Indigenous lands and health access: The influence of a sense of place on disparities in post-stroke recovery in Taiwan.

Despite many countries having policies and systems for universal healthcare coverage, health disparity persists, with significant variations in disease prevalence and life expectancy between different groups of people. This focused ethnography explored the post-stroke recovery of Indigenous and non-Indigenous populations in three geographical areas in Taiwan. Forty-eight observations and 24 interviews were carried out with 12 dyads of stroke survivors and family caregivers, revealing their varied experiences of healthcare. Findings indicate that repeatedly engaging in social activities in the same place increases stroke survivors' attachment to the environment, facilitating their reintegration into the community and improving wellbeing following stroke. The significance of 'place' in post-stroke life and healthcare access is particularly salient for Indigenous people's recovery. Indigenous people tend to employ cultural symbols, such as Indigenous languages and kinship ties, to define and interpret their surrounding environment and identity. Indigenous people residing within or close to their own native communities make better recoveries than those based in urban settings, who are attached to and yet located away from their native lands. A sense of place contributes to identity, while loss of it leads to invisibility and healthcare inaccessibility. To promote equitable healthcare access, future policymaking and care practices should address the environmental and cultural geography and structural barriers that impede the connection between minority groups and the mainstream community healthcare system. The study findings suggest extending welfare resources beyond Indigenous administrative regions and establishing partnerships between Indigenous organisations and the mainstream healthcare system. Leveraging Indigenous people's attachment to cultural symbols and increasing healthcare facilities staffed with Indigenous healthcare workers could help ease structural barriers, maintain identifiable Indigenous beneficiaries and increase entry points into the mainstream healthcare system.

Biographical continuation: recovery of stroke survivors and their family caregivers in Taiwan.

AIM: To explore the experiences pertaining to long-term care services from the perspectives of dyads of stroke survivors and their family caregivers in indigenous and non-indigenous communities. BACKGROUND: Stroke occurrence is a life-changing event associated with quality of life for stroke survivors and their families, especially those who provide primary support. Indigenous people are more likely to experience a stroke at a younger age and have a higher likelihood of hospitalisation and death due to health disparities. Few studies have investigated family dyads or indigenous populations to understand their experiences of coping with changed body-self and to contextualise their reintegration into communities post-stroke. METHODS: Ethnographic fieldwork over nine months in 2018-2019 with indigenous, urban-based, and non-indigenous populations, resulting in 48 observations and 24 interviews with 12 dyads in three geo-administrative communities. FINDINGS: The post-stroke recovery trajectory is illuminated, delineating the dyads' life transitions from biographical disruption to biographical continuation. The trajectory is shaped by seven states involving four mindsets and three status passages. The four mindsets are sense of loss and worry, sense of interdependence, sense of independence, and wellbeing state. The status passages identified in this study are acceptance, alteration, and identification. A community-based and family-centred long-term care system, aligning with medical healthcare and community resources, underpinned each dyad's biographical continuation by: (1) providing rehabilitation that afforded time and space for recovery adaptation; (2) acknowledging the individuality of family caregivers and helping to alleviate their multitasking; and (3) reintegrating stroke survivors into their communities. Key to determining the quality of recovery for the indigenous participants was their reintegration into their native community and regaining of identity. Therefore, integrating post-stroke care into various care contexts and incorporating indigenous-specific needs into policymaking can support dyads in adapting to their communities.

Professional competence, personal occupational well-being, and mental workload of nurse educators - A cross-sectional study in four European countries.

BACKGROUND: Nurse educators need a high level of professional competence to educate future health care professionals. Professional competence supports occupational well-being whilst high mental workload can undermine it. There is little existing research into nurse educators' professional competence, occupational well-being, mental workload, and the relationships between them, particularly in the European context. OBJECTIVES: To describe the professional competence, personal occupational well-being, and mental workload of nurse educators in four European countries, and to explore how the professional competence and mental workload of nurse educators relate to their personal occupational well-being. DESIGN: Cross-sectional study design with quantitative survey data. SETTING: Nurse educators from Finland, Spain, Slovakia, and Malta. METHODS: The data were collected from 302 nurse educators through an online questionnaire which used the Health and Social Care Educator's Competence (HeSoEduCo) instrument. This contains 43 items which measure areas of professional competence. Statistical analysis involved descriptive and multivariate analysis. RESULTS: Nurse educators self-assessed their overall professional competence as high. Competence in evidence-based practice was assessed as the highest whilst cultural competence was perceived to be the lowest of the six competence areas. Nurse educators perceived their levels of personal occupational well-being and the balance of mental workload as moderate. However, these levels varied between the four countries. Professional competence, more specifically administrative and curriculum competence, and a balanced mental workload were positively related to personal occupational well-being. CONCLUSIONS: The educators who perceive themselves to have very good professional competence and a balanced mental workload are more likely to report high occupational well-being. The findings suggest that nurse educators' cultural competence needs to be strengthened and intervention research is needed to determine ways of reducing mental workload and increasing the occupational well-being of nurse educators.

Perceptions, knowledge, and practices of breastfeeding in indigenous regions of Mexico during Covid-19 pandemic.

OBJECTIVE: To explore the perceptions, knowledge, and practices of breastfeeding in the context of Covid-19 of pregnant and postpartum women, midwives, and health providers in an indigenous region of Chiapas, Mexico. MATERIALS AND METHODS: Qualitative thematic analysis study involving semi-structured interviews (n = 46) with pregnant women (n = 19), postpartum women (n = 6), health providers (n = 10, i.e., doctors/nurses), and midwives (n = 11). RESULTS: Among mothers, 47% (n = 11) did not know if Covid-19 is transmitted through breastfeeding. They mentioned that they would stay away from their newborns if infected. Health providers and midwives have not received education or any supporting material on the value of breastfeeding during Covid-19 infection. CONCLUSION: Breastfeeding mothers' promotion and counseling remain poor in indigenous communities and have worsened during the Covid-19 pandemic. Breastfeeding training among health providers and midwives should be provided or strengthened even more in emergency situations.

Understanding Parental Role in Children's Participation in Decision Making during Hospitalisation: An Ethnographic Study in Malaysia.

Introduction: Despite a growing recognition internationally that children have a right to participate in matters that affect their lives, they are not always involved in decision-making processes concerning their health care. There is a lack of information on how parents influence children's participation in this decision making. This study explored the roles parents assume in processes regarding their children's participation in communication exchanges and decision making in a paediatric oncology unit in Malaysia. Methods: This study adopted a focused ethnography design within a constructivist research paradigm. Participant observations and semi-structured interviews were conducted with 21 parents, 21 children and 19 nurses in a paediatric oncology unit in Malaysia. All observation fieldnotes and interview recordings were transcribed verbatim. A focused ethnographic data analysis technique was performed to analyse the data. Results: Three themes emerged regarding parents' roles in the communication and decision-making processes involving their children: i) facilitators of communication; ii) communication brokers and iii) communication buffers. Conclusion: Parents controlled decision-making processes concerning their children, while children preferred and welcomed parents as consultants in the decision-making processes regarding their health care.

Case study analysis of end of life care development in the Chinese cultural context of Macao: a social movement perspective.

BACKGROUND: The modern hospice movement is often recognised as a social movement. However, such understanding is primarily based on historic reflection and this approach has lacked theoretical exploration. There is a lack of systematic examination of the modern hospice movement by way of social movement theories. AIM: Focusing on the Chinese socio-cultural context of Macao, this study aimed to understand the EoLC movement by applying the social movement theory, the Framing Perspective, as proposed by Snow and Benford in 1988. METHODS: A case study approach was conducted. Semi-structured interviews were held between 2012 and 2013, with pioneers (n = 11) of the EoLC in Macao. Thematic analysis was adopted to analyse the interviews. RESULTS: The Framing Perspective analysis illuminated that there was both growth and stagnation of the EoLC movement. Three themes emerged: 1) the suffering of people at the end of their lives was considered as a social problem needed to be addressed urgently, 2) the incoherent EoLC strategies developed by pioneers indicated the lack of internal ideological cohesion within the movement, 3) external constraints contributed to the stagnation of the movement. CONCLUSIONS: The EoLC development in Macao can be understood as a social movement. The Framing Perspective provided a theoretical way to understand the emergence of EoLC; offering a novel perspective to conceptualise the modern hospice movement. This sociological and theoretical lens opened up new ways for future research to study the emergence of EoLC in different socio-cultural contexts.

Cue acquisition: A feature of Malawian midwives decision making process to support normality during the first stage of labour.

OBJECTIVE: to explore Malawian midwives decision making when caring for women during the first stage of labour in the hospital setting. DESIGN AND METHODS: this focused ethnographic study examined the decision making process of 9 nurse-midwives with varying years of clinical experience in the real world setting of an urban and semi urban hospital from October 2013 to May 2014.This was done using 27 participant observations and 27 post-observation in-depth interviews over a period of six months. Qualitative data analysis software, NVivo 10, was used to assist with data management for the analysis. All data was analysed using the principle of theme and category formation. FINDINGS: analysis revealed a six-stage process of decision making that include a baseline for labour, deciding to admit a woman to labour ward, ascertaining the normal physiological progress of labour, supporting the normal physiological progress of labour, embracing uncertainty: the midwives' construction of unusual labour as normal, dealing with uncertainty and deciding to intervene in unusual labour. This six-stage process of decision making is conceptualised as the 'role of cue acquisition', illustrating the ways in which midwives utilise their assessment of labouring women to reason and make decisions on how to care for them in labour. Cue acquisition involved the midwives piecing together segments of information they obtained from the women to formulate an understanding of the woman's birthing progress and inform the midwives decision making process. This understanding of cue acquisition by midwives is significant for supporting safe care in the labour setting. When there was uncertainty in a woman's progress of labour, midwives used deductive reasoning, for example, by cross-checking and analysing the information obtained during the span of labour. Supporting normal labour physiological processes was identified as an underlying principle that shaped the midwives clinical judgement and decision making when they cared for women in labour. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the significance of this study is in the new understanding and insight into the process of midwifery decision making. Whilst the approach to decision making by the midwives requires further testing and refinement in order to explore implications for practice, the findings here provide new conceptual and practical clarity of midwifery decision making. The work contributes to the identified lack of knowledge of how midwives working clinically, in the 'real world setting. These findings therefore, contribute to this body of knowledge with regards to our understanding of decision making of midwives.

These terrifying three words: A qualitative, mixed methods study of students' and mentors' understandings of 'fitness to practise'.

BACKGROUND: There is little empirical published research pertaining to fitness to practise and pre-registration nursing students. Much of the existing fitness to practise literature focuses on medical students and there is a preponderance of literature reviews and descriptive or discursive papers. OBJECTIVES: The multicentre study aimed to explore students' and mentor's understandings of fitness to practise processes in pre-registration nursing programmes. DESIGN: A qualitative study in the interpretive paradigm with interpretive analysis involving 6 focus groups and 4 face-to-face interviews with nursing students and mentors. SETTING: Eleven Higher Education Institutions providing pre-registration nursing education in the UK. Data were collected January 2014-March 2015 following ethical approval. PARTICIPANTS: Purposive sampling was used to recruit mentors and nursing (but not midwifery) students from pre-registration nursing programmes at different stages of educational preparation. METHODS: Qualitatively driven semi-structured focus groups (n=6) and interviews (n=4) were conducted with a total of 35 participants (17 pre-registration nursing students and 18 nursing mentors). RESULTS: Three themes identified from the student and mentor data are considered: Conceptualising Fitness to Practise; Good Health and Character; and Fear and Anxiety Surrounding Fitness to Practise Processes. CONCLUSIONS: Uncertainty about understandings of fitness to practise contributed to a pervasive fear among students and reluctance among mentors to raise concerns about a student's fitness to practise. Both students and mentors expressed considerable anxiety and engaged in catastrophic thinking about fitness to practise processes. Higher Education Institutes should reinforce to students that they are fit to practise the majority of the time and reduce the negative emotional loading of fitness to practise processes and highlight learning opportunities.

Involving users and carers in the assessment of preregistration nursing students' clinical nursing practice: a strategy for patient empowerment and quality improvement?

AIMS AND OBJECTIVES: To examine (1) nursing lecturers' and (2) preregistration nursing students' perspectives of user and carer involvement in the formal assessment of preregistration nursing students' clinical practice. BACKGROUND: The involvement of service users and carers in the assessment of clinical practice in nursing education is a recent phenomenon. The Nursing and Midwifery Council Standards in the UK clearly reflect a shift in thinking from paternalistic approaches to person-centred approaches. This shift in thinking includes service user and carer involvement in student nursing assessment and there is evidence that this is being developed in several countries. DESIGN: Located in the interpretive paradigm, data from a two-staged, multicentre qualitative study are presented. METHODS: Interpretive analysis of semi-structured, one to one interviews with nursing lecturers (n = 15) and focus groups with nursing students (n = 51) across 11 Higher Educational Institutions. RESULTS: There is a strong commitment for working alongside service users and carers in the education and training of nursing students; however, involving service users and carers in formal practice assessment is identified as more challenging compared with other areas of service user/carer involvement. Service user/carers should provide feedback/review or comment, but not necessarily formal, summative 'assessment'. CONCLUSIONS: The evidence base for involving users and carers in assessment is limited. Involvement of users and carers in providing feedback to nursing students is welcomed. However, concerns exist about the preparedness of users and carers for formal clinical assessment. RELEVANCE TO CLINICAL PRACTICE: Discussion and clarification with clinical mentors and user and carer groups is necessary to understand if they agree with the policy direction of user and carer involvement in the assessment of nursing students. Quality assurance concerns are raised by students and lecturers when involving user and carer in assessing nursing students' clinical skills. Mentors are seen as key to this process, but little is known about their perspectives.

Understanding pre-registration nursing fitness to practise processes.

BACKGROUND: Protection of the public is a key aspect of pre-registration nursing education and UK Nursing and Midwifery Council monitoring processes. Universities must ensure that nursing students are "fit to practise" both during their programme and at the point of registration. However, current evidence suggests that institutional fitness to practise policies and processes can be inconsistent, lacking in clarity, and open to legal challenge. OBJECTIVES: To examine fitness to practise processes in pre-registration nursing programmes in Scotland. PARTICIPANTS: Academic personnel (n=11) with key roles in fitness to practise processes in nine of the eleven Scottish universities providing pre-registration nursing programmes. METHODS: Semi-structured qualitative interviews were conducted with eleven academics with responsibility for fitness to practise processes in pre-registration programmes. The qualitative data and documentary evidence including institutional policies and processes were thematically analysed. FINDINGS: In this paper, we focus on illuminating the key theme of Stages and Thresholds in Fitness to Practise processes i.e. Pre-fitness to practise, Stage 1, Stage 2, and Appeal, along with two thresholds (between Pre-fitness to practise and Stage 1; between Stage 1 and Stage 2. CONCLUSIONS: Diverse fitness to practise processes are currently in place for Scottish pre-registration nursing students. These processes draw on a shared set of principles but are couched in different terminology and vary according to their location within different university structures. Nevertheless, universities appear to be confronting broadly similar issues around ensuring fitness to practise and are building a body of expertise in this area. Examples of good practice are identified and include the use of staged processes and graduated outcomes, the incorporation of teaching about fitness to practise into nursing programmes, positive attitudes around health and disability, and collaborative decision making. Areas of challenge include systems for student support and consistent, equitable, and auditable fitness to practise processes.

Navigating the self in maternity care: how Chinese midwives work on their professional identity in hospital setting.

OBJECTIVE: to explore the strategies Chinese midwives employed to work on their professional identity in hospital setting and the consequence of such identity work. DESIGN AND METHODS: this paper draws upon findings from a Constructivist Grounded Theory study that explored the professional identity construction of 15 Chinese midwives with a mixture of midwifery experiences, practising in three different types of hospital settings in a capital city in Southeast China. The accounts from participants in the form of in-depth individual interviews were collected. Work journals voluntarily provided by three participants were also included. FINDINGS: in everyday practice, hospital midwives in China were working on their professional identity in relation to two definitions of the midwife: the external definition ('obstetric nurse'), bound up in the idea of risk management under the medical model of their work organisations; and the internal definition ('professional midwife'), associated with the philosophy of normal birth advocacy in the professional discourse. Six strategies for identity work were identified and grouped into two principle categories: 'compromise' and 'engagement'. The adoption of each strategy involved a constant negotiation between the external and internal definitions of the midwife, being influenced by midwifery experiences, relationships with women, opportunities for professional development and the definition of the situation. A 'hybrid identity', which demonstrated the dynamic nature of midwifery professional identity, was constructed as a result. KEY CONCLUSIONS AND IMPLICATIONS: this paper explored the dynamic nature of midwifery professional identity. This exploration contributes to the body of knowledge regarding understanding the professional identity of hospital midwives in China, while also extending the current theoretical knowledge of identity work by elaborating on the various strategies individuals use to work on their professional identity in the workplace.

Shifting the balance of care? A qualitative study of policy implementation in community nursing.

AIM: This qualitative study examined the interaction between policy implementation and service organisation and delivery for community nursing services. BACKGROUND: Leadership in nursing is at the fore front of the policy agenda for shifting the balance of care from hospitals to the community setting and for improving the quality of healthcare services. Yet, little is known about the implementation of policy within the community setting. METHOD: A qualitative, interpretive analysis including semi-structured interviews with nurse leaders (n = 12) and community nurses (n = 27) and three focus groups (n = 13) with community nurses (Total N = 39) in three Health Boards in Scotland. RESULTS: Policy implementation is not adequately integrated between primary and secondary care service at the point of care delivery. The 'top down approach' to policy implementation for shifting the balance of care is currently at odds with the grass roots service organisation and delivery in the community setting. CONCLUSIONS: The aspirations of integrated, collaborative health and social care require more clinicians working at the frontline in both primary and secondary care to value more the work of colleagues in the different sectors. IMPLICATION FOR NURSING MANAGEMENT: The current 'top down approach' to policy implementation encourages resistance in the frontline community nurses rather than commitment. A more 'bottom up' integrated approach to policy implementation is therefore required.

Contrasting perceptions about the delivery of care in the community.

UK government policy emphasises the role of leadership in meeting the NHS healthcare quality agenda. As care is delivered increasingly in the community, it is important to evaluate the quality of nursing care provided to patients and families in community settings. However, few quality indicators have been designed for use in this sector. A study was undertaken to examine the effects of nursing leadership in the community on quality of care, and the results suggest that there is tension between nurse 'leaders' and 'followers' about the value of leadership. While nurse leaders see the leadership role as critical to improving quality through workforce planning and organisation, front line staff perceive individual nurse's skills as more pertinent to the quality of community nursing care.

Does nursing leadership affect the quality of care in the community setting?

AIM: To examine perceptions about how nursing leadership affects quality of care in the community setting. BACKGROUND: Quality care is considered an essential component of nursing work and recent policy has emphasized the role of leadership in meeting the quality agenda. As shifting the balance of nursing care from the hospital to the community occurs in the UK, there is an imperative to confirm more effectively the quality of care that patients and families receive from nurses working in the community. METHODS: A qualitative study involving community nurse leaders (n = 12) and community nurses (n = 27) in semi-structured individual interviews (n = 31) and three focus groups (n = 13). RESULTS: Tensions exist between 'leading' for quality care and 'delivering' for quality care. Organisational decision making is challenged by limited measures of quality of care in the diverse roles of community nursing. CONCLUSIONS: Frontline community nurses and nurse leaders need to articulate how they intend quality of nursing care to be appreciated and actively indicate ways to show this. IMPLICATIONS FOR NURSING MANAGEMENT: Mechanisms to monitor patient safety, a key aspect of the policy agenda for quality care and other technical aspects of care are important for nurse leaders to develop with frontline community nurses.

Followers and the co-construction of leadership.

AIMS: This study aimed to (1) identify how leadership is perceived and experienced by community nurses, and (2) examine the interaction between recent policy and leadership development in community nursing in the United Kingdom (UK). BACKGROUND: Leadership is a 'hot topic' yet little is known about leadership in community nursing. Traditionally, the study of leadership is viewed from a leader-centric perspective in which the discussion of followership and its impact on leadership in theory and research is noticeable absent. METHODS: A qualitative study using individual interviews (n = 31) and three focus groups (n = 13) was conducted. RESULTS: 'Following' is a complex process with a socially co-constructed view of leaders undertaken in a variety of ways through 'doing following''standing by' or 'resisting following'. Followers do not necessarily fit into one category but may move between categories depending on the situation. Future research into leadership requires consideration of leadership and followership as interdependent concepts. CONCLUSIONS: Successful leadership is dependent on the actions of many within organizations. Followers play an active role in leadership. IMPLICATIONS FOR NURSING MANAGEMENT: Failure to consider differences amongst followers denies the impact followers have on the success (or failure) of the leadership process and ultimately on an organization's ability to achieve goals.

Understanding the relationship between followers and leaders.

Contemporary healthcare policies tend to imply that successful leadership can be attributed to a single leader. Such an understanding of leadership ignores the significant contribution followers make to successful leadership and their influence on leaders. In reality, followers rarely simply follow leaders. Following is a complex process that depends on the context and involves followers making judgements about prospective leaders while deciding whether or not to follow them. This interdependence is ignored all too often or misunderstood by those who see leadership as something that can resolve the problems of the NHS. Using data from a study of leadership in community nursing in which the authors were involved, they argue that senior staff who ignore followers and their contribution to leadership do so at the peril of their organisations.

Emotional labour within community nursing leadership.

Recent months have seen great emphasis on leadership within the U.K. Unlike politicians, leaders of community nursing have little support from aides and advisors as they grapple with the implementation of policy agendas. This paper gives insight into some of the emotions involved in leading community nursing to meet some of the recent NHS policy agendas, such as shifting the balance of care. The focus of this paper aims to examine emotions in leadership, particularly collegial emotional labour within community nursing. Qualitative interviews with 12 leaders of community nursing pointed to the current trials and tribulations of undertaking a leadership role in community nursing. The nurse leaders indicated how they undertook surface acting to mask their emotions, to maintain a dignified and professional demeanour with colleagues. Interviews with nurse leaders highlighted the tensions in their roles and that they often felt unsupported. Few community nurse leaders had access to emotional support in their leadership role unless they became stressed and unwell. A recommendation is that support through coaching or mentorship should be made available for people in leadership positions whether new, experienced, senior or junior due to the challenges of the role.

Understanding leadership in community nursing in Scotland.

There is limited evidence concerning leadership in community nursing. NHS policy also fails to clarify and define what leadership is, though regarding it as key to developing safe and high quality care. This paper reports the findings of a research study that aimed to identify how leadership is perceived and experienced by community nurses, and to examine the interaction between recent policy and leadership development in community nursing. Mixed qualitative methods were used involving 31 individual interviews and three focus groups with community nurses and nurse leaders (n-39) in three health boards in Scotland. Findings indicate the leadership qualities valued by participants, including the importance of leaders' visibility. Team leaders in particular were recognised for their visibility and clinical leadership. Strategic and professional leadership was less evident, so acting as a barrier to the development of the profession. The strategic vision was often not clear to community nurses, and they engaged in differing ways with the strategies and action plans of senior nurse leaders. New leadership roles, like change, need time to evolve and new leaders need space and the education to develop leadership. Future leaders in community nursing need to focus beyond clinical leadership, ensuring that good leadership is a process requiring interdependence between leaders and followers.