Barriers to Advance Care Planning in Older Adults With Dementia, Their Families and Healthcare Professionals: An Umbrella Review of Qualitative Evidence.

This umbrella review aimed to examine and synthesize qualitative studies that explored the barriers and facilitators of advance care planning for persons with dementia, their families, and their healthcare professionals and caregivers. The modified umbrella review approach developed by the Joanna Briggs Institute was followed. Five major English databases were searched. Four reviews based on 38 primary qualitative studies were included. The methodological quality of the included reviews was moderate to high. The synthesis yielded 16 descriptive themes and five analytical themes: making the wishes/preferences of persons with dementia visible; constructive collaboration based on stakeholders having positive relationships; emotional chaos in facing end-of-life substitute decision-making; initiating the advance care planning process; and preparedness and commitment of healthcare providers to advance care planning. Comprehensive and workable strategies are required to overcome complex and interrelated barriers involving not only healthcare professionals but also organizational and systemic challenges.

Followership in health care clinicians: a scoping review.

OBJECTIVE: The objective of this scoping review was to identify and map the existing literature on the current state of followership research in relation to health care clinicians. INTRODUCTION: Health care clinicians need to be flexible in switching between leader and follower roles, as appropriate, to advance patient care; however, much of the existing research has concentrated on leadership. Effective followership in health care organizations is necessary to enhance clinical team performance in order to improve patient safety and quality of care. This has led to recommendations to increase the amount of research on followership. It is therefore important to synthesize the available evidence on followership to identify what has been studied and to highlight the research gaps in this area. INCLUSION CRITERIA: Studies that involved health care clinicians (eg, physicians, nurses, midwives, allied health professionals) and were focused on the concept of followership (eg, conceptualization of followership, attitudes toward the role of followership) were included in the review. Any clinical health care practice setting where direct patient care is provided was included. The review considered studies with quantitative, qualitative, or mixed methods designs; systematic reviews; and meta-analyses. METHODS: The search was conducted in JBI Evidence Synthesis , Cochrane Database of Systematic Reviews, CINAHL, MEDLINE, EPPI, Scopus, ScienceDirect, and Epistemonikos databases. In addition, unpublished or gray literature was searched for in ProQuest Dissertations and Theses Global and Google Scholar. No limits on the date or language were applied to the search. Data were extracted from the papers by 3 independent reviewers, and review findings are presented in tables, figures, and a narrative summary. RESULTS: A total of 42 papers were included. In articles that researched followership in health care clinicians, 6 categories were identified: followership styles, followership impact, followership experience, followership features, assertive followership, and followership interventions. Several study types were employed to investigate followership among health care clinicians. Descriptive statistics were used to identify clinicians' followership/leadership styles and characteristics in 17% of the studies. Approximately 31% of the studies were qualitative and observational studies used to understand health care clinicians' roles, experiences, perceptions of followership, and barriers to effective followership. For 40% of the studies, an analytical approach was used to explore the impact of followership on individuals, organizations, and clinical practice. Approximately 12% of studies were interventional studies that examined the effectiveness of training and education in enhancing health care clinicians' followership knowledge and skills. CONCLUSIONS: While several aspects of followership among health care clinicians have been addressed, research is still lacking in some important areas, such as the impact of followership on clinical practice and followership interventions. The literature also lacks practical capability and competency frameworks on followership. No longitudinal studies have examined the association between followership training and occurrence of clinical errors. Cultural effects on the followership styles or behaviors of health care clinicians were not addressed. There is also a lack of mixed methods approaches in followership research. More research is required to fully understand the role of followership in health care clinicians. SUPPLEMENTAL DIGITAL CONTENT: An Arabic-language version of the abstract of this review is available [ http://links.lww.com/SRX/A20 ].

Followership in nurses working in Saudi Arabian hospitals: A cross-sectional study.

AIM: To explore the followership styles and their associations with nurses' sociodemographic profiles in Saudi Arabia. BACKGROUND: In Saudi Arabia, nurses' role is seen as less important and passive. However, whether they were actually passive followers has not been examined. No previous research has examined nurses' followership styles in Saudi Arabia. METHODS: This cross-sectional study used a convenience sample of nurses. The Kelley followership questionnaire-revised was used to determine the prevalence of the five followership styles. Participants' demographic characteristics, which included age, gender, nationality, education level, years of experience, and role, were collected to investigate their associations with followership styles. An online survey was designed and distributed using SurveyMonkey®. Data were analyzed with logistic regression and expressed as odds ratios. RESULTS: This study included 355 nurses. Findings revealed that the predominant followership style was exemplary (74%), followed by the pragmatist (19%), conformist (4%), and passive styles (3%). Logistic regression analysis revealed that expatriates, higher education, and a leader role had an independent association with an exemplary followership style. Male gender was associated with a passive style. Younger age, male gender, Saudi Arabian nationality, undergraduate qualification, no previous leadership experience, a follower role, and fewer years of experience increased the odds of having a pragmatist style. CONCLUSION AND IMPLICATIONS: Followership styles were influenced by sociodemographic and work-related factors. Young nurses with less experience tend to be pragmatist followers. Nursing managers should integrate followership styles when planning leadership and team development courses to ensure maximum team effectiveness as leadership and followership are interdependent.

The experiences and perceptions of nurses regarding patient care provision in acute medical and surgical care units of two hospitals in Ethiopia.

BACKGROUND: Patient safety is a major concern for health care systems in both high-income and low- and middle-income countries (LMICs). Nurses play a key role in ensuring patient safety. Existing research on nurses' perception of patient safety is limited to high-income countries and there is a relative scarcity of evidence on the perceptions of nurses from LMICs. Therefore, the aim of this study was to explore nurses' perceptions and experiences of the provision of patient care and its impact on patient safety, and nurses' own health and wellbeing. METHODS: An exploratory descriptive qualitative study using in-depth semi-structured interviews was conducted in two hospitals' medical and surgical units in Amhara Regional State, Ethiopia. Purposeful sampling was used for the selection of participants. Thirteen nurses were interviewed. Thematic analysis was conducted using NVivo 12. RESULTS: Three major themes were identified: nurses are concerned about patient safety and quality of care provided; nurses' own health and wellbeing; and lack of support for nursing practice from hospital administration. Nurses reported that their working units were not suitable to ensure safe and quality patient care. Their level of concern differed from one unit to another. Inadequate nurse staffing and material resources, unfavourable work environment, and lack of appropriate leadership support for nursing practice were among the main challenges reported by nurses. CONCLUSIONS: Nurses described that they were committed to providing high-quality nursing care. However, they did not feel that their work environment was conducive to facilitating this care. Ensuring a favourable work environment for nurses would help to improve the quality of patient care, and in the reduction of nurses' turnover.

Missed nursing care, nurse staffing levels and patient safety outcomes in low-income country acute care settings: An observational study.

AIMS: The aim of this study was to measure the level of missed nursing care and determine its relationship with nurse staffing and patient safety outcomes in acute care settings in Ethiopia. BACKGROUND: Missed nursing care in hospitals increases the likelihood of patient adverse events, complications, disability and death. However, little is known about the level of missed nursing care and its impact on patient outcomes in low-income countries. METHODS: An observational study was conducted comprising of a survey of nurses at two time points (n = 74 and 80, respectively) and a medical record review of 517 patients in four units across two hospitals between September 2018 and March 2019. RESULTS: The level of missed nursing care in the study units was very high. The hospital type and hours nurses worked during the last week were significantly associated with missed nursing care. A unit increase in missed nursing care score increased the incidence of adverse patient outcomes by 10%. CONCLUSION: There was a higher level of missed nursing care in the study units compared with similar studies from high-income countries. Higher level of missed nursing care was significantly associated with higher incidence of adverse patient safety outcomes.

Profiles of intended responses to requests for assisted dying: A cross-sectional study.

BACKGROUND: Responding to legal medically assisted dying requests may become the most frequent form of nurses' participation in that service. Recent research has explored nurses' discrete responses to requests about or for assisted dying; however, nurses likely hold intentions for multiple responses to these requests. These intentions form patterns shaped by individual factors such as attitude and beliefs. No research has investigated patterns of multiple responses to requests for assisted dying, how these patterns form profiles of nurses and factors that might explain these response profiles. OBJECTIVES: Identify patterns of multiple responses that nurses intend for requests for assisted dying. Explore how these patterns form profiles of nurses' who share similar patterns of intended responses. Finally, investigate how attitude, norms and beliefs distinguish response profiles. DESIGN: Cross-sectional survey SETTINGS: Online survey of Australian nurses PARTICIPANTS: 365 experienced registered nurses (years in nursing mean = 23, SD = 14.21) working primarily with adults across various practice settings. METHODS: Principal components analysis identified five types of intended responses. K-means cluster analysis was then used to develop profiles of nurses' intended responses across these five responses. Multinomial logit regression was utilised to examine psychosocial variables that distinguished different profiles RESULTS: Cluster analysis resulted in five profiles that reflect different patterns of intended responses by nurses - Facilitator, Complier, Expediter, Objector, and Detached. Logit regressions of explanatory variables indicated that nurses' attitude toward assisted dying, ethical beliefs, and social norms predicted nurses' membership in intended response profiles. The overall model was statistically significant, χ2(20) = 106.527, p < .001, and the predictors accounted for 25.3% of the variance in the profiles (Cox and Snell test: Pseudo R2 = 0.253). CONCLUSION: Nurses intended responses have been usefully constructed as five patterns or profiles of multiple responses. These profiles represent different types and levels of engagement with requests. Further, attitude and social expectations distinguish profiles with stronger intentions to engage positively. Using a cluster analysis methodology provides a more holistic understanding of nurses' intended responses to assisted dying requests by focusing on various responses and demonstrating that nurses have distinctive patterns of responses.

Followership in health care clinicians: a scoping review protocol.

OBJECTIVE: The main objective of this scoping review is to identify and map followership literature in order to understand the current state of followership research in relation to health care clinicians. INTRODUCTION: Health care clinicians need to be flexible in switching between leader and follower roles as appropriate to advance patient care; however, much of the research effort in this regard has primarily concentrated on leadership. Effective followership in health care organizations may be necessary to enhance clinical team performance in order to improve patient safety and quality of care. There have been increasing calls in the literature recommending research of followership in the provision of health care. Thus, it is important to synthesize the available evidence on followership to identify what has been studied and highlight research gaps in this area. INCLUSION CRITERIA: The review will focus on followership in health care clinicians. Only studies with participants who are health care clinicians will be included. The review will include studies of quantitative, qualitative, and mixed methods designs; systematic reviews; and meta-analyses. METHODS: The search will include JBI Evidence Synthesis, Cochrane Database of Systematic Reviews, CINAHL, MEDLINE, EPPI-Centre, Scopus, and Epistemonikos. In addition, unpublished or gray literature will be searched in ProQuest Dissertations and Theses Global and Google Scholar. No limits on date or language will be applied to the search. Data will then be extracted from included papers by three independent reviewers. Results from extracted data will be presented in tabular form accompanied by a narrative summary.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review.

OBJECTIVE: The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries. INTRODUCTION: Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries. INCLUSION CRITERIA: Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools. METHODS: Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro. RESULTS: Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism. CONCLUSIONS: Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42018119428.

Role of attitude in nurses' responses to requests for assisted dying.

BACKGROUND: Legal assisted dying is a rare event, but as legalisation expands, requests for it will likely increase, and the nurse most often receives the informal, initial request. OBJECTIVES: To assess the effects of attitude in interaction with normative and control beliefs on an intention to respond to a request for legal assisted dying. ETHICAL CONSIDERATIONS: The study had the lead author's institutional ethics approval, and participants were informed that participation was both anonymous and voluntary. METHODOLOGY: This was a cross-sectional correlational study of 377 Australian registered nurses who completed an online survey. Generalised linear modelling assessed the effects of independent variables against intended responses to requests for legal assisted dying. RESULTS: Compared to nurses who did not support legal assisted dying, nurses who did had stronger beliefs in patient rights, perceived social expectations to refer the request and stronger control in that intention. Nurses who did not support legal assisted dying had stronger beliefs in ethics of duty to the patient and often held dual intentions to discuss the request with the patient but also held an intention to deflect the request to consideration of alternatives. DISCUSSION: This study advances the international literature by developing quantified models explaining the complexity of nurses' experiences with requests for an assisted death. Attitude was operationalised in interaction with other beliefs and was identified as the strongest influence on intentions, but significantly moderated by ethical norms. CONCLUSION: The complex of determinants of those intentions to respond to requests for an assisted death suggests they are not isolated from each other. Nurses might have distinct intentions, but they can also hold multiple intentions even when they prioritise one. These findings present opportunities to prepare nurses in a way that enhances moral resilience in the face of complex moral encounters.

Nurse staffing models in medical-surgical units of acute care settings: A cross-sectional study.

BACKGROUND: Nurse staffing models have been developed across different countries to address nursing shortages and improve quality of nursing care. However, there is no published study that describes nurse staffing models in Ethiopian hospitals. AIMS: To describe the existing staffing models for nursing practice in acute care units of two hospitals (one public and one private) in Ethiopia. METHODS: A cross-sectional study was conducted from July to December 2018. A self-administered questionnaire was used to collect data such as shift patterns, hours worked, and number of patients cared for per shift. Unit-level data on nurse staffing were collected using a checklist developed specifically for this study. RESULTS: Fifty-nine percent (59.9%) of participants reported that they worked six or seven days per week. On average, they worked 50 hours per week and 12% working over 60 hours per week. The number of patients they provided care for during their last shift ranged from four to 45 with an average of 13 patients. CONCLUSION: This study demonstrates that nurses working in acute care settings in Ethiopia are typically working more than 40 hours per week and caring for many patients per shift, which has the potential to impact patient safety.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to demonstrate the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries.

Geriatric Nursing Sensitive Indicators and quality nursing care for the older person: a scoping review protocol.

REVIEW QUESTION: The objective of the scoping review is to locate and describe the international literature relating to Nursing Sensitive Indicators (NSIs) and their use in evaluating geriatric care. Specifically the review question is: What definitions and key concepts of NSIs are identified in the current literature that are relevant in evaluating nursing care of the older person?Findings from the review will inform future research and health care responses to support the provision of quality nursing care to the older person.

The Profile of Saudi Nursing Workforce: A Cross-Sectional Study.

INTRODUCTION: The Royal Monarchy in Saudi Arabia decreed that all sectors of the workforce would be subject to a policy of "Saudisation" to reduce the reliance on the expatriate workforce and to reduce the unemployment rate of Saudi nationals (Al-Mahmoud et al., 2012). METHODOLOGY: A cross-sectional design was chosen to investigate the research questions. The population of this study comprised Saudi Registered Nurses working in MOH hospitals in Riyadh which is the main health care provider in Saudi Arabia (Aboul-Enein, 2002; MOH, 2009). RESULTS AND FINDINGS: A total number of 1,198 questionnaires were distributed and 61.2% (n = 741) were returned. The findings of the study showed that the questionnaires were collected from an equal portion of the study locale and that a sample of 741 is enough to create a strong conclusion and answer the problem set in this study and all the questions in the study have been provided with answers with enough data and literatures to supports its findings. CONCLUSION AND RECOMMENDATIONS: The results indicate that an increase in the recruitment of Saudi males may simply reflect cultural issues such as gender specific facilities and the Saudisation program's nondiscriminatory approach to employment of both genders into nursing.

Experiences of healthcare professionals of having their significant other admitted to an acute care facility: a qualitative systematic review.

BACKGROUND: Most healthcare professionals at some time will experience having a significant other admitted to an acute care hospital. The knowledge and understanding that these individuals possess because of their professional practice can potentially alter this experience. Expectations of staff and other family members (FMs) can potentially increase the burden on these health professionals. All FMs of patients should have their needs and expectations considered; however, this review specifically addresses what may be unique for healthcare professionals. OBJECTIVES: To synthesize the qualitative evidence on the experiences of healthcare professionals when their significant others are admitted to an acute care hospital. INCLUSION CRITERIA TYPES OF PARTICIPANTS: The current review considered studies reporting the experiences of healthcare professionals, specifically registered nurses (RNs) and physicians. PHENOMENA OF INTEREST: The experiences of RNs and physicians when a significant other is admitted to an acute care facility. TYPES OF STUDIES: Qualitative studies that have examined the phenomenon of interest including, but not limited to, designs such as phenomenology and grounded theory. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies with no date restrictions. Only studies published in English were considered for inclusion in this review. METHODOLOGICAL QUALITY: Qualitative papers selected for retrieval were assessed using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). DATA EXTRACTION: Data were extracted from the seven included papers using the standardized data extraction tool from JBI-QARI. DATA SYNTHESIS: The data were synthesized using the JBI approach to meta-synthesis by meta-aggregation using the JBI-QARI software and methods. RESULTS: Seven studies of moderate quality were included in the review. Forty findings were extracted and aggregated to create 10 categories, from which five synthesized findings were derived: CONCLUSION: In contrast to "lay" FMs, health professionals possess additional knowledge and understanding that alter their perceptions and expectations, and the expectations others have of them. This knowledge and understanding can be an advantage in navigating a complex health system but may also result in an additional burden such as role conflict.

Using holistic interpretive synthesis to create practice-relevant guidance for person-centred fundamental care delivered by nurses.

Nursing policy and healthcare reform are focusing on two, interconnected areas: person-centred care and fundamental care. Each initiative emphasises a positive nurse-patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse-patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice-relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse-patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse-patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person-centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.

Nutritional interventions for optimizing healthy body composition in older adults in the community: an umbrella review of systematic reviews.

BACKGROUND: Optimizing body composition for healthy aging in the community is a significant challenge. There are a number of potential interventions available for older people to support both weight gain (for those who are underweight) and weight loss (for overweight or obese people). While the benefits of weight gain for underweight people are generally clearly defined, the value of weight loss in overweight or obese people is less clear, particularly for older people. OBJECTIVES: This umbrella review aimed to measure the effectiveness of nutritional interventions for optimizing healthy body composition in older adults living in the community and to explore theirqualitative perceptions. INCLUSION CRITERIA TYPES OF PARTICIPANTS: The participants were older adults, 60 years of age or older, living in the community. TYPES OF INTERVENTIONS: The review examinedsix types of nutritional interventions: (i) dietary programs, (ii) nutritional supplements, (iii) meal replacements, (iv) food groups, (v) food delivery support and eating behavior, and (vi) nutritional counselling or education. TYPES OF STUDIES: This umbrella review considered any quantitative systematic reviews and meta-analyses of effectiveness, or qualitative systematic reviews, or a combination (i.e. comprehensive reviews). TYPES OF OUTCOMES: The quantitative outcome measures of body composition were: (i) nutritional status (e.g. proportion of overweight or underweight patients); (ii) fat mass (kg), (iii) lean mass or muscle mass (kg), (iv) weight (kg) or BMI (kg/m), (v) bone mass (kg) or bone measures such as bone mineral density, and (vi) hydration status. PHENOMENA OF INTEREST: The phenomena of interestwere the qualitative perceptions and experiences of participants. SEARCH STRATEGY: We developed an iterative search strategy for nine bibliometric databases and gray literature. METHODOLOGICAL QUALITY: Critical appraisal of 13 studies was conducted independently in pairs using standard Joanna Briggs Institute tools. Six medium quality and seven high quality studies were identified. DATA EXTRACTION: Data was extracted independently in pairs from all 13 included studies using the standard Joanna Briggs Institute data extraction tool. DATA SUMMARY: Only quantitative studies of effectiveness were included. The strength of evidence assessing the effectiveness of interventionswas graded using a traffic light system (green, amber, red). An overall assessment of the quality of the evidence for each comparison was undertaken. RESULTS: More systematic reviews investigating weight gain than those investigating weight loss were included. Studies onweight gain showed improved body composition for oral nutritional supplements on its own, for oral nutritional supplements in combination with resistance exercise training, and for oral nutritional supplements in combination with nutrition counselling. Studies on weight loss showed that diet in combination with exercise, diet in combination with exercise and nutrition counselling, and nutrition counselling on its own all can lead to reduced weight in older people. The outcomes of lean mass and weight/BMI were responsive to nutritional interventions, but fat mass did not vary. There were no qualitative reviews identified. CONCLUSIONS: Although effective interventions for weight gain and weight loss to optimize body composition of older people in the community were identified,making long term, clinically relevant changes in body composition is difficult. Multiple interventions are more effective than single interventions.

Healthcare professionals' experiences of having a significant other admitted into an acute care facility: a qualitative systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to synthesize the qualitative evidence regarding the life experiences of healthcare professionals when their significant others are admitted to an acute-care hospital. Specifically, the review will address the following research question: what are the experiences of healthcare professionals as significant others to hospitalized loved ones in an acute-care facility?

An example of qualitative comparative analysis in nursing research.

AIM: To describe an example of qualitative comparative analysis (QCA) in a study about the role of clinical placement, nursing education and patient outcomes. BACKGROUND: Clinical placement is often considered an essential aspect of nursing education and an invaluable way to prepare students for the reality of nursing. However, many questions about the role of clinical placement remain unanswered, such as duration, style and learning outcomes. QCA is a novel approach to data analysis, which has been used for some time in social science research, and may be useful in tackling such questions. DATA SOURCES: Participants (n= 16) involved in a case study using questionnaire, in-depth interview and document analysis. REVIEW METHODS: Few examples of QCA exist in nursing-related research. Examination of approaches to social sciences and educational research, and the conditions that influence nursing education and clinical placement were conducted via a number of online database searches. DISCUSSION: The paper presents an example of how QCA was used to consider whether there is any causal relationship between certain features of clinical placement, such as duration, level of preparation, level of benefit, and the capacity of recently graduated registered nurses to provide a range of nursing interventions for pneumonia, falls and pressure-area care. Effective and contemporary curriculum design requires examination of the components of clinical placement that influence graduates and their learning, particularly important at a time when access to the clinical placement setting is becoming increasingly difficult. This paper should stimulate nurse researchers to consider the potential for QCA and case study in addressing many of the complex questions that lend themselves to research designs with small numbers of participants. CONCLUSION: This paper will be of interest to nurse researchers looking for innovative approaches to data analysis and educators responsible for curriculum design and the delivery of clinical placement experience. IMPLICATIONS FOR PRACTICE: A greater understanding of the role o f clinical placement experiences inthe education of nurses has direct implications for the provision of better health care.

Violence in the emergency department: an ethnographic study (part II).

Violence in the emergency department (ED) is a significant and complex problem worldwide. This is a part II of a 2-part series on an ethnographic study. The study which aimed at exploring the cultural aspects of violence was carried out at a major metropolitan ED for 3 months. This paper presents the findings and discussions of the study. One hundred and three violent incident questionnaires were completed. A total of 242.5h of observation and 34 (33%) interviews with nurses were conducted. From the data analysis, three critical cultural themes (i.e. 'problems and solutions', 'requests and demands' and 'them and us') were identified. The study indicated that the cultural meanings of violence were complex and highly subjective. Factors such as environment, conflicting messages regarding waiting time, and the nurse-patient/relative behaviours and the resulting reciprocal relationships were critical. Nurses' efforts to establish rapport with patients was crucial and needed to occur early. There was usually a 'turning point' that provided an opportunity for the nurse to avoid violence. While violence is a complex issue with many paradoxes, the study indicates that effective interpersonal empathetic communication has a significant role in reducing violence in the ED.