Participatory Action Research and Photovoice: Applicability, Relevance, and Process in Nursing Education Research.

ABSTRACT: Participatory action research (PAR) is a philosophy and approach to qualitative research. The purpose of this article is to generate a clearer understanding of PAR and its relevance to the discipline and profession of nursing. The authors provide a description of the principles and process of implementing PAR methodology, using photovoice as an innovative, participant-directed data collection method in rural nursing preceptorship. Participants were undergraduate nursing students and faculty advisors assigned to rural communities during the final clinical preceptorship. Participants described opportunities and challenges experienced during the preceptorship and how these experiences influenced their learning and overall preceptorship experience.

'We have to drive everywhere': rural nurses and their precepted students.

INTRODUCTION: Travel safety culture is a vital aspect of nursing in rural western Canada, where long distances and severe weather are commonplace. However, this culture is poorly understood owing to the absence of official policy, and the tendency of rural nurses to take travel risks and burdens in stride, rather than advocating for change. Travel risks and burdens include extreme weather events such as tornadoes and blizzards; unmarked routes and hazards; distance, time and expense; and driver fatigue. In such rural settings, the safety and health of visitors, novices and students are of particular concern. The researchers sought to elicit the tacit knowledge of rural registered nurses, and their students undertaking rural nursing preceptorships, pertaining to rural travel issues and best practices for safety and wellbeing. METHODS: Through purposive and snowball sampling, the researchers recruited seven senior nursing students and five nurse preceptors. Seven rural acute and community care sites, between 42 km and 416 km distant from the students' primary place of study, were covered by the study. Photovoice, a participant action modality, was employed to collect photographic and qualitative interview data from participants over 10 weeks, between February and April 2016. The data were analyzed thematically, in collaboration with participants, who in turn validated the results. A digital storytelling initiative was attempted, to further involve participants in dissemination of findings, but only one participant took part in this phase of the project. RESULTS: The central finding of the study was that nursing students learn to accept and manage limitations - and to recognize and capitalize on opportunities - when undertaking rural preceptorships. With regard to road safety, the students were found to be particularly vulnerable to long distances, hazardous conditions, fuel and cellular data expenses, and fatigue. These issues were compounded by the students' reluctance to speak up, or to miss shifts, when they felt unsafe or unwell. Their preceptors role modeled autonomy and community ethos as the foundations of a frontline, extemporaneous road safety culture. This entailed personal safety measures borne from rural experience and background, familiarity with the countryside, and community connectedness with other healthcare sites in place of any official public alert system. The preceptors furthermore benefited from strong union protection for occupational health and safety concerns, but students being taught in rural settings had no such advantage. CONCLUSIONS: Nursing students should have the same occupational health and safety protections as their rural preceptors, especially the right to refuse travel, without penalty, in unsafe circumstances. Better travel subsidies and road safety measures during rural preceptorship may help increase the likelihood of students considering a rural career path. Furthermore, the frontline, community-based road safety experience of rural nurses is an untapped source of information for educators and policymakers. Such information will become more and more vital as a diminishing number of rural nurses are called upon to care for an aging client base.

No resistance to tenofovir disoproxil fumarate detected after up to 144 weeks of therapy in patients monoinfected with chronic hepatitis B virus.

UNLABELLED: Tenofovir disoproxil fumarate (TDF) is a nucleotide analogue with potent activity against human immunodeficiency virus type 1 and hepatitis B virus (HBV). To date, no reports of HBV clinical resistance to TDF have been confirmed. In two phase 3 studies (GS-US-174-0102 and GS-US-174-0103), 375 hepatitis B e antigen-negative (HBeAg(-) ) patients and 266 HBeAg(+) patients with chronic hepatitis B (some nucleoside-naive and some lamivudine-experienced) were randomized 2:1 to receive TDF (n = 426) or adefovir dipivoxil (ADV; n = 215) for 48 weeks. After week 48, eligible patients received open-label TDF with no interruption. The studies are being continued through week 384/year 8; week 144 data are presented here. Per protocol, viremic patients (HBV DNA level ≥ 400 copies/mL or 69 IU/mL) had the option of adding emtricitabine (FTC) at or after week 72. Resistance analyses of HBV polymerase/reverse transcriptase (pol/RT) were based on population dideoxy sequencing. Phenotypic analyses were conducted in HepG2 cells with recombinant HBV derived from patient serum. Most patients maintained TDF monotherapy treatment across both studies (607/641, 95%). A resistance analysis of HBV pol/RT was performed at the baseline for all patients, for viremic patients at week 144 or at the last time when they were on TDF monotherapy (34 on TDF and 19 on ADV-TDF), and for patients who remained viremic after the addition of FTC (7/20 on TDF and 5/14 on ADV-TDF). No patient developed amino acid substitutions associated with resistance to TDF. Virological breakthrough on TDF monotherapy was infrequent over 144 weeks (13/426, 3%) and was attributed to documented nonadherence in most cases (11/13, 85%). Persistent viremia (≥400 copies/mL) through week 144 was rare (5/641, 0.8%) and was not associated with virological resistance to TDF by population or clonal analyses. CONCLUSION: No nucleoside-naive or nucleoside-experienced patient developed HBV pol/RT mutations associated with TDF resistance after up to 144 weeks of exposure to TDF monotherapy.

The pedagogical ebb and flow of human patient simulation: empowering through a process of fading support.

The use of the high-fidelity human patient simulator (HPS)-based clinical scenario in undergraduate nursing education is a powerful learning tool, well suited to modern nursing students' preference for immersive construction of knowledge through the provision of contextually rich reality-based practice and social discourse. The purpose of this study was to explore the social-psychological processes that occur within HPS-based clinical scenarios. Grounded theory method was used to study students and faculty sampled from a Western Canadian baccalaureate nursing program. The process of leveled coding generated a substantive theory that has the potential to enable educators to empower students through the use of fading support, a twofold process composed of adaptive scaffolding and dynamic assessment that challenges students to realistically self-regulate and transform their frame of reference for nursing practice, while limiting the threats that traditional HPS-based curriculum can impose.

Generational clashpoints in nursing preceptorship.

The success of the preceptorship approach to teaching-learning depends on the formation of positive working relationships. Preceptors and nursing students are frequently of different generations and often have differing world-views. A phenomenological study, guided by van Manen's approach, was conducted to develop an understanding of how generational differences influence the formation of the preceptor-student relationship and the overall success of the experience. Three main themes were revealed: being affirmed, being challenged, and being on a pedagogical journey. A key subtheme of being challenged was colliding generational worldviews; in this article, our purpose is to explore this particular subtheme. The data suggest that generational clashpoints are occurring during preceptorship experiences, and the implications of these are serious, particularly from a nursing recruitment and retention perspective. It is vital that proactive measures be taken to inspire the future generation of nurses, rather than stifling their spirit and assertiveness.

A student evaluation workshop with rural nursing preceptors.

Increasingly, clinicians and faculty members are motivated to provide students quality preceptorship placements in rural areas, particularly in light of the potential for recruitment of new graduates to underserved areas. Invariably, student performance evaluation is an onerous task for many preceptors and one in which they often feel ill-prepared. Rural preceptors may face additional challenges given the lesser availability of educational resources and professional development. In this article, the authors detail the development, pilot testing, and evaluation of a workshop on student evaluation that was created in collaboration with rural nurse preceptors.

A phenomenological perspective on preceptorship in the intergenerational context.

Pairing a student with an experienced nurse through preceptorship is an approach to teaching/learning that promotes critical thinking, cultivates practical wisdom, and facilitates competence. Frequently, nursing students are of a different generation than their assigned preceptors and differences in worldviews and expectations can impact upon the success of preceptorship. A phenomenological study, guided by van Manen's approach to human science research, was conducted to explore preceptorship within this intergenerational context. Data were generated using unstructured interviews with a purposive sample of seven preceptors and seven students recruited from an undergraduate nursing program. The findings reveal three main themes: being affirmed, being challenged, and being on a pedagogical journey. The findings of this study have the potential to enhance generational understanding in the pedagogical context and foster a teaching/learning culture in the clinical practice setting inclusive of divergent generational expectations.

Preceptorship: shaping the art of nursing through practical wisdom.

With so much emphasis having been focused on the development of nursing science and most recently on evidence-based practice, little attention has been directed toward the art of nursing or the practical wisdom that constitutes the spirit of that art. Practical wisdom is the performance of actions intended to preserve and enhance the well-being of others regardless of the context or circumstances involved. Although technically and from a knowledge perspective, nurses consider the most effective and efficient way to administer care, it is through their use of practical wisdom that they actually engage in the art of nursing to provide that care. Because preceptorship is so pivotal to influencing students in the way they approach their nursing care, this approach to teaching-learning in the clinical environment provides an excellent modality by which to cultivate practical wisdom and ultimately to shape the art of nursing.

Transformative learning as a context for human patient simulation.

Nurse educators are charged with the responsibility of empowering novice nurses to become autonomous thinkers with the capacity to cope with the many challenges of modern day practice. Human patient simulation is a powerful technology-based educational tool ideally suited for the application of emancipatory pedagogies that aid in the transformation of individual meaning schemes. Transformative learning theory provides educators with the tools to empower students to challenge their preconceived beliefs, assumptions, and values and socialize them appropriately to thrive in modern day clinical practice. The purpose of this article is to critically analyze the role of clinical scenarios using human patient simulation to promote transformative learning events in undergraduate nursing education. The authors focus on the role of debriefing in the promotion of the critical reflection and social discourse that is integral to the learning process and the implementation of scenarios that provide students with disorientating dilemmas for perspective transformation.

The one-to-one relationship: is it really key to an effective preceptorship experience? A review of the literature.

Currently, considerable focus is directed at improving clinical experiences for nursing students, with emphasis placed on adequate support and supervision for the purpose of creating competent and safe beginning practitioners. Preceptors play a vital role in supporting, teaching, supervising and assessing students in clinical settings as they transition to the graduate nurse role. Intrinsic to this model is the assumption that the one-to-one relationship provides the most effective mechanism for learning. With the current Registered Nurses (RN) shortage, among other factors, the one-to-one relationship may not be feasible or as advantageous to the student. Thus, nurse educators need to carefully assess how this relationship is configured and maintained to assist them in fostering its evolution. In this review of the literature, the authors explore the assumption that a one-to-one relationship in the preceptorship experience fosters a rich and successful learning environment, and implications for nursing education, practice and research are outlined.

Crisis and continuity: Rural health care students respond to the COVID-19 outbreak.

The COVID-19 outbreak in Winter (2020) has caused widespread disruption for health sciences students undergoing clinical placements-vital periods of experiential learning that cannot be substituted with distance alternatives. For students placed in rural areas, already coping with isolation, precarious supply chains and shortages of essential personnel, the effects of the COVID-19 outbreak may have far-reaching implications for psychosocial wellness, self-efficacy and clinical judgment. Four nursing and eight medical students (n = 12) supplied photographs and commentary documenting the experience of withdrawing suddenly from clinical sites in rural Alberta. Collaborative, thematic analysis revealed continuities between pre- and post-outbreak life, both for the students and their rural hosts. Social determinants of health such as seclusion, environmental hazards, and health-seeking behaviors carried over and compounded the effects of the outbreak on the placement communities and clinical sites. Other continuities included the reliance on technology for clinical and social connectivity, and capitalizing on natural settings to cope with isolation and confinement. Prolonged liminality, lack of closure, and the loss of team identity were the greatest stressors brought on by the suspension of clinical activities. However, the participants felt well equipped to deal with these circumstances through the resilience, adaptability, and community ethos acquired during their placements.

The triple combination of tenofovir, emtricitabine and efavirenz shows synergistic anti-HIV-1 activity in vitro: a mechanism of action study.

BACKGROUND: Tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) are the three components of the once-daily, single tablet regimen (Atripla) for treatment of HIV-1 infection. Previous cell culture studies have demonstrated that the double combination of tenofovir (TFV), the parent drug of TDF, and FTC were additive to synergistic in their anti-HIV activity, which correlated with increased levels of intracellular phosphorylation of both compounds. RESULTS: In this study, we demonstrated the combinations of TFV+FTC, TFV+EFV, FTC+EFV, and TFV+FTC+EFV synergistically inhibit HIV replication in cell culture and synergistically inhibit HIV-1 reverse transcriptase (RT) catalyzed DNA synthesis in biochemical assays. Several different methods were applied to define synergy including median-effect analysis, MacSynergyII and quantitative isobologram analysis. We demonstrated that the enhanced formation of dead-end complexes (DEC) by HIV-1 RT and TFV-terminated DNA in the presence of FTC-triphosphate (TP) could contribute to the synergy observed for the combination of TFV+FTC, possibly through reduced terminal NRTI excision. Furthermore, we showed that EFV facilitated efficient formation of stable, DEC-like complexes by TFV- or FTC-monophosphate (MP)-terminated DNA and this can contribute to the synergistic inhibition of HIV-1 RT by TFV-diphosphate (DP)+EFV and FTC-TP+EFV combinations. CONCLUSION: This study demonstrated a clear correlation between the synergistic antiviral activities of TFV+FTC, TFV+EFV, FTC+EFV, and TFV+FTC+EFV combinations and synergistic HIV-1 RT inhibition at the enzymatic level. We propose the molecular mechanisms for the TFV+FTC+EFV synergy to be a combination of increased levels of the active metabolites TFV-DP and FTC-TP and enhanced DEC formation by a chain-terminated DNA and HIV-1 RT in the presence of the second and the third drug in the combination. This study furthers the understanding of the longstanding observations of synergistic anti-HIV-1 effects of many NRTI+NNRTI and certain NRTI+NRTI combinations in cell culture, and provides biochemical evidence that combinations of anti-HIV agents can increase the intracellular drug efficacy, without increasing the extracellular drug concentrations.

Nursing pedagogy and the intergenerational discourse.

This article examines the effects of intergenerational diversity on pedagogical practice in nursing education and highlights the need for nurse educators to engage in a critical discourse regarding the adequacy of current pedagogy in fostering an ethos that can optimize the teaching-learning process and promote ongoing learning for the future. It is evident that further research is needed to promote awareness and understanding of the expectations of today's students and to reform nursing pedagogy to accommodate the current generation of learners in colleges and universities. In this article, the context of intergenerational diversity is explored, the importance of evidenced-based practice is reinforced, and current nursing pedagogy is examined, with the intention to stimulate a philosophical discourse among nurse educators regarding fundamental values and beliefs about pedagogical practice.

Rural-hospital-based preceptorship: a multidisciplinary approach.

In this ethnographic study, undergraduate nursing students' experience of a rural-hospital-based preceptorship was a team effort that involved all members of the hospital staff. Daily and intimate interaction with the interdisciplinary hospital team had a significant impact on these students' ability to develop a professional identity. Indeed, for students to be successful in their preceptorship, nursing faculty members need to develop strategies that help the hospital team support students during a preceptorship.

Meeting the challenge of new graduate role transition: clinical nurse educators leading the change.

The transition from new graduate to professional nurse can be a challenging process. In some cases, more than 50% of new graduates have left their first position within the first year. One strategy that has been shown to yield positive results in facilitating new graduate role transition is nurse internship programs. All studies of internship programs in this review demonstrated lower turnover at 1 year after hire when compared with traditional clinical orientation programs.

Community Spirit, Cultural Connections, and Authentic Learning in Rural Preceptorship.

BACKGROUND: An authentic learning environment fosters socialization of nursing students to a particular community context and unique culture of the individuals who reside in that culture. The final preceptorship provides an extended clinical practice experience allowing for this immersion, while providing consolidation of learning as preparation to enter practice. METHOD: PhotoVoice was used as an innovative data collection method to engage participants throughout the research process. Participants self-selected photographic images that represented the unique rural preceptorship experience through their eyes. RESULTS: Rurality was described by participants as more than a geographic location, but as a sense of place, or a way of being and doing, that represented rural life. Rurality was depicted more specifically by participants in terms of community spirit and cultural contexts. CONCLUSION: Rural practice placements have the potential to enrich undergraduate nursing education and to expose undergraduate nursing students to the role of the rural nurse. More research is needed about rural health to understand the cultural and contextual factors that uniquely affect the health status of rural Canadians. [J Nurs Educ. 2019;58(3):144-151.].

Socializing for Authentic Caring Engagement in Nursing Practice: Nursing Student Moral Development in Preceptorship.

BACKGROUND: The purpose of this study was to explore the basic psychosocial process of undergraduate nursing student moral development in clinical preceptorship. METHOD: A grounded theory approach was used to explore the process within the context of clinical practice and the student-preceptor-faculty member relationship. RESULTS: Socializing for authentic caring engagement in nursing practice emerged from the data as the basic psychosocial process of nursing student moral development in preceptorship. This process included four key categories: (a) distinguishing nursing and moral identity in practice, (b) learning to recognize the patient's experience, (c) identifying moral issues in practice and creating meaning of practice encounters, and (d) becoming an advocate and reconciling moral issues in practice. CONCLUSION: Findings emerging from this study illustrate the processes of how nursing students work through moral issues and the role of faculty and preceptors in engaging students with moral encounters in the context of preceptorship.

Precepting an unsafe student: the role of the faculty.

According to a recent study, one of the central findings indicated that preceptors require significantly more support than they are currently receiving from faculty especially when precepting a student who is engaging in unsafe practice. In this grounded theory study, 22 preceptors were interviewed. The findings reveal some interesting implications not only regarding the staffing of preceptorship programs but also the process of preparing faculty as to how to provide preceptors with sufficient and appropriate support throughout the preceptorship experience.

Strategies for precepting the unsafe student.

Precepting a student who is unsafe is distressing both for the preceptor and the student. This article derives from a grounded theory study that describes the careful thought reflected in strategies used by preceptors to teach students who are unsafe. Both preceptors of undergraduates and new employees may find these strategies useful, with the ultimate goal being patient safety. The findings have implications not only for preceptor preparation in the area of evaluation but also for faculty support and the need for evaluation guidelines.

Hallmarks of unsafe practice: what preceptors know.

During a preceptorship experience, certain students do not progress in their learning at the same rate as others and may engage in unsafe practice. Twenty-two preceptors working with fourth year baccalaureate nursing students for 340 hours in a final practicum were interviewed. This study reaffirmed that early identification and intervention of unsafe practice are critical and consist of red flags regarding knowledge, attitudes, skills, and professionalism.