New graduate nurses' clinical competence: A mixed methods systematic review.

AIM: To appraise and synthesize evidence of empirical studies reporting assessment of new graduate nurses' clinical competence in clinical settings. DESIGN: Mixed methods systematic review. DATA SOURCES: The search strategy included keywords relevant to: new graduate nurse; clinical competence; and competence assessment. The searched literature databases included CINAHL, MEDLINE, Embase, PsycINFO and Web of Science. The search was limited to full-text papers in English or French, published between 2010 -September 2019. REVIEW METHODS: Inclusion criteria were: 1) empirical studies; 2) detailed method and complete results sections; 3) competence assessment in clinical settings; and 4) new graduate nurses (≤24 months). Two independent reviewers screened eligible papers, extracted data and used the Mixed Methods Appraisal Tool framework for quality appraisal. Divergences were solved through discussion. RESULTS: About 42 papers were included in this review: quantitative (N = 31), qualitative (N = 7) and mixed methods (N = 4). Findings suggest that new graduate nurses exhibit a good or adequate level of competence. Longitudinal studies show a significant increase in competence from 0-6 months, but findings are inconsistent from 6-12 months. CONCLUSION: There are a multitude of quantitative tools available to measure clinical competence. This suggests a need for a review of their rigor. IMPACT: No recent reviews comprehensively synthesized the findings from new graduate nurses' clinical competence. This review has found that new graduate nurses' competence has been mostly assessed as good, despite the expectation that they should be more competent. Longitudinal studies did not always show a significant increase in competence. These findings can help nurse educators in providing more support to new graduate nurses throughout the transition period or design improved transition programme. This review also identified quantitative tools and qualitative methods that can be used for competence assessment.

Measurement properties of scales assessing new graduate nurses' clinical competence: A systematic review of psychometric properties.

BACKGROUND: New graduate nurses' competence is a concern for all healthcare organizations. Previous reports show heterogeneous levels of competency amongst them. As a positive association between competency and quality of care in clinical settings has been suggested, it is essential for researchers and clinicians to select valid, reliable, and responsive scales to assess new nurses' competence. However, a systematic evaluation of the measurement properties of scales measuring new nurses' competence had yet to be published. OBJECTIVE: To analyse, evaluate and synthesize the measurement properties of scales used to assess new nurses' clinical competence. DESIGN: A systematic psychometric review based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methods. DATA SOURCES: The search strategy included a combination of keywords and thesaurus terms related to new graduate nurses, clinical competence, and competence assessment. Five databases were searched: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. The search was limited to full-text papers published in English or French, from 2010 to 2019. REVIEW METHODS: Two independent reviewers screened eligible papers, extracted data related to validity, reliability, and responsiveness of each scale, and evaluated the quality of their measurement properties as well as risk of bias in their psychometric evaluation. Divergences were solved through discussion. RESULTS: Ten scales were included: eight original scales, one culturally adapted and one modified. Of these scales, eight were developed or adapted in the 2010s decade and the other two scales were developed earlier. Most scales are divided into 6 to 8 subscales and use an adjectival scale with either 4, 5 or 7 points. The content validity study of all scales in this review was deemed to be doubtful or inadequate quality. Reliability was almost exclusively assessed by calculating the internal consistency with Cronbach's alpha coefficient which gives no information on equivalence or stability of the measure. Responsiveness was never properly assessed in the reviewed studies. CONCLUSIONS: There is little evidence on the measurement properties for each scale regarding their validity and reliability; responsiveness was not assessed for any scale. Every scale evaluated in this review had different characteristics (length, subscales, response options). Therefore, selection of the most appropriate scale depends on the context and purpose of the assessment. Prospero registration number: CRD42018109711 Tweetable Abstract: Systematic review of scales measuring new nurses' competence: we must do better and conduct more validity/reliability testing of existing scales.

Locating "gold standard" evidence for simulation as a substitute for clinical practice in prelicensure health professional education: A systematic review.

AIMS AND OBJECTIVES: To extract, examine and report the highest available levels of evidence from healthcare disciplines in the use of simulation-based education as substitution for clinical placement in prelicensure programmes. BACKGROUND: Simulation is widely employed across prelicensure health professional education to create safe, realistic clinical learning experiences for students. Whether simulation can be employed to substitute for actual clinical placement, and if so, in what proportion, replacement ratio and duration, is unclear. METHODS: A systematic review and quality appraisal of primary studies related to prelicensure students in all health disciplines, guided by the PRISMA checklist. RESULTS: Ten primary studies were included, representing 2,370 students from three health disciplines in four countries. Nine studies were experimental and quasi-experimental and methodological quality was assessed as moderate to high with good to very good inter-rater agreement. Direct substitution of simulation for clinical practice ranged from 5% to 50%. With one exception, replacement ratios were 1:1 and duration of replacement ranged from 21 hr-2 years. Levels of evaluation included measures of reaction, knowledge and behaviour transfer; no negative outcomes were reported. We appraised practicalities for design of substitution, design limitations and knowledge transfer to accreditation standards for prelicensure programmes. CONCLUSIONS: This review synthesised highest levels and quality of available evidence for substitution of simulation for clinical placement in health professional education. Included studies were heterogenous in simulation interventions (proportion, ratio and duration) and in the evaluation of outcomes. Future studies should incorporate standardised simulation curricula, widen the health professions represented and strengthen experimental designs. RELEVANCE TO CLINICAL PRACTICE: Current evidence for clinical educational preparation does not appear to be translated into programme accreditation standards governing clinical practice experience for prelicensure programmes in relevant jurisdictions. Overall, a stronger evidence base is necessary to inform future curricula and policy development, to strengthen clinical practice in health.

Complementary and alternative medicine: Interaction and communication between midwives and women.

BACKGROUND: Many pregnant women use complementary and alternative medicine. Although midwives are often supportive, how they communicate with women about the safe use of these therapies has received limited research attention. AIM: The aim of this study was to explore how midwives interact with women regarding use of complementary and alternative medicine during pregnancy. METHODS: We utilised grounded theory methodology to collect and analyse data. Twenty-five midwives who worked in metropolitan hospitals situated in Melbourne, Australia, participated in the study. Data were collected from semi structured interviews and non-participant observations, over an 18-month period. FINDINGS: How midwives communicate about complementary and alternative medicine is closely associated with the meaning they construct around the woman's role in decisionmaking. Most aim to work in a manner consistent with the midwifery partnership model and share the responsibility for decisions regarding complementary and alternative medicine. However, although various therapies were commonly discussed, usually the pregnant woman initiated the dialogue. A number of contextual conditions such as the biomedical discourse, lack of knowledge, language barriers and workplace constraints, limited communication in some situations. CONCLUSION: Midwives often interact with women interested in using CAM. Most value the woman's autonomy and aim to work in partnership. However, various contextual conditions restrain overt CAM communication in clinical practice.

Involvement of emergency medical services at unplanned births before arrival to hospital: a structured review.

OBJECTIVE: While infrequent, unplanned births before arrival (BBAs) are clinically significant events at which, conceivably, paramedics will be the first health professionals in attendance. This review aims to demonstrate that paramedics not only attend and transfer birthing women, but also use critical clinical and decision-making skills. It further proposes strategies that will support paramedics manage out-of-hospital obstetric emergencies. DESIGN: The bibliographic databases EMBASE, MEDLINE, CINAHL and Maternity and Infant Care were searched from 1991 to 2012 for relevant English language publications using key words and Medical Subject Heading (MeSH) terms. Data were extracted with respect to study design, incidence of BBAs, attendance of paramedics, complications and recommendations. RESULTS: Fourteen studies were selected for inclusion arising from the US, UK and Europe. While all studies acknowledged paramedics attend BBAs, seven reported the incidence of BBAs attended by paramedics, and two discuss issues specifically encountered by paramedics. Paramedics attended between 28.2% and 91.5% of all BBAs. While the articles reviewed noted that most of the births encountered by paramedics were uncomplicated, they all reported maternal or neonatal complications. Eight articles reported the most common maternal complication was excessive bleeding after birth, and nine reported the most frequent neonatal complication was hypothermia regardless of gestation. CONCLUSIONS: Paramedics need to be adequately educated and equipped to manage BBAs at both undergraduate and graduate levels. Protocols should be developed between health and ambulance services to minimise risks associated with BBAs. A dearth of information surrounds the incidence of BBAs attended and the management performed by paramedics highlighting the need for further research.

Keeping childbearing safe: midwives' influence on women's use of complementary and alternative medicine.

The use of complementary and alternative medicine during pregnancy is common. However, many modalities have not been well researched and safety concerns have been raised. This article describes a grounded theory study which explored how midwives interact with women regarding use of these therapies. Participants were recruited from metropolitan hospitals in Victoria, Australia. Twenty-five midwives were interviewed and a subgroup was also observed. The findings revealed that when working with women interested in complementary and alternative medicine, midwives usually aimed to facilitate informed decisions whilst prioritising safety. However, participants assessed the risk associated with various therapies differently. Although many endorsed the use of various therapies, only a few were integrated into practice. In conclusion, midwives play an important role in mediating women's behaviour towards complementary and alternative medicine. Yet, currently many do not have the appropriate education to appreciate the associated risks, as well as the potential benefits.

From alternative, to complementary to integrative medicine: supporting Australian midwives in an increasingly pluralistic maternity environment.

BACKGROUND: The use of complementary and alternative medicine during pregnancy has become increasingly popular over the past decade in Australia. AIM: The purpose of this discussion paper to make recommendations and foster a constructive debate regarding the appropriate response by the midwifery profession. DISCUSSION: Midwives should receive basic education regarding the use of complementary and alternative medicine. All women should be routinely question women about their use and this should be documented. While a few therapies could be safely integrated, in most situations interested women should be referred to a qualified practitioner. Referral frameworks and flexible clinical guidelines should be investigated. CONCLUSION: With the appropriate education and support, midwives are in an excellent position to engage women in open dialogue and raise awareness of the benefits and risks of CAM practices. The way forwards for midwifery profession is to focus on self-governance, education and flexible clinical guidelines.

Navigating a safe path together: a theory of midwives' responses to the use of complementary and alternative medicine.

OBJECTIVE: this paper presents the findings from a qualitative study that aimed to explain the processes midwives engaged in when considering the use of complementary and alternative medicine by pregnant women. DESIGN: grounded theory methodology was employed for the study. Data was generated from in-depth interviews and non-participant observation of midwives interacting with expectant mothers. Twenty-five midwives who worked in four hospitals and associated community clinics in Victoria, Australia, participated. FINDINGS: the theory 'Navigating a safe path together' offers a possible explanation of how midwives are responding. When working with women interested in the use of complementary and alternative medicine, midwives move through an iterative process of individualising pregnancy care, encountering diverse perspectives and minimising the risks associated with childbearing. KEY CONCLUSION: at the heart of the theory is the meaning midwives' construct around safe childbirth and their professional roles. Despite widespread support for the therapies, midwives' actions in clinical practice are mediated by a number of factors including the context of their professional work, their beliefs and knowledge, and the woman's expectation and health. IMPLICATIONS FOR PRACTICE: the research highlights the need for improved education and greater professional guidance to equip midwives to respond with greater understanding, and confidence to the increasing prevalence of CAM in the maternity setting.

Complementary and alternative medicine in midwifery practice: managing the conflicts.

BACKGROUND: Midwives commonly endorse the use of complementary medicine. However many work in hospitals where there can be significant opposition to use of these therapies. This paper describes how one group of midwives negotiated the conflicting perspectives. METHOD: Grounded theory was employed. Twenty five participants were recruited from metropolitan hospitals in Australia. Data was collected from interviews and observations. RESULTS: Midwives' behaviour was influenced by the meaning they constructed around their professional role and authority. Some emphasised ideological congruence, historical ties, and the ability of certain complementary therapies to reduce medical interventions, in order to legitimise their use. However, many were aware of biomedical opposition and undertook various strategies to protect themselves from conflict. CONCLUSIONS: Conflict regarding the use of complementary and alternative medicine is context specific. In some situations midwives can successfully negotiate the competing perspectives and expectations, while at other times they struggle to reconcile the disparities.

Midwives' support for Complementary and Alternative Medicine: a literature review.

OBJECTIVE: There is evidence that the use of Complementary and Alternative Medicine by childbearing women is becoming increasingly popular in industrialised countries. The aim of this is paper is to review the research literature investigating the midwives' support for the use of these therapies. METHOD: A search for relevant research published from 2000 to 2009 was undertaken using a range of databases and by examining relevant bibliographies. A total of thirteen studies were selected for inclusion in this review. RESULTS: The findings indicate that the use of Complementary and Alternative Medicine is widespread in midwifery practice. Common indications for use include; labour induction and augmentation, nausea and vomiting, relaxation, back pain, anaemia, mal-presentation, perineal discomfort, postnatal depression and lactation problems. The most popular therapies recommended by midwives are massage therapy, herbal medicines, relaxation techniques, nutritional supplements, aromatherapy, homeopathy and acupuncture. Midwives support the use Complementary and Alternative Medicine because they believe it is philosophically congruent; it provides safe alternatives to medical interventions; it supports the woman's autonomy, and; incorporating Complementary and Alternative Medicine can enhance their own professional autonomy. CONCLUSIONS: There is considerable support by midwives for the use of Complementary and Alternative Medicine by expectant women. Despite this enthusiasm, currently there are few educational opportunities and only limited research evidence regarding CAM use in midwifery practice. These shortfalls need to be addressed by the profession. Midwives are encouraged to have an open dialogue with childbearing women, to document use and to base any advice on the best available evidence.

Complementary and alternative medicine for induction of labour.

BACKGROUND: Induction of labour is a common obstetric procedure. Some women are likely to turn to complementary and alternative medicine in order to avoid medical intervention. AIM: The aim of this paper is to examine the scientific evidence for the use of complementary and alternative medicine to stimulate labour. METHOD: An initial search for relevant literature published from 2000 was undertaken using a range of databases. Articles were also identified by examining bibliographies. RESULTS: Most complementary and alternative medicines used for induction of labour are recommended on the basis of traditional knowledge, rather than scientific research. Currently, the clinical evidence is sparse and it is not possible to make firm conclusions regarding the effectiveness of these therapies. There is however some data to support the use of breast stimulation for induction of labour. Acupuncture and raspberry leaf may also be beneficial. Castor oil and evening primrose oil might not be effective and possibly increase the incidence of complications. There is no evidence from clinical trails to support homeopathy however, some women have found these remedies helpful. Blue cohosh may be harmful during pregnancy and should not be recommended for induction. Other complementary and alternative medicine (CAM) therapies may be useful but further investigation is needed. CONCLUSIONS: More research is needed to establish the safety and efficacy of CAM modalities. Midwives should develop a good understanding of these therapies, including both the benefits and risks, so they can assist women to make appropriate decisions.

The use of complementary and alternative medicine by pregnant women: a literature review.

BACKGROUND: The use of complementary and alternative medicine (CAM) has become increasingly prevalent in industrialised countries, with women being the most prolific users. Some women continue to consume these therapies when they become pregnant. AIM: To review the literature exploring prevalence and motivation for use of complementary and alternative medicine by pregnant women. METHOD: A search for relevant literature published from 2001 was undertaken using a range of databases and by examining relevant bibliographies. RESULTS: Although the estimates vary widely from 1% to 87%, the general trend indicates that a significant number of pregnant women use complementary and alternative medicine. Common modalities used include massage, vitamin and mineral supplements, herbal medicine, relaxation therapies and aromatherapy. Reasons for use are varied and include the belief that these therapies offer safe alternatives to pharmaceuticals, they allow greater choice and control over the childbearing experiences, and they are congruent with their holistic health beliefs. The influence of traditional cultural practices on the use of these therapies is unclear. Most expectant women rely on advice from family and friends, and many do not disclose their use to their pregnancy care providers. CONCLUSIONS: Many women use complementary and alternative medicine when they are pregnant. Further research is needed to gain a greater understanding of the true prevalence and expectant women's motivation for the use of complementary and alternative medicine. Health-care professionals are encouraged to ask women about their use of these treatments and seek out relevant information.

Exploring a pedagogical approach to integrating research, practice and teaching.

Application of evidence is accepted as an important component of clinical practice. Teaching research to undergraduate students has been reported internationally as a challenge, particularly for nurse educators. In this paper, reported is a strategy designed to enhance research learning for undergraduate midwifery students at one university, which formed part of a larger, international investigation into women's responses to caesarean birth. Following theory classes and briefings, students worked with their clinical educators in practice to interview women using existing tools, and were engaged in qualitative data analysis. A number of challenges were encountered throughout the process, both for the educators and students. However, the teaching approach provided benefits for students in learning about midwifery research. Recommended as essential is for continued development of pedagogical approaches that make research tangible for students. Furthermore, provision of support for clinical staff working with students is important for success of such approaches.

Uncovering knowing in practice during the graduate year: an exploratory study.

Becoming a graduate nurse is both a complex and stressful transition. Graduates must socialise into the context of nursing practice while developing their own clinical expertise and knowledge as novice registered nurses. This paper describes a study that explored graduate nurses' development of knowing and reflectivity during their graduate programs. This study used a series of audio-taped focus groups and anecdotes collected from participants during the first eighteen months of being a nurse. Anecdotes were submitted as word files, electronically to the chief researcher and thematically analysed using Carper's (1978) ways of knowing as a framework. Four ways of knowing were identified through the anecdotes: knowing self, empirical, personal, and ethical. Substantiation of these was further enhanced from focus group data. Development of practical knowledge as a novice is influenced by the degree of engagement afforded to the graduate nurse and their skills of critical reflectivity. .

Exploring continuous clinical placement for undergraduate students.

Clinical placements are integral to health professional preparatory courses. These placements allow for the application of classroom-based learning into real patient care situations. In doing so, they provide opportunities for applying theoretical knowledge into practice contexts, skills development and socialisation into the chosen profession. However, despite its recognised importance across health professions, little has been written about optimal structures for supporting clinical learning. This paper presents one group of findings from a larger qualitative study aimed at exploring health professional student's clinical experiences and their impact on career intentions. Findings reported here present a group of undergraduate midwifery student's perspectives on a "home" hospital clinical placement model where continuous clinical placements were taken in the same agency (or hospital group) for 2 days per week over the final 2 years of their course. Two main themes emerged from the data analysis, these being, 'familiarity' and 'continuity'. It is concluded that continuous placements in the same clinical setting have the potential to offer greater opportunities for learning and early professional socialisation than traditional block (Monday to Friday) placements. They can offer a more integrated approach to classroom theory and its application into practice.

Discursive influences on clinical teaching in Australian undergraduate nursing programs.

Clinical teaching is a vital, yet multidimensional component of Australian undergraduate nursing courses. Unlike other parts of curricula, clinical teaching relies on the both higher education and health care sectors to meet prescribed goals and for effective student learning to occur. As such it is influenced by discourses from within both education and health. Whilst there is considerable literature related to undergraduate nursing clinical teaching; it mainly deals with practical aspects such as effectiveness of clinical teaching or discussions of models employed. Only a small pool of literature exists that discusses the construction of clinical teaching including the factors that have influenced the development of practices both in the past and present. Using the work of Foucault, this paper examines dominant and competing discourses influencing clinical teaching through their constructions within the literature. These are discourses of academia, nursing, and economics. The discussion situates these discourses and discusses how some of the resultant issues surrounding clinical education remain largely unresolved.

Experiences and learning during a graduate nurse program: an examination using a focus group approach.

The graduate nurse year requires individuals to make a huge transition from university student to registered nurse as part of the health care workforce. New graduates experience steep learning curves throughout the first year of professional practice. This study sought to explore experiences and learning occurring throughout the graduate nurse program for a group of seven new nurse graduates. Focus group interviews were conducted at six months and 12 months into the program using the same set of guiding questions. The first interview highlighted that graduates early in the graduate year were internalised, concentrating on their own survival in managing workloads, facing practice realities and coming to terms with themselves as nurses. Learning was primarily about survival strategies and performing tasks. By the second interview, graduates were much less focussed on themselves. They understood their place in the health care team, had gained confidence in their relationships, and were showing concern for the next graduates arriving. Learning at this stage involved more higher order skills, including critical thinking.

Crossing cultural boundaries: flexible approaches and nurse education: a case study.

Computer-mediated conferencing commonly is used to promote collaborative learning, including student learning across distance. This article presents the outcomes and experiences of Master of Nursing students in three countries using flexible learning approaches facilitated by the use of computer-mediated conferencing. It examines issues relating to support for global nursing education, presents an evaluation of one particular unit, and presents themes in the feedback from students about their experience. The authors report the findings in three categories: broadened perspectives, tackling the technology, and adaptive learning. Furthermore, the article offers suggestions for enhancing student-learning experiences when computer-mediated conferencing facilities are used.