FSH administration at 12-hour intervals for the first 2 days, combined with mandatory GnRH-agonist trigger and blastocyst vitrification in women (<80Kg) with high AMH levels, results in higher cumulative live birth rates and is safer.

We aimed to determine if a programme change to 12 hourly injections of FSH (150 IU per injection) for the first 2 days of stimulation in women with high ovarian reserve (AMH ≥ 30 pmol/L), followed by 24 hourly injections, would elicit increased earlier follicular recruitment, higher egg yields and blastocyst embryos for cryopreservation, leading to potential higher cumulative pregnancy rates, than conventional daily injections throughout. For safety reasons, the approach required mandatory cryopreservation of all blastocysts (mFET group; n = 74), after ovulation trigger with GnRH-agonist, in GnRH-antagonist controlled cycles. The 'Comparator group' (n = 91) comprised women with the same high AMH levels treated with the same base dose of FSH, with the aim of fresh blastocyst transfer and cryopreservation of supernumerary embryos, treated over the preceding 2 years. There was no difference in age, AMH, weight or BMI between the groups. The mFET group achieved higher egg (17.7 versus 11.7; p < 0.001) and embryo (10.9 versus 7.2; p < 0.001) yields and fewer cases with sub-optimal embryo yields (7% versus 22%; p = 0.018). The cumulative live birth rate was superior in the mFET group (73% versus 43%), as was the safety profile, and negligible rate of treatment plan modification.

The Experience of Acute Mechanical Ventilation From the Patient's Perspective.

BACKGROUND: The Pain, Agitation, and Delirium guidelines influenced practice to support targeted, light sedation for the mechanically ventilated patient. This practice is associated with improved clinical outcomes, but it remains unclear how it impacts the patient experience. OBJECTIVE: The objective was to determine the pervasive patient experience components and how the experience may have been influenced by targeted, light sedation practices. METHODS: A prospective observational study using mixed methodology and a convenience sample was conducted after institutional review board approval was obtained. Inclusion criteria were the following: acute mechanical ventilation of less than 14 days, 18 years or older and able to provide consent, English speaking, and delirium-free. Exclusion criteria were the presence of delirium or intravenous opioids/sedatives within 24 hours prior to the interview. The quantitative component included simple yes or no questions and identification of quantitative adjectives describing the mechanical ventilation experience. Every 10th patient was invited to participate in an expanded qualitative interview. RESULTS: Data were collected for 12 months with a total sample size of 130 patients participating in the quantitative component and a subset of 15 patients also participating in the qualitative interview. Sixty percent of the total sample consisted of cardiothoracic surgery patients, and 40% were mixed intensive care unit patient populations. Descriptive statistics include the following averaged values: Richmond Agitation Sedation Scale scores -1.7 throughout mechanical ventilation, aged 59.9 years, days mechanically ventilated 1.4, intensive care unit length of stay 4.6 days, and Acute Physiology and Chronic Health Evaluation II score 16.1. The most significant finding was that 56.2% of patients who could not communicate reported feeling afraid, whereas 32.5% of those who could communicate reported feeling afraid (P < .027). The themes identified in the qualitative component of the study reinforced these quantitative findings; 10 of the 15 patients interviewed reported experiencing fear, and all of the patients reported issues with communication. DISCUSSION: The clinical implications of this research study primarily affect critical care nursing. Changes in nursing practice can address these findings to improve and more effectively acknowledge the patient experience.

Factors Influencing Registered Nurses' Perceptions of Their Professional Identity: An Integrative Literature Review.

BACKGROUND: This review synthesizes contemporary research investigating the factors influencing RNs' perceptions of their professional identity. METHOD: The method used was an integrative literature review. RESULTS: Factors influencing RNs' perceptions of their professional identity were synthesized into three categories: the self, the role, and the context. The self is the nurse who enacts the role in practice, and the context is the practice setting. Poor alignment of these categories leads to stress, tension, and uncertainty affecting work-force retention. Strong alignment leads to satisfaction with the nursing role, increased staff retention, and improved quality of care and patient outcomes. These three categories should be considered when planning nursing professional development activities. CONCLUSION: This integrative review identified a lack of research addressing how nurses' perceptions of their professional identity change over time. A deeper understanding of their perspective is needed to establish whether career longevity and continued professional development are influences. J Contin Educ Nurs. 2018;49(5):225-232.

Show Your Stuff and Watch Your Tone: Nurses' Caring Behaviors.

BACKGROUND: Although it is perceived as essential, documentation of caring behaviors executed by nurses is rarely done. To facilitate what is important to patients and their family members, we need to understand what behaviors are perceived as caring or not caring. OBJECTIVE: To explore perceptions of nurses' caring behaviors among intubated patients and their family members. METHODS: A phenomenological study of 14 patients who were intubated, restrained, sedated, and received pain medication in an acute cardiovascular intensive care unit. The 14 patients and 8 of their family members were interviewed about their perceptions of this experience. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. RESULTS: Themes that emerged most often were providing information, providing reassurance, demonstrating proficiency, and being present. Other behaviors identified as caring behaviors were nurses giving guidance and using a soothing tone of voice. Behavior that was contrary to the perception of caring appeared as isolated incidents. These included negative attitude, interrupting sleep, not receiving information, and poor pain management. CONCLUSION: When patients and family members are asked directly about their experience, valuable insight is gained into what they perceive as caring and what contributes to recovery as perceived by those in crisis and in high-intensity medical settings. Capturing these data is elemental to designing high-quality, safe environments that facilitate healing.

Child and adolescent mental health nursing seen through a social constructionist lens.

AIM: To discuss the theoretical framework of social constructivism and justify it s appropriateness for and compatibility with an interpretive approach to child adolescent mental health (CAMH) nursing research. BACKGROUND: Recent changes to national nursing legislation in Australia have resulted in the removal of the separate register with regulatory authorities that existed for the specialty of mental health nursing. Aspects of mental health nursing age are not easily defined, with some being tacit. CAMH nursing is a sub-specialty area of mental health in which the role and function of these nurses is also not overtly understood. DATA SOURCE: An interpretive research study was designed to develop a deeper understanding of the role and work of CAMH nurses when working in an inpatient setting. REVEW METHODS: An interpretive enquiry methodology was used fro the study, with three sequential stages of data collection: document analysis, focus group interviews and semi-structured individual interviews. DISCUSSION: Social constructionism was the chosen theoretical framework for this study as it provided a useful lens for interpreting and understanding the work of the CAMH nurse. CONCLUSION: The social constructionist lens was simpatico with mental health nursing, as they both involved making meaning of or assessing information and understanding of social processes and interactions. IMPLICATIONS FOR REEARCH/PRACTICE: A useful lens for further research into mental health nursing practice.

Discovery of unexpected pain in intubated and sedated patients.

BACKGROUND: The perceptions of patients who are restrained and sedated while being treated with mechanical ventilation in the intensive care unit are not well understood. The effectiveness of sedation used to aid in recovery and enhance comfort during intubation is unknown. OBJECTIVE: To explore the perceptions of patients who were intubated and receiving pain medication while sedated and restrained in the intensive care unit, in particular, their experience and their memories of the experience. METHODS: In a phenomenological study, 14 patients who were intubated and receiving pain medication while sedated and restrained were interviewed at the bedside. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. RESULTS: Three major themes were identified from the data: lack of memory of being restrained; a perception of being intubated as horrific; nursing behaviors that were helpful and comforting. An unexpected discovery was that sedation may be interfering with pain assessment and management. CONCLUSION: Being intubated can be painful and traumatic despite administration of sedatives and analgesics. Sedation may mask uncontrolled pain for intubated patients and prevent them from communicating this condition to a nurse. Nurses may need to evaluate current interventions in order to provide maximum comfort and promote optimal positive outcomes for intensive care patients who are intubated.

Conceptualizing the clinical and professional development of child and adolescent mental health nurses.

Aspects of mental health nursing and its subspecialties are not easily defined. Child and adolescent mental health (CAMH) nursing is a subspecialty of mental health nursing, and some of its characteristics are tacit. This paper presents a deeper understanding of the meaning that CAMH nurses make of their role and work in the inpatient setting. The research was undertaken through a PhD candidature. The epistemological framework for the research was social constructionism. Interpretive enquiry was the methodology, as it allowed for the interpretation of multiple realities, which resulted in a rich description of the role and work of CAMH nurses. Methods of data collection were document analysis, focus group interviews, and individual interviews. Participants included nurses and multidisciplinary staff. Iterative and aggregative analyses were utilized for the documents. The focus group and individual interview data were analysed utilizing a thematic analysis process. This paper presents the findings of the combined analysis and the resultant holistic conceptual framework for the work of the CAMH nurse in the inpatient unit. The findings have contributed new knowledge to mental health nursing, specifically CAMH nursing, making the parameters of practice more explicit. Implications for practice, education, and research are identified.

Interactive learning research: application of cognitive load theory to nursing education.

The purpose of this research was to investigate the effectiveness of interactive self-paced computerized case study compared to traditional hand-written paper case study on the outcomes of student knowledge, attitude, and retention of the content delivered. Cognitive load theory (CLT) provided the theoretical framework for the study. A quasi-experimental pre-test post-test design with random group assignment was used to measure by self-report survey student cognitive load and interactivity level of the intervention. Student scores on quizzes in semester 1 and post-test follow-up quizzes in semester 3 were assessed for the intervention's effects on knowledge retention. While no significant statistical differences were found between groups, the students in the interactive case study group rated their case study as more fun and interactive. These students also scored consistently higher on the post-test quiz items in their third semester, showing the viability of using CLT to improve student retention of nursing curricula information.

Document analysis using an aggregative and iterative process.

This paper is a descriptive commentary concerning the use of document analysis in qualitative research concerned with developing an understanding of the role of child and adolescent mental health nursing in an inpatient. The document analysis was undertaken using thematic analysis with both an iterative process (Attride-Stirling) and an aggregative process, the Joanna Briggs Institute Thematic Analysis Program (TAP). After the initial iterative process the data were entered into an online software program, TAP, for aggregation and further analysis. The TAP software consisted of a three-step approach in the analysis of data extraction of illustrations, aggregation to categories and synthesis of categories into themes. A TAP chart was generated displaying the connections between the illustrations, categories and themes. The advantage and limitations of utilising the TAP software compared with Computer Assisted Qualitative Data Analysis Software were discussed. The program afforded direct involvement by the researcher in the cognitive process of the analysis; rather than just the technical process. A limitation of the program would be the volume of the data if the research involved a vast amount of data. The TAP program was a clearly defined three-step software program that was appropriate for the documents analysis for the research. The program would have a wide application for facilitating the thematic analysis of documents, although the program is suitable for smaller amounts of data.

An examination of maternity staff attitudes towards implementing Baby Friendly Health Initiative (BFHI) accreditation in Australia.

BACKGROUND: The Baby Friendly Hospital Initiative (BFHI) influences health care practices and increases the initiation and duration of exclusive breastfeeding. Consistent definitions enable the accurate monitoring of breastfeeding rates and behaviour. This information refines policy and helps reach national breastfeeding targets. Only 21% (66/317) of Australian hospitals are BFHI accredited. OBJECTIVE: To examine the factors perceived to promote or hinder BFHI accreditation. METHOD: Focus group interviews explored opinions of 31 participants, in differing roles and levels of employment, across midwifery, medical, nursing and ancillary staff at six South Australian maternity hospitals. RESULTS: The results suggest that staffs' understanding and personal views are often discordant with BFHI aims. Perceived difficulties include the accreditation process, hospital dynamics, and the Ten Steps implementation plus a bottle feeding culture and maternal employment that impact upon continued breastfeeding. CONCLUSIONS: Upper management support, specific funding, a dedicated co-ordinator with "area leaders", development of a specific breastfeeding policy incorporating various disciplines and staff, containing detailed protocols that comply with the International Code of Marketing of Breast Milk Substitutes and subsequent World Health Assembly (WHA) resolutions, are all required. Staff and mothers require multiple modes of education to understand the BFHI, including sponsorship for training of lactation consultants. Full implementation of BFHI across Australia will assist the development of nationally accepted breastfeeding definitions, improve monitoring and evaluation of rates and practices, and improve breastfeeding outcomes.

Encountering the culture of midwifery practice on the postnatal ward during action research: An impediment to change.

BACKGROUND: The reduction of time available to midwives during the hospital postnatal stay suggests that there is a need to review postnatal care. Innovative strategies are required which give attention to specific family needs and assist in the transition to parenthood. Nevertheless, new ideas and changes are not always readily accepted in midwifery practice. AIM: To enhance the provision of postnatal care to parents in the early postnatal period given time constraints for parents' hospital stay. METHODS: Action research was employed to explore the educational experiences of parents in the postnatal period. An action research group (ARG) was established, comprising predominantly of midwives. Based on data collected from parents through questionnaires, focus groups and interviews, three actions were developed and implemented on a postnatal ward. RESULTS: The actions were evaluated by 122 parents through self-report questionnaires. Midwives working on the postnatal ward and midwives involved in the ARG provided feedback regarding the actions through separate focus group discussions. The parents who participated in the study and, the midwives involved in the ARG, were positive about the actions and perceived them to be beneficial in preparing parents for parenthood. Many of the ward midwives, however, were negative about the actions and questioned their benefit for midwifery practice. DISCUSSION: The negativity of the ward midwives regarding the innovations implemented in the study contrasted strikingly with the positive responses from both parents and the action research midwives. Two themes emerged which may explain the response of midwives to the actions, notably, a lack of ownership of the actions and the problematic nature of the current culture of the postnatal-care environment. CONCLUSION: It appears that the provision of hospital postnatal care has been influenced by an underlying culture in midwifery practice, which in turn, has impeded the change required to enhance postnatal care.

Enhancing fathers' educational experiences during the early postnatal period.

Since the 1970s, men have been encouraged to actively participate in the childbirth process, resulting in a shared experience for couples. Nevertheless, after the baby is born, many fathers find themselves displaced, unsure of how to embrace the transition to parenthood. The shift in cultural practice and evolving needs of families calls for the recognition of fathers as well as mothers in the provision of midwifery services. Innovative strategies must be considered to enhance postnatal education that is father-inclusive and responsive to the needs of families in the 21st century. This article introduces one strategy created from an action research study conducted to develop, implement, and evaluate strategies to improve postnatal education for parents.

Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.

OBJECTIVE: to investigate the relationship between adherence to six of the Baby Friendly Hospital Initiative (BFHI) Ten steps to successful breast feeding and the duration of breast feeding in first-time mothers. DESIGN: a prospective study to assess the duration of breast feeding up to 6 months postpartum. Survival analysis techniques (Kaplan-Meier curves and Cox proportional hazard models) were used to interpret the data. PARTICIPANTS: 317 women who had given birth to their first baby (at term) in a large teaching maternity hospital in Adelaide, South Australia, during the period March to November 2003. FINDINGS: ignoring all other factors, we found that women whose babies received a bottle feed, used a pacifier or dummy, or who used a nipple shield during their postnatal stay, were at significantly greater risk of weaning (p0.05). After adjusting for socio-demographic variables, self-efficacy, intended duration of breast feeding, and method of delivery, the results unexpectedly showed that the only significant predictor of early weaning was breast feeding on demand. However, a composite variable indicating use of one or more of nipple shields, a dummy or bottle feeds while in hospital resulted in a significantly greater risk of weaning (p=0.05). IMPLICATIONS FOR PRACTICE: socio-demographic and cultural factors may be more important determinants of the duration of breast feeding than some of the very specific hospital practices targeted in the Ten steps to successful breast feeding. From a public health perspective, we may influence the duration of breast feeding through better post-discharge support services, or through interventions that improve attitudes to breast feeding in specific socio-cultural and economic groups.

Breast feeding self-efficacy and other determinants of the duration of breast feeding in a cohort of first-time mothers in Adelaide, Australia.

OBJECTIVE: to assess the ability of a Breast-Feeding Self-Efficacy Scale (BSES) score measured at 1 week postpartum to predict the duration of breast-feeding in first-time mothers, and to develop a minimal set of potential confounders, including the BSES and demographic variables, for comparing the apparent effect of other influences on the duration of breast-feeding. DESIGN: a prospective cohort study, with primary outcome the duration of breast feeding up to 6 months postpartum. PARTICIPANTS: 317 women who had given birth to their first baby (at term) in a large teaching maternity hospital in Adelaide, South Australia, during the period March to November, 2003. FINDINGS: the BSES at 1 week postpartum was a strong predictor of the duration of breast-feeding in these first-time mothers. Its ability to predict the duration of breast-feeding was largely independent of the other factors (intended duration of breast-feeding, mother's level of education, country of birth, housing situation, smoking status and method of delivery), which were also found to be significant predictors of breast-feeding duration. IMPLICATIONS FOR PRACTICE: the BSES (including a new short form version) has been confirmed by our study as an important instrument for identifying women at risk of early cessation of breast-feeding. Together with other demographic variables, it should be useful for targeting limited resources to those most in need.

Insights from Australian parents into educational experiences in the early postnatal period.

OBJECTIVE: to investigate the provision of parent education during the early postnatal period in order to gain insight that, through stakeholder collaboration, will contribute to the development of innovative strategies to enhance the provision of postnatal education in a contemporary health-care environment. DESIGN: the study comprises the first stage of an action-research project. The first stage of research sought to explore the experiences of mothers and fathers in the early postnatal period by conducting a questionnaire within 4 weeks of the birth of their baby. The data obtained from the questionnaire is to inform an action-research group for stage two of the project. SETTING: The Children, Youth and Women's Health Service, a large city maternity hospital in South Australia, covering a range of socio-economic strata. PARTICIPANTS: 85 parents completed and returned the questionnaire, comprising 52 mothers and 33 fathers. MEASUREMENT: an anonymous self-report questionnaire was purpose designed to provide each parent with an opportunity to reflect on their own experience, with particular emphasis given to the provision of education and support during the early postnatal period. FINDINGS: a number of themes emerged, including a window of opportunity during the postnatal hospital stay to provide education and support, despite the reduction in the length of stay; the need for a family-centred approach to maternity services; and the significance of self and social network in the early transition to parenthood. CONCLUSIONS: The findings from this stage of the research, combined with a review of the literature, provide insight that will contribute to stage two of the study. At this stage, an action-research group will continue planning to develop specific actions to enhance the provision of education to parents in the early postnatal period. These actions will subsequently be implemented and assessed.

The seven principles of good practice: applications for online education in nursing.

Traditional education has been studied over time for the purpose of documenting what constitutes good practice in teaching. Online education in nursing is still relatively new and has not endured the same scrutiny as classroom education. The authors discuss how Chickering and Gamson's Seven Principles of Good Practice for Undergraduate Education apply to online nursing education and provide practical examples of how the principles can be implemented in Web-based nursing courses.

Congratulations you're a mother: a strategy for enhancing postnatal education for first-time mothers investigated through an action research cycle.

The transition to motherhood is a time of great change and an experience for which many women do not feel adequately prepared. This study sought to benefit women in the transition to motherhood by enhancing the postnatal teaching offered to first-time mothers in hospital following childbirth. The study followed an action research cycle to design, implement and evaluate an educational resource for first-time mothers during the immediate postnatal period. Methods for collecting data included focus groups and an anonymous self-completed questionnaire. The research was undertaken at a suburban public hospital in Adelaide. The findings showed that both midwives and first-time mothers considered lack of time as a significant factor in giving and receiving postnatal education. It was also found that the provision of relevant information was important. The study identified that specific information relating to baby-care and self-care are primary educational needs for first-time mothers. The resource, "Congratulations You're a Mother" was developed in response to these findings and was found to be beneficial in providing postnatal education. The study provides a platform for further investigation of postnatal education using larger samples in the broader context of Australian society.

Testing the effect of kinesthetic training on handwriting performance in first-grade students.

OBJECTIVE: The purpose of this study was to investigate the effect of kinesthetic training' on handwriting performance in first-grade students 6 to 7 years of age who had kinesthetic deficits and handwriting difficulties. METHOD: With a randomized-blinded three group research design, 45 children were assigned to either a kinesthetic training group, a handwriting practice group, or a no treatment group. Kinesthesis and handwriting legibility were measured before and after intervention. Teachers' judgments of handwriting legibility in the classroom setting were sought at 4 weeks after the intervention to see whether any improvement gained would be maintained in the natural setting. Two-way repeated-measures analysis of variance was used for data analyses. RESULTS: At posttest, all groups showed significant improvement of kinesthesis, with no significant difference in the magnitude of improvement among the groups. There was no significant improvement of handwriting legibility as measured by a standardized test in any of the groups, although teachers indicated improvement of handwriting legibility in the classroom setting in all groups. Teachers also reported maintenance of handwriting legibility at 4 weeks after posttest. CONCLUSION: Kinesthetic training did not improve handwriting or kinesthesis in these children. The findings of this study offer no support for use of kinesthetic training to improve handwriting legibility in first-grade students.