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PubMedDate not supplied

Just 'doing the observations': reflective practice in nursing.

The first part of this article explores the development, definition, and design of reflective practice. In the second part the author relates an 'ordinary nursing' story--'10 minutes with Mr Kandinski'--and uses an existentialist framework for reflective analysis. Reflection on personal experience can expose something of the interrelationship of theory and practice, perhaps helping practitioners to improve their work. More importantly, reflective practice provides a means for nurses to reveal a more complete picture of the reality of nursing work to others.

Clinical Competence↗

PubMedDate not supplied

Critical companionship. Part 2: Using the framework.

Part 1 presented the critical companionship framework for facilitating experiential learning, with exemplars of expertise. The development and testing of the framework were outlined. In Part 2, we show the framework being used by new critical companions, without educational backgrounds or previous facilitation of learning experience. The reflective accounts of the critical companions not only show how they analysed their work using the framework, but also reveal that these early experiences helped those they were facilitating to unravel their practice and look critically at how they, and others, practise. Some accounts hint at the outcomes for patients and relatives and show how critical companionship became integrated with leadership roles. We conclude that the framework can be useful in helping new critical companions to acquire effective critical companionship skills. In addition, we tentatively suggest that the development of expertise, as demonstrated in Part 1, is likely to take at least five years, unless the individual is already a skilled facilitator.

Clinical Competence↗

PubMed1996

Take two classes and call me in the morning: the case for training wellness.

The purpose of this article is to show how a well-conducted needs assessment coupled with a well-conceived training plan can improve training and, indeed, total organizational wellness. This is important on two fronts--organizational and individual. Conceptually, providing training is not much different than providing any other product or service. We often have no idea of how to get the ¿right stuff to the right people at the right time under the right conditions.¿ Thus, this article will provide a framework for ¿getting it right¿ (the first time)! The message? Make your training time and dollars count, no training simply for the sake of training; we must apply it to the training wellness equation.

Decision Making, Organizational↗

PubMed2000

Classifying clinical decision making: a unifying approach.

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

Clinical Competence↗

PubMed2003

Leadership qualities framework provides a useful tool for nurses.

Good leadership can be difficult to define, but it is vital to inspiring staff to improve services. A framework has been developed to enable NHS leaders at all levels to assess their strengths and identify their development needs. It is applicable to leadership roles at any level, including nurses.

Humans↗

PubMedDate not supplied

Nurses' under-medication of analgesia in cardiac surgical patients: a personal exploration.

This paper examines aspects of care which may account for some of the reasons why critical care nurses fail to relieve patients' pain following cardiothoracic surgery. Factors that may influence the critical care nurses' decision regarding the amount of opiate analgesia to give a patient are examined using the 'Theory of Planned Behaviour' as a framework for enquiry. The skills required by the critical care nurse in planning how to play the phenomena of 'the doctor-nurse game' may be a key element in meeting the goal of pain relief for the patient following cardiac surgery.

Analgesics, Opioid↗

PubMedDate not supplied

The Shuler nurse practitioner practice model: a theoretical framework for nurse practitioner clinicians, educators, and researchers, Part 1.

Because nurse practitioners (NPs) have expanded their nursing knowledge and skills into medicine they need a model that reflects this expanded role. This article presents the Shuler Nurse Practitioner Practice Model, which is wellness-oriented and suggests how patient interaction, assessment, intervention, and evaluation should occur.

Clinical Competence↗

PubMed2003

The dual pathway model of AD/HD: an elaboration of neuro-developmental characteristics.

The currently dominant neuro-cognitive model of Attention Deficit Hyperactivity Disorder (AD/HD) presents the condition as executive dysfunction (EDF) underpinned by disturbances in the fronto-dorsal striatal circuit and associated dopaminergic branches (e.g. meso-cortical). In contrast, motivationally-based accounts focus on altered reward processes and implicate fronto-ventral striatal reward circuits and those meso-limbic branches that terminate in the ventral striatum especially the nucleus accumbens. One such account, delay aversion (DEL), presents AD/HD as a motivational style-characterised by attempts to escape or avoid delay-arising from fundamental disturbances in these reward centres. While traditionally regarded as competing, EDF and DEL models have recently been presented as complimentary accounts of two psycho-patho-physiological subtypes of AD/HD with different developmental pathways, underpinned by different cortico-striatal circuits and modulated by different branches of the dopamine system. In the current paper we describe the development of this model in more detail. We elaborate on the neuro-circuitry possibly underpinning these two pathways and explore their developmental significance within a neuro-ecological framework.

Attention Deficit Disorder with Hyperactivity↗

PubMed2003

Attachment-based family therapy for depressed adolescents: programmatic treatment development.

Few effective psychosocial treatment models for depressed adolescents have been developed, let alone ones that use the developmentally potent context of the family as the focus of intervention. Attachment-based family therapy (ABFT) is a brief, manualized treatment model tailored to the specific needs of depressed adolescents and their families. Attachment theory serves as the main theoretical framework to guide the process of repairing relational ruptures and rebuilding trustworthy relationships. Empirically supported risk factors for depression are the primary problem states that therapists target with specific treatment strategies or tasks. Parent problem states include criticism/hostility, personal distress, parenting skills, and disengagement. Adolescent problem states include motivation, negative self-concept, poor affect regulation, and disengagement. Intervention tasks include relational reframing, building alliances with the adolescent and with the parent, addressing attachment failures, and building competency. A small, randomized clinical trial provides initial support for the model. Several process research studies, using both qualitative and quantitative methods, have helped refine the clinical guidelines for each treatment task. ABFT is a promising new treatment for depressed adolescents and more research on it is warranted.

Adolescent↗

PubMed2001

Construction of a genetic linkage map of the model legume Lotus japonicus using an intraspecific F2 population.

Among leguminous plants, the model legume Lotus japonicus (Regel) Larsen has many biological and genetic advantages. We have developed a genetic linkage map of L. japonicus based on amplified fragment length polymorphism (AFLP), simple sequence repeat polymorphism (SSRP) and derived cleaved amplified polymorphic sequence (dCAPS). The F2 mapping population used was derived from a cross between two L. japonicus accessions Gifu B-129 and Miyakojima MG-20. These parental accessions showed remarkable cytological differences, particularly with respect to size and morphology of chromosomes 1 and 2. Using fluorescence in situ hybridization (FISH) with BAC clones from Gifu B-129 and TAC (Transformation-competent Artificial Chromosome) clones from Miyakojima MG-20, a reciprocal translocation was found to be responsible for the cytological differences between chromosomes 1 and 2. The borders of the translocations were identified by FISH and by alignment toward the L. filicaulis x L. japonicus Gifu B-129 linkage map. The markers from the main translocated region were located on linkage groups 1 and 2 of the two accessions, Gifu B-129 and Miyakojima MG-20, respectively. The framework of the linkage map was constructed based on codominant markers, and then dominant markers were integrated separately in each linkage group of the parents. The resulting linkage groups correspond to the six pairs of chromosomes of L. japonicus and consist of 287 markers with 487.3 cM length in Gifu B-129 and 277 markers with 481.6 cM length in Miyakojima MG-20. The map and marker information is available through the World Wide Web at http://www.kazusa.or.jp/lotus/.

Chromosome Mapping↗

PubMed1984

Clonotypic surface structure on human T lymphocytes: functional and biochemical analysis of the antigen receptor complex.

Recent studies using cloned antigen-specific T lymphocytes and monoclonal antibodies directed at their various surface glycoprotein components have led to identification of the human T cell antigen receptor as a surface complex comprised of a clonotypic 90KD Ti heterodimer and the monomorphic 20/25KD T3 molecules. Approximately 30,000-40,000 Ti and T3 molecules exist on the surface of human T lymphocytes. These glycoproteins are acquired and fully expressed during late thymic ontogeny, thus providing the structural basis for immunologic competence. The alpha and beta subunits of Ti bear no precursor-product relationship to one another and are encoded by separate genes. The presence of unique peptides following proteolysis of different Ti molecules isolated by noncrossreactive anticlonotypic monoclonal antibodies supports the notion that variable regions exist within both the alpha and beta subunits. Moreover, N-terminal amino acid sequencing of the Ti beta subunit shows that it bears homology to the first V-region framework of immunoglobulin light chains and represents the product of a gene that rearranges specifically in T lymphocytes. Soluble or Sepharose-bound anti-Ti monoclonal antibodies, like physiologic ligand (antigen/MHC), enhanced proliferative responses to purified IL-2 by inducing a 6-fold increase in surface IL-2 receptor expression. In contrast, only Sepharose-bound anti-Ti or physiologic ligand triggered endogenous clonal IL-2 production and resulted in subsequent proliferation. The latter was blocked by antibodies directed at either the IL-2 receptor or IL-2 itself. These results suggest that induction of IL-2 receptor expression but not IL-2 release occurs in the absence of T3-Ti receptor crosslinking. Perhaps more importantly, the findings demonstrate that antigen-induced proliferation is mediated through an autocrine pathway involving endogenous IL-2 production, release, and subsequent binding to IL-2 receptors.

Antibodies, Monoclonal↗

PubMed2000

The effect of race on the referral process for invasive cardiac procedures.

Coronary artery disease is the leading cause of death in the United States. Blacks are more likely than whites to experience premature disease, and they have poorer prognosis after acute myocardial infarction. Multiple studies have demonstrated that blacks are less likely to be referred for certain invasive cardiac procedures. Few studies have examined the effect of race on physician and patient decision making in referrals for cardiac procedures. The authors present a framework for the complex series of steps involved in obtaining invasive cardiac care. Patient race can affect each of these steps, and differences in physician and patient race may be a particular impediment to effective communication about symptoms and preferences and to the establishment of a therapeutic partnership. The potential role of communication in race-discordant physician-patient relationships suggests a need for more research in physician decision making and for efforts to promote cultural competency as a core component of medical education.

Adult↗

PubMedDate not supplied

[Learning of the process of nursing diagnosis by nursing students. An experiment at the San Miniato School].

In order to guarantee the quality of health care, it is necessary that the care focus on patients' needs. This requires that care givers possess diagnostic competency skills that allow them to quickly identify the patients' needs, using suitable methods and instruments. In Italy, the development of diagnostic competency skills is generally overlooked in nursing schools; this is due in part to the lack of applied and experimental educational models in teaching and training. During the 1992-1993 year, a didactic teaching intervention to assist students in the acquisition of diagnostic skills was tested. The sample included all students in the third year class of the San Miniato nursing school. The Zanotti's model "Nursing as a stimulus for health-harmony" was used as framework. The purpose of the research was to test: (a) validity and reliability of a new needs' analysis model; (b) the effectiveness of a didactic method for the acquisition of such a model by the students. Students enhanced their skills in data assessment and shifted from the medical perspective to the nursing perspective in using those data to evaluate the patient's status.

Education, Nursing↗

PubMed1996

The medical record: narration and story as a path through patient data.

Kay and Purves' proposed narratological model of the medical record is based on the familiar phenomenological insight that the perception of data is conditioned by the conceptual framework of the perceiver. Unfortunately, unless handled very carefully, this approach will make the significance of a medical record unique to the person who constructed it and impermeable to outside scrutiny. However, when integrated into the analog-model of the medical record, the narratological model can be accommodated as the clinician-relative construction of a patient profile within the data that make up the medical record. Some implications for the construction of expert systems and competence analysis are indicated.

Data Collection↗

PubMedDate not supplied

Observing the work of the Clinical Nurse Specialist: a pilot study.

UNLABELLED: The Clinical Nurse Specialist (CNS) is an advanced practice nurse (APN) with graduate preparation as a clinical expert within a specialty area of nursing practice. There is a need for information about the work of the CNS in order to link CNS activities to outcomes and costs of care. PURPOSE: To describe the work of the CNS in the acute care setting using the National Association of Clinical Nurse Specialists (NACNS) model as an organizing framework. DESIGN: Descriptive pilot study of the work of the CNS in acute care. SETTING: A 500-bed academic medical center located in the Midwestern United States. SAMPLE: Five masters-prepared APNs in a unit-based CNS role. METHODS: Direct observation and time study were used to record activities and time for 4 hours with each CNS (n = 5) for a total of 20 hours of observation. FINDINGS: CNS activity and time within each practice domain included patient/client (30%), nursing (44%), organization/system (10%), and other activities (16%). Specific activities observed were linked to possible outcomes in the NACNS framework. CONCLUSIONS: The NACNS model provided a useful framework for developing a data collection tool that can be used in a larger study that analyzes the work of the acute care CNS. IMPLICATIONS: Describing the work of the CNS is an important preliminary step to measuring outcomes and costs of care.

Academic Medical Centers↗

PubMed1996

Profession building in the new health care system.

To further the goals of greater legitimacy and power, it is necessary for nursing to abandon many of the profession building strategies it has pursued in the past. We describe the traditional framework for profession building in nursing and some reasons it is no longer effective. In contrast, a contemporary framework for profession building in nursing is presented. Because nursing, like other complex adaptive systems, is strongly anchored by its past trajectory, it will require considerable energy and resources to make the transition.

Health Care Reform↗

PubMed1997

The advanced practice nurse's role in differentiated practice: Martha's story.

The changing health care environment and increasing patient acuity necessitate a coordinated effort among all health care disciplines to assure the best patient outcomes. The advanced practice nurse in the role of case manager is well qualified to serve as the leader of this team. Within the framework of differentiated practice, advanced practice nurses work in tandem with associate and primary nurses to ensure positive quality, financial, and satisfaction outcomes. Clinical expertise and knowledge of systems allow the advanced practice nurse to assist the patient through complex systems to achieve these ends.

Case Management↗

PubMed1992

[The human chorionic gonadotropin (hCG) receptor: a new class within the family of GTP protein coupled receptors. Epitope mapping of receptor-bound agonistic and antagonistic forms of hCG].

Human chorionic gonadotropin (hCG) is a member of the glycoprotein hormone family. It is composed of an alpha and a beta subunit, the latter being closely homologous to that of human luteinizing hormone (hLH). HCG and hLH bind to the same receptor. The molecular mass of hCG is 38 kD, up to 30% of which is contributed by the carbohydrate moieties linked to each of the two subunits. Structure-function relationship studies have indicated that both subunits interact with the receptor and that altogether four different peptide domains (two on each subunit) are responsible for high-affinity receptor binding. The carbohydrate units are responsible for expression of agonist activity: deglycosylated hCG (degly-hCG) is unable to induce a biological response (cAMP increase), despite high-affinity binding. We have previously mapped the antigenic surface of hCG and described 14 different epitopes that can be recognized by specific monoclonal antibodies (MCA), i.e. five epitopes on the alpha subunit, five on the beta subunit and four epitopes which are formed through association of the two subunits (conformational or alpha beta epitopes). The number and topography of epitopes was found to be the same on degly-hCG. This framework of immunological coordinates was then applied to probe the orientation of hCG, as well as that of the competitive antagonist degly-hCG in their receptor-bound states. With a receptor-hormone-125I-MCA sandwich approach we found that while hCG still presented two of the 14 epitopes, i.e. beta 3 and beta 5, no epitope was accessible on receptor-bound degly-hCG. This differential pattern thus correlates with the signal transduction-competence of the respective ligand. Overall, these data indicate that most of the surface of hCG is masked by moieties of the receptor. Accordingly, that moiety must itself be folded in a way that it provides a large contact surface. No portion other than the 341-residue long extracellular domain would seem capable of doing that. Computer-assisted secondary structure predictions support this view. This domain is the novel feature that distinguishes glycoprotein-hormone receptors from the other members of the G protein-coupled receptor superfamily.

Amino Acid Sequence↗