From Centralized to Decentralized Model of Simulation-Based Education: Curricular Integration of Take-Home Simulators in Nursing Education.

In a centralized model of simulation-based education (Ce-SBE), students practice skills in simulation laboratories, while in a decentralized model (De-SBE), they practice skills outside of these laboratories. The cost of "take-home" simulators is a barrier that can be overcome with additive manufacturing (AM). Our objective was to develop and evaluate the quality of education when year one nursing students practiced clinical skills from home following normal curricular activities but in the De-SBE format. A group of expert educators, designers, and researchers followed a two-cycle, iterative design-to-cost approach to develop three simulators: wound care and urethral catheterization (male and female). The total cost of manufacturing all three simulators was USD 5,000. These were sent to all year one nursing students who followed an online curriculum. Twenty-nine students completed the survey, which indicated that the simulators supported the students' learning needs, and several changes were requested to improve the educational value. The results indicate that substituting traditional simulators with AM-simulators provided an acceptable alternative for nursing students to learn wound care and urethral catheterization off-campus in De-SBE. The feedback also provided suggestions to improve each of the simulators to make the experience more authentic.

Pediatric practicums in undergraduate nursing programs: an integrative review.

BACKGROUND: Practicum Placements are the signature andragogy used in undergraduate nursing programs to bring about knowledge consolidation. Little is known, however, about the types of pediatric practicum placements utilized by nursing programs to provide practical learning opportunities in child health to their students. The purpose of this integrative review is to identify and appraise existing literature on practical pediatric practices in undergraduate nursing education. METHOD: Searches were conducted using the main relevant databases and search engines. Of the numerous articles retrieved, screened, and reviewed, 15 met the inclusion and exclusion criteria. Results were then analyzed using thematic analysis. RESULTS: Two overarching themes were identified: (1) Adaptation, and (2) Learning. CONCLUSION: Findings revealed that most nursing programs utilize alternative placement sites to meet the learning need of their students. These sites provided students with the opportunities to care for children and adolescents, and engage in a variety of health promotion and teaching activities.

The Effect of Context-Based Interventions at the Systems-Level on Participation of Children with Disabilities: A Systematic Review.

AIMS: To synthesize evidence on the impact of context-based interventions on the participation of children with disabilities in the community. METHODS: A systematic review was conducted using the American Academy for Cerebral Palsy and Developmental Medicine Guidelines for systematic reviews. Seven databases were searched; articles included were on children with developmental disabilities under the age of 19 years, describing systems-level, context-based interventions aimed to improve participation and Participation-related outcomes of the Family of Participation-related Constructs framework. Intervention characteristics were coded using the Community Wellbeing Framework (CWF). RESULTS: Eleven articles were included for knowledge synthesis. Four studies were level I, II, and III based on the Center for Evidence-Based Medicine hierarchy. All four showed that context-based interventions had a positive effect on participation and participation-related outcomes. All 11 studies had intervention properties that were coded to at least one domain on the CWF. CONCLUSION: There is a scarcity of high-quality studies that focus on context-based interventions at the systems-level, as opposed to the individual-level. Albeit low-level quality, existing evidence emphasized the importance of using known facilitators to participation, such as staff training, peer mentorship, awareness-raising, and development of partnerships to change the system and promote participation.

Advice from Canadian Mothers Who Express Human Milk: An Interpretive Description Qualitative Study.

OBJECTIVES: Human milk expression has become an increasingly common means for providing milk to an infant, with women expressing to address breastfeeding problems or to allow for flexible feeding options. This study explored the experiences and recommendations of mothers who expressed human milk, with this paper reporting on the advice mothers would offer to other mothers to address common challenges. METHODS: Interpretive description was used in this qualitative project. Using purposive sampling, mothers of infants aged 0-24 months who expressed human milk were recruited to participate from two health regions in western Canada. Individual, audio-taped interviews were completed with 35 women. NVIVO™ software was used for data analysis. RESULTS: Mothers reported the desire to offer experiential advice to other mothers navigating milk expression and encouraged other mothers to seek guidance from health care professionals such as lactation consultants, peer support online, and from family and friends. Experiential knowledge shared included: (a) product recommendations, (b) expression tips, (c) support for workplace expression, (d) encouragement to seek help, and (e) moral support. CONCLUSIONS: Healthcare professionals should include evidence-based expression information as part of routine lactation support, while recognizing the importance of mother-to-mother knowledge transfer and emotional support. Services that assist mothers to determine and access pumps appropriate to their unique breastfeeding needs and goals should be offered, and the opportunity for peer support through creation of, or referral to, appropriate in-person or online support groups should be made available.

"We Just Kind of Had to Figure It Out": A Qualitative Exploration of the Information Needs of Mothers Who Express Human Milk.

BACKGROUND: Human milk expression, primarily by pump, is practiced by the majority of breastfeeding mothers in affluent countries. Existing literature is focused on determining prevalence and duration rates and the factors behind this trend. There is less research exploring mothers' perspectives and experiences related to expression. RESEARCH AIM: To gather the experiential wisdom of mothers with a focus on their information needs and sources related to human milk expression. METHODS: Audiotaped interviews were conducted with 35 mothers of infants, aged birth to 24 months, who had expressed milk at least once in western Canada. This study was guided by interpretive description, an applied qualitative research approach. RESULTS: Registered nurses and international board-certified lactation consultants were the most common sources of information, with Internet, friends/family, and other mothers also important. Inconsistent expression advice was confusing for participants, and many reported health care providers did not address all their expression learning needs. Desired topic areas included practical advice on how to express, determining expression frequency/timing/duration, milk storage guidelines, the influence of expression on milk supply, product information, and general support/encouragement. CONCLUSIONS: Assessment of expression learning needs should be part of routine lactation support at each encounter. Nonjudgmental, factual guidance will assist mothers in making evidence-informed decisions related to expression practices that are consistent with their unique breastfeeding goals. This should be supplemented by reputable online resources that provide timely and accurate information as well as efforts to connect mothers with peer support groups.

Nursing, sexual health and youth with disabilities: a critical ethnography.

AIM: To explore the experiences of nurses providing sexual health care to adolescents with physical and/or developmental disabilities, with attention to the institutional and social discourses that shape these interactions. BACKGROUND: Previous research has shown that nurses demonstrate a lack of attention to the impact of illness or disability on sexual health. However, in their therapeutic relationship with patients and families, nurses are in an ideal position to promote sexual health. DESIGN: A critical ethnography study was conducted in an urban paediatric rehabilitative facility. METHOD: Field work occurred over 4 months (2008-2009) and data collection included interviews (n = 9), key informant discussions, collection of documentary evidence and observation of the institutional setting. FINDINGS: Four themes were identified (institutional space, professional interactions, engaging with sexuality, nursing experience), which revealed that nurse-patient interactions about sexual health were affected by a complex network of discourses. These encounters were shaped by practical discourses, such as time and space and by more complex discourses, such as professional relationships, normalization and asexuality. CONCLUSION: Nurses occupy and strive to maintain, the role of a caring agent. However, aspects of the clinical, institutional and broader social environments may undermine their ability to promote sexual health. In nurses' efforts to maintain therapeutic relationships with clients, sexual health is often medicalised to legitimize it as an appropriate topic of discussion with patients and families. Facilities serving youth with disabilities should take steps to address barriers to the delivery of sexual health promotion and several solutions are proposed.

Reversing Kristeva's first instance of abjection: the formation of self reconsidered.

Psychoanalyst Julia Kristeva defines the theoretical concept of abjection as an unconscious defence mechanism used to protect the self against threats to one's subjectivity. Kristeva suggests that the first instance of abjection in an individual's life occurs when the child abjects the mother. However, the instance of abjection addressed within this paper is the reverse of this: the abjection of the child, with a disability, by the parent, and more broadly society. Using the contemporary example of prenatal testing, the authors explore how parents of children with disabilities may be influenced in abjecting the child. The implications of abjection of the child are then used to explore normalization, routinization of care and the development of standardized care practices within health-care. Prenatal screening practices and standardized care permeate medical obstetric care and social discourses regarding pregnancy and childbirth, thereby affecting not only healthcare professionals but also parents in their position as consumers of health-care. In a time when the focus of health-care is increasingly placed on disease prevention and broader medical and social discourses glorify normalcy and consistency, the unconscious abjection of those that do not fit within these standards must be identified and addressed.

Reflexivity, critical qualitative research and emancipation: a Foucauldian perspective.

AIM: In this paper, we consider reflexivity, not only as a concept of qualitative validity, but also as a tool used during the research process to achieve the goals of emancipation that are intrinsic to qualitative research conducted within a critical paradigm. BACKGROUND: Research conducted from a critical perspective poses two challenges to researchers: validity of the research must be ensured and the emancipatory aims of the research need to be realized and communicated. The traditional view of reflexivity as a means of ensuring validity in qualitative research limits its potential to inform the research process. DATA SOURCES: The Medline and CINAHL data bases were searched (1998-2008 inclusive) using keywords such as reflexivity, validity, subjectivity, bias, emancipation, empowerment and disability. In addition, the work of Michel Foucault was examined. DISCUSSION: Using the work of the late French philosopher Michel Foucault, we explore how Foucault's 'technologies of the self' can be employed during critical qualitative research to achieve emancipatory changes. Using research conducted with marginalized populations as an example (specifically, individuals with disabilities), we demonstrate the potential for using reflexivity, in a Foucauldian sense, during the research process. CONCLUSION: Shifting the traditional view of reflexivity allows researchers to focus on the subtle changes that comprise emancipation (in a Foucauldian sense). As a result, researchers are better able to see, understand and analyse this process in both the participants and themselves.

Nursing Best Practice Guidelines: reflecting on the obscene rise of the void.

AIM(S): Drawing on the work of Jean Baudrillard and Michel Foucault, the purpose of this article is to critique the evidence-based movement [and its derivatives - Nursing Best Practice Guidelines (NBPGs)] in vogue in all spheres of nursing. BACKGROUND: NBPGs and their correlate institutions, such as the Registered Nurses' Association of Ontario (RNAO) and 'spotlight' hospitals, impede critical thinking on the part of nurses, and ultimately evacuate the social, political and ethical responsibilities that ought to distinguish the nursing profession. EVALUATION: We contend that the entire NBPG movement is based on the illusion of scientific truth and a promise of ethical care that cannot be delivered in reality. We took as a case study the Registered Nurses' Association of Ontario (RNAO), in the province of Ontario, Canada. KEY ISSUES: NBPGs, along with the evidence-based movement upon which they are based, are a dangerous technology by which healthcare organizations seek to discipline, govern and regulate nursing work. CONCLUSION(S): Despite the remarkable institutional promotion of 'ready-made' and 'ready-to-use' guidelines, we demonstrate how the RNAO deploys BPGs as part of an ideological agenda that is scientifically, socially, politically and ethically unsound. Implications for nursing management Collaborations between health care organizations and professional organizations can become problematic when the latter dictate nursing conduct in such a way that critical thinking is impeded. We believe that nurse managers need to understand that the evidence-based movement is the target of well-deserved critiques. These critiques should also be considered before implementing so-called 'Nursing Best Practice Guidelines' in health care milieux.

Supporting cancer patients with palliative care needs: district nurses' role perceptions.

The aim of this study was to examine UK district nurses' perceptions of their role in supporting palliative care cancer patients. Patients with cancer are living longer with the disease. District nurses are the largest UK workforce caring for people with cancer at home, the preferred place of care. Meeting patients' supportive and palliative care needs is complex. Little is known about district nurses' supportive role in the early phase of palliative care. Semistructured interviews were conducted with 34 district nurses. Data were analyzed thematically, with assistance from Atlas/ti. A dominant theme emerging from the interviews was ambiguity in the district nurses' supportive role in early palliative care. District nurses discussed the importance of making contact early on to support cancer patients and their families but had difficulty articulating this "support." Ambiguity, lack of confidence, and perceived skill deficits presented district nurses with dilemmas that were difficult to resolve. District nurses have great potential for meeting cancer patients' supportive and palliative care needs, a potential not currently realized. Education alone is unlikely to improve practice without an understanding of the tensions faced by district nurses in their work. Recognizing and addressing dilemmas in the everyday work of district nurses is central to moving practice forward.

Palliative care in primary care: a study to determine whether patients and professionals agree on symptoms.

BACKGROUND: Difficulties in managing symptoms of palliative care patients at home have been identified, yet there has been no investigation of agreement on symptom assessment in primary care. Lack of agreement between patients' and primary care professionals' symptom assessments may be contributing to difficulties in symptom control. AIM: To investigate agreement on symptom assessments between patients at home and GPs and district nurses. DESIGN OF STUDY: Prospective, self-completed, structured symptom assessments. SETTING: Routine contacts with adult palliative care patients estimated to be in their last year of life. METHOD: Patient and professional symptom assessments were obtained using CAMPAS-R, a comprehensive and reliable measure validated for palliative care in the community. Prevalence of reported symptoms was calculated in patient-professional pairs. Intraclass correlation techniques (ICCs) and percentage agreement were used to determine how well symptom assessments of patients and professionals agreed. RESULTS: Anxiety and depression were significantly more likely to be reported by professionals, and GPs over-identified nausea, vomiting and constipation. Professionals assessed emotional symptoms as more severe than patients. Agreement on scoring of physical symptoms was better, although this was at least partially due to agreement on absence of symptoms. Unlike previous reports, pain scores recorded by doctors in this study, were not significantly different from patients. CONCLUSION: This quick and easy to complete assessment tool, CAMPAS-R, has potential for monitoring quality of palliative care symptom control at home.

Recruiting patients into a primary care based study of palliative care: why is it so difficult?

In the UK, researchers' access to study populations and control over selection of participants is becoming increasingly constrained by data protection and research governance legislation. Intervening stages placed between researchers and the population they wish to study can have serious effects on recruitment and ultimately on the validity of studies. In this paper we describe our experiences of gaining access to patients for a study of palliative care in primary care. Despite considerable time and resources dedicated to recruitment, a smaller than anticipated study sample was achieved. We found that gatekeeping by ethics committees and practitioner control over sample selection were significant hurdles in accessing patients for the study. Gatekeeping responsibilities represent considerable challenges for researchers seeking to obtain a representative study sample, not just in palliative care, but for research in general in health care.

Validation of a symptom measure suitable for use among palliative care patients in the community: CAMPAS-R.

The purpose of the study was to investigate psychometric properties of CAMPAS-R, an instrument for prospectively monitoring patients' symptoms and needs during palliative care at home. CAMPAS-R was piloted for face and content validity and then administered alongside criterion measures to a home care sample. Cronbach's alpha was used to test internal consistency and criterion-related validity was tested by non-parametric correlation with Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS) and EORTC QLQ-C30. Predictive validity was assessed by relating CAMPAS-R scores to survival. One hundred and nine patients were recruited to the study. Good reliability and high correlations between CAMPAS-R and criterion measures were found. Predictive validity was demonstrated by significant differences in symptom scores between groups differing in length of survival. CAMPAS-R is acceptable to patients, families and primary care professionals and is a valid, reliable instrument, which has the benefit of being easy to score.