Gratitude interventions to improve wellbeing and resilience of graduate nurses transitioning to practice: A scoping review.

Background: New graduate nurses are the nursing cohort at greatest risk for turnover and attrition in every context internationally. This has possibly been heightened during the COVID-19 pandemic. Workplace conditions significantly impact nursing turnover; however, interventions under the positive psychology umbrella may have a mediating impact on the intention to leave. New graduate nurses are generally challenged most in their first three years of clinical practice, and the need for support to transition is widely accepted. Gratitude practice has been reported to improve individual control and resilient response to setbacks and, therefore, is of interest in testing if this intervention can impact turnover intention in the workforce. Objective: To report on a scoping review undertaken to identify whether 'gratitude practice' as an intervention had the potential to improve new graduate nurses' wellbeing and resilience. Methods: Arksey and O'Malley's scoping review approach. Primary research papers of any methodology, published in English between January 2010 and July 2022 were included. Literature was sourced from seven databases, including CINAHL PLUS, ERIC, MEDLINE, Professional Development Collection, APA PsychInfo, APA PsychArticles, and Psychological and Behavioural Sciences Collection. Results: We identified 130 records, of which we selected 35 for inclusion. A large range of interventions were identified; most had some form of writing, journaling, or diarising. The next most common intervention was teaching gratitude strategies via workshops, and many interventions had some form of list or activity trigger for participants to complete. Five studies had complex combined interventions, while the rest were simple, easily reproducible interventions. Interventions were delivered both face-to-face or asynchronously, with some being online only and others sent out as a 'kit' for participants to work through. Conclusion: Our review of existing literature shows a significant gap in research on gratitude practice and its impact on nursing populations. To ensure robust future studies, we suggest defining concepts clearly and selecting outcome measures and tools that are not closely related. Intervention design may not be as important as the choice of measures and tools to measure outcomes.

Student Nurses' Perceptions of the Role of High-Fidelity Simulation in Developing Decision-Making Skills for Clinical Practice: A Qualitative Research Study.

Introduction: The integration of high-fidelity simulation (HFS) in nursing education has increased, but its effect on students' clinical decision-making skills and their ability to transfer these skills to clinical practice remains unclear. Aim: This qualitative study aimed to explore nursing students' perceptions of simulation's role in developing decision-making skills for clinical practice. Methods: Twenty-three self-selected final-year nursing students participated in an HFS exercise in 2016. They engaged in "think-aloud" activities during the simulation, reviewed videos of their performance, and attended a structured debriefing session. Four to six weeks later, face-to-face semistructured interviews were conducted to gather their views on the application of learning from simulation into practice. Thematic analysis was used to analyze the interview data. Results: Four themes emerged from the analysis: "enhancing clinical decision-making skills," "recognition of the types of clinical decision-making," "recognition of cognitive biases," and "transferability and integrating theory into practice." Simulation improved student self-awareness, decision-making skills, and recognition of cognitive biases applied in practice. Overall, students found that the simulation improved their ability to apply theoretical knowledge gained through simulation to practice. The students' perception of the authenticity of activities in relation to real-world scenarios played a crucial role in enhancing the transferability and application of acquired knowledge from simulation to clinical practice. Conclusion: The findings provide valuable insights into how simulation optimizes learning and decision-making skills, ultimately promoting effective care in clinical settings.

Investigating the clinical decision-making of nursing students using high-fidelity simulation, observation and think aloud: A mixed methods research study.

AIMS: The aim of this study was to investigate nursing students' clinical decision-making by using high-fidelity simulation of a deteriorated patient scenario. DESIGN: A convergent parallel mixed methods research design was used consisting of quantitative and qualitative data collection. METHODS: Twenty-three students completed the Health Science Reasoning Test before and after the simulation between October 2015 and June 2016. They were presented with a simulated scenario and asked to 'think aloud' during and after the simulation. The students were audio-video recorded and observations were collected by the researcher. RESULTS: There was a significant moderate increase in the 'deduction' and 'analysis' sub-scale scores and overall test score, suggestive of improved analytical decision-making processes through the simulation experience. Think-aloud and observation data identified that students predominantly applied 'forward' reasoning during the simulated 'patient's' deterioration, focusing mainly on cue acquisition. 'Backward' reasoning with a focus on cue interpretation was most prominent in the debriefing data, in line with the survey outcomes. Accurate cue interpretation of critical, key cues appeared more useful than the total number of cues in solving the main clinical case problem. CONCLUSION: Students learn different clinical decision-making skills during the simulation compared to what they learn from debriefing. Using observation and think-aloud methods have significant benefits for researchers seeking to optimize the evaluation of the clinical decision-making process.

The Use of 360-Degree Video in Developing Emotional Coping Skills (Reduced Anxiety and Increased Confidence) in Mental Health Nursing Students: A Protocol Paper.

Higher education institutions are uniquely placed to introduce emotional coping skills to promote resilience in pre-registration nurses in order to reduce anxiety and increase confidence before they enter clinical placement for the first time. In this qualitative study, we will explore the use of a 360-degree video in developing skills for coping. The participants will be mental health nursing students. We will develop a 360-degree video in collaboration with a mental health service user. All participants will watch the video. A sub-group will receive a supportive clinical supervision discussion within a cognitive reappraisal/solution-focused/VERA framework. We will record the experiences of the participant to explore: (1) how students felt about the use of 360-degree video, as an education tool to build skills of resilience; (2) whether the students involved felt more confident and less anxious about the situation in the video as a result of participating in the cognitive reappraisal/solution-focused/VERA supervision discussion.

Utilization of Job Demands-Resources (JD-R) Theory to Evaluate Workplace Stress Experienced by Health Care Assistants in a UK In-Patient Dementia Unit after 10 Years of National Financial Austerity (2008-2018).

AIMS: Workplace stress for support workers in UK hospitals (Health Care Assistants; HCAs) is poorly understood. This study explores experiences of HCAs working in a National Health Service in-patient dementia unit after 10 years of national financial austerity (2008-2018). DESIGN: Qualitative evaluation. METHODS: 15 HCAs (42%) from a specialist dementia care Unit were interviewed. Interviews were guided by UK Health & Safety Executive published dimensions of work stress. Framework analysis was applied to interview transcriptions, corroborated by a follow-up focus group (6 HCAs). Post hoc interviews with 10 nurses were later introduced to obtain a balanced view of teamwork on the Unit. RESULTS: Health care assistants were altruistic regarding demands of dementia care but otherwise negative of most aspects of their work environment. Staff shortages had increased job demands: workload, poor shift rotas, and excessive reliance on inexperienced agency staff. According to HCAs, job resources of the care team were in significant deficit: nurses in charge were perceived as poor team leaders, had poor interpersonal skills, lacked respect for experienced HCAs, and deemed to be frequently absent from the ward so failing to support carers. HCAs' lack of decision-latitude exacerbated the situation. In contrast, nurses interviewed did not recognise the teamwork issues raised by HCAs, who were considered obstructive, unsupportive, lacked awareness of nurses' responsibilities, and of insights how understaffing meant excessive administration and time required to support patients' relatives. Such dissonant inter-group views caused considerable friction and exacerbated the work pressure. CONCLUSION: Study outcomes spotlighted impacts of socioeconomic issues for HCAs. Staff shortage, exacerbated by financial austerity measures (pre-COVID pandemic), increased job demands for HCAs but their psychosocial job resources were in serious deficit, so putting them at risk of burnout. Inter-group relations are key for a collaborative ethos, and are amenable to interventions. Such difficulties should not be allowed to fester.

Promotion of professional quality of life through reducing fears of compassion and compassion fatigue: Application of the Compassionate Mind Model to Specialist Community Public Health Nurses (Health Visiting) training.

AIMS AND OBJECTIVES: To identify whether a Compassionate Mind Model-based curriculum reduces students' perceived fears of compassion and improves their professional well-being. BACKGROUND: Enabling compassion is mandatory within nurse education but evidencing it is challenging. Research suggests that application of the Compassionate Mind Model might reduce students' fears of compassion and also decrease compassion fatigue. This study reports outcomes of a post-registration curriculum based on that model for training Specialist Community Public Health Nurses (Health Visiting). DESIGN: A quantitative, prospective evaluation of a 12-month training course for Health Visiting students. Reporting was guided by the STROBE checklist for observational studies. METHODS: Fears of compassion scales were applied at course start (time 1), mid-point (time 2; +6 months) and end (time 3; +12 months) to evaluate fears of compassion of 26 post-registration student Health Visitors (81% of course cohort) who provided data at all three points. The Professional Quality of Life tool was administered simultaneously to evaluate compassion satisfaction and burnout/secondary traumatic stress (compassion fatigue). RESULTS: Between time 1 and time 3, mean fears of compassion scores decreased by 16.6-48.5% (repeated measures analysis of variance); mid-point scores were intermediary. At time 3, compassion satisfaction had increased slightly (+4.1%), negatively correlated with fears of compassion for self (r = -0.602; p = .001; n = 26) and fears of receiving compassion from others (r = -0.568; p = .002; n = 26). Burnout score decreased by 18.7%, correlated positively with fear of compassion for self (r = 0.493; p = .011; n = 26) and fear of receiving compassion from others (r = 0.615; p = .001; n = 26). Secondary traumatic stress score decreased by 16.5% but was not correlated with any fear of compassion. CONCLUSION: Findings suggest that application of the Compassionate Mind Model might reduce practitioners' fears of compassion linked to a decrease in risk of compassion fatigue. RELEVANCE TO CLINICAL PRACTICE: The Compassionate Mind Model could provide an effective vehicle to promote compassion and nurse well-being.

Work Stress in NHS Employees: A Mixed-Methods Study.

The United Kingdom's National Health Service (NHS) has a higher-than-average level of stress-related sickness absence of all job sectors in the country. It is important that this is addressed as work stress is damaging to employees and the organisation, and subsequently impacts patient care. The aim of this study was to gain an in-depth understanding of working conditions and wellbeing in NHS employees from three employing NHS Trusts through a mixed-methods investigation. First, a cross-sectional organisational survey was completed by 1644 respondents. Questions examined working conditions, stress, psychological wellbeing, job satisfaction, and presenteeism. This was followed by 33 individual semistructured interviews with NHS staff from a variety of clinical and nonclinical roles. Quantitative findings revealed that working conditions were generally positive, although most staff groups had high levels of workload. Regression outcomes demonstrated that a number of working conditions influenced mental wellbeing and stress. Three themes were generated from thematic analysis of the interview data: wellbeing at work, relationships, and communication. These highlight areas which may be contributing to workplace stress. Suggestions are made for practical changes which could improve areas of difficulty. Such changes could improve staff wellbeing and job satisfaction and reduce sickness absence.

Releasing latent compassion through an innovative compassion curriculum for Specialist Community Public Health Nurses.

AIMS: To evaluate the impact of a curriculum based on the Compassionate Mind Model (CMM) designed to facilitate the expression of compassion in Specialist Community Public Health Nurses. BACKGROUND: The CMM identifies that fear of compassion creates a barrier to the flow of compassion. There is some evidence linking self-compassion to compassionate care but no previous research has explored this potential with postregistration specialist community public health nursing students. DESIGN: Prospective, longitudinal design using focus group interviews. METHODS: Twenty six students (81% of cohort) agreed to participate in a wider evaluation (2014-2015). For this study, two groups were drawn from those participants (total 13 students) who attended audio-taped group interviews at the course mid- and end-points to explore their perceptions on compassion and compassionate care. Transcripts were analysed thematically. FINDINGS: Several subthemes were identified. "Cultural change in the NHS", "Workload and meeting targets" and "Lack of time were barriers to compassionate care, as was negative "Role modelling". These were collated under a macro-theme of "A culture lacking in compassion". Secondly, the subthemes "Actualization of compassion" and "Transformation" were collated within a macro-theme: "Realization of compassion". This theme identified realization of latent compassion from their previous roles that in some transferred into students' personal lives suggesting a transformation beyond professional attitude. CONCLUSION: The curriculum facilitated a realization of compassion in students over the period of the course by enhancing their capacity to be self-compassionate and by actualization of compassion that had previously been suppressed.

The impact of prolonged disorders of consciousness on the occupational life of family members.

The impact of vegetative state (VS) and minimally conscious states (MCSs) on an individual is devastating. VS and MCSs may be transitional towards recovery, but may become permanent. Although devastating for the individual the nature of these conditions also has a profound effect on the family. This study examined the impact on the family member and the changes in the individuals' occupation. Six participants (spouses, partners or parents) were recruited to the study. Mixed methods were adopted to meet the requirements of the research and participants. Data were collected at 6 and 12 months post-injury, using time diaries, a questionnaire and semi-structured interviews. At 6 months post-injury the greatest amount of carers' time was allocated to occupations involving the person in a Disorder of Consciousness and less time to social and leisure activities. Participants had difficulty viewing the future, lacked the desire or capacity to engage in previously enjoyed activities. At 12 months those impacts were still evident although changing. The transition to balanced occupational activity is slow, requiring a number of catalysts to change. A conceptual framework for a return to balance is provided, and guidance on advice from family members to families in a similar situation is given.

Influence of Study Design on Outcomes Following Reflexology Massage: An Integrative and Critical Review of Interventional Studies.

BACKGROUND: Interpretation of the efficacy of reflexology is hindered by inconsistent research designs and complicated by professional views that criteria of randomized controlled trials (RCTs)are not ideal to research holistic complementary and alternative medicine practice. The influence of research designs on study outcomes is not known. This integrative review sought to evaluate this possibility. MATERIALS AND METHODS: Thirty-seven interventional studies (2000-2014) were identified; they had RCT or non-RCT design and compared reflexology outcomes against a control/comparison group. Viability of integrating RCT and non-RCT studies into a single database was first evaluated by appraisal of 16 reporting fields related to study setting and objectives, sample demographics, methodologic design, and treatment fidelity and assessment against Jadad score quality criteria for RCTs. For appraisal, the database was stratified into RCT/non-RCT or Jadad score of 3 or more or less than 3. Deficits in reporting were identified for blind assignment of participants, dropout/completion rate, and School of Reflexology. For comparison purposes, these fields were excluded from subsequent analysis for evidence of association between design fields and of fields with study outcomes. RESULTS: Thirty-one studies applied psychometric tools and 20 applied biometric tools (14 applied both). A total of 116 measures were used. Type of measure was associated with study objectives (p < 0.001; chi-square), in particular of psychometric measures with a collated "behavioral/cognitive" objective. Significant outcomes were more likely (p < 0.001; chi-square) for psychometric than for biometric measures. Neither type of outcome was associated with choice of RCT or non-RCT method, but psychometric responses were associated (p = 0.007) with a nonmassage control strategy. CONCLUSIONS: The review supports psychometric responses to reflexology when study design uses a nonmassage control strategy. Findings suggest that an evaluation of outcomes against sham reflexology massage and other forms of massage, as well as a narrower focus of study objective, may clarify whether there is a relationship between study design and efficacy of reflexology.

Scoping the common antecedents of job stress and job satisfaction for nurses (2000-2013) using the job demands-resources model of stress.

AIM: To identify core antecedents of job stress and job satisfaction, and to explore the potential of stress interventions to improve job satisfaction. BACKGROUND: Decreased job satisfaction for nurses is strongly associated with increased job stress. Stress management strategies might have the potential to improve job satisfaction. EVALUATION: Comparative scoping review of studies (2000-2013) and location of their outcomes within the 'job demands-job resources' (JD-R) model of stress to identify commonalities and trends. DISCUSSION: Many, but not all, antecedents of both phenomena appeared consistently suggesting they are common mediators. Others were more variable but the appearance of 'emotional demands' as a common antecedent in later studies suggests an evolving influence of the changing work environment. The occurrence of 'shift work' as a common issue in later studies points to further implications for nurses' psychosocial well-being. CONCLUSIONS: Job satisfaction problems in nursing might be co-responsive to stress management intervention. Improving the buffering effectiveness of increased resilience and of prominent perceived job resource issues are urgently required. IMPLICATIONS FOR NURSING MANAGEMENT: Participatory, psychosocial methods have the potential to raise job resources but will require high-level collaboration by stakeholders, and participative leadership and facilitation by managers to enable better decision-latitude, support for action planning and responsive changes.

Self-efficacy and relevance of bioscience for nursing, midwifery and healthcare students.

AIMS AND OBJECTIVES: To examine nursing, midwifery and allied healthcare students' self-efficacy for science, perceived relevance of bioscience to their studies and expectations for academic success and the changes that occur after completing first-year introductory bioscience subjects. BACKGROUND: Bioscience is a foundation subject that underpins nursing, midwifery and other allied health courses. Bioscience subjects continue to be source of anxiety for students in those courses. Raising students' self-efficacy and perceptions of the importance and utility of bioscience to practice may be a way of ameliorating students' expectations and confidence in this subject area. DESIGN: A prospective correlational survey design. METHODS: Students were surveyed in the first semester of first year and the commencement of the second year. Students were drawn from nursing, midwifery, public health and allied health courses. The surveys contained scales for self-efficacy for science, perceived relevance of bioscience to their course and personal expectations for success in their bioscience subject. RESULTS: Ninety-seven and 82 students completed survey 1 and 2 respectively. Twenty-six surveys could be matched. Self-efficacy increased from survey 1 to survey 2, but expectations for academic success and task value, a measure for relevance, were lower. This was statistically significant for the matched pair sample. Using a mean split, students with high self-efficacy valued science more and had higher expectations for success in their bioscience courses than those with low self-efficacy. CONCLUSION: Academic success in bioscience, confidence undertaking science tasks and perceiving bioscience as relevant to their course are interwoven concepts that are important for nursing, midwifery and applied healthcare students and ultimately for their professional practice. RELEVANCE TO CLINICAL PRACTICE: Literature indicates practitioners may not feel confident in their bioscience knowledge. Assisting undergraduate students to develop confidence in and perceive the relevance of bioscience to their discipline may ultimately impact on clinical practice.

The 'bioscience problem' for nursing students: an integrative review of published evaluations of Year 1 bioscience, and proposed directions for curriculum development.

BACKGROUND: The difficulties that nursing students have in learning human biosciences have given cause for concern for over 20 years but the problem remains. OBJECTIVE: To conduct an integrative review of published primary research into the 'bioscience problem', evaluate their outcomes, and provide a contemporary analysis of potential directions for curriculum planners. REVIEW METHODS: A systematic search of electronic databases CINAHL, Medline, British Nursing Index and Google Scholar was conducted for empirical research studies, published between 1990 and 2013, designed to either predict performance of students in bioscience assessments in Year 1 of their studies or identify in-course curriculum delivery issues. RESULTS: The search generated nineteen papers that met inclusion criteria. Twelve papers involved predictive factors for bioscience attainment and seven surveyed student views on curriculum issues. Four others that surveyed reflections of later-year students or qualified nurses on Year 1 outcomes were also retained for additional context. Prediction based on pre-admission academic achievement was not reliable. Student factors including age at entry, self-efficacy in science, and having appropriate study skills in particular appear to be confounding factors. In-course influences such as teaching strategy or lecturer skills are also inconsistent and likely to represent confounders operating at local, institutional level. CONCLUSIONS: The integrative review approach enabled analysis of incongruencies between studies that have been a barrier to curriculum development. Sound admissions criteria based on pre-university academic performance show promise in resolving the 'bioscience problem' but will likely be contingent on innovative support early in Year 1 for study skills and the fundamentals of human bioscience, plus attention to local quality assurance for curriculum delivery.

Biosciences within the pre-registration (pre-requisite) curriculum: an integrative literature review of curriculum interventions 1990-2012.

BACKGROUND: The learning of biosciences is well-documented to be problematic as students find the subjects amongst the most difficult and anxiety-provoking of their pre-registration programme. Studies suggest that learning consequently is not at the level anticipated by the profession. Curriculum innovations might improve the situation but the effectiveness of applied interventions has not been evaluated. OBJECTIVE: To undertake an integrative review and narrative synthesis of curriculum interventions and evaluate their effect on the learning of biosciences by pre-registration student nurses. Review methods A systematic search of electronic databases CINAHL, Medline, British Nursing Index and Google Scholar for empirical research studies was designed to evaluate the introduction of a curriculum intervention related to the biosciences, published in 1990-2012. Studies were evaluated for design, receptivity of the intervention and impact on bioscience learning. RESULTS: The search generated fourteen papers that met inclusion criteria. Seven studies introduced on-line learning packages, five an active learning format into classroom teaching or practical sessions, and two applied Audience Response Technology as an exercise in self-testing and reflection. Almost all studies reported a high level of student satisfaction, though in some there were access/utilization issues for students using on-line learning. Self-reporting suggested positive experiences, but objective evaluation suggests that impacts on learning were variable and unconvincing even where an effect on course progress was identified. Adjunct on-line programmes also show promise for supporting basic science or language acquisition. CONCLUSIONS: Published studies of curriculum interventions, including on-line support, have focused too heavily on the perceived benefit to students rather than objective measures of impact on actual learning. Future studies should include rigorous assessment evaluations within their design if interventions are to be adopted to reduce the 'bioscience problem'.

Evaluation of the currency of the Davies and Oberle (1990) model of supportive care in specialist and specialised palliative care settings in England.

AIMS AND OBJECTIVES: To evaluate the extent to which the Davies and Oberle (1990) model of supportive nursing has currency across specialist and specialised care settings in England. BACKGROUND: The model describes attributes of palliative nursing for practice and associated educational curricula. It is influential but predates introduction of specialist/specialised care. Its applicability in contemporary care settings has not been evaluated. DESIGN: Evaluation was undertaken using sequential mixed methods, predominantly qualitative. Data collected during 2008-2009. METHODS: Four stages: (1) focus groups involving hospital and community palliative clinical nurse specialists and nurses from three hospice settings (total = 25) to identify setting-specific characteristics, (2) survey of nurses (n = 48 respondents/31%) with follow-up interviews (n = 25) to identify congruence with the model, (3) interviews with patients (n = 6) and carers (n = 13) for practice evidence and (4) reconvened focus groups (n = 19 nurses) for confirmation. RESULTS: All major dimensions were evidenced. 'Connecting' had reduced emphasis in the hospital setting where specialist nurses spend limited time with patients, but diminishing time to 'connect' with patients and carers as service develops could potentially become problematic across all settings. Two new dimensions ('Displaying expertise' and 'Influencing other professionals') with subdimensions (e.g. 'Advanced communication skills') are proposed as additions to reflect advanced practice. Further new subdimensions ('Making the assessment', 'Prioritising', 'Agreeing the plan') are suggested to be best aligned with the existing dimension 'Connecting'. CONCLUSIONS: A revised model of supportive care incorporating dimensions of advanced nursing has currency in contemporary specialist/specialised care settings, although evaluation is required as to the actual impact of the model on care outcomes. 'Connecting' is currently being affected by pace of work and lateness of referrals. IMPLICATIONS FOR PRACTICE: 'Spending time' is increasingly difficult to sustain so challenging nurses as to how they may continue to 'connect' with patients as service delivery continues to change.

Biology of stress revisited: intracellular mechanisms and the conceptualization of stress.

Application of allostatic theory to stress during the 1990s refocused attention on internal responses to a perceived hazard, and the last 20 years has seen considerable developments in the biological contexts of stress. Evidence from neuroscience now suggests that secretion of the hormone cortisol is not only stimulated by the outcomes of cognitive transaction but it also feeds back and contributes positively to the cognitive adaptation that is a feature of stress resilience. More recently, the operative intracellular mechanisms are beginning to be understood and provide an insight into the regulation and maintenance of intracellular homeostasis that underpins adaptive change and vulnerability. The maintenance or appropriate modulation of intracellular homeostasis usually provides a buffering of potential adverse interactions. However, the capacity to do so is diminished during chronic stress leading to intracellular and subsequently systemic, homeostatic failure and hence maladaptation. This area of research seems far removed from cognitive theory, but placing intracellular homeostasis at the core of cognitive and biological responses supports the concept of stress as a genuinely psycho-biological phenomenon.

Cough strength, secretions and extubation outcome in burn patients who have passed a spontaneous breathing trial.

The aim of this study was to develop a clinical prediction model to inform decisions about the timing of extubation in burn patients who have passed a spontaneous breathing trial (SBT). Rapid shallow breathing index, voluntary cough peak flow (CPF) and endotracheal secretions were measured after each patient had passed a SBT and just prior to extubation. We used multiple logistic regression analysis to identify variables that predict extubation outcome. Seventeen patients failed their first trials of extubation (14%). CPF and endotracheal secretions are strongly associated with extubation outcome (p<0.0001). Patients with CPF ≤60 L/min are 9 times as likely to fail extubation as those with CPF >60 L/min (risk ratio=9.1). Patients with abundant endotracheal secretions are 8 times as likely to fail extubation compared to those with no, mild and moderate endotracheal secretions (risk ratio=8). Our clinical prediction model combining CPF and endotracheal secretions has strong predictive capacity for extubation outcome (area under receiver operating characteristic curve=0.96, 95% confidence interval 0.91-0.99) and therefore may be useful to predict which patients will succeed or fail extubation after passing a SBT.

Homeostasis 5: nurses as external agents of control in breast cancer.

Breast cancer is caused by a homeostatic imbalance of cell division. Healthcare practitioners need to understand cellular activities to appreciate the physiological basis of health (homeostasis), the pathophysiological basis of illness and the physiological rationale of healthcare. Cells are the 'basic unit of life' (Clancy and McVicar, 2011a). This article describes normal cell division and the anatomy and physiology of the breast and, using a case study, will show how breast cancer is a homeostatic imbalance of cell division. There are analogies between the components of homeostasis and the components of the nursing (healthcare) process (Clancy and McVicar, 2011b) in the condition of breast cancer. After reading this article, nurses should be able to: understand that breast cancer is a cellular hence chemical imbalance that causes uncontrollable mitotic division of breast cells; understand how the cell cycle of cancer cells differs from that of normal cells; identify nature-nurture interactions involved in the aetiology of breast cancer; understand that when caring for people with breast cancer, health professionals including oncology nurses are acting as external agents of homeostatic control as the patient 'recovers' from breast cancer, and also to some extent when reducing signs and symptoms, hence quality of life, by providing palliative care.

Homeostasis 6: nurses as external control agents in rheumatoid arthritis.

All disorders involve a disturbance of cellular and hence chemical function in the body. Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease that usually attacks synovial joints and surrounding ligaments, muscles and their tendons and blood vessels. This article applies the concept of health professionals operating as external agents of homeostatic control (Clancy and McVicar, 20011a; 2011b) to RA and to the care of affected patients, using a case scenario to illustrate attempts to minimize homeostatic imbalances. After reading the article, nurses should be able to understand: how the principles of homeostatic theory apply to skeletomuscular function, in particular to synovial joint function; the skeletomuscular homeostatic role in movement; and that homeostatic failure of reduced mobility, as in RA, is a result of nature-nurture interaction; that illness arises from a cellular, hence chemical, homeostatic imbalance(s) (Clancy and McVicar, 2011a; 2011b; 2011c; 2011d; 2011e). RA is considered a cellular (B-lymphocyte) hence chemical (autoantibody) imbalance that causes the homeostatic imbalances (inflammatory pain, reduced mobility, reduced activities of daily living) associated with the condition. Health professionals are able at act as external agents of homeostatic control to only a limited extent when caring for people with RA because, as with any progressive disorder, they will only be managing signs and symptoms to improve patients' quality of life.

Homeostasis 2: nurses as external agents of homeostatic control.

There are analogies between the components of homeostatic control and the components of the nursing process. Some nurses are familiar with the terms 'normal' and 'homeostasis' when referring to parameters of assessment associated with observations of vital signs, blood results and urinalysis. However, few nurses relate the components of homeostasis with the components of the nursing process. The last article, the first in a series of six (Clancy and McVicar, 2011), discussed the principles of homeostasis in restoring normal body function. This article, and others in this series, will discuss how the principles of homeostasis apply to health, illness and healthcare intervention. Taking a case study approach, the authors will highlight the role of the nurse as an external agent of homeostatic control. Nature-nurture interactions are responsible for health, illness and individualized health care.