Care erosion in hospitals: Problems in reflective nursing practice and the role of cognitive dissonance

Nursing Students' Operating Room Experiences: A Qualitative Meta-Synthesis

PURPOSE

Missed nursing care is a condition that is likely to be encountered frequently in the surgical care process and is generally related to the educational and emotional needs of the patients. Perception of and witnessing missed care can affect nursing images, expectations, and experiences by causing nursing students to experience professional disappointment. The purpose of the study was to explore nursing students' perception of missed perioperative nursing care according to "role theory" and Benner's "novice to expert" theories.

METHODS

The study used a qualitative design based on Heidegger's hermeneutical phenomenological approach. Study data were collected using a semistructured interview form prepared by the researchers through face-to-face interviews lasting approximately 50 minutes. The analysis of the data was conducted using van Manen's thematic analysis. The Standards for Reporting Qualitative Research (SRQR) checklist was used in reporting the study.

RESULTS

This study, which was conducted to explore awareness of perioperative missed nursing care (PMNC), consisted of 12 students, including five males and seven females. Nursing students who noticed PMNC in clinical practice experienced internal conflict about the issue, were concerned about the image of nursing, and experienced role and professional identity confusion. The themes of the study were formed in light of these experiences of nursing students. Three themes and 11 subthemes emerged in the study. The themes of the study were (1) perceived PMNC applications-behavior patterns (2) internal reflections of PMNC-its impact on professional identity development and (3) perceptions of professionalism in perioperative nursing CONCLUSIONS: This study provided important data about the awareness of PMNC in the surgical clinical practice of nursing students in Turkey and the effects of this awareness on the professional roles and professional identity process. Students were aware of the behavioral patterns of PMNC and experienced internal conflict, anxiety about the nursing image, role confusion, and professional identity confusion due to this awareness. Some students justified the PMNC behaviors of the nurses and others saw themselves as the power to change the PMNC behaviors.

Nursing Students' Perception of Missed Perioperative Nursing Care: Hermeneutic Phenomenology

PURPOSE

Missed nursing care is a condition that is likely to be encountered frequently in the surgical care process and is generally related to the educational and emotional needs of the patients. Perception of and witnessing missed care can affect nursing images, expectations, and experiences by causing nursing students to experience professional disappointment. The purpose of the study was to explore nursing students' perception of perioperative missed nursing care (PMNC) according to "role theory" and Benner's "novice to expert" theories.

DESIGN

The study used a qualitative design based on Heidegger's hermeneutical phenomenological approach.

METHODS

Study data were collected using a semistructured interview form prepared by the researchers through face-to-face interviews lasting approximately 50 minutes. The analysis of the data was conducted using van Manen's thematic analysis. The Standards for Reporting Qualitative Research checklist was used in reporting the study.

FINDINGS

This study, which was conducted to explore awareness of PMNC, consisted of 12 students, including five males and seven females. It was understood that nursing students noticed PMNC in clinical practice, experienced internal conflict about the issue, were concerned about the image of nursing, and experienced role and professional identity confusion. The themes of the study were formed in light of these experiences of nursing students. Three themes and 11 subthemes emerged in the study. The themes of the study were (1) perceived PMNC application-behavior patterns, (2) internal reflections of PMNC-its impact on professional identity development, and (3) perceptions of professionalism in perioperative nursing.

CONCLUSIONS

This study provided important data about the awareness of PMNC in the surgical clinical practice of nursing students in Turkey and the effects of this awareness on the professional roles and professional identity process. Students were aware of the behavioral patterns of PMNC and that they experienced internal conflict, anxiety about the nursing image, role confusion, and professional identity confusion due to this awareness. Some students justified the PMNC behaviors of the nurses and others saw themselves as the power to change the PMNC behaviors.

Discursive analysis of nursing care toward childhood fever and its contextual differences: An ethnomethodological study

Fever is the most common clinical sign during infancy. Nurses deal with fever in children most directly and it is an integral aspect of their role as pediatric nurses. The objective of this study is to analyze the perceptions, knowledge and attitudes toward childhood fever of nurses in three health contexts: pediatric hospitalization, pediatric emergency and primary care. To respond this objective, a qualitative study with ethnomethodological approach has been carried out. In-depth interviews were conducted and theoretical clinical cases were presented to nurses working in pediatrics in the three settings studied. After the analysis of the discourses, the codes were classified into three categories: static and number-centric knowledge, dependent nursing attitude, and unconscious model nurses. On the one hand, when we analyze and compare the perceptions, attitudes and knowledge of the nurses between the different contexts, we find differences that consist mainly of what the context requires of them. On the other hand, in general and regardless of the context, the nurses interviewed place themselves in a traditional framework when faced with the phenomenon of fever in children.

Nursing students' perceptions of unfinished nursing care: A cross-sectional study

AIM

To investigate the prevalence, patterns and reasons for unfinished nursing care as perceived by nursing students.

BACKGROUND

Unfinished nursing care (UNC) is a frequently observed phenomenon in the acute care setting. To date, studies have focused primarily on the perspective of nurses or patients, but another important perspective is that of nursing students who provide nursing care in all healthcare settings.

DESIGN

A descriptive cross-sectional study.

METHODS

The study included 738 undergraduate nursing students from nine Slovak universities. Data were collected between September 2022 and February 2023 using the Slovak version of the Unfinished Nursing Care Survey tool (UNCS). Data were analyzed using descriptive and inferential statistics.

RESULTS

The mean composite score of UNCS was 2.48 (SD=0.68). In general, 100% of nursing students reported that nurses missed at least one or more nursing care activities during their last clinical placement. The average number of missed nursing care activities was 11.2 per nurse as perceived by nursing students during their last clinical placement. Nursing students reported that the most frequently omitted nursing care activity was spending time with patients and their caregivers (3.15 ± 1.11; 92.9%). The most frequently reported reason for UNC was an inadequate number of nurses on the ward (4.31 ± 1.01; 98.1%). In the study, reported UNC could be predicted by previous experience in healthcare, previous clinical rotation, number of patients per shift, perceived staff adequacy and outcome expectations (p <0.05).

CONCLUSIONS

The findings reveal that UNC is a widespread phenomenon and all nursing students report this phenomenon during their clinical placements. Spending time with patients and their caregivers emerged as the most frequently omitted nursing care activity, highlighting the importance of patient-centered care. The primary reason cited for UNC was an inadequate number of nurses, highlighting staffing issues as a significant contributing factor. These findings emphasize the need for targeted interventions to address staff shortages and improve nursing education to prepare students to address UNC in their future practice.

Examining the Perspectives of Nurse Managers on Missed Nursing Care in Surgical Units

OBJECTIVE

To examine nurse managers' perspectives on missed nursing care (MNC) on surgical units.

BACKGROUND

The phenomenon of MNC is an important concern for nurse researchers. However, the reality of how it is experienced by clinical nurse managers is largely unexplored. Understanding nurse managers' experiences with MNC could help develop useful approaches to reducing levels of MNC.

METHODS

A descriptive qualitative study was conducted between December and June 2020, using face-to-face semistructured interviews with 10 nurse managers.

RESULTS

Five themes were identified: 1) awareness of MNC; 2) rationale for MNC; 3) consequences of MNC; 4) questions of reporting; and 5) management of MNC.

CONCLUSIONS

Nurse managers must use their positions and leadership skills to expect appropriate staffing approaches and material resources for surgical units, effective process for newly hired nurses, and the establishment of a reporting system for MNC to reduce the phenomenon in practice.

Missed nursing care and complexity theory: a conceptual paper

Background

Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care.

Aim

This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory.

Methods

The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare.

Results

We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care.

Conclusions

This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Nurses’ views of fundamental relational skills used in clinical practice: a cross-sectional pilot study

Objective

Effective communication skills are one of the core competencies of nursing curricula internationally. Nurses are generally regarded as proficient. Despite our complete trust in the profession, deficiencies and gaps exist. However, it is not clear to which extent nurses use key communication skills in practice, and whether or not confident in using these skills compounds environmental issues that occur. This study explored nurse's confidence and application of relational skills competencies in nursing practice.

Methods

A 13-item online survey was used to collect data.

Results

Being self-aware on key areas where there was more uncertainty. Nurses also lacked confidence in exploring the impact of their personal feelings and values on their interactions. Nurses were also less confident on responding appropriately to instances of unsafe or unprofessional practice and using information and communication systems and technology.

Conclusions

Given the potential impact of poor relational skills on quality client care, an increased emphasis on caring and compassion, and the ever-expanding use of communication technologies, there is a need to explore the need for reflective practice to enhance continuous professional development for nurses to enhance their relational skills.

Nursing perspectives on reducing sedentary behaviour in sub-acute hospital settings: A mixed methods study

AIM AND OBJECTIVES

To determine the factors influencing nurses' decisions and capacity to reduce sedentary behaviour in hospital inpatients in sub-acute hospital settings.

BACKGROUND

Sedentary behaviour in hospital inpatients is a complex issue that can be resistant to resolution. There is little research investigating factors influencing nurses' promotion of reduced levels of sedentary behaviour in sub-acute hospital settings.

DESIGN

An explanatory sequential design was employed, comprising quantitative and qualitative phases.

METHODS

An online survey was conducted with a convenience sample of 138 nurses from five Australian states. Logistic regression modelling identified demographic and behavioural characteristics of nurses who often encouraged patients to reduce their sedentary behaviour. In-depth interviews were conducted with 11 ward nurses and nurse managers, with the content subjected to thematic analysis. STROBE and GRAMMS checklists were employed.

RESULTS

Nurses recognised their role in promoting reduced sedentary behaviour but faced a range of personal and organisational barriers in achieving this outcome for patients. Few nurses were aware of national physical activity and sedentary behaviour guidelines. Five themes emerged from interviews (nursing role, care challenges, expectations of advocates, teamwork and improving the experience). Overall, many nurses experienced a lack of agency in promoting reduced sedentary behaviour and cognitive dissonance in feeling unable to undertake this role.

CONCLUSIONS

The results of this study are significant in confirming that reducing sedentary behaviour in hospital inpatients is influenced by a range of complex and multi-level factors. There is a fundamental need for organisational and clinical leadership in building a culture and climate in which staff feel empowered to promote reduced sedentary behaviour in their patients.

RELEVANCE TO CLINICAL PRACTICE

The results of this study highlight the importance of taking action to reduce sedentary behaviour in sub-acute hospital settings. A co-design approach to developing interventions in local health services is warranted.

Nursing students' evolving professional values: Capturing their journey through co-operative inquiry

AIM/OBJECTIVE AND BACKGROUND

Despite a worldwide emphasis in nursing codes of practice that state nurses must uphold professional values to be caring and compassionate, evidence continues to emerge of poor-quality care standards. Existing literature attests to a tendency to deteriorating caring values as students' progress through their nursing programme. In response, one university in England exposed pre-registration nursing students to a values-based curriculum which embedded Todres et al.'s (2009) Humanising Values Framework.

DESIGN AND METHODS

This paper describes the later stages of a co-operative inquiry, where students as participants explore their evolving values around person-centred approaches to care as they engaged with clinical practice. Data were collected between 2013 and 2016.

RESULTS AND CONCLUSION

Findings reveal how students developed their confidence and resilience in the face of situations that challenged their value base by internalising a humanised approach to care. They demonstrated this in practice by using problem-based coping strategies, peer and mentor support. Engagement with a curriculum based on humanistic philosophy encouraged students as participants to feel confident in the practice of person-centred care.

Mindfulness, Compassion, and Self-Compassion as Moderator of Environmental Support on Competency in Mental Health Nursing

This research explored the established relationship between environmental support and competency for Mental Health Nurses, intending to investigate whether the tendency to display higher levels of mindfulness, compassion, and self-compassion might buffer the effect of a poor environment on competency. One questionnaire was comprised of five pre-developed questionnaires, which included all items examining environmental support, competency, mindfulness, compassion, and self-compassion. Mental Health Nurses (n = 103) were recruited from online forums and social media group pages in the UK. The result showed environmental support related positively to competency. Furthermore, the positive relationship of competency with environmental support was moderated when controlling for compassion but did not with mindfulness and self-compassion, although subscales showed some further interactions. When poor environmental support influences the competency of mental health professionals, compassion and mindfulness-based interactions may have the potential to uphold competency.

Opportunities to enhance ward audit: a multi-site qualitative study

BACKGROUND

Hospitals in many countries are encouraged to develop audits to assess and improve the quality of care. Ward audit is a specific form of audit and feedback that is commonly used but little studied. The aim of this study is to describe the content and application of hospital ward audit in order to identify potential enhancements to such audits.

METHODS

Multiple qualitative methods were used to study a diversity sample of four English National Health Service organisations over a 16-month period. We undertook semi-structured interviews (n = 32), documentary analysis (n = 44) and 25 h of observations of healthcare workers involved in the design and implementation of ward audit. Data were analysed using framework analysis. Findings were presented iteratively to stakeholders who used them to develop a description of the content and delivery of ward audit.

RESULTS

Ward audit consisted of seven stages: impetus; method; preparation of staff; assessing practice; analysis; feedback; and decide on action to improve. Two key stages were the monthly assessment of practice using case note data extraction, and the resulting feedback to clinical staff, ward managers, matrons and directors of nursing. At three organisations, the case note data were extracted by staff and there was evidence that this resulted in misrepresentation of the clinical performance audited. The misrepresentation appeared to be associated with the anticipation of punitive feedback from directors of nursing and matrons, as well as time pressures and a lack clarity about the method of audit data collection. Punitive feedback was reported to occur if no data were collected, if data demonstrated poor performance or if performance did not improve.

CONCLUSIONS

Organisations invest considerable clinical resources in ward audit, but such audits may have unintended, potentially negative, consequences due to the impacts from punitive feedback. We discuss potential enhancements to ward audit (e.g. providing feedback recipients with suggested actions for improvement) and discuss implications for theory. There is a need to reduce the use of punitive feedback.

Undergraduate nursing students' experiences of rationed nursing care - A qualitative study

BACKGROUND

Nursing students are required to spend a significant portion of their educational preparation in clinical practice. Because of the prevalence of missed or rationed care, it seems irrefutable that students are exposed to rationed care during their practice placement, or that they contribute to its prevalence either actively or passively.

OBJECTIVES

The study aimed to discover how nursing students interpret the concept of rationed care, and their experiences of rationing in practice.

DESIGN

A descriptive qualitative study.

PARTICIPANTS

Eighteen final year nursing students from three universities within the Slovak Republic.

METHODS

Semistructured face-to-face interviews were conducted (n = 18). Data were analyzed using thematic analysis which resulted in the development of themes and subthemes.

RESULTS

We identified three meaningful themes focused on the phenomenon of rationed care from the perspective of nursing students, namely Incomplete care is normalized; Provision of impersonal patient care; and the Existence of a hidden curriculum for practice placements.

CONCLUSIONS

Student nurses were quite demanding about the learning experience during their clinical training. They are often frustrated by inconsistencies between their theoretical preparation and the realities of practice. They recognise difficulties for registered nurses in providing safe, high quality care in constrained circumstances, and although they are critical of this, they acknowledge their own acceptance of the situation. Based on this, students must establish an understanding of the theory behind, and reasons for rationed care before commencing clinical placement. A greater understanding would enable students to develop strategies for coping with inconsistencies and voicing concerns.

The inclusion of cognitive behavioural therapeutic components in the undergraduate nursing curriculum. A systematic integrative review of the evidence

BACKGROUND

Despite the increasing evidence base for the use of cognitive behavioural interventions in nursing, the extent to which therapeutic interventions and their components are included in the undergraduate curriculum in Australia remains unclear.

OBJECTIVES

To explore if and how cognitive behavioural components are being taught to undergraduate nursing students to deliver outcome benefits to students and patients.

DESIGN

An integrative literature review reporting links between CBT components and methods taught in pre-registration nurse education.

FINDINGS AND CONCLUSION

Based on an analysis of current literature, it is suggested that evidence-based cognitive behavioural components are being taught to undergraduate nursing students. The study reports that teaching cognitive behavioural components can bring clinical benefits to positive patient outcome, to student wellbeing and study performance. However, the teaching of cognitive behavioural conceptual models as a therapeutic skill was found to be limited. Recommendations to incorporate a simple, evidence based cognitive behavioural conceptual tool, highlights how nurse educators can address the requirement to teach from the current evidence base.

Care erosion in sedation assessment: A prospective comparison of usual care Richmond Agitation-Sedation Scale assessment with protocolized assessment for medical intensive care unit patients

OBJECTIVES

To determine concordance between an explicit protocolized assessment of the Richmond Agitation-Sedation Scale and an assessment performed during usual care nursing practice.

RESEARCH DESIGN

In an urban, safety-net hospital, intensive care nurses previously trained in sedation assessment recorded a bedside Richmond Agitation-Sedation Scale assessment, while study investigators used an explicit script to perform the assessment at a similar time point. Kappa indices determined concordance of the assessments. Bivariate analyses explored factors associated with discordance and unresponsiveness.

RESULTS

Twenty-one subjects with 38 observations were analysed. Bedside nursing assessment was poorly concordant with protocolized assessment (ƙ = 0.21) with the former reporting significantly lighter sedation (median -2 vs. -5, p = .01). Bedside assessment was significantly less likely than protocolized assessment to categorize subjects as unresponsive (29 vs. 50%, p = .02).

CONCLUSION

Methods used in usual clinical practice to assess adequacy of sedation frequently led to oversedation. We propose that care erosion, the deterioration of skills over time, may help explain this finding.

IMPLICATIONS FOR NURSING MANAGEMENT

Results suggest sedation assessment may be particularly vulnerable to care erosion. Nurse managers should monitor for signs of care erosion and consider utilization of explicit scripts during sedation assessment and/or frequent education to ensure sedation assessment accuracy.

Are data on missed nursing care useful for nursing leaders? The RN4CAST@IT cross-sectional study

AIM

To describe nurses' reported missed nursing care activities among hospitalized adult patients medical and surgical wards and explore gaps in service provision.

BACKGROUND

In 2015, Italy replicated the RN4CAST study, which heralded the exposition of missed care as an international phenomenon. In Italy, nurse-patient workload is high, with high levels of burnout and dissatisfaction reported, all factors associated with missed care.

METHODS

A cross-sectional study (n = 3,590) was conducted using the 13-item online Task Left Undone Tool aimed at collecting data on missed nursing care.

RESULTS

The frequency of omission of activities ranged between 7% and 50%. There were significant differences between morning, afternoon and night shifts and the various clinical settings. Oral care was the most frequently missed care activity.

CONCLUSIONS

This study takes step forward in identifying and reducing missed care on medical and surgical wards, both in Italy and also internationally, which needs to take into account the specific organisational characteristics of each setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Although more essential activities are missed less frequently, much is known about the relational deficits such as information giving, education, communication and discharge advice, which managers ought to spearhead through local initiatives to improve these practices.

Conflict, confusion and inconsistencies: Pre-registration nursing students' perceptions and experiences of speaking up for patient safety

There is growing evidence demonstrating that nursing students encounter unsafe and poor clinical practice when on clinical placement. The impact on nursing students remains relatively under-explored, especially in the Australian context. This two-phased qualitative study used Interpretive Description to explore 53 pre-registration nursing students' perceptions and experiences of speaking up for patient safety. Results of the study identified students believe speaking up is the right thing to do, and their professional responsibility. The study results add to previous research by describing the dissonance students experience due to the inconsistencies between what is taught at university and performed in practice. Student's distress arises when observing nurses taking short cuts, justifying such actions and making excuses about poor practice. Students report experiencing dissonance, bewilderment and confusion and at times, anger when observing poor practice. The clinical environment culture influences students' decisions to speak up or remain silent. Understanding students' perceptions and responses will promote awareness and discussion essential to the future development of curricula and clinical support strategies that will enable students to speak up.

Contextualising missed care in two healthcare inquiries using a socio-ecological systems approach

AIMS AND OBJECTIVES

To examine missed care within two patient safety public inquiries using a socio-ecological model.

BACKGROUND

Missed care is a care which has been omitted or rendered incomplete. Possible outcomes of missed care have been identified including poor patient outcomes such as higher mortality rates, reduced care quality and lower patient satisfaction, job dissatisfaction, staff burnout and higher attrition rates.

DESIGN

A qualitative design, specifically document analysis, was used to review two serious case reviews.

METHODS

Between August-December 2018, two public patient safety inquiries were examined using a document analysis method. Both inquiries are based in acute hospital care settings of nursing (UK) and midwifery (Ireland). The Standards for Reporting Qualitative Research checklist provided a framework to report the study methods, context, findings, analysis and interpretation.

RESULTS

Findings highlighted instances of missed care related to practice which contributed to poor patient outcomes. Missed care was located within contingency factors, such as unintended negative patient health and safety outcomes in multiple system levels which resulted in care deficits.

CONCLUSIONS

A socio-ecological model enabled consideration of how multi-system deficits combine to impact nursing and midwifery care delivery. To tackle current and future practice challenges, broader contextual issues that influence front-line cases should be identified and addressed before they create conditions which result in substandard care.

RELEVANCE TO CLINICAL PRACTICE

This paper adds to the scholarship on missed care by incorporating a greater contextual lens. Findings suggest that some factors contributing to missed care events may be systemic in origin. Practice, policy, research and education should foster nurses' and midwives' review of the totality of influencing factors impacting missed care and care deficits. Consequently, early warning signs and proactive responses at a system level should be inherent in all settings that nurses' and midwives' practice.

A cross-sectional multisite exploration of Italian paediatric nurses' reported burnout and its relationship to perceptions of clinical safety and adverse events using the RN4CAST@IT-Ped

AIM

To explore Italian paediatric nurses' reported burnout and its relationship to their perceptions of safety and adverse events.

DESIGN

A cross-sectional study using the RN4CAST@IT-Ped database with a web-based survey design.

METHODS

The RN4CAST@IT-Ped questionnaire was used to collect data in 2017. This comprised three main components: three dimensions (22 items) of the Maslach Burnout Inventory including emotional exhaustion, depersonalization and personal accomplishment. Participants also scored an overall grade of patient safety and estimated the occurrence of adverse clinical events.

RESULTS

Nurses (N = 2,243) reported high levels of burnout. Most rated clinical safety as high. The risk of adverse events ranged from 1.3-12.4%. The degree of burnout appeared to influence the perception of safety and adverse events.

CONCLUSION

The association between nurses' burnout and perceptions of higher rates of adverse events and reduced safety in clinical practice is an important finding. However, it is unclear whether this was influenced by a negative state of mind, and whether reduced safety and increased adverse events negatively influenced nurses' well-being, thus leading to burnout. Regardless, the association between nurses' burnout and these quality concepts needs further exploration to examine the effect, if any, on burnout and safety, and identify supportive mechanisms for nurses.

IMPACT

The association between reported burnout and perception of safety and risk of adverse events in Italian paediatric nurses has been reported for the first time. Nurses reporting burnout are at greater risk of intensely negative perceptions of clinical safety and adverse events. This is an important finding as perceptions can influence practice and behaviours. Quality measures in children's clinical environments need to go beyond obvious indicators to examine nurses' well-being as this also influences quality and safety.

Dignity, privacy, respect and choice-A scoping review of measurement of these concepts within acute healthcare practice

AIMS AND OBJECTIVES

To synthesise and review literature related to instruments that measure psychosocial aspects of fundamental care in acute hospital care settings.

BACKGROUND

Psychosocial aspects of care often receive less priority in terms of care provision in acute care environments. At the same time, if these elements are overlooked, there may be consequences. Despite the availability of many instruments designed to measure specific aspects of care, these concepts are often not studied within the broader context of fundamentals of care, but rather coexist as isolated explorations of specific subelements.

DESIGN

A scoping review was conducted, based on Arksey & O'Malley's (2005) methodological framework and following the PRISMA checklist.

METHODS

Using the five recommended steps-identifying the research question; identifying relevant studies; study selection; charting the data; and summarising and reporting the results-three databases were searched: MEDLINE/PubMed, CINAHL and EMBASE, in February 2019.

RESULTS

Following independent screening by two of the authors, 48 papers were included. From these 48 papers, 33 instruments were identified. Only five of these tools thoroughly assessed psychosocial aspects elements of care (dignity, respect, privacy and patients' choice) through dedicated items.

CONCLUSIONS

This review provides nurses with a synthesis of 33 instruments that assess the psychosocial aspects of care. This provides an important resource to guide measurement of dignity, respect, privacy and patients' choice. The findings also provide guidance to future research in this field.

RELEVANCE TO CLINICAL PRACTICE

This paper reviews and synthesises these instruments to provide a resource to nurses to inform their decisions and practice around measurement and evaluation of these key aspects of care. This provides a useful guide to measure and monitor the improvement of fundamental care delivery in practice and points to strengths and weaknesses of the instruments concerned.

The Ottawa model for nursing curriculum renewal: An integrative review

BACKGROUND

High-quality and relevant nursing education is needed to ensure graduates meet entry to practice competencies. Despite the important role of curricula in the development of nurses and the nursing profession, there does not appear to be a consistent or widely accepted approach to nursing curriculum renewal.

OBJECTIVE

To identify and synthesize existing curriculum renewal/redesign practices, create an aggregated logic model depicting an evidence-informed process for nursing curriculum renewal, and stimulate dialogue about how to keep nursing curricula relevant in an ever-changing healthcare context.

DESIGN

An integrative review, modeled on the Joanna Briggs Methodology of Systematic Reviews, of the available published articles, including empirical research and discussion articles.

DATA SOURCES

We searched for quantitative, qualitative, and non-research literature (English and French) on full nursing programs or curriculum revisions for pre-licensure nursing students enrolled in an undergraduate or associate degree program. Databases included CINAHL, Nursing and Allied Health, and Medline from January 2010 to January 2017. We then did a hand search for articles from January 2017 to April 2019.

SYNTHESIS

Extracted data were synthesized into an aggregated logic model based on Yin's method of cross-case analysis. Data included information about the internal context, the external context, drivers, the preparatory phase, the active phase, outcomes, and evaluation methods of the described curriculum renewal process.

RESULTS

Twenty articles were included, which were published between 2010 and 2018. The resulting logic model, The Ottawa Model for Nursing Curriculum Renewal, includes information on the context, process and outcomes of the renewal process, and how and when to evaluate curricula.

CONCLUSION

This synthesis aids in defining the process of curriculum renewal for undergraduate nursing education. It stimulates systems level thinking and reveals gaps, such as the need for further research into curriculum evaluation. The Ottawa Model for Nursing Curriculum Renewal is a usable template to aid educators undertaking their own process of curriculum renewal.

A qualitative descriptive inquiry of the influences on nurses' missed care decision-making processes in acute hospital paediatric care

AIM

To explore influences on nurses' missed care decision-making processes in acute hospital paediatric care.

BACKGROUND

Many contemporary studies describe the phenomenon of missed care. It is clear that environment and organizational culture influence the nursing activities; however, what influences their decision-making processes has not been investigated.

METHOD

A descriptive qualitative inquiry was performed using semi-structured interviews with paediatric nurses (n = 20) from one Italian paediatric hospital.

FINDINGS

Thematic analysis revealed four themes: nurses' value system; hospital logistics, structures and resources; prioritization processes; and the informal caregiver's role.

CONCLUSION

This paper offers insights into the various factors involved in nurses' decision-making process when contemplating missed care that will be of use to managers when planning care or addressing missed care in the paediatric clinical setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Knowledge and awareness of missed care in children's nursing needs greater exploration, especially in relation to what influences nurses' decision-making choices around missed care. Overall, a greater understanding of this will help managers to manage situations effectively and ethically so that missed care does not impact on outcomes for children in health care.

Current teaching of psychology in undergraduate adult and comprehensive nursing curricula

The need for nurses to understand human behaviour in the context of effective caring has long been established; however, there is no consensus over the teaching and learning of psychology. Recent reported failures in compassionate care have prompted academics and clinicians to revisit this discussion and examine the challenges this poses to education. The author therefore recognises the need to take stock to see if we are any closer to answering the critical question of how to help students use psychology to understand themselves and the people they will be caring for. A literature review was conducted to examine current research and texts that address the teaching of psychology to undergraduate adult nursing students. The aim was to frame recent discussion in the context of current pre-registration education, rather than revisit the historic argument. Three common themes emerged from the review: the content of psychology taught; the methods of teaching psychology to nurses; and the application of psychological theory to nursing practice. These themes became the focus of further content analysis. A consensus is emerging from the traditionally opposed skills and theory camps that psychological literacy is essential to caring. Psychological content must not be diluted, neglected or eroded, and the essentials of this need to be defined and taught in a manner that is simple to understand and can be applied to real people. In undergraduate education, there is an increasing emphasis on structured reflection, which is used to forge links between student cognition, emotion and behaviour to reinforce theoretical psychological concepts. The similarities between models of reflection and cognitive behavioural psychological conceptualisation are a possible area for future investigation.

Selecting and Performing Service-Learning in a Team-Based Learning Format Fosters Dissonance, Reflective Capacity, Self-Examination, Bias Mitigation, and Compassionate Behavior in Prospective Medical Students

More compassionate behavior should make both patients and their providers happier and healthier. Consequently, work to increase this behavior ought to be a major component of premedical and medical education. Interactions between doctors and patients are often less than fully compassionate owing to implicit biases against patients. Such biases adversely affect treatment, adherence, and health outcomes. For these reasons, we studied whether selecting and performing service-learning projects by teams of prospective medical students prompts them to write reflections exhibiting dissonance, self-examination, bias mitigation, dissonance reconciliation, and compassionate behavior. Not only did these students report changes in their behavior to become more compassionate, but their reflective capacity also grew in association with selecting and performing team service-learning projects. Components of reflective capacity, such as reflection-on-action and self-appraisal, correlated strongly with cognitive empathy (a component of compassion) in these students. Our results are, however, difficult to generalize to other universities and other preprofessional and professional healthcare programs. Hence, we encourage others to test further our hypothesis that provocative experiences foster frequent self-examination and more compassionate behavior by preprofessional and professional healthcare students, especially when teams of students are free to make their own meaning of, and build trust and psychological safety in, shared experiences.

Critical emancipatory reflection on a practice-based issue in relation to the working relationship between doctors and nurses in China

Objective

Reflection is viewed as the most significant skill and should be advocated for lifelong learning. In order to grasp the process of reflection and embrace the reflective skill, one of the authors of this paper reflects on a practice-based issue in relation to the communication between doctors and nurses, to gain new understanding and thus improve the authors’ clinical practice.

Methods

Smyth’s framework with four stages is utilized as an ideal framework to guide the author’s reflection on the practice-based issue to free the author from her entrenched assumptions and the oppressive forces that limit her practice.

Results

The espoused and enacted theory, together with the critical reflection theory, are used to explore the values and beliefs that essentially govern the author’s practice and how these are distinct from the author’s worldviews. Following this, critical emancipatory reflection is undertaken to explore the dominant power structures within the author’s workplace. Furthermore, given the hegemonic and chaotic working context of this issue, hegemony and symbolic interaction theory are applied to unearth the various hidden constraining and oppressive forces. Additionally, socialization theory is utilized to help the author achieve professional identity.

Conclusions

Reconstructing the practice-based issue empowers the author to realize that in the future, she should act as a reflective practitioner, creating a daily habit, staying alert to practice, seeing things freshly, finding support systems, improving communication skills, conducting reflective research, and reifying reflective practice. Ultimately, the author will be sufficiently equipped to be able to transform her practice and change its outcomes.

Critical emancipatory reflection on establishing an equal, trusting relationship among surgery participants in clinical practice in China

Objective

Reflection is considered to be one of the important ways to learn from one’s experience, and one should be encouraged to apply the skill of reflection in lifelong learning. The author used the critical emancipatory reflection theory to reflect on a practice issue, which was related to the relationship between doctors and nurses, and tries to become a lifelong reflective practitioner in clinical work.

Methods

Smyth’s reflective framework, which includes the steps describe, inform, confront, and reconstruct, will be used in this article to help the author to understand the process of reflection and improve the skill of reflection. Utilizing Smyth’s reflective framework to reflect on an issue in practice allows the author to break the routine way of thinking and learn from experience, as well as providing a higher quality of service for patients.

Results

The theory of emancipatory reflection along with the critical reflection theory will be used to determine the beliefs and values that rule the author’s action and derive how these are distinct from what the author is supposed to achieve. Besides, critical emancipatory reflection theory will be used to discover the dominant power structures in clinical practice; symbolic interaction and hegemony will be utilized to discover the factors that prevent the author from achieving the desired goals; socialization theory will be applied to facilitate the author in improving the professional identity.

Conclusions

Using the critical emancipatory reflection on the issue in practice helps the author to find out the constraints in practice, bridge the espoused value and enacted value, and thereafter undertake transformative changes in practice. Eventually, the author can improve the skill of critical emancipatory reflection and become a lifelong reflective practitioner, and the quality of clinical practice can be improved as a result.

Advancing the quality of care and nursing practice through emancipatory reflection

Reflection is a fundamental skill of health-care professionals and plays an important role in ensuring the quality of care in health-care practice. It is believed that undertaking reflection in practice can help nurses develop an awareness of a sense of personal power and agency, cultivate their critical thinking ability and help them promote their professional development. However, reflection has not been introduced widely as a nursing curriculum in China, and literature shows that some clinical nurses lack critical thinking skills and critical reflective practice skills by reason of not receiving systematic education on reflection when they were at nursing college. Therefore, we present a series of seven articles focused on prevalent and interesting practice-based events to reflect on in this special issue. The main aim is to disseminate reflective methodology and techniques and present examples of reflective writing for nurses. It is expected that these articles will help to lead Chinese nurses to adopt critical emancipatory reflective processes to bring about transformative actions.

Role-modelling and the hidden curriculum: New graduate nurses' professional socialisation

AIMS AND OBJECTIVES

To explore new graduate nurses' experiences of professional socialisation by registered nurses in hospital-based practice settings, and identify strategies that support professional identity development.

BACKGROUND

Professionalism is reinforced and stabilised in the clinical environment through the "hidden curriculum", with major learning coming from practice role-models. New graduates observe attitudes, behaviours, decision-making and skills, and gain feedback from registered nurses, which they translate into their own practice. Professional socialisation occurs through encounters with desirable and undesirable role-modelling; both are significant in professional identity formation.

DESIGN

Qualitative descriptive design.

METHOD

Data collection was undertaken through semistructured interviews with five new graduate nurse participants. A general inductive approach guided analysis. The meaningful descriptions gained provided insight into their experiences.

RESULTS

Three main themes identified from the data include: "Lessons from the wilderness"; "Life in the wild"; and "Belonging to a wolf pack". The data set highlighted the major transitional process from student identity to registered nurse.

CONCLUSIONS

New graduates' rethinking of beliefs and professional nursing identities were influenced by organisational pressures and experienced nurses' role-modelling practices contrary to professional values. Despite encountering a range of professional behaviours, attitudes and dilemmas, new graduates were capable of moral agency and critical thinking. However, they rapidly acculturated and described compromises to cope. To promote high morale and a sense of belonging, a concerted effort is required by all nurses to facilitate the socialisation process to encourage self-authorship.

RELEVANCE TO CLINICAL PRACTICE

A well-developed professional identity enhances nursing as a profession, contributing towards better healthcare delivery and outcomes. It is critically important how professional values are learnt within the culture of nursing. Tensions in clinical practice need to be understood better to avoid moral distress caused by dissonance between expectation and experience. It is advantageous to increase early positive socialisation.

Fundamental care guided by the Careful Nursing Philosophy and Professional Practice Model©

AIMS AND OBJECTIVES

To propose the Careful Nursing Philosophy and Professional Practice Model^© as a conceptual and practice solution to current fundamental nursing care erosion and deficits.

BACKGROUND

There is growing awareness of the crucial importance of fundamental care. Efforts are underway to heighten nurses' awareness of values that motivate fundamental care and thereby increase their attention to effective provision of fundamental care. However, there remains a need for nursing frameworks which motivate nurses to bring fundamental care values to life in their practice and strengthen their commitment to provide fundamental care.

DESIGN

This descriptive position paper builds on the Careful Nursing Philosophy and Professional Practice Model^© (Careful Nursing). Careful Nursing elaborates explicit nursing values and addresses both relational and pragmatic aspects of nursing practice, offering an ideal guide to provision of fundamental nursing care.

METHOD

A comparative alignment approach is used to review the capacity of Careful Nursing to address fundamentals of nursing care.

CONCLUSIONS

Careful Nursing provides a value-based comprehensive and practical framework which can strengthen clinical nurses' ability to articulate and control their practice and, thereby, more effectively fulfil their responsibility to provide fundamental care and measure its effectiveness.

RELEVANCE TO CLINICAL PRACTICE

This explicitly value-based nursing philosophy and professional practice model offers nurses a comprehensive, pragmatic and engaging framework designed to strengthen their control over their practice and ability to provide high-quality fundamental nursing care.

Litigation in Perinatal Care: The Deposition Process

Litigation in perinatal nursing represents a disproportionate share of indemnity payouts and results in excessive psychological stress. Testimony at deposition or trial can be challenging for clinicians; little is taught in training or postgraduate education regarding litigation. Nurses, midwives, and physicians can effectively navigate the deposition process and prepare for trial testimony by understanding the plaintiff's goals, recognizing the role of documentation, and becoming familiar with various plaintiff's strategies including reptile theory. Knowledge of psychological concepts such as confirmation bias and cognitive dissonance may assist clinicians in responding to plaintiff's lines of questioning. Deposition preparation is crucial to the defense and requires active participation on the part of clinicians; it may include mock deposition or use of simulation laboratories. Common mistakes in deposition may be avoided with foresight and anticipatory planning by clinicians working closely with risk managers and defense attorneys. This article provides an overview of the deposition process, including the plaintiff's goals and common approaches, as well as the role of documentation and common errors of deponents.

Caring as Coercion: Exploring the Nurse's Role in Mandated Treatment

When nurses work in environments that have overlapping medical, legal, institutional, social, and therapeutic priorities, nursing care can become an effective tool in advancing the competing goals of these multiple systems. During the provision of patient care, nurses manage the tensions inherent in the competing priorities of these different systems, and skillful nursing can have the effect of rendering these tensions invisible. This puts nurses in an ethically complex position, where on one hand, their humanizing empathy has the potential to improve the delivery and effect of mandated care yet, on the other hand, their skillfulness can render invisible the weaknesses in medicolegal structures. In this article, we present a composite case study as a vehicle to illustrate the way this dilemma manifests in day-to-day nursing interactions and explore the potential of microethics to inform the everyday decisions of nurses delivering care-as-coercion.

Effects of word-of-mouth on the behavior of Austrian blood donors: a case study of the Red Cross Blood Donation Service

The procurement of blood is an essential challenge of today’s health care. Current studies emphasize the influence of word-of-mouth (WOM) on health care behavior, including blood donation. Still, there exists no study which systematically investigates how WOM affects the behavior of blood donors. Therefore, this paper aims to contribute to this lack of research by focusing on Austrian blood donors as possible receivers and senders of WOM. A survey was distributed to 300 donors of the Austrian Red Cross with a return of 245 surveys. The results highlight the strong influence of WOM on the awareness of the blood service and the willingness to donate blood. Further, structured and organized procedures, friendly employees and respectful interaction were found to be important factors determining willingness to recommend blood donation. Family members as well as friends are the preferred WOM-receivers and the personal face-to-face contact is the favored channel of communication. The results also show that WOM-behavior is strongly influenced by factors such as age, gender and donation frequency. By helping blood bank managers to better understand how WOM affects donation intention and behavior, this study provides a new approach to attract blood donors.

Understanding and addressing missed care in clinical placements - Implications for nursing students and nurse educators

This paper addresses the issue of substandard care and its effects on healthcare practice. It explores some recent concerns about the problem in nursing, its potential effects on students, how it can be conceptualised and what action needs to be, by both nurses and educators to prevent it. Recent healthcare scandals have tarnished the public image of nursing, and are also likely to influence nursing students' images, expectations and experiences of nursing. While much attention has been paid to the examination of such lapses in care, and potential corrective actions, little attention has been paid to the potential or actual effect on nursing students in practice. While good resources and staffing levels are crucial to ensuring optimal nursing care, developing and encouraging nursing students' awareness of and openness about personal behaviours, reflecting critically on practice reflection and strengthening nurse educators' collaborative links with healthcare practice can all serve to positively influence care deficits.

Reciprocal Relationship between Internet Addiction and Network-Related Maladaptive Cognition among Chinese College Freshmen: A Longitudinal Cross-Lagged Analysis

This study explored the reciprocal relationship between Internet addiction (IA) and network-related maladaptive cognition (NMC) in Chinese college freshmen. A short-term longitudinal survey with a sample of 213 college freshmen was conducted in Shandong province, China. The results revealed that IA can significantly predict the generation and development of NMCs, and that when such maladaptive cognitions have been established, they can further adversely affect the extent of the students' IA. A vicious cycle was observed between these two variables, with IA having predictive priority in its relationship with NMC. This study also determined that the relationship between these two variables was the same for both males and females; therefore, the final model we established can be extensively applied to Chinese college freshmen, regardless of gender. Understanding the reciprocal relationship between these two variables can assist in interventions in IA at the outset of students' college life.

Teaching psychology to nursing students-a discussion of the potential contribution of psychology towards building resilience to lapses in compassionate caring

Psychology is a required element in nursing education in many countries. It is particularly aimed at teaching nursing students to get a better understanding of patients, colleagues, health care organizations and themselves, and moreover to apply what they learn about psychology to optimise their care. A meaningful integration of psychology within nursing education requires an emphasis on its application in understanding aspects of care and skills development. However, its ultimate value is demonstrated when addressing problem areas in nursing and health care. In this paper the authors outline an approach to psychology education in nursing which emphasises its development as a problem solving support. An example is presented which focuses on the application of psychology to the challenge of care erosion and deficient critical nursing reflection. The discussion includes the organisational context, social pressure, social cognition, reflection and the role of inner conflict (cognitive dissonance). Nursing educators can contribute to the prevention of care erosion by a combined effort to teach awareness of psychological mechanisms, 'critical' reflection, mastery in practice, strong values and standards, and 'inoculation' against justifications of substandard care.