NGN) depends on several factors related to the characteristics of skills to be developed, the target population and the organizational context. Few studies describe both how nurses develop their skills and how institutions promote this development. The objectives of this manuscript are to (1) describe the behaviors that the NGN use to develop their reasoning skills and leadership and (2) document the organizational elements that facilitate this development. Method. Individual interviews were conducted with nurses (n = 34) using a grid of semistructured interviews and two group interviews were conducted with nurses (n = 7) and managers (n = 19) in two teaching hospitals in eastern Canada. The results show that nurses develop mainly by reflecting on their professional practice in their workplace. However, the lack of time for reflection in the workspace is a considerable obstacle while managerial leadership is an important asset.

Priorities for action to improve cardiovascular preventive care of patients with multimorbid conditions in primary care--a participatory action research project.

BACKGROUND: Cardiovascular disease (CVD) prevention in patients with multimorbid conditions is not always optimal in primary care (PC). Interactive collaborative processes involving PC community are recommended to develop new models of care and to successfully reshape clinical practices. OBJECTIVE: To identify challenges and priorities for action in PC to improve CVD prevention among patients with multimorbid conditions. METHODS: Physicians (n = 6), nurses (n = 6), community pharmacists (n = 6), other health professionals (n = 6), patients (n = 6) and family members (n = 6), decision makers (n = 6) and researchers (n = 6) took part in a 1-day workshop. Using the Chronic Care Model (CCM) as a framework, participants in focus groups and nominal groups identified the challenges and priorities for action. RESULTS: Providing appropriate support to lifestyle change in patients and implementing collaborative practices are challenging. Priorities for action relate to three CCM domains: (i) improve the clinical information system by providing computerized tools for interprofessional and interinstitutional communication, (ii) improve the organization of health care and delivery system design by enhancing interprofessional collaboration, especially with nurses and pharmacists, and creating care teams that include a case manager and (iii) improve self-management support by giving patients access to nutritionists, to personalized health care plans including lifestyle recommendations and to other resources (community resources, websites). CONCLUSIONS: To optimize CVD prevention, PC actors recommend focussing mainly on three CCM domains. Electronic medical records, collaborative practices and self-management support are perceived as pivotal aspects of successful PC prevention programme. Developing and implementing such models are challenging and will require the mobilization of the whole PC community.

"From Health Experts to Health Guides": Motivational Interviewing Learning Processes and Influencing Factors.

Motivational interviewing is an evidence-based counseling approach. However, its learning processes and their influencing factors are understudied, failing to address the suboptimal use of motivational interviewing in clinical practice. A participatory action research was conducted in collaboration with 16 primary care clinicians, who encountered similar challenges through their previous counseling approaches. The study aimed to facilitate and describe the clinicians' professional transformation through interprofessional communities of practice on motivational interviewing (ICP-MI). Data were collected using the principal investigator's research journal and participant observation of four independent ICP-MIs (76 h) followed by focus groups (8 h). The co-participants performed inductive qualitative data analysis. Results report that learning motivational interviewing requires a paradigm shift from health experts to health guides. The learning processes were initiated by the creation of an openness to the MI spirit and rapidly evolved into iterative processes of MI spirit embodiment and MI skill building. The intrinsic influencing factors involved the clinician's personal traits and professional background; the extrinsic influencing factor was the shared culture disseminating the expert care model. Previously described in a fragmented manner, motivational interviewing learning processes, and its influencing factors were presented as integrated findings. Considerations in elaborating effective MI training/implementation programs are discussed for clinicians, trainers, and decision-makers. Future areas of investigation are also highlighted calling forth the research community to contribute to knowledge advancement on health education in primary care.

Motivational Interviewing Implementation in Primary Care: A "Terrifying Challenge" Becoming a "Professional Revelation".

INTRODUCTION: Motivational interviewing (MI) is an evidence-based counseling approach within primary care. However, MI rarely translates to practice following introductory training programs, and a lack of evidence regarding its implementation persists today. This study describes primary care clinicians' professional transformation in implementing MI through interprofessional communities of practice (ICP-MI). METHOD: Qualitative data collection involved the research journal, participant observation of four ICP-MIs (76 hours/16 clinicians), and focus groups. A general inductive approach was used for data analysis. Results were conceptualized based on the Consolidated Framework for Implementation Research. RESULTS: Four processes of MI implementation in primary care are presented as a motivational endeavor: ambivalence, introspection, experimentation, and mobilization. The clinicians were initially ambivalent, taking into consideration the significant challenges involved. After introspecting actual practices, they realized the limits of their previous clinician-centered approaches. The experimentation of MI in the workplace followed and enabled clinicians to witness MI feasibility and its added value. Finally, they were mobilized to ensure MI sustainability in their practices/organization. Intrinsic factors of influence included the clinicians' personal traits and their perception about MI as a clinical priority. Organizational support was also a crucial extrinsic factor in encouraging the clinicians' efforts. CONCLUSION: As described in a fragmented manner in previous studies, MI implementation processes and influencing factors are presented as integrated findings. Incorporating engaging educational activities to provide clinicians with motivational support and collaborating with health care organizations to plan appropriate resources should be considered in the development of MI implementation programs from the onset.

Nursing Students and Nurses' Recommendations Aiming at Improving the Development of the Humanistic Caring Competency.

BACKGROUND: Most nursing education programs prepare their students to embody humanism and caring as it is expected by several regulatory bodies. Ensuring this embodiment in students and nurses remains a challenge because there is a lack of evidence about its progressive development through education and practice. PURPOSE: This manuscript provides a description of nursing students' and nurses' recommendations that can foster the development of humanistic caring. METHODS: Interpretive phenomenology was selected as the study's methodological approach. Participants (n = 26) were recruited from a French-Canadian university and an affiliated university hospital. Data was collected through individual interviews. Data analysis consisted of an adaptation of Benner's (1994) phenomenological principles that resulted in a five-stage interpretative process. RESULTS: The following five themes emerged from the phenomenological analysis of participants' recommendations: 1) pedagogical strategies, 2) educators' approach, 3) considerations in teaching humanistic caring, 4) work overload, and 5) volunteerism and externship. CONCLUSION: The findings suggest the existence of a challenge when using mannikins in high-fidelity simulations with the intention of developing humanistic caring. The findings also reaffirm the importance of giving concrete and realistic exemplars of humanistic caring to students in order to prevent them from making "communication" synonymous to "humanization of care".

Use of a script concordance test to assess development of clinical reasoning in nursing students.

The methods for assessing and measuring clinical reasoning as it pertains specifically to nurses are inadequate, if not nonexistent. The purposes of this methodological study were to develop a script concordance test and conduct a preliminary validation of its psychometric qualities. A script concordance test was created and the test scoring grid was constructed using the combined-score method and based on the responses of a panel of 15 experts. Thirty first-year bachelor of nursing students completed the test. The scores for the experts and students were compared with a t test, and the reliability of the scores was measured by Cronbach's alpha coefficient. A statistically significant difference was found between the scores of the experts and novices. The scores' reliability is high. The script concordance test is an innovative instrument that provides a standardized method for assessing nurses' clinical reasoning.

From student to emergency nurse: a qualitative study of an educational support seminar.

The purpose of this qualitative study was to document the transition experience of new nursing graduates who participated in an educational support seminar during their first year of emergency room (ER) practice. Study participants reported that the seminar provided learning and nurturing that facilitated their integration into the ER team, influenced their decision to stay in the ER, and grounded the process of their professionalization. Important considerations regarding education, professionalization, and leadership emerged.