Bridging the gap: a five stage approach for developing specialty-specific entrustable professional activities.

BACKGROUND: Entrustable Professional Activities (EPAs) are increasingly used as a focus for assessment in graduate medical education (GME). However, a consistent approach to guide EPA design is currently lacking, in particular concerning the actual content (knowledge, skills and attitude required for specific tasks) for EPAs. This paper describes a comprehensive five stage approach, which was used to develop two specialty-specific EPAs in emergency medicine focused on the first year of GME. METHODS: The five stage approach was used to gain consensus on the task, content and entrustment scale for two specialty-specific EPAs in emergency medicine. The participants consisted of twelve clinical supervisors working in the emergency department. The five stages were: 1) Selecting the EPA topic; 2) Developing the EPA content by collecting data from participants using focus group and individual interviews; 3) Drafting the EPAs based on analysis of collected data; 4) Seeking feedback on the draft EPAs from the participants and other stakeholders; 5) Refining and finalising the EPAs based on feedback. RESULTS: Two specialty-specific EPAs were developed using the five stage approach. The participants reached consensus on the specific tasks and criteria for performance for the two EPAs. They also agreed that both day-to-day (ad hoc) and formal (summative) entrustment decisions were put into practice through the intensity of supervision provided to PGY1 doctors. As a result, a three level entrustment and supervision scale consisting of direct active, indirect active, passive was developed reflecting the shift in the intensity of supervision from close supervision to minimal supervision. CONCLUSIONS: The five stage approach described in this paper was used successfully to develop two specialty-specific EPAs in emergency medicine along with a three level entrustment scale.We propose that the five stage approach is transferable to a range of medical training contexts to design specialty-specific EPAs.

Misunderstood as mothers: women's stories of being hospitalized for illness in the postpartum period.

AIM: This paper aims to explore women's experiences with healthcare providers to ascertain ways health care may be improved for women disrupted in their mothering. BACKGROUND: Women can find it difficult to relinquish care even when they are acutely unwell requiring hospitalization. Despite mothering being a priority for women, many healthcare professionals do not understand the importance of continuing to mother during maternal illness. DESIGN: This research used a qualitative methodology drawing on principles of feminism and storytelling. METHODS: Women's stories were collected through face-to-face interviews, email and via the telephone. The twenty-seven women who participated were from either Australia or the USA, had between one and six children and identified themselves as having been disrupted in their mothering by illness. Data were collected in 2011 and were analysed thematically. FINDINGS: The majority of participants had been hospitalized at some point in time for acute illness. A subset of participants reported feeling judged by nurses and that their efforts to continue to mother their newborn children despite their illness were misunderstood and not facilitated. CONCLUSION: Findings from this study suggest that women are more likely to remember times that health professionals failed to understand the primacy that mothering held for them or facilitate their efforts to continue to mother despite illness. Nurses and midwives should regularly reflect on their personal values in regard to mothering, validate women's attempts to mother to the best of their ability during illness and find ways to support and empower women in their mothering.

Men in nursing on television: exposing and reinforcing stereotypes.

AIMS: To describe the results of a study of images of men in nursing on television. BACKGROUND: Previous research has highlighted stereotypical images around nursing, such as the battle-axe, naughty nurse and handmaiden. More recent research focuses on images of nurses who are men, because of the growing numbers of men in the nursing workforce. Given that negative images can harm recruitment and retention in the profession, it is important to interrogate how men in nursing are portrayed in popular culture. Representations on television are particularly critical to explore because of the medium's wide audience. DESIGN: Qualitative study. METHODS: Five American medical television programmes appearing between 2007 and 2010 were analysed for their construction of men in nursing: Grey's Anatomy, Hawthorne, Mercy, Nurse Jackie and Private Practice. FINDINGS: Men in nursing on television were portrayed in ways that engaged with explicit and implicit stereotypes. The men were often subject to questions about their choice of career, masculinity and sexuality and their role usually reduced to that of prop, minority spokesperson or source of comedy. Thus, rather contradictorily, although the programmes often sought to expose common stereotypes about men in nursing, they nonetheless often reinforced stereotypes in more implicit ways. CONCLUSION: This research has implications for better understanding not only the status of nursing in our society but also for nursing practice and education and attracting more men to the profession.

Nursing on television: student perceptions of television's role in public image, recruitment and education.

AIMS: To explore nursing students' perceptions of how their profession is portrayed on medical television programmes. BACKGROUND: Recruitment and retention in nursing have been linked to the image of the profession in society. Images of nursing in popular media frequently draw on stereotypes that may damage the appeal of nursing for potential students and denigrate the value and status of the profession. A growing body of work analyses how nursing is portrayed in popular media, but less research asks nursing students themselves to reflect on this area. DESIGN: Convergent parallel mixed methods. METHODS: Data were collected in 2011 from surveys of 484 undergraduate nursing students at a large university in New South Wales, Australia, that included demographic data, their viewing habits of medical television programmes and their opinions of how the shows handled nursing ethics and professionalism and the image of nursing on television and nursing role models. RESULTS: Most students watch medical television programmes. Students who do not speak English at home watched fewer programmes but were more positive about the depictions of professionalism. The qualitative data showed students were concerned that television can have a negative influence on the image of nursing, but they also recognized some educational and recruitment value in television programmes. CONCLUSIONS: It is important for nurses, educators and students to be critically engaged with the image of their profession in society. There is value in engaging more closely with contemporary media portrayals of nursing for students and educators alike.

Psychometric testing of the English Language Acculturation Scale in first-year nursing students.

AIM: This article is a report of the psychometric testing of the five-item English Language Acculturation Scale, an indicator of English language usage as reported by first-year undergraduate nursing students. BACKGROUND: Nursing students who have English as an additional language can struggle clinically and academically due to low levels of English language proficiency. A self-report screening tool may provide early identification of nursing students at risk of underperformance. DESIGN: Prospective correlational survey design. METHODS: The study used a prospective, correlational survey design. In 2010 and 2011, 1400 commencing nursing students were surveyed about their English language usage using the English Language Acculturation Scale. In addition to descriptive statistics, exploratory and confirmatory factor analyses and Cronbach's alpha reliabilities, the relationship between English Language Acculturation Scale score and Grade Point Average at the end of first year was computed. RESULTS: Results show good reliability and construct validity of the English Language Acculturation Scale. Principal component analysis yielded only one component in which all five items loaded highly. This was further supported by confirmatory factor analysis, with standardized factor loadings ranging from 0·79 to 0·90. The results also showed strong association between English language use and academic performance; students in the high English Language Acculturation Scale score group were most likely to be in the high Grade Point Average group at the end of first year. CONCLUSION: Language screening tools can be an important strategy to identify nursing students at risk of underperforming in their studies. The English Language Acculturation Scale has the potential to be a useful brief self-report measure for commencing nursing students.

Games, civil war and mutiny: metaphors of conflict for the nurse-doctor relationship in medical television programmes.

Metaphors of medicine are common, such as war, which is evident in much of our language about health-care where patients and healthcare professionals fight disease, or the game, which is one way to frame the nurse-doctor professional relationship. This study analyses six pilot episodes of American (Grey's Anatomy, Hawthorne, Mercy, Nurse Jackie) and Australian (All Saints, RAN) medical television programmes premiering between 1998 and 2009 to assess one way that our contemporary culture understands and constructs professional relationships between nurses and doctors. Analysis shows that these popular television programmes frequently depict conflict, with games, civil war and mutiny between nurses and doctors over patient safety rather than professionals working collaboratively in teams to deliver health-care. Although the benefit of this televised conflict is the implication that nurses are knowledgeable, skilled professionals, the negative connotations include a dysfunctional and dangerous healthcare system, and also ongoing power struggles. Given that popular culture can sometimes influence the public's understanding of real-life nursing practice, it is important to explore what these metaphors of conflict are communicating about the nurse-doctor relationship.

Autobiography as genre for qualitative data: a reservoir of experience for nursing research.

This paper is concerned with the use of published literary autobiographies that contain first-hand accounts of illness narratives, to explore their usefulness as a form of qualitative data to generate knowledge that can inform nursing practice. There is increasing realisation that the experiences of patients and families should be used to guide health care service delivery, and autobiographical accounts are a valuable resource, providing first-hand accounts of the ways illness, disability, and health care, are experienced by patients and their families.

'Part of the team': professional identity and social exclusivity in medical students.

OBJECTIVES: Medical students must develop not only their professional identity but also inclusive social attitudes for effective medical practice in the future. This study explores the elements that contribute to medical students' sense of professional identity and investigates the concept of social exclusivity and how this might relate to students' development of their identity as medical professionals. METHODS: The study is based on qualitative data gathered in telephone interviews with 13 medical students enrolled in Years 1 or 3 at an undergraduate medical school at a university in Australia. The questions were open-ended and asked students about their experiences in medical school, sense of identity and social connections. RESULTS: Two main components contributed to a strong sense of professional identity in medical students: professional inclusivity and social exclusivity. Students experienced professional inclusivity when they attended clinical placements and when they were treated as future medical professionals by lecturers, doctors and patients. Social exclusivity was demonstrated by participants' perceptions of themselves as socially separate from non-medical students and isolated from students in other disciplines. Students described a sense of peer unity and a shared sense of identity as medical students within the medical school. CONCLUSIONS: It is important to understand how students develop their sense of identity as medical professionals and the ways in which medical education and clinical placements can influence this professional identity. Although this study noted a very strong sense of social exclusivity in its findings, there were also high levels of intra-discipline inclusivity. These results suggest that there is a reciprocal and reinforcing relationship between student experiences of professional inclusivity and social exclusivity that creates a defined sense of professional identity.

Psychometric testing of the abbreviated Clinical Learning Environment Inventory (CLEI-19).

AIM: This paper is a report of a test of the psychometric properties of a 19-item version of the Clinical Learning Environment Inventory. BACKGROUND: Although the clinical learning environment provides the 'real-life' context essential for preparing nursing students for their professional role, the quality of student learning is influenced by the quality of the clinical placement. METHODS: Nursing students completed an abbreviated (19-item) form of the Clinical Learning Environment Inventory to rate their perception of the clinical learning environment. Descriptive statistics, principal component analysis, discriminant validity and Cronbach's alpha reliabilities were computed. RESULTS: Between March and December 2009, 231 online surveys were submitted. The mean age of participants was 30.3 years (sd: 10.4) and 87% were female. All 19 items loaded on two factors, 'Clinical Facilitator Support of Learning' and 'Satisfaction with Clinical Placement', with factor loadings above the 0.4 threshold. Cronbach's alpha coefficient was 0.93 for the total Clinical Learning Environment Inventory-19, with subscales ranging from 0.92 to 0.94. Multiple regression uncovered that participants who engaged in health-related paid work were independently and significantly more positive on the 'Clinical Facilitator Support of Learning' subscale, whereas those who worked >16 hours a week, or allocated the afternoon shift were independently and significantly more negative on the 'Satisfaction with Clinical Placement' subscale. CONCLUSION: Providing an effective and productive clinical experience is vital in preparing nursing students to become competent clinicians. The Clinical Learning Environment Inventory-19 offers a useful measure to explore nursing students' satisfaction with two aspects of this clinical experience--clinical facilitator support of learning and the clinical learning environment.

Australian medical students' perceptions of professionalism and ethics in medical television programs.

BACKGROUND: Medical television programs offer students fictional representations of their chosen career. This study aimed to discover undergraduate medical students' viewing of medical television programs and students' perceptions of professionalism, ethics, realism and role models in the programs. The purpose was to consider implications for teaching strategies. METHODS: A medical television survey was administered to 386 undergraduate medical students across Years 1 to 4 at a university in New South Wales, Australia. The survey collected data on demographics, year of course, viewing of medical television programs, perception of programs' realism, depiction of ethics, professionalism and role models. RESULTS: The shows watched by most students were House, Scrubs, and Grey's Anatomy, and students nominated watching 30 different medical programs in total. There was no statistical association between year of enrolment and perceptions of accuracy. The majority of students reported that friends or family members had asked them for their opinion on an ethical or medical issue presented on a program, and that they discussed ethical and medical matters with their friends. Students had high recall of ethical topics portrayed on the shows, and most believed that medical programs generally portrayed ideals of professionalism well. CONCLUSIONS: Medical programs offer considerable currency and relevance with students and may be useful in teaching strategies that engage students in ethical lessons about practising medicine.

Struggling for legitimacy: nursing students' stories of organisational aggression, resilience and resistance.

There is a considerable body of literature scrutinising and theorising negative and hostile behaviour such as violence and interpersonal conflict in the nursing workplace. However, relatively little empirical work has examined the experiences of undergraduate nursing students in the context of negative workplace cultures, and even fewer studies have explored how students develop and enact strategies to counter hostile behaviours in the clinical workplace. Based on qualitative analysis of open-ended survey questions, this study explored undergraduate students' experiences of negative behaviours in the clinical environment to identify strategies used to manage and resist such behaviours. While dominant individuals in the clinical environment sought to enforce and uphold their version of legitimacy--one where students were relegated to complete subordination--the tenacity and resourcefulness of students was evident in their attempts to counter this oppression with acts of resistance. Our findings provide new and valuable insights into organisational aggression and acts of resistance in the nursing workplace. The resistance offered by these students draws attention to the struggles for legitimacy within institutions. In drawing attention to organisational aggression as a mechanism by which students are 'othered' through pejorative behaviour, homogenisation, and de-authentication, and the dynamics of resistance offered by these student nurses, we provide an alternative explanation of nursing socialisation.

Evaluating an academic writing program for nursing students who have English as a second language.

Academic writing skills are essential to the successful completion of preregistration nursing programs, yet the development of such skills is a challenge for many nursing students, particularly those who speak English as a second language (ESL). It is vital to develop and evaluate strategies that can support academic writing skills for ESL nursing students. This qualitative study evaluated a four-day academic writing intervention strategy designed to support ESL first-year nursing students. Data from the program showed two major areas of difficulty for participants relating to academic writing: problems understanding course content in English, and problems expressing their understanding of that content in English. The participants noted a key benefit of this program was the provision of individual feedback. Programs such as this intervention successfully meet the demands of ESL nursing students, although ongoing support is also needed.

Social support for mothers in illness: a multifaceted phenomenon.

BACKGROUND: Many women privilege the mothering role over other areas of their lives, and for ill women, it can be difficult to relinquish maternal responsibility. Not being able to mother in their usual way can have consequences for women's wellbeing and view of themselves as 'good' mothers. METHOD: In this study, 77 mothers of dependent children were interviewed about their experiences of illness, and the social support they received. RESULTS: Despite their illnesses, participants in this study continued to feel they were primarily responsible for the wellbeing and care of their children, and were distressed if they were unable to adequately fulfil the primary carer role. As participants sometimes found it difficult to care for their children, help with childcare emerged as an important element of social support. Seeking assistance with care for children revealed a tension between support that was accessible and support that was acceptable. CONCLUSION: Mothering while ill is difficult and women facing illness may need encouragement to accept help to continue to meet their maternal responsibilities. Nurses are in an excellent position to encourage women to identify and draw upon sources of support to assist them in maintaining their mothering role while ill.

Nurses involved in whistleblowing incidents: sequelae for their families.

Nurses involved in whistleblowing often face economic and emotional retaliation, victimization and abuse. Yet for many nurses, one major part of their whistleblowing experience is the negative impact it has on their families. This paper reports findings from a qualitative study pertaining to the effects of whistleblowing on family life from the perspective of the nurses. Using a narrative inquiry approach, fourteen nurses were interviewed who were directly involved in whistleblowing complaints. Data analysis drew out three themes: strained relationships with family members, dislocation of family life, and exposing family to public scrutiny. The harm caused to the nurses involved in a whistleblowing event is not restricted to one party but to all those involved, as the harrowing experience and its consequences are echoed in the family life as well. It is important for organizations to seek strategies that will minimize the harmful effects on nurses' families during whistleblowing events.

Terminal (mis)diagnosis and the physician-patient relationship in LM Montgomery's The Blue Castle.

LM Montgomery's The Blue Castle was first published in 1926, yet contains many insights into medical practice that remain relevant today. The protagonist, Valancy, mistakenly receives a terminal diagnosis in a letter from her physician, who has sent her a note intended for another patient. Her interactions with the physician raise issues that are still relevant in contemporary medical education and practice, primarily the importance of effective communication in the physician-patient relationship, especially in the context of diagnosing terminal illness and handling a diagnostic error. The Blue Castle offers a useful starting point for debate and discussion in medical education about these topics.

Embedded academic writing support for nursing students with English as a second language.

AIM: This paper reports a study which evaluated a brief, embedded academic support workshop as a strategy for improving academic writing skills in first-year nursing students with low-to-medium English language proficiency. BACKGROUND: Nursing students who speak English as a second language have lower academic success compared with their native English-speaking counterparts. The development of academic writing skills is known to be most effective when embedded into discipline-specific curricula. METHODS: Using a randomized controlled design, in 2008 106 students pre-enrolled in an introductory bioscience subject were randomized to receive either the intervention, a 4-day embedded academic learning support workshop facilitated by two bioscience (content) nursing academics and a writing and editing professional, or to act as the control group. The primary focus of the workshop was to support students to work through a mock assignment by providing progressive feedback and written suggestions on how to improve their answers. RESULTS: Of the 59 students randomized to the intervention, only 28 attended the workshop. Bioscience assignment results were analysed for those who attended (attendees), those randomized to the intervention but who did not attend (non-attendees), and the control group. Using anova, the results indicated that attendees achieved statistically significantly higher mean scores (70.8, sd: 6.1) compared to both control group (58.4, sd: 3.4, P = 0.002) and non-attendees (48.5, sd: 5.5, P = 0.001). CONCLUSION: A brief, intensive, embedded academic support workshop was effective in improving the academic writing ability of nursing students with low-to-medium English language proficiency, although reaching all students who are likely to benefit from this intervention remains a challenge.

Trial and retribution: a qualitative study of whistleblowing and workplace relationships in nursing.

This paper reports a study aiming to present and describe the effects of whistleblowing episodes on nurses' workplace relationships. Eighteen participants with direct experience of whistleblowing were recruited into the study, which was informed by a qualitative narrative inquiry design. Findings were clustered into four main themes, namely: Leaving and returning to work-The staff don't like you; Spoiled collegial relationships-Barriers between me and my colleagues; Bullying and excluding-They've just closed ranks; and, Damaged inter-professional relationships-I did lose trust in doctors after that. Findings suggest a need to facilitate a climate in which it is safe for nurses (and others) to raise concerns about patient care or organisational wrongdoing, and to eliminate the existing belief that whistleblowing is a negative act fuelled by revenge or sedition.

"Some say no, some say yes": Receiving inconsistent or insufficient information from healthcare professionals and consequences for diabetes self-management: A qualitative study in patients with Type 2 Diabetes.

AIMS: To explore the information-seeking experiences of patients with Type 2 diabetes and how these influenced self-management behaviours. METHODS: We interviewed 18 patients with Type 2 Diabetes attending outpatient diabetes centers in South Western Sydney. Data were analyzed thematically. RESULTS: Patients described a number of challenges they faced when seeking information about diabetes self-management. One major challenge was receiving inconsistent and insufficient information from healthcare professionals, which consequently undermined patients' ability to self-manage diabetes. This became a disincentive in carrying out self-management tasks, and led to confusion and mistrust regarding the veracity of information received. Participants also described finding reliable information, and difficulty understanding and accessing relevant information as challenges. Medical jargon and lack of comprehensive explanations exacerbated knowledge deficits compounded by the complex maze of internet resources that some patients accessed. In response to what they perceived as confusing or inconsistent information, some patients followed "their own way" of managing their diabetes. CONCLUSIONS: Inconsistent information not tailored to the needs of patients adversely affects self-management. Taking time to provide simple explanations and assisting patients in navigating reliable web resources is becoming a vital role of healthcare professionals to reduce knowledge gaps in patients with low health literacy.

Hate the course or hate to go: semester differences in first year nursing attrition.

Most of the attrition from nursing courses occurs in the first year of study. Devising university strategies to reduce attrition requires an understanding of why students leave. The aim of this study was to explore whether students who leave a nursing course in the first semester leave for the same or different reasons than students who leave in the second semester of study. Seventeen students who had left the course were interviewed by telephone: seven in the first semester and ten in the second. In the first semester, students who leave consider themselves unprepared for university, have competing roles outside university and develop a strong dislike of the nursing course. They decide quickly that the course is unsuitable and leave. Those who leave in second semester would prefer to stay but events in their life create a crisis where they can no longer cope with university studies. These students hope to return to nursing whereas students who leave in the first semester are unlikely to consider returning. Attempts to retain students in the first semester may be futile as these students may be unsuited or uncommitted whereas there is greater scope to retain those who leave in the second semester.