A role for virtue in unifying the 'knowledge' and 'caring' discourses in nursing theory.

A critical examination of contemporary nursing theory suggests that two distinct discourses coexist within this field. On the one hand, proponents of the 'knowledge discourse' argue that nurses should drop the 'virtue script' and focus on the scientific and technical aspects of their work. On the other hand, proponents of the 'caring discourse' promote a view of nursing that embodies humanistic qualities such as compassion, empathy and mutuality. In view of this, we suggest a way to reconcile both discourses despite the fact that they appear to be at odds theoretically and practically. To that end, we argue that nursing theory must give a prominent role to the Aristotelian conception of virtue, and we offer an account that includes both character and intellectual virtues. This account allows for a focus on moral competence but also accommodates the demands for discipline-specific knowledge. Our account incorporates the caring discourse by suggesting a way for individuals to cultivate the conditions within themselves that make 'caring in nursing' possible, while the knowledge discourse is accommodated via the acquisition of the intellectual virtues. The process for achieving both these ends is the same: an intention to consistently develop, hone and exercise certain character traits over time.

Brief Report: Competence, Value and Enjoyment of Childcare Activities Undertaken by Parents of Children With Complex Needs.

UNLABELLED: Parents combine many roles when caring for a child with complex needs, but few studies measure parental value and enjoyment of childcare related activities. This study aimed to describe parental competence, enjoyment and value of childcare related activities, particularly healthcare related activities, when parenting a child with complex needs. DESIGN AND METHODS: This was a pilot cross sectional study. Ten mothers of children with complex needs rated their competence, value and enjoyment of 156 childcare related activities using the Occupational Questionnaire (Smith, Kielhofner, & Hawkins Watts, 1986). RESULTS: The mothers rated childcare related activities as important and rated themselves as competent to undertake them. Mothers disliked performing healthcare related activities, but enjoyed emotional care activities. CONCLUSION: This study extends the current knowledge regarding the role tension described by parents of children with complex needs. The finding that parents dislike performing healthcare related activities despite self-reporting high levels of competence warrants further investigation. PRACTICE IMPLICATIONS: Gaining a better understanding of the role tension described by parents of children with complex needs may enable pediatric nurses to better understand the impact of home based care provision on parents and assist them to find ways to support families so this care can continue to be provided.

Developing a patient focussed professional identity: an exploratory investigation of medical students' encounters with patient partnership in learning.

Patient encounters are central to the provision of learning opportunities for medical students and their development as medical professionals. The primary aim of the study reported in this paper was to discover how partnering medical students with patients with chronic illness in undergraduate learning influenced the development of a patient centred professional identity and professionalism. An exploratory interpretive research design was used to address the research aim within a patient partner program (P3). Three qualitative data collection methods were used: (1) focus groups (2) extended response questionnaire and (3) semi-structured interviews. Data were coded and analysed thematically. The professional identity of medical students is constructed along traditional lines in the preclinical years. Patient-partnership offers a disruption to this development by way of an intersection with patients with chronic illness which potentially allows meaningful construction of what a patient-centred identity should be. This point of reflection provides an opportunity to engage at a higher level in medical identity development and professionalism. The findings discussed in this paper further stimulate the patient-centred agenda by understanding the conflict associated with the student-patient nexus in medical education and its potential for building professionalism and a patient-centred professional identity. To continue the drive for a patient-centred professional identity there must be ongoing engagement with patients in medical education, preferably commencing early in a student's journey so that it becomes the expected norm. This study has highlighted that a true patient-centred emphasis is being encountered too late in their socialisation process.

Sleep deprivation in parents caring for children with complex needs at home: a mixed methods systematic review.

A significant number of children with a range of complex conditions and health care needs are being cared for by parents in the home environment. This mixed methods systematic review aimed to determine the amount of sleep obtained by these parents and the extent to which the child-related overnight health or care needs affected parental sleep experience and daily functioning. Summary statistics were not able to be determined due to the heterogeneity of included studies, but the common themes that emerged are that parents of children with complex needs experience sleep deprivation that can be both relentless and draining and affects the parents themselves and their relationships. The degree of sleep deprivation varies by diagnosis, but a key contributing factor is the need for parents to be vigilant at night. Of particular importance to health care professionals is the inadequate overnight support provided to parents of children with complex needs, potentially placing these parents at risk of poorer health outcomes associated with sleep deprivation and disturbance. This needs to be addressed to enable parents to remain well and continue to provide the care that their child and family require.

Palliative care in end-stage kidney disease.

Patients with end-stage kidney disease have significantly increased morbidity and mortality. While greater attention has been focused on advanced care planning, end-of-life decisions, conservative therapy and withdrawal from dialysis these must be supported by adequate palliative care incorporating symptom control. With the increase in the elderly, with their inherent comorbidities, accepted onto dialysis, patients, their nephrologists, families and multidisciplinary teams, are often faced with end-of-life decisions and the provision of palliative care. While dialysis may offer a better quality and quantity of life compared with conservative management, this may not always be the case; hence the patient is entitled to be well-informed of all options and potential outcomes before embarking on such therapy. They should be assured of adequate symptom control and palliative care whichever option is selected. No randomized controlled trials have been conducted in this area and only a small number of observational studies provide guidance; thus predicting which patients will have poor outcomes is problematic. Those undertaking dialysis may benefit from being fully aware of their choices between active and conservative treatment should their functional status seriously deteriorate and this should be shared with caregivers. This clarifies treatment pathways and reduces the ambiguity surrounding decision making. If conservative therapy or withdrawal from dialysis is chosen, each should be supported by palliative care. The objective of this review is to summarize published studies and evidence-based guidelines, core curricula, position statements, standards and tools in palliative care in end-stage kidney disease.

Enhancing Graduate Nurse Transition: Report of the Evaluation of the Clinical Honors Program.

BACKGROUND: The Bachelor of Nursing with Clinical Honors (Transition to Practice) program supports the transition of nursing graduates. It is the first initiative of its kind in Australia and is designed to integrate with existing graduate transition programs. The program is clinically focused, collaborative, and accessible online. METHOD: A 2015 evaluation comprised a program performance review, a questionnaire-based research component, and participating partner interviews. Quantitative and qualitative data were collected and analyzed. RESULTS: The student and graduate surveys indicate that the program promotes evidence-based practice and learning, critical thinking, and reflection. Medication safety, its link to the national quality and safety agenda, and the promotion of safe medication administration were highlighted. The results of the industry partner interviews indicate that the program supports the missions and values of the participating organizations. CONCLUSION: The Clinical Honors program provides an evidence-based, theoretically structured program supporting transition to practice for new RNs. It supports the development of critical thinking, reflection, skill enhancement, and confidence. J Contin Educ Nurs. 2018;49(8):348-355.

The 'radiographer-referrer game': image interpretation dynamics in rural practice.

INTRODUCTION: Effective interprofessional communication is intrinsic to safe health care. Despite the identified positive impact of collaborative radiographic interpretation between rural radiographers and referrers, communication difficulties still exist. This article describes the strategies that Australian rural radiographers use for communication of their radiographic opinion to the referring doctor. METHODS: In a two-phase interpretive doctoral study completed in 2012, data were collected from radiographers working in rural New South Wales, Western Australia and Tasmania using a paper based questionnaire followed by in-depth semistructured interviews. Data were analysed thematically in order to identify, analyse and report the emergent themes. RESULTS: The overarching theme was Patient Advocacy, where in the interest of patient care radiographers took measures to ensure that a referring doctor did not miss radiographic abnormalities. Strong interprofessional relationships enabled direct communication pathways. Interprofessional boundaries shaped by historical hierarchical relationships, together with a lack of confidence and educational preparation for radiographic interpretation result in barriers to direct communication pathways. These barriers prompted radiographers to pursue indirect communication pathways, such as side-stepping and hint and hope. CONCLUSION: A lack of formal communication pathways and educational preparation for this role has resulted in radiographers playing the radiographer-referrer game to overtly or covertly assist referrers in reaching a radiographic diagnosis. The findings from this study may be used to plan interventions for strengthening interprofessional communication pathways and improve quality of healthcare for patients.

Assessing competence in undergraduate nursing students: the Amalgamated Students Assessment in Practice model.

Assessment of competence is characterised by ambiguity and inconsistency despite its critical role in assessing readiness for entry to the nursing profession. In 2012 the Amalgamated Student Assessment in Practice (ASAP) model and tool were developed and trialled within an Australian University. Developed in response to the inadequacies of existing tools to assess competence, the ASAP model offers an integrated multilayered assessment that is designed to enable focussed diagnosis of practice deficits and implementation of targeted support. The ASAP model was evaluated by gathering clinical facilitator and student feedback over two 13-week semesters during practice and formal meetings, as well as review of student performance data. The ASAP model functioned effectively as an assessment tool, focussed diagnostic tool, removal from Professional Experience Placement (PEP) support tool and a framework for documenting evidence. Student failure rates decreased and the number of complaints and successful appeals was reduced. The ASAP model offers comprehensive focussed assessment of nursing students' performance in practice. It supports both formative and summative feedback and can be used to accurately identify specific areas of practice deficiency requiring redirection and support. It is transferable across settings and assessors.

Supporting Graduate Nurse Transition: Collaboration Between Practice and University.

Making the transition from student to RN is challenging and demanding. In Australia, where nurses commonly graduate after 3 years in a Bachelor of Nursing program, graduate transition programs have been established in the workplace to support and socialize new graduates to nursing practice. These programs vary in content, rigor, and available support mechanisms, and no nationally agreed upon standards of expected graduate performance exist. Providing a structured, evidence-based, and clinically focused education and support program specific to the needs of graduate nurses contributes to quality care and patient safety and has significant benefits for the individual graduate, the employing organizations, and health care. This article presents the development and implementation of the Bachelor of Nursing With Clinical Honors (Transition to Practice) program offered by the University of Tasmania, in collaboration with St. Vincent's Private Hospital, Sydney, Australia.

Nurses' advocacy in an Australian operating department.

Acting as a patient advocate in the OR is challenging for many nurses. Personal, professional, and organizational barriers to effective advocacy exist, and the term advocacy is not clearly defined in the context of nursing practice. Findings from an ethnographic study conducted in an Australian operating department shed light on the way in which nurses experience the role of patient advocate in the OR. This article explores nurses' perceptions of the barriers they face as patient advocates and the strategies used to address these barriers.

The invisible nurse--behind the scenes in an Australian OR.

THE DWINDLING NUMBER of RNs choosing to work in the OR has been caused by many factors, such as restricted undergraduate exposure to the perioperative experience and fewer postgraduate opportunities. PRESSURE TO IDENTIFY alternative health care workers to replace RNs in the OR is escalating to a point where the role of the perioperative RN, as currently understood, is threatened. FINDINGS from an Australian ethnographic study suggest that both patients and non-nursing colleagues have limited appreciation of the contribution that perioperative nurses make. THE NEED FOR NURSES to take a proactive stance on this subject is discussed within the context of professional and structural change.

Pathways to palliative care for patients with chronic kidney disease.

BACKGROUND: Despite the terminal nature of chronic kidney disease (CKD), end-of-life care planning is often inconsistent and pathways to palliative care are unclear. Health professionals' perceptions of palliative care and the prevailing context may influence their end-of-life decision making. OBJECTIVES: To identify predictors of conservative treatment decisions and their associations with referral to palliative care, and to determine the perceptions that health professionals have about the role of palliative care in management of CKD. METHODS: A retrospective audit of deceased patients' charts, spanning three years, and a survey of renal healthcare professionals, documenting CKD palliative care practices, knowledge and attitudes was carried out. Records of all patients with CKD dying between 1 January 2006 and 31 December 2008 in Australian regional renal service were audited. Renal staff from the service were surveyed. Logistic regression for binomial outcomes and ordinal logistic regression when more than two outcome levels were involved; and thematic analysis using a continual cross comparative approach was undertaken. RESULTS: Loss of function, particularly from stroke, and severe pain are interpreted as representing levels of suffering which would justify the need to withdraw from renal replacement therapy. Family and/or patient indecision complicates and disrupts end-of-life care planning and can establish a cycle of ambiguity. Whilst renal healthcare professionals support early discussion of end-of-life care at predialysis education, congruity with the patient and family when making the final decision is of great importance. CONCLUSION: Healthcare professionals' beliefs, values and knowledge of palliative care influence their end-of-life care decisions. The influence of patient, family and clinicians involves negotiation and equivocation. Health professionals support the early discussion of end-of-life care in CKD at predialysis education to enable clearer decision making.

Do you want to play? Factors influencing nurse academics' adoption of simulation in their teaching practices.

Simulation based education (SBE) in healthcare is gaining popularity. It provides an opportunity for students to acquire and practice clinical skills in a safe and controlled environment and is also a potential solution to alleviating the increasing pressure on clinical placement availability. While there is growing evidence of the value of simulation to learners there is little understanding of the factors that influence academics attitudes towards and choices about the use simulation. Through an exploratory research design using semi-structured interviews, nurse academics' opinions, experiences and attitudes regarding simulation were captured. Thematic analysis was conducted utilising a cross comparative approach. Three themes Simulation as a Separate Entity; Getting Political, and Academic Adaptation were identified. These themes were then explored through the five essential characteristics of innovation identified in the persuasion phase of Roger's Diffusion of Innovation Model (1995). The findings indicated that in order to successfully integrate simulation into a university curriculum, the factors influencing nurse academics' attitudes and choices around simulation must be understood and addressed to avoid fragmentation of teaching and learning and to support strong learning outcomes.

The daily patterns of time use for parents of children with complex needs: a systematic review.

The aim of this systematic review was to critically examine the research that quantifies and describes the daily patterns of time use by parents of children with complex needs. Four electronic databases were searched. A total of 32 studies (30 peer-reviewed journal articles and two theses) met the inclusion criteria. Three key findings emerged from the review: (a) Parents of children with complex needs carry a significant caregiving burden that often does not reduce as the age of the child increases, (b) supervision or 'vigilance' is a category of childcare that carries a particular time requirement for these parents and (c) parents of children with complex needs spend (sometimes considerable) time undertaking health care-related tasks outside the 'normal' parenting role. The time demands placed on parents caring for a child or children with complex needs at home should be considered when health professionals are negotiating essential and/or additional therapies or treatments to be included in a child's home care regime.

Evaluation of the national pharmacy preceptor education program.

OBJECTIVE: The process evaluation findings and key issues from a trial of the effectiveness and national applicability of a national online educational curriculum for pharmacist preceptors are presented. DESIGN: A multi-method triangulated research design was used to elicit qualitative and quantitative data preceptors. The data collection method involved an anonymous questionnaire with both quantitative components and open-ended qualitative responses. SETTING: An online education program for preceptors of Australian pharmacy students in rural areas. PARTICIPANTS: Rural pharmacists in the three states were invited to trial the package and participate in the associated research/evaluation project. MAIN OUTCOME MEASURES: The Australian Pharmacy Preceptor Education (APPE) program is an important and valuable educational tool for the professional development of pharmacists. It contained pertinent information and appropriate activities, and the delivery strategy was well accepted. The evaluation findings support a national implementation. RESULTS: Program strengths include the ease of access, self-directed learning and the interactive nature emphasising the benefit of sharing ideas and feedback. Potential program limitations include technical delays and unclear instructions for undertaking the program. CONCLUSION: The online APPE program is a flexible delivery strategy which has the potential to dramatically improve the skills and knowledge of pharmacists acting as preceptors and, thereby, impact on the learning provided in rural hospitals and community pharmacies for undergraduate students and new graduates alike.

Nursing in a technological environment: nursing care in the operating room.

Operating room nurses continue to draw criticism regarding the appropriateness of a nursing presence in the operating room. The technological focus of the theatre and the ways in which nurses in the theatre have shaped and reshaped their practice in response to technological change have caused people within and outside the nursing profession to question whether operating room nursing is a technological rather than nursing undertaking. This paper reports findings from an ethnographic study that was conducted in an Australian operating department. The study examined the contribution of nurses to the work of the operating room through intensive observation and ethnographic interviews. This paper uses selected findings from the study to explore the ways in which nurses in theatre interpret their role in terms of caring in a technological environment.

Australian national strategy for pharmacy preceptor education and support.

OBJECTIVES: (i) To develop a national strategy for pharmacy preceptor education and support, with special consideration for rural and remote practitioners. (ii) To deliver an innovative national core pharmacist preceptor education and support model that could be customised for specific undergraduate programs. DESIGN: A steering committee, with representatives from four Pharmacy Schools in three Australian states, was established to develop an educational curriculum and implementation strategy. SETTING: The project was designed to provide an online educational program for preceptors of Australian pharmacy students, particularly those in rural areas. SUBJECTS: The recipients of this program will primarily be rural pharmacy preceptors but could also be urban practitioners. INTERVENTIONS: After consultation with an advisory group, the steering committee considered the educational content, delivery strategy and adaptability of the package to maintain its currency and links to universities, pharmacy boards and professional organisations: an extensive literature search was conducted; writers and an educational designer were employed. The steering committee reviewed and modified the content before transfer of the program to the worldwide web. MAIN OUTCOME MEASURE: The development of a Pharmacy Preceptor Education Program suitable for national application and able to fulfil the needs of rural preceptors. RESULTS: A Preceptor Education Program has been developed suitable for use in all Australian states and capable of meeting the needs of rural pharmacy preceptors. CONCLUSIONS: Collaboration between four schools of pharmacy and pharmacy professional bodies has resulted in development of a flexible program for preceptors of undergraduate pharmacy students. This program can be developed for use by preceptors of pharmacy graduates, and in other disciplines.