Influences of Leadership, Organizational Culture, and Hierarchy on Raising Concerns About Patient Deterioration: A Qualitative Study.

BACKGROUND: Raising concerns is essential for the early detection and appropriate response to patient deterioration. However, factors such as hierarchy, leadership, and organizational culture can impact negatively on the willingness to raise concerns. OBJECTIVES: This study aims to delve into how leadership, organizational cultures, and professional hierarchies in healthcare settings influence healthcare workers, patients, and caregivers in raising concerns about patient deterioration and their willingness to do so. METHODS: The study used a qualitative approach, conducting focus group discussions (N = 27), utilizing authentic audio-visual vignettes to prompt discussions about raising concerns. Deductive thematic analysis was employed to explore themes related to hierarchy, leadership, and organizational culture. RESULTS: Positive leadership that challenged traditional professional hierarchies by embracing multidisciplinary teamwork, valuing the input of all stakeholders, and championing person-centered practice fostered a positive working culture. This culture has the potential to empower clinical staff, patients, caregivers, and family members to confidently raise concerns. Staff development, clinical supervision, and access to feedback, all underpinned by psychological safety, were viewed as facilitating the escalation of concerns and, subsequently, have the potential to improve patient safety. CONCLUSIONS: This study offers crucial insights into the intricate dynamics of leadership, hierarchy, and organizational culture, and their profound impact on the willingness of staff and patients to voice concerns in healthcare settings. Prioritizing the recommendations of this study can contribute to reducing avoidable deaths and elevating the quality of care in healthcare settings.

The impact of prior care experience on nursing students' compassionate values and behaviours: A mixed methods study.

BACKGROUND: Compassion is critical to the provision of high-quality healthcare and is foregrounded internationally as an issue of contemporary concern. Paid care experience prior to nurse training has been suggested as a potential means of improving compassion, which has been characterised by the values and behaviours of care, compassion, competence, communication, courage, and commitment. There is however a dearth of evidence to support the effectiveness of prior care experience as a means of improving compassion in nursing. OBJECTIVE: To explore the impact of paid prior care experience on the values and behaviours of pre-registration nursing students indicated as characterising compassionate care. DESIGN: Longitudinal mixed methods design employing a modified concurrent triangulation strategy, comprising two work packages. Work package 1 was qualitative, and work package 2 adopted a concurrent embedded strategy with a dominant quantitative component. Research is reported in accordance with the Good Reporting of a Mixed Methods Study framework. SETTING(S): Three United Kingdom universities. PARTICIPANTS: Pre-registration nursing students attending one of three universities, and individuals who had previously participated in a Health Education England paid prior care experience pilot. Participant numbers at time point 1 were questionnaires n = 220, telephone interviews n = 10, and focus groups n = 8. METHODS: Work package 1 consisted of longitudinal semi-structured telephone interviews. Work package 2 comprised validated online questionnaires measuring emotional intelligence, compassion satisfaction and fatigue, resilience, psychological empowerment, and career commitment (as proxies of compassionate values and behaviours), and focus groups. Qualitative data were thematically analysed. Quantitative data were analysed via Analysis of Variance in SPSS v 26. RESULTS: Qualitative findings suggest that prior care experience has both positive and negative effects on students' compassionate values and behaviours, however positive effects do not extend to qualification. No statistically significant differences were found in any of the quantitative outcome measures between participants with and without paid prior care experience. A statistically significant increase in compassion fatigue was identified in both groups of participants post-qualification. Paid prior care experience did not prevent participants from experiencing reality shock on becoming a student or on qualification. CONCLUSIONS: There is insufficient evidence of longitudinal beneficial impact to recommend paid prior care experience as an effective intervention to foster nursing students' compassionate values and behaviours. These findings do not support mandating a period of paid care experience as a prerequisite for entry into nurse education. REGISTRATION: N/A. Tweetable abstract Insufficient evidence of longitudinal beneficial impact to recommend prior care experience as an effective intervention to foster nursing student compassion @PriorCareExp @Sarah_F_R.

Evaluation of the impact of leadership development on nurses and midwives underpinned by transformational learning theory: a corpus-informed analysis.

PURPOSE: The purpose of this paper is to evaluate the impact of leadership development programmes, underpinned by Transformational Learning Theory (TLT). DESIGN/METHODOLOGY/APPROACH: A corpus-informed analysis was conducted using survey data from 690 participants. Data were collected from participants' responses to the question "please tell us about the impact of your overall experience", which culminated in a combined corpus of 75,053 words. FINDINGS: Findings identified patterns of language clustered around the following frequently used word types, namely, confidence; influence; self-awareness; insight; and impact. RESEARCH LIMITATIONS/IMPLICATIONS: This in-depth qualitative evaluation of participants' feedback has provided insight into how TLT can be applied to develop future health-care leaders. The extent to which learning has had a transformational impact at the individual level, in relation to their perceived ability to influence, holds promise for the wider impact of this group in relation to policy, practice and the promotion of clinical excellence in the future. However, the latter can only be ascertained by undertaking further realist evaluation and longitudinal study to understand the mechanisms by which transformational learning occurs and is successfully translated to influence in practice. ORIGINALITY/VALUE: Previous research has expounded traditional leadership theories to guide the practice of health-care leadership development. The paper goes some way to demonstrate the impact of using the principles of TLT within health-care leadership development programmes. The approach taken by The Florence Nightingale Foundation has the potential to generate confident leaders who may be instrumental in creating positive changes across various clinical environments.

The impact of care experience prior to commencing pre-registration nurse education and training: A scoping review.

OBJECTIVES: Compassion in nursing and interventions to support it are of international relevance and concern. Prior care experience as a prerequisite for entry into pre-registration nurse education is suggested as a means of improving compassion. The impact of prior care experience has not been comprehensively reviewed, therefore the potential effectiveness of prior care experience as a means of improving compassion is unknown. The scoping review question was 'What is known about the impact of care experience prior to commencing pre-registration nurse education and training?' The primary objective was to scope and synthesise existing literature relating to the topic and ascertain key themes pertaining to impact. A secondary objective was to appraise literature, to contextualise findings and assess the state and stage of knowledge and research in the area. DESIGN: The review was guided by Arksey and O'Malley's methodological framework and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist. DATA SOURCES: Health sciences databases CINAHL, Medline and PubMed. METHODS: Databases were searched in February 2019, updated August 2021. Data (study characteristics, findings, methodological observations) were extracted from papers meeting inclusion criteria (including peer-reviewed empirical papers with English language, electronic full-text available) and findings thematically analysed. RESULTS: Forty-five papers from 14 countries were included. The majority (64.4 %) were published in Europe (31.1 % in the United Kingdom) between 2010 and 2021 (69 %), 60 % from 2013. Four qualitative themes (compassionate care, commitment, competence and communication) describe the impact of prior care experience, which was variable. CONCLUSIONS: Evidence to support the effectiveness of prior care experience as a prerequisite for entry into nurse education to improve compassion, is inconsistent and insufficient. The literature displays methodological limitations and conclusions should be interpreted in light of these caveats. Recommendations are made for future research, to improve quality and comparability.

In Nightingale's footsteps: A qualitative analysis of the impact of leadership development within the clinical learning environment.

AIM: To identify and describe the impact areas of a newly developed leadership development programme focussed on positioning leaders to improve the student experience of the clinical learning environment. BACKGROUND: There is a need to consider extending traditional ways of developing leaders within the clinical learning in order to accommodate an increased number of students and ensure their learning experience is fulfilling and developmental. The Florence Nightingale Foundation implemented a bespoke leadership development programme within the clinical learning environment. Identifying the areas of impact will help to inform organisational decision making regarding the benefits of encouraging and supporting emerging leaders to undertake this type of programme. METHOD: For this qualitative descriptive study, eight health care professionals who took part in a bespoke leadership development programme were interviewed individually and then collectively. The Florence Nightingale Foundation fellowship/scholarship programme is examined to determine impact. RESULTS: Two key themes were described in relation to impact of the programme. These were 'Personal Development' and 'Professional Impact'. The two key themes comprised several subthemes. The notion of time and space to think was subsumed within each theme. CONCLUSION: Data highlights that the Florence Nightingale Foundation programme had a distinct impact on participants by transforming thinking and increasing self-confidence to enable changes to make improvements both within their organisations and at national level. IMPLICATIONS FOR NURSING MANAGEMENT: Health care managers must continue to invest in building leadership capacity and capability through programmes that can help position individuals to realize their potential to positively influence health outcomes and wider society.

Development of Nightingale Frontline: a leadership support service for nurses and midwives during the COVID-19 crisis.

BACKGROUND: As COVID-19 hit the UK, it was apparent that frontline healthcare workers would be faced with challenges they had never encountered before. The longer-term leadership support needs of nurses and midwives were considered central to how they would psychologically emerge from the COVID-19 response. In response, a national leadership support service for nurse and midwife leadersat all levels, was rapidly established. METHODS: A collaborative approach was used, drawing from an established community of healthcare leadership development consultants and senior healthcare leaders. Practical plans for how the service would run were formulated via online meetings, held between February and March 2020. An internal questionnaire was distributed to attendees, requesting demographic data and feedback to capture the perceived impact of the service on leadership. RESULTS: Overall, confidence in leadership ability/skills increased after attending the service; 68.8% of those who completed post-attendance questionnaires reported having learnt new leadership skills and a motivation to facilitate co-consulting sessions for their teams. The service was positively appraised and there were reports of a degree of influence on leadership, and improved confidence after attending. CONCLUSION: Leadership and well-being support provided by an independent and external organisation can offer a unique and safe forum for reflection and for healthcare leaders to decompress. This requires a sustainable investment to mitigate the predicted impact of the pandemic.

Establishing quality standards for graduate entry master of nursing curricula in Australia and New Zealand: A Delphi study.

AIM: To describe the common elements of Graduate Entry Master of Nursing curricula and identify a set of standards and quality indicators for benchmarking purposes within and across jurisdictions. BACKGROUND: Internationally, there has been an increase in universities offering Graduate Entry Masters programs in Nursing. Such programs specify a bachelor degree as an entry requirement and then offer an intensive program of study that prepares graduates for registration as a nurse. To date, no formal standards exist to guide evaluation of these curricula. DESIGN: A two phased sequential mixed-methods design comprising thematic content analysis of curricula and a Delphi study. The setting was the Australian and New Zealand tertiary education sectors. Participants were nurse academics who were recruited to participate in the Delphi study. Quota sampling was used to identify educators from the education providers meeting organisational inclusion criteria (program coordinator and one lecturer working as a subject coordinator of the program) and nominated by their Head of Department. METHODS: Phase One of the study involved a thematic analysis of the curricula of nine Graduate Entry Master of Nursing programs to identify common elements of curricula and domains of quality. In Phase Two these themes were used in a series of Delphi rounds to identify a set of agreed quality domains, statements and indicators. RESULTS: Participants (n = 16) responded over three Delphi rounds. A total of nine domains of quality were determined, a set of 26 quality statements were identified based on the acceptance threshold of > 75% level of agreement and 27 quality indicators were established. CONCLUSIONS: Our research provides an agreed set of indicators for evaluating the quality of Graduate Entry Master of Nursing programs. This work will also make it possible to measure the immediate and longer-term impacts of Graduate Entry Master of Nursing programs for the nursing workforce. Future work must focus on testing feasibility and optimising utility while refining indicators across jurisdictions.

Interventions to support graduate nurse transition to practice and associated outcomes: A systematic review.

OBJECTIVE: The aim of this mixed methods systematic review was to: i) document the interventions that support and facilitate graduate nurse transition from university to practice in a diversity of healthcare settings and ii) to identify outcomes from graduate nurse transition interventions for the graduate, patient or client, and health service. DESIGN: This mixed methods systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. All quantitative, qualitative, and mixed methods studies were included if they met the inclusion criteria. DATA SOURCES: Primary research studies located in Medline, EmBase, CINAHL, Prospero, Cochrane Library, PsycInfo, and Web of Science (Social Science Citation Index). All quantitative, qualitative, and mixed methods studies were included if they met the inclusion criteria. REVIEW METHODS: Using a comprehensive search strategy, retrieved articles were screened by two reviewers at the title, abstract, and full-text stage. Reviewer disagreements were discussed until consensus was achieved. The well-validated Mixed-Methods Appraisal Tool was used to assess quality of the quantitative, qualitative, and mixed methods studies. RESULTS: A total of 130 studies were included as the review dataset. There was a myriad of terms used to describe transition interventions, and programme length and settings varied. The content of transition interventions was not well defined, and there was a lack of studies outside acute hospital settings. Data collection methods varied widely. The majority of authors reported outcomes for the graduate or the graduate and service, with only one reporting outcomes for the patient or client. There was a significant variation in quality across the studies. CONCLUSIONS: This review addresses a significant gap in the literature by documenting transition interventions in a diversity of health settings and outcomes from these interventions. Interest in transition to practice continues to rise, but there is an urgent need to conduct well designed, robust, and larger-scale studies at the national and transnational levels.

The effects of compassion-based feedback on wellbeing ratings during a professional assessment healthcare task.

BACKGROUND: There is a need for higher education policy to consider how student nurses might be supported to help them to develop the resilience and mental wellbeing needed to cope with stressful environments. Reviews and qualitative research in this area suggest that compassion can improve wellbeing, however, compassion-based feedback is yet to be explored as a pedagogical intervention using quantitative methods. PURPOSE: To explore the effect of different feedback types on subjective wellbeing. METHODS: In this experimental design, nursing students were presented with three feedback types, 'compassion-based feedback, simple descriptive feedback, and utilitarian feedback' and were asked to provide post-trial ratings of subjective wellbeing, in relation to each type, whilst undertaking a nursing-related task. Participants also rated the helpfulness of 'Type of Feedback'. RESULTS: We report a significant difference of 'Type of Feedback' with higher ratings of wellbeing when participants were presented with compassion-based feedback. CONCLUSION: Compassion-based feedback could lead to higher wellbeing in educational tasks related to nursing.

Adopting a Global Virtual Team Approach to Enhance Performance of an International Nursing Research Collaboration.

ABSTRACT: Global mobility, technological developments, and evolved organizational design have expanded the scope of workplace teams beyond traditional arrangements, giving rise to global virtual teams. As universities across the world encourage mobility, there are unprecedented opportunities to create discipline-specific international networks, increase cross-cultural understanding, and create rich interactions in research. Team structure, trust formation, and communication processes are known to positively influence global virtual team performance. They are discussed to illustrate the value of a structured model of work in an international research-focused collaboration of nursing academics from the United States, the United Kingdom, and Australia.

The implementation of resilience based clinical supervision to support transition to practice in newly qualified healthcare professionals.

BACKGROUND: Healthcare workforce shortages are an international issue. This service development targets the contributory element of poor retention amongst newly qualified nurses. Resilience Based Clinical Supervision is underpinned by the principles of Compassion Focused Therapy. It aims to alleviate work related stress and support individuals to reframe their experiences through structured and reflective discussion. It incorporates skills which develop proficiency in mindfulness, distress tolerance and positive reframing. OBJECTIVES: To explore the acceptability, feasibility, and experience of Resilience Based Clinical Supervision to support transition to practice in newly qualified nurses. DESIGN: An extensive program of champion (N = 40) and cascade (N = 78) training for facilitators was implemented as a development of their standard transition to practice package. SETTINGS: Six pilot sites within the UK. PARTICIPANTS: Newly qualified nurses (266) received a minimum of six Resilience Based Clinical Supervision sessions over a one-year period. METHODS: Data were gathered via eleven focus groups (n = 48). A deductive and collaborative approach to content analysis was utilised to consider the perceived outcomes, challenges, experience and best practice amongst both facilitators and nurses' transitioning from student to registered practitioner. RESULTS: Analysis showed the new registrants were extending and accepting compassion to and from their peers, signifying the compassionate flow within the group setting. This was continued through the development of self-care strategies utilised in practice, which allowed compassion to flow into patient care and towards colleagues. CONCLUSIONS: The main perceived outcome of RBCS was recognised as restorative. However, the growth of skills for self-care, emotional intelligence, and confidence to challenge poor working conditions also indicated a developmental function. These perceived outcomes have the potential to result in positive implications for workforce retention. Importantly, findings draw attention to the importance of wider organisational commitment and structures which support and respond to RBCS facilitator and participant concerns.

Enhancing the quality of clinical supervision in nursing practice.

Clinical supervision has been an aspect of nursing practice in various forms for several years; however, it remains challenging to ensure its widespread implementation across healthcare organisations. There is an increasingly evident need for formalised support in nurses' busy practice settings, so it is important to improve the quality of clinical supervision in healthcare. This will also assist nurses in providing evidence of their continuing professional development as part of revalidation. This article provides an overview of clinical supervision, outlining its features and functions in healthcare practice. It includes three case studies related to group clinical supervision, discussing how this was implemented in each case and the various methods of group-working that were used.

A focus group study exploring student nurse's experiences of an educational intervention focused on working with people with a diagnosis of personality disorder.

WHAT IS KNOWN ON THE SUBJECT?: Research has consistently shown that poor attitudes exist in mental health care towards people with a diagnosis of personality disorder and that nurses can find working with this group of patients professionally and personally challenging. Power imbalances of practitioner over students exist on training placements. This can result in students being exposed to negative attitudes towards service users with a diagnosis of personality disorder and not feeling able to challenge these attitudes. The Knowledge and Understanding Framework (KUF) is a specialist programme of personality disorder training that has demonstrated effectiveness with qualified mental health professionals. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Although the subject of personality disorder is considered within preregistration education, an opportunity for a more robust approach to supporting student's nurses with this complex subject area is required (Ross & Goldner 2018). Attempts to integrate and evaluate specific educational interventions of this nature into preregistration nurse education have not been explored elsewhere. This study utilized focus groups to examine the experience of the KUF training and the perceived impact on attitudes and approaches to personality disorder of a group of nursing students who had completed the KUF programme. The students exhibited positive attitudes towards people with a diagnosis of personality disorder and confidence to influence negative attitudes in practice. The KUF shifted the students' focus from identifying patient behaviours as problematic towards an understanding of these difficulties arising from their own emotional responses. This was a small study so the results should be treated with caution. There was no follow-up once the students had qualified, so it is not clear whether such effects would endure long term. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Training students using the KUF may foster positive attitudes to people with a diagnosis of personality disorder and provide them with the skills to positively influence other colleagues practice. ABSTRACT: Introduction Negative attitudes exist in practice towards those with a diagnosis of personality disorder. Preregistration training offers the opportunity to address this by developing understanding of the diagnosis, confidence in working with people with the diagnosis and empowering new nurses to challenge prevailing attitudes. Attempts to integrate and evaluate specific educational interventions of this nature into preregistration nurse education have not been explored elsewhere. Aim To explore preregistration, nurses' experience of a programme of training focused on personality disorder and their perception of its influence on attitudes, understanding of clients and their experience of practice. Method A qualitative study using thematic analysis of two focus groups of preregistration mental health nursing students. Results Evidence of positive attitudes and confidence to supportively challenge negative attitudes in practice were found. Students showed a shift away from a focus on changing the perceived "difficult" behaviour of a client towards an understanding of their own emotional responses to the behaviours. Discussion The Knowledge and Understanding Framework training shows potential for students to change attitudes and develop progressive practice working with people with personality disorder. Implications for practice The integration of the Knowledge and Understanding Framework should be considered as part of preregistration training. Further research into the sustained influence of the training post registration is required.

Exploring the influence of feedback given by people with lived experience of mental distress on learning for preregistration mental health students.

WHAT IS KNOWN ON THE SUBJECT?: The involvement of those with lived experience is broadly understood to be beneficial to student learning. The consequence of the process and implications for learning are predominantly unexplored. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper explores an innovative co-produced model of involving people with lived experience in the assessment process of mental health nursing students. This method of assessment enables students to further critically analyze the application of humanistic skills and theories of person-centred care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The involvement of people with lived experience in the assessment process of students promotes self-awareness and empathy. It is questionable if learning which is potentially troublesome should act as a form of academic assessment which is exposed to the external judgement of another and awarded a credit-bearing grade. ABSTRACT: Introduction Despite a positive and established perception of people with lived experience of mental distress contributing to the assessment of healthcare professionals, the consequence and implications for learning are predominantly unexplored. Aim To gain a greater understanding of the influence of feedback given by people with lived experience, in the role of formative assessor, on student learning. Method Qualitative analysis, underpinned by the theory threshold concepts, was conducted on the written reflective assessments, submitted by students, following engaging in an assessment with a lived experience assessor. Results Student learning was influenced positively by the involvement of lived experience assessors in relation to person-centred care. However, students reported the experience to be anxiety provoking due to the desire to seek external approval and conceal personal challenges. Discussion The results indicate that the feedback from those with lived experience promotes greater self-awareness and empathy amongst students. The perceived expectation to present a competent and professional performance acts as a barrier to authentic person-centred practice. Implications for practice It is questionable if learning which is potentially troublesome should act as a form of academic assessment, which is exposed to the external judgement of another and awarded a credit-bearing grade.

The concept of compassion within UK media-generated discourse: A corpus-informed analysis.

AIMS AND OBJECTIVES: To examine how the concept of compassion is socially constructed within UK discourse, in response to recommendations that aspiring nurses gain care experience prior to entering nurse education. BACKGROUND: Following a report of significant failings in care, the UK government proposed prior care experience for aspiring nurses as a strategy to enhance compassion amongst the profession. Media reporting of this generated substantial online discussion, which formed the data for this research. There is a need to define how compassion is constructed through language as a limited understanding exists, of what compassion means in health care. This is important, for any meaningful evaluation of quality, compassionate practices. DESIGN: A corpus-informed discourse analysis. METHODS: A 62,626-word corpus of data was analysed using Laurence Anthony software "AntCon", a free corpus analysis toolkit. Frequent words were retrieved and used as a focal point for further analysis. Concordance lines were computed and analysed in the context of which frequent word-types occurred. Patterns of language were revealed and interpreted through researcher immersion. RESULTS: Findings identified that compassion was frequently described in various ways as a natural characteristic attribute. A pattern of language also referred to compassion as something that was not able to be taught, but could be developed through the repetition of behaviours observed in practice learning. In the context of compassion, the word-type "nurse" was used positively. CONCLUSION: This study adds to important debates highlighting how compassion is constructed and defined in the context of nursing. Compassion is constructed as both an individual, personal trait and a professional behaviour to be learnt. Educational design could include effective interpersonal skills training, which may help enhance and develop compassion from within the nursing profession. Likewise, ways of thinking, behaving and communicating should also be addressed by established practitioners to maintain compassionate interactions between professionals as well as nurse-patient relationships. Future research should focus on how compassionate practice is defined by both health professionals and patients. RELEVANCE TO CLINICAL PRACTICE: To maintain nursing as an attractive profession to join, it is important that nurses are viewed as compassionate. This holds implications for professional morale, associated with the continued retention and recruitment of the future workforce. Existing ideologies within the practice placement, the prior care experience environment, as well as the educational and organisational design, are crucial factors to consider, in terms of their influences on the expression of compassion in practice.

The importance, impact and influence of group clinical supervision for graduate entry nursing students.

This paper will report on an evaluation of group clinical supervision (CS) facilitated for graduate entry nursing (GEN) students whilst on clinical placement. The literature suggests educational forums which enable GEN students to engage in critical dialogue, promote reflective practice and ongoing support are an essential element of GEN curricula. The model of supervision employed was informed by Proctor's three function interactive CS model and Inskipp and Proctor's Supervision Alliance. Both emphasise the normative, formative and restorative functions of CS as task areas within an overarching humanistic supervisory approach. The three-function model informed the design of a questionnaire which intended to measure their importance, impact and influence through both structured and open-ended questions. Findings suggest the restorative function of supervision is most valued and is facilitated in an environment where humanistic principles of non-judgement, empathy and trust are clearly present. Also the opportunity to learn from others, consider alternative perspectives and question personal assumptions regarding capability and confidence are a priority for this student group. It is suggested that the restorative function of CS should be prioritised within future developments and models which view this function as a key purpose of CS should be explored.

Diagnosing and treating Enquiry Based Learning fatigue in Graduate Entry Nursing students.

The use of student directed study approaches such as Enquiry Based Learning (EBL) in the design and implementation of Graduate Entry Nursing Circular is well established. The rational relates to the maximisation of graduate attributes such as motivation to learn, the ability to identify, search and assimilate relevant literature and the desire to take ownership of the direction and pace of learning. Existing alongside this however, is the observation that students remain under confident in the application of knowledge to a clinical context and frustrated with learning approaches which do not appear directly related to improving their competence in this area. We suggest the result of this is a gradual disengagement and dissatisfaction the learning forum amongst students and faculty, which we have defined as EBL fatigue. The symptoms and consequences of EBL fatigue amongst students and faculty are discussed alongside strategies which we suggest may act as preventative measures in reducing the risk of a local epidemic.

Do graduate entry nursing student's experience 'Imposter Phenomenon'?: An issue for debate.

The recruitment of Graduates into the nursing profession is seen as advantageous in the academic literature. Conversely educated nurses are often portrayed in the media as "too posh to wash". We would argue these conflicting discourses have a negative effect on graduate entry nurse education. Graduate nursing students may be particularly susceptible to "Imposter Phenomenon" a concept that describes an "internal experience of intellectual phoniness" exhibited by individuals who appear successful to others, but internally feel incompetent. We would like to encourage debate through the presentation of a small set of pilot data that established that 70% of the participants had frequent to intense experiences of Imposter Phenomenon. Students experienced feelings of failure despite consistent high achievement. Our findings and the prevalent negative rhetoric surrounding highly educated student nurses raise concerns regarding the impact of the anti-intellectualism on the Graduate entry student's perception of self. Others may argue that this could simply be a 'natural' or expected level of anxiety in a time of transition that has no lasting impact. We debate this issue in relation to the existing literature to encourage critical dialogue.

A critical narrative analysis of shared decision-making in acute inpatient mental health care.

Shared decision-making (SDM) is a high priority in healthcare policy and is complementary to the recovery philosophy in mental health care. This agenda has been operationalised within the Values-Based Practice (VBP) framework, which offers a theoretical and practical model to promote democratic interprofessional approaches to decision-making. However, these are limited by a lack of recognition of the implications of power implicit within the mental health system. This study considers issues of power within the context of decision-making and examines to what extent decisions about patients' care on acute in-patient wards are perceived to be shared. Focus groups were conducted with 46 mental health professionals, service users, and carers. The data were analysed using the framework of critical narrative analysis (CNA). The findings of the study suggested each group constructed different identity positions, which placed them as inside or outside of the decision-making process. This reflected their view of themselves as best placed to influence a decision on behalf of the service user. In conclusion, the discourse of VBP and SDM needs to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.