Exploring Differential Perceptions and Barriers to Advance Care Planning in Dementia among Asian Patient-Caregiver Dyads-A Mixed-Methods Study.

A parallel mixed-methods study on 20 patient-caregiver dyads in an Asian population was conducted to explore the differential perceptions and barriers to ACP in dementia. We recruited English-speaking patients with mild dementia and their caregivers. A trained ACP facilitator conducted ACP counseling. Patient-caregiver dyads completed pre-post surveys and participated in post-counseling qualitative interviews. We used mixed-methods analysis to corroborate the quantitative and qualitative data. Differential perceptions of ACP were reported among dyads, with caregivers less inclined for further ACP discussions. Post-ACP counseling, caregivers were significantly more likely to acknowledge barriers to ACP discussions than patients (57.9% versus 10.5%, p = 0.005). Thematic analysis of the interview transcripts revealed four themes around barriers to ACP: patient-related factors (transference of decision making, poor cognition and lack of understanding, and dis-inclination to plan for the future), caregiver-related factors (perceived negative impact on the patient, caregiver discomfort, and confidence in congruent decision making), socio-cultural factors (taboos, superstitions, and religious beliefs), and the inappropriate timing of discussions. In a collectivist Asian culture, socio-cultural factors pose important barriers, and a family-centric approach to initiation of ACP may be the first step towards engagement in the ACP process. For ACP in dementia to be effective for patients and caregivers, these discussions should be culturally tailored and address patient, caregiver, socio-cultural, and timing barriers.

Effectiveness of the "living successfully with low vision" self-management program: Results from a randomized controlled trial in Singaporeans with low vision.

OBJECTIVE: To determine the effectiveness of the "Living Successfully with Low Vision" (LSLV) self-management program to improve patient-reported outcomes in Singaporeans. METHODS: In this randomized controlled trial, 165 participants with low vision (LV) were recruited and assigned to usual care (LV aid training only; N = 82) or LSLV program (N = 83). The LSLV program focuses on problem solving, coping mechanism and anticipation/preparation for future needs. The primary outcome was vision-related quality of life (VRQoL; measured using the Impact of Vision Impairment [IVI] questionnaire), while secondary outcomes included health-related quality of life; mental health; and self-efficacy, assessed at baseline, 2-weeks and 6-months post-intervention. Within- and between-group comparisons were conducted using paired t-tests and repeated measures analysis of covariance, respectively. RESULTS: A total of 128 individuals (77.6%) completed all assessments. At 2 weeks, LSLV participants alone experienced a significant within-group improvement in the mean IVI Emotional score (P = 0.05) but not at 6 months. No other within- or between-group effects were observed. CONCLUSION: While SM programs have shown promising results in the management of many chronic diseases, our findings suggest that the LVSM program was not an effective approach for LV rehabilitation in Singapore. PRACTICE IMPLICATION: Other evidence-based strategies to improve QoL in patients with LV may be warranted.

A qualitative study of patient experiences of Type 2 Diabetes care delivered comparatively by General Practice Nurses and Medical Practitioners.

AIMS AND OBJECTIVES: To explore patient experiences of type 2 diabetes mellitus care delivered by general practice nurses in collaboration with the general practitioner. BACKGROUND: Australian general practice nurses are expanding their role in multidisciplinary type 2 diabetes care with limited research on patient perceptions of care provision within this collaborative model. DESIGN: Qualitative interpretive. METHODS: Purposeful sampling was used to invite the patients (n = 10). Data were collected from semi-structured face-to-face interviews. Braun and Clarke's () inductive coding thematic analysis process was used to interpret the data. RESULTS: All participants experienced their General Practice Nurse consultation as a clinical assessment for their General Practitioner. While they appreciated the extra time with the General Practice Nurse, they were unsure of the purpose of the consultation beyond clinical assessment. They described the ongoing challenge of living with T2DM and identified a need for additional information and advice. CONCLUSION: The results suggest that the model of general practice nurse type 2 diabetes care has an important role to play in the delivery of effective ongoing care of patients. However, this role requires further development to ensure that it is understood by the patients as a role that not only conducts clinical assessments but also provides relevant education and self-management support as part of a collaborative approach to care delivery with General Practitioners. RELEVANCE TO PRACTICE: The findings are relevant to primary health care clinicians providing diabetes care to inform more relevant supportive care by general practice nurses.

Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia: phase 2 results.

AIM: This is the first two-phase Australian study to explore the factors impacting upon compassion satisfaction, compassion fatigue, anxiety, depression and stress and to describe the strategies nurses use to build compassion satisfaction into their working lives. BACKGROUND: Compassion fatigue has been found to impact on job satisfaction, the quality of patient care and retention within nursing. This study provides new knowledge on the influences of anxiety, stress and depression and how they relate to compassion satisfaction and compassion fatigue. METHOD: In Phase 2 of the study, 10 nurses from Phase 1 of the study participated in individual interviews and a focus group. A semi-structured interview schedule guided the conversations with the participants. RESULT: Data analysis resulted in seven main themes: social networks and support;infrastructure and support; environment and lifestyle; learning; leadership; stress; and suggestions to build psychological wellness in nurses. CONCLUSION: Findings suggest that a nurse's capacity to cope is enhanced through strong social and collegial support, infrastructure that supports the provision of quality nursing care and positive affirmation. These concepts are strongly linked to personal resilience. IMPLICATIONS: for nursing management These findings support the need for management to develop appropriate interventions to build resilience in nurses.

A systematic review of the experience of older women living and coping with type 2 diabetes.

This paper reports on a systematic review that sought to answer the research question: what is the experience of women living and coping with type 2 diabetes? A range of relevant terms were identified and electronic databases were searched. Only qualitative studies that explored the meaning of living and coping with type 2 diabetes and that included adult women aged ≥ 18 years were considered. We found evidence that women are challenged by their multi-caregiving roles and the complexities of managing their diabetes simultaneously. For female patients with diabetes, holistic care and individual psycho-education programmes appear to be facilitate more effective and successful diabetes management. In addition, carer programmes that provide information so that family and friends can support and assist the woman with diabetes are required.

The role of intrinsic motivation in a group of low vision patients participating in a self-management programme to enhance self-efficacy and quality of life.

Self-management programmes have previously been found to decrease health problems, enhance quality of life and increase independence. However, there is no literature that examines the influence of the participants' intrinsic motivation on the outcomes of such programmes. This study examined the role of intrinsic motivation in a pilot low vision self-management programme to enhance self-efficacy and quality of life of the programme participants. A positive association was observed between the female participants' perceived choice and perceived competence, two underlying dimensions of the Intrinsic Motivation Inventory. In addition, a positive correlation was observed between the younger participants' perceived competence and the change in their quality of life. The findings provide some support for consideration of participants' intrinsic motivation in the development of effective self-management programmes.

Compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in Australia: study 1 results.

AIM: To explore compassion fatigue and compassion satisfaction with the potential contributing factors of anxiety, depression and stress. BACKGROUND: To date, no studies have connected the quality of work-life with other contributing and co-existing factors such as depression, anxiety and stress. METHOD: A self-report exploratory cross sectional survey of 132 nurses working in a tertiary hospital. RESULT: The reflective assessment risk profile model provides an excellent framework for examining the relationships between the professional quality of work factors and contributing factors within the established risk profiles. The results show a definite pattern of risk progression for the six factors examined for each risk profile. Additionally, burnout and secondary traumatic stress were significantly related to higher anxiety and depression levels. Higher anxiety levels were correlated with nurses who were younger, worked full-time and without a postgraduate qualification. Twenty percent had elevated levels of compassion fatigue: 7.6% having a very distressed profile. At-risk nurses' stress and depression scores were significantly higher than nurses with higher compassion satisfaction scores. IMPLICATIONS FOR NURSING MANAGERS: The employed nurse workforce would benefit from a psychosocial capacity building intervention that reduces a nurse's risk profile, thus enhancing retention.

'Diabetes is nothing': the experience of older Singaporean women living and coping with type 2 diabetes.

PURPOSE: The purpose of this study was to describe, through qualitative methods, the experiences and ways of coping of older Singaporean Chinese women with type 2 diabetes. METHODS: Using a qualitative approach, 10 Singaporean Chinese women between the ages of 60-69 described their experiences of living and coping with type 2 diabetes. Data were collected via semi-structured interviews and analysed using thematic analysis. RESULTS: Three themes were identified in the analysis: (i) Living with diabetes; (ii) Coping with diabetes; and (iii) Caring for the self in diabetes. CONCLUSIONS: Findings indicate that women living and coping with diabetes confront numerous issues. In order to help these patients initiate and sustain lifestyle modifications, healthcare providers are encouraged to be empathetic and supportive and an understanding of the coping strategies used will ensure that effective coping strategies are utilised. Furthermore, diabetes education for family members will assist them to provide essential, ongoing support for the patient.

A new community-based outdoor intervention to increase physical activity in Singapore children: findings from focus groups.

INTRODUCTION: Myopia is a significant public health problem in Singapore with estimates that more than 50% of the population is affected by it by the time of adulthood. Childhood obesity is also increasing and has been linked to long-term health problems. Recent studies have found that Singaporean children in Primary 1 spend less than 3 hours a day outdoors which is less than children in other countries. Physical activity has been shown to be protective against obesity and recently, there has been some evidence to suggest that time spent outdoors may reduce the prevalence and severity of myopia. This study aims to explore the barriers and enablers to children in Singapore participating in outdoor activities. MATERIALS AND METHODS: Qualitative data, gathered from focus group discussions was thematically analysed against the PRECEDE component of the PRECEDE-PROCEED model which provided a conceptual framework for examining factors relevant to children participating in an outdoor activity intervention. A total of 31 people participated in 4 focus groups held over a 6-month period. RESULTS: This feasibility study was exploratory in nature but provided valuable information concerning barriers and enablers to participation. Data informed the development of a larger study. CONCLUSION: Results indicated that families preferred structured activities such as orienteering and a choice of weekend attendance days and times.

Singapore nursing students' perceptions and attitudes about spirituality and spiritual care in practice: a qualitative study.

PURPOSE: This exploratory study investigated nursing students' perceptions and attitudes about spirituality and spiritual care in practice. STUDY DESIGN: A qualitative interpretative approach was used to investigate the research question. METHOD: In-depth interviews were conducted with 16 final-year preregistration nursing students from 3 different educational institutions offering a degree or diploma program in Singapore. Data were analyzed using the Miles and Huberman's method of thematic analysis. FINDINGS: Thematic analysis identified three themes: (a) students' perceptions of spirituality, (b) spiritual care, and (c) factors influencing spiritual care in practice. CONCLUSIONS: The study informed that though young, spirituality matters to the nursing students. Accordingly, nursing is perceived to play an integral role in spiritual care. Enabling factors need to be systematically addressed both in the education and practice arenas before the perennial issue of disconnect between development and implementation of spirituality in practice can be bridged.

Nurses' perceptions of risk from emerging respiratory infectious diseases: a Singapore study.

The recent emergence of virulent respiratory infectious diseases such as Severe Acute Respiratory Syndrome (SARS) and Influenza A/H1N1 viruses predisposes nurses to occupational risks. This qualitative study investigated how Chinese Singaporean nurses perceived the risks of exposure to these infectious diseases and the factors that influenced this risk perception. Data were collected through face-to-face interviews and were analyzed using Braun and Clarke's process of thematic analysis. Three themes emerged: living with risk; the experience of SARS; and acceptance of risk. The nature of nursing work was perceived to place participants at risk of infection. Another significant finding of this study is that the government's, organizations' and nurses' perceptions of new emerging respiratory infectious diseases were influenced by their previous experience with SARS. Similar to previous studies, nurses working at the 'front line' believed that infection from these diseases was an unavoidable occupational hazard.

The experiences of and meaning for women living and coping with type 2 diabetes: a systematic review of qualitative evidence.

BACKGROUND: Effective management of diabetes not only relies on lifestyle modification and adherence to a treatment regime, but also the ability to cope with the impact of the disease on daily activities. Stress associated with the multi-caregiver role of women may affect the ability to manage the disease effectively. OBJECTIVES: To explore the experience of women living and coping with type 2 diabetes. INCLUSION CRITERIA: Adult women aged 18 years and above diagnosed with type 2 diabetes.The meaning of living and coping with type 2 diabetes.Qualitative studies, including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. SEARCH STRATEGY: The search strategy used sought only to identify published English research papers from the year 1990 to 2010. A three-step search strategy was undertaken. METHODOLOGICAL QUALITY: The retrieved papers were assessed for methodological quality by two independent reviewers using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. DATA COLLECTION: Data was extracted using the Joanna Briggs Institute Qualitative Assessment and Review data extraction tool. DATA SYNTHESIS: The data were synthesised using the Joanna Briggs Institute approach of meta-synthesis by meta-aggregation. RESULTS: Nine studies were included in the review. Forty-one findings were obtained and then grouped into 11 categories which were then aggregated into four synthesised findings: "Living with type 2 diabetes is emotionally and mentally challenging", "Support (of self, by others, spiritual) provides the ability to cope with diabetes", "Women see their personal responsibility in the management of diabetes and try to maintain their autonomy. Despite this, women place the needs of the family over their own needs thereby resulting in ineffective management" and "Effective management of diabetes is hindered by role duties of women as well as their attitudes and the attitudes of the healthcare providers". CONCLUSIONS: Women are challenged by their multi-caregiving roles and the complexities of managing their diabetes simultaneously. Holistic, individual psycho-education programs for female patients with diabetes and carer programs educating families and friends will facilitate more effective and successful management. IMPLICATIONS FOR PRACTICE: As supported by the evidence obtained in this review, diabetic education programs should include strategies that facilitate emotional coping. Family members should be encouraged to attend diabetes management programs or workshops designed for caregivers or family members to enable them to support female family members with diabetes effectively. Education programs for doctors should focus on the therapeutic helping relationship and the role this relationship plays in facilitating improved health outcomes for patients. IMPLICATION FOR RESEARCH: Implementation of action research with interventions that address the key issues identified in this systematic review would be useful. Additionally, further longitudinal studies that link the incidence and severity of complications and quality of life issues associated with diabetes management to such intervention programs will clarify the benefits, modifying factors and barriers. Despite a plethora of literature examining the coping styles and experiences of Caucasian people with diabetes there is a paucity of literature investigating similar issues among Asian populations. Thus further research studies that examine the experience of living and coping with type 2 diabetes in Asian populations are needed to enhance understanding for these patients.

Comprehensive systematic review of healthcare workers' perceptions of risk and use of coping strategies towards emerging respiratory infectious diseases.

AIM: To determine healthcare workers' perceptions of risk from exposure to emerging acute respiratory infectious diseases and the perceived effectiveness of strategies used to facilitate healthy coping in acute hospital and community healthcare settings. METHODS: Electronic databases (Cumulative Index to Nursing and Allied Health Literature, Ovid, PubMed, ScienceDirect, Scopus and Wiley InterScience) were searched using a three-step search strategy to identify the relevant quantitative and qualitative studies published in English from 1997 to 2009. The grey literature was not included in the review. The identified studies were evaluated using the Meta-Analysis of Statistics, Assessment and Review Instrument and the Qualitative Assessment and Review Instrument from the Joanna Briggs Institute. Fourteen quantitative studies were included and the findings included in a narrative summary. The findings from the two qualitative studies were categorised into a meta-synthesis that generated two synthesised findings. RESULTS: Findings indicated that healthcare workers perceived personal and familial health risks and stigmatisation from their exposure to emerging acute respiratory infectious diseases, but the majority were accepting of these risks. Organisational implementation of infection control measures, avoidance of patients and complying with personal protective equipment were identified as risk-mitigating strategies. Demographic, individual and organisational factors were found to influence their risk perceptions and their adoption of strategies to mitigate the risk. CONCLUSIONS: It appears that healthcare workers' risk perceptions can influence their behaviour towards patients with emerging acute respiratory infectious diseases as well as their use of risk-mitigating strategies. Institutions need to ensure that appropriate infection control safeguards are in place to protect workers and their families. Institutions can also offer incentives to encourage healthcare workers to comply with the policies and procedures introduced to mitigate risk. IMPLICATIONS FOR PRACTICE: Institutions and government need to ensure that policies and procedures are communicated and adequate institutional measures (i.e. personal protective equipment; education and training; and personal support) are implemented to safeguard healthcare workers during and after pandemic outbreaks. IMPLICATIONS FOR RESEARCH: Future research needs to examine how perception of risk related to acute emerging respiratory infectious diseases, epidemic or pandemic, and the factors that would influence healthcare workers': decisions to stay within the workforce and provide care or resign from the workforce and compliance with institutional and government policies and procedures, as well as compliance to use of personal protective equipment.

A comprehensive systematic review of healthcare workers' perceptions of risk from exposure to emerging acute respiratory infectious diseases and the perceived effectiveness of strategies used to facilitate healthy coping in acute hospital and community healthcare settings.

BACKGROUND: Emerging acute respiratory infectious diseases, such as Severe Acute Respiratory Syndrome (SARS) and the Avian Influenza A/H5N1 virus are contagious with high morbidity and mortality rates. Hence, health care workers, who are in close contact with affected patients, face many risks. There need to be a greater understanding of: individual HCWs' risk perceptions; adopted risk-mitigating strategies; and factors influencing both. OBJECTIVES: This review aimed to establish the best evidence regarding health care worker's risk perceptions and workplace strategies towards emerging acute respiratory infectious diseases in acute hospital and community healthcare settings; and to make recommendations for practice and future research. INCLUSION CRITERIA: Participants Studies that included male and female health care workers practising in acute and community health care settings were considered.Types of intervention (s)/Phenomena of interest This review considered studies that investigated: health care workers' risk perceptions; perceived meaning/effectiveness of the individual and workplace strategies implemented; and the factors influencing both.Types of outcomes This review focused on factors affecting: health care worker' risk perceptions; use of risk-mitigating strategies; and their perceived meaning and effectiveness.Types of studies Both qualitative and quantitative study designs published in the English language were including in the study. SEARCH STRATEGY: Using a three-step search strategy, the following databases from 1997-2009 were accessed: CINAHL, PubMed, SCOPUS, ScienceDirect, Sociological Abstracts, PsycINFO, and Web of Science. METHODOLOGICAL QUALITY: Two independent reviewers assessed each paper for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute. Disagreements were resolved through discussion, or with a third reviewer. DATA EXTRACTION: Information was extracted by two independent reviewers from each paper using the standardised data extraction tools from JBI. DATA SYNTHESIS: The findings are presented in narrative form, as textual pooling and statistical pooling was not possible for the qualitative and quantitative papers respectively. RESULTS: Ten quantitative studies and one qualitative study were included in the review. Findings indicated that although health care workers perceived personal and familial health risks and stigmatization from their exposure to emerging acute respiratory infectious diseases, the majority were accepting of these risks. Organizational implementation of infection control measures; avoidance of patients; and complying with personal protective equipment were identified as risk-mitigating strategies. Demographic, individual and organizational factors were found to influence their risk perceptions and their adoption of these strategies. CONCLUSIONS: There is a nebulous relationship between health care workers' risk perceptions and how these perceptions affect their use of risk-mitigating strategies. Hence, future research needs to examine the nuances of this relationship, as well as the influencing factors involved. In this review, several key factors influencing health care workers' risk perceptions and risk-mitigating strategies were identified and these may form the implications for new practice. IMPLICATIONS FOR PRACTICE: Institutions need to: empower health care workers through education and training; protect them with organizational safeguards; and offer incentives to encourage willingness to work, especially for those with high risk perceptions. IMPLICATIONS FOR RESEARCH: Future research need to examine the: differences between HCWs' intentions to care during SARS and influenza outbreaks; relationship between intentions to care and actual care provided; difference between their intentions to care/resign and acceptance of risks; factors influencing their intentions to care; and factors influencing compliance to infection control measures.

The experience and expectations of terminally ill patients receiving music therapy in the palliative setting: a systematic review.

BACKGROUND: Music therapy is a popular form of complementary therapy used in the hospice in Western countries, as people who are terminally ill have several needs arising directly from the disease process. In the area of palliative care, no systematic review has been conducted on the experience of patients using music therapy from the qualitative perspective. Hence, a synthesized summary of the experience of music therapy is presented. OBJECTIVES: The aim of this review was to critically analyse and synthesize existing evidence related to terminally ill patients' experiences of using music therapy in the palliative setting. INCLUSION CRITERIA: This review considered quantitative descriptive studies, and qualitative research with adult participants who were terminally ill receiving palliative care in a hospital, an in-patient hospice, a nursing home, or their own homes, regardless of their diagnosis who had undergone at least one music therapy session with a trained music therapist and were not cognitively impaired. Healthcare workers who have witnessed patients participating in music therapy were also included in the review. SEARCH STRATEGY: Only published primary research studies were included in the review. This review was limited to papers in English. A three-step search strategy was undertaken. First, an initial limited search of CINAHL and MEDLINE was done. Second, an extensive search using all identified keywords and index terms across all included databases was done. Finally, a hand search of the reference lists and bibliographies of included articles was conducted METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (QARI) for qualitative papers, and Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) for quantitative descriptive papers. Any disagreement that arose between the reviewers was resolved through discussion with a third reviewer. DATA COLLECTION: Information was extracted by two reviewers from each paper using the Joanna Briggs Institute Qualitative Assessment and Review data extraction tool (QARI) for qualitative papers, and the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) for quantitative descriptive papers. Any disagreement that arose between the reviewers was resolved through discussion with a third reviewer. DATA SYNTHESIS: Qualitative findings were pooled using the JBI-QARI while quantitative data were presented in narrative format. RESULTS: A total of 10 studies were identified, and of these, 3 were included in the review. Only qualitative papers were included in the studies as the quantitative descriptive papers did not meet the inclusion criteria. Two synthesized findings were developed - "Music therapy should be used in palliative settings to promote social interaction and communication with family, friends, other patients, and healthcare workers", and "Music therapy should be promoted in palliative care setting to provide support for holistic needs of patients". CONCLUSION: From the meta-syntheses of review, it was shown that patients experienced improved social interaction and communication with the people around them, and a more holistic care for as their physical, psychological and spiritual needs were met. No papers relating to the patients' expectations of music therapy was found. IMPLICATIONS FOR RESEARCH: Further research should be conducted to explore the expectations of terminally ill patients with music therapy as no such paper was found from the systematic review. Quantitative studies to find out the effectiveness of music therapy in promoting social interaction and communication and in providing holistic care for patients can be done to quantify the findings. It can also be investigated if the quality of life of terminally ill patients improve after receiving music therapy, since music therapy has been found to have positive benefits for the patients. Also, qualitative studies that aim to find out the experiences of terminally ill patients through the interviewing of the patients should also be done, as the papers found either reported on the perception of healthcare providers, or through the analysis of patients' song lyrics. IMPLICATIONS FOR PRACTICE: The use of music therapy should be encouraged in the palliative setting as the review has shown that music therapy is able to promote social interaction and communication with family members, healthcare workers and the people in their lives, and provides holistic care for patients by relieving physical symptoms, facilitating "moving on" to the next phrase of their life, improving their personal well-being, and providing an outlet for spirituality.

Exploring patient experiences of cancer services in regional Australia.

Numerous previous studies have suggested that cancer care in rural and regional Australia is fragmented and that rural and regional patients have less access to services. However, knowledge concerning inequality of health and cancer care in regional and rural settings is still inconclusive. The social and economic disadvantages in regional locations are often linked to insufficient resources and infrastructures to support cancer care and treatment. The aim of this study was to explore cancer patients' experiences from the perspective of patients and healthcare providers in a regional area of Western Australia. It was found that patients who had the involvement of a cancer nurse coordinator and cancer support workers had better experiences and more streamlined care than did those who had to navigate the journey alone. This study endorses the function of cancer nurse coordinators and cancer support workers in providing better coordination of care in rural and regional cancer patients.

Letting go and moving on: a grounded theory analysis of disengaging from university and becoming a registered nurse.

This study describes the third phase of a constructivist grounded theory titled becoming a registered nurse. The study identifies that mature-aged students experience three phases in their university journey. These phases or subcategories are called taking the first step, keeping going and, finally letting go and moving forward. In this article mature students' experiences of letting go and moving forward are explicated. Data gathered through semi-structured interviews and focus groups with mature students from two rural university campuses in Australia are used to illustrate this construct. Grounded theory methods of concurrent data generation and analysis, coding, developing categories and memoing were used. It was found that mature students experienced anxiety as they transitioned out of university and into employment. Despite reports of a nursing crisis in rural Australia some students were unable to find employment in their local rural areas. These students allege that it is not the nursing shortage but rather a shortage of money to pay more nurses that is the real issue. Furthermore mature students did not have a sense of termination of their university studies as there was no formal recognition that they had completed at the time, rather the formal recognition, university graduation, occurred some months after completion.