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PubMed2004

Lecturer practitioners in UK nursing and midwifery: what is the evidence? A systematic review of the research literature.

BACKGROUND: Lecturer practitioner roles have been widely established in the UK, and are seen as having the ability to overcome the theory-practice gap in nursing, as well as offering other benefits including functioning as a link between education and practice. AIMS AND OBJECTIVES: This article systematically reviews the research literature on UK lecturer practitioner roles in nursing and midwifery, in order to construct a picture of the themes that emerge from their national implementation. CONCLUSIONS: Only eight published research studies meeting the inclusion criteria were identified in journals, and five more included from the 'grey literature', totalling 13 suitable research reports. Of these 13 papers, six involved nurses and midwives. Key themes from the literature are outlined and discussed. There is an overwhelming preference for qualitative methodologies, although there is a strong argument for quantitative work in mixed-methods studies. RELEVANCE TO CLINICAL PRACTICE: Lecturer practitioner roles can make an important contribution to nursing and midwifery education, but this is problematic. It is essential that managers clarify the purpose, responsibilities, support and review of lecturer practitioner roles if they are to be successful.

Evidence-Based Medicine↗

PubMed2006

Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward.

AIMS AND OBJECTIVES: The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process. BACKGROUND: One of the challenges of nursing today is to meet the health-care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided. DESIGN: This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence-base for an evolving model of care. METHODS: The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self-care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients. RESULTS: The participatory action research process resulted in improved heath-care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient-centred care relationship based on Orem's self-care model. CONCLUSIONS: This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting. RELEVANCE TO CLINICAL PRACTICE: This study is significant because of its evidence-base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the 'grass roots' level. Therefore, being involved in the decision-making process provided an incentive to actively implement change.

Acute Disease↗

PubMed2005

An exploration of factors affecting the implementation of a randomized controlled trial of a transitional discharge model for people with a serious mental illness.

Information about the contexts in which trials are carried out helps to identify confounding influences on the application of a trial. Furthermore, the ways in which context and implementation of trials influence participation are particularly important for trials which utilize people as part of the intervention. This is particularly likely in the mental health and psychosocial fields. The researchers used mixed methods to identify quality issues encountered during the conduct of a trial, aiming to explore process and contextual factors encountered during its implementation in a mental health setting. Staff and peer volunteers who contributed to the intervention provided information on implementation via diaries and group meetings. Findings in this paper relate to staff feedback. By providing an insider view, researchers were able to highlight the importance of obtaining feedback on implementation. Findings relate to the context of the study, particularly organizational, practitioner and trial preparation issues and illustrate the importance of building quality assurance mechanisms into research plans, such as monitoring and feedback processes. The issue of 'people involvement' in trial delivery requires sensitive management and flexibility in both preparation and delivery.

Feedback↗

PubMed1997

Breaking a social silence: registered nurses share their stories about tertiary nursing education.

This research presents some of the qualitative findings from a mixed methods study exploring the personal and professional effects of tertiary education for post registration women nurses. The researcher combined both qualitative and quantitative approaches. The specific methods employed were survey questionnaire, 'journalling' and interviews. The results demonstrated that the participants were able to identify and verbalise personal and professional experiences associated with tertiary study, through multiple voices. A distinctive theme of empowerment emerged in their stories. However, by sharing their stories, it was evident that encounters in their lives were enmeshed with dialectical relationships. In conclusion, the associated tension that characterized their personal and professional relationships, indicated that these women could not control their social worlds and that their experiences were integrally linked to their engendered nature.

Attitude of Health Personnel↗

PubMed2006

Impact of institutional review board practice variation on observational health services research.

OBJECTIVE: To describe, qualitatively and quantitatively, the impact of a review by multiple institutional review boards (IRBs) on the conduct of a multisite observational health services research study. DATA SOURCE AND SETTING: Primary data collection during 2002, 2003, and 2004 at 43 United States Department of Veterans Affairs (VA) primary care clinics. DESIGN: Explanatory sequential mixed methods design incorporating qualitative and quantitative elements in sequence. DATA COLLECTION AND ABSTRACTION METHODS: Field notes and documents collected by research staff during a multisite observational health services research study were used in thematic analysis. Themes were quantified descriptively and merged with timeline data. PRINCIPAL FINDINGS: Approximately 4,680 hours of staff time over a 19-month period were devoted solely to the IRB process. Four categories of phenomena impacting research were observed: (1) Recruitment, retention, and communication issues with local site principal investigators (PIs). Local PIs had no real role but were required by IRBs. Twenty-one percent of sites experienced turnover in local PIs, and local PI issues added significant delay to most sites. (2) Wide variation in standards applied to review and approval of IRB applications. The study was designed to be qualified under U.S. government regulations for expedited review. One site exempted it from review (although it did not qualify for exemption), 10 granted expedited review, 31 required full review, and one rejected it as being too risky to be permitted. Twenty-three required inapplicable sections in the consent form and five required HIPAA (Health Insurance Portability and Accountability Act of 1996) consent from physicians although no health information was asked of them. Twelve sites requested, and two insisted upon, provisions that directly increased the risk to participants. (3) Multiple returns for revision of IRB applications, consent documents, and ancillary forms. Seventy-six percent of sites required at least one resubmission, and 15 percent of sites required three or more (up to six) resubmissions. Only 12 percent of sites required any procedural or substantive revision; most resubmissions were editorial changes to the wording of the consent document. (4) Process failures (long turnaround times, lost paperwork, difficulty in obtaining necessary forms, unavailability of key personnel at IRBs). The process required from 52 to 798 (median 286) days to obtain approval at each site. CONCLUSIONS: Several features of the IRB system as currently configured impose costly burdens of administrative activity and delay on observational health services research studies, and paradoxically decrease protection of human subjects. Central review with local opt-out, cooperative review, or a system of peer review could reduce costs and improve protection of human subjects.

Ethics Committees↗

PubMed2005

Total body water volume for white children and adolescents and anthropometric prediction equations: the Fels Longitudinal Study.

BACKGROUND: There are few studies of total body water (TBW) volume in children. Such studies are needed, as are new prediction equations for the clinical management of children with renal insufficiency and those receiving dialysis. METHODS: Mixed longitudinal data were from 124 white boys and 116 white girls 8 to 20 years of age. TBW volume was measured by deuterium nuclear magnetic resonance spectroscopy, and random effects models were used to determine patterns of change over time. Sex-specific TBW prediction equations were developed using regression analysis. RESULTS: Boys had significantly greater (P < 0.05) mean TBW volumes than girls at all but 3 ages. TBW was significantly (P < 0.05) associated with age and maturation in the boys and the girls. In boys, mean TBW/WT varied from 0.55 to 0.59, while in the girls the mean declined from 0.53 to 0.49 by 16 years of age. Boys had significantly larger means for TBW/WT than girls, who had a significant, slight negative trend with age. The prediction equations were TBW = -25.87 + 0.23 (stature) + 0.37 (weight) for boys and TBW =-14.77 + 0.18 (stature) + 0.25 (weight) for girls. CONCLUSION: Means are provided for TBW in white children from 8 to 20 years of age, whose average fatness affected the percentage of TBW in body weight. These updated TBW prediction equations perform better than those available from the past.

Adolescent↗

PubMed2006

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors.

BACKGROUND: Physician disclosure of medical errors to institutions, patients, and colleagues is important for patient safety, patient care, and professional education. However, the variables that may facilitate or impede disclosure are diverse and lack conceptual organization. OBJECTIVE: To develop an empirically derived, comprehensive taxonomy of factors that affects voluntary disclosure of errors by physicians. DESIGN: A mixed-methods study using qualitative data collection (structured literature search and exploratory focus groups), quantitative data transformation (sorting and hierarchical cluster analysis), and validation procedures (confirmatory focus groups and expert review). RESULTS: Full-text review of 316 articles identified 91 impeding or facilitating factors affecting physicians' willingness to disclose errors. Exploratory focus groups identified an additional 27 factors. Sorting and hierarchical cluster analysis organized factors into 8 domains. Confirmatory focus groups and expert review relocated 6 factors, removed 2 factors, and modified 4 domain names. The final taxonomy contained 4 domains of facilitating factors (responsibility to patient, responsibility to self, responsibility to profession, responsibility to community), and 4 domains of impeding factors (attitudinal barriers, uncertainties, helplessness, fears and anxieties). CONCLUSIONS: A taxonomy of facilitating and impeding factors provides a conceptual framework for a complex field of variables that affects physicians' willingness to disclose errors to institutions, patients, and colleagues. This taxonomy can be used to guide the design of studies to measure the impact of different factors on disclosure, to assist in the design of error-reporting systems, and to inform educational interventions to promote the disclosure of errors to patients.

Attitude of Health Personnel↗

PubMed1983

Effects of an antenatal load of pyridoxine (vitamin B6) on the blood oxygen affinity and prolactin levels in newborn infants and their mothers.

The effects of a loading dose of pyridoxine (100 mg) given intramuscularly or per os to 24 earlier non-supplemented pregnant women at term was investigated. The in vitro oxygen affinity (P50) and the prolactin level in both maternal and newborn blood was sampled. The blood P50 values were measured by a variant of "mixing method". Blood prolactin levels were determined by RIA. After pyridoxine administration, the maternal P50 values increased moderately and the newborns' cord blood P50 values increased significantly when compared with the control group's (number of cases 12) values. The decrease of blood oxygen affinity was most pronounced in the supplemented groups in newborns' capillary blood at the age of five days. The pyridoxine supplementation had no effect on the maternal and the newborns' cord blood prolactin level or on the daily amount of breast milk. Pyridoxine supplementation of the mother at labour may influence favourably the oxygen transport function of the newborn's blood and it may be especially advantageous in early postnatal adaptation disturbances of newborns.

Administration, Oral↗

PubMed2003

Contraceptive use in a changing service environment: evidence from Indonesia during the economic crisis.

In the late 1990s, most Southeast Asian countries experienced substantial economic downturns that reduced social-sector spending and decreased individuals' spending power. Data from Indonesia were collected in 1997 (just before the crisis) and in 1998 (during the crisis) that are used in this study to examine changes in the contraceptive supply environment and in women's choices regarding contraceptive use. Despite substantial changes in providers' characteristics during the first year of the crisis, no statistically significant differences are found between 1997 and 1998 in overall levels of prevalence, in unmet need, or in method mix. Women's choices regarding source of contraceptive supplies, however, changed considerably over the period. Changes in the contraceptive supply environment are linked here to changes in women's choice of source of supply, and a number of providers' characteristics are found to be significantly associated with women's choices in this regard.

Adolescent↗

PubMed2004

Reassessing the level of unintended pregnancy and its correlates in Vietnam.

Despite rapidly increasing contraceptive use and rapidly declining fertility, unintended pregnancy and induced abortion remain common in Vietnam. This study reassesses the level of unintended pregnancy in Vietnam and its correlates, drawing on retrospective calendar data gathered for the Vietnam Demographic and Health Survey II. Data from 13,540 "segments" of outcomes and contraceptive practice were analyzed. Based on the calendar data, 40 percent of pregnancies during the 1994-97 period are estimated to have been unintended, a proportion 48 percent higher than the prevailing estimate calculated from the reported intendedness of live births. When concealment of pregnancies ending in induced abortions is taken into account, the unintended pregnancy rate in Vietnam is likely to approach levels found only in developing countries. Unintended pregnancy was found to be associated with age, early marriage, spousal age difference, number of living sons, past unintended pregnancy, geographic region, contraceptive use prior to pregnancy, and the family planning supply environment. The findings suggest that broadening the method mix at the community level, targeting high-risk and underserved groups, and expanding postabortion counseling and services are likely to have a dramatic impact on the unintended pregnancy rate in Vietnam.

Abortion, Induced↗

PubMed2006

Patient choice: an influencing factor on policy-related research to decrease bedrail use as physical restraint.

BACKGROUND: This paper shows patients' enactment of choice in mixed methods, multidisciplinary study on the use of bedrails as restraints. APPROACH: Under the pressure of the implementation of impending legislation, patients from a Canadian elderly care rehabilitation unit were recruited to be part of this study and assigned to either a study or control group. Study group patients were exposed to a new facility policy on restraints in which bedrails were not to be used on a patient's bed except under specified conditions. Patients in the control group continued to have bedrails on a routine basis according to the facility's old policy. Following group assignments, patients could choose to crossover to either the control or study group based on their opinions about bedrails. FINDINGS: After patients crossed over into either the study or control group, findings for the new groups differed significantly. Participants in the rails-up group had lower admission Functional Independence Measure scores (p = .001) and higher admission Cumulative Illness Rating scores (p = .000) compared to those in the rails-down group. CONCLUSIONS: Patients have specific concerns related to the use of bedrails that might affect implementing bedrail minimization policies. Additionally, the authors conclude that patients' input into research design may increase patients' support of the protocol and help maintain study integrity.

Aged↗

PubMed2004

Transformation in family nurse practitioner students' attitudes toward homeless individuals after participation in a homeless outreach clinic.

PURPOSE: To use a retrospective pre/post self-assessment survey to determine the attitudes of family nurse practitioner (FNP) students toward homeless individuals before and after participating in a homeless outreach clinic (HOC) and to elicit, through focus groups, their perspectives on the homeless population after their HOC participation. DATA SOURCES: A mixed-methods study using focus group tapes and transcripts of 15 FNP students who were divided into two separate focus groups as well as three completed survey measures: Demographic Data Form, Attitudes Toward Homelessness Inventory, and HOC Attendance Form. CONCLUSIONS: Overall, the FNP students revealed no stigmatizing attitudes toward homeless people prior to their HOC participation, but a significant positive change in their attitudes occurred after the experience. There were significant mean differences in 6 out of the 11 scale items and in the overall total mean scores after the HOC experience (p = .013). The focus groups revealed the transformation of the students' attitudes toward homeless individuals after their HOC participation, supporting and illuminating the survey findings. IMPLICATIONS FOR PRACTICE: The study findings underscore the importance of including the care of homeless patients in FNP educational programs. Such exposure provides FNP students with an opportunity to develop the social responsibility to care for all segments of society, especially homeless people, in keeping with nursing's social contract as a helping profession.

Adult↗

PubMed2006

The relationship between marriage and family therapists and complementary and alternative medicine approaches: a qualitative study.

In this article, we delineate the qualitative phase of a mixed-method research study focused on understanding the relationship between Clinical Members of the American Association for Marriage and Family Therapy (MFT) and complementary alternative medicine (CAM). Based on an analysis of the data derived from telephone interviews with 54 respondents, we describe four themes: definitional issues, depth of awareness of CAM, fit with MFT, and ethical considerations. Our discussion focuses on the findings of this phase, considerations from the quantitative phase, and reflections on the research study as a whole. While acknowledging the limitations of the study, we conclude that the growing awareness of and involvement with CAM approaches and practitioners among MFTs suggest a need for further education for both professionals and clients. We also note the importance of additional research support for the use of CAM practices.

Adult↗

PubMed2006

Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh.

OBJECTIVE: To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. DESIGN: Mixed methods qualitative study. SETTING: Large government medical college hospital in Bangladesh. SAMPLE: Providers and users of EmOC. METHODS: Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. RESULTS: Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal "poor fund" system to help the poorest women. There was no formal assessment of poverty; rather, doctors made "adjudications" of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a "wait and see" policy that meant women's condition could deteriorate before help was provided. CONCLUSIONS: Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.

Academic Medical Centers↗

PubMed2006

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of "vulnerable system syndrome", Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into key trends in the interview data, including team members' definition of error as the breaching of standards of practice, nurses' sense of scope of practice as a constraint on their reporting behaviours, and participants' reports of the forces influencing tacit agreements to work around safety regulations. However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as "relational coordination" to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.

Anesthesiology↗

PubMed2006

An ethnographic study of tobacco control in hospital settings.

BACKGROUND: Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm. OBJECTIVE: To study hospital workplace culture relevant to tobacco use and control as part of a mixed-methods research project that investigated hospital-based registered nurses' integration of cessation interventions. DESIGN: The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient-care documents on 16 adult in-patient wards. RESULTS: The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses framed patients' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence. CONCLUSION: Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues.

Adult↗

PubMed1996

Resting energy expenditure and oxygen cost of breathing in patients with cystic fibrosis.

BACKGROUND: Resting energy expenditure (REE) is often increased and may contribute towards energy imbalance in patients with cystic fibrosis. Several mechanisms may lead to increased REE including the gene defect, the effect of chronic infection, and abnormal pulmonary mechanics. Increased oxygen cost of breathing (OCB) has been demonstrated in patients with chronic obstructive pulmonary disease (COPD), but has not been the subject of extensive study in cystic fibrosis. METHODS: Ten clinically stable patients with cystic fibrosis and 10 healthy control subjects were studied. OCB was estimated using the dead space hyperventilation method. Mixed expired gas fractions were measured by online gas analysers and ventilation by a pneumotachograph. After measurement of resting ventilation and gas exchange, minute ventilation (VE) was stimulated by 6-10 1/min by the addition of a dead space and OCB calculated from the slope of the differences in oxygen uptake (VO2) and VE. REE and the non-respiratory component of REE were calculated from gas exchange data. To assess the repeatability of OCB all subjects had a further study performed one week later. RESULTS: The patients had lower weight, fat free mass (FFM), forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and transfer factor for carbon monoxide (TLCO) than controls. Resting respiratory rate, VE, and oxygen uptake per kilogram of FFM (VO2/kg FFM) were higher in patients (20 (7), 10.4 (1.4) 1/min and 5.5 (0.8) ml/kg FFM/min) than in controls (13 (4), 7.0 (1.2), and 4.2 (0.5), respectively.) The error standard deviation for replicated measures of OCB was 0.5 ml O2/l VE in controls and 0.8 ml O2/l VE in patients with coefficients of variation of 24% in controls and 28% in patients. The mean OCB in patients was 2.9 (1.4) ml O2/l VE and 2.1 (0.7) ml O2/l VE in controls. OCB, expressed as ml/min (VO2resp) was 28.5 (11.7) in patients and 14.0 (3.6) in controls. REE was higher in patients (125.9 (14.0)% predicted) than in controls (99.0 (9.4)%). The estimated non-respiratory component of REE was 112.1 (14.9)% for patients and 93.0 (10.0)% for controls. CONCLUSIONS: In clinically stable patients with cystic fibrosis the OCB at rest is increased but is not the sole explanation for increased metabolic rate. This contrasts with the finding in COPD where the increase in REE is largely explained by increased OCB. This study also showed poor repeatability and OCB measurements similar to earlier studies, which indicates that the technique is not suitable for longitudinal studies.

Adult↗

PubMed2002

Allergenic relevance of Cupressus arizonica pollen extract and biological characterization of the allergoid.

BACKGROUND: Cupressaceae (cypress) pollens can cause pollinosis in winter. However, the lack of specific commercial extracts combined with the early pollination period of cypress trees make a precise diagnosis difficult. The need for a reliable and effective cypress extract for diagnostic and therapeutic purposes is increasingly felt. METHODS: Mixed or single Cupressus arizonica, lusitanica and sempervirens pollen extracts precipitated with ammonium sulfate (PPT) were compared by direct RAST, RAST inhibition and SDS-PAGE techniques. The major allergen of C. arizonica (Cup a 1), purified by anion exchange chromatography, was checked by immunoblotting experiments before chemical modification, in parallel with a C. arizonica extract, with potassium cyanate (KCNO) to obtain a monomeric allergoid. The allergoid extract was characterized for its biological, chemico-physical and immunological features by RAST inhibition, SDS-PAGE and ELISA assays. RESULTS: Direct RAST, RAST inhibition, and SDS-PAGE data indicated that the PPT C. arizonica pollen extract showed the most allergenic potential, and it can be considered representative of the Cupressus spp. Immunoblotting data confirmed Cup a 1 as a major allergen. RAST inhibition and ELISA showed that modified PPT C. arizonica extract had less IgE reactivity than the native, non-modified extract, while preserving the immunogenic capacity typical for an allergoid. Finally, the SDS-PAGE profile of Cup a 1 allergoid was similar to native Cup a 1 allergen, suggesting the modified C. arizonica extract shows the characteristics of a monomeric allergoid. CONCLUSIONS: The PPT C. arizonica pollen extract shows good in vitro diagnostic potential and its chemically modified form offers the features of a monomeric allergoid. It might therefore lend itself to the development of a product to be administered by the sublingual or oromucosal route for immunotherapy of individuals with cypress pollinosis.

Allergens↗