Дисертації з теми "Expert nurse"

This study explores how expert nurse educators design instruction. Six female expert nurse educators volunteered to participate. Each participant had over ten years experience teaching, and all were recognized for their teaching excellence. They also had master's or doctoral degrees. Participants worked in small private schools, community colleges, or large public universities. The methodology was based in developmental research. Qualitative data sources included interviews, think-aloud protocols, and artifacts. Interviews and think-aloud protocols were audio-taped, transcribed, and member-checked. Artifacts, such as course packets and participant-authored books or interactive CDs, were collected. Data was coded and triangulated. Event-state diagrams and narratives were developed and member-checked. A between-subjects approach also was used to analyze data to develop a composite diagram and narrative that describes how expert nurse educators design instruction. Results indicate that the participants generally followed the steps of analysis, design, develop, implement, and evaluate (ADDIE), as they design instruction. Little was mentioned about actually developing material. However, six key elements were common among the participants. Enthusiasm, meaningful, prior knowledge, engaged, faculty-student relationships, and faculty preparation were common themes that the faculty found important in their process of designing instruction. This study provides information to build a knowledge base on instructional design in nursing education. It may also foster discussion to improve the effectiveness of how nurse educators design instruction.
Ph. D.

Registered nurses practice in an environment that involves complex healthcare issues requiring continuous learning and evaluation of cognitive and technical skills to ensure safe and quality patient care. The purpose of this basic qualitative study was to gain a better understanding of the continuing educational needs of the expert nurse. This study focused on the use of simulation as a learning platform in the continuation of competency. The study was based on the theories of adult learning and novice to expert. A sample of 10 expert nurses was interviewed regarding their experiences in the use of simulation during continuing education endeavors. The finding indicated that the use of simulation in this study population was effective in the maintenance of competency or in the delivery of new information. The study finding also offered developmental ideas for nurse educators in the planning and delivery of simulation to this study population.

Experienced nurses depart the workforce in significant numbers; therefore, it is critical to understand how those departures affect patient care and safety. The focus of this systematic review included appraisal of recent research to provide an understanding of strategies used in acute care settings to retain experienced nurses. Guided by Benner's model of skill acquisition, the purpose of this systematic review was to identify factors that influence the decision of nurses with experience to leave or remain working in acute care work settings. The 19 articles selected for this review were limited to those pertaining to experienced registered nurses who have worked in the acute care setting for 2 years and longer. The review excluded articles pertaining to registered nurses with fewer than 2 years of experience, who were considered at the novice or proficient level of nursing. The results of this literature review showed that management conflicts, lack of support, work environments, work schedules, and disproportionate staffing levels were among the factors leading to morale distress and burnout in experienced nurses. These findings have the potential to contribute to positive social change by guiding administrative efforts to retain experienced nurses and improve mentoring of newer nurses and, ultimately, improve patient outcomes.

The intent of this thesis was to increase understanding of the nurse's presence in clinical nursing practice within the critical care setting. Nurse presence is employed to achieve an enhanced connection with patients and has been described as both being there for and being with the other. Highly technological intensive care environments have the potential to objectify patients and present unique challenges to nursing professionals attempting to integrate this aesthetic art into their care. Purpose. The purpose of this study was to examine how critical care nurses practice and develop nurse presence with their patients. Method. Grounded theory method was used. Data were obtained from semi-structured interviews with nine expert critical care nurse participants. Results. Presence as a practice emerged as a three phased process---commitment, presencing strategies and connection. The development of nurse presence as an evolutionary process was gradual, iterative and cumulative and was subject to two major influences---transitional influences and professional influences. Each patient experience with presence contributed to knowing the uniqueness of the individual as a whole person as well as to knowing a richer and deeper understanding of presence as a nursing practice. This integration of the practice and developmental components of this nursing phenomenon is described by the basic social process 'knowing the whole'. Conclusions. Presencing emerged as a powerful and humanizing, aesthetic element of nursing the critically ill. Unlike previous studies on this concept, the grounded theory method revealed three stages of practicing presence and demonstrated that it is learned.

Tens of thousands of qualified applicants are turned away from baccalaureate and associate degree nursing programs each year due to the ongoing shortage of nurse educators. It is anticipated that many nurse educators will retire, adding to the current shortage. To meet the need for the ongoing shortage, additional qualified nurse educators are needed. Benner’s Novice to Expert Theory provided the theoretical framework for this qualitative phenomenological study which explored the transition experiences of novice nurse educators. As expert clinicians transition from clinical practice to academic settings, specific factors emerge as motivators, challenges, and barriers during the transition from expert clinician to novice nurse educator. The purpose of this study was to explore the motivations and experiences of expert clinicians, with at least five years of clinical experience, as they transition to the role of novice nurse educator. The underlying concept that emerged from this study was being at sea, which symbolizes the expert clinician embarking on a new adventure, entering the sea of academia, as a novice nurse educator. Narratives from this study shed light on the myriad of issues that continue to affect the transition from expert clinician to novice nurse educator. The perspectives of 12 novice nurse educators provide an understanding of the difficulties faced during the transition and lend to the current body of knowledge by providing insight into the needs and desires of expert clinicians as they transition to the role of novice nurse educator in the first academic year.

Background: An increasing number of patients with an oncology diagnose will be seen in the future. The oncology care is complex and in great need of nurses with a high level of competence. There is a lack of previous research in the specialist oncology nurses competence and therefore knowledge of their skills can reveal an understanding of their competence. Aim: The aim of the study was to describe the competence of the specialist oncology nurse. Method: Four oncology nurses and two directors of oncology care were interviewed. The interview text was analyzed using qualitative content analysis. Results: The result showed that the oncology nurses had developed six different competences within different areas. These competence areas were assertiveness, patient-centered care, ethical and moral-, pedagogical-, to lead and develop- and theoretical competence. They described their competences in a way of feeling more confident and they had a deeper theoretical knowledge. They also described that the needs of the patient as central. They found it easier to communicate and to give information and had a greater ambition to develop the oncology care. Conclusion: Deeper theoretical knowledge is a necessity to develop new competence. Theoretical knowledge seems essential in order to develop new competence. To be able to use their new competences, time, opportunities and support must be given to the specialist oncology nurse. It is also important for the specialist oncology nurse to claim and believe in her competence.

Palliativ vård är en speciell vårdform som inriktar sig på att ge lindrande vård till patienter som lever med en livshotande sjukdom. Den inriktar sig på att lindra patientens obehag och lidande, öka välbefinnandet och skapa förutsättningar för en förbättrad livskvalité. Själva sjukdomen står inte i fokus i den palliativa vården och den erbjuds därför människor med obotlig livshotande sjukdom. Syfte: Syftet var att genom en litteraturstudie beskriva faktorer som sjuksköterskor anger upplevelsen av palliativ vård. Metod: För att ge en objektiv och systematiserad sammanfattning av den befintliga kunskapen görs en litteraturstudie. Resultat: Den palliativa vården är komplex och resultaten beskriver nio faktorer. Dessa faktorer var professionell erfarenhet och kunskap, bristande professionell erfarenhet och kunskap, stärkande relationer, kollegialt stöd, bristande förmåga att hålla professionell distans, anhörigas förnekelse, bristande samarbete mellan sjuksköterska och läkare, holistisk omvårdnad och symtomkontroll samt bristande holistisk omvårdnad och symtomkontroll. Dessa faktorer påverkade sjuksköterskans upplevelse både positivt och negativt. Positivaupplevelser var att finna mening i sitt arbete, tillfredställelse, personlig utveckling och bekräftelse. Negativa upplevelser var meningslöshet, stress, otillräcklighet och oro.

Palliative care is a special kind of care that focuses on giving relief care to patients that are living with life threatening diseases. The disease is no longer in focus in palliative care and it is therefore offered to people who have an incurable life threatening disease. It focuses on relieving the patient’s discomfort and suffering, increase wellbeing and create conditions for an increased quality of life. Aim: The aim was to describe factors that influence on nurse’s experience of palliative care. Method: In order to give an objective and systematic conclusion of the current knowledge a literature study was chosen. Result: The palliative care is complex and nine factors emerged that play an important role in the nurse's experiences of palliative care. These factors were professional experience and skills, lack of professional experience and skills, strengthening relationships, co-worker support, and lack of ability to keep a professional distance, relative’s denial, lack of cooperation between the nurses and doctors, holistic care and symptom control and lack of holistic care and symptom control. These factors influenced nurse’s experiences, both positive and negative. Positive experiences were to find meaning in their work, satisfaction, personal development and confirmation. Meaningless, stress, inadequacy and anxiety were negative experiences.

The U.S. Army Licensed Practical Nurse (LPN) dates back to the fall of 1947 and evolved from severe professional nursing shortages of World War II. Today, as in the past, to sustain U.S. Army readiness the highly medically trained combat soldier must possess skills and competency of an LPN, which is a result of successful completion of a 52-week 91WM6 training program. The purpose of this two-part descriptive study includes evaluation of quantitative and qualitative data. The Delphi technique and a retrospective student record review were utilized to gather data. Dependent variables included student demographics such as age, rank, gender, years of military experience, marital status, prior education and medical related experience, Armed Services Vocational Aptitude Battery (ASVAB) scores, specifically Skilled Technical (ST) and General Technical (GT), students’ interpretation of stressors of military life, occupational goals, number of college units attained, number of examinations failed and physical fitness tests failed, Article 15’s administered, and counseling. The independent variable was successful completion of the National Council Licensure Examination for Practical Nursing (NCLEX) examination on the first attempt. Major research findings of this study included: 1. The research revealed higher pass rates for a private first class and specialist, as compared to lower pass rates of corporals and sergeants. Additionally, soldier students in the study who had completed at least one college unit (had attended college), had a 92% pass rate as compared to those who had not completed any additional education or college after high school (75.0%). It is suggested that prior experience may improve entry cognitive skills that enhance academic performance along with the student’s achievement. 2. The research revealed that those soldier students who tended to have higher GT and ST scores failed program tests significantly fewer times. 3. Based on the results of the expert opinions of the panelists (Delphi) who participated in the study, the highest-rated predictors in completing the course were positive study habits, demonstrating diligence, and motivation. For predictors related to passing the NCLEX-PN, the highest rate was the ability to think critically and specifically preparing for the NCLEX examination.

Bakgrund: Akutmottagningen är en arbetsplats som ställer höga krav på sjuksköterskan som arbetar där då vården som bedrivs är mångfacetterad och snabbt skiftande i intensitet. Detta ställer krav på sjuksköterskans förmåga att sortera intrycken för att hantera situationerna som uppkommer på en akutmottagning. Som nyanställd sjuksköterska på en akutmottagning är detta en stor utmaning vilket ställer höga krav på det introduktionsprogram som erbjuds. Syfte: Syftet var att belysa och beskriva nyanställda sjuksköterskors upplevelse och erfarenhet av introduktionsprogrammet samt hur detta förberedde dem inför arbetsuppgifterna på akutmottagningen. Metod: En kvalitativ intervjustudie med deskriptiv design valdes utifrån studiens syfte. Semistrukturerade intervjuer med intervjuguide genomfördes med 11 informanter som var allmänsjuksköterskor på en akutmottagning i södra Sverige. En kvalitativ innehållsanalys med induktiv ansats utfördes på manifest och latent nivå. Resultat: Resultatet presenterades i temat att vara oförberedd på det oförutsedda i vilket det ingick fyra kategorier som beskrev informanternas upplevelse av introduktionen. Dessa var; yttre påverkansfaktorer, inre upplevelser, hantering av situationen samt förslag till förbättringar. Slutsatser: De nyanställda sjuksköterskorna på akutmottagningen upplevde introduktionen för kort i förhållande till informationsmängden och den informationen som gavs upplevdes bristfällig. Studiens resultat bör kunna ses som ett bidrag vid en förändring av introduktionsprogrammet på akutmottagningen. Vidare forskning behövs inom området för att möjliggöra en bra introduktion för sjuksköterskor samt i slutänden kunna leda till ett bra omhändertagande av patienter.

Agitation and aggression are challenging symptoms commonly experienced by hospitalised cognitively impaired patients. Pain is one well-established cause; however, nurses may not recognise pain-related agitation. This descriptive correlational study examined the clinical decisions of 274 nurses in a virtual simulation of pain-related agitation. Despite high formal knowledge about pain, 95% failed to recognise pain-related agitation and 89% administered antipsychotics. Experiential knowledge, the unconscious but accurate classification of available cues, was identified as crucial to performance. To develop accurate experiential knowledge about pain-related agitation, workplaces may need conditions for deliberate practice, where nurses receive immediate and accurate feedback about their performance.

This quantitative non-experimental descriptive correlational design sought to answer the question if there was a difference in newly licensed RN (NLRN) performance at one-year post hire after participation in a nurse residency program that offers a formalized curriculum that extends throughout the entire year, one that offers a formalized curriculum that does not extend throughout the entire year, or one that does not provide a formalized curriculum. The study utilized the Six Dimension Scale of Nursing Performance (SDNP) and evaluated NLRN performance on six subscales: leadership, critical care, teaching/collaboration, planning/evaluation, interpersonal relations/communication, and professional development at one-year post hire. Benner’s novice-to-expert model served as the theoretical framework for this study. The results of the Mann-Whitney U test revealed there was not a statistically significant difference between the type of nurse residency the NLRN participated in and his or her self-reported performance on the individual subscale scores of the SDNP. The results of the point-biserial correlation based on how well the NLRN performed the task did not reveal any significant correlations between the nurse residency and performance. However, a negative correlation was noted within the critical care (r = -.052) and the planning/evaluation (r = -.050) subscale scores. Results from this study corroborate what the literature has previously noted. NLRNs need an experiential opportunity to transition into the practice environment and progress on the novice-to-expert continuum.

Thesis advisor: Callista Roy
Despite the concept of healing being central to nursing, there has been a lack of conceptual clarity. This study sought to understand how expert nurses in practice conceptualize healing and how this conceptualization affects their practice. The sample consisted of 50 practicing nurses from multiple practice settings in an academic health system in Western Massachusetts. The study used a mixed method design using an electronic adaptation of the Delphi method. Findings from the study suggested a high level of consensus about the concept of healing in nursing. Qualitative data from the open-ended questions of Round 1 were coded into items about healing on subsequent quantitative surveys in Rounds 2 and 3. Participants ranked their level of agreement or disagreement with these statements. Ultimately, 49 statements met the a priori criteria for consensus as to what healing means from a nursing perspective. The overarching themes of statements were comprised of Nursing Actions to Promote Healing, Theoretical Understanding of Healing, Nurse Attributes to Promote Healing, Other Factors that Promote Healing, Types of Healing and Assessment of Healing. This study adds to the literature an exclusively nursing perspective on healing. The nursing-specific concept of healing synthesized from the data could be described as progression towards wholeness, with subjective and objective outcomes, promoted by the actions of nurses. The clarification of the concept of healing can inform research to create measurements for healing. It also can improve practice by articulating an existent conceptual framework, allowing nurses and administrators to better promote healing both directly and indirectly. Lastly, the results of this study offer students a simple yet accurate way of prioritizing nursing interventions
Thesis (PhD) — Boston College, 2015
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

New nurses do not possess the clinical skills necessary to thrive in a fast-paced, rapidly changing telemetry unit. The study explores the idea that nurses with less than two years’ experience may not have the self-confidence or experience to begin a career on a telemetry unit. A search of the literature was performed to identify the skills needed to be successful in a critical care telemetry unit. Established orientation programs, nurse internships, and nursing experience were the keywords researched. Patricia Benner’s Theory: From Novice to Expert Excellence and Power in Clinical Nursing Practice (1984) serves as the foundation for this investigation. The theory views nursing competency as a continuing learning experience based on individual experiences, exposures, and cumulative time in practice. The design is descriptive using qualitative, narrative analysis on focus group data. Two focus groups of five nurse participants were purposely selected for the study. One group represented novice nurses, and the other represented expert nurses. Novice nurses placed importance on completing the task list, keeping the patient safe, and receiving positive feedback from co-workers and management. Anticipation, symptomology, and intervention were demonstrated in the expert nurses in this study. Preceptorships, internships, and simulator science may assist in orienting novice nurses new to telemetry to critical thinking and time management skills, and for expert nurses learning a new cardiac skill-set for telemetry care and acting as resource personnel for less experienced colleagues.

Bakgrund: Sjuksköterskeyrket är en profession med komplexitet där den professionella sjuksköterskan bör inneha kunskap och förståelse, färdighet och förmåga, värderingsförmåga och förhållningssätt, för att kunna leda och ansvara för en god patientsäker omvårdnad. Det examineras ungefär 5000 sjuksköterskor varje år i Sverige. Sjuksköterskestudenter som närmar sig examen upplever blandade känslor. Både en glädje över att snart vara färdiga sjuksköterskor, en oro över att inte besitta kompetens nog för rollen samt en osäkerhet inför att arbeta självständigt och att ansvara för beslut i patientrelaterade omvårdnadsfrågor. Efter två år i yrket väljer 30 % av de nyutexaminerade sjuksköterskorna att lämna yrket. Syfte: Syftet var att få en fördjupad förståelse av nyutexaminerade sjuksköterskors erfarenheter av sitt första år inom professionellt kliniskt arbete. Metod: Metoden som används är en litteraturöversikt som baseras på elva artiklar bestående av två med mixad metod, en av kvalitativ design samt sju med kvantitativ studiedesign med Benners (1984) teori från Novis till Expert som stöd som vid resultatdiskussion. Resultat: Den nyutexaminerade sjuksköterskans erfarenheter sammanfattas under fyra huvudteman: Rollförväntningar, Arbetskultur och Miljö, Utvecklande av kompetens samt Fokusskifte. Undertema till Rollförväntningar är Osäkerhet och Kaos. Undertema till Arbetskultur och Miljö är Introduktion och Handledning. De nyutexaminerade sjuksköterskorna hade förväntningar på rollen som sjuksköterska som ledde till en skrämmande erfarenhet i den kliniska verksamheten. Positiva erfarenheter hos de nyutexaminerade sjuksköterskorna var förenade med att ha en bra handledare och en stödjande arbetsmiljö. Efter att utövat professionen i nästan ett år upplevde de nyutexaminerade sjuksköterskorna en tillfredsställelse med utvecklingen av yrkeskompetensen. Under de första sex till tolv månaderna koncentrerade de nyexaminerade sjuksköterskorna sina krafter på lära känna den nya arbetsmiljön och erhålla acceptans från arbetskollegor. Vart efter trygghet i rollen växte, skiftade sjuksköterskan fokus från sina egna behov till patientens. Diskussion: Resultatet diskuterades med stöd av Benners teori. Resultatet visade på att flertalet av de nyutexaminerade sjuksköterskorna inte uppfattade sig redo att självständigt agera, hantera och organisera omvårdnaden och upplevde ett behov av mer empirisk erfarenhet för att hantera sin roll som sjuksköterska. De nyutexaminerade sjuksköterskorna var i behov av stöd vilket även Benner beskriver i sin teori. Att uppleva stöd från arbetskollegor och andra sjuksköterskor med mer gedigen erfarenhet var ytterst viktiga faktorer för den nyutexaminerade sjuksköterskans hälsa och kompetensutveckling, men flertalet av studierna visade på att nyutexaminerade sjuksköterskor upplevde att de saknade stöd. Den nyutexaminerade sjuksköterskan koncentrerar sig på den egna utvecklingen samt att följa utstakade riktlinjer, vilket kan orsaka att patienten hamnar i bakgrunden för den nyutexaminerade. Det är först när den nyutexaminerade sjuksköterskan skaffat sig tillräckligt med erfarenheter och självförtroende hen skiftar fokus från sina egna behov till patientens.
Background: The nursing profession is a profession with complexity where the professional nurses must have knowledge and understanding, skills and abilities, judgment and approach, to be able to lead and be responsible for good and safe patient care. Approximately 5000 nurses graduate every year in Sweden. Nursing students approaching graduation experienced mixed feelings. Both a delight to soon be finished nursing while concern was expressed about not possessing the skills enough for the role, as well as an uncertainty to work independently and be responsible for decisions in patient-related health issues. After two years in the profession approximately 30 % of the newly graduated nurses choose to leave the profession. Aim: The aim was to gain a deeper understanding of how the newly graduated nurses experience their first year in the professional clinical work. Method: The method used is a literature review based on eleven articles consisting of two with mixed method, one of qualitative design and seven with quantitative study design with Benner's (1984) theory from Novis to Expert as support for discussion of the results. Results: Four major themes emerged: Role Expectations, Work Culture and Environment, Development of expertise and Focus shift. Subthemes to Role Expectations is Uncertainty and Chaos. Subthemes to Work Culture are Environment's Introduction and Mentoring. The newly graduated nurses had expectations about the nursing role that led to a terrifying experience in clinical practice. Positive experiences of the graduate nurses were associated with having a good supervisor and a supportive work environment. After practicing the profession for nearly a year, the newly graduated nurses experienced satisfaction with the development of the professional skill. During the first six to twelve months the newly graduated nurses concentrated their energy on getting to know the environment and receive acceptance from colleagues. When security grew in the nursing role, the nurse shifted the focus from their own needs to the patient's needs. Positive experiences of the newly graduated nurses were associated with having a good supervisor and a supportive work environment. Discussion: The results were discussed with Benners theory. The results showed that the majority of the newly graduated nurses did not perceive themselves ready to act independently, manage and organize care, and felt a need for more empirical experience to handle the nursing role. The newly graduated nurses stated a need for support from an experienced nurse, in which Benners agrees and describes in her theory. Experience support of colleagues and other nurses with more experience was extremely important factors for the newly graduates health and development of competence, but most of the studies showed that newly graduated nurses felt that they lacked support. As the competence increased the newly graduated nurse experienced that their previous focus on getting acceptance from colleagues was replaced by a focus on the patient and their care. According to Benners theory the newly graduated nurses concentrate on their own development and guidelines, which can cause the newly graduated nurse to lack focus on the patient.

In the nursing literature to date there have been no reported applications of `cognitive simulation' nor of intelligent Computer Assisted Learning. In Chapter 1 of this thesis a critical review of existing nurse education by computer is used to establish a framework within which to explore the possibility of simulation of thinking processes of nurses on computer. One conclusion from this review which is offered concerns the importance of firstly undertaking reliable study of nursing cognition. The crucial issue is that an understanding must be gained of how expert nurses mentally represent their patients in order that a valid model might be constructed on computer. The construction of a valid computer based cognitive model proves to be an undertaking which occupies the remainder of this thesis. The approach has been to gradually raise the specificity of analysis of the knowledge base of expert and proficient nurses while seeking concurrently to evaluate validity of the findings. Reported in Chapter 2, therefore, are the several experimental stages of a knowledge acquisition project which begins the process of constructing this knowledge base. Discussed firstly is the choice of the skill domain to be studied - pressure sore risk assessment. Subsequently, the method of eliciting from nurses top-level and micro-level descriptors of patients is set out. This account of knowledge acquisition ends with scrutiny of the performance of nurse subjects who performed a comprehensive simulated patient assessment task in order that two groups might be established - one Expert and one Proficient with respect to the nursing task. In Chapter 3, an extensive analysis of the data provided by the simulated assessment experiment is undertaken. This analysis, as the most central phase of the project, proceeds by degrees. Hence, the aim is to `explain' progressively more of the measured cognitive behaviour of the Expert nurses while incorporating the most powerful explanations into a developing cognitive model. More specifically, explanations are sought of the role of `higher' cognition, of whether attribute importance is a feature of cognition, of the point at which a decision can be made, and of the process of deciding between competing patient judgements. Interesting findings included several reliable differences which were found to exist between the cognition of subjects deemed to be proficient and those taken as expert. In the final part of this thesis, Chapter 4, a more formal evaluation of the computer based cognitive model which was constructed and predictions made by it was undertaken. The first phase involved analysis in terms of process and product of decision making of the cognitive model in comparison to two alternative models; one derived from Discriminant Function Analysis and the other from Automated Rule Induction. The cognitive model was found to most closely approximate to the process of decision making of the human subjects and also to perform most accurately with a test set of unseen patients. The second phase reports some experimental support for the prediction made by the model that nurses represent their patients around action-related `care concepts' rather than in terms of diagnostic categories based on superficial features. The thesis concludes by offering some general conclusions and recommendations for further research.

The nature of nursing judgment in clinical practice situations remains incompletely explored. It is known that nurses perform endotracheal suctioning as part of the nursing care of critically ill children. However, the ways in which nurses judge the need for suctioning and the method used to suction are not well understood. This research study was conducted to describe the cues that expert pediatric critical care nurses use in making the judgment to suction and to describe how those cues are used in determining the timing of endotracheal suctioning. A qualitative naturalistic study was conducted in a quaternary pediatric critical care unit in Central Canada. A purposive sample of seven expert pediatric critical care nurses participated in the study. Data were collected using three methods---participant observations (field notes), think aloud (concurrent verbalizations) and semi-structured interviews (retrospective verbalizations)---as participants cared for ventilated, critically ill children. (Abstract shortened by UMI.)

This thesis provides the rationale for the necessity of a redefining of the holistic back into nursing after the consequences of technological restructuring. This study revealed that the impact of modern technology-based, prescriptive changes on professional nursing practice in Canada has resulted in an increasing alienation of labour for nurses, including direct interference with patient-based nursing care, authority, necessity for broader knowledge systems, stability and fragility in job security. The implications of this examination have demonstrated that this shift has not been the result of mechanical technologies alone, but the science-based management philosophies and communicative nature of technologies as well.
This project has verified that more importantly than the advancing technological shift itself the danger for professional nursing has been in what these systems are actively replacing. Namely, prescriptive technologies work to establish a managerial or 'expert' presence and authority within the practice of nursing serving to change professional understandings for nurses as well as to decrease value in the judgement and holistic care skills of registered nurses.

The aim of the study was to describe how anaesthetic nurses, within both advanced beginner and expert levels, experience their professional role as they perform a general anaesthetic.

The study had a descriptive design with a qualitative approach in which ten advanced beginners- and ten expert anaesthetic nurses from an operating theatre and an ambulatory surgical ward at a hospital located in the middle of Sweden, participated. All data was collected in an interview with semi-structured questions which focused on how the anaesthetic nurses experience their work. The data were analysed with qualitative content analysis. The results are presented in categories and themes. The themes were formed from the categories. Themes for the advanced beginners were: support develops self confidence that gives the feeling of satisfaction and lack of support impedes further development of independency and gives the feeling of insecurity. Themes for the experts were: experience and new challenges in a supported environment give satisfaction and lack of support and own insecurity give dissatisfaction. The advanced beginners described their experiences in a more descriptive way, while the experts had more difficult to describe what they experienced. The advanced beginners wanted more support from their colleagues while the experts wanted to be more independent and were also more confident in their professional role.

Syftet med studien var att beskriva hur anestesisjuksköterskor på avancerad nybörjarnivå respektive expertnivå upplever sin yrkesroll vid generell anestesi. Studien hade en deskriptiv design med kvalitativ ansats där tio avancerade nybörjare respektive tio expert anestesisjuksköterskor, från en allmän operations avdelning och en dagkirurgisk avdelning vid ett Mellansvenskt sjukhus, deltog i studien. Data samlades in via halvstrukturerade intervjufrågor som inriktade sig på anestesisjuksköterskors upplevelser av sitt arbete. Data analyserades med kvalitativ innehållsanalys. Resultatet redovisas utifrån kategorier som bildade olika teman. Teman som för avancerade nybörjare var stöd utvecklar självförtroende som ger en känsla av tillfredställelse samt brist på stöd hindrar utvecklingen av självständighet och ger känsla av osäkerhet. Teman för experterna var erfarenhet och nya utmaningar i en stödjande miljö ger tillfredställelse samt bristande stöd och egen osäkerhet ger otillfredsställelse. Avancerade nybörjarna beskrev sina upplevelser på ett mer beskrivande sätt medan experterna hade svårare att beskriva vad de upplevde. Avancerade nybörjarna ville ha mer stöd medan experterna ville vara mer självständiga och var mer trygg i sin yrkesroll.

In 2006, Japan was one of the markets that contributed to the 4 million dollars live bee sales in Australia. In 2007, the export of queen honey bee from Australia was suspended when Nosema apis was detected in the nurse bees that were escorting the queens during a quarantine inspection off the Japanese ports. Nosemosis or nosema is a worldwide endemic disease caused by N. apis. Infected bees have reduced life span, energy, productivity, and develop deformed glands. As a result of this suspension, many Japanese fruit farmers had to hand pollinate many of their crops while Australian beekeepers suffered financial losses from the loss of trade. Thus, it will be extremely beneficial for both Japanese and Australian farmers if nosema-free nurse bees could be produced and used as escort nurse bees. Two novel approaches of producing nosema-free bees are proposed: (1) treating infected nurse bees with heat therapy and (2) raising newly hatched nurse bees (HNB) in isolation of infected hives. These approaches may produce nosema-free escort nurse bees. Escort nurse bees feed royal jelly to queen bees in cages during the export journey, thus it is essential that HNB can synthesize and secrete royal jelly. This means that HNB need to develop functional hypopharyngeal glands (HG) in order to secrete royal jelly. Proteins found in pollen are said to be 100 % effective in stimulating full development of the HG. When bees have fully developed and functional HG, they should be able to feed and keep queens alive for the duration of the exporting journey (more than 8 days). This project investigated whether nosema-free escort nurse bees could be produced by raising them in cages; whether feeding pollen and artificial feed could stimulate full development of the HG; whether there is a relationship between how much bees ate and the extent the HG development; whether the cage-raised escort bees are able to feed and keep 100 % of the queen bees alive during export for at least 8 days; and whether applying heat therapy could cure infection caused by N. apis without killing the bees. Bees fed nutritionally balanced artificial feeds designated as Sub2, FB, Sub1 had significantly higher head weights (>10 mg) than those fed pollen feeds used in this experiment. Only Sub2 maintained a consistently higher head weight compared to hive-raised mature nurse bees that were fed icing sugar. Bees that consumed PrSub and Sub1 showed a significant (P <0.05) positive correlation between feed consumption and the head weight of individual bees. Despite carefully isolating combs from hives, newly emerged bees became contaminated with N. apis so nosema-free nurse bees could not be produced. The cage-raised nurse bees fed 16 different pollen and artificial feeds were not able to keep 100 % of the queen bees alive during export for 8 days. Bees that were fed pollen and artificial feed had median survival time of 4 days or less. Queens caged with nurse bees that fed on icing sugar survived much longer than queens caged with nurse bees that fed on pollen and artificial feed. In general, mated queens had significantly longer median survival time than virgin queens. These findings suggest that protein consumption is not the key factor which regulates the development of the HG. Cage-raised nurse bees suffer abnormal behavioural and physiological developments because of possible lack of appropriate stimulations, hence their inability to properly nurture and feed queen bees. It is clear that cage-raised bees are fundamentally different from hive-raised bees, and so far, the only way to ensure bees develop properly is by raising them in hives. However N. apis spores are in virtually all hives, that means to truly produce nosema-free bees, research should focus on breeding naturally resistant nurse bees or genetically modify bees to become resistant to N. apis. For decades, beekeepers and researchers have tried to formulate artificial feeds which can substitute pollen. Bees need pollen for protein to build and strengthen hives but pollen is expensive to buy and its availability is unpredictable. To prove that a nutritionally balanced artificial feed such as Sub2 can replace pollen, further research should be conducted in larger cage experiments measuring nutrition composition, longevity and brood rearing.

Articulating what nursing is and what nurses do, has been a challenge since the creation of the profession. This research draws on technology to solve the issue of revealing and investigating the tacit nature of nursing through the concept of the nursing gaze. Drawing on the visual attention of nurses, this two-phase experiment identified that the nursing gaze is complex but can be identified with eye tracking and verbal utterances. Both phases of the study utilised videos of simulated nursing practice that acted as the stimulus for viewing. The practical challenges of tracking eye movement and verbal utterances when stimulus is video was identified and led to the development of Gaze-to-Text to solve these. This novel method drew on ethnographic techniques to combine both eye movement and verbal utterances of novice identifying the tacit nature of the gaze. Concurrent eye tracking and recording of the viewers ‘think aloud’ commentaries led to the identification of eight verbal performative signifiers used by nurses to judge the behaviour and actions. Analysis of both novice and expert nurse’s eye movement demonstrated areas of convergence and divergence and when combined with the verbal utterances, allowed conclusions to be drawn about the cognitive and perceptive processes involved in the nursing gaze. The findings of the study have implications for developing novice nurses through the articulation of expert nurses gaze. The method of Gaze-to-text offers potential for understanding visual attention and the tacit elements of professionals in other fields.

Emergency departments (EDs) are often thought of solely as places where life-saving interventions occur. However, EDs are also places where dying patients receive end of life care. Though research examining expert nurse behaviours in care of the dying has been conducted in a variety of care settings, little is known about this topic as it relates to care of the dying adult in the ED. A descriptive exploratory study was conducted with registered nurse experts (n = 6) in two urban EDs in Western Canada. Five expert nurse behaviours deemed essential in care of the dying adult patient in the ED were identified: 1) providing comfort; 2) honouring the personhood of the patient; 3) responding to the family; 4) responding after the death of the patient; and 5) responding to colleagues. These findings contribute to the empirical evidence concerning expert nursing care of the dying.

Background: There is commonality amongst the definition and characteristics of Nurse Practitioner (NP)/Advanced Practice Nurse (APN) role and practice internationally in terms of education, practice standards and regulation; operationally there is variability. The NP role has been implemented internationally; at least 70 countries are considering some form of APN role.ICN/APN network 2012 cited in(1) NPs provide advanced clinical care and were implemented as part of health service reform to improve access and timeliness of healthcare.(2) Whilst much has been written on advanced practice nursing roles per se, there has been little focus specifically on the orthopaedic nursing context. This review will focus on orthopaedic nurse practitioners (ONP) in an international context. Objective: To appraise and synthesise the best available evidence on the experience and effectiveness of the role and practice of ONPs. Inclusion Criteria: Types of Participants ONP/APN in acute care or sub-acute orthopaedic settings. Types of Interventions Interventions of ONP specific care. Phenomena of Interest The experience of becoming or being an ONP in relation to role development, role implementation and (ongoing) role evaluation. Types of Studies This comprehensive systematic review looked at both quantitative and qualitative studies together with narrative text and opinion papers. Quantitative study designs included in this review included observational cohort/case control studies and descriptive case report/series. Phenomenology was the qualitative study design included. Mixed method studies were also included in this review. Types of Publications The textual component of this review considered publications of expert opinion, discussion papers, position papers and other relevant text where there existed a particular focus on the ‘orthopaedic’ aspect of NP practice. Types of Outcomes A range of outcome measures were included but were not limited to primary patient outcomes: occasions of service/numbers seen, length of stay (LOS), wait times, patient satisfaction, readmission, and other patient encounter data or relevant nurse-sensitive outcome data that characterised ONP practice. Secondary and related outcomes data relative to process indicators/outcomes such as: NP satisfaction, key stakeholder (other health professional) satisfaction, knowledge, LOS, cost benefit were considered. Search Strategy: Both published and unpublished English language studies were considered from individual database inception and searched up to December 2012. The search was repeated in early 2013 to ensure no recent papers had been published. A three step search strategy was employed for each component of this review. Methodological Quality: All retrieved studies and opinion papers were assessed by two independent reviewers using the standardised Joanna Briggs Institute critical appraisal tools. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. Data Collection Quantitative data was extracted using the JBI-MAStARI tool. The data extracted included details about the interventions, populations, study methods and outcomes of significance to the review question. Qualitative data was extracted using the JBI-QARI tool. The data extracted included details about the methodology, method, phenomena of interest, participants, data analysis and relevant findings. Textual data was extracted using JBI-NOTARI tool. The data extracted included the type of text, stated allegiance or position, setting, geographical and cultural influences and messages and conclusions located within the publication. Data Analysis/Synthesis: Quantitative data was analysed using JBI-MAStARI. Meta-analysis of the quantitative data was not possible due to a lack of clinical and statistical heterogeneity; findings were presented in narrative format including tables to aid in data representation. As only one qualitative study was included, meta-synthesis by meta-aggregation was not possible. Textual data were synthesised using the Joanna Briggs Institute approach of aggregation using JBI-NOTARI. Results A total 31 studies and publications were included in the review. Nineteen quantitative studies were included, 10 comparable cohort and 9 descriptive studies. Seven broad review outcomes measures were identified: Three of which were patient related (primary) outcomes and three nurse related (secondary) outcomes. Three sub category patient-related outcomes focussed on (1) specialist care interventions, (2) patient satisfaction/acceptance, (3) wait times and access to care. Another four sub category nurse-related or process-related review outcomes focussed on (4) education, (5) length of stay, (6) other cost-related issues and (7) barriers. One unpublished qualitative thesis discussed four themes: (1) having knowledge, (2) being in and outside the role, (3) being an advocate and (4) being in control with decision making & anticipation as sub themes. The author concluded that advanced practice is a continuum. Eleven text and opinion publications were included where 39 conclusions were identified. From these conclusions eight categories emerged and three synthesised findings. The synthesised findings related to ‘Duality’, ‘Role & Relationships’ at a personal, organisational and professional level with an emphasis on collaboration, and ‘Moving Forward’ with an emphasis on resources needed to support the NP in this. Conclusions: The findings of this comprehensive review demonstrate the experience and effectiveness of NPs in orthopaedic settings is influenced by multiple factors from within and external to the individual. Overall the results derived from quantitative evidence indicated that NPs in orthopaedic settings provide comparable care when compared to conventional methods of health care delivery. However the results showed better outcomes in specific units where care is led by Clinical Nurse Specialists, NP management of distal radius fracture, and NP screening for developmental hip dysplasia. Decreased length of stay, improved patient wait times & access and patient satisfaction were demonstrated across the evidence, generally. Caution is required however when interpreting the results due to the lower quality of study designs. The qualitative and textual evidence demonstrated that the role of the ONP is multidimensional with confidence, knowledge and experience as essential elements to deal with complex and challenging situations. The experience of becoming or being an ONP is relational and collaborative at a personal, organisational and professional level. A ‘duality’ of purpose for ONP’s emerged from the textual evidence with interplay between benefits and barriers to ONP practice. Barriers as an outcome emerged from both quantitative and textual evidence. The experience of ONP is characterised by moving forward along a continuum – where the continuum represents the entire journey/career/professional life of the NP. From the comprehensive evidence on the effectiveness and experience of NPs in orthopaedic settings this review identified four ‘shared findings’ across the evidence base: Acceptance, Collaboration, Education/Knowledge/Experience, Duality.
Thesis (M.Clin.Sc.) (Research by Publication) -- University of Adelaide, School of Translational Health Science, 2015.

Background: Shortages of health care professionals and an ageing nursing workforce are some of the factors leading to the creation and evolution of many new nursing roles. Advanced practice nurses across the globe are working under many different titles and within various contexts, in order to address gaps within current health care systems. Comparison of roles between countries is difficult and possibly inappropriate due to Australia’s unique environmental and demographic characteristics. A context-specific systematic review on the qualitative evidence of the experience of being an advanced practice nurse in Australia has not been undertaken previously, however it is imperative for nursing managers and leaders to understand the complexities of advanced nursing roles in order to effectively utilise and retain these experienced and valuable nurses. Aim: This study aims to provide deeper understanding of the experience of being an advanced practice nurse working in Australian acute settings and identify personal, professional and organisational factors influencing experiences. Methods: A three-step search strategy, following the Joanna Briggs Institute method was used to identify published and unpublished interpretive studies meeting set inclusion criteria. Critical appraisal and data extraction were completed the Joanna Briggs Institute Qualitative Assessment and Review Instruments. Results: Following the search and appraisal process, four studies were assessed as meeting the inclusion criteria and from these, 216 findings were extracted. Six meta-syntheses under the headings of expert knowledge, confidence, education, relationships, negative experiences and patient centered experience were formed from the findings. Conclusion: This review has increased our understanding about the experience of being an advanced practice nurse in Australian acute care settings and provided evidence of the role being multifactorial and complex. The patient is central to the APN experience but organisational factors impact and influence their experience also. Health care organisations must be aware of the impact they have on the nurse’s experience if they are to commit to nurse retention and patient safety. Nurses must continue to improve articulating their experiences in order to quantify the more intangible aspects of their practice. Implications: There is a pragmatic aspect to this review as implications for practice are specific to the functioning of the advanced practice nurse in the Australian acute care environment. The complexity of the role has been highlighted which may assist to inform future research into other aspects of APN practice.
Thesis (M.Phil.) -- University of Adelaide, School of Nursing, 2013

Les services téléphoniques de consultation en soins infirmiers sont en progression partout dans le monde. On sait que les infirmières qui possèdent une plus longue expérience de pratique au téléphone obtiennent davantage d’informations sur la condition de santé du client qui les consulte que celles qui comptent moins d’années d’expérience. Nous pouvons présumer que les niveaux d’expertise décrits par Benner (1984) expliquent cette différence. Toutefois aucune étude à ce jour ne décrit comment se manifeste cette différence entre les niveaux d’expertise dans la conversation au cours d’une intervention entre l’infirmière et l’appelant. Le but de cette étude descriptive était d’identifier les manifestations de cette expertise dans la communication, lors de la consultation téléphonique. À l’aide du Roter Interaction Analysis System (RIAS), 190 enregistrements d’appels, entre infirmières (N = 15), de divers niveaux de compétence selon la nomenclature de Benner (1984) et les appelants qui les ont consultées, ont été analysés. Les appels étudiés, issus d’une étude de plus grande envergure, devaient être faits par le parent d’un enfant de moins de cinq ans, et devaient faire l’objet d’une première consultation. Il a été possible de nommer des caractéristiques, des forces et des faiblesses communes aux infirmières de chaque niveau d'expertise à l’étude. Bien qu’il existe des différences entre les moins expérimentées et celles qui ont une longue expérience clinique au téléphone, les résultats semblent indiquer que les infirmières de tous les niveaux d’expertise sont fortement centrées sur la tâche d’évaluation de la situation de santé de l’appelant, mais que leurs interventions incluent peu d’énoncés orientés vers l’établissement d’un réel partenariat avec l’appelant. Les résultats obtenus fournissent des informations qui pourraient être utilisées pour élaborer des stratégies de développement professionnel, et guider les administrateurs de ce service dans le choix des indicateurs d’évaluation de la qualité du service et de ses retombés sur sa clientèle. Toutefois un plus grand nombre d’infirmières participantes et un plus grand nombre d’appels permettraient de confirmer les résultats obtenus à partir de ces 190 appels.
Nurse telephone consultation services are rapidly progressing throughout the world. It is known that nurses with a greater experience in telephone practise obtain more information on the client’s health condition when in consultation, than nurses with less experience. We can presume that Patricia Benner’s «levels of nursing experience», (1984), will provide us with an explanation for these differences. Yet, to this day, no study describes how these differences between levels of experience are manifested in conversation during an intervention between the nurse and the client. The object of this descriptive study was to identify the manifestations of this communication expertise during a telephone consultation. Using the Roter interaction analysis system (RIAS), 190 recorded calls between nurses (N = 15) with differing levels of expertise, according to Benner’ nomenclature (1984), and the callers who have consulted them were analyzed. The calls that were studied, from a larger study, were first calls from parents regarding their child aged five years or less. It was possible to observe characteristics, strengths, and weaknesses common to nurses within each level of expertise in this study. Despite the fact that there are differences between nurses with fewer years of experience and nurses with more clinical telephone experience, results seem to indicate that, regardless of their experience, nurses are strongly centered on the task of assessing the caller’s health situation; however, their interventions include few phrases aimed at establishing a true partnership with the caller. Results obtained provide information that could be used to elaborate professional developmental strategies, and guide administrators in their choice of indicators when evaluating service quality and its effect on clientele. Nevertheless, an increased number of nurse participants and a greater number of calls would enable us to confirm the results obtained from these 190 calls.
Ce mémoire est un des segments d'une recherche de plus grande envergure sur le service Info-Santé, et qui se déroule au Centre de Santé et de Services sociaux de Laval.

Thesis (M.S.)--University of Wisconsin--Madison, 1985.
Typescript (photocopy). eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 195-201).

Little is known about how expert nurses make decisions regarding IV PCA therapy and the factors and/or barriers affecting those decisions. The purpose of this research was to examine how expert nurses manage acute postoperative pain using the modality of IV PCA, and the processes nurses use to make decisions about IV PCA therapy in day-to-day clinical practice. The qualitative method of noncategorical, interpretive description guided the study. Seven participants were recruited via a process of nomination. Data collection included a modified think-aloud technique and post-think aloud interviews. Data were transcribed verbatim and analysis involved data inductively produced from the interviews and think aloud statements. A reflexive journal was used to provide insight into decisions made by the researcher and the rationale for making those decisions. The study generated six conclusive statements. (1) Nurses make a distinction between having IV PCA expertise and being an expert nurse in IV PCA therapy. (2) Nursing knowledge related to pain management and IV PCA, clinical judgment, and clinical reasoning are intimately interconnected and contribute to nurses' decision-making and pain management outcomes. (3) Three types of decisions are used (a) immediately intervene, (b) wait and watch with potential intervention at a later time, and (c) to do nothing. (4) Personal and institutional factors influence all of these decisions. (5) Pain management outcomes resulting from the nurses' decisions in regard to IV PCA were usually less than optimal. (6) Nurses do not consistently implement physicians' standing prn orders within the specified time frames to optimally manage acute postoperative pain using IV PCA. Implications of this research focus largely on the need for development and commitment to pain management standards of care (both generic and for IV PCA) and ongoing education around pain management. Further research is indicated to monitor and evaluate the outcomes of IV PCA.

ABSTRACT Sharon Ann Milligan USING THE NURSING INTERVENTIONS CLASSIFICATION (NIC) TO CODIFY THE NURSING ACTIVITIES OF ADVANCED BEGINNER, COMPETENT/PROFICIENT, AND EXPERT NURSES There is an increasing awareness of the need to achieve interoperability, the capability of different clinical documentation systems to communicate with each other. This sharing of data can only be achieved by the implementation of structured terminologies, such as the Nursing Interventions Classification (NIC). The classification of nursing data will enable nursing practice to be measured consistently. A nursing research study on the complexity of nursing provided a unique opportunity for the secondary analysis of actual observed nursing activities. An evaluation of these activities was conducted to determine if the NIC could be used to code the data. Observational data from two advanced beginner nurses, two competent/proficient nurses, and two expert nurses were coded with the NIC by two health informatics graduate students. The agreement between coders in the identification of a nursing intervention, unitizing inter-rater reliability, was calculated as 91.55%. The consistency of coding between coders, interpretive inter-rater reliability, was calculated as 75.60%. The results of this study show that the flexibility inherent in the design of the NIC can pose issues in the consistent assignment of interventions to the observed nursing activities. The challenges of implementing the NIC in a complex nursing environment can also be seen.