Home and expatriate nurses' perceptions of job satisfaction: Qualitative findings.

AIM: This paper is part of a larger doctoral study that investigated the impact of nationality on the job satisfaction of nurses and their intentions to leave Saudi Arabian government hospitals. The paper aims to gain an understanding of the impact of expatriate status on nurses' perceptions, by comparing the factors that influence job satisfaction among Saudi nurses to those that affect nurses recruited from other countries. BACKGROUND: Job satisfaction is a known predictor of nurse retention. Although there is a broad understanding of the factors that affect job satisfaction, little is known about how these vary between home and expatriate nurses working in countries which rely on a multicultural migrant workforce. METHODS: A descriptive qualitative approach was taken, in which 26 semi-structured interviews were conducted with nurses selected from different nationalities, all of whom were working in Saudi Arabian hospitals. Eight participants were Saudi Arabian, six Filipino, four Indian, four South African, two Jordanian and two Malaysian. FINDINGS: Five themes were identified that differentiated the perceptions of expatriates regarding their job satisfaction from those of the home nurses: separation from family, language and communication, fairness of remuneration, moving into the future and professionalism. CONCLUSION: Focusing on the enhancement of job satisfaction experienced by expatriate nurses can result in a healthier work environment and greater retention of these nurses. IMPLICATIONS FOR NURSING AND NURSING POLICY: To enhance nurse retention, policy makers in countries with migrant nurses should address their socio-economic needs. This includes providing both greater access to their dependent family members, and language lessons and cultural orientation to reduce linguistic and cultural challenges.

The development and testing of a co-designed distance learning programme to improve the knowledge of trained auxiliary nurse midwives in normal midwifery practice in central India.

BACKGROUND: In the Indian State of Madhya Pradesh maternal health is poor, and women's social status is low. For some women, autonomy and decision-making within the family is limited as they seek medical treatment through their husband or father-in-law. The then state government identified a need to strengthen midwifery care given by auxiliary nurse midwives to improve maternal and neonatal health.>. METHODS: This cross-cultural, two phase study was designed in partnership with an Indian non-governmental organisation, utilising Elliot's action research model within the paradigm of critical theory. Phase 1 investigated the then current situation and established a potential solution to strengthening midwifery practice within Madhya Pradesh. This comprised an educational approach using a specifically designed self-directed distance learning programme focussing on normal pregnancy and childbirth. The distance learning programme was a hard copy workbook supported by a multimedia resource informed by the Rowntree and Analysis Design Development Implementation Evaluation models of educational material development. Phase 2 involved the use and evaluation of the distance learning programme with an initial primary group sample of 28 comprising auxiliary nurse midwives (22), lady health visitors (4) and staff nurses (2) in Madhya Pradesh. Fourteen auxiliary nurse midwife participants completed knowledge tests using a pre- and post-programme multiple choice question paper. This primary group negotiated a 3-day workshop to cover identified gaps within their original 12-week study period. Nineteen additional auxiliary nurse midwife participants joined this workshop (group 2). RESULTS: The multiple choice question test results indicated that the first group had poor knowledge of the normal process of pregnancy and childbirth. After the workshop, they marginally improved their personal performance scores. The second group demonstrated greater change, which suggests that coupling self-directed guided study material with an enabling, face-to-face environment can be successful. CONCLUSIONS: Distance learning among auxiliary nurse midwives in central India may be enhanced when accompanied by face-to-face workshops. Partnership working - at organisational, team and individual levels, was a crucial, and empowering, component of this cross-cultural action research study. Both points have relevance for others undertaking similar studies.

A Qualitative Study to Explore Patients', Carers' and Health Professionals' Views to Culturally Adapt CBT for Psychosis (CBTp) in Pakistan.

BACKGROUND: Cognitive Behaviour Therapy (CBT) has an established evidence base and is recommended by the national organizations in United Kingdom and the United States. CBT remains under utilized in low and middle income countries. CBT was developed in the west and it has been suggested that it is underpinned by western values. It therefore follows that to make CBT accessible for non western clients, it needs adapting into a given culture. AIMS: Our aim was to develop guidelines for adapting CBT for psychosis in Pakistan by incorporating the views of the patients, their carers and mental health professionals. METHOD: We conducted a series of qualitative studies in Pakistan to adapt CBT for psychosis (a total of 92 interviews). The data were analyzed by systematic content and question analysis. Analysis started by identifying emerging themes and categories. Themes emerging from the analyses of interviews by each interviewer were compared and contrasted with others interviewers constantly. Triangulation of themes and concepts was undertaken to further compare and contrast the data from the different participating groups. RESULTS: The results of these studies highlighted the barriers in therapy as well as strengths while working with this patient group. Patients and their carers in Pakistan use a bio-psycho-spiritual-social model of illness. They seek help from various sources. Therapists make minor adjustments in therapy. CONCLUSIONS: The findings from this study will help therapists working with this client group using CBT for psychosis in Pakistan. These results need to be tested through controlled trials.

Talking about persons--thinking about patients: An ethnographic study in critical care.

BACKGROUND: Nursing involves caring for the 'whole person' and it is considered inappropriate for nurses to think or talk about patients in objectifying or dehumanising ways. Objectifying discourses can dominate within the arena of critical care, and critical care nurses can experience moral distress as they struggle to think about patients as persons. No previous study has examined the role played by 'impersonal' talk in the delivery of nursing care. This paper reports a study which examined the relationship between nursing practice and the way(s) in which critical care nurses think and talk about patients. OBJECTIVES: The study objectives were to (1) identify and characterise the ways in which critical care nurses think and talk about patients; and (2) describe patterns of nursing practice associated with these different ways of thinking. STUDY DESIGN: An ethnographic study was undertaken within one critical care unit in the United Kingdom. Data were collected over 8 months through 92h of participant observation and 13 interviews. Seven critical care nurses participated in the study. Data analysis adopted the perspective of linguistic ethnography. FINDINGS: Analysis of these data led to the identification of seven Discourses, each of which was characterised by a particular way of talking about patients, a particular way of thinking about patients, and a particular pattern of practice. Four of these seven Discourses were of particular significance because participants characterised it as 'impersonal' to think and talk about patients as 'routine work', as a 'body', as '(un)stable' or as a 'medical case'. Although participants frequently offered apologies or excuses for doing so, these 'impersonal' ways of thinking and talking were associated with practice that was essential to delivering safe effective care. CONCLUSIONS: Critical care practice requires nurses to think and talk about patients in many different ways, yet nurses are socialised to an ideal that they should always think and talk about patients as whole persons. This means that nurses can struggle to articulate and reflect upon aspects of their practice which require them to think and talk about patients in impersonal ways. This may be an important source of distress to critical care nurses and emotional exhaustion and burnout can arise from such dissonance between ideals and the reality of practice. Nursing leaders, scholars and policy makers need to recognise and legitimise the fact that nurses must think about patients in many ways, some of which may be considered impersonal.

Using cognitive behaviour therapy with South Asian Muslims: Findings from the culturally sensitive CBT project.

It has been suggested that cognitive behaviour therapy (CBT) needs adaptation for it to be effective for patients from collectivistic cultures, as currently CBT is underpinned by individualistic values. In prior studies we have demonstrated that CBT could be adapted for Pakistani patients in Southampton, UK, and for local populations in Pakistan. Findings from these studies suggest that CBT can be adapted for patients from collectivistic cultures using a series of steps. In this paper we focus on these steps, and the process of adapting CBT for specific groups. The adaptation process should focus on three major areas of therapy, rather than simple translation of therapy manuals. These include (1) awareness of relevant cultural issues and preparation for therapy, (2) assessment and engagement, and (3) adjustments in therapy. We also discuss the best practice guidelines that evolved from this work to help therapists working with this population. We reiterate that CBT can be adapted effectively for patients from traditional cultures. This is, however, an emerging area in psychotherapy, and further work is required to refine the methodology and to test adapted CBT.

Tuning Nursing Educational in an Italian academic context.

BACKGROUND: The European Union Bologna Process has laid the foundation for a common European competence-based educational framework. In many countries, nursing education is in transition from vocational to higher education, with many diverse systems. The competence-based approach provided by the project Tuning Educational Structures offers a common and coherent framework able to facilitate the implementation of the principles underpinning the Bologna Process reform. OBJECTIVES: This study aimed to ascertain the relevance that Italian nursing university lecturers attributed to the 40 competences of the Italian version of the nursing Bachelor's and Master's Degrees. These competences were developed through adoption of the Tuning Methodology in the nursing context. SETTING: The study was conducted in the 4 universities of one region of Italy which offer nursing Bachelor's and Master's Degrees. PARTICIPANTS: A total of 164 Italian university nursing lecturers. METHODS: Using a four point scale, a cross sectional survey was conducted from March 2011 to April 2012. Participants evaluated each competence according to its relevance for Bachelor's or Master's Education. Frequency analysis was conducted. RESULTS: The significance for each competence of Tuning was rated very high by Italian lecturers and appeared to overlap partially with the original European study. In Italy, the most relevant competences for Bachelor's Degree were the skills associated with the use of appropriate interventions, activities and skills in nursing and the skills associated with nursing practice and clinical decision-making. For Master's Degree, leadership, management and team competences were the most important. CONCLUSIONS: The Tuning Nursing Project was accepted by the Italian lecturers. The competence-based approach was considered by Italian lectures as a support enabling to reflect on the current Italian nursing education cycles of study and to ensure shared visions and common approaches between Italian and European lecturers.

Views of depressed patients in Pakistan concerning their illness, its causes, and treatments.

Although the core symptoms of depression appear uniform across cultures, their presentations might vary from one culture to another. This interview study was part of a project to establish whether cognitive behavior therapy could be effective for the treatment of depression in a developing country. We interviewed outpatients from a university teaching hospital in Pakistan who were diagnosed as having depression. We tried to elicit their knowledge and perceptions of depression, its causes, and treatments, and their views about nonpharmacological treatments. We discovered that patients had very little knowledge of mental illnesses in general, and depression in particular. They believed that mental health problems were the result of stress or trauma, and that only medicines could help them. Patients had no knowledge of the roles of psychologists or psychotherapy. Their model of understanding mental illnesses appeared to represent a psychosocial understanding, with physical symptoms being their main concern.

The concept of reflection in nursing: qualitative findings on student and teacher perspectives.

BACKGROUND AND AIM: This study sought to increase the understanding of the concept of reflection within nursing. The research focused on the social construction of reflection through a post-registration, palliative care programme in the United Kingdom (UK). DESIGN AND PARTICIPANTS: An interpretive ethnographic approach was used to study reflection from the perspective of students and teachers, whilst paying attention to local organisational, contextual and cultural issues. METHODS: Data collection included: observations of teaching and learning interactions, interviews, extracts from programme documentation and student reflective learning contracts (RLCs). FINDINGS: Findings identified a learning culture committed to reflection as a valuable way of helping nurses make sense of their practice. Similar to Barnett's (1997) concept of 'critical being', students and teachers described reflection as a way of 'being' rather than simply 'thinking' or 'doing', since reflection intertwined propositional, affective and active elements. This process of reflective 'being' was connected with a humanistic approach to nursing, which emphasises the importance of actively using and expressing oneself in order to care for people. CONCLUSION: This paper contributes empirical knowledge on the meaning of reflection in nursing regarding: teachers' and students' perspectives, reflection as a way to make sense of practice, and reflection as a way of 'being' and its association with humanistic nursing.

Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: findings from Developing Culturally-sensitive CBT Project (DCCP).

BACKGROUND: There is sufficient research evidence in favour of cognitive therapy in western world. However, only limited research has been carried out on its effectiveness in other countries. It is suggested that adaptations in content, format and delivery are needed before CBT can be employed in non-western cultures. We describe a preliminary evaluation of culturally adapted CBT for depression in Pakistan. AIMS: We aimed to evaluate the efficacy of this culturally adapted CBT using a therapist manual. METHOD: In a randomized controlled trial we compared combination of CBT and antidepressants with antidepressants alone (treatment as usual) in primary care. Referred patients with ICD-10 diagnosis of depression were invited to participate and randomized to the intervention and control groups. Hospital Anxiety and Depression Scale (HADS) and Bradford Somatic Inventory (BSI) were used to measure changes in depression, anxiety and somatic symptoms. RESULTS: Seventeen patients each were randomized to each arms of the trial. Except for financial status there were no differences between the two groups on various demographic variables. Patients receiving CBT showed statistically significant improvement on measures of depression (p < .001), anxiety (p < .001) and somatic symptoms (p < .000) as compared to antidepressant alone group. 82% patients attended six or more sessions of therapy. CONCLUSIONS: A culturally sensitive manualized CBT was effective in reducing symptoms of depression and anxiety in Pakistan.

Developing culturally sensitive cognitive behaviour therapy for psychosis for ethnic minority patients by exploration and incorporation of service users' and health professionals' views and opinions.

BACKGROUND: Studies of cognitive behaviour therapy (CBT) for schizophrenia demonstrate that African-Caribbean and Black African patients have higher dropout rates and poor outcomes from treatment. AIM: The main aim of the study was to produce a culturally sensitive adaption of an existing CBT manual for therapists working with patients with psychosis from specified ethinic minority communities (African-Caribbean, Black-African/Black British, and South Asian Muslims). This will be based on gaining meaningful understanding of the way members (lay and service users) of these minority communities typically view psychosis, its origin and management including their cultural influences, values and attitudes. METHOD: This two-centre (Hampshire and West London) qualitative study consisted of individual semi-structured interviews with patients with schizophrenia (n = 15); focus groups with lay members from selected ethnic communities (n = 52); focus groups or semi-structured interviews with CBT therapists (n = 22); and mental health practitioners who work with patients from the ethnic communities (n = 25). Data were analyzed thematically using evolving themes and content analysis. NVivo 8 was used to manage and explore data. RESULTS: There was consensus from the respondent groups that CBT would be an acceptable treatment if culturally adapted. This would incorporate culturally-based patient health beliefs, attributions concerning psychosis, attention to help seeking pathways, and technical adjustments. CONCLUSION: While individualization of therapy is generally accepted as a principle, in practice therapists require an understanding of patient-related factors that are culturally bound and influence the way the patient perceives or responds to therapy. The findings of this study have practical implications for therapists and mental health practitioners using CBT with people with psychosis from BME communities.

Psychologists experience of cognitive behaviour therapy in a developing country: a qualitative study from Pakistan.

BACKGROUND: Psychological therapies especially Cognitive Behaviour Therapy (CBT) are used widely in the West to help patients with psychiatric problems. Cognitive Behaviour Therapy has an established evidence base for the treatment of different emotional disorders. In spite of these developments in the developed world, patients in most developing countries hardly benefit from non pharmacological interventions. Although a significant number of psychologists are trained in Pakistan each year, psychological interventions play only a minor role in treatment plans in Pakistan. We conducted interviews with psychologists in Pakistan, to explore their experiences and their views on "providing CBT in Pakistan". These interviews were conducted as part of a project whose focus was to try to develop culturally-sensitive CBT in Pakistan. METHODS: In depth semi structured interviews were conducted with 5 psychologists working in psychiatry departments in Lahore, Pakistan. RESULTS: All the psychologists reported that psychotherapies, including CBT, need adjustments for use in Pakistan, although they were not able to elicit on these in details. Four major themes were discovered, hurdles in therapy, therapy related issues, involvement of the family and modification in therapy. The biggest hurdles in therapy were described to be service and resource issues. CONCLUSIONS: For CBT to be acceptable, accessible and effective in Non Western cultures numerous adjustments need to be made, taking into consideration; factors related to service structure and delivery, patient's knowledge and beliefs about health and the therapy itself. Interviews with the psychologists in these countries can give us insights which can guide development of therapy and manuals to support its delivery.

How military nurses rationalize their postoperative pain assessment decisions.

AIM: This paper is a report of a study to explore how military nurses rationalize their postoperative pain assessment decisions, particularly when these differ from patients' pain self-reports. BACKGROUND: Postoperative pain is a complex phenomenon influenced by many factors that make assessment difficult. Nurses are taught to believe what patients say about their pain. However, their attitudes to pain are influenced by their cultural background and they may disagree with patients' self-reports. Military nurses belong to a military culture with different pain attitudes that may also influence their postoperative pain assessment. METHOD: An ethnomethodological ethnography study was carried out in 2003. A purposive sample of 29 British military surgical/orthopaedic Registered Nurses were interviewed to identify their taken-for-granted assumptions and commonsense cultural knowledge surrounding postoperative pain assessment. The data were analysed using a systematic process of inductive reasoning aided by Non-numerical, Unstructured Data for Indexing, Searching and Theorizing (QSR N6, NUD*IST). FINDINGS: Participants told two distinct stories in their postoperative pain narratives. The first, the cultural story, described how military nurses normally assess postoperative pain and revealed taken-for-granted assumptions surrounding this assessment. However, when military nurses believe that patients over- or under-report their pain, the cultural story was challenged through a collective story in which nurses used their commonsense knowledge to account for these differences. CONCLUSION: Postoperative pain assessment within a military culture is complex, but all nurses need to be aware that their socialization into different nursing cultures may influence their attitudes to postoperative pain assessment.

Inconsistent grading of evidence across countries: a review of low back pain guidelines.

OBJECTIVE: The aim of this study was to report clinical treatment recommendations for low back pain (LBP) based on 5 international guidelines and best evidence from the Cochrane database of systematic reviews. METHODS: Five LBP guidelines available in English language were appraised, including 4 studies published since the seminal work by Koes et al (Spine 2001;26:2504-5213). The guidelines were examined for treatment recommendations concerning nonspecific LBP and guideline quality with application of the Appraisal of Guidelines for Research and Evaluation instrument. Secondly, a systematic literature search for reviews and randomized controlled trials was conducted using a modified version of the search strategy recommended by the Cochrane Back Review Group. Two systematic reviews were identified. RESULTS: According to best evidence from review of the Cochrane database of systematic reviews, there remains a lack of consensus regarding reported efficacy of spinal manipulative therapy for the treatment of nonspecific LBP. Furthermore, the guidelines reviewed in the present study have not changed significantly with respect to treatment recommendations for nonspecific LBP since the original review, and there is inconsistency between the guidelines regarding optimal time to introduce spinal manipulation to treat nonspecific LBP. CONCLUSION: Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence.

Nursing practice as bricoleur activity: a concept explored.

The debates concerning the nature of nursing practice are often rooted in tensions between artistic, scientific and magical/mythical practice. It is within this context that the case is argued for considering that nursing practice involves bricoleur activity. This stance, which is derived from the work of Levi-Strauss, conceives elements of nursing practice as an embodied, bricoleur practice where practitioners draw on the 'shards and fragments' of the situation-at-hand to resolve the needs of the individual patient for whom they care. This conceptualisation of nursing practice will be analysed with a particular emphasis on its implication for nursing epistemology, pedagogy and praxis. The evidence to support this argument is drawn from empirical work that investigated nurses' use of intuition, the work of Levi-Strauss, and issues in nursing epistemology and ontology. The paper itself is written from the perspective of a bricoleur who uses 'bits and pieces' from the domains of nursing, philosophy, psychology, education, sociology and anthropology.

Virtual interactive practice: utilizing healthcare information systems to contextualize the skills associated with clinical decision making within nurse education.

This paper reports on a Virtual Interactive Practice (VIP) project that has the potential to revolutionise the educational delivery and learning of clinical skills complementing "real" practice. The focus is currently on nurse learning but the principles could equally be applied to multi and inter-professional learning and clinical decision-making. This project represents a new model to enhance clinical skill acquisition and clinical reasoning using a structured competency base. Integral to this is a strong partnership between education and practice utilising "real" live and recorded anonymised patient data from a critical care clinical information system (CIS) within a large district general hospital to structure scenarios fostering problem-based learning. This educational practice interface enables the synthesis of clinical data using virtual technology and sophisticated scenario-based simulation within a skills laboratory. The aim is to enhance the more ad hoc system of learning within conventional practice placements. Early findings suggest that VIP enhances practice providing a safe but challenging learning experience with the benefit of instant performance feedback to students.

Virtual Interactive Practice: a strategy to enhance learning and competence in health care students.

This paper reports the processes and initial outcomes of a pilot study which investigated a week long 'virtual' children's ward experience for nursing students. Providing sufficient and meaningful experiences which enable students to quickly and effectively achieve competence in diverse areas of practice is often frustrated by the realities of available clinical experiences. Our response to this challenge was to more fully exploit and evaluate technologies which can be used to provide these learning experiences. Students experienced 'real time' scenario based work involving SIM-MAN; interactive information technology scenarios, critical incidents, master classes, video conferencing, and observational skill development exercises. Evaluation methodologies included observation of student performance, competence self rating scales; analysis of videotaped performance episodes and other data generated through the learning activities and lived experience accounts of participants. Initial findings indicate (1) statistically significant improvements in student competence measured through self reports; and (2) evidence of improvement gleaned from observed accounts, video analysis and qualitative evaluative comments. The final outcomes, including work with a control group, will be available for Conference.