Adams Dave Allen nee Ryan Patricia Arkins Brigid Autar Ricky Baldwin Clive Ball Elaine C. Barnes ...

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Adams Dave Allen nee Ryan Patricia Arkins Brigid Autar Ricky Baldwin Clive Ball Elaine C. Barnes Susie Barron Carol – concurrent paper Barron Carol – poster presentation Clynes Mary Baxter Rosario Beal Margaret W. Beeman Pamela B. Paulanka Betty J. Begley Cecily M Begley Thelma Boyle Thomasina Brady Vivienne Brady Nevin Caroline Brennan Anne Gordon Evelyn Brennan Damien Brennan Miriam Kelly Marcella Mee Lorraine Bride Ann

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Brophy Sarah Jane Büchner Claire Bulfin Susan Burton Aileen Butchko Kerr Rita McBride Nancy Butler Michelle - Nurse's Role Butler Michelle - Care of Older Persons Byrne Anne S. Byrne Evelyn – concurrent paper Byrne Evelyn - poster Byrne Geraldine Byrne Gobnait – concurrent paper Byrne Gobnait – poster McCabe Catherine Fahey-Mc McCarthy Elizabeth Corry Rita Glacken Michele Macgregor Caitriona Adams Audrey Cannon Catherine Cannon Mary Cardwell Pauline Carey Cliona Carey Eileen Carter Bernie Casey Dympna

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Casey Dympna Murphy Kathy Cerruti Dellert Jane Gasalberti Denise Chamley Carol Anne Carson Elizabeth Pauline Clarke Jean Clynes Mary Coffey Alice Coleman Claire Coleman Deborah Coleman Laniece Collins Rita Condell Sarah Conteh Magnus Lunn Cora Conway Edel Cooley Clodagh Corbett Andrea Corcoran Philip Corroon Anne-Marie Cowman Seamus Coyne Imelda Conlon Joy Cronin Gerard Cronin Gerard Cronin Camille

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Crow Jayne Jones Shirley Culleton-Quinn Elizabeth Culley Lorraine Curtis Elizabeth A Day Mary Rose – concurrent paper Day Mary Rose – poster Deady Rick Delamere Sandra Mooney Brona Delaney Duffy Anita Dempsey Jennifer Dempsey Laura Denny Margaret Devane Declan Devine Maurice Dowling Maura Doyle Carmel Doyle Carmel Murphy Maryanne Drennan Jonathan – concurrent paper Drennan Jonathan - poster Drennan Jonathan Byrne Anne S. Drummond Elaine Duffy Mel

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Dunnion Mary Kelly Billy Egan Suzanne Ellis Mairghread JH Ellis Roger Evans William Nicholl Honor Farrell Miriam Feely Malachy Flood Anne – concurrent paper Flood Anne - poster Gale Eve Hegarty John Gallagher Pamela Gallagher Patrick Gibbons-Twomey Colette - concurrent paper Cannon Catherine Flood Anne Gibbons-Twomey Colette – poster Gidman Janice Gillen Ailsa Gilrane-Mc Garry Ursula Glacken Michele Higgins Agnes Gleeson Madeline Glover Donna Godfrey Mary

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Gonc Vida Goonan Noreen Gordon Evelyn Gormley Sandra Graham Margaret Cassidy Irene Tuohy Dympna Griffiths Colin McCabe Catherine Hackett Myles Hall Jennifer Hardie Anne M. Hardy Steve Harnett Alison Harrison Nigel Lyons Christina Hartnett Liz Hatamleh Reem Haycock-Stuart Elaine Hayden Deborah Hayes Claire Healy Denise Healy Maria Hegarty Josephine Burton Aileen Higgins Agnes Hindley Carol

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Hiney Geraldine Hourican Susan Howe Rachel Howlin Frances Hughes Christine Hutchings Maggie Jansen Pat Jean-Baptiste Giovannie Jones Jean Hardie Anne Robertson Alison Joyce Pauline Cowman Seamus Kane Raphaela Kavanagh McBride Louise Keane Noreen Kearns Alan J Keenan Iain Crow Jayne Keenan Paul Kelly Mary Keogh Johannes Kielty Lucy A. Kiger Alice Kilcullen Nora Kinsella Margaret

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Kothari Áine

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

E-/BLENDED LEARNING IN NURSE/MIDWIFERY EDUCATION Dr Winifred Eboh PhD, BSc, RM, RGN (Lecturer); Dr Sheelagh Martindale PhD, MSc, RGN (Lecturer); Dave Adams MSc, RGN, RMN (Lecturer); Neil Johnson MSc, RGN (Lecturer); Elaine Mowatt, M Ed, RGN (Lecturer). The Robert Gordon University School of Nursing and Midwifery Faculty of Health and Social Care Garthdee Campus Garthdee Road ABERDEEN AB10 7QG An ever changing and technically advancing society (Mowforth et al., 2005) has placed demands on nurses and midwives to embrace these changes in their practice to meet the needs of a more knowledgeable and expectant public. For these expectations to be realised within clinical settings, nursing and midwifery educators are equally challenged to train professionals who are up to the challenge. As nurse lecturers based at a school of nursing and midwifery which has two student intakes a year with numbers ranging from 200 to 300 per intake. Delivering a modular course can present countless challenges demanding more innovative ways of teaching that goes beyond face to face class room contacts. To that end the principle author has received a Winston Churchill Travel fellowship to visit centres in Europe that use e-/blended learning media to deliver health related subjects to diverse healthcare professionals including nurses and midwives. It is anticipated that the module team will use these two media (as well as traditional methods) to deliver specific courses within our school which will address certain long-term expectations (Hovenga, 2004); these include: • Teaching modules to large class sizes undertaking different branches of nursing e.g. adult, children, mental health and midwifery; • Providing the right level of education in accordance with the QAA standards for diploma and degree nurse education to students with entry qualifications ranging from PhD to Standard/O levels; school leavers to mature students returning to education after bringing up their children; • Generating interest in traditional academic subjects e.g. research, anatomy and physiology and skill-based subjects including cardiac resuscitation and the carrying out of observations like blood pressure, temperature, pulse and respiration amongst many others. This paper will present the findings from the fact finding European trip and module development programmes. References: Hovenga, E.J.S. (2004) Globalisation of Health and medical informatics education – what are the issues? International Journal of Medical Informatics 73 101-109 Mowforth, G., Harrison, J., Morris, M. (2005) An investigation into adult nursing students’ experience of the relevance and application of behavioural sciences (biology psychology and sociology) across two different curricula Nurse Education Today 25 41-48

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Quality Assurance Agency for Higher Education http://www.qaa.ac.uk (accessed 18th April 2005).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Transactional Analysis and the Assessment of Clinical Practice. Ms Patricia Allen nee Ryan RMN, DipN, MSc (Inter-professional Health and Welfare Studies), PGCE (A), Ed.D. (in progress) Senior Lecturer 27 Manor Avenue Caterham Surrey CR3 6AP England [email protected] Since the Fitness for Practice report (UKCC 1999) and Making a Difference directives (Dept of Health 1999) the assessment of clinical practice in nursing is purported to be as important as the assessment of the theoretical aspects of nursing programmes with a professed 50% theory, 50% practice split. However, despite the message of the philosophical value of practice there are in reality, major differences between how clinical practice and theoretical work is assessed. In most Higher Education Institutions that provide nurse education programmes there can be up to five stages where theoretical assignments are scrutinised and verified. This will can include first marking by a qualified teacher, sometimes second marking, moderation, an internal department or school panel and the external examiners as well. In the practice assessment process the attention to detail, fairness and parity are sadly lacking and whilst it is acknowledged that this may not be deliberate, it is nevertheless true. In my experience as a practitioner and a lecturer, busy clinicians, who have to juggle competing priorities in a less than ideal situation, often undertake practice assessment. I recently heard of a student who had to complete their own summative practice assessment as her mentor, the manager of a busy acute admission ward, had become unexpectedly unavailable due to several unforeseen admissions to the unit. I wonder how unusual this is…. Students report relationships with mentors are unpredictable, as is the mentor’s interest, their level of clinical skills and experience. Mentors report that students can be equally diverse and also have variable levels of motivation, intelligence and skills. In addition to these unsurprising differences there are also other factor to consider including race, culture, gender, age, and religion to name a few. What then is the answer to the problem of providing an equally stringent approach to the assessment of clinical practice and theoretical work? My research will offer some insights into this dilemma by seeking the views of both the students and their mentors alike using an action research methodology. It will seek to discover a way forward to ensure an equal relationship between the assessment of theory and practice and consider some of the methods used by other health professional groups to assess practice will be examined to establish if there are lessons to be learned from them.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Banning M (2004) The use of structured assessments, practical skills and performance indicators to assess the ability of pre-registration nursing students' to apply the principles of pharmacology and therapeutics to the medication management needs of patients. Nurse Education in Practice Jun 4(2): 100-6 Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. HMSO: London United Kingdom Central Council (1999) Fitness for Practice: Report of the UKCC Commission for Nursing and Midwifery Education (Peach Report). London: United Kingdom Central Council for Nursing, Midwifery and Health Visiting.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Therapeutic Value of Mixed Sex and Female Acute Admission Wards in Psychiatry Brigid Arkins RPN, MSc Lecturer School of Nursing and Midwifery, Brookfield Site,University College Cork, Cork Main Study Aim The main aim of the study is to ascertain if the female acute admission ward is more therapeutic than mixed sex acute admission wards Introduction There has been very little research into the therapeutic value of mixed and female acute admission wards. The research conducted is preliminary to this area. Since the 1990’s there has been many concerns raised about the safety of women on mixed sex wards. Some studies conducted during this period stated that women prefer mixed sex wards as they are more therapeutic. Whilst other studies highlighted that women suffered from sexual harassment and assaults on acute admission wards. The research took place in a London mental health hospital that had 4 mixed sex acute admission wards and 1 female acute admission ward. Methodology Non experimental research Ex Post Facto (correlation) Qualitative descriptive Data collection Ward Atmosphere Scale (Moo’s (1996) was given to 42 staff from different discipline 31 female patients were interviewed 10 staff from different disciplines partook in the semi structured interviews Data analysis Statistical analysis through SPSS Thematic analysis Results • The ability develop therapeutic relationships was enhanced on the female ward. • Women felt safer on the female ward • Women felt frightened on both mixed sex and female wards • Women’s ward preference is context related • More women on the female ward felt that the admission was helping their recovery References Clearly M & Warren R. (1998) An exploratory investigation into women’s experience in a mixed sex psychiatric admission unit Australian and New Zealand Journal of Mental Health Nursing 7, pg. 33-40 Kettles A. (1997) Survey of patient’s preferences for mixed or single sex wards. Journal of Psychiatric and Mental Health Nursing 4 pg. 56 - 57 Mind (2000) Environmentally Friendly? Patients Views of Conditions on Psychiatric Wards, London Mind Publications

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Moo’s RH (1996) Ward atmosphere Scale Sampler set Annual Test Booklets and Scoring Key. Development, Application and Research. A Social Climate scale. 3rd ED. California, Mind Garden

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

ADVANCING NURSING PRACTICE IN THE MANAGEMENT OF DEEP VEIN THROMBOSIS (DVT). DEVELOPMENT, APPLICATION AND EVALUATION OF THE AUTAR DVT RISK ASSESSMENT SCALE SUBMITTED BY RICKY AUTAR, PhD, MSc, BA (HONS) DIP N, RGN, RMN, CERT ED, RNT PRINCIPAL LECTURER DE MONTFORT UNIVERSITY CHARLES FREARS CAMPUS 266 LONDON ROAD LEICESTER LE2 1RQ ENGLAND EMAIL: [email protected] PHONE; +44 116 201 3945

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Advancing nursing practice in the management of Deep vein Thrombosis (DVT). Development application and evaluation of the Autar DVT Risk Assessment Scale. ABSTRACT Deep Vein Thrombosis (DVT) is a disease of hospitalised patients and poses a serious threat to their recovery. DVT is most preventable and venous thromboprophylaxis consensus groups recommend that patients be risk assessed so that prophylaxis can be tailored to individuals.In the spirit of such recommendation, the Autar DVT risk assessment scale was developed (Autar 1994;1996a;1996b). Founded on Virchow’s triad in the genesis of DVT and comprising seven subscales of thrombogenic risk factors, the DVT risk calculator was validated on a small orthopaedic population. Although positive outcomes were reported, the small yet well formed study did not permit generalisability of findings and wider application across the boundaries of practice. Further to revalidate the DVT scale for its universal application and finding and generalisability , 150 patients were randomly recruited from Orthopaedic, Surgical and Medical specialities. DVT is a continuing problem and therefore all patients were followed up for a minimum of three months after discharge from hospital. Interestingly, 39 per cent of the patients with DVT (11/28) developed DVT at home. Five reproducibility studies on the orthopaedic, medical and surgical directorates achieved kappa values ranging 0.88 to 0.95, confirming the consistency of the instrument. A Receiver Operating Characteristic (ROC) curve was constructed to determine the optimal predictive accuracy of the DVT scale and a cutoff score of 11 yielded approximately 70 per cent sensitivity. Data from two patients, who could not be followed up, were excluded for evaluation of the predictive accuracy of the DVT scale. Overall, 115 patients out of the 148 (78%) were correctly classified and predicted. This predictive accuracy of the DVT risk calculator was an underestimation of its efficacy as it was masked by the administration of prophylaxis to a large number of high risk patients. As a result of the findings and the availability of new and compelling research evidence , the Autar DVT scale was revisited and revised for maximisation of its predictive validity (Autar 2002; Autar 2003). INTRODUCTION Venous Thromboembolism (VTE) is a spectrum of disease ranging from Deep Vein Thrombosis (DVT) to Pulmonary Embolism (PE), a potentially fatal condition. Fifty percent of patients with initial DVT go on to develop Post- Thrombotic Syndrome (PTS) a chronic disabling condition (Strandness et al, 1983; Prandoni et al, 1996). VTE seriously damages health and is a silent killer (Autar 1996a).The scale of this problem is highlighted in table1 by the risk level according to patient group.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Table1: Incidence of DVT by patient group Speciality DVT% ( Weighted mean) General surgery 25 Orthopaedic surgery 45-51 Urology 9-32 Gynaecological surgery 14-22 Neurosurgery including strokes 22-56 Multiple trauma 50 General medicine 17 Data: International Consensus Statements (1997; 2002). BACKGROUND VTE is most preventable (Kakkar & Stringer 1990) and routine prophylaxis saves between 4000-8000 lives annually (Hull et al, 1990). Essentially, primary and secondary prophylaxes are the two approaches to VTE management. Primary prophylaxis is the proactive prevention of DVT. This is achieved by risk assessment and the stratification of such risk followed by the implementation of the most effective prophylaxis. On the other hand, secondary prophylaxis is reactive to the treatment of DVT, directed at preventing PE and PTS (Clagett et al, 1992). Notably, primary prophylaxis is superior to secondary prophylaxis, both in terms of cost and quality of life perspectives (Anderson and Wheeler, 1995). In the light of abundancy of evidence overwhelmingly supportive of the efficacy of prophylaxis, VTE consensus groups vigorously recommend risk stratification of patients followed by a tailor made prophylaxis for individual based on the category of risk(Table 2). Table2: VTE consensus groups. • National Institutes of Health (NIH) 1986 • European Consensus statement 1991 • Scottish Intercollegiate Guidelines Network (SIGN) 1995 • American College of Chest Physicians (ACCP) 1995 • THRiFT 1992/1998 • International Consensus Statements 1997/2001 VTE risk assessment, stratification and management A framework for a systematic and comprehensive DVT risk stratification and venous thromboprophylaxis management is outlined in flow chart below:

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

VTE risk management Aim:to prevent DVT, PE, PTS ↓ Identify patient related risk factor (s) ↓ Identify patient condition related risk factor(s) ↓ Stratify patient onto one of the three related risk groups ↓ ↓ ↓ Low Moderate High ↓ Is pharmacological prophylaxis contra-indicated? ↓ ↓ Yes ↓ Mechanical prophylaxis GCS IPC ↓

No ↓ Pharmacological prophylaxis LDUH LMWH

Outcome:to prevent DVT, PE, PTS Clinical risk assessment and stratification identify patients into one of the three risk categories which ultimately facilitate the implementation of the appropriate interventions (THRiFT, 1998). Risk stratification involves the cumulative consideration of the patient’s related risk factors with their condition related risk factor(s), which calculate the overall category of risk (Anderson and wheeler 1995; Autar, 1998). A plethora of prognostic indexes have been formulated to identify patients at risk of DVT (Table 3). Table 3: Prognostic indices *Nicolaides & Irving 1975 *Clayton et al 1976 *Rakoczi et al 1978 *Crandon et al 1980 *Lowe et al 1982 *Melbring & Dahlgren 1983 *Sue-Ling et al 1986 *Janssen et al 1987 *Rocha et al 1988

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

All of the indexes combined clinical risk factors and fiddly laboratory procedures to arrive at some equations for identifying DVT risk. However, the equations are forbiddingly complex to work out and reliance on non standardised laboratory results delayed prompt risk assessment and explained why the prognostic indexes were not widely and favourably implemented (Gallus, 1989). A risk assessment tool is one that is easy to use and modelled on simple proven clinical risk factors are more likely to be widely applied (Ruckley 1985). It is within this guided philosophy that the Autar DVT scale (1994; 1996b was developed.(Figure 1).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Figure 1: AUTAR DVT RISK ASSESSMENT SCALE (1994; 1996) Name: Unit No: Ward: AGE SPECIFIC GROUP (years)

Age: Type of admission: Diagnosis score

10-30 31-40 41-50 51-60 61+

MOBILITY

0 1 2 3 4

score

Ambulant Limited (uses aids, self) Very limited (needs helps) Chair bound Complete bed rest

0 1 2 3 4

Head injury Chest injury Spinal injury Pelvic injury Lower limb injury

Build Underweight Average/ Desirable Overweight Obese Very obese (morbid)

BMI 16-18 20-25 26-30 31-40 41+

SPECIAL RISK CATEGORY Oral Contraceptives:

score 0 1 2 3 4 score

20-35 years 35+ years Pregnancy/ Puerperium

1 2 3

SURGICAL INTERVENTION: Score only one appropriate surgical intervention. score

TRAUMA RISK CATEGORY Score item(s) only preoperatively.

BUILD / BODY MASS INDEX (BMI) Wt(kg/ Ht (m)2

score 1 1 2 3 4

Minor surgery < 30 mins Planned major surgery Emergency major surgery Thoracic Abdominal Urological Neurosurgical Orthopaedic (below waist)

1 2 3 3 3 3 3 4

HIGH RISK DISEASES: Score the appropriate item(s) score

ASSESSMENT PROTOCOL Score range Risk Categories

Ulcerative colitis Anaemia: Sickle Cell Haemolytic Polycythaemia Chronic heart disease Myocardial infarction Malignancy Varicose veins Cerebrovascular accident Previous DVT

≤6 7-10 11-14 ≥ 15

1 2 2 2 3 4 5 6 6 7

No risk Low risk Moderate risk High risk

SCORING: Identify appropriate items, add and record daily Assessor Date Score

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Founded on Virchow’s triad and the fibrinolytic body system, in the genesis of VTE, the Autar DVT scale comprised the following seven subscales: 1. 2. 3. 4. 5. 6. 7.

Age Specific group Build/ Body Mass Index (BMI) Mobility Special Risk Category Trauma Surgery High risk diseases

After an initial pilot study, the DVT risk assessment tool was evaluated on 21 patients on a Trauma/ Orthopaedic unit. Seven days data collected on each of the 21 patients to validate the sensitivity, specificity and consistency of the DVT scale, yielded as much data for analysis as what would have been collected on 147 patients being singly risk assessed within 24 hours of admission. Analysis of data gathered achieved 100% sensitivity, 81% specificity and a value of r at 0.98 for consistency (Autar 1996b). However, the external validity in terms of generalisability of the findings is questionable; on account of sample size and limited representation of the populations in the study. Since its development and application, the Autar DVT scale has been the subject of ongoing scrutiny and evaluation (Autar 1994; Autar 1996; Autar 1998).Due to the evolving nature of medicine, systematic reviews, new evidence derived from robust research findings and consensus statements published from 1991-2001, it is imperative for any new tool to be modified in order to reflect the new findings to guide best practice. As a result, the Autar DVT scale was revisited and revalidated as a doctoral initiative. OBJECTIVE OF STUDY The objective of the study was to revalidate the Autar DVT scale for its predictive validity, reliability and practical application. Available data were utilised to determine the current protocol, in relation to venous prophylaxis. METHOD It was essentially a quantitative and longitudinal study. An apriori power analysis was undertaken to determine a medium effect sample size. Statistical sampling package G* Power (Erdfelder et al 1996) was applied and Cramer’s V statistic selected to calculate the power of x2. Choosing the conventional alpha input of 0.05, a minimum considered acceptable power (1- ß) of 0.80 as default, G* Power calculated a sample of 149 patients required for the study. As a result, 50 inpatients were randomly recruited from each of the three clinical specialities: orthopaedic/trauma, general surgery and the medical directorates. The choice of the three specialities enables the examination of the problem of VTE in the high risk patient groups as in surgery and on the medical unit where a weighted mean of 17 % of DVT were reported (International Consensus statement, 1977). Table 4 illustrates the variability of the risk categories within the sample

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Table 4: Sample representation of the risk categories. Risk categories High Moderate Low No risk Total

Number of patients 19 37 51 43 150

% 13 25 34 28 100

All adult patients over the age of 18 were randomly recruited; irrespective of gender as sex difference is no respecter of DVT, unless additional risk factors such as HRT and oral contraceptives are present. Patients admitted with current DVT and receiving active treatment for the condition were excluded in order to obviate any bias outcome, in relation to the effectiveness and predictive validity of the DVT scale. DATA COLLECTION The 150 patients were risk assessed for DVT within 24 hours of admission. The choice of risk assessment within 24 hours was considered timely for optimal predictive accuracy of the DVT scale, when the patients are deemed to be most vulnerable due to the acute nature of their condition or surgical intervention, with accompanying fibrinolytic shutdown (Merli & Martinez, 1987: Kakkar & Stringer, 1990). Elective patients undergoing surgery were also risk assessed within the 24 hours defined time frame, but immediately after their surgical intervention, when both hypercoagulable state and venous stasis, favouring thrombi formation are at their peak (Nicolaides 1990).However, elective surgical patients who could not be risk assessment within the 24 hours defined time frame from admission, due to postponed or delayed surgery, were excluded from the study. Further to evaluate the DVT scale for its practical utility and application, a Likert type postal questionnaire was applied to the users of the DVT scale. The questionnaire comprised 29 items formulated at evaluating the appropriateness and clarity of each the variables of the seven subscales. A response rate of 88% (22/25) was recorded. DATA ANALYSIS AND RESULTS Reliability of the DVT scale To establish the consistency of the DVT scale, data rated independently and simultaneously by instructed paired registered nurses on the 150 patients were computed. Estimates of reliability computed by different procedures for the same instrument are not identical (Polit, 1996) and total percentage agreement (T %), kappa statistic (k) and Intra-class Correlation Coefficients (ICC) were applied. Data on the 150 patients that estimated the T% agreement, were converted into the four nominal categories of no risk, low moderate and high risk

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

As the number of observation recorded for each subject was the same, Intra-class Correlation Coefficients (ICCs) were also computed for all the five clinical areas. ICC estimates the average among all possible pairs of observation (Bland & Altman, 1996). Paired observation data used to estimate the T% agreement and k values were also computed to estimate the ICCs on the five wards, using SPSS (version 11) via statistic pull down and selection of intra-class correlation coefficient. The T (%) agreement ranging between 85-98%, kappa values within 0.88- 0.95 and ICCs values of .94-.99 confirmed the reliability of the DVT scale. Predictive accuracy of the Autar DVT scale Patients were closely monitored for DVT throughout inpatient stay and for three months beyond. Unavoidably, data from 2 of the 150 patients were excluded from the analysis as it was not possible to make contact with them during the follow up period. The gold standard for DVT was defined as patients with confirmed diagnosis of DVT, treated by secondary anticoagulant therapy. Twenty-eight such subjects (19%) met the gold standard (Table 5) and patients admitted primarily for anticoagulant therapy for DVT were not included in the study. Table 5: Prevalence of DVT on the three clinical specialities Speciality

No of patients

%

No of DVT

Orthopaedic Trauma 50 8 16 Medical 50 12 24 Surgical 48 8 17 Total 148 28 19 The distribution of patients with and without DVT as predicted by the absolute cutoff score of 15≥ is illustrated in the contingency table 6. Table 6: Distribution of patients with without DVT by absolute scores. DVT present Score 15 ≥ Score ≤ 14 Total

A C

7 TP 21FN 28 (19%)

DVT absent B 12 FP D 108 TN 120

Total 19 129 148

True positives (TP) are those who are predicted positive and have DVT.7 patients were correctly predicted as true positive. False positives (FP) are those incorrectly predicted to have DVT but did not: 12 FP were recorded. 108 patients were correctly

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

predicted negative for the disease are true negatives (TN). False negatives are incorrectly those predicted negative for DVT (TN): 21 FN were recorded. Test accuracy is defined as the number of true positive and true negative divided by the number of patients studied (Wheeler et al, 1994). 78 % of patients (7TP+108 TN/ 148) were accurately recorded. 78 % of those predicted negative that do not have DVT. However, the administration of venous thromboprophylaxis masked the predictive accuracy of the DVT scale, as 50% of patients in the study were recipient of some known form of primary venous thromboprophylaxis. DISCUSSION & CONCLUSION As new evidence becomes available, it is mandatory to make the appropriate changes to guide and inform clinical practice (Sackett et al, 1996). In the light of the results and the new evidence, the following changes to the DVT subscales were made (figure 2) and rationales for such recommendations highlighted. The recommendations relate specifically to some of the subscales, notably the age specific group, special risk category, the surgical intervention category and some of the variables in the high risk disease subscale.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AUTAR DVT RISK ASSESSMENT SCALE revisited: Figure2 Age: Type of admission: Diagnosis

Name: Unit No: Ward: AGE SPECIFIC GROUP (years)

BUILD / BODY MASS INDEX (BMI) Wt(kg/ Ht (m)2

score 10-30 31-40 41-50 51-60 61-70 71+

0 1 2 3 4 5

Build Underweight Average/ Desirable Overweight Obese Very obese (morbid)

score

MOBILITY Ambulant Limited (uses aids, self) Very limited (needs helps) Chair bound Complete bed rest

0 1 2 3 4

TRAUMA RISK CATEGORY Score item(s) only preoperatively.

SPECIAL RISK CATEGORY Oral Contraceptives: 20-35 years 35+ years Hormone replacement therapy Pregnancy/ puerperium Thrombophilia

score 0 1 2 3 4 score 1 2 2 3 4

SURGICAL INTERVENTION: Score only one appropriate surgical intervention. score

score

Head injury Chest injury Spinal injury Pelvic injury Lower limb injury

BMI 16-18 20-25 26-30 31-40 41+

1 1 2 3 4

Minor surgery < 30 mins Planned major surgery Emergency major surgery Thoracic Gynaecological Abdominal Urological Neurosurgical Orthopaedic (below waist)

1 2 3 3 3 3 3 3 4

CURRENT HIGH RISK DISEASES: Score the appropriate item(s) score

ASSESSMENT INSTRUCTION Complete within 24 hours of admission

Ulcerative colitis Polycythaemia Varicose veins Chronic heart disease Acute myocardial infarction Malignancy (active cancer) Cerebrovascular accident Previous DVT

Scoring: Ring out the appropriate item(s) from each box, add score and record total below;

Score range

1 2 3 3 4 5 6 7

ASSESSMENT PROTOCOL Risk categories

≤ 10

Low risk

11-14

Moderate risk

15 ≥

High risk

Please record any other clinical observations that may supplement this DVT risk assessment.

Total score: Assessor: Date:

VENOUS THROMBOPROPHYLAXIS Low risk: Ambulation+ Graduated Compression Stockings. Moderate risk: Graduated Compression stockings+ Heparin + Intermittent Pneumatic Compression Stockings. High risk: Graduated Compression Stockings+ Heparin+ Intermittent Pneumatic Compression. International Consensus Group recommendation, 2001 © R Autar, 2002.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Age Specific group There is a linear and strong correlation between advancing age and the development of DVT (Nordstrum et al, 1992). Post mortem and clinical studies have demonstrated that the frequency of DVT increases exponentially with age (Gibbs, 1957; Rosendall, 1997). A DVT rise of 20 per cent is reported in the 40-60 year old patients. This doubles between the age of 60 and 70 years and in patients over 70 the figure trebles (Borrow & Goldson, 1981; Caprini & Natonson, 1989). Older people in the 70s and 80s now comprise two thirds of all the patients in acute setting (DOH, 2001) and 328 recorded cases of DVT were reported for the 70s and 80s, compared to only 100 per 1000 for 65-69 age group(OPCS 1990). In the age specific subscale, the 51-60 and 61+ age groups were assigned risk scores of 3 and 4 respectively. Relative to the incidence of DVT that rises sharply in the different age groups, the elderly patients in the 70-80 age groups are recognised as the highest risk group (Anderson & Wheeler, 1995) and accordingly assigned a relative risk score of 5. Special risk category (HRT) At the time of the development, application and evaluation of the Autar DVT scale (1994) there were insufficient and inconclusive data available supporting the causal relationship between DVT and HRT (RCOG, 1995). It was noted that most women receiving HRT had other risk factors, particularly age or undergoing gynaecological surgery ( Notelovitz & Ware). 1982. Carter (1992) also found no association between DVT and HRT. It was held that the lower dose of oestrogen in HRT than oral contraception and their smaller effect on haemostasis in comparison carries little or no risk. Since, three studies published in 1996 (Jick et al, 1996, Daly et al, 1996 and Grodstein et al, 1996) have all confirmed that there is a 2-4 fold increase in DVT both in oestrogen only and combined oestrogen / progestogen preparations. Most recently, a randomised controlled trial (Lowe et al, 2000) confirmed a two to fourfold increase of DVT in women taking HRT.

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There is now compelling evidence that a causal relationship between HRT and DVT exists. HRT is now a new addition to the special risk hypercoagulability subscale and is assigned a risk score of 2. Thrombophilia Hereditary hypercoaguable states are associated with an increased risk of thrombosis (Shafer, 1985).The number of hypercoaguable states is still growing but the nine that have been confirmed and classified as Thrombophilia or Hereditary Thrombotic Diseases (HTD) are listed below: •

Protein C deficiency

•

Protein S deficiency

•

Antithrombin III deficiency

•

Plasminogen deficiency

•

Dysfibrinogenia

•

Tissue Plasminogen Activator deficiency (t-PA).

•

Plasminogen Activator Inhibitor excess (PAI).

•

Heparin cofactor II

•

Factor V Leiden

Of these hypercoaguable states listed above, Protein C (10%), Protein S (12%) and Antithrombin III deficiencies (3%) are most common (Cooper, 1994). Factor V Leiden is an inherited mutation in the gene coding for Factor V and accounts for about 5 % of the white population. It causes activated protein C resistance (APCR) resulting in an increased susceptibility to develop DVT (Vandenbroucke et al, 1996). 90-95 per cent of patients with thrombophilia present with DVT (Marlar & Mastovich, 1990). Proportional to the magnitude of the problem, thrombophilia is assigned a risk score of 4 in the special risk subscale. Surgical intervention category The questionnaire survey reveals that clarification of several variables would enhance the practical application and predictive accuracy of the DVT scale.

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Emergency major surgery carries a DVT risk of 2.7% compared to 0.2 to2.0% for elective major surgery (Coon, 1976). In order to highlight the difference in risk, major surgery has been renamed “Elective major surgery”. Similarly, the variable orthopaedic surgery has been redefined as below “waist orthopaedic surgery”, to explicitly reflect the high risk with orthopaedic procedures such as total hip and knee arthroplasties and repair of fractured femur, tibia and fibula.

High risk diseases subscale New findings of the high risk diseases in the causation of DVT, directly and indirectly, have also necessitated their critical review. Sickle cell anaemia and haemolytic anaemia have been implicated in earlier literature for the reason of restricted blood flow and the release of cell breakdown products. In sickle cell anaemia thrombi occur frequently in the microcirculation, but there is no recorded data that it causes DVT (Bell & Simon, 1982). Similarly, there is no current classified data to support haemolytic anaemia with causal association with DVT (Belcher, 1993). Sergeant (1992) claims that early publications linking sickle cell anaemia and haemolytic anaemia to DVT, due to increased blood viscosity may have been exaggerated and speculative. As both sickle cell anaemia and haemolytic anaemia do not appear to have any DVT predictive currency, they have been duly deleted in the revalidated DVT scale (Autar, 2002).

Varicose veins Consistent with its high ranking by the European Consensus Group (1991) and THRiFT (1992), varicose veins as a DVT risk factor was assigned a high risk score of 6 (Autar, 1994). In previous studies derived from regressive analysis of covariates, varicose veins were found to be an independent risk factor (Nicolaides & Irving, 1975; Clayton et al 1976; Crandon et al, 1980; Lowe et al 1982).

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However, literature on varicose veins is controversial. The studies showing a relationship between DVT and varicose veins were undertaken in patients who had major abdominal surgery and invited criticism for the population sample also contained older and obese patients. Varicose veins may have coexisted incidentally with major abdominal surgery, advancing age and obesity as additive factors to cause DVT. In a study of 1231 patients, Anderson and Wheeler (1995) reported a DVT incidence of only 5.8 per cent due to varicose veins. The retention of the high risk score of 6 for varicose veins over predicts risk, is unjustified and its original risk score regraded to 3 based on odds ratio and relative risk calculation. Myocardial Infarction In this high risk disease category, the variable “myocardial infarction”, was deemed to be ambiguous and opened to interpretation as either an acute episode or a past medical history. A previous myocardial infarction does not necessarily carry risk (Carter et al, 1987) and aptly redefining the variable as “acute myocardial infarction”, emphasises an acute event, capable of causing DVT. CVA and previous DVT CVA and a previous DVT are very well recognised high risk diseases in the causation of DVT, each associated with a risk score of 7 (Autar, 1994). The incidence of DVT ranges between 42-60 per cent for CVA (Kamal 1987; Brunner & Suddarth, 1992). Reportedly, in patients with a previous history of DVT, the recurrence of an episode is between 48-68 per cent (Dalen et al, 1986). An even higher risk than CVA was reported by Samama et al (1993) who recorded an odds ratio of 7.9 for patients with previous DVT. There is now a strong consensus that previous DVT predisposes to the recurrence of the condition and is acknowledged as the highest risk factor in the causation of DVT (Nordstrom et al, 1992; Samama et al, 1993; Anderson et al, 1995). Previous DVT is riskier than CVA and is capped at the risk score of 7. CVA is assigned a revised score of 6 and in this way; the small difference in the risk associated with these conditions is maintained.

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The DVT risk assessment protocol The DVT risk assessment strategy (Autar, 1994) places patients into one of the four risk categories: no risk, low, moderate and high risk. The justification of a no risk category assessment protocol arose out of the need to differentiate between those who are not, in order to facilitate allocation of limited resources effectively. A latest study (Anderson & wheeler, 1995) reported a DVT incidence of 11% in patients with no single risk factor. The association between DVT and the number of risk factors present is illustrated in Table 7. Table 7: Association between risk factors and DVT (Anderson & Wheeler, 1995). No of risk factors

DVT (%)

0

11

1

24

2

36

3

50

≥4

100

Data extrapolation on the medical wards studied, identified two patients in the no risk category who developed DVT. Resultantly, the four risk categories of the DVT scale have been reviewed to three risk categories (figure 2). The removal of the no risk category from the assessment protocol places the low risk category into a wider risk score range of less than 10 and resolves any problem of spurious precision between the no and low risk categories. The other risk score ranges of 11-14 and 15≥ are maintained to identify the moderate and high risk categories respectively. This modified risk assessment protocol is also consistent with the recommended antithrombotic assessment strategy. (International Consensus Group, 1997 & 2001). The Autar DVT scale relies on routine data gathered on admission, allowing for a prompt DVT risk assessment and timely intervention. Like the universally recognised Glasgow coma scale, the Autar DVT scale can be applied by nurses and doctors alike and other health care professionals

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The use of computer programmed with logistic regression formulas, as devised by Janssen et al (1987) is technology for the future. Until artificial intelligence is readily available for carrying bedside assessment, paper and pencil assessment tools as the DVT scale, remain the most effective method of predicting risk and guiding decision making.

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Campbell WB, Ridler BMF (1995) Varicose vein surgery and deep vein thrombosis. British Journal of Surgery. 82:1494-1497. Campbell B (1996) Thrombosis, phlebitis and varicose veins. British Medical Journal. Vol 312: 198-199. Caprini JA, Natonson RA (1989) Postoperative Deep vein Thrombosis: Current Clinical Considerations. Seminars in Thrombosis and Hemostasis. Vol. 15, No 3: 244249. Carter CJ, Gent M, Leclerc JR (1987) The epidemiology of venous thrombosis. In: Colman RW, Hirsh J, Marder VJ, Salzman EW (eds) Hemostasis and thrombosis: basic principles and clinical practice. Second edition. JB Lippincott Company, Philadelphia. Carter CJ (1992) Thrombosis in relation to oral contraceptives and hormone replacement therapy. In: Haemostasis and Thrombosis in Obstetrics and Gynaecology. (Eds Greer IA, Turpie AGG, Forbes CD) London, Chapman and Hall: 371-385. Clagett GP, Anderson FA, Levine MN, Salzman E, Wheeler HB (1992) Prevention of Venous Thromboembolism. Chest. Vol 102, No 4: 391S – 407S. Clayton JK, Anderson JA, McNicol GP (1976) Preoperative prediction of postoperative deep vein thrombosis. Br Med Journal. 2: 910-912. Cohen JA (1960) A coefficient of agreement for nominal scales. Educational and Psychological Bulletin. 20: 37-46. Cooper DN (1994) The molecular genetics of familial venous thrombosis. Bailliere’s Clinical Haematology. Vol 7, No3: 637-674 Coon WW (1976) Epidemiology of venous thromboembolism. Ann Surg 186(2) 149164. Crandon AJ, Peel KR, Anderson JA, Thompson V, McNicol GP (1980) Postoperative deep vein thrombosis: identifying high risk patients. Br Med Journal. 7: 343- 344. Crookes P, Davies S (1998) Research into Practice. Bailliere Tindall. London. Dalen JE, Paraskos JA, Ockene IS et al (1986) Venous thromboembolism. Scope of the problem. Chest. Suppl 371S-373S. Daly E, Vessey MP, Painter R et al (1996) Risk of venous thromboembolism in users of hormone replacement therapy. Lancet. 348: 977-980. DoH (2001) National service framework for older people. HMSO, London.

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Erdfelder E, Faul F, Buchner A (1996) G Power: a general power analysis programme. Behaviour Research Methods, Instruments and computer. 28: 1-11. Heinrich Heine University. Dussuldorf. Essex-Sorlie D (1995) Medical Biostatics and Epidemiology. First edition. Prentice Hall International Inc, London. European Consensus Statement (1991) Prevention of venous thromboembolism. MedOrion Publishing, London. Gallus AS (1989) Overview of Management of Thrombosis and Hemostasis. Vol15, No 2:99-109 Gibbs NM (1957) Venous Thrombosis of the lower limbs with particular reference to bedrest. Br J Surg. Vol X1V,No 191: 15-253 Geerts WH, Code KI, Jay RM et al (1994) A prospective study of venous thromboembolism after major trauma. The New England Journal of Medicine. Vol 331,No 24: 1601-1606. Grodstien F, Stampfer MJ, Goldhaber SZ et al (1996) Prospective study of exogenous hormones and risk of pulmonary embolism in women. Lancet. 348: 983-987. Hull R, Raskob GE, Gent M et al (1990) Effectiveness of Intermittent Pneumatic Leg Compression for preventing Deep vein thrombosis after Total Hip replacement. JAMA. Vol 263, No 17: 2313-2317. International Consensus Statement (1997) Prevention of venous thromboembolism. Med-Orion Publishing Company, London. International Consensus Statement (2001) Prevention of venous thromboembolism. International Angiology, Vol 20,No 1: 1-37. International Consensus Statement (2002) Prevention of Venous Thromboembolism. Med-Orion Publishing Company. London Janssen HF, Schachner J, Hubbard J et al (1987) The risk of deep venous thrombosis: a computerised epidemiologic approach. Surgery. Vol 101,No 2:205-212. Jick H, Derby IE, Myers MW (1996) Risk of hospital admission for idiopathic venous thromboembolism among users of post menopausal oestrogens. Lancet. 248: 981-983. Kakkar V V, Howe C, Nicolaides AN, Renney JTG, Clark MB (1970) Deep Vein Thrombosis of the legs. Is there a high risk group? Am J Surg. 120:527-530. Kakkar VV, Stringer MD (1990) Prophylaxis of venous thromboembolism. World Journal of Surgery.14: 670-678. Kamal A (1987) Cerebro-Vascular Disease and its management. Wolfe Medical Publication LTD, London.

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Lindblad B, Sternby NH, Bergqvist D (1991) Incidence of venous thromboembolism verified by necropsy over 30 years. BMJ. Vol 302:709-711. Lowe GD, McArdle BM, Carter DC et al (1982) Prediction and selective prophylaxis of venous thrombosis in elective gastro-intestinal surgery. Lancet.1: 409-412. Lowe GD, Woodward M, Vessey MP et al (2000) Thrombotic variables and risk of idiopathic venous thromboembolism in women aged 45-64 years. Relationships to hormonal replacement therapy. Thrombosis and Haemostasis. 83(4) 530-535. Marlar RA, Mastovitch S (1990) Hereditary Protein C deficiency. A review of the genetics, clinical presentation, diagnosis and treatment. Blood Coagulation Fibrinolysis. 1: 319-330. Melbring G & Dahlgren S (1983) prediction of Post-operative Venous Thrombosis. Lancet 1:1382. Merli GJ, Martinez J (1987) Prophylaxis for deep vein thrombosis and pulmonary embolism in surgical patients. Medical Clinics of North America. 71: 377-397. Moore B (1976) Sequential Mestranol and Novethisterone in the treatment of climateric syndrome. Postgraduate Medical Journal. 52(6) 39-47. National Institutes of Health (1986) Consensus development conference on the prevention of venous thrombosis and pulmonary embolism. J Am Med Ass. 25b: 744749. Nicolaides AN, Irving D (1975) Clinical Factors and the Risk of Deep Venous Thrombosis: In Nicolaides AN ed, Thromboembolism Aetiology. Advances in prevention and management. MTP, Lancaster:pp 193-204. Nicolaides AN (1990) Benefits of prophylaxis in general surgery. Acta Chir Scand. Suppl 556: 25-29. Nordstrom M, Linblad B, Berqvist D, Kjellstrom (1992) A prospective study of the incidence of deep vein thrombosis within a defined urban population. Journal of Internal Medicine. 232: 155- 160. Notelovitz M, Ware M (1982) Coagulation risk with post menopausal oestrogen therapy. In: Progress in Obstetrics and Gynaecology (ed Studd JWW). Churchill Livingstone, Edingburgh. 2: 228-240. OPCS (1990) Mortality Statistics Cause: England and Wales. DH2 No 17: HMSO, London. Perez- Gutthann S, Rodriguez G, Castellsagne J et al ( 1997) Hormone replacement and risk of venous thromboembolosm. British Medical Journal. 314: 796-800.

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Polit DE (1996) Data Analysis and Statistics for Nursing Research. Appleton & Lange. Conneticut. Prandoni P. Anthonie WA,Lensing MD et al (1996) The long term clinical course of acute deep vein thrombosis. Annals of Internal medicine. Vol 125, No 1:1-7 Royal College of Obstetricians and Gynaecologists (1995) RCOG working party on prophylaxis against Thromboembolism in Gynaecology and Obstetrics, RCOG. London Rocha E, Alfaro MJ,Paramo JA, Canadell JM (1988) Pre-operative identification of patients at high risk of deep vein thrombosis despite prophylaxis in total hip replacement. Thrombosis Haemostasis. 59: 93-95 Rakoczi I,Chamone D,Collen D, Verstraete M (1978) Prediction of post-operative leg vein thombosis in gynaecological patients. Lancet 1:509-510. Rosendaal FR (1997) Thrombosis in the Young: Epidemiology and Risk factors. A focus on Venous Thrombosis. Thrombosis and Haemostasis. Vol 78, No 1: 1-6. Ruckley CV (1985) Protection against thromboembolism. Br J Surg. 72 (^) 421-422. Sackett D, Haynes RB, Guyatt GH, Tugwell P (1996) Clinical Epidemiology. A Basic Science for Clinical Medicine. Second Edition. Little, Brown and Company. Toronto Samama MM, Simmoneau G, Wainstein JP (1993) Sirius study. Epidemiology of risk factors of deep venous thrombosis (DVT) of the lower limbs in community practice. Thrombosis Haemostasis. Vol 69: 763. Sergeant GR (1992) Sickle Cell Disease.2nd edition. Oxford University Press. Oxford. pp 117-119. Shafer AJ (1985) The hypercoaguable states. Ann Intern Med. 102: 814. SIGN (1995) Scottish Intercollegiate Guidelines Network. Prophylaxis of Venous Thromboembolism. A national clinical guideline recommended for use in Scotland. SPSS 11.0 (2001) Application Guide. SPSS Inc,Chicago. Strandness DE, Langlois Y, Cramer M et al (1983) Long term sequelae of acute venous thrombosis. JAMA, 146: 1289-1272. Sue-Ling Hm, Johnson D, McMahon MJ, Philips PR (1986) Pre=operative identification of patients at risk of deep vein thrombosis after elective major abdominal surgery. Lancet,1: 1173-1176. THRiFT (1992) Risk of and Prophylaxis for Venous Thromboembolism in Hospital Patients. BMJ.Vol 305: 567-574.

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THRiFT (1998) Risk of and Prophylaxis for Venous Thromboembolism in Hospital Patients. Phlebology. 13: 87-97. Vandenbroucke JP, Van der Meer FJM, Helmerhorst FM et al (1996) Factor V Leiden: Should we screen oral contraceptive users and pregnant women? British Medical Journal. Vol 312: 1226 Wheeler HB, Hirsh J,Wells P et al (1994) Diagnostic Tests for Deep Vein Thrombosis. Arch Intern Med.Vol 154: 1921-1928. ADVANCING NURSING PRACTICE IN THE MANAGEMENT OF DEEP VEIN THROMBOSIS (DVT). DEVELOPMENT, APPLICATION AND EVALUATION OF THE AUTAR DVT RISK ASSESSMENT SCALE SUBMITTED BY RICKY AUTAR, PhD, MSc, BA (HONS) DIP N, RGN, RMN, CERT ED, RNT PRINCIPAL LECTURER DE MONTFORT UNIVERSITY CHARLES FREARS CAMPUS 266 LONDON ROAD LEICESTER LE2 1RQ ENGLAND EMAIL: [email protected] PHONE; +44 116 201 3945

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WORK IN PROGRESS. Not to be cited or quoted without written permission of the author © Clive Baldwin 2005 Perspectives on Munchausen syndrome by proxy: Lessons from narrative analysis Clive Baldwin, Senior Lecturer School of Health Studies University of Bradford p.c.baldwin@bradford .ac.uk Abstract In recent years the diagnosis of Munchausen syndrome by proxy (MSbP) – an alleged form of child abuse in which the perpetrator (usually a mother) fabricates or induces illness in another (usually a child) - and its proponents have come under increasing criticism from lay people, health professionals, the courts and politicians. The debate tends to be polarised between those who think that MSbP (and its successor Factitious or Induced Illness – FII) is so fundamentally flawed that it should be abandoned and those who believe in its validity and efficacy in protecting children. Both sides make claim and counter-claim against the actions of the other, each seeking to negate the challenge posed by the other. This does little, however, to move the debate forwards. In this paper I intend to draw on narrative analysis in order to shed light on the conceptualisation and operationalisation of the diagnosis of MSbP. Such sociological research can raise new questions, pose new challenges and contribute to the current debate. Based on case study materials (interviews, court documents, medical records, social work reports and so on) I will illustrate the narrative features involved in cases of alleged MSbP; in particular, characterisation and agency, trajectory, smoothing, coherence, fundamentalism and the narrative mobilisation of bias. These features interact in ways that influence the investigation of alleged cases of MSbP and their presentation in court. The paper will conclude with recommendations for professional practice in cases of alleged MSbP, in particular the restoration of authorship and accountability, the need for reflexivity, clarity of central action, symmetrical approaches to evidence and professional agnosticism. Introduction Munchausen syndrome by proxy (MSbP is an alleged form of child abuse in which the perpetrator (usually the mother) induces or fabricates illness in another (usually a child) in order to seek medical attention. There are basically two polarised and incommensurable narratives around MSbP. A The first, told by many in the medical, health care and social work communities, is that MSbP is a theory with a respectable history; the second, told among some in the above communities but also some lawyers, politicians, academics and lay people, is that MSbP is a theory without scientific merit.

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If one looks closely at the literature and current debate around MSbP, it is a concept that is undergoing a great deal of critique. A highly contested and controversial diagnosis MSbP: a) Incorporates a number of conceptual and empirical problems: a. Contradictory indicators; b. Catch-all indicators; c. No research baseline for its major tenets; d. No rigorous research to support its use; b) Does not meet criteria for clinical validity (Kendall); c) Is not recognised by either the WHO or the APA; d) Has been rejected by courts in the UK, US and Australia as failing to meet the necessary evidentiary standard and/or as an unproven and unhelpful concept e) Even among its proponents there is disagreement about what it is, the underlying motivation and whether it is a paediatric or psychiatric diagnosis. These problems work themselves out through individual cases – for example, in one case four different definitions of MSbP were used. In this presentation I want to take a rather different stance to the exploration of the issues raised by the diagnosis of MSbP – that of narrative analysis. Narrative analysis can mean all sorts of things, but here I am using it, not as a shorthand for thematic analysis of cases (a way it is often used) but as introducing narrative theory into the analysis of MSbP. In particular I want to look at two areas: the features of narrative character and agency, emplotment, fundamentalism and coherency; and, second, narrative techniques used to enhance the persuasiveness of any given narrative. I should, at this point, make clear the limits of this presentation. While what I have to say may be applicable, to a greater or lesser extent, to both narratives of abuse and narratives of innocence I will only be dealing here with how narratives of abuse are constructed and the techniques utilised by the narrators of such narratives in order to enhance the narrative’s persuasiveness. Second, I will only incidentally be dealing with the meta-narrative of the theory of MSbP, focusing more closely here on the narratives of individual cases. The sources for this analysis come from cases of alleged abuse where the allegations were unfounded or the narrative of abuse has been undermined by further hearings. Data comes from case records, interviews with mothers, personal documents and official documents. Narrative features a) Character and agency

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In cases of MSbP there is a distinct a-symmetry in how characters are portrayed and the allocation of responsibility for action. Although ‘character work’ is deployed by the narrators of both the narratives of guilt and innocence, the opportunities for and the reception of such character work are unevenly distributed in favour of the narrators of guilt. For example, allegations made about the mother (say, lying about a house fire in the case of P,C&S) can be made with impunity (and even though untrue did not bring any censure of the social worker who made such allegations); while attempts by the mother to characterise professionals as, say, inept, are recuperated into the narrative of guilt as indicators of evasion, hostility or personality disorder. In the narrative of guilt, the mother is portrayed as deceitful, duplicitous, manipulative, hostile etc, etc, etc. Her general morality is questioned (e.g. in one case via suspicions of benefit fraud and living off immoral earnings – neither of which were substantiated) and her actions are to be scrutinised – both those regarding the alleged harm to the child, and those during the investigation and court case (for example, the social services requesting that the ‘expert’ psychiatrist be allowed to sit in the court to assess the mother while the mother was giving testimony. On the other hand, if one reads official records, one would be forgiven for thinking that the narrative of guilt was natural and inevitable. Decisions are made by meetings, not individuals; the motives behind actions of professionals go unnoticed or certainly un-commented upon (while those of the mother are constantly under scrutiny), the progress of a case – its narrative trajectory – is taken as a given, rather than the result of the actions of individuals. Thus, it seems, that professionals are ‘character-less’ and the process ‘agent-less’. This implies that the emergent narrative of guilt is unaffected by human action and is the inevitable outcome of a dispassionate review of the ‘evidence’. b) Emplotment Emplotment is the process whereby events, people, items etc are introduced into the narrative in order to further the story-line. The choice of what to include is thus vitally important because a persuasive story is one that limits ambiguity (i.e. one that limits the possibility of alternative narratives) and one that appeals to stories that are already familiar and accepted. One way of limiting ambiguity is to only introduce into the narrative things that will be used later on. As Chekhov said, if there is a rifle on the wall in Act One, it will be used in Act Three. Extraneous material should be avoided if at all possible. In the case of P,C&S this process can be seen at work in the Local Authority hiding the first expert report (my interpretation is that the report was hidden because it was too ambiguous for the purposes of moving forward the narrative of an extremely dangerous mother) and forcing the parents into a further ‘expert’ evaluation which produced a far more negative report, which could then be introduced in order to further the required story-line. Similarly, allegations made about a father that he impersonated a therapist in order to help a mother evade the authorities, was introduced in order to move on the plot of a family not to be relied upon to protect the child – even though no evidence could be brought to substantiate this allegation – and was re-introduced at several points in the proceedings.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The second part of emplotment is to link the story you are telling to stories that are already familiar to and accepted by your audience and to tell them in such a way that they are as close to those ‘canonical’ stories (stories that typify this sort of story) as possible – a process of narrative smoothing. Thus we see the introduction of material that, while unsubstantiated, serves the purpose of bringing the story into line with canonical stories – eg, in the case of P,C&S allegations were made that the mother had lied about a house fire (such behaviour being common in cases of MSbP), the mother endangering the child by ignoring medical advice and having to be rushed to hospital by ambulance (drama and child endangerment being features of MSbP), the mother being resistant to therapy, hostile and unco-operative (again, features of other MSbP cases) – all of which were unsubstantiated but fitted with the canonical story of MSbP. c) Fundamentalism A persuasive narrative is often one that is relatively simple, clear and unambiguous. Furthermore, the conviction of the narrator may also play a part in promoting the narrative’s persuasiveness. Stories that are hedged about with ‘may be’, ‘possibly’, ‘alternatively’, ‘I think it might be’ are likely to be less persuasive than those presented forcefully, clearly and definitely. Consequently, there is a tendency in adversarial proceedings – and let us be clear that despite the official claims that family court hearings in the UK are inquisitorial not adversarial this is simply not the case – towards a fundamentalist story-telling. This fundamentalism can be quite clearly seen in P,C&S where the local authority argued on a number of occasions for estoppel – that the conviction of the mother for a misdemeanour in the US was proof that she had harmed her child by administering laxatives in a case of MSbP abuse even though there was no ruling of MSbP (according to the juvenile court) and no such findings of fact in the US courts – prior to the full care proceedings in the UK. Furthermore, even Justice Wall criticised the Guardian ad Litem for pre-judging the case. This Guardian ad Litem is also reported as saying that she would not accept the court’s ruling if it went against her. A similar fundamentalism can be detected in the narratives of other professionals. For example, David Southall, a pre-eminent advocate of MSbP, is on record saying that he has never wrongly diagnosed child abuse when it was not there – i.e. false positives. This despite mothers whom he has accused being cleared by the courts. Fundamentalism might also explain Prof Southall’s recent censure by the GMC – preventing him from child protection work for three years and having to report to the GMC every 6 months – as the GMC criticised Prof Southall for holding onto his theory despite lacking the evidence to support it. d) Coherency According to Bennett and Feldman, a coherent narrative is more persuasive than a less coherent narrative – even if the coherent one is not true. Thus, if a narrative can be presented as coherent, it will appear more persuasive. In order to enhance the perceived coherency of a narrative three tactics can be identified:

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

iii.

i.

Ignoring contradictory evidence – such as evidence that shows the mother in a good light or the hiding of a report that did not fit with the required narrative.

ii.

Recuperating evidence so that it adds to the coherency of the story being told – for example, the mother in P,C&S challenged the expert’s interpretation of the medical records in great detail – identifying test results that indicated genuine illness, noting errors in the expert’s arithmetic, indicating alternative explanations and so on. Rather than deal with this challenge, the whole report was dismissed as ‘typical of a Munchausen mother’ thus re-establishing the coherency of the narrative of guilt. A third tactic was to protect the narrators from challenge. For example, in P,C&S the two US doctors on whose evidence the Local Authority were relying were not even present in court to be cross-examined and the mother was prevented from cross-examining the UK experts in a way that questioned their expertise.

e) Narrative trajectory A narrative trajectory is the path that any particular narrative takes after being launched. I choose the word ‘trajectory’ carefully in order to indicate that the course taken is very much a function of the aim of the initial narrative and that without intervention, the narrative will continue on its predetermined path. Attempts to deflect the trajectory may be made, as also can counter-measures to maintain it. For example, the trajectory set in P,C&S was one of guilt from the outset – indicated by the refusal of the social services to even contemplate the offer of the parents for longterm residential assessment and their insistence on admission of guilt from the beginning of the investigations even prior to the court hearings. The trajectory of guilt was then protected in a number of ways – for example, the parents complained about the way the investigation was being handled but were told that such complaints would only be dealt with after the proceedings. Ironically, the European Court of Human Rights ruled that the Local Authority had removed the child at birth unnecessarily and without relevant or sufficient reason. f) Silencing All narratives require an audience and one way of controlling unacceptable narratives is to silence them. This both prevents the development of alternative narratives and limits the potential challenge to the acceptable narrative. So, for example, the silencing of mothers accused of MSbP – through injunctions or coerced undertakings to the court – can be seen as a means of silencing the narrative of innocence. A less obvious means of silencing the narrative of innocence is to refuse to allow elements of the story to be told or developed within the court proceedings themselves. So, for example, a judge’s refusal to hear a witness for the mother on an area of expertise can be interpreted as silencing the development of that particular argument; preventing a mother form cross-examining witnesses can also be viewed in this vein; the social services not soliciting information from professionals previously involved

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

with the mother but supportive of her also effectively silenced that element of the narrative of innocence. g) Mobilisation of bias Mobilisation of bias is a concept taken from political science and refers to: " a set of predominant values, beliefs, rituals, and institutional procedures ("rules of the game") that operate systematically and consistently to the benefit of certain persons and groups at the expense of others. In UK child protection investigations and legal proceedings such bias can be identified in: ƒ

Policies, procedures and guidelines that favour the development of the narrative of guilt; for example, in cases of MSbP the mother’s testimony is to be treated with suspicion; assessment should be undertaken by someone with expertise in MSbP (and of course these are pro-MSbP experts not those who question it);

ƒ

The uncritical acceptance of other discourses e.g. professionals as benevolent and benign;

ƒ

Previously circulated narratives (see above re canonical narratives).

Re-establishing narrativity In conclusion I want to suggest that if my argument about the narrative construction of cases of MSbP is persuasive then we need to find ways of determining better from worse narratives. I think that this can be done in a number of ways. Firstly. By restoring authorship and accountability, professionals once again become characters and agents with their own motives, influences, involvements and fallibilities. They once again become decision-makers – and are thus responsible for those decisions and actions they choose. This increases the transparency of the narrative - why this narrative is being constructed and how has it been constructed. We can thus ask questions about the process – for example, why did the social worker in P,C&S choose to fabricate evidence? Why did the Guardian ad Litem fail to mention this fabrication in her report? What was the motivation behind hiding an expert report? In a more recent developing story-line involving Roy Meadow, the creator of MSbP – we may want to ask questions why he thought it acceptable to speak outside of his expertise in the Sally Clarke case; or what motivated David Southall to provide court reports when he had not seen the evidence. Despite claims that Meadow is being scapegoated, a narrative analysis at least gives Meadow the respect of being the author of his own narrative – that he, as an expert witness, chose to step outside his expertise in giving evidence on statistics. A second advantage of restoring narrativity is that reflexivity is thus restored – we can see how professionals, as characters and actors, affect the situation they are

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

involved in. In the current way of looking at things, one would be forgiven for thinking that professionals are simply observers and reporters of situations. However, professionals are not simply observers but characters and actors within the developing narrative ad as such contribute to the course of that narrative. For example, it was claimed that one mother had an abnormal degree of medical knowledge about her son’s condition – interpreted as an indicator of MSbP – even she had been encouraged to find out about and lent books on the subject by medical personnel. Similarly, the alleged ‘hostility’ of one mother towards the social services might have been as result of the social workers deliberately deceiving her about their plans to remove the child. Focusing on reflexivity goes some way to redressing the balance between competing narratives and ameliorating the worst effects of the bias that appears to be built into the process of investigating and prosecuting cases of MSbP. A third element that might aid us in discerning between good and less good narratives is the degree of conceptual clarity that is being utilised in any given narrative. If MSbP is to be taken seriously as what Bennett and Feldman call the ‘central action’ then it is important that this central action is clear and coherent. Currently, MSbP lacks this conceptual clarity and standard operationalisation. In a review of approx 20 cases, Pankratx (personal communication) identified nonstandard usage of the concept of MSbP. As stated above, in one case at least four different definitions of MSbP were in play (sometimes at the same time). While a lack of conceptual clarity and non-standard operationalisation facilitated the development of a persuasive narrative of guilt it cannot be said to have helped the cause of justice. In terms of MSbP this lack of conceptual clarification currently includes: ƒ

Confusing and contradictory indicators;

ƒ

No agreement on motivation;

ƒ

Disagreement as to whether it is a paediatric of psychiatric diagnosis

ƒ

The limits of MSbP - cf Schreier vs Jones debate as to whether MSbP involves attention-seeking behaviour towards a range of professionals (eg lawyers, teachers, sheriffs etc) or just towards health professionals.

Conceptual clarification, agreement and standard operationalisation would facilitate the process of deciding between competing narratives because then at least both narratives are dealing with the same central action (although from opposite sides). Fourth, I would argue that there should be a symmetrical approach to competing narratives, without privilege being given to any source or narrative from the outset. Thus, if we are to treat the mother’s story with suspicion we should also treat those of professionals with suspicion. The case of P,C&S illustrates that professionals are not above lying, fabricating evidence, hiding evidence, bad-mouthing, covering-up and so on. In conclusion

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

In conclusion I want simply to emphasise the need for professional agnosticism when faced with allegations of MSbP. If facts depend on the persuasiveness of the narrative not the other way around, then it is of paramount importance that we do not favour one narrative over another until both have been constructed and subjected to examination (including the narrative features outlined above). It might be claimed that this is what happens under the current process – that the social services investigate allegations and the process is inquisitorial rather than adversarial. Such a view cannot be upheld in the light of cases such as P,C&S where it is apparent that the development of the narrative of guilt was favoured in the investigation and court proceedings, not only by the actions of individuals but by policies and procedures. By restoring narrativity and using its lessons to help us discern between good and less good narrative processes and products I believe that we have a firmer basis on which to evaluate competing narratives in difficult areas of practice such as child protection. WORK IN PROGRESS. Not to be cited or quoted without written permission of the author © Clive Baldwin 2005

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The function of the first author in Evidence Based Practice Dr Elaine C. Ball RGN, BA, MA, Cert Ed, Ph.D Senior Lecturer in Nursing School of Nursing University of Salford Peel House Eccles Manchester M20 0NN England ABSTRACT In the teaching of Evidence Based Practice (EBP) there is a given synchrony through which the student is advised to work: the student formulates a question from a problem they have identified in their practice arena. They then undertake a complex reading of multiple texts in which to reason through their ideas, and appraise their argument. However, having taught on the EBP course, it is not uncommon for students to ‘lose’ their own highly important practice issues in a miasma of published (authoritative) texts. Moreover, as nursing is now becoming a credible research profession, the need to be skilled in the art of extracting information embedded in healthcare literature has never been more important. Therefore, I have devised what I term a “familial model” (model may not be the final descriptor I use) which names a way in which to approach multiple texts and a metanarrative without losing sight of the students own valuable ideas. Feedback from the students has so far been extremely positive. My paper will explain how the familial model works, why it should be so called, and why it has a certain hierarchy in place (for example, the formal language of the multiple texts against the informal speech of the mother texts comes into a power struggle for supremacy and will be examined). The paper will also give examples of the familial-model 6 texts and show how they interplay The familial model Mother text: your argument from which all ideas grow (giving birth to ideas) Father text: attachment text (systematic reviews, canonical text …) Sister text: subsidiary or supporting arguments Brother text: subsidiary or counter arguments Granny text: old texts that still hold importance Grandfather text: old arguments that will not go away

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

NURSING THE OLDER PATIENT WITH RENAL FAILURE The Older Kidney! Susie Barnes BSc (Hons) PGCE, RN Catherine Monaghan MSc, BSc (Hons), PGCE, RMN, RN Teaching Fellows, School of Nursing & Midwifery, Queen’s University Belfast [email protected] 028 9097 2383 [email protected] 028 9097 2385

Background Rising demographic within both the general population and the renal patient population. Stats NI / DHSS / Renal Review, relevant statistics pertaining to this population group Carers and responsibility Rationale for Class Bringing the two specialists together (Renal & Care of the Older Person) Highlighting awareness of the specific problem areas that the older person encounters upon a diagnosis of ESRD To raise the students’ awareness regarding this particular client group Regional renal course serving the education, service/provision for all of N.I List Aims & Objectives 1. Kidney and ageing process 2. Assessment of renal function and difficulties encountered with the older person 3. LITERATURE REVIEW – pertaining to different modalities this group of patients are choosing AND/OR being offered 4. HD 5. PD 6. Carers/psychosocial aspects Explain why this particular teaching strategy was employed i.e. - Case Studies Case Studies presented in a BOX format – fictional patients Key themes - emergent from the class discussion/tutorial – “jigsaw picture”

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Recommendations for Education in light of IPE paper could be utilised within the educational arena Practice holistic nursing encouraged/consider the social package. Enhanced the regional service speciality and answering the service’s need for this type of patient demographic Research highlight need for further research into how the patient manages with this particular type of disease and treatment AND indeed how the carer “copes” or does not cope with a relative requiring this type of treatment. Needs analysis of this particular type of patient and their needs within the social arena

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Boys and girls come out to play; child regulated sex segregation and socio dramatic play in the primary school playground Carol M. Barron Lecturer RGN, RCN, RNT, Dip Pharm, Ba (HONS), MSc School of Nursing, Dublin City University Dublin 9 Email [email protected] Within this ethnographic account of anthropological fieldwork conducted over a three-month period in an English primary school with five and eight year old children it became clear that children self regulate who they play with. Predominantly children played with other children of the same sex and nowhere was this more apparent than the playground. Differences in the types and forms of socio dramatic play were observed between the sexes. Much evidence suggests that in differing societies there are common sex behaviours of children (Whiting and Edward’s 1973). Boys are reported to behave in a more aggressive, assertive, and self-reliant fashion than girl’s, while girl’s are said to be more nurturing, obedient, co-operative and take turns. Based on a comprehensive review of the evidence at the time Maccoby and Jacklin (1974) conclude that the difference between boy’s and girl’s play is that girls play intensively with one or two friends while boys play in larger groups. Many studies conducted since these publications have confirmed this finding (Archer 1992). Boys and girls interact mainly with their own sex, and their patterns of relationships are very different, boys interact in larger groups where status and reputation are important, and girls show more intimate interactions with smaller group sizes. When the boy’s articulated the differences between the play of girls and boys, they emphasise physical and behavioural differences. Matt: ( 8yrs) Girls don’t play nicely together. Researcher; Why’s that? Matt: (8yrs) I don’t know, they’re horrible to each other, they call each other naught names, they’re always telling the teacher. Peter: (8yrs 2 months) Girls get in a row and call each other names. Boys get in a fight that’s the difference, fighting is rougher. It has been argued that boys and girls, from pre-school age onwards, inhabit separate social worlds with different rules and little communication between them and that this sex segregation becomes more pronounced during primary school (Maccoby 1986, 1988). Within this fieldwork, it did indeed appear as if boys and girls occupied differing social worlds at playtime, however there were some marked exceptions. Both boys and girls played chasing games such as “tag” together. It was in these and other forms of chasing games that I observed boys and girls playing with each other willingly. The games of chasing crossed the gender boundaries that were very strong within the culture of this playground and these children. Socio dramatic is argued to be at its height between the ages of 4 and 5 and seems to decline thereafter (Fein 1981). Research indicates that the first roles undertaken by children are imitative and kinship based with a gradual progression to uptake of thematic fantasy characters (Garvey 1974, Garvey and Berndt 1977). Kane (1996) in

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

his work with 4 to 5-year-old children noted a decrease in traditional socio-dramatic play like Mummies and Daddies and occupational role-play. With an accompanying increase in what he termed imaginative role-play involving animal families. Evaldson and Cosaro (1998) found that the 5-year-old children in his fieldwork in Italy rarely engaged in traditional family role-play. My findings do not support this. Many of the 5-year-old children played “Mummies and Daddies” and “babies” on a daily basis. However the 8-year-old children, especially the girls had clearly a dramatic decrease in traditional socio-dramatic play and did indeed regularly instigate imaginative roleplay involving animal families such as “The Hunter”. The 8-year-old boys re-enacted fictional but also real character’s e.g. the former were “Action Man” and the latter being “Nato”. The differences that were apparent, however, were that older children had much more complex rules, routines in their pretend play, each episode could be sustained for much longer time periods than with the younger children. Also the 8year-old girls had a larger repertoire of pretend play scenarios than the boys who tended to re enact combat style games. In summary, my material supports the decrease discussed by Evaldson and Corsaro (1998) and Kane (1996) but at different ages. References Archer, J. (1992) Childhood Gender Roles. In H. Mc Gurk (Ed) Childhood Social Development Contemporary perspectives. Evaldson, A. and Corsaro, W. (1998) Play and games in the peer cultures of preschool and preadolescent children: An interpretative approach. Childhood. Vol. 5 (4) p377-402 Fein, G. (1981) Pretend play in childhood: an integrative review. Child Development Vol. 52 p1095-1118 Fine, G. and Sandstrom, K. (1988) Knowing Children: Participant Observation with Minors. London. Sage Publications. Garvey, C. (1974) Some properties of social play. Merill-Plamer Quarterly 20 p163180 Garvey, C. and Berndt, R. (1977) The Organisation of Pretend Play. JSAS Catalogue of Selected Documents in Psychology. Vol. 7 Kane, S. (1996) The Emergence of Peer Culture through Social Pretend Play. In H. Furth (Ed) Desire for Society: Children’s Knowledge as Social Imagination. New York. Plenum Press Maccoby, M. (1986) Social groupings in childhood: Their relationship to prosocial and antisocial behaviour in boys and girls. In D. Olweus, J. Block, and M. RadkeYarrow (Eds.) Development of Antisocial and Prosocial Behaviour: Research, Theories and Issues. New York. Academic Press Maccoby, M. (1988) Gender as a social category. Developmental Psychology 24 p755-765

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Maccoby, M. and Jacklin, C. (1987) Gender segregation in childhood. In H. Reese (Ed) Advances in Child Development and Behaviour. Vol. 20 p239-287. New York Academic Press Whiting, B. and Edwards, C. (1973) A cross-cultural analysis of sex differences in the behaviour of children aged 3 - 11. Journal of Social Psychology. 91 p171-188

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

CURRICULUM EVALUATION OF THE “NURSING CARE OF CHILDREN WITH ASTHMA” DEGREE MODULE Carol M. Barron Lecturer RGN, RCN, RNT, Dip Pharm, Ba (HONS), MSc School of Nursing, Dublin City University Dublin 9 Email [email protected] Mary Clynes, Nurse Tutor, BA (Hons), MSc Children’s University Hospital Temple Street Dublin 1 [email protected] The module entitled “Nursing Care of Children with Asthma” was developed by the Children’s University Hospital, Temple Street, Dublin in partnership with the School of Nursing, Dublin City University. The module was developed at degree level and the first programme ran one day a week over the autumn 2004 academic semester. It was accessible to all registered nurses working with children with asthma. The “Nursing Care of Children with Asthma” module aims to build upon and advance the registered nurse’s repertoire of knowledge, skills, attitudes and professional values, in order to develop competent professionals who are able to function effectively as members of the multidisciplinary team involved in the care of children with asthma in variety of healthcare settings. Curriculum evaluation is an integral part of curriculum development. It is a systematic process of ascertaining the worth or significance of the curriculum by detailed appraisal and study (Quinn 2000). The curriculum was evaluated using focus group interviews. Two focus group interviews consisting of eight and six participants respectively were conducted with nurses who had just completed the module. Thematic content analysis of data was carried out. Findings can be divided into two main categories. Firstly, the specific evaluation of the content and the delivery of the asthma module and secondly, generic issues in relation to post-registration nurse education in Ireland today. References Quinn F. (2000) Principles and Practice of Nurse Education.4th Edition. Stanley Thormes: Cheltenham.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

‘A Grounded Theory Study of Decision-making for Ill children: Generating a Theory of Children’s Nursing’ Dr Rosario Baxter Lecturer in Nursing Room B002 University of Ulster Cromore Road Coleraine Co Derry BT521SA [email protected] The following presentation is the result of a Doctorate in Nursing Science completed in November 2004. The letter appended to this abstract, testifies to the quality and significance of my research for children’s nursing. Background The researcher elected to study this area of paediatric care as the focus for this study because of a series of unanswered questions that emerged from previous research, which explored the ethical and legal status of children as organ donors. This led to a desire, as a researcher, to learn more about the general moral and legal status of children in the health care system, and in particular about the decision making principles that should or do, guide caring practice. During the course of this study it became increasingly evident that the weak theoretical and research base of children’s nursing in general, mitigates against the development of well grounded policy to guide ethical decision making for ill children and their families. This mirrors the general paucity of research into most aspects of children in health care. It therefore seemed reasonable to follow this line of enquiry as a worthwhile endeavour. Design of the study Data obtained from children, their families, and professionals, has been analysed using a grounded theory methodology to explore matters of concern with in decision making in relation to children in health care. Using a theoretical sampling technique, families, nurses and physicians were interviewed and documentary sources of data pursued in keeping with theoretical sampling principles. Through abstraction of identified concepts and the application of a paradigm model (Strauss and Corbin, 1990), a theory of children’s nursing has been generated which is entitled: “An Invitation to Coalescent Decision-making” The findings of the research have profound implications for advancing child health policy in respect of the rights of families and ill children. This theory has the potential to offer a meaningful way forward in the professional nursing practice of caring for ill children and their families I am keen to disseminate my findings and feel they will be of interest to children’s nurses.

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Baxter. R. (1996) Children and organ donation in the United Kingdom: a literature review Journal of Pediatric Nursing. Vol 11 no 2 pp136-141. Baxter. R. Long, A. and Sines, D. (1998) The legal and ethical status of children in health care in the UK Nursing Ethics 5(3) pp 189-199. Strauss, AL. and Corbin, J. (1990) Basics of qualitative research. London: Sage

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CONTRACEPTION IN THE IMMEDIATE POST-ABORTION PERIOD Margaret W. Beal Ph.D., R.N., C.N.M. Nurse-Midwife, Planned Parenthood of Connecticut Associate Professor and Director, Graduate Entry Prespecialty in Nursing Yale University School of Nursing 100 Church Street SOUTH P O Box 9740 New Haven, CT 06536-0740 USA Half of all pregnancies in the United States are unintended, and one in five end in abortion, an abortion rate that is close to that reported internationally (Finer, 2003). A recent review of literature on contraceptive practices of women accessing abortion services (Carr, 2004) revealed that the majority reported either lack of use or incorrect use of a contraceptive method in the month of conception (Jones, 2002), and women are particularly receptive to information on contraception immediately following abortion (McIntosh & Teplin, 1999). Although women undergoing repeat abortions believed themselves to be knowledgeable about contraception, one researcher found that over half showed significant knowledge deficits (Alouini, 2002). Health service networks vary in the level of continuity between abortion providers and ongoing reproductive health services, and many women do not present to any provider for follow up care. There is a lack of data in the literature on current trends in provision and utilization of contraception in abortion care settings. This retrospective, descriptive study of patients undergoing medical and surgical abortion in late 2003 was conducted to pilot a data collection tool and describe trends in 1) prescription and dispensing of contraception and 2) utilization of contraception in the immediate post-abortion period in one urban health center in the United States. While 98% of patients discussed contraception at the time of the abortion, significant differences were found in the contraceptive prescription practices and follow up rates of women undergoing medical vs. surgical abortion. Study findings are discussed with implications for further research, clinical practice and teaching. Alouini, S., M. Uzan, et al. (2002). Knowledge about contraception in women undergoing repeat voluntary abortions, and means of prevention. European Journal of Obstetrics, Gynecology, & Reproductive Biology. 104(1): 43-8. Carr, R. (2004). Optimizing Contraceptive Care of Abortion Patients. Unpublished Master’s Thesis submitted to the faculty of Yale University School of Nursing, New Haven, CT, USA. Finer, L. B. and S. K. Henshaw (2003). Abortion incidence and services in the United States in 2000. Perspectives on Sexual & Reproductive Health. 35(1): 6-15. McIntosh K, S. G., Teplin D (1999). Routine Aftercare and Contraception. In Paul M. A Clinician's Guide to Medical and Surgical Abortion. New York, Churchill Livingstone: 185196.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The transformation of graduate education: Future choices for nurse educators Pamela B. Beeman, RN, PhD Associate Professor of Nursing Betty J. Paulanka, RN, EdD Dean and Professor of Nursing College of Health Sciences University of Delaware 345 McDowell Hall Newark, DE 19716 302 831-8370 [email protected] Introduction In 2002, a task force commissioned by the American Association of Colleges of Nursing (AACN) reviewed and compared current doctoral programs and postgraduate degrees in nursing. Their exhaustive investigations included an assessment of the history and context of both the role and the educational level needed by health care professionals in order to deliver well-prepared, safe, and knowledgeable health care to consumers. The task force then made a number of recommendations for future nursing education. Based on these suggestions the AACN published, in October of 2004, a Position Statement on the Practice Doctorate in Nursing. Individuals from the AACN member institutions then endorsed this proposal, recommending that, by the year 2015, the educational preparation necessary for advanced nursing practice move from the master’s degree to the doctorate level (AACN 2004). According to Sperhac and Clinton (2003), the new practice doctorate will be seen as the terminal professional degree and those nurses holding it will have attained the highest level of clinical competence. They say that, with the DNP degree, “the focus is on direct practice, leadership and health care policy and offers nursing an opportunity to meet the demand for expert teachers and clinicians” (p.292). Professional education As part of the information compiled for the 2004 Position Statement, the authors recognized that the “core function of health care is to provide the best possible clinical care to individuals, families, and communities” (AACN 2004, p. 3). In the past half-century, nursing has been mostly successful in requiring and providing undergraduate and master’s level educational experiences in order to meet this definition of the “core function.” The path, however, to universal agreement on what constitutes the appropriate educational requirements for nursing has not been particularly straightforward. In 1965, the American Nurses Association (ANA) reinforced a professional commitment to the best possible nursing clinical care through education and issued a position statement proposing the Bachelor of Science in Nursing (BSN) as the minimal level of education for the “professional” nurse generalist (ANA 1965). This was an attempt by a major professional nursing organization to set educational guidelines and standards for all nurses. Additionally, it was hoped that a more defined approach to

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

nursing education might reduce degree confusion for both nurses and the public they served. Rather than unifying the profession, however, the reaction was chaos and dissent amongst nurses, some of which is still evident today. Despite this intraprofessional conflict, nursing at the 2- and 4-year degree-granting institutions remains a popular career choice (NCSBN, 2005). During the last quarter of the 20th century, masters’ degree programs in nursing expanded in the University setting. This was in part a response to the increased sophistication of health care delivery and technology as well as to meet personal, professional, and consumers’ needs for a better prepared professional nurse. Consequently, nursing programs throughout the world have developed and promoted master’s level education for nurses in order that they may practice in education, administration, and highly specialized advanced practice roles such as clinical specialists, nurse midwives, nurse practitioners, and nurse anesthetists. Inevitably, as consumers’ expectations of the health care community’s professional and educational credentials—and nurses’ credibility—have risen, nurses have sought further education. Currently, at the post graduate level, there are two types of nursing doctoral programs: research-focused and clinical-based, or practicefocused. While most research-focused programs in nursing offer education for a doctorate in philosophy (PhD), some offer a professional doctorate in nursing science (DNS, DNSc). Advanced practice doctoral degrees, or practice-focused degrees, are offered in a few universities’ nursing programs; these include the Doctor of Nursing (ND), the Doctor of Nursing Practice (DNP and DrNP), as well as the DNSc. Other disciplines with practice-focused degrees include the Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), and the Doctor of Psychology (PsyD). There exists, then, some confusion about the similarities and differences amongst these doctoral degree programs; in addition, it is often unclear as to what is the most appropriate or the best content required for a specific degree. Thus, the AACN 2015 Position Statement is a bold and timely initiative that represents an opportunity for nursing to develop a viable alternative to the researchfocused doctorates accepted as the terminal degree in nursing. At the same time, because of the need to define nursing's role in the health care delivery arena, this proposal offers the possibility of unifying a number of nursing degrees in order to clarify nursing titles, as well as professional education and standards. Nursing’s educational history The concept of the practice-focused doctorate as a terminal nursing degree prompts, for many nurses, recollections and past memories of nursing educational reform; some find the current AACN Position Statement reminiscent of the earlier, ANA 1965 Position Paper on nursing education. The remnants of the entry-intopractice debates and the subsequent professional divisiveness still color many professional nursing relationships today. Some in the nursing profession are wondering what, if anything, was learned from this previous experience and if nurses and educators will be able to work together in a collegial manner to enhance this new opportunity for both validating the unique aspects of doctoral education in nursing and, at the same time, for advancing the nursing profession.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

In 1989 Florence Downs addressed the role of nursing within a larger societal context and stated that “Nursing, perhaps more than any other profession, is intimately entwined with the larger social fabric of our world and consequently is more difficult to define as an entity and more susceptible to the ebb and flow of social change” (1989, p. 263). As the idea of a practice doctorate in nursing took shape, nursing leaders spoke to the role of nurses within society. Marion and her colleagues (2003) pointed to the shifts in information, to demographic changes, to the expectations of consumers as well as health care providers, and to the growing disparities in both health care access and delivery as factors that create new demands on the nursing profession. Sperhac and Clinton (2003) noted that social trends—the aging but more sophisticated consumer, health care delivery systems, heath care provider shortages—have left nursing programs scrambling to meet the needs for new skills and new knowledge. In an illuminating and timely article, Nelson and Gordon (2004) examined the discontinuous nature of nursing practice and its history. They postulate that the lack of a standard route for entry into practice contributes to both nursing’s comparatively lower salaries as well as a lower status amongst other health care professionals and the general public. The authors argue that members of the nursing profession have failed to recognize and to build upon the knowledge and skills gained through their very real contributions to health care delivery over the years; consequently, nurses must continually reinvent themselves and nursing. Ann Whall (2005) wrote in support of Nelson and Gordon’s contention that it is in nursing’s history to view current issues as though they exist in a vacuum. She suggests that nursing practice is not “a ‘stand alone’ phenomenon” but is rooted directly in philosophic—in this instance, the philosophy of science—beliefs (p. 1). In 2003, Margaret McClure, then president of the American Academy of Nursing, made a strong case that “the time has come for the nursing profession to put its educational house in order” (p. 151). Some would argue that the AACN Position Statement, like that of the ANA in 1965, demonstrates proactive thinking on the part of the nursing profession and, by calling for a move in the graduate educational preparation necessary for a practicing nurse, reflects the realities of the continuously changing health care arena. Well-respected nursing educators have differing opinions on the DNP. Dracup, Cronenwett, Meleis, & Benner (2005) identify a number of concerns about the possible unintended consequences of such a degree upon the profession. They explore the possibility that the number of PhD graduate nurses may decline; this will have a serious effect on the profession as well as on the larger society as a whole. The authors wonder as well how nurse educators with practice doctorates will fit into the university setting, where research-based PhDs are the norm for faculties. The timing and cost of the DNP initiative for those smaller nursing programs invested in offering masters degree programs but without the resources or infrastructure to support doctoral education poses another dilemma. And they raise an interesting question about the consumer. Might not patients be confused by the number of health care providers who call themselves “doctor?” And what are the educational standards required of the “doctor” providing their care? Dracup, et al. recommend that “the

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

adoption of the DNP only occur after thoughtful discussion both within and outside the profession” (p. 177). Mary Mundinger of Columbia University School of Nursing presents another perspective. She argues that the timing is right for the doctor of nursing practice (DrNP), and believes that a “formal and standardized educational process leading to a doctoral degree is essential for quality assurance, to clarify and validate authority /responsibility, and to recognize and identify” those advanced practice nurses who have been informally acquiring expanded skills (2005, p. 173). Mundinger suggests that the nursing doctorate may fill a very important and necessary health care delivery need for consumers. Clinical nurse specialists are particularly interested in the DNP proposal, as it directly affects their professional education and practice. In April 2005 the National Association of Clinical Nurse Specialists (NACNS) responded to the DNP proposal with a White Paper on the Nursing Practice Doctorate, outlining areas of opportunity, concerns, and continuing questions regarding the proposed doctorate in nursing practice (NACNS, 2005). The authors identify numerous possible problems, including the implications of such a degree for the profession, for nursing education, and for patient safety. The economics of the educational shift, its implementation, and the overall impact of such a degree on the various Nurse Practice Acts are also of concern. Members of the NACNS ask critical questions that are reminiscent of the debate and discord of the entry into practice proposal. They wonder how these educational changes will affect the numbers of advanced practice nurses (APNs) and what will happen to the current APNs after 2015 (NACNS, 2005). Yet on the whole, the White Paper indicates that Clinical Nurse Specialists applaud this opportunity to promote a national dialogue related both to advanced nursing practice competencies as well as the complexities of nursing practice that might differentiate the current Clinical Nurse Specialist and the Advanced Practice Nurse from the proposed DNP. The task ahead The AACN has begun to address the myriad questions raised by their position statement on the nursing practice doctorate as the credibility of the DNP must be established. To that end, a task force of multidisciplinary constituencies in advanced practice nursing have worked together to identify eight essential standards, with related educational content and competencies, relevant to the complex nursing roles of clinical nurse specialists, nurse practitioners, nurse midwives and nurse anesthetists. These standards will be shared with even more diverse groups in a series of regional meetings, with the hope of promoting meaningful conversations and the intention of achieving input and support from interested stakeholders—health care providers, educators, and consumers. The AACN have posted on their website a draft document, DNP Essentials, spelling out curricular requirements and expectations during the development of the new degree; see http://www.aacn.nche.edu/DNP/DNPPositionStatement.htm (AACN, 2005). It is expected that the new educational standards will be worked on and refined for final confirmation in Fall 2006. Additionally, in the United States, recognition and approval of the proposed educational standards by the United States Department of Education (DOE), as well as the profession’s national accrediting bodies—CCNE and NLNAC—are important

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

factors in promoting validity and credibility of nursing degrees. This approval assures that any educational program offering the doctoral degree will fulfill universal educational standards and practice competencies. Because the standards for nursing doctoral degrees have not yet been developed, this is a crucial step for the success of all nursing doctoral programs. Finally, the task of educational programs will be to demonstrate how students meet the highest level of practice competencies with the varied depth and focus needed for their specific specialty area of practice. Nursing programs will have to show the direct care versus the systems focus, or indirect care, competencies needed to meet the select career objectives of students’ desired programs of study. Nursing’s educational future The future of nursing is dependent upon the ability of nursing programs to educate professionals for a variety of nursing choices, not limited to but including nursing practice, research and education. Decisions about the focus of nursing curricula at all levels remain one of the biggest challenges for nurse educators. They must make educational decisions responsive to the needs of many community stakeholders: nursing students and their families, health care providers and facilities, and nursing faculties themselves. They must explore many factors, seeking answers to questions such as whether or not the community needs more nurse practitioners or more nurses at the bedside, more nurses for the elderly, or for children. And who will educate these future nurses? What are the economic ramifications of the educational choices? And, what is “good” for nursing? Fifteen years ago, when Florence Downs cautioned against educational change without thoughtful deliberation, she expressed concern that the profession may be in danger of “heading toward of model of PhD education that will define the future of nursing far more narrowly than is desirable” (1989, p. 265). Nurse educators, she believed, must remember and value the importance of nursing curricula developed to meet students’—as opposed to faculties’—needs. Before forging forward, it might be wise to explore the lessons learned from the experience of the ANA’s 1965 Statement. Identifying mistakes from the past may assist nurses in resolving any residual or lingering bitterness and encourage them to embrace this change for a smoother transition to the future of nursing education. Understanding nursing’s educational history and comparing the similarities and reasons for these changes may provide important clues for avoiding the mistakes that created tension between and amongst the various levels of entry level programs of the past. Thus, the first step to promoting consensus on the DNP Position Statement is to review its overall purpose and the underlying problems that prompted these bold moves on the part of professional nursing organizations to change nursing education to meet current practice demands. It strengthens the argument for the DNP to have input and support from a wide and diverse community of health care professionals. Generally speaking, these professional organizations have a vision for the future of nursing that reflect the realities of a continuously changing healthcare arena. Many professional nurses recognize the validity of the proposed change in educational preparation and few doubt the intentions expressed by the AACN of

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

providing the best possible clinical care to individuals, families, and communities. The fear of some nurses that the educational shift will once again divide the nursing profession and stimulate conflict and competition amongst nursing programs is an especially serious consideration during this era of a critical shortage of nurses at all levels of education. There is, however, much professional agreement that nursing needs a new vision with a focus on the future, validating the unique expertise of nurses in clinical practice at the highest level and simplifying degree confusion and educational preparation. And this proposal may be an important first step if nurses wish to achieve equal status and respect as leaders amongst other healthcare providers. The question is whether nurses are ready at this time to embrace such a move given their experiences of the past, the stress of economic constraints, and the current severe faculty and clinical placement shortages that limit expansion and change. Reference List American Association of Colleges of Nursing. (October 2004), AACN position statement on the practice doctorate in nursing, [Online], AACN. Available from: http://www.aacn.nche.edu/DNP/DNPPositionStatement.htm [30 August 2005]. American Association of Colleges of Nursing (18 August 2005). DNP essentials draft, [Online], AACN. Available from: (http://www.aacn.nche.edu/DNP/pdf/DNPEssentialsDraft_8-18-05.pdf [20 August 2005]. American Nurses Association. 1965, Educational preparation for nurse practitioners and assistants to nurses: a position paper. ANA, New York. Downs, F. 1989, “Differences between the professional doctorate and the academic/research doctorate”, Journal of Professional Nursing, vol.5, no. 5, pp. 261-265. Dracup, K., Cronenwett, L., Meleis, A.I. & Benner, P.E. 2005, “Reflections on the doctorate of nursing practice”, Nursing Outlook, vol. 53, no. 4, pp. 177-182. Marion, L., Viens, D., O’Sullivan, A.L., Crabtree, K., Fontana, S. & Price, M. M. 2003, “The practice doctorate in nursing: future or fringe?”, Topics in Advanced Practice Nursing eJournal, [Online], vol. 3, no. 2, pp. 1-9. Available from: http://www.medscape.com/viewarticle/453247 [30 August 2005]. McClure, M. L. 2003, “From the President: another look at entry into practice”, Nursing Outlook, vol. 51, no. 4, p. 151. Mundinger, M.O. 2005, “Who’s who in nursing: bringing clarity to the doctor of nursing practice”, Nursing Outlook, vol. 53, no. 4, pp. 173-176.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

National Association of Clinical Nurse Specialists. (April 2005), White paper on the nursing practice doctorate, [Online]. Available from: http://www.nacns.org/nacns_dnpwhitepaper2.pdf [30 August 2005]. National Council of State Boards of Nursing (NCSBN). Testing services: NCLEX psychometrics: NCLEX examination pass rates. Available from: http://www.ncsbn.org/testing/psychometrics_nclexpassrates.asp[30 August 2005]. Nelson, S. & Gordon, S. 2004, “The rhetoric of rupture: nursing as a practice with a history?” Nursing Outlook, vol. 52, no. 5, pp. 255-261. Sperhac, A. M. & Clinton, P. 2004, “Facts and fallacies: the practice doctorate”, Journal of Pediatric Health Care, vol. 18, no. 6, pp. 292-296. Whall, A. L. 2005, “’Lest we forget’: an issue concerning the doctorate in nursing practice (DNP)”, Nursing Outlook, vol. 53, no. 1, p. 1.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The changing levels of assertiveness and attitudes towards normality in childbirth of Irish student midwives Cecily M. Begley, RGN, RM, RNT, FFNRCSI, MA, MSc, PhD, FTCD Professor of Nursing and Midwifery/Director, Margaret Carroll, RM, RNT, BNS, MSc, Director of Academic and Professional Affairs in Midwifery, School of Nursing and Midwifery Studies, Trinity College Dublin, 24, D’Olier St, Dublin 2, Ireland, Tel: 01 – 6083979, Fax: 01 – 6083001, e-mail: [email protected] LITERATURE REVIEW Professional status cannot be attained for nurses and midwives without the use of essential assertiveness skills (Parkin 1995). Studies of the midwife’s role in relation to other members of the multidisciplinary team show that their interactions with obstetricians still demonstrate a lack of assertion and that, despite their knowledge and expertise, their opinions are seldom sought (Hunt and Symonds 1995). Most midwives are nurses first, and such lack of assertiveness in nursing is commonly stated as being due to oppression in the nursing group, particularly as it is mainly composed of females (Roberts 1983, Torres 1988). At the time of this study, direct entry midwifery had not been introduced, and student midwives had to be qualified nurses before entry to the programme. They may therefore have undergone socialisation into the medical model, including more passive ways of behaving. Some studies in the United Kingdom and Ireland have shown a perceived improvement in the assertiveness skills of nursing students as they go through their period of education (Gray and Smith 1999, Howard 2001, Begley & Glacken 2004). A small study of nurse managers in Ireland also found that the Diploma in Nursing students, who were educated in the university, were believed to be more assertive than the apprentice-ship trained nursing students had been (Begley & Brady 2002). Assertiveness is a useful communication skill that can be exercised to manage oppressive situations, to control bullying and to foster empowerment (Fulton 1997, McCabe & Timmins 2003). Midwives who are themselves disempowered are unable to give empowering care to women, yet this is necessary to develop strong, able mothers (Rothman 1996). The attitude of midwives towards pregnancy and their perceptions of pregnancy as either a healthy or unhealthy state may also influence how they care for women, and may affect the amount of empowerment and autonomy that they are prepared to encourage in women. AIM OF STUDY To ascertain the perceived assertiveness levels of student midwives at the start, and near the conclusion, of their two-year education programme. This was a sub-section of a larger study designed to explore the opinions, feelings and views of student midwives of their education as they progressed through their twoyear programme in Ireland.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

METHODS A survey was carried out using a purpose-designed questionnaire, which was administered twice, at the beginning and end of the two-year course to enable comparison. Midwifery education at this time was conducted solely in the hospitals, not in the universities. The students were, therefore, taking a two-year programme with only 13 weeks of theoretical education, with the remainder in clinical practice as part of the workforce. Ethical approval was granted by the Directors of Midwifery and Principal Tutors of all seven of the midwifery schools in Southern Ireland. All students commencing midwifery training in Ireland in the first intake of 1995 (either May 1995 or October 1995) were met by the researcher (CB) during their first (n=104) or second (n=22) week in the classroom. They were given a brief written research proposal, questions were answered and they were assured that their questionnaires would be destroyed as soon as their data were entered under a code number into the computer. All students present in class on that day handed back a completed questionnaire (n=122, 97%). The questionnaire was re-administered 2 to 3 months before the students finished their training. The total number of students who were present and completed questionnaires on both occasions was 116 (92%). The questionnaire consisted of 18 questions relating to demography and health attitudes, and 28 questions derived from Gerry’s work (Gerry 1989) on assertiveness in student nurses. This 28-question section had been pre-tested and found to have good face validity, a “Fog” value (Burns and Grove 1993) of 7 and a test-retest reliability of 0.57 demonstrating a moderate linear relationship (Burns and Grove 1993). The instrument had also been used to conduct a study of student nurses’ assertiveness (Begley and Glacken 2004). Each of the 28 assertive statements on the questionnaire could be ticked by respondents as “Always”, “Often”, “Rarely” or “Never”. Four marks were given for “Always”, three for “Often” and so on. Negatively-phrased statements were reversescored so that the higher the total score is, the higher the respondent’s level of assertiveness is deemed to be. Data were analysed using the software package “Statistix”, a statistical software package produced by NH Analytical Software. The Wilcoxon signed rank test (Daly & Bourke 2000) was used to compare mean assertiveness scores before and at the end of the programme. McNemar’s test (Daly & Bourke 2000) was used to compare percentages of those who had marked ‘Always’ or ‘Often’ (combined) with those who had marked ‘Rarely’ or ‘Never’ (combined). RESULTS Demographic details of respondents One of the students was British and the remainder were Irish. They were all female and aged from 21 to 39 years with a mean age of 24 years, 7 months (S.D. 2.64). All students were registered general nurses and had been practising for between 6 months and 17 years (mean 2 years, 7 months, S.D.= 2.18). Only 56 (46%) stated that they intended to work as a midwife after qualifying, and 51 (42%) were taking midwifery education because they intended to work as a public health nurse. Respondents’ views of pregnancy as a healthy or ill-healthy state Students were asked to ‘X a spot’ illustrating where they believed “pregnancy” to be on a line denoting health to ill-health, where “0” equalled “pregnancy is an illness” and “7” indicated “pregnancy is a normal event in a woman’s life” (Figure 1). The minimum mark given by students before the course was 2 and the

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

maximum was 7 (mean 6.46, S. D. 0.87). The minimum and maximum marks given at the end of the course were 3 and 7 (mean 6.10, S. D. 0.94). This showed that the students’ view of pregnancy had altered more towards the ‘ill-health’ mark (p=0.001, using the Wilcoxon signed rank test). However, this result may not necessarily have any clinical significance.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Figure 1 Ill-health

Health

,_______,_______,_______,_______,_______,_______,_______, 0 1 2 3 4 5 6 7 0 = pregnancy is an illness

7= pregnancy is a normal event in a woman's life

Students’ level of assertiveness Question 15: “I am very careful to avoid hurting other people’s feelings,” gained the lowest mean score in both questionnaires, 1.39 (S.D. 0.55) prior to the start of the students’ training and 1.52 (S.D. 0.50) near the end. One hundred and twelve of the respondents in the first administration (97%) ticked either ‘Always’ or ‘Often’ in relation to this statement (Table 1) and all 116 of the respondents in the second. The highest mean score, and therefore the highest level of assertiveness, was found in question 9: “I would feel uncomfortable paying a compliment to a junior colleague” (3.72, S.D. 0.47 in the first questionnaire and 3.66, S.D. 0.51 in the second). Eightyfour of the respondents in the first administration (73%) said that they would never feel uncomfortable paying a compliment to a junior colleague (Table 1) and 78 (67%) at the end of the course. The total mean “level of assertiveness” score was 74.00 (S.D. 7.43) at the beginning of the programme and 72.58 (S.D. 8.51) at the end, a significant difference (p=0.01). The proportions of agreement or disagreement with each statement were compared between the two questionnaires, with significant differences seen in 14 of the areas (Table 1). An improvement in assertiveness was seen in the 3 areas of: ignoring the demands of a senior colleague if they were busy, not trying to avoid hurting people’s feelings and not feeling uncomfortable expressing annoyance at a senior colleague as much as they had at the beginning of training. A decrease in assertiveness was seen in the 11 areas of: keeping their feelings to themselves, feeling uncomfortable asking a colleague to do favours for them, not enjoying starting conversations with people as much, not wanting to know their rights in the work situation, finding it difficult to refuse a friend making an unreasonable request, not making decisions in a group situation, not asking for constructive criticism as much, not challenging a colleague if they upset a patient, not telling a senior colleague if they disagreed with their decision, not asking questions at work for fear of sounding stupid and feeling unsure of what to say when given a compliment (Table 1). DISCUSSION The majority of these midwifery students were Irish, single and with a mean age of twenty-four. Only 56 (46%) of the students stated that they were taking this course in order to work as a midwife after qualifying. Twenty-seven midwifery students (64%) in another Irish study in one of the three maternity hospitals in Dublin, said that they intended to stay in midwifery after qualifying (McCrea et al 1992). The

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

students’ view of pregnancy, as shown by their choice of marks on a health/illhealth line, had altered more towards the ‘ill-health’ view by the end of their programme. This change in attitude, as measured by a single mark, may or may not affect the care that midwives give. Students developed their assertiveness skills in three areas, all related to relationships with senior colleagues. Other sections of this study have found that relationships between this cohort of students and their senior colleagues were difficult on occasions (Begley 2001b, 2002), so it is possible that students may have developed assertiveness skills as a method of coping with unsympathetic treatment during their clinical placements (Howard 2001), instead of as a result of the education they received. In 11 other areas the students’ assertiveness, as described by themselves, had decreased. Student midwives, in a small qualitative study exploring their preparation for autonomous practice, related how a lack of assertiveness in the midwives supervising them impacted in a negative fashion on their learning (Currie 1999). This may come about because the midwives themselves are working within a highly medicalised model of maternity care (Wagner 2001), and thus may not be able to demonstrate skills necessary for autonomous practice. A small study of Irish midwives’ perceptions of their role (Hyde & Roach -Reid 2004) found that medical dominance and too much use of interventions and technology prevented them from fulfilling their role. Rather than confronting those who dominated them, these midwives tried to fulfil their role by ‘indirectly and informally circumventing obstetric interference’ (Hyde & Roach-Reid 2004 p2619), a very similar pattern to that seen in a study in the United Kingdom (Hunt & Symonds 1995). It is interesting that Irish student nurses appear to be more assertive than the student midwives in this study. Seventy student nurses nearing qualification in one small Irish study (97%) ‘always’ or ‘often’ wanted to know their rights (Begley & Glacken 2004), compared with only 85 (74%) of the student midwives in this study. Thirty-five (60%) of the senior student nurses reported that they would ‘always’ or ‘often’ challenge a colleague if they upset a patient (Begley & Glacken 2004), in contrast with only 61 (53%) of this group of student midwives. This does not auger well for the midwifery profession in Ireland, as midwives need to be assertive in order to fulfil their obligation to act as advocates for the women in their care. CONCLUSION The midwifery students in this small study were working in a situation where they were primarily viewed as employees rather than students (Begley 1999, 2001a), where high priority was not always given to their emotional needs (Begley 2001b, 2002) and where the system of maternity care is highly medicalised (Wagner 2001). The midwives who act as their role models do not, ordinarily, demonstrate assertive, autonomous behaviour (Hyde & Roach-Reid 2004). The overall decrease in levels of assertiveness that these students demonstrated from beginning to end of their midwifery education programme, is not, therefore, wholly surprising. What gives even more cause for concern is the fact that their attitudes towards pregnancy did not progress towards a more health-oriented viewpoint as they continued through their two-year programme. It is recommended that education in assertiveness skills be given in order to assist student midwives to develop sufficient expertise in this area to protect them from aggression. Increased assertiveness will also enable them to act as advocates for

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

women in their care. In addition, more emphasis needs to be put in their education programme on pregnancy as a healthy state and on encouraging a non-interventionist approach in normal pregnancy and childbirth. With these alterations in emphasis, increased numbers of students might choose to continue in the midwifery profession and midwives in the future, with greater ability to assert themselves, will give more empowering care to women. Acknowledgements We are grateful to the students who took part in this study and to the Directors of Midwifery and Principal Tutors who granted permission for the study to take place.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Table 1 Comparison before and near the end of the programme of the students’ views of their level of assertiveness Always

Often

Rarely

Never

N

McNemar P chi-sq. value

df.

1. At work I tend to keep my feelings to myself

1st q. 2nd q.

6 9

77 82

31 25

2 0

116 116

8.00

0.01

1

2. I feel uncomfortable asking a colleague to do a favour for me

1st q. 2nd q.

6 13

39 40

62 52

9 11

116 116

8.00

0.01

1

1 q. 2nd q.

0 0

4 4

40 55

69 54

113 113

0.00

1.00

1

1st q. 2nd q.

15 9

45 53

52 50

4 4

116 116

2.00

0.16

1

1st q. 2nd q.

44 38

57 54

12 19

3 5

116 116

9.00

0.01

1

1st q. 2nd q.

9 6

41 47

64 54

1 8

115 115

3.00

0.08

1

1 q. 2nd q.

51 32

42 53

19 29

3 1

115 115

8.00

0.01

1

8. If a friend makes an unreasonable request, I would find it difficult to refuse

1st q. 2nd q.

13 7

47 58

47 43

9 8

116 116

5.00

0.03

1

9. I would feel uncomfortable paying a compliment to a junior colleague

1st q. 2nd q.

0 0

1 2

30 35

84 78

115 115

1.00

0.32

1

0 1

4 10

63 66

49 39

116 116

7.00

0.01

1

3. I find it difficult to compliment and praise friends and acquaintances 4. If a senior colleague made an unreasonable request, I would refuse 5. I enjoy starting conversations with acquaintances and strangers 6. I find criticism from friends and acquaintances hard to take 7. I want to know what my rights are in the work situation

10. If I was busy, I would ignore the demands of a senior colleague

st

st

st

1 q. 2nd q. st

11. When I know a friend’s opinion is wrong, I would disagree with him/her

1 q. 2nd q.

50 41

55 62

10 13

1 0

116 116

2.00

0.16

1

12. At work I feel unsure what to say when I am praised

1st q. 2nd q.

12 9

59 64

38 36

7 7

116 116

2.00

0.16

1

1st q. 2nd q.

6 11

45 41

58 57

6 6

115 115

1.00

0.32

1

1st q. 2nd q.

68 53

42 53

3 7

0 0

113 113

4.00

0.05

1

13. I tend to be over-apologetic to friends and acquaintances 14. I try to avoid conflict at work

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

15. I am very careful to avoid hurting other people’s feelings

1st q. 2nd q.

75 56

37 59

4 1

0 0

116 116

3.00

0.08

1

Table 1 (cont.) Comparison before and near the end of the programme of the students’ views of their level of assertiveness 1st q. 2nd q.

0 1

60 54

52 54

3 6

115 115

5.00

0.03

1

1st q. 2nd q.

21 13

60 50

33 49

2 4

116 116

8.00

0.01

1

1st q. 2nd q.

59 50

53 62

4 4

0 0

116 116

0.00

1.00

1

1st q. 2nd q.

27 17

48 44

38 47

2 7

115 115

14.00

0.01

1

20. If I disagreed with a decision made by a senior colleague, I would tell him/her

1st q. 2nd q.

12 16

55 31

43 57

4 10

114 114

20.00

0.01

1

21. At work I avoid asking questions for fear of sounding stupid

1st q. 2nd q.

1 3

20 31

57 50

38 32

116 116

13.00

0.01

1

6 6

29 32

64 61

17 17

116 116

3.00

0.08

1

12 10

36 53

57 43

11 10

116 116

15.00

0.01

1

49 46

51 51

15 15

1 4

116 116

3.00

0.08

1

1 q. 2nd q.

8 8

47 48

50 55

11 5

116 116

1.00

0.32

1

1st q. 2nd q.

9 9

66 66

40 38

1 3

116 116

0.00

1.00

1

1st q. 2nd q.

23 21

75 73

17 18

0 3

115 115

4.00

0.05

1st q. 2nd q.

8 9

67 66

39 35

2 6

116 116

16. In a group I make the decisions 17. I would ask for constructive criticism about my work 18. When I am with friends, I am frank and honest about my feelings 19. If a colleague upsets a patient, I would challenge him/her about it

22. I feel uncomfortable asking friends to do favours for me 23. When someone pays me a compliment, I feel unsure of what to say 24. If I was impressed by the actions of a senior colleague, I would tell him/her 25. I tend to be over-apologetic to colleagues 26. I tend to be over-concerned about patients’ welfare 27. I would feel uncomfortable expressing annoyance at a senior colleague 28. I am a follower, rather than a leader

“1st q.” = First questionnaire “2ndq.” = Second questionnaire

st

1 q. 2nd q. st

1 q. 2nd q. st

1 q. 2nd q. st

1 0.00

1.00

1

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Significant differences in results between the two questionnaires in bold type

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

REFERENCES Begley, C.M. Student midwives’ views of 'learning to be a midwife' in Ireland. Midwifery, 1999 15(4), 264-273. Begley, C.M. ‘Giving midwifery care’: student midwives’ views of their working role. Midwifery, 2001a 17(1), 24-34. Begley, C.M. ‘Knowing your place’: student midwives’ views of relationships in midwifery. Midwifery, 2001b 17(3), 222-233. Begley, C.M. ‘Great fleas have little fleas’: Irish student midwives’ views of the hierarchy in midwifery. Journal of Advanced Nursing, 2002, 38(3), 310-317. Begley, C.M; Brady, A. Irish Diploma in nursing students’ first clinical allocation: the views of nurse managers. Journal of Nursing Management, 2002 10, 339-347. Begley, C.M; Glacken, M. Irish nursing students’ changing levels of assertiveness during their pre-registration programme. Nurse Education Today, 2004 24(7), 50110. Burns, N; Grove, S.K. The practice of nursing research: conduct, critique and utilization, 2nd ed. Philadelphia: W.B.Saunders Company; 1993 Currie, S.M. Aspects of the preparation of student midwives for autonomous practice. Midwifery, 1999 15(4), 283-292. Daly, L.; Bourke, G. Interpretation and uses of medical statistics (5th edition). Oxford: Blackwell Science; 2000. Fulton, Y. Nurses’ views on empowerment: a critical social theory perspective. Journal of Advanced Nursing, 1997 26, 529-536. Gerry, E. An investigation into the assertive behaviour of trained nurses in general hospital settings. Journal of Advanced Nursing, 1989 14, 1002-1008. Gray, M; Smith, L. The professional socialization of diploma of higher education in nursing students (Project 2000): a longitudinal qualitative study. Journal of Advanced Nursing, 1999 29, 639-647. Howard, D. Student nurses’ experience of project 2000. Nursing Standard, 2001 15, 33-38. Hunt, S; Symonds, A. The social meaning of midwifery. London: Macmillan; 1995. Hyde, A; Roche-Reid, B. Midwifery practice and the crisis of modernity: implications for the role of the midwife. Social Science & Medicine, 2004 58, 2613-2623. McCabe, C; Timmins, F. Teaching assertiveness to undergraduate nursing students. Nurse Education in Practice, 2003 3(1), 30-42. McCrea, H; Carswell, L; Thompson, K; Bradley, F; Whittington, D. The role of the midwife in the Rotunda Hospital, Dublin Centre for Health and Social Research. Coleraine: University of Ulster; 1992. Parkin, P.A.C. Nursing the future: a re-examination of the professionalisation thesis in light of some recent developments. Journal of Advanced Nursing, 1995 21, 561567. Roberts, S.J. Oppressed behaviour: implications for nursing. Advances in Nursing Science, 1983 5, 21-30. Rothman, B.K. Women, providers and control. Midirs Midwifery Digest, 1996, 6(4), 480. Torres, G. The nursing education administrator: accountable, vulnerable and oppressed. Advances in Nursing Science, 1988 3, 1-16. Wagner, M. Fish can't see water: the need to humanize birth. International Journal of Gynecology & Obstetrics. 2001 75, S25-S37.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

WHO AM I NOW? POSTGRADUATE PAEDIATRIC STUDENT NURSES EXPERIENCES OF ROLE TRANSITION THELMA BEGLEY RGN RSCN BNS MSc Nursing College of Nursing/ Centre for Nurse Education Adelaide and Meath Hospital Dublin Incorporating the National Children’s’ Hospital Tallaght Dublin 24. Phone 01- 4142981 E mail – [email protected] Abstract The transition from student to staff nurse has been identified as stressful and is well documented in the nursing literature. However, role transition from staff nurse to postgraduate student is an under researched area of nursing, especially in the area of paediatrics. Therefore, there is no literature available to glean information about the experiences of nurses making this transition. Two previous studies have been conducted into the experiences of postgraduate midwifery students (McCrea et al 1994, Begley 1997) but as stated there is a paucity of research into postgraduate sick children’s nursing students’ experiences. A hermeneutic phenomenological approach was employed to interpret what it means to be a postgraduate sick children’s student nurse during the first clinical placement. Data was collected on a purposive sample of six students, using unstructured interviews. Thematic content analysis informed by Cohen et al (2000) was utilised to produce an interpretation of nurses’ experience within the first clinical placement. Who am I now? reflects the participants’ role confusion when changing from being a staff nurse in one discipline to being a postgraduate student in another. They find previous experience is not acknowledged and students from different backgrounds and disciplines in nursing have different experiences in the first placement. References Begley, C.M. (1997) Midwives in the making: A longitudinal study of the experiences of student midwives during their two- year training in Ireland. Unpublished PhD Thesis, School of Nursing and Midwifery, Trinity College, Dublin. Cohen, M., Kahn, D. and Steeves, R. (2000) Hermeneutic phenomenological research: a practical guide for nurse researchers. Sage Publications, London. McCrea, H., Thompson, K., Carswell, L. and Whittington, D. (1994) Student midwives’ learning experience on wards. Journal of Clinical Nursing, 3, 97- 102.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Study of registers nurses' perceptions of skills required for effective management Ms Thomasina Boyle RGN, ENB100, Staff Nurse 28 Binn Bhán Cappagh Road Knocknacarra Galway Ireland ABSTRACT Background: In Ireland as a result of the recommendations of the Commission on Nursing (1998) the charge nurse role developed to that of nurse manager, and as a consequence registered nurses regularly manage their practice areas. From a review of the literature much has been written about nurse management and leadership from the head nurse perspective but a gap exists with regard to the registered nurse in a management role. The purpose of the study is to identify registered nurses perceived importance of technical, human, conceptual, leadership and resource management skills as to their contribution to management effectiveness when undertaking a “charge role”. A conceptual framework was developed using these concepts. The design was a descriptive survey. Data was collected via self administered structured questionnaires and yielded a 42.6 per cent response rate. Findings highlighted the need for further research to explore why many registered nurses do not undertake this role. They also suggest empowering registered nurses to undertake management practice.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EXPLORATION OF THE TRANSITION FROM STUDENT TO MIDWIFE. A PHENOMENOLOGICAL STUDY

NAME:

Vivienne Brady RM, RGN, RNT, BSc (Hons), MSc.

ADDRESS:

13 Verschoyle Vale, Saggart Abbey, Saggart, Co. Dublin

JOB TITLE:

Midwife Teacher

ABSTRACT This phenomenological study exposes the unique and essential elements of the experience of transition from student to newly qualified midwife. The literature review provides a background to the role of the midwife from an Irish perspective and elsewhere and briefly explores suggested themes associated with the process of transition. Five newly qualified midwives were interviewed in order to elicit the core elements of transition that are described as unique to each co-researcher. Study participants are referred to as co-researchers throughout this work as the success of the research depends upon their commitment to uncovering the essential truth of the phenomenon and their subsequent engagement with the process of phenomenological inquiry. Data analysis incorporated the process of phenomenological reduction with textural and structural synthesis of each description. Although phenomenology seeks to explore the unique and essential elements of the experience as it is described for each co-researcher, core themes and commonalities are observed and reported. Core findings include lack of clarity in terms of role definition and subsequent difficulty with role adaptation. The concept of dissonance manifests as compromise between personal philosophy of care and care giving; discord between formal theory and practice and conflict due to organizational constraint and conflicting ideologies for women. Loss of control is also identified, in addition to the value of support in the workplace and the call for preceptorship.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

‘Mini Doctors’ or ‘Advanced Nurse Practitioners’ Advanced Practice in the Endoscopy Setting’ Ms Caroline Brady Nevin RGN, BNS, RNT, H.Dip CHSE, MSc Lecturer Catherine McAuley School of Nursing & Midwifery Brookfield Health Sciences Complex University College Cork Cork Ireland + 353 21 4901480 [email protected] Background

Advanced nurse practitioners are frequently perceived as ‘mini doctors,’ concerned more with the biomedical and technical aspects of health care than with the holistic, psychological elements. With an interest in advanced practice roles within the Irish context, a structured questionnaire designed to examine nurses’ perceptions was administered to a convenience sample of 70 endoscopy nurses from six urban endoscopy departments. Findings indicated these nurses are generally positive in their attitudes, but they have concerns about the perceived increased vulnerability to litigation, exploitation, and fragmentation of their nursing role. On the basis of the findings of this study, a number of recommendations are made in relation to ensuring professional and educational support systems are in place for nurses as they develop their clinical practice. For this study, a convenience sample of 70 endoscopy nurses from six endoscopy departments in Ireland were surveyed. All endoscopy nurses with a minimum of one year endoscopy experience were eligible. Aim To determine if endoscopy nurses in Ireland are interested in advancing their practice to include the performance of endoscopic procedures. To identify perceived barriers that exists regarding implementation of this role. Study design A quantitative approach using a descriptive study design was chosen in order to − Incorporate a larger number of endoscopy nurses. − Obtain a broader range of nurse’s perceptions towards advanced practice in endoscopy. − Gain information that will help to narrow the gap in published research literature in relation to the perceptions of nurses to advanced practice in endoscopy.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Ethical Considerations Ethical approval was granted from each of the six hospital ethical committees to conduct this study and from Trinity College Dublin. Findings A response rate of 75.7% was achieved. The largest percentage of nurses’ agreed/ strongly agreed (60.4%, n=32) to the advancement of practice to include the performance diagnostic tests in endoscopy. However a large number of participants (n= 24) also agreed with nurses performing therapeutic procedures. However there were a substantial number of subjects that were undecided at this time (n=19). In comparison to staff nurses, CNMs were nearly all in agreement to nurses performing endoscopic procedures. However, despite the availability of clear guidelines and a definition of advanced practice the overwhelming majority of nurses felt that more information on the implications of advanced practice was needed. Attention to issues such as advancing the scope of practice, incorporation of protocol driven treatments, and accountability was also identified as paramount in the service development. There were widespread consensuses as to the benefits of advanced practice with the majority of subjects in agreement that education and training should be at a Masters Degree level (Department of Health & Children, 1998). Conclusion From conducting his study, it is evident Irish endoscopy nurses are willing to advance their practice; however, aspects such as understanding the role of the advanced nurse practitioner and advancing the scope of practice in endoscopy did reveal variations of opinion among endoscopy nurses. The lack of preparation and training as well as lack of support from physicians is an apparent concern for Irish endoscopy nurses. Tapping the opinions of Irish endoscopy nurses who are at the front line in the provision of health care for gastroenterology patients provides important insight into the advancement of advanced nursing practice in the endoscopy setting. The experiences of highly skilled and experienced staff would appear to be an important knowledge source from which to ascertain any improvement in health care provision for patients or clinical career opportunities for nurses. The views of the 53 subjects in this study have provided invaluable knowledge regarding the future of nursing role developments in endoscopy prior to the implementation of the ANP role in the Irish endoscopy setting.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

REPORT ON EVALUATION OF PILOT PROJECT IN CLINICAL SUPERVISION IN NURSING. Authors Anne Brennan, MSc, RPN, Nurse Practice Development Co-ordinator, St Vincent's Hospital, Fairview, Dublin 3. Telephone 01 884 2448. E mail [email protected]. Evelyn Gordon, MSc, RPN, Lecturer, Dublin City University, D 9. Telephone 01 770 7704. E mail [email protected]. Abstract Clinical supervision in nursing is an evolving phenomenon that is gaining increased attention within the literature, nurse teaching curricula at undergraduate and postgraduate levels and within nursing practice. This paper reports on a small qualitative pilot study that explored nurses’ experiences and perceptions of clinical supervision within a mental health context. The study aimed to explore the lived experiences of nurses engaged in clinical supervision as supervisors and supervisees. Data was gathered from in-depth interviews and questionnaires in order to provide the opportunity for the perspectives of all those who participated in the project to be included in the evaluation process. This involved, 1. Conducting interviews with a purposeful sample, with varying levels of supervisory experience (n= 4), and 2. Administering questionnaires to all remaining participants (n = 12). Analysis of all data was conducted using thematic analysis, additionally the data from questionnaires was analysed using the SPSS computer package. Following data analysis the researchers developed an understanding of the supervisors and supervisees level of preparation for, use, experience, understanding and perceived impact of, and recommendations for clinical supervision within a nursing setting.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Law and Mental Illness in Ireland: Intervention or Instigation Damien Brennan Lecturer Course Coordinator - MSc Nursing and Midwifery, School of Nursing and Midwifery Studies, Trinity College, Dublin 2. Ph. 01-6083114 [email protected] A dynamic relationship between individuals, communities, law and the asylum system in Ireland has resulted in a large cohort of individuals being institutionalised in asylums in Ireland since their establishment in 1817. This paper will draw from a data set that has been developed which maps the rise and fall of psychiatric hospital utilisation in Ireland from 1817 to 2000. The Irish experience contrasts sharply with other countries particular as Ireland had the highest rate internationally of psychiatric hospital utilisation. This paper will consider the role of Irish law in this trajectory, particularly examining if legalisation was an instrument of intervention or instigation of mental illness. Three critical junctures will be examined; the 1838 Dangerous Lunatic Act; the 1945 Mental Treatment Act; and the 2001 Mental Health Act. It will be proposed that these acts correlate closely with the rise and fall of psychiatric institutional unitisation in Ireland. Three themes will be considered within this analysis, (1) the challenges that such a correlation presents to the bio-medical thesis on mental illness, (2) the relationship between the individual, communities and law as a social structure, and (3) the location and role of Irish psychiatric nursing within such an analysis.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THE DEVELOPMENT AND APPLICATION OF AN ELECTRONIC MODULE EVALUATION TOOL Miriam Brennan, Lecturer, MSc (Nursing), BNS, RNT, RM, RGN, Centre for Nursing Studies, National University of Ireland, Galway. Marcella Kelly, Lecturer, MSc (Nursing), BSc (Community Health Studies), PHN, HV, DPMS, RM, RGN, Centre for Nursing Studies, National University of Ireland, Galway Lorraine Mee, Lecturer, MSc (Nursing), BHS, Dip (Management), RNT, RCNT, RM, RGN, Centre for Nursing Studies, National University of Ireland, Galway Academic staff with the help of an information technology expert and an administrator developed an electronic evaluation tool to evaluate programme modules offered by the Centre for Nursing Studies, National University of Ireland, Galway. As part of the quality monitoring process within the Centre for Nursing Studies there is a policy of module and programme evaluation ex post. However, annual reviews of response rates from the existing module evaluation process, demonstrated a perennial problem of low response rates across the different programmes. In addition, there was a high administrative commitment associated with computing the data and collating the evaluation reports. Concluding from this the existing evaluation process was reviewed in terms of improving effectiveness and efficiency while also maintaining its quality This project entailed the development of an electronic evaluation tool, its piloting and subsequent evaluation.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

CLINICAL TUTORS’ EXPERIENCE OF WORKING WITH BACHELOR OF NURSING STUDENTS IN CLINICAL PRACTICE Ann Bride R.N. B.A Soc Sc, Masters (Applied) Nursing 40b Karina Rd Highlands Park New Plymouth Phone. 06 7589145 Email. [email protected] Introduction Since the transition of apprentice training to faculty responsibility, from free labour work to educational accountability (Tang & Chou, 2005) there has been an ongoing debate on how best to provide quality clinical education to prepare students for the responsibilities of a beginning practitioner. Statistics indicate that nursing education fails to prepare graduates for the challenges of today’s health care work place (Tong & Henry, 2005). While nurse educators respond to changes in education they are also striving to meet the challenges of assisting nurse students towards competence in the application of evidence based principles into clinical practice (Tanner, 2005). Clinical tutors referred to in this study were experienced nurses and had been employed to facilitate the students learning while working in clinical practice but they did not have input into the preparation or delivery of the theory component of the Bachelor of Nursing programme. The participants in this study were offered an opportunity to express their views about the positive aspects of their work and to identify difficult and challenging situations they may have encountered. Experienced nurses understand the challenges of students, they can help nursing schools to develop ways to improve student clinical performance and clinical judgement (Callister, Malsumura, Lookinland, & Loucks, 2005). These practitioners are experts in their field of practice; it is therefore appropriate that they should play a major role in providing learning opportunities for students when they are in the clinical setting. The clinical tutors expertise and familiarity with the clinical setting is highly valued but they are also required to assist the student apply theory to practice and assess competence of students professional development and clinical performance, often without an in-depth knowledge of the curriculum. Literature describes the perceived problems that students encounter when working in the clinical setting and almost without exception the attitudes and behaviors of the clinical tutors are highlighted as being critical to effective learning. However, there is less written from the perspective of the clinical tutor who is employed on contract to teach in the clinical setting only but does not participate in the teaching of the theory component.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Background Clinical learning for students in the hospital-based system was at times unpredictable and in a disciplinary environment could stifle critical thinking and problem solving. Students were taught the ‘what’ and ‘how’ but were rarely encouraged to question the ‘why’. Under the present educational environment students became supernumerary in the clinical setting, no longer included in staffing levels. (Booth, 1997). As a result of these changes and contracts with hospitals that provide the clinical placements there has been an increasing use of clinical tutors and preceptors working with students in practice. The preceptor is the experienced nurse who facilitates learning and socializes students to the nursing role while continuing to be assigned nursing functions (Letizia & Jennrich, 1998). Literature Review Clinical learning is the heart of educational experience for nursing students (Star Mahara, 1998) and clinical teaching is seen as the "core of nursing education" (Ferguson, 1996). Clinical tutors are required to provide an optimum learning environment to help students integrate theory and practice. The student experiences and sense of belonging largely depend on the attitude and willingness of the clinical teacher and the clinical setting continues to provide a valuable educational resource. Clinical tutors are asked to prepare students who will base practice on current knowledge, theory and research, evaluate nursing care outcomes and participate on shaping the health care delivery system. (Callister, et al, 2005). However clinical tutors brought in for short spells of time who may be inexperienced teachers, unfamiliar with curriculum and clinical competencies, are less likely to have the time resources or inclination to pursue the required study. This may affected their observation and decision making skills and leave them unprepared for the complexities of the teaching role (Duke, 1996). Students see a clinical tutor familiar with the clinical setting, as an advantage. In a study by Hart & Rotem (1994) students’ found clinical tutors who were willing and knew the staff in the area were of help to them, however it was also found that clinical tutors who are not familiar with the curriculum at times presented with unrealistic objectives, and this had a negative influence on their experience. Students felt that clinical tutors, who were seconded from the clinical setting, had a relationship with the staff and this meant there was less resentment when students entered the clinical area. Students perceived that a major role of the clinical teacher was to smooth the entry for students into the clinical environment and facilitate the relationship between students and staff (Watson, 1997). Marat (1998) identified perceived stressors by student nurses also included approaching and interacting with clients, performing physical assessments, and administration of medication for the first time. Students also stated they wanted to be valued as individuals (Fowler, 1995) and they appreciate tutors with

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

a sense of humour, who were able to give positive feedback (Berg, 2004) & (Tang & Chou, 2005) Student preferred to have a tutor link with the college however the role of the nurse tutor responsible for teaching the theory component of the programme has changed to include, research and publishing (Dyson, 1995) and therefore keeping up own clinical skills was a concern (Clifford, 1993). The economic restraints brought by shrinking resources a profit philosophy plus the costs of clinical access, excessive paperwork, endless meetings, lack of credibility in the clinical area, and lack of time were given as reasons for perceived frustrations by nurse educators (Lee, 1996) (Landers, 2000). Method Focus group interviews Focus groups were chosen to obtain more definitive information and was used as an effective means of gathering insights and opinions, perceptions and attitudes from participants’ everyday experiences in a defined area of interest (Brooks, Fletcher & Wahlstedt, 1998) as well as generating interaction on a topic. The Participants in the Study The participants were New Zealand Registered Nurses with a combined total of 80 years experience in a variety of areas of nursing including medical, surgical, acute care, gerontology and mental health. They had recently been employed in a health care setting where students gain clinical experience, and were employed by the educational institute because of their local knowledge and expertise in a specific area. Results Thematic analysis was used to analyse the data and four themes were identified. 1. Being effective 2. Working with others 3. Maintaining connections 4. Approaching learning Being Effective The discussion within the group gave a clear insight into the desire by the clinical tutors to provide the best learning opportunities for students but this meant expanding their knowledge in a variety of clinical settings and at times being pushed beyond their comfort zone. One participant described the situation as First you are expected to work with first year students then within a few weeks or even within the same clinical week you may be working with second and third year students. Students perceived clinical tutors as credible when they demonstrated specialist knowledge which they could apply in clinical areas (Forrest, Brown & Pollock, 1996) The familiarity of a particular area was of significance to one participant.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

I felt that the students were able to value my input. Students indicated to me that getting help from clinical tutors that have not had the opportunity to keep up their clinical experience is less value. However until the clinical tutor was satisfied with their own knowledge and competence in the area they were reluctant to allow students to take responsibility and therefore at times they felt ineffective in their role Seeing things from a different perspective All participants felt they had an advantage as a result of their recent clinical practice but were also aware of the problems some nurse practitioners had when asked to preceptor a student. The clinical tutors found themselves having to react to staff in a different way and each of the participants found at some time they had to Match personalities or smooth things out to ensure a relationship between the staff and the student that facilitated learning for the student. Students learn best from staff who are approachable and interested (Cahill, 1996) but this may not occur when they (preceptors) stated “they could not do their job with someone tagging behind me”. Keeping the relationship with staff is an important part of the role Students experience and sense of belonging largely depends on the preceptor’s attitude and willingness to teach (Anderson, 2004). Participants used the term ‘breaking through the barriers’ to illustrate the experiences they have when they first meet students on the ward. They believed that students had an expectation of me but when a good relationship was established the clinical tutor was then able to become functional and helpful and provide useful learning opportunities. Finding a Happy Medium Clinical tutors recognized difficulties encountered when the student was keen to practice professional competencies. The group generally agreed that At times it is a difficulty knowing when to stand back, when to let the student continue with the work, and when to step in and assist. They stated “that it was hard to keep your hands off. You want to get in and ‘do’, but you know you have to stand back and allow the students the opportunity. You have to find that happy medium”. Preceptors may also be reluctant to allow students to carry out certain learning opportunities if the clinical tutor was not there. Being prepared The participants in this study felt that to effectively provide valuable learning experiences for students they need to be prepared. Participants stated that the orientation day was helpful. But often it was a matter of finding out for themselves.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

It was generally felt that students wanted consistency of information and the participants would have appreciated more preparation in relation to assessment and documentation related to student clinical performance. The participants felt particularly helpful when they were able to contribute to student knowledge and when they saw the students gain confidence and develop a trust with them. A participant stated that It’s nice when a student comes to you to share what’s going on. It is particularly satisfying when you are in a busy ward and you actually function as a part of the ward with your student. Working with Others Fitting in Discussion arose within the group about the process of developing a good working relationship with students and clinical staff and the nurse educator. some students could be quite negative about what is happening or not coping with the fact that you are the clinical tutor for the whole week. Statements such as “this is not how we were taught by other tutors’” provided an opportunity for the clinical tutor to discuss the importance of being adaptable and versatile, while at the same time maintaining standards. Familiarity was important to the participants Doing what they do best in an area that they are familiar with, ensured that the clinical tutor gained the rapport and confidence of the student. Working in a familiar area meant they knew the staff and their capabilities, and the resources that can be accessed. One participant found the prospect of working in unfamiliar areas somewhat unnerving and stated When they were required to work in different wards, they visited each area before starting with the students to introduce themselves, and orientate to the area. They felt they were answerable to so many people, the staff, the students, and the institute Students generally appreciate the link with the educational institute (Neville & Crossley, 1993). Liaison between clinical staff, students and polytechnic staff was an important issue to participants. The more information and knowledge they could receive the better. The main thing that students want was consistency. Maintaining Connections As the students gained confidence, they begin to make connections. One participant stated for example, that the student can put the information together and make the right decision and if they are interested and motivated they are in the right environment to learn and respond to the learning opportunities

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One participant noted this especially with third year students who are actually pointing things out about the patients that other staff had not picked up. It is good to see the students keen and motivated and using their initiative. Clinical tutors liked the way it made them keep one step ahead. Students begin to reflect on their practice assign meaning, problem solve, predict, plan and apply information described as “putting it all together” (Twibell, Ryan & Hermiz, 2005) Following through. Participants experienced frustration in relation to assisting students to meet clinical competencies. Assessment of student’s competencies is a source of concern for clinical tutors. It was generally agreed that preceptors are reluctant to verbalise concerns they may have about students in relation to clinical performance, however clinical tutors were aware of the importance of students having to complete competencies in a limited time. One participant explained how she and the student had been working well together. They had become quite focussed to achieve the outcomes. It was very satisfying. However, there were times when another tutor took over and signed everything off. Clinical tutors felt quite annoyed when this happened, because they like to follow it through with the student The clinical tutor felt that she had worked hard to assess the student’s capabilities and was not able to follow through. I have actually swapped duties with another tutor, so I could follow through with the student but this is not often possible. Approaching Learning Getting together Participants agreed that group tutorials are usually of value to students. The students all ask each other questions and feed off each other. Sometimes the students will say they seem to be off the ward all the time. They want to continue in the practical area. There were times when the tutors heard the students making statements that concerned them as they had obviously got the wrong idea and a debriefing session or a time out to share experiences would was of value. The participants acknowledged the reality of students having to work to financially support themselves through the programme, and they understood why the student often preferred to remain in the placement to gain as much clinical experience as possible however the process of debriefing was felt to be an important part of being there for the learner. Sharing information and seeking advice about issues in clinicals was an important area of discussion by these clinical tutors. They felt that there was not enough opportunity to share ideas and experiences with fellow colleagues/nurse educators. Sometimes they just wanted some support or an opportunity to discuss how to deal with a situation but they end up meeting in the corridors of the hospital

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The participants identified four specific areas where improvements could be made: 1 2 3 4

Collaboration. Staff development Communication Orientation

Collaboration The challenge for nurse educators is collaboration with all people involved with the student’s clinical experience this includes clinicians who are employed for short spells of times to work with students in clinical settings. The experience of the clinician who is seconded into the role of clinical tutor continues to be of value to the education of students and impacts on their professional growth and development. At the same time they assume the responsibility and the challenge of guiding supporting and teaching students. (Litizia & Jennrich, 1998). Continued effective liaison with participants established through a process of collaboration will promote the development of planned learning experiences and prevent the ‘ad hoc’ arrangements the students can confront when they walk into a busy clinical setting. Students need also to be part of the collaboration process to reduce the ‘mystique’ and uncertainty of why they are there, what they can do and what they cannot do. Staff Development Provision of staff development for clinical tutors should include access to an Adult Learning course. Clinical tutors need to be able to give constructive feedback to students (Cooke, 1996) and the way this feedback is given will influence how students perceive their clinical progress. The participants in this study agreed that they would benefit from learning about teaching methods with a focus on adult learning. They acknowledged the change of student profile in nursing in New Zealand and realized that students are often juggling school, work and family demands. Students are therefore in the clinical setting to learn. This has provided a challenge to clinical tutors who are familiar with the traditional methods of teaching but have not been exposed to interactive collaboration methods of learning. Communication. With students clinicians and nurse educators and agencies is necessary on a regular basis to overcome the feelings of isolation and for the exchange of ideas and issues. Debriefing sessions with students and colleagues is highly valued by the participants. Students also stated that instructors have an important role in shaping their ability to think critically and that clinical conference (debriefing) promotes critical thinking. (Twibell, Ryan & Hermiz, 2005).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Debriefing Participant’s felt debriefing time is mostly valued by students and often considered a positive learning experience. These sessions provide students with the opportunity to reflect on their practice in a safe congenial environment. Sharing information and seeking advice about issues in clinicals was important to the clinical tutors. If problems do occur the student and tutor need a safe place to discuss and resolve the issues, reflect on their practice and establish learning goals. Orientation Preparation for the role. Participants in this study generally agreed their orientation to the clinical role had been minimal. Members gained benefit from a brief orientation, though felt follow up sessions would have been valuable. Assessment and evaluation of students in clinical practice has assumed increased significance in recent years as nurse educators respond to the cry from both education and health care sectors for increased accountability, definite standards and cost effectiveness. (Star Mahara, 1998). The clinical tutors did not feel confident at times in relation to assessing student’s clinical competence in clinical practice. Conclusion Clinical tutors recognized areas of concern which need to be addressed to ensure the quality of clinical supervision. Innovative roles such as joint teaching/service posts and lecturer practitioner roles have been suggested as possible ways forward (Davies, White, Riley & Twinn, 1996). It was also evident from the findings of this study that clinical tutors’ experiences when supervising students in clinical areas were influenced by institutional and organizational constraints. The development of joint positions is now providing extra opportunities for students to practice in simulated laboratories as well as practicing in the real clinical setting. Clinical tutors can be of value if they are able to participate in this area of clinical teaching so they become familiar with the expectations of assessments. Although recommendations are from a small study they should be viewed positively as a means of gaining insight into the effectiveness of the role of clinical tutors and highlights the need for continued research and preparation of all personnel involved in the clinical teaching of nurse students (Cooke, 1996). Nurse educators are continually exploring options of how to best provide quality clinical experience. This can include clinical tutors facilitating student with considerable input from preceptors. In an environment of advanced technology, cost cutting, staff shortages both in health and education the principles of collaboration and cooperation are imperative. There is a need now for nurse educators to be aware of both the student’s voice and the discussions of the clinical tutors and use the recommendations as a basis for future

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

actions. By listening to concerns and adopting suggestions from this study nurse educators can enable changes to be made which will effectively support clinical tutors in their role and thereby provide quality education for future nurse students.

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Anderson, D. (2004). Nurse: nurture your young. Nurse Management, 35 (1), 18-20 Berg, C, & Lindseth, G. (2004). Student’s perspective of effective and ineffective nursing instructors. Journal of Nursing Education, 43 (12), 565-569 Bergman, K, & Gaitskill, T. (1990). Faulty and student perception of effective clinical teachers: An extensive study. Journal of Professional Nursing, (1), 33-44. Booth, W. (1997). Towards partnerships for praxis. Unpublished thesis. Victoria University Wellington. Brooks, E., Fletcher, K., Wahlstedt, P. (1998). Focus group interviews. Assessment of continuing education needs for the advanced practice nurse. The Journal of Continuing Education in Nursing, 29 (1), 27-31. Burns, N, & Grove, S. (1993). The practice of nursing research conduct, critique and utilization. (2nd Ed) Philadelphia. W.B.Saunders Cahill, H.A. (1996). A qualitative analysis of student nurses experiences of Mentorship. Journal of Advanced Nursing. (24), 791-799. Callister, L., Malsumura, G., Lookinland, S & Loucks, C. (2005). Inquiry in baccalaureate nursing education: fostering evidence based practice. Journal of Nursing Education, 44 (2), 59-65 Clifford, C. (1993). The clinical role of the nurse teacher in the United Kingdom. Journal of Advanced Nursing, (18), 281-289 Cooke, M. (1996). Nursing students’ perceptions of difficult or challenging clinical situations. Journal of Advanced Nursing, (24), 1281-1287. Davies, S., White, E., Riley E. & Twinn, S. (1996). How can nurse teachers be more effective in practice settings. Nursing Education Today, (16), 19-27 Duke, M. (1996). Clinical evaluation-difficulties experienced by sessional clinical teachers of nursing: a qualitative study. Journal of Advanced Nursing, (23), 408-418. Dyson, L. (1995). Clinical teaching: Change and opportunity. Paper presented at International Nurse Educators Conference. Waikato. Ferguson, d. (1996). The lived experiences of clinical educators. Journal of Advanced Nursing, (23), 835-841. Forrest, S., Brown, N & Pollock, L. (1996). The clinical role of the nurse teacher. An exploratory study of the nurse teacher’s present and ideal role in the clinical area. Journal of Advanced Nursing, (24), 1257-1264 Hart, G., & Rotem, A. (1994). The best and the worst: Students experiences of clinical education. The Australian Journal of Advanced Nursing, 11 (3), 27-33.

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Landers, M (2000). The theory-practice gap in nursing: the role of the nurse teacher. Journal of Advanced Nursing, 32 (6), 1550-1556 Lee, D. (1996). The clinical role of the nurse teacher: A review of the dispute. Journal of Advanced Nursing. (23) 1127-1136. Letizia, M., & Jennrich, J. (1998). A review of preceptorship in undergraduate nursing education: Implications for staff development. The Journal of Continuing Education in Nursing, 29 (5), 211-215. Mahat, G. (1998). Stress and coping; junior baccalaureate nursing students in clinical settings. Nursing Forum, 33 (1), 11-20 Star Mahara, M. (1998). A perspective on clinical evaluation in nursing education. Journal of Advanced Nursing, 28 (6), 1339-1346 Tang, F., Chou, S & Chiang, H. (2005) Students perceptions of effective and ineffective clinical instructors. Journal of Nursing Education, 44 (4), 187-193 Tanner, C. The art and science of clinical teaching. Journal of Nursing Education, 44 (4), 151-158). Tong, V & Henry, D. (2005) Performance-based development system for nursing students, Journal of Nursing Education, 44 (2), 95-97. Twibell.R., Ryan, M, & Hermiz, M. (2005). Faculty perceptions of critical thinking in student clinical experiences. Journal of Nursing Education, 44 (2), 71-82 Watson, L. (1997). Student nurses perception of the factors that promote and inhibit learning during clinical placements. Paper presented at Australasian nurse educators conference Webster, R. (1990). The role of the nurse teacher. Clinical credibility. Senior Nurse. 10 (8), 16-18 Yong, V. (1996). Doing clinicals: The lived experience of nursing students. Contemporary Nurse. A Journal for the Australian Nursing Professional, 5 (2), 7379.

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CONSIDERING CASE STUDY: A RESEARCH APPROACH

Sarah Jane Brophy Clinical Nurse Educator Professional Development Unit Christchurch Hospital Canterbury District Health Board P.O. Box 4710 Christchurch New Zealand +64-3-3641529 [email protected] CONSIDERING CASE STUDY: A RESEARCH APPROACH Research occupies a central role that is transforming nursing practice and nursing interventions in contemporary healthcare environments, where an emphasis is placed on evidence-based best practice. New nursing knowledge generated by nurse researchers is furthering the development of research as an advanced nurse competency, as well as contributing to the development of the discipline of nursing in general. Research methodology is not a random choice, however, therefore the research purpose must guide and inform the process of determining the most appropriate methodology. Those considering a case study approach for conducting research within a healthcare context will find that the flexibility and utility of this methodology is an advantage across a wide spectrum of clinical settings and specialty practices. In addition, application of appropriate data management techniques will protect the evidence quality of new nursing knowledge produced, and in turn, this will support the on-going development of evidence based best practice in the discipline of nursing.

References Bassey, M. (1999). Case study research in educational settings. Philadelphia: Open University Press. Bergen, A. (1992). Evaluating nursing care of the terminally ill in the community: a case study approach. Int J. Nurs. Stud., 29(1), 81-94. Bergen, A. (2000). A case for case studies: Exploring the use of case study design in community nursing research. Journal of Advanced Nursing, 31(4), 926-934. Bryar, R. M. (1999/2000). An examination of case study research. Nurse Researcher, 7(2), 61-78. Burgess, E. W. (1927). Statistics and case studies as methods of social research. Sociology and Social Research, 12, 103-120.

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Camiah, S. (1997). Utilization of nursing research in practice and application strategies to raise research awareness amongst nurse practitioners: a model for success. Journal of Advanced Nursing, 26, 1193-1202. Campbell, D. T. (1975). Degrees of freedom and case study. Comparative Political Studies, 8(2), 178-193. Campbell, J. P., Daft, R.L., & Hulin, C.L. (1982). What to study: generating and developing research questions. Beverley Hills, CA: Sage Publications. Eckstein, H. (1975). Case study and theory in political science. In F. P. Greenstein, N. (Ed.), Strategies of inquiry. Reading, Massachusetts: Addison-Wesley Publishing. Eisenhardt, K. M. (1989). Building theories from case study research. Academy of Management Review, 14(4), 532-550. Gillham, B. (2000). Case study research methods. New York: Continuum. Gomm, R., Hammersley, M., & Foster, P. (2000). Case study method: key issues, key texts. London: Sage. Gray, M. (1998). Introducing single case study research design: An overview. Nurse Researcher, 5(4), 15-24. Hamel, J., Dufour, S., & Fortin, D. (1993). Case study methods. Newbury Park, CA: Sage Publications. Hennings, J., Williams, J. & Haque, B.N. (1996). Exploring the health needs of Bangladeshi women: A case study in using qualitative research methods. Health Education Journal, 55, 11-23. Iliffe, S., Lenihan, P., Wallace, P et al. (2002). Applying community-orientated primary care methods in British general practice: A case study. British Journal of General Practice, 52, 646-651. Jenicek, M. (2003). Foundations of evidence-based medicine. New York: The Parthenon Publishing Group. Keyzer, D. M. (2000). Nursing research in practice: The case study method. Aust. J. Rural Health, 8, 266-270. Lackey, N. R. (1992). Qualitative research methodologies: Application, Part II. Journal of Post Anesthesia Nursing, 7(2), 119-128. Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA: Sage. McCormack, B. (1992). A case study identifying nursing staffs' perception of the delivery method of nursing care in practice on a particular ward. Journal of Advanced Nursing, 17, 187-197. McDonnell, A., Lloyd Jones, M. & Read, S. (2000). Practical considerations in case study research: The relationship between methodology and process. Journal of Advanced Nursing, 32(2), 383-390. McNair, M. P., & Hersum, A.C., (Ed.). (1954). The case study method at Harvard Business School. New York: McGraw-Hill Book Company Inc. Merriam, S. B. (1988). Qualitative research and case study applications in education. San Francisco: Jossey-Bass Publishers. Merriam, S. B. (1998). Qualitative research and case study applications in education (Rev ed.). San Francisco: Jossey-Bass Inc., Publishers. Meyer, J., Spilsbury, K., & Prieto, J. (1999/2000). Comparison of findings from a single case in relation to those from a systematic review of action research. Nurse Researcher, 7(2), 37-59. Muscari, M. E. (1994). Means, motive and opportunity: Case study research as praxis. Journal of Pediatric Health Care, 8(5), 221-226.

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Pearson, P. (1991). Client's perceptions: the use of case studies in developing theory. Journal of Advanced Nursing, 16, 521-528. Pegram, A. (1999/2000). What is case study research? Nurse Researcher, 7(2), 5-16. Platt, J. (1992). Case study in American methodological thought. Current Sociology, 40, 17-48. Sandelowski, M. (1996). One is the liveliest number: The case orientation of qualitative research. Research in Nursing and Health, 19, 525-529. Sharp, K. (1998). The case for case studies in nursing research: The problem of generalisation. Journal of Advanced Nursing, 27, 785-789. Stake, R. E. (1983). The case study method in social inquiry. In G. F. Madaus, Scriven, M.S. & Stufflebeam, D.L. (Ed.), Evaluation models. Thousand Oaks, CA: Sage. Stake, R. E. (1994). Case studies. In N. K. Denzin, & Lincoln, Y.S. (Ed.), Handbook of qualitative research. Thousand Oaks, CA.: Sage. Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage. Stake, R. E. (2003). Case studies. In N. K. Denzin, & Lincoln, Y.S. (Ed.), Strategies of qualitative inquiry (2nd ed.). Thousand Oaks, CA.: Sage. Stoecker, R. (1991). Evaluating and rethinking the case study. The Sociological Review, 39(1), 88-112. Woods, L. P. (1997). Designing and conducting case study research in nursing. NT research, 2(1), 48-56. Yin, R. B. (1992). The case study method as a tool for doing evaluation. Current Sociology, 40, 119-137. Yin, R. B. (1994). Case study research: design and methods. London: Sage.

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ARE NURSE EDUCATORS READY, WILLING AND ABLE TO MEET THE CHALLENGES OF INFORMATION MANAGEMENT AND TECHNOLOGY (IM&T) IN THE UNDERGRADUATE CURRICULUM? Ms Claire Büchner BSc (Hons), RN, PGCE Nurse Lecturer School of Nursing and Midwifery Queen's University Belfast Medical Biology Centre 97 Lisburn Road Belfast BT97BL Northern Ireland + 44 28 90972390 [email protected] The healthcare arena has become inundated with advances in information technology over the past ten years. These changes must be viewed as a challenge rather than a risk to the nursing profession. There is appreciation that all nurses will need to have core informatics competencies to practice effectively in the future, in order to improve patient care. This paper will discuss informatics education for nurses and explore the obstacles to its implementation within undergraduate curricula. The aims of the study presented in this paper are to reveal if nurse educators have an understanding of the main components of nursing informatics; to disclose if nurse educators have the underlying information management and technology skills to teach information management and technology and to investigate nurse educators’ opinion on nursing informatics and its usefulness in nursing practice. The NHS Information Authority publication Learning to Manage Health Information: a theme for clinical education (NHSIA, 1999) provides the standards for learning and has been used as the framework for an online survey of nurse educators in a large undergraduate School of Nursing and Midwifery in Northern Ireland. Results from the study provide empirical evidence of the critical need to include IM&T into the undergraduate nursing curriculum. The majority of nurse educators primarily are at the proficient or competent level regarding use of information technology. For those who rated themselves at lower levels of skill acquisition there was a willingness to improve this. The need for educators to be knowledgeable in current initiatives and developments within health informatics and how these can affect nursing practice is paramount; therefore recommendations must be made to develop educational opportunities for educators to ensure they achieve a level of competence to prepare future nurses for practice. National Health Service Information Authority (1999) Learning to Manage Health Information: a theme for clinical education. NHS, UK

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Transforming Care in the Emergency Department

Anne Boykin, PhD, RN Dean and Professor and Susan Bulfin, MN, RN Project Director Florida Atlantic University Christine E. Lynn College of Nursing 777 Glades Road Boca Raton, FL 33431-0991

John Baldwin, MSN, RN Director, Emergency Services Department Boca Raton Community Hospital 800 Meadows Road Boca Raton, FL 33486

Rebecca Southern, MS, RN Executive Director, Clinical Development and Relations Boca Raton Community Hospital 800 Meadows Road Boca Raton, FL 33486

Contact Information: Susan J. Bulfin, MN, ARNP, Clinical Instructor, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, Boca Raton, Florida Phone: 954 941 6744 Fax: 954 941 5660 Email: [email protected]

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Abstract Much has been written about the need for innovative models for healthcare delivery. There is a universal call for systems of care based on a commitment to values such as caring and respect for person. This article describes the evolution of such a model in the emergency department at a not-for-profit community-based hospital. Key words: nursing practice, caring, healthcare delivery systems, emergency department Transforming Care in the Emergency Department Introduction Much has been written about the current and projected future healthcare crisis in America. Situational challenges influencing the workforce crisis are well documented. These include the lack of an aptly-prepared workforce, poor morale, increasing workplace demands, low salaries, and inadequate staffing.1, 2 Each of these seems to negate quality care. The combination of these factors has led to the present system which fails to embody the essential values held dear to those who choose to be members of a helping profession. Physicians, nurses, and other health professionals enter their chosen profession as a response to a call to make a difference in the lives of those for whom they are privileged to care. It is this which matters. Often times, it is the struggle to profess and express values which lies at the heart of workforce dissatisfaction. When professional values such as “respect of the individuals’ worth, trustworthiness and protection of important values”3,p.1 are not lived out, dissatisfaction, burnout, demoralization, and the experience of ‘not having responded to the call for care’ results. As articulated in the document In Our Hands, the first challenge to building a thriving workforce in a healthcare setting is to design hospital work “to meet patient, worker, and organizational needs and ensure that the work of caregivers and support staff is meaningful.”4, p.14 The purpose of this article is to describe the evolvement of a model of care in the emergency department (ED) of a community-based hospital that is explicitly grounded in the essential value of caring. As many both in and out of the healthcare professions are aware, the call today is for transformation of healthcare settings – to infuse systems of care with values that will result in meaningful work. Where could this be more vital and challenging than in the emergency department? Most of us have either experienced or have been told of the trauma of bringing a loved one to the ED only to be met with crowded conditions, insufficient staffing, prolonged stays and poor communication. This experience often results in patients and families feeling they have not been heard nor cared for. Yet, the ED is the entry point for 40% of hospital inpatient admissions.5 It is the “major diagnostic and resuscitation site”5, p.5 of our healthcare system. One of the major problems in the ED is a lack of nurse staffing, resulting in frustration, tiredness, impersonalization and the inability to complete the most basic aspects of care.6 Nurses report that they are missing the opportunities to touch lives in more personal ways.6 In essence, nurses aren’t nursing.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

We believe that these issues must be addressed. We believe healthcare systems must return to their most fundamental mission—which is to ‘care’. We believe that in order to provide care that matters, healthcare systems must intentionally refocus on living the value of caring. In this article, Nursing as Caring7 is the theoretical base for creating caring environments and for reframing ways of being with colleagues and those cared for. Brief Overview of Nursing as Caring From the lens of Nursing as Caring, the focus of nursing as a discipline and profession is “nurturing persons living in caring and growing in caring.”7,p.11 This focus is grounded in the following assumptions: • Persons are caring by virtue of being human • Persons are caring moment-to-moment; each moment provides the opportunity to express one’s caring uniquely and to grow in caring, • Persons are whole and complete in the moment; this calls for the celebration of human wholeness valuing and respecting each person’s beauty, worth, and uniqueness, • Personhood is living grounded in caring; it is living in the context of relational responsibilities. These assumptions provide the essential foundation for the design, implementation and evaluation of a new model of care in the ED. They may lead one to question; how does a person come to know caring? Knowing Caring In discussing what caring truly meant to those in the emergency department setting, one of the necessary challenges was to assist others to appreciate caring as a substantive concept. In the ordinariness of life, caring is often understood as a feeling or emotion—something that comes and goes. Some staff questioned the priority of ‘caring’, especially when involved in more vital work such as resuscitative efforts and urgent interventions. The staff came to understand that caring can be known not merely as “a matter of good intentions or warm regard”8,p.13, but rather as “understanding another’s needs in order to respond properly to them.”8,p.13 Technical expertise and diagnostic skill are integral components of caring, as are compassion, commitment and respect for person. Through the study of a language of caring, the staff began to know caring as a substantive concept. The philosopher, Milton Mayerhoff, is one person we are indebted to for his language of caring. Mayeroff proposes that in the “context of a man’s life, caring has a way of ordering his other values and activities around it”.8,p.2 He suggests that this ordering helps one to be “in place”8(p2) in the world or finding meaning in one’s life. His description of major ingredients of caring offer an explanation as to what it means to live caring. These ingredients include: • Knowing—there are different ways of knowing • Alternating Rhythm—the rhythm of moving between widening and narrower views • Patience—an active participation with others • Honesty—genuineness and openness to truly see • Trust—allowing one to grow in their own time and space • Humility—the need for continual learning • Hope—the possibilities of the present • Courage—the willingness and ability to take risks; to go into the unknown

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The first phase of the model development, transforming care from objectcentered to patient-centered care, focused on strategies to understand and know self and other as caring person. The process of staff coming to know self as caring person began during the data gathering phase of this project. All staff persons who were directly or indirectly involved with patients in the Emergency Department, as well as patients and their loved ones, were invited to share a story of caring. The telling of these stories provided an occasion for reflection on living caring. For example, one of the nurses shared a story about an encounter with an angry patient and his living of humility. He described how ‘just being with her’ allowed her to calm down and discuss what mattered most to her at that point in time. The staff used Mayeroff’s caring ingredients as a basis for continuing dialogue. They considered questions such as: what does it mean to live the caring ingredients in everyday life? Do I live these caring ingredients in my practice? As another way to help illuminate the living of caring, the staff created a videotape which depicted staff members reenacting their own poignant stories of caring. This video was used to facilitate dialogue on caring at staff meetings. It helped them understand that each person expresses caring uniquely. They began to see that caring is something real; that caring can be articulated. They were growing in their understanding of a language of caring and in a new way of knowing self and other. As Proust suggests, the voyage of discovery comes not from seeking new landscapes, but from having new eyes.9 A Model for Practice In creating a model of care grounded in Nursing as Caring, it was imperative that the nurse administrator responsible for the overall operations of this lifeline to the organization. understand, embrace, and clearly articulate in words and lived experiences the core concepts of caring. This modeling is important to capture the hearts and hands of the nursing service personnel in the ED. That is, it is crucial that nurse administrator first identify their own way of living and growing in caring. Knowing self is preeminent in this endeavor. As one comes to know self as caring person, it is easier to both professionally and personally “see” others as individuals expressing calls for caring (i.e., a “call for nursing administration”). Indeed, this is the very focus of nursing (whether it be at the service level or the administrative level)….to nurture persons living and growing in caring.7 If, as M.Leininger10 has asserted, caring is the very essence of nursing, then it is the role of the nurse administrator to create an environment, or “culture” if you will, that promotes, supports, and maintains caring as the very basis of nursing service wherever it is carried out. The Dance of Caring Persons,7 a key concept of Nursing as Caring, is used as the grounding value for the evolvement of the practice model described in this paper. This model, unlike a more traditional one of a bureaucratic structure, envisions a circle of dancers where each person is valued, respected, and supported in their specialized roles (e.g., nursing, medicine, radiology, dietary, laboratory, etc.) without the encumbrances of power, authority, and positional importance restricting their unique contributions to the dance..…the dance being the very act of caring. This model assumes that each person within the organization is caring. All disciplines are on equal footing to the benefit of all, unlike a more traditional hierarchical structure. Transformation to person-centered care requires a commitment to intentionally focus on creating a caring-based value system. This is exactly what is being lived in the ED. There was regular discussion on Mayeroff’s caring ingredients to assure a growing understanding of what it means to develop a practice grounded in Nursing as Caring. Staff regularly shared experiences which nurtured and supported their living

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

of caring. Examples of processes which supported this knowing included: the administrator focused on coming to know what mattered most to staff; stories of caring were shared during daily rounding within departments; a caring notebook was designed where notes and articles on caring could be shared with others; and dialogue at monthly staff meetings centered on caring. A team representing all categories of staff (primary nurses, charge nurses, ED technicians, unit secretarial personnel, patient/guest relations staff, and departmental leadership/administration) was designed to lead the evolvement of this caring-based practice model. This team met every two weeks to engage in discussions that focused on experiences of living caring within the department. All discussions and suggestions for further development of a culture grounded in the value of caring were shared at monthly staff meetings for further dialogue and input. It was through a commitment to live the value of caring that meaningful changes began to occur. Living Caring Although the ED has only been in the implementation phase of this project for approximately six months, some significant developments have occurred. Some examples are: 1. Leadership rounding by administrators of departments (e.g. Environmental Services, Radiology, Respiratory Therapy, Patient Flow Coordinators, Business Office, Registration) that have a direct impact on the daily operations of the ED was established in order that they may collectively address how their areas might enhance the experience of having been cared for. 2. A new hiring process has evolved. The process includes a discussion of the caring model, including dialogue on what it means to live caring in practice. All employees must be aware of the values guiding practice in the ED. 3. Thank You cards, given to every patient upon discharge from the ED or upon admission to the inpatient units, were created. The note, signed by every healthcare discipline that provides any element of care for the patient, utilizes the newly-developed slogan for the ED of “Our Family Caring for Yours.” By contrast to financial charges sent to the patient, this message is meant to express the personal concern and gratitude for the opportunity to care for them. 4. A “Catering-to-You” concept of patient dietary tray delivery was developed. Each patient admitted to the ED of the hospital, as well as family members, now receives individual attention by the dietary department staff. 5. A blanket warmer has been placed in the typically cold triage area. The average age of patients entering the ED and the hospital is 73. Many patients complained of being cold and the blanket warmer was a response to their call for comfort. 6. Visits from Dr. Rusty, a golden Labrador retriever, whose supervised visits in the waiting room and individual patient rooms provide a diversion and an aspect of connectedness. 7. Hand-written notes are sent to the staff acknowledging and celebrating their exquisite caring responses to patients and families. 8. An annual performance appraisal tool is being developed that will encompass the value of caring. The intent is to create a process which will assist staff to grow in their living of caring. For example, one aspect of the evaluation process may be that asking staff to write or tell a story on how they live caring, compassion, and competence in practice.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The impact of these initiatives has resulted in significant positive feedback from patients and significant others. The efforts described above reinforce the creation of an environment where calls for nursing are heard and nurturing responses are offered. It must be remembered that caring is as much personal as it is professional, and that it is as important to live caring with colleagues as it is with patients and families nursed. Living caring transforms one’s way of being in an organization and hence changes organizational cultures. The following nursing situations exemplify how a caring “lens” for practice changes what is seen and responded to. Nursing Situations: Exemplars of Transformation The nursing situation, another key tenet of Nursing as Caring,7 is understood as a “shared lived experience in which the caring between the nurse and the one nursed enhances personhood”7,p.13 The intention of the nurse is to come to know the person nursed as caring person; to identify calls for nursing; and to respond in a way which represents the unique lived caring of the nurse. The first nursing situation is a seemingly ordinary experience. So ordinary perhaps that it may be considered routine…however, in this case it is the living of caring which makes it extraordinary. The situation began with a patient who entered the ED experiencing chest pain. Although the nurse dutifully monitored all signs and symptoms and answered her questions, the patient demanded more and more time. The nurse determined that the patient’s call was for some control of her situation. When the nurse consulted with the cardiologist, it was determined the chest pain was not life threatening. The nurse was then able to respond to what mattered most to this person by supporting her to make decisions related to her care. The nurse’s focus was on hearing what mattered and supporting and sustaining the hope of this person. Another example of living and growing in caring involves the case of a 40+ y/o male who was brought to the ED as a cardiac arrest victim. During the report from the local EMS provider about the imminent arrival of this patient, it was also shared that the patient’s spouse (who was a nursing supervisor in another local hospital) had already been notified and was even then on her way to our hospital. Immediately the staff not only prepared for the arrival of the patient but also made preparations for addressing the needs of the wife. Upon arrival of the patient, the staff of the ED took over the resuscitative efforts from the EMS personnel who shared that their efforts had been underway for a substantial amount of time without apparent response. The on-duty ED physician assumed the leadership role of the clinical situation, with support from the nursing staff. Resuscitative efforts were continued while more history about the patient was shared and appropriate interventions were performed. After a considerable amount of time the physician believed that further medical intervention would be to no avail. However, before ceasing resuscitation, he verified that the patient’s wife was on site and was indeed a healthcare provider herself. It was at his suggestion that efforts continue until she was brought into the room. The doctor believed the wife should be allowed to witness the efforts being made on her husband’s and her behalf and to be an active participant in making the decision to continue or stop the resuscitative efforts. He immediately went to her and greeted her, placing an arm around her shoulders. He escorted her to the bedside and proceeded to give her a report of the ongoing efforts and current status of her husband. She offered many bits of information and asked questions. He calmly responded to each of these while continuing to touch her and even fostered her touching her husband’s hand. He eventually explained to her his assessment of the

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

situation but asked her thoughts. She did express deep emotion and initially vacillated but eventually agreed that it was indeed the best decision to cease further resuscitative efforts. She was allowed to stay with her husband during his final moments and then was escorted to a more private room to discuss necessary arrangements with the assistance of support staff. Later she was invited and accepted the offer to again spend some private time with her husband before his body was removed from the ED. In reviewing the events of this situation, it became apparent that not only had the nursing staff grasped the need to be caring in all situations, but so had members of our medical staff. (We had included them in our discussions of caring and in the implementation of some caring strategies, such as the Thank You card.) In retrospect, it became clear to us that we had transcended the medical model of healthcare. Rather than just obtain a history, perform the prescribed elements of ACLS, and finally to pronounce the patient, we had engendered, in very real and tangible ways, elements of caring not heretofore practiced, at least in this particular environment. These examples—as part of our daily living of caring—reinforce our basic belief that caring must be the focus of healthcare settings. As individuals, we are touched routinely when people transform the impersonalness of a society by their small acts of concern. It is our belief that when the assumptions of Nursing as Caring are valued in practice…when healthcare professionals are able to respond to their calls to care…that a transformation from object-centered to patient-centered care results. It is this call for person-centered care that must be responded to if we are to humanize the healthcare system now and in the future.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

1.

References Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 1999.

2.

Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001.

3.

Oreopoulos, D.G. Is medical professionalism still relevant? Humane Healthcare. 2003; 3(2): www.humanehealthcare.com/vol3n2e/07___31__03__.Relevant.html. (Accessed on June 12, 2004).

4.

American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands. Chicago: American Hospital Association; 2002.

5.

Schriver, J., Talmadge, R., Chuong, R., & Hedges, J. Emergency Nursing: Historical, current and future roles. Journal of Emergency Nursing. 2003; 29(5):431-439.

6.

Keough, V.A., Schlomer, R., & Bollenberg, B. Serendipitous findings from an Illinois ED nursing educational survey reflect a crisis in emergency nursing. Journal of Emergency Nursing. 2003; 29(1):17-22.

7. 8.

Boykin, A., & Schoenhofer, S. Nursing as Caring: A Model for Transforming Practice. Boston: Jones and Bartlett; 2002. Mayeroff, M. On Caring. New York: Harper and Row; 1971.

9.

Proust, M. Remembrance of Things Past. New York: Random House; 1934.

10. Leininger, M. Caring: An Essential Human Need. New Jersey: C.B.Slack; 1981.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

An Observational study examining compliance with hand washing and glove use in relation to patient care activities in a post anaesthetic care unit. Aileen Burton Lecturer School of Nursing & Midwifery, University College Cork 021 4901464 [email protected] Abstract Hand washing is an old cultural custom. It served primarily for the removal of dirt, but also delivered people symbolically from physical and moral evils. Today hand washing is critical in reducing the incidence of cross infection. This is a simple measure but all too often is poorly carried out and compliance with hand decontamination and glove use guidelines is sub-optimal amongst a range of healthcare professional groups This study examined nurse’s compliance with hand disinfection and glove use in relation to patient care activities in the recovery unit (post anaesthesia care unit) in an acute general hospital in the Republic of Ireland The post-operative recovery unit is an area of the hospital where intensity of patient care and the number of contacts between nursing staff patients are high. Whilst one to one care is the norm, individual nurses might, because of emergency or support roles make rapid and sequential contact with more than one patient .Within the recovery unit environment nurses conduct procedures that necessitate cross infection precautions such as wound care and catheter care. In addition the recovery unit is usually an open ward, without barriers, such as walls between patients. There is a high throughput of patients and hence a big potential for cross infection. Observation was the method used to collect data along with field notes to describe the context of care give. Data was analysed using SPSS computer package. Findings in relation to compliance were analysed in terms of full compliance, partial and non compliance.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Interdisciplinary Family-Focused Health Care Across Cultures: A USA/EU International Education Project Rita Butchko Kerr, PhD, RN and Nancy McBride, BSN, RN, CEN Capital University School of Nursing, 1 College and Main Columbus, Ohio 43209, USA [email protected] [email protected] telephone – 614-236-6365 fax – 614-236-6157 Introduction Quality health care and the distribution of health care resources are major concerns for health professionals across the globe. The three primary goals of the International Organization of Nursing (ICN) include bringing nurses together, advancing nurses and nursing worldwide, and influencing health policy (http://www.icn.ch/abouticn.htm). The World Health Organization (WHO) supports and encourages research and the exchange of information to ensure better patient care (http://www.who.int/about/en/). Within the frameworks of WHO and ICN, the problem addressed by this FIPSE/EU funded grant was the relative isolation in which nurses and other health care professionals practice in their particular home base. There is infrequent sharing of knowledge and lack of feedback from colleagues outside of one’s own country. The need for nurses to acquire expertise in global health care, share knowledge beyond national boundaries, and work in interdisciplinary settings toward better family health maintenance was the focus of this project. Our partners came from University of Tampere, Finland; Witten-Herdecke University, Germany; University of Rome “’la sapienza’, Italy; Capital University, Columbus, Ohio; Florida international University, Miami, Florida; and the University of Wisconsin, Eau Claire, Wisconsin. The strategies for mutually raising the consciousness of graduate nursing students and faculty about trends and developments in health care delivery in the three EU countries USA states included: 1) Cultural Immersion through learning basic language skills and transatlantic e-mail discussions; 2) The development of web-based courses in modular format; 3) Course work and practical experience abroad for 5 exchange students from and to each university; 4) A home-based contingency of students at each university who take the courses with a focus on a partner country of choice; and 5) Final implementation of a change at home based on new ideas from abroad. The curriculum included four web-based courses. A Cultural Immersion seminar introduced students to a transatlantic culture, language training, cultural values, and social and interpersonal patterns. Cultures, Communities, and Health Care covered models of culture theory and health care treatment internationally; Interdisciplinary Health Care Across Cultures explored interdisciplinary health care delivery, the role of team members and policies, and ethnic and ethical issues concerning families. Family Theory and Intervention Across Cultures focused students on family intervention theories and models, ethnicity, family lifestyle preferences, and family assessment and intervention. The focus of the final course, Leadership Seminar, was to assist students to introduce an innovation in a home-based setting. The goals of the project were to produce nurse leaders who were sensitive to cultural differences and the unique health needs for differing populations; promote an

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

interdisciplinary, family-focused approach to health care; develop an advanced culturally competent nursing role for the future that included a clinical focus on the family as the unit of health care management; educate graduate students to serve as expert care providers, educators, patient advocates, researchers, and consultants to health care institutions; institute beneficial changes in health care delivery on both sides of the Atlantic; and advocate for new models for culturally congruent health maintenance and preventive care. The program has been evaluated through curriculum reviews and evaluation of student performances, products of student learning including presentations and written papers, and student course evaluations. Faculty believes the goals of the program have been met both by those students who crossed the Atlantic as well as those students who studied at home. Students who crossed the Atlantic learned the health care system of their host country. Students who stayed at home learned about a specific subculture within their own local area. For example, in Columbus, students could focus on Asians, Somali, or Latino cultures. In Wisconsin, students focused on the Hmong. In Florida, students studied multiple Latino cultures. The challenges and opportunities for both students and faculty over the last five years, however, have been daunting. The Structure of the FIPSE/EU Grant FIPE/EU provided structured exchanges at their annual conferences, either in the USA, EU, or Canada. The consortium had to arrange other conferences on its own. Over the course of three years, representatives from the six schools visited five of the participating campuses. The first meeting of the partners occurred within two months of receiving the grant. It was at this point that the consortium realized how different each university had interpreted the grant even though the consortium members had worked on the application together. In addition, university calendars had nothing in common with each other. It was from these diverse attitudes and university time sequences that the group began to plan future meeting times. They also partnered one USA University with one EU University for the development of the four major web courses. Our first, major, and only tragedy occurred after the first year of the program when our colleague from Wisconsin, Dr. Audrey Bryan, died an untimely death. She had been a crucial member of the teamwork, and her loss is still felt among our group. Audrey was instrumental in developing the proposal as well as the Interdisciplinary Course. Of all of the issues one can think about when working with six partners from both sides of the Atlantic, the death of one of the partners who has been so important to the development of the project was never expected. Two areas of cooperation were web-based instruction and student exchange. Both European and US partners developed four Web-based Masters’ level courses during one academic year. They included a Cultural Immersion course, a Culture and Health Care course, a Family Nursing course, and an Interdisciplinary Health Care course. The WebCT learning environment platform was the main learning technology in use. One University used Blackboard. Students were able to adapt to both systems much easier than expected. The web-based learning environment served as a basis for sharing learning material and course information, discussions, and publishing student documents on the Web. Collaborative learning and distributed knowledge and

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

expertise were the key ideas for the design of these distance-learning environments. Good collaboration, good communication, trust in each other, several meetings, discussions via e-mail, and the importance of this topic were crucial in planning and teaching the courses together. Five students from each university were supposed to cross the Atlantic between years two and three of the grant. To achieve this goal, the grant had to be extended two more years. Finding graduate students who were willing to leave full-time jobs and family was a daunting task. Those who finally crossed the Atlantic in each direction were very pleased at their choice to do so. Long-term goals for the grant included cooperation in creating new methods for family-focused health care education and the development of a common ground for research cooperation in family-focused nursing science among the partner universities. Program Challenges and Accomplishments from a Faculty Perspective The program has succeeded in overcoming some of the problems of differing conceptions, institutional cultures and technologies in Europe and in the USA. Faculty members from a EU university and a USA university developed all planned courses during the first year. Use of web-based course offerings presented a learning curve for all universities. A major benefit was the implementation of new pedagogical methods. Assistance was more available for technology than for the pedagogy that needed to accompany the technology. At the time the program was implemented, web-based instruction was a new pedagogical world, and time was needed to create a good distance-learning environment. Careful planning for instructional ideas and learning material preparation was needed in advance. Course teachers themselves were learning what it was like to be a teacher in a virtual learning environment. Virtual learning was also new to students but, once learned, students and faculty, in general, were proud of their technical mastery. It is important to note that a web-based learning environment is not a self-teaching or studying environment. The professor and tutors had to set up a learning community and follow up discussions and support for the students. All faculty members agreed that teaching on the web was more time intensive than teaching in a classroom. Usually two faculty members taught one course in the beginning. One teacher was not able to cope with everything in an international distance-learning environment. Also, faculty needed local expertise for the web in terms of solving technical questions. Varying educational systems and term schedules accounted for the relatively low number of students at the beginning of the program. As a result, each university had to intensify its marketing efforts to make the courses and exchange opportunities known. Also, the courses needed to become better integrated into each university’s standard educational curriculum. The European partners had to deal with very strange notions from the US universities such as course credit and grades. In effect, USA students earned grades during the courses, and EU faculty received reports about the work of their students.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

There were lots of feedback and cultural differences to cope with in a virtual international learning environment. The EU students see USA professors as much more linear. US Course syllabi tended to be very specific and directed. US students expect defined beginnings and endings to courses while EU students are directed more internally to follow their personal interests and are less inclined to follow a precise standard of time. Program Evaluation The systematic collection of feedback and evaluation data was very important. By the time faculty offered the courses for the second time, they had better integration of students’ practical and clinical experiences with the theoretical aspects of the learning material. They also integrated new research articles into the content material as basis for the discussion. Students from the different universities who have been in more than one web course together welcomed each other back. They helped new students adjust to the learning environment. Because all of us were on new ground and missed the face-to-face contact, faculty and students put their pictures and interests on the web. In addition, as faculty travelled to each of the campuses, they had a chance to meet some of the students they had taught. The framework became more familiar and less alien as time went on. The issue of communication required careful consideration. Asynchronous communication within a web course had the advantage of allowing students to post their thoughts and contributions at their own pace and without being under undo pressure. On the other hand, synchronous communication, n involving a wellmoderated and structured chat, allowed faculty to create a sense of community and improved the readiness to contribute to the discussion. However, synchronous communication depends both on the number of students and the number of faculty teaching in the course. One of the highlights of doing something so new was that students and faculty learned together, although asynchronously, and strived to improve their pedagogical teaching and learning experiences. On the other hand, students sometimes entered the courses at different times because of differing time schedules across universities. Flexibility of the faculty was the key issue for instruction. Program Challenges from a Student Perspective Feedback from individual students about the web-based courses has been positive. The courses created and added an international atmosphere to regular studies. Students from the various universities took joy in the similarities and differences they shared with their counterparts from both across the Atlantic and from the three different states. However, if international web-based courses are not well integrated in the regular curriculum, students begin to lack motivation. A minority of students dropped the curriculum. Some were intimidated by the use of English. Others found the web a challenge they refused to overcome. Those students who endured received and contributed to helping each other. Studying on the web demanded careful time and study planning from the student side. From the faculty side, it demanded very specific pre-planning. The up side is that

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

once a course was developed, faculty use of time during the course was devoted solely to student interaction. A web-based distance-learning environment can create a gap between a coordinating teacher and a local distance study group. Answers may come a bit late, and sometimes there are difficulties when expressing oneself in literal form on the Web (especially for students with English as a second language). Also, students needed pedagogical and technical orientation to Web-based environments in the beginning with local tutors, who reduced the confusion when starting the web studies. In addition, the trans-Atlantic nurse exchange made available through the FIPSE Grant was an important step toward establishing a dialogue among nursing professionals and educators about current health care concerns and practices as well as among health care providers interested in promoting nursing practice, research and education. The Observations of One Student It was not difficult for me to select Capital University for my graduate studies or decide upon my concentrate, Family Focused Health Care Across Cultures. The concept that culture and family played an important part in health outcomes was not foreign to me. It made sense in the scheme of what we as nurses attempt to do everyday- to take a holistic approach to the patient. The opportunity to explore nursing, medicine, and the patient experience outside the United States filled a life long desire and passion for me to gain a greater understanding of the human condition and health. The concentrate’s course curriculum integrated traditional classroom work, web-based courses, clinical experience, and an opportunity to travel abroad if desired. While I am an advocate for face-to-face classroom interaction, I found the web-based courses challenging, intriguing and satisfying. It took a couple of classes to become proficient at navigating the web-based technology, but students and faculty were patient and helpful with one another. The idea that I was sharing thoughts and exchanging ideas about patient care and health care frustrations with students from Germany, Finland, or Italy fascinated me. It took courage for students for whom English was a second language. I applaud them and thank them for sharing. These exchanges and conversations were reassuring and hopeful. Large credit for the success of the webbased class conversations is due to the faculty who integrated our thoughts, different cultural approaches, and concepts on-line. As a nurse observer and a student in Rome, Italy in the spring of 2004 I had an opportunity to learn about the nursing profession, education and practice in Italy. Dr. Julita Sansoni and graduate students at the University of Rome, la sapienza guided me and three other nurse exchange students through the experiences that made this opportunity an experience of a lifetime. The measureless perspective gained from living and studying in Rome came from a variety of personal, cultural, and clinical experiences. Day to day life in Rome was a challenge – attempting to converse in Italian, using a different currency, or troubleshooting the transportation system helped me build confidence in unfamiliar situations. One soon learns that being timid in these situations limits the acclimation process.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The clinical observations made available to us by our hosts were invaluable. Discussions with other health care providers, educators, and clinical leaders helped us understand the Italian socialized health care system. In addition we were each given an opportunity to spend time in clinical areas of our interest or expertise. Observation with a nurse in the Emergency Services Department at Ospedale San Camillo provided me with a unique experience and gave me a better understanding of emergency services in Rome. My nurse mentor explained the flow of their system, common patient complaints, and current medical and nursing interventions. Beyond our discussion of health care issues, we grew to know each other personally. One day she remarked to me, “Tutto il mundo e paese” which means the whole world is but a small village. She was telling me that we may be in different circumstances, or in different countries, but we basically all have the same needs –shelter, food, dignity, and someone who cares for us. We have stayed in touch through e-mails and many of the events that the citizens of Rome have faced over the last year, I feel, I have also faced. This feeling of belonging and continued connection has been the most valuable part of this exchange. Discussions about health care systems, nursing interventions or education practices allowed both Italians and Americans a glimpse into each other’s health care communities. Through our discussions we realized each system had its benefits and shortcomings. Technologically speaking, a number of interventions and practices were similar. Overall we did not feel one system or intervention was better than the other. That was not the point, or purpose, of this exchange. The idea was to broaden our individual perspectives and gain a more global perspective. The exchange was an exceptional graduate experience. As nurses in a world where globalization seems to be making the world a smaller place, it is important that we understand different health care systems, evaluate the differences of our respective philosophies of heath and wellness influenced by different cultures and value systems, and learn from each other’s perspectives. Conclusion To emphasize again, the two key concepts when working as a cross-Atlantic team were communication and flexibility. When faculty were flexible, students seemed to have an easier time adjusting to the process. Feedback from students indicated that once they had adjusted to the Web, they began to feel more comfortable with the process, looked forward to engaging with students from other universities, and began to learn. It was the initial adjustment that was difficult, and it remains the job of local faculty and technicians to assist students in their initial adjustment. References International Council of Nurses. About ICN. [online]. Available from: http://www.icn.ch/abouticn.htm . [Retrieved September 12, 2005]. World Health Organization. About WHO. [online]. Available from: http://www.who.int/about/en/. [Retrieved September 12, 2005].

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Nurse as the Vital Link in Patient Care: Exploring General Nurses’ Views of Their Contribution to Patient Care Authors: Dr Michelle Butler PhD MSc BSc RGN RM, Lecturer Treacy MP, Scott AP, Hyde A, Drennan J, Irving K, Byrne A School of Nursing and Midwifery University College Dublin Belfield Dublin 4 Ireland [email protected] Background: In 2001, a five-year joint programme of nursing research was established between the School of Nursing and Midwifery, UCD and the School of Nursing, DCU, with funding from the Health Research Board. The first part of this research was the development of a Nursing Minimum Data Set which would identify the minimum number of nursing phenomena required to capture most of what nurses do. The aim of this was to make the nursing contribution to patient care explicit, thus making nursing visible. The research began with a review of the nursing literature and the exploration of the nursing contribution to patient care with experienced general and mental health nurses. This paper focuses on a particular theme that emerged in the work with general nurses – that the nurse is the vital link in patient care. Design of study: Focus groups were used to explore nurses’ perceptions of their contribution to patient care. Focus groups lasted about an hour and were conducted by a moderator who was assisted by an assistant moderator. A topic guide was developed around the key areas of interest to ensure a standardised approach across focus groups. Sample selection methods: 59 experienced general nurses participated in eleven focus which were conducted across four hospital sites, three of which were in Dublin. Nurses working in general medical, general surgical, oncology and cardiology specialties were invited to participate and were provided written information on the study and provided written consent to participate. Ethical approval was provided by the medical ethics committee at each site and access to general nurses was sought through Directors of Nursing. Data collection and analysis: Focus group interviews were recorded digitally, transcribed and analysed using the NVivo software package. This content analysis involved reading transcripts to identify emerging themes and then applying codes to segments of text containing these themes. Emerging themes were organised into categories and descriptions built of the themes and the relationships between themes and categories.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Results: Six categories were identified in the data: the nursing contribution to patient care, the context of nursing, assessment, patient problems, nursing interventions, and outcomes. The focus of this paper is on a theme that emerged in relation to perceptions of the nursing contribution to patient care – that the nurse is the vital link in patient care. In relation to this theme, participants described the nature of and the importance of the link role and related this to the particular relationship that nurses have with patients and the continuity that patients have with nurses above and beyond that with other health professionals.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EFFECTIVE INTERVENTIONS TO REDUCE LONELINESS IN OLDER PEOPLE IN IRELAND: THE VIEWS OF PROVIDERS AND PLANNERS Authors: Dr Michelle Butler PhD MSc BSc RGN RM, Lecturer Treacy, MP; Drennan J; Irving K; Byrne A; Frazer K School of Nursing and Midwifery University College Dublin Belfield Dublin 4 Ireland [email protected] Background: This paper reports on one aspect of a study commissioned by the National Council on Ageing and Older People to explore the prevalence and the experience of loneliness and social isolation among older people in Ireland. This aspect explored the views of service planners and providers on effective interventions to deal with loneliness among older people in Ireland. In Ireland, over 11.2 per cent of the population are aged sixty-five years and over and many live alone or with an elderly partner. Research conducted in Ireland and abroad suggests loneliness and social isolation may be part of the experience of old age. Design of study: As a part of a larger study that involved telephone interviews and face-to-face interviews with a large sample of older people, four focus groups were conducted with representatives from statutory and voluntary organisations involved in planning or providing services for older people in two health board 1 areas. Sample selection: Organisations and individuals involved in the planning and delivery of services in two health board regions were identified and invited to participate in the research. Written invitations included an information sheet and a high positive response rate was achieved. Two focus groups involved managers, planners and co-ordinators of services for older people and two involved providers of services for older people. The groups comprised of a range of personnel from a variety of organisations including; statutory, charitable, voluntary and community groups. Data collection and analysis: Separate topic guides for managers and providers discussions were devised by the research team and were informed by current literature on the topic. Each focus group discussion lasted for approximately one and half hours and was tape-recorded and transcribed verbatim. The constant comparative method of analysis was used to identify and categorise themes within the data. Results: The general view amongst focus group participants was that the prevalence of loneliness among older people in the two health board regions is still quite low. This was contrasted however, with a report of a significant increase in calls related to 1

Now Health Service Executive regions.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

loneliness received by the Seniors Helpline. Several factors involved in loneliness were identified, some of which were related to changes within society, and it was suggested that loneliness does not automatically arise out of being socially isolated. A range of currently existing measures that were perceived to be effective in dealing with loneliness was identified, along with a range of additional measures that would be useful. One major theme in relation to the effectiveness of existing measures and additional measures was the need for appropriate and flexible transport, particularly in rural areas, to enable older people to actively engage in social networks.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THE NURSING MINIMUM DATA SET FOR IRELAND: RESULTS OF THE PILOT STUDY Authors: Byrne A.S., Drennan J., Treacy P., Scott P.A., Hyde A., MacNeela P., Butler M., Irving K. Presenter: Anne S Byrne, Research Fellow, MSc, BSc, RGN, School of Nursing and Midwifery, Health Sciences, University College Dublin, Belfield, Dublin 4. Summary: This poster will provide a critical review of the methodological issues that emerged during the piloting of the Irish Nursing Minimum Data Set (I-NMDS) with general nurses. Background: A nursing minimum dataset is a data collection tool designed to identify, describe, and compare essential nursing data across different clinical populations, settings, geographical areas and time (Werley et al., 1991). The I-NMDS was empirically developed from prior qualitative studies and a Delphi survey of general nurses to identify the core elements of nursing care in Ireland. The pilot I-NMDS instrument consisted of specific nursing care items organised into four main categories; patient problems (40 items), interventions (25 items), co-ordination of care activities (8 items) and nursing sensitive outcomes (40 items). The I-NMDS form is designed to capture nursing data for each patient over a maximum period of five in-patient days. Aims: The aims of the pilot study were as follows; i. To establish the usability and validity of the of the I-NMDS instrument ii. To assess some degree of data quality iii. To conduct preliminary statistical analysis on the pilot data Design A multistage approach was adopted consisting of three phases; content validation, cognitive interviewing and pilot testing of the I-NMDS form. Content validation is concerned with the degree to which the instrument measures the concept under investigation (Carter & Porter, 2000). This phase was conducted with academics, nurse managers, ward managers and general nurses. Cognitive interviewing was conducted with a number of nurses to explore respondents’ views on the usability and validity of the instrument. The instrument was amended in view of comments from respondents in preparation for the next pilot stage. The pilot phase was conducted with 38 nurses across four different specialties. The I-NMDS form was completed for 11 patients with data collected for 46 in-patient days. Analysis Qualitative data collected during the piloting process was analysed and the I-NMDS was revised in preparation for a larger scale national validation of the instrument. Statistical analysis was conducted to assess some degree of data quality. In addition, issues relating to the process of implementing a data collection tool in the ward setting were synthesized and a protocol for the validation phase is currently being developed.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Conclusion: Content validation and cognitive interviewing methods used together with a pilot study enhanced the usability and validity of the I-NMDS instrument in preparation for large scale validation. Werley, H et al., (1991). The nursing minimum data set: Abstraction tool for standardised, comparable, essential data. American Journal of Public Health 81: 421426 Carter, D. and Porter, S. (2000). Validity and Reliability. In D. McCormack (ed.) The Research Process in Nursing. Oxford: Blackwell Science.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THIRD YEAR STUDENT NURSES’ PERSPECTIVES OF A SIMULATED WARD EXERCISE Author: Evelyn Byrne RCN, RGN, RNT, MSc. Clinical Skills Co-ordinator. Centre for Nursing and Midwifery Studies, National University of Ireland, Galway. Background Simulation “mirrors” the real word and is a powerful tool in the education of health professionals and in the development of clinical competence. Students “performance in simulated environments is very similar to performance in real practice” (Mole & McLafferty 2004, p.92). However, there have been few studies which have explored students’ perspectives of simulated ward exercises. Design of the Study and Sample Selection A quantitative study using a semi-structured questionnaire was undertaken. The entire population of third year students (n=82) engaged in the general stand of the Bachelor of Nursing Science programme at NUI, Galway was utilised. Method Four exercises were conducted during semester 1, year 3 of the Bachelor of Nursing Science programme over a 2-day period. The duration of each exercise was 1.5-2 hours and involved 20-21 students, 5-6 teaching staff and 5-7 actors ranging in age from 11 years to 65 + years. The sessions were videotaped. Case scenarios were developed based on the 1st and 2nd year content of the curriculum. Lecturers interested in simulation learning were asked to participate as an observer and to select a case scenario of their choice. Before the exercise began, each lecturer discussed the relevant case scenario with the actor and prepared him/her accordingly i.e. secured an intravenous cannula, applied a scalp lesion and simulated blood. Prior to the exercise, the clinical skills co-ordinator discussed with the students their role during the exercise and the rationale for videotaping the exercise (to critically evaluate their performance after the session). At the end of each exercise, the students discussed their performance with the actors in the presence of the lecturer, viewed the video and reflected on their performance. A semi-structured questionnaire was developed to ascertain the students’ perspectives of the extent of which the simulation exercise had contributed to their learning. Content validity was determined by expert feedback prior to undertaking the study. Data Collection and Analysis Questionnaires were distributed to 82, 3rd year students after the exercises. The response rate was 79% (n=65). Quantitative data were analysed using descriptive statistics and qualitative data were categorised into themes. Results Eighty-six percent (n=56) enjoyed the exercise and stated that the simulated environment mirrored the clinical setting 75% (n=49). Students perceived that the client scenarios were realistic 97% (n=63), that the exercises gave them the

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

opportunity to perform a variety of clinical skills 88% (n=57) and that the exercises enhanced their assessment and organisational skills 77% (n=50). Viewing the video was beneficial 86% (n=56) and reflection augmented the students’ learning 91% (n=59). The main themes that emerged were preparation for clinical practice, promotion of self development skills, learning from client’s perspective, and reflecting on performance. References: Mole L. J. & McLafferty I. H. (2004) Evaluating a simulated ward exercise for third year student nurses. Nurse Education in Practice 4, 91-99.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THE BENEFITS OF SIMULATION LEARNING AND THE STEPS INVOLVED IN COORDINATING A SIMULATION EXERCISE FOR STUDENT NURSES Authors:

(Hons),

Evelyn Byrne RCN, SRN, RNT, MSc. Clinical Skills Co-ordinator Centre for Nursing and Midwifery Studies National University of Ireland Galway Siobhan Smyth RPN, Dip. CPN, RNT, PG Dip. CHSE, BNS MSc. Lecturer Centre for Nursing & Midwifery Studies National University of Ireland Galway Abstract

The aim of the poster is to highlight the benefits of simulation learning and the steps involved in co-ordinating a simulation exercise for student nurses. Simulation is a powerful learning tool which promotes the acquisition of professional skills. Most students value the ‘reality’ of a simulated environment. During a simulation exercise, an attempt is made to replicate many of the essential aspects of a clinical situation so that the phenomena which occur will be understood and managed more effectively in the clinical setting. Simulation is not a replacement for clinical experience but a way of bridging the theory and practice gap. Simulation based training has the potential to reduce the occurrence of adverse events (Aggarwal et al., 2004) and enrich everyday clinical practice (Nestel et al., 2003). Perhaps this accounts for its increasing popularity among professionals especially healthcare educationalists. Although simulation has been a part of nursing education since the 1950s (Peteani 2004), its use in nursing education in Ireland is in its infancy. Skills laboratories are an ideal environment for simulation sessions. Simulated ‘clients’ contribute greatly to students’ learning especially when they provide feedback on the impact of their nursing skills and their interactions during simulation sessions. Feedback is an essential component of the learning process which can be obtained by videotape, through lecturer and peers in addition to simulated ‘clients’. Self-feedback enables students to identify strengths and weaknesses and facilitates self-directed learning. The factors that need to be considered when developing a simulation session encompass the following: write case scenarios based on students’ level of education and clinical experience; recruit and brief actors and lecturers; brief students; identify and order consumables; prepare the setting; and organise technical support. References:

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Aggarwal R., Undre S., Moorthy K., Vincent C. and Darzi A. (2004) The simulated operating theatre: comprehensive training for surgical teams. Qual Saf Health Care 13, i27- i32. Nestel D., Kneebone R., and Kidd J. (2003) Teaching and learning about skills in minor surgery. Journal of Clinical Nursing 12(2), 291-296. Peteani L.A. (2004) Enhancing clinical practice and education with high-fidelity human patient simulators. Nurse Educator 29 (1), 25-30.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Contribution of NHS Direct to the Quality of Care and its Impact on Health Services in Hertfordshire and Bedfordshire Authors Dr Geraldine Byrne Ph.D, RNT, PGCE, BA (Hons), RN, Principal Lecturer, School of Nursing and Midwifery, University of Hertfordshire, College Lane, Hatfield, Hertfordshire, AL10 9AB. Tel: UK01707 285286, Fax: UK 01707 285995, E-mail: [email protected] Janice Morgan, M.Sc., B.Sc.Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Professor Sally Kendall, Ph.D. B.Sc. RN, RHV, CRIPACC, University of Hertfordshire, Debbie Saberi, B.Sc., RN. NHS Direct Background In recent years there has been an increase in the use of telephone consultation and triage; the process where calls from people with a health care problem, are received, assessed and managed by giving advice or by referral to a more appropriate service. This has, in general, been used to assist provision of out of hours care, manage demand for care, or provide an additional source of help to callers. One impetus for the development of telephone consultation has been to reduce the burden on GPs (General Practitioners) and A&E (Accident and Emergency) departments. A&E attendances in the UK have increased (Audit Commission, 2000), as has the demand for the service of GPs, although it has been estimated that more than half of out-ofhours calls could be handled by telephone advice alone (Christensen and Olesen, 1998; Dale and Crouch, 1998) Other driving forces towards telephone consultation have been the emphasis on increasing the accessibility of health services, improving patient experience and using technology more effectively to enhance patient care (DOH, 2002). To date relatively little information exists on whether telephone consultation reduces pressure on other services. In Denmark demand for home visits fell by 28% after the introduction of telephone consultation by doctors (Christiansen and Olafsen, 1998). A systematic review of telephone consultation and triage on health care use and patient satisfaction (Bunn et al, 2004) found that telephone consultation and triage can reduce GP workload and appear to be safe. Overall there was not an increase in the use of other services and patients were satisfied with the help they received. However, data on factors such as cost and adverse effects was limited with few studies reporting these outcomes Although some telephone consultation is done by doctors (Christensen and Olesen, 1998), much is now done by qualified nurses using computer based clinical decision support systems. This reflects changes in the role of the nurse in recent years and the move towards some nurses taking on roles previously undertaken by doctors. One of the largest telephone consultations in operation is NHS Direct in the UK. This is a 24 hour nurse-led telephone advice system, based in England, which aims to help callers to self-manage problems and reduce unnecessary demands on other National Health Service (NHS) provision (Munroe et al, 2000)

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

NHS Direct was established in 1997 part of the modernisation of the National Health Service with the purpose of achieving the following objectives: •

To offer the public a confidential, reliable and consistent source of health care 24 hours a day so they can manage many of their problems at home or know where to turn to for appropriate care.

•

To provide simple and speedy access to a comprehensive and up-to-date range of health and related information.

•

To help improve the quality, increase cost-effectiveness and reduce unnecessary demands on other NHS Services by providing a more appropriate response to the needs of the public.

•

To allow professionals to develop their role in enabling patients to be partners in self-care and help them to focus on those patients for whom their skills are most needed.

Much of the literature about NHS Direct is based on commentary rather than empirical evidence and there has been much professional debate about its value, with doctors in particular being sceptical about its value (Hayes, 2000; BMA, 2005). Caller satisfaction, however, has been found to be high (O’Caithan, et al., 2000) with the majority of callers (95%) reporting that they found the advice very or quite helpful and most (85%) reporting that they had followed the advice given. Pearce and Rosen (2000), who conducted an interview based study of health professionals and users involved in the implementation of NHS Direct in London, suggested that perhaps the most important issue of quality is the clinical outcome for each patient-nurse interaction. A second important issue is whether or not callers follow through on their pre-intention and the impact this has on service use. To date neither of these has been formally investigated. The present study therefore aimed to investigate quality by examining patient outcomes, behaviour and experiences for callers to NHS Direct and patients who attended a GP or A&E. Aims The overall aim of the present study was to evaluate the contribution of NHS Direct to the quality of health care and its impact on services within the Hertfordshire and Bedfordshire area. Objectives • To compare service use and patient outcomes of NHS Direct callers and controls attending GPs or A&E (matched by symptom group and perceived severity) • To compare NHS Direct callers recommended and actual service use • To explore the patient’s experience of their episode of care. Design A comparative survey of callers to NHS Direct, and similar patients independently attending either a GP or A&E department, with symptoms of either, (1) cough and/or sore throat OR (2) abdominal pain.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Methods Postal survey of patients Analysis of patient records Qualitative interviews Sampling The study involved 1 NHS Direct site 4 A&E departments 6 GP Practices Over a one year period each site was visited on four occasions and questionnaires sent to all callers or patients who had used the service in the previous three weeks who met the inclusion criteria. Inclusion criteria Patients who complained of cough and/or sore throat Patients who complained of abdominal pain. Exclusion criteria People with known malignant disease Children aged under one year A sample of 15 – 20 people who had used each service were purposively selected to participate in qualitative semi-structured interviews Procedure All patients who met the inclusion criteria at the time of data collection were sent a semi-structured questionnaire, together with a letter explaining the study and a consent form. A total of 3024 questionnaires were distributed (NHS Direct, n = 1119; A&E, n = 1168; GP, n = 737). 886 questionnaires were returned (NHS Direct, n = 278; A&E, n = 331, GP, n = 277) giving a response rate of approximately 30%. Respondents were asked if they were willing to be interviewed and of those who indicated willingness X were interviewed (NHS Direct, n = 23; A&E, n = 16; GP, n = 22) the interviews were conducted in the respondents home and were tape recorded. Thematic analysis (Silverman, 2001) was used to explore patients’ experiences of using the services Results This is a large-scale study currently in progress. Data input and analysis is currently taking place. This presentation focuses on the pathway of care and patient outcome for callers to NHS Direct who were referred to another health service. Initial findings suggest that most callers to NHS Direct who are referred to A&E or to a GP received one or more interventions, such as an investigation, a prescription or admission to hospital, which appeared to justify the referral. Of the 268 NHS Direct callers, 193 72% were referred to A&E or a GP. Of the 49 referred to A&E, 47 (96%) received one or more interventions. Of the 144 referred to a GP, 106 (74%) received one or

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

more interventions. Most callers who were advised to self-care did not require any further intervention, although 14 (20%) were given a prescription for antibiotics and one was admitted to hospital. Qualitative data illuminates the uncertainty that NHS Direct callers experienced about their health, and their fear that their condition might deteriorate if they did not get health care. The majority of callers appreciated the reassurance and advice they were given by NHS Direct, especially at night when access to other services was restricted. Conclusions Almost all callers to NHS Direct who were referred to A&E or a GP received a further intervention which appeared to justify the referral. Most of those advised to self-care did not require any further intervention, although a minority were did receive a prescription. The qualitative data suggested that callers found the service useful and appreciated the reassurance they were given and guidance about how to look after themselves. Further analysis is needed to compare those referred by NHS Direct to A&E or a GP with those attending directly, to explore if NHS Direct is successful in promoting self-care and to investigate whether callers follow the advice they are given. References Audit Commission (2000) Review of National Findings Accident and Emergency. London: The Audit Commission. Bunn, F., Byrne, G.S. and Kendall, S (2004) Telephone consultation and triage systems: effects on health care use and patient satisfaction (Cochrane Review): In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd Christensen, M. and Olensen, F. (1998) Out of hours service in Denmark; evaluation five years after reform. BMJ, 316, 1502 05. Dale, J. and Crouch, R. (1998) Primary care: nurse-led telephone triage and advice out of hours. Nursing Standard, 12, 47, 41 - 45. Department of Health (2002) The NHS Plan. London: Department of Health. Hayes, D. (2000) The Case Against NHS Direct. Doctor, 13, 36 -39. Munroe, J. Nicholl, J., O’Caithan, A., Knowles, E. (2000) Evaluation of NHS Direct First Wave Sites Second Interim Report to the Department of Health. Medical Care Research Unit. University of Sheffield. O.Caithan, A., Munroe, J.F., Nicholl, J.P., Knowles, E. (2000) How helpful is NHS Direct? Postal survey of callers. BMJ, 2000, 320, 1035. Pearce, K. and Rosen, (2000) NHS Direct: Learning from the London Experience. London: Kings Fund. Silverman, D. (2001) Interpreting Qualitative Data; analysing talk, text and interaction. London: Sage.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

E- LEARNING- EVALUATING STUDENTS VIEWS OF A COMBINED ELEARNING AND CLASSROOM LEARNING MODULE ON PRIMARY HEALTHCARE AND HEALTH PROMOTION Gobnait Byrne RGN, BNS (Hons), RNT, MPH, PG Dip Stats. Lecturer in Nursing School of Nursing & Midwifery Studies University of Dublin, Trinity College Dublin 2 Ireland 00 353 1 6083106 [email protected] Rationale: Third level institutions are providing more online learning programmes as they are attractive to potential students due to their accessibility and flexibility (Kearns, Shoaf, & Summey 2004). McGuinness and Noonan (2004) differentiate between web-based, where the content is completely conveyed online and “web-enhanced” where classroom teaching is supported by access to online resources. The module which the author will discuss is a combination of webct and classroom contact with the majority of teaching being delivered online. Web based programmes are time consuming to develop and require enormous technical help and support. It is important to evaluate students’ views of this module in order to ascertain if this module met their learning needs. Evaluation is further required also to both maintain and attract future students registering on this programme and to support the expansion of other web based programmes within the School of Nursing and Midwifery Studies. Previous educationalists have compared web based with traditional programmes and reported higher satisfaction with the former (Anderson and Mercer 2004; Kearns, Shoaf, & Summey 2004). This programme is unique as it is an undergraduate programme marketed at registered nurses/ midwifes with no previous academic experience. The aim of this module is to enhance student’s understanding of health promotion and primary healthcare and to explore the role of the nurse/ midwife in health promotion. This presents a challenge as nurses from a variety of clinical backgrounds undertake this module and thus a large amount of online resources is required to meet the diverse learning needs of this group. Aim: To evaluate the students views of this webct module and to recommend future changes for this module. Design & Sampling: Evaluative Research Design and Census sampling was utlised. Data collection: Study specific semi-structured questionnaires were employed to evaluate students’ views of this module. The ethical issues in relation to human research were respected. Data was analysed using descriptive statistics. Findings: Students reported a high level of satisfaction with this module. Some respondents reported that there were an excessive number of online resources while other students requested more resources specific to their speciality. Further research

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

is required to ascertain if webct promotes more active learning than classroom teaching. References Anderson, E.T. & Mercer, Z.B. (2004) Impact of Community Health Content on Nurse Practitioner Practice: A comparison of Classroom and Wewb-Based Teaching. Nursing Education Perspectives 25 (4) 171- 175. Kearns, L. E., Shoaf, J.R. & Summey, M.B. (2004) Performance and Satisfaction of Second-Degree BSN Students in Web-Based and Traditional Course Delivery environments. Journal of Nursing Education 43 (6) 280- 284. McGuinness, T.M. & Hoonan, P. (2004) Top 10 Reasons to take your Graduate Program in Psychiatric Nursing online. Journal of Psychosocial Nursing & Mental Health Services 42 (12) 33- 38.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EVALUATION OF GROUP SUPERVISION FROM THE STUDENTS’ PERSPECTIVE Gobnait Byrne RGN, BNS (Hons), RNT, MPH Lecturer in Nursing School of Nursing & Midwifery Studies University of Dublin, Trinity College Dublin 2 Ireland 00 353 1 6083105 [email protected] Co-Authors: Catherine McCabe, Elizabeth Fahey-Mc McCarthy, Margarita Corry, Michelle Glacken, Caitriona Macgregor, & Audrey Adams Lecturers in Nursing School of Nursing & Midwifery Studies University of Dublin, Trinity College Dublin 2 Ireland 00 353 1 6082692 Rationale: Third level institutions often support students undertaking literature reviews and proposals in the traditional one-to-one approach to research supervision. However, as the number of nursing students requiring supervision has begun to out number the number of persons with the relevant experience and skill to supervise small-scale research projects group supervision may provide the necessary support. Group supervision involves one person guiding a group of students that are conducting research on a similar topic area (Marland & Little, 2003). The importance of the groups being well structured, organised, facilitated and with established, transparent ground rules is fundamental to the success of any group process for students regardless of the student’s academic level (Parry et al 1997; Martand & Little 2003). At postgraduate level Parry et al (1997) found that the group approach provided a mutually supportive environment that resulted in problems and solutions being shared, it protected against feelings of isolation and loneliness and meant that students did not become frustrated or anxious as a result of minimal contact with their supervisors The sample for Parry et al’s study included graduate students at PhD level so the relevance of these findings at under-graduate level is questionable. As group supervision has not been subjected to widespread empirical investigation it is important that the process is evaluated in order to determine its suitability as a means of providing support to novice researchers. Aim: To evaluate the students views of group supervision of a literature review assignment. Design: Evaluative Research Design

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Sampling/sample: Census sampling was employed with all students who have had group supervision. Data collection: Study specific semi-structured questionnaires were employed to evaluate the efficacy of the supervision process. The ethical issues in relation to human research were respected. Data analysis: Analyzed using SPSS and via thematic analysis. Findings: Group supervision emerged as an effective means of supporting students with their research assignment. The findings from each year led to changes being instigated in each subsequent year in order to make the process acceptable from both students’ and supervisors’ perspectives. Group supervision has emerged as a model of supervision worthy of use. Reference Martland, G.R. & Little, C.P. (2003) Research Supervision Nursing Standard 17 (25) 33- 37 Parry, O., Atkinson, P. & Delamont, S. (1997) Research Note: The structure of PhD Research Sociology 31 (1) 121- 129.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

PROFESSIONAL DEVELOPMENT PROGRAMME CRITICAL CARE NURSING FOR LETTERKENNY GENERAL HOSPITAL Catherine Cannon, Specialist Coordinator. RGN, SCM, CCU, Infection Control Certificate, BA (Hons) Health Care Management. Address; Centre for Nursing and Midwifery Education Letterkenny Co Donegal Anne Flood MSc, BSc (Hons),RGN Address Centre for Nursing and Midwifery Education Letterkenny Co Donegal The Clinical Nurse Managers within the Intensive Care Unit identified a need for new entrants to the critical care setting to receive structured training and education to enable them to practice in this setting at an independent level. A working group was formed to address the issues. It was generally accepted within the group that a course at graduate or post graduate level did not fulfil this specific need. It was therefore recommended that a short course run locally and taught by clinical experts was more appropriate at this level. This type of training would be referred to as a professional development programme and be incorporated into the individual professional development plan or orientation. Walker (2001) describes the approval of short skillsbased training programmes in the UK by the ENB as a move to meet the needs of nurses working in acute care settings. The duration of course was six months from Sept 2004-March 2005. Eleven nurses completed the course successfully from the critical care areas within the hospital. The course content was theoretically and clinically based and reflected the varying themes specific to the critical care area. Saggs (2003) agrees that work-based learning should be a central component of continuing education in critical care. It was agreed and ratified that a clinical educator was essential to this programme. Williamson and Webb (2001) state that these types of roles were introduced to bridge the theory practice gap and recognise their value. Assessment was divided into three areas; (a) A correlation written assignment, (b) A ten-minute presentation on an aspect of their written assignment and (c) Clinical competencies. The working group established an evaluation process that enabled each unit of learning to be formally evaluated. Current success rates were 60 – 80% with participants expressing extremely positive outcomes in their course evaluation responses. Senior managers in the Critical Care department expressed satisfaction and positive views regarding the service needs of the critical care area. This course is now in the process of being accredited by the Letterkenny Institute of Technology, and it is hoped that it will be referenced at a Level Eight within the National Framework of Qualifications. In summary the programme is aimed at the novice or new beginner within the critical care environment, (Benner, 1984) who does not necessarily wish to or is not sufficiently experienced to enter the CNS/ANP career pathway but wishes to gain the knowledge and skills to become a competent practitioner. It is envisaged that on completion of this course the nurse may progress onto the Graduate Diploma Programme if they wish to.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Benner, P. (1984) From Novice To Expert: Excellence and Power in Clinical Nursing Practice, Menlo Park: Addison-Wesley Saggs, P. (2003) Developing postgraduate awards for critical care. Nurse Education Today. 23 307-311 Walker, W. (2001) Comprehensive critical care education is critical to success. Intensive and Critical Care Nursing. 17 237-241 Williamson, G.; Webb (2001) Supporting students in practice. Journal of Clinical Nursing.10 : 284-292

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

WHAT ARE THE PERCEIVED CONTINUING EDUCATION NEEDS OF NURSES WORKING IN RESIDENTIAL SERVICES FOR OLDER PERSONS IN THE NORTH EASTERN HEALTH BOARD? Mary Cannon Strategy Implementation Officer RGN, MSC in Health Service Management Mary Cannon 45, College Rise, Dunshaughlin Co. Meath Continuing education has become a major topic for discussions amongst nurses, across Ireland, working in services for the older person. The Commission on Nursing highlighted the need to strengthen the availability of professional development for all nurses and midwives (Government of Ireland, 1998). They also identified Care of the Elderly as a key area for development in nursing. The aim of this study was to identify the perceived educational needs of nurses working in residential care for the older person across the North Eastern Health Board. The quantitative research design was used, with self administered questionnaires distributed to 320 nurses currently employed in nursing older people in residential settings. A response rate of 59% was achieved. The majority of the respondents (52%) had been working in care of the older person in excess of 10 years, with most of the nurses having completed their basic qualification in nursing over 15 years ago. This has great relevance for the planning of future continuous professional education (C.P.E.). The reason for attending future CPE was identified and would concur with the findings in the literature review. This study showed that relevance of the course, meeting the clients’ needs, and time off to attend were the major factors influencing attendance at continuing education events. Staff shortages, lack of time off, and inaccessibility of courses were also seen as factors discouraging attendance at CPE. In conclusion this study recommends the need for education and training relevant to the specific needs of the older person, with programmes tailored to the needs of nurses based on the principles of adult learning.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

FAMILY-CENTRED CARE –A CONCEPT ANALYSIS Authors: Mrs PBM Cardwell Staff Nurse RN, RN (Children’s), BSc. Ward 3 North, Craigavon Area Hospital, 68 Lurgan Road, Portadown. Co. Armagh. BT63 5QQ Mrs MA Smith, Lecturer, RN, RM, MTD, BA, MSc. School of Nursing, Faculty of Life and Health Science, University of Ulster, Newtownabbey. Co Antrim. BT37 0QB. Abstract: Family-centred care has long been espoused as the philosophical paradigm underpinning paediatric nursing care. This thinking is continually evolving, changes recurring include: use of terminology and shifts in partnership configuration, which may contribute to the ambiguity surrounding the concept. To date no definitive definition of the concept is universally accepted. A concept analysis of family-centred care, utilising the Wilson framework (1969, cited by Walker and Avant, 1988) and the development and explication of the concept will be presented. The aim of the analysis is to consider how the attributes of family centred care contributes to and informs children’s health care delivery in the twenty first century. The examination of relevant literature and studies into family-centred care, are utilised to inform the development of the concept, identifying defining attributes, antecedents, consequences and empirical referents. Findings indicate that defining attributes include: family involvement in care provision, negotiation in care planning, equality in care provision, informed participation and preservation of family routine. Antecedents are identified as interpersonal relationships and respect. Communication is integral to these processes. Consequences, include the recognition of the uniqueness and individuality of both the child and family and their expectations of how healthcare delivery systems impact on family-centred care. Nursing care tailored to meeting the needs of the individual child and family: must preserve the integrity of the family unit; reduce the child’s anxiety; promote parental empowerment and the development of coping strategies. The

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

literature further indicates that nurse education must address the acquisition of competencies in information giving and the skills to negotiate with and empower parents. In reference to family centred care these characteristics have been identified as empirical referents. Considerations of these findings and their implications for advancing professional practice are at the core of developing a conceptual model of family centred care that remains useful, applicable and effective. In conclusion, the literature reveals that methods employed to research the concept were highly biased towards the views of mothers. Research is required to expand the professional knowledge base by eliciting the views of other family members and professional care givers. REFERENCES Walker, L.O., Avant, K.C. (1988) Strategies for Theory Construction In Nursing, (2nd Ed.), Norwalk, Appleton and Lange.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

DEVELOPING THE QUALITY OF POSTGRADUATE NURSE EDUCATION THROUGH AN EVALUATION OF THE IMPACT OF THE GRADUATE DIPLOMA IN NURSING UPON THE NURSING PRACTICE OF ITS GRADUATES. Cliona Carey BA (Hons), MPsychSc. Research Associate School of Nursing Dublin City University Collins Avenue Dublin 9 This study explored the impact of the graduate diploma in nursing on the practices of its of graduates. A total of 18 graduates and 11 managers from five different pathways (Child and Adolescent Mental Health, Addiction, Mental Health of Older People, Renal and Urology) completed a 36-item questionnaire, based on the learning outcomes of the Graduate Diploma. Questionnaires were followed up with semistructured qualitative interviews (n = 7, graduates, n = 4 mangers) which set out to evaluate the impact of the programme on the quality of individual care and nursing practice, career and professional development, relationships with colleagues and the relevance of the programme to everyday work in the specialist area. Preliminary analyses of the questionnaire responses revealed a high level of agreement among graduates and mangers with regard to the relevance of the graduate diploma to their work, the impact of the programme on clinical practice and the influence of the programme on the career and personal development of the graduates. Thematic analyses of the interview data revealed mixed attitudes regarding the relevance of the programme to clinical practice. The programme mainly impacted on others through increasing the communication skills of the students and in increasing the knowledge base of the students such that there was a higher level of dissemination of learned skills and information among the health care team. There were mainly subtle improvements to the quality of care and practices of the graduates. On the positive side, it was felt that the programme increased nurses’ interest in the rights of service users. On the other hand, many felt that there was no visible impact on the quality of care and that changes were, for the most part, subtle and immeasurable. The three main themes that emerged in the area of career and personal rewards include, barriers to career development, job satisfaction and change in professional role. Those who noted barriers to career development highlighted that there was currently a lack of opportunities or managerial oppositions to change. These findings are discussed and some implications are proposed for improving the impact of the programme.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Processes in Action: Description and analysis of processes used to implement person centred planning in a residential centre Ms Eileen Carey MSc. Advanced Nursing Studies, BSc. Nursing Studies, RNT, RMHN, PG Dip. in Education, Dip. Child Psycholog Lecturer Department of Nursing & Midwifery Health Sciences Building College of Science University of Limerick Castletroy Limerick Ireland This study described and analysed processes used to implement a person-centred approach to care devised by staff in a residential service in the Mid-Western region of Ireland. The degree to which the spiritual needs of the person are realised was also examined. The research design was mainly quantitative informed by a qualitative component. From a population of 250 the defined sampling frame was N=168 health care employees. A focus group interview and a pilot study enabled the adaptation of an instrument devised by Holburn et al (2000) and development of the Indicators of Processes of Person-Centred Planning Scale (IPPCPS). The final draft of the IPPCPS was distributed to N=147 health care employees. The findings demonstrate core systematic processes, which are conducive to person-centred planning are operating in the residential centre. Systematic processes are in place to meet some of the spiritual needs of the service user. However, this study found a substantial lack of consideration for identifying the preferences and perspectives of the service user in relation to quality of life issues. This residential centre is challenged to move beyond the traditional approach to care of ‘protection’ and ‘mothering’ and to develop good practice guidelines ensuring person-centred care. In providing a holistic approach to care, staff must move beyond the care plan and understand the service user in the context of living.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

GETTING APPRECIATIVE INSTEAD OF PROBLEMATIC: THE POTENTIAL OF USING APPRECIATIVE INQUIRY TO AFFIRMATIVELY RESEARCH AND TRANSFORM PRACTICE Dr Bernie Carter PhD, PGCE, PGCE, BSc, RSCN, SRN Professor of Children’s Nursing Department of Nursing University of Central Lancashire Preston, Lancashire PR1 2HE United Kingdom [email protected] Appreciative Inquiry (AI) has been widely used in organisational change and change management and also as research methodology in a range of complex settings such as health care Reed et al. (2002) and the prison system Liebling et al. (1999). AI is based on the 4-D cycle which consists of four phases – discovery (the best of what is or has been), dreaming (what might be), designing (what should be) and destiny (what will be). Whilst AI’s roots clearly lie in action research the move from problemorientation to an appreciative stance results in a greater transformational potential. AI takes a relational constructionist view that is grounded in affirmation, appreciation and dialogue Cooperrider & Whitney, 1999. Many existing research approaches require the researcher to identify a research problem and then to design a project that will allow the researcher to come up with an ‘answer’. AI moves away from such a problem-oriented approach Hammond (1998) where researchers aim to uncover/discover/identify (1) ‘what’s wrong’ and (2) ‘how to fix it’. AI is based on generative rather than degenerative dialogue. It focuses on dialogue that celebrates and appreciates what is working, dialogue that draws on the resources, assets, successes and achievements occurring within an organisation or setting. Whilst retaining a critical stance about using AI as an approach to re-frame research we have found that its basis in affirmation and appreciation has created opportunities for our participants to share their successes, celebrate their achievements and critically reflect on what is working. It has fostered an atmosphere that is supportive and collaborative. It has helped create an understanding that each participant is one ‘expert among many.’ We have now used AI within three studies focusing on: (1) multi-agency working practices with children with complex needs; (2) developing services for young people requiring mental health services; and (3) the experiences of parents of children with myalgic encephalopathy. Using AI is more than just dropping the problem-orientation. It is literally a case of having to adopt or acquire a new mindset. This paper will explore some of the experiences of using AI and our conclusions about it as a research approach. References Cooperrider, D. L., Whitney, D. (1999). Appreciative Inquiry: A positive revolution in change. In Holman, P., Devane, T. (Eds.), The change handbook: Group methods for shaping the future. San Francisco, CA: Berrett-Koehler Publishers, Inc. Hammond, S.A. (1998) The Thin Book of Appreciative Inquiry. [2 ed]. Thin Book Publishing Co.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Liebling, A., Price, D., & Elliott, C. (1999) Appreciative inquiry and relationships in prison. Punishment & Society. 1(1):71-98. Reed, J., Pearson, P., Douglas, B., Swinburne, S. & Wilding, H. (2002) Going home from hospital – an appreciative inquiry study. Health and Social Care n the Community. 10(1): 36-45.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

TEACHING HEALTH PROMOTING SKILLS TO HOSPITAL BASED NURSES Dympna Casey RGN, BA, MA Lecturer Centre for Nursing Studies IDA Business Park NUI Galway Ireland Health promotion is defined as “… the process of enabling people to increase control over and to improve their health” (WHO 1986 p 5). Within nursing health promotion is considered the remit of every nurse yet many studies indicate that hospital based nurses in particular seem reluctant to take on this role. One of the main barriers identified in the literature is that nurses lack the training and skills to confidently engage in health promoting nursing practice (Twinn and Diana 1997, Gomm et al 2002, Locke et al 2002, Chiverton et al 2003). In an effort to overcome this limitation following a review of the literature an innovative method of teaching health promoting skills to nurses was developed. An examination of the literature revealed that the stages of change model incorporating motivational interviewing could be an appropriate approach for nurses to use in their day-to-day practice to promote health. Motivational interviewing (MI) is a “client centred, directive, method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller and Rollinick 2002, p25). Miller also suggested that MI is best understood within the context of a model of behaviour change and he suggested the use of Prochaska and DiClemente’s transtheoretical model of behaviour change. This model incorporating motivational interviewing formed the theoretical basis for a skills training workshop delivered to nurses working in an acute setting. This paper describes the literature, which led to the development of the skills training workshop and the format and content of the workshop. References World Health Organisation (1986) Ottawa Charter for Health promotion: An International conference on health promotion. Copenhagen: World Health organisaiton Regional Office for Europe. Twinn, S. & Diana, L. (1997) The practice of health education in acute care settings in Hong Kong: and exploratory study of the contribution of registered nurses. Journal of Advanced Nursing. 25(1), p178-185. Gomm, M., Lincoln, P. England, P. & Rosenberg, M. (2002) Helping hospitalised clients quit smoking: a study of rural nursing practice and barriers. American Journal of Rural Health. 10, p26-32.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Locke, C. Kaner, E. Lamount, S. & Bond, S. (2002) A qualitative study of nurses’ attitudes and practices regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing 39(4), p333-342. Chiverton, PA. McCabe Votava, K. & Tortoretti, D.M. (2003) The Future Role of Nursing in Health Promotion. American Journal of Health Promotion. 18(2), p192194. Miller, WR. & Rollick, S. (2002). Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guilford.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

“Not many other people are going to have this experience… it’s just something so unique, especially for nursing”: service learning in undergraduate nursing education Dympna Casey (RGN, BA, MA), Lecturer, Centre for Nursing Studies, NUI, Galway Kathy Murphy, (PhD, MSc, BA, RN, RNT), Head of Nursing, Centre for Nursing Studies, NUI, Galway Irish nurses are increasingly coming in contact with and caring for clients from diverse cultural backgrounds. It is imperative therefore to develop nurses’ global understanding of international health services and structures to prepare nurses for leadership roles in national and international arenas (Grant and Mckenna 2003). In brief students should to be given the opportunity to “…‘see the big picture’ and …broaden their worldview and recognise the importance of global issues including the impact that their practices, beliefs and values have on the care they provide” (Leh et al 2004, p86). One method of promoting a global perspective and encouraging cultural sensitivity is to provide student with the opportunity to work with culturally diverse populations between and within national borders (Koskinen and Tossavainen 2003). This can be achieved through the innovative process of service learning. Service learning connects academic study to community service (Olsan et al 2004). It is a powerful teaching strategy that enables students to make meaningful connections between classroom theory and real life experiences (Callister and Hobbins-Garbett 2000). This paper firstly describes the development of a module offered to second year Bachelor of Nursing Science degree students, which incorporates a service-learning placement in a different cultural context. Secondly the findings from a small qualitative study, which explored students’ experiences of service learning, will be presented. References Grant, E. and McKenna, L. (2003) International clinical placement for undergraduate students. Journal of Clinical Nursing. 12(4), p529-35. Leh, S., Waldspurger, R., Wendy, J. and Albin, B. (2004) The student/faculty international exchange: responding to the challenge of developing a global perspective in nursing education. National League for Nursing 25(2), p86-90. Koskinen, L., and Tossavainen, K. ( 2003) Relationships with undergraduate nursing exchange students-a tutors perspective. Journal of Advanced Nursing. 41(5), p499508. Olsan, T, Forbes, R, Macwilliam, G, Norwood, W, Reifsteck, M, Trosin, B, and Weber, M. Strengthening nurses political identify through service learning partnerships in education. Journal of the New York State Nurses Association 34 (2), p16-21.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Callister, L. and Hobbins-Garbett, D. (2000) “Enter to learn, go forth to serve”: Service learning in nursing education. Journal of Professional Nursing 16, P177-183.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

OUTCOMES OF CHILD CARE HEALTH CONSULTATION IN NEW JERSEY 1. Jane Cerruti Dellert, PhD, RN, CPNP Assistant Professor Department of Family and Community Nursing College of Nursing Seton Hall University 400 South Orange Avenue South Orange, New Jersey USA 07079 [email protected] 2. Denise Gasalberti, PhD, RN Assistant Professor Department of Family and Community Nursing College of Nursing Seton Hall University 400 South Orange Avenue South Orange, New Jersey USA 07079 [email protected] 3. Kathleen Sternas, PhD, RN Associate Professor Department of Family and Community Nursing College of Nursing Seton Hall University 400 South Orange Avenue South Orange, New Jersey USA 07079 [email protected] 4. Patricia Lucarelli, MSN, RN, CPNP, APN-BC, CCHCC Child Care Health Consultant Coordinator Child Care Resources 3301C State Route 66, P.O. Box 1234 Neptune, NJ 07754-1234 [email protected] 5. Judith Hall, MS, RN,CS Public Health Consultant I, Nursing and Healthy Child Care NJ, Project Director New Jersey Department of Health and Senior Services Division of Family health Services, Child Health Program P.O. Box 364 Trenton, NJ 08625-0364 [email protected] The Problem Child Care Health Consultation is a service available to child care providers and the children and families they serve. In New Jersey, these services are coordinated by

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Registered Nurses. The focus of the service is technical assistance to and education of the child care community in matters related to child health and safety. This consultation is available to all regulated child care providers in New Jersey, and may include on-site visits, telephone consultation, providing educational seminars, making referrals to community health and social service resources, assistance with policy development and addressing issues related to children with special needs. Data was gathered from child care providers relative to their experience with Child Care Health Consultation services in Part I of this study, and parental perceptions and direct experiences with child care health consultation services were surveyed in Part II. Purpose and Significance The purpose of these studies was to obtain insights into perceptions of Child Care Health Consultation services in order to learn how to best serve children in child care. Health and safety are important quality indicators for child care. Child care health consultants are proposed to be effective providers of services to improve health and safety of children in child care (Alkon, Farrer & Bernzweig 2004; Alkon, SokalGutierrez & Wolff, 2002; American Academy of Pediatrics 2002; Crowley 1990; Cryer & Phillipsen 1997; Fenichel, Griffin & Lurie-Hurvitz n.d.; Gaines et al. 2004; Lucarelli 2002; Ulione & Crowley 1997). Because responsibility for children rests mainly with the parents, and parents are concerned with health and safety of their children in child care, it is important to understand parents’ views on child care health consultation. Because child care providers stand in locus parentis and responsible for children’s health and safety, the effective delivery of health consultation services has the potential for significant impact on the child care environment and beyond. Methods After approval by the Institutional Review Board at Seton Hall University, a two-part research series was initiated. A descriptive cross-sectional study of child care providers’ perceptions regarding health consultation services by registered nurses was Part I. Data were collected from child care providers by a mailed questionnaire and by telephone interview, after separate consents for each. Questionnaires were mailed to 868 child care sites, and returned by 60 respondents. Of those, 20 completed telephone interviews. For Part II, a second descriptive cross-sectional study of parents of children in child care was designed. Willing parent participants were asked to complete a short questionnaire and return it to a sealed box at participating child care centers. Boxes were returned by the child care providers by mail to the researchers at Seton Hall University. Findings: Part I – Child care providers’ perceptions In general, the respondents reported familiarity with various child care health consultation services, ranging from 12% for direct health services to children to 87% for telephone consultation and child care provider training. Perceptions of child care health consultation services provided by registered nurses in New Jersey were positive overall, as 87% would use child care health consultation services again. Positive and significant correlations were found among the variables usefulness of services, satisfaction with services, changes at the child care site, and improvement in staff caregiving. Regression analysis showed that perceived usefulness of child care

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

health consultation services predicts child care center changes and improvement in staff caregiving as well as child care provider satisfaction with services. Telephone interviews were offered as an additional confidential option to questionnaire respondents to provide for direct contact and an opportunity to expand on responses to the questionnaire. The results were analyzed by the constant comparative method by two investigators working separately, and then the results compared. Overall, there was nearly 100% agreement between the investigators. Interviewees reported varied locations and titles for their local child care health consultant, with many nurses incorporating child care health consultation into other existing job responsibilities. While the overall opinion of nurses doing child care health consultation was very positive, those who had more negative experiences identified lack of accessibility and dependability and lack of knowledge as areas of concern. Interviewees liked the idea of regularly scheduled visits by a child care health consultant, but emphasized that having someone “on call” was especially important to them. The interviewees’ opinions varied on the issue of paying for child care health consultation, but among those willing to consider paying for the services (75%), suggested fees ranged from $5 for a class up to $100-200 per hour for consultation. Findings: Part II – Parental perceptions Approximately 84.29% of parents surveyed indicated that they did not receive direct service from a Child Care Health Consultant. Parents indicated that a nurse with a Bachelor of Science degree in Nursing was the preferred educational level for the Child Care Health Consultant, that services related to health, dental, and child developmental screenings were the most beneficial services. Parents (62%) indicated a willingness to pay for the services, suggesting the amount of five dollars ($5.00) per month. It is encouraging that parents indicated a willingness to pay for services, as child care providers have expressed concern that paying for child care health consultation services would drive parents away from their child care sites. Implications for Nursing Potential implications for nursing practice include issues related to the delivery and promotion of Child Care Health Consultation services. Matching services to the needs of the child care community could be improved by periodic surveys in each county to determine the interests and needs of child care providers for health-related services. Tailoring the services offered to the needs of the local child care community can enhance utilization of child care health consultant services, resulting in meaningful change in the child care environment. On-going assessment of health consultation needs also could be tied to routine followup with service recipients to obtain data on quality and outcomes of services. A statewide computer data base that contains a variety of outcome data on child care health consultation services would allow data on quality indicator measures to be aggregated, analyzed, and used for strategic planning. It is clear that the Child Care Health Consultants are underutilized. Improved marketing of child care health consultation services to both child care providers and to parents of children in child care is an important issue. Child care health consultants

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

need to develop effective marketing techniques to both prospective child care provider clients and to parents who use child care, demonstrating the value of child care health consultation for assuring health and safety of children in child care. References Alkon, A, Farrer, J & Bernzweig, J 2004, ‘Child care health consultants’ roles and responsibilities: Focus group findings’, Pediatric Nursing, vol. 30, no. 4, pp. 315321. Alkon, A, Sokal-Gutierrez, K & Wolff, M 2002, ‘Child care health consultation improves health knowledge and compliance’, Pediatric Nursing, vol. 28, no.1, pp. 61-65. American Academy of Pediatrics 2002, Caring for Our Children. National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care, 2nd edn, American Academy of Pediatrics, Elk Grove Village, Illinois. Crowley, AA 1990, ‘Day care center directors’ perceptions of the nurse consultant’s role’. Journal of School Health, vol. 60, no. 1, pp. 15-18. Cryer, D & Phillipsen, L 1997, ‘Quality details: A close-up look at child care program strengths and weaknesses’, Young Children, vol. 52, no. 5, pp. 51-61. Fenichel, E, Griffin, A & Lurie-Hurvitz, E (25 April 2005). ‘The quest for quality in infant/toddler child care: Elements and indicators’, [On-line], National Child Care Information Center. Available from http://nccic.org/pubs/qcare-it/quest.html [10 February, 2003] Gaines, SK, Wold, JL, Bean, MR, Brannon, CG & Leary, JM 2004, ‘Partnership to build sustainable public health nurse child care health support’, Family and Community Health, [On-line] vol. 27, no. 4, pp. 346-354 Available from ProQuest Nursing Journals. [9 February 2005]. Lucarelli, P 2002, ‘Raising the bar for health and safety in child care’, Pediatric Nursing, vol. 28, no. 3, pp. 239-291. Ulione, MS & Crowley, AA 1997, Nurses as child care health consultants, Healthy Child Care America, vol. 1, no. 2, pp. 1, 4-5.

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Emancipatory pedagogy: inter-professional education delivering child and family centred care Presenters: Carol Anne Chamley. Senior Lecturer Children’s Nursing M.Ed, BA,RGN, RSCN,RNT,ONC, RCNT, Diploma Nursing (London), Diploma Group Management Skills (MSSM), ENB N51. School of Health and Social Sciences Coventry University, Jordan Well, Coventry. CV1 5FB. Pauline Elizabeth Carson Senior Lecturer Children’s Nursing Msc(Child Health), Bsc (Hons),PGCE(HE) RGN,RSCN School of Health, Boundary House, University of Wolverhampton, Walsall Campus, Gorway Rd, Walsall WS1 3BD. Abstract The value of inter-professional education for health and social care workers has been an interesting subject for many decades among academics, clinicians, statutory and non-statutory bodies, policy makers and practitioners. The United Kingdom Centre for the Advancement of Inter-professional Education (CAIPE) (1997) discern the differences between multi-professional and inter-professional learning, claiming that multi-professional education occurs when two or more professions learn side by side. However, inter-professional learning occurs when two or more professions learn from and about each other to improve collaboration and quality of care. The NHS Plan (Department of Health 2000), emphasises the need for health care professionals to work across traditional boundaries, reviewing expertise and the nature of the contribution they make to the patient’s journey. Bradshaw et al (2003) highlights inter-professional education as the key strategy in the development of child and family- centred care as a multi-professional philosophy. It not only has the potential to break down traditional barriers but also harness crossboundary workings. However, there is some evidence to suggest that child and family centred care is practiced erratically and there is some dissonance between what is taught and practiced in the real world of children’s nursing. A small-scale qualitative study with a sample size of 12 participants explored how Child Branch students learn the conceptual basis of child and family centred care (Carson 2002). Data were gathered using semi- structured interviews and analysed using content analysis, identifying emerging themes. Whilst the results are not generalizable interestingly they reinforced the juxtapostion posed between learning and practicing child and family-centred care. Concomitantly the data will inform the development of an innovative inter-professional curriculum to be delivered to undergraduate health science students at Coventry University 2005(Holmes 2005). The challenges for nurse education revolve around translating the theory of child and family- centred care into practice, facilitated by innovative and emancipatory pedagogies. By utilising action learning including problem-based learning, patient journeys, virtual learning sets, inter-professional analysis of critical incidence and other digitally orientated resources, reflection and critical thinking it is asserted that

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

these strategies will aid the of integration of child and family- centred care into interprofessional theory and practice. The focus of inter-professional education must be the patient (child), therefore interprofessional education at undergraduate preregistration level is potentially the key to unlock the way in which health care students learn and are exposed to child and family-centred care, harnessing active engagement through interprofessional, uni-professional and core learning. Therefore, this paper contributes to the current debates about interprofessional education and how best to prepare undergraduate health professionals to work inter-professionally to deliver child and family- centred care. References. Bradshaw, M. Coleman, V. Smith,L.(2003) Inter-professional Learning and Child and Family Centred Care. Paediatric Nursing. 15,30-33. Carson, P. (2002) How Do Children’s Nurses Learn Child and family – Centred care? Unpublished Masters Dissertation. London. Royal College of Nursing. Department of Health. (2000) The NHS Plan: A Plan for Investment :A Plan for Reform. London. The Stationary Office. Holmes,S.(2002)Inter-professional Education and Training Strategy for Courses leading to Initial Registration for Health and Social Care Professions. Coventry. Coventry University.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THE EXPERIENCES OF PROFESSIONAL CARE WORKERS OF CARING FOR CHILDREN WITH LIFE-LIMITING CONDITIONS Authors: Dr J. Clarke, Head of Department, RSCN, RGN, RM, RPHN, MSc, PhD, School of Nursing, Dublin City University, Glasnevin, Dublin 9. Dr S. Quin, Senior Lecturer, BSocSc, MSc. PhD, Department of Social Policy, University College Dublin, Belfield, Dublin 4. The specialist practice of palliative care is a relatively recent one for medicine as a whole, dating from the 1980s, and for children, more recent still. Paediatric palliative care (PPC) is both a philosophy of care and a practice discipline, whose goal is optimum quality of life for both the patient and the family. It is an active and total approach to care, embracing physical, emotional, social and spiritual elements. It focuses on enhancement of quality of life for the child and support for the family and includes the management of distressing symptoms, provision of respite and care through death and bereavement (ACT, 2003). This paper will provide an account of professional and voluntary workers experiences of providing palliative care for children with life-limiting conditions. It draws on data from a national, multi-method study of the palliative care needs of children with life-limiting conditions in Ireland2. Specifically, data are drawn from 15 focus group interviews with multidisciplinary paediatric care teams (n = 7), voluntary organisations (n = 5), community care childcare teams (n = 2), a palliative care team (n = 1), and answers to open-ended questions included in questionnaires to paediatricians, clinical nurse managers, clinical nurse specialists, medical social workers, general practitioners, public health nurses and voluntary organisations. Data were analysed for emergent themes (patterns of information) and for saturation of themes. The paper will explore elements of the ‘complexity of defining and engaging with palliative care’. Elements are not mutually exclusive; instead, they are evidence of the multifaceted and overlapping nature of the phases of palliative care and of how the experiences of palliative care are an interwoven dynamic of need that transcends the trajectory of the life-limiting / dying experience and into bereavement. Reference: (Association for Children with Life-Threatening or Terminal Conditions and their Families (ACT) and the Royal College of Paediatrics and Child Heath (RCPCH), 2003). This research was funded by the Department of Health and Children and the Irish Hospice Foundation

2

Funded by Department of Health and Children and The Irish Hospice Foundation.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AN EXPLORATORY STUDY OF STAFF NURSES’ EXPERIENCES OF PROVIDING FEEDBACK ON CLINICAL PERFORMANCE TO POSTREGISTRATION STUDENT NURSES (SICK CHILDREN’S NURSING) Mary Clynes, Nurse Tutor, RCN, RSCN, BA (Management), M.Sc (Nursing), Children’s University Hospital, Temple Street, Dublin 1 There is a dearth of research which deals specifically with the issue of feedback on clinical performance. While pre-registration students nurses’ experiences of receiving feedback have been explored, albeit as an element of mentorship/preceptorship relationships, the experiences of preceptors/mentors in providing feedback has largely been ignored. Therefore, it is important to consider the issue of feedback from the preceptors/mentors’ perspective, to ensure that a balanced view is presented. Furthermore, it has not been examined in relation to postregistration students who may have different feedback needs. The researcher chose a qualitative approach using a qualitative descriptive design as a chosen methodology. Using purposive sampling, ten preceptors were chosen to participate in the study. Data was collected using semi-structured interviews. Thematic content analysis was carried and data was sorted into categories, subcategories and codes and, finally, reduced to five major categories. The participants’ main concerns were in relation to the provision of negative feedback, written feedback, and maintaining student relationships. The acceptance of feedback was seen to be contingent on the delivery method with due consideration required in relation to the individual needs of the student. A number of factors such as insufficient contact time, busy wards, and inadequate preparation for the role, were viewed as inhibiting the feedback process.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Identifying the cultural indicators to ensure person centred continence care for older people Ms Jayne Wright Research Associate Nursing Development Centre Level 3 Bostock House Royals Hospital Belfast BT12 6BA Northern Ireland Ms Alice Coffey Research Associate/College Lecturer School of Nursing and Midwifery University College Cork Cork Ireland Abstract In settings for older people, the promotion and improved management of continence is a key theme in developing practice. At present practice in this area generally reflects the need to help people who experience continence problems to remain clean and to prevent skin damage. Despite major advancements in the evidence base underpinning continence promotion and management of continence (DoH 2001b), there continues to be little emphasis placed on detailed and individualised assessment or programmes of treatment. Existing evidence into the utilisation of research in practice identifies ‘context’ as a key issue. McCormack et al (2002) identified three elements of practice context that need to be assessed in order for research evidence to be utilised; existing measures of effectiveness, leadership and work place culture. A two year All-Ireland research project, (funded by the Northern Ireland DHSSPS R&D Office and the Republic of Ireland Health Research Board) between the University of Ulster Belfast and the University College Cork began in 2004. In both locations the focus is a rehabilitation unit for older people. The two 2 year research project aims to; • Determine contextual indicators that enable or inhibit effective continence promotion and continence management. • Develop an instrument for assessing the contextual factors in rehabilitation settings for older people in order to introduce appropriate continence promotion and strategies • Test the reliability and validity of the instrument in rehabilitation settings in Ireland. The overall research question is: What are the components of practice context that enable or hinder proactive approaches to the promotion of continence and treatment in rehabilitation settings for older people?

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Aim of presentation To provide and overview of the project with a focus on understanding and developing the ‘context’ of rehabilitation settings for older people in order to ensure person centred practise The presentation will be co-presented by the research associates from each site and will include the two phases of the project. Phase 1; evaluating existing context and culture of practice and identifying the key detriments that impact on practice. The project utilises a case study methodology (Stake 2002) and multiple data collection methods including observations of practice, focus groups and patient interviews. Phase 2; Instrument development, refinement and testing. Development of a questionnaire for assessing practice context in order to establish person centred continence practice. References: Stake R. E (2002) Case Studies in Denzin N. and Lincoln Y. (eds) Handbook of Qualitative research. Newbury Park, CA Publications. Department of Health (2001b) The Essence of Care Benchmarks. DoH: London McCormack McCormack B, Kitson A, Harvey G, Rycroft-Malone J, Titchen A, Seers K (2002) Getting evidence into practice: the meaning of ‘context’. Journal of Advanced Nursing, 38(1), 94-104

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AN EXPLORATION OF THE ACCEPTABILITY OF CONTACT TRACING DURING A SYPHILIS OUTBREAK Ms Claire Coleman RGN, BA (Hons) Dip NS, Dip Stats PhD Candidate School of Nursing and Midwifery Studies University of Dublin Trinity College Dr Maria Lohan PhD, Lecturer School of Nursing and Midwifery Queens University Belfast Prof. Cecily Begley PhD, MSc, Dip Stats, FFNRCSI, RNT, RM, RGN Director School of Nursing and Midwifery Studies

University of Dublin Trinity College Dr Susan Hopkins MB, MRCPI Registrar Dept of Genitourinary Medicine and Infectious Diseases St James Hospital Dublin 8 Prof. Fiona Mulcahy MB FRCPI Consultant in Genitourinary Medicine Dept of Genitourinary Medicine and Infectious Diseases St James Hospital Dublin 8 Dr Colm Bergin MB FRCP Consultant in Infectious Diseases Dept of Genitourinary Medicine and Infectious Diseases St James Hospital Dublin 8

BACKGROUND A large outbreak of infectious syphilis occurred in Dublin between 2000 and 2003. The majority of cases (over 80%) occurred among men who have sex with men (MSM). Intensive contact tracing was introduced through the appointment of a designated health advisor. Effectiveness of contact tracing depends on acceptability. There is however a lack of data on the acceptability of contact tracing from the perspective of non- professionals. Some reports suggest that MSM are a ‘difficult’ group in relation to contact tracing. Occurring in the context of an outbreak of

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

syphilis, this study provided a unique opportunity to explore the MSM perspective on an age old practice. DESIGN OF STUDY The quantitative component of a larger mixed methods study that has both qualitative and quantitative parts will be presented. SETTINGS AND SAMPLING METHODS The settings for the main study (clinical component) were two genitourinary medicine clinics. The population of interest for this study were all MSM with syphilis (‘cases’), and all MSM attending either of two clinical sites as a result of contact tracing (‘contacts’). All people fitting the inclusion criteria and presenting during the twelve month recruitment period were invited to participate. The settings for the community-based (‘community’) component of the study were clubs, pubs and saunas. MSM in these social venues were invited to participate at a time that coincided with blood testing for syphilis. DATA COLLECTION AND ANALYSIS Three separate questionnaires for the three subpopulations were designed and tested for reliability and validity. Data were analysed using SPSS version 11. RESULTS Two hundred ‘cases’, 104 ‘contacts’, and 204 community participants completed questionnaires (response rates: 90%, 87.3%, 81.6% respectively). Although the majority of participants considered contact tracing an acceptable practice, indications of difficulty with the process was reported by all of the three subpopulations. Approximately a third of all ‘cases’ reported embarrassment (30.7%) and concerns about confidentiality (28.2%) as reasons for not informing contacts. Not knowing the contact details of partners was an even greater issue; with over two thirds (71.3%) stating that this was a reason why contact tracing could not be conducted. The findings from these three questionnaires indicate that for the majority of participants contact tracing is an acceptable practice; however, for a large proportion difficulties with the process exist, and certain approaches to contact tracing are preferred over others.

Funding for this study was received from the Health Research Board and the School of Nursing and Midwifery Studies, University of Dublin, Trinity College.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Measuring the impact of isolation on health and well-being of older people living in isolated, border areas: Northern Ireland and Republic of Ireland. Deborah Coleman Teaching Fellow Queens University Belfast Medical Biology Centre 97 Lisburn Road Belfast BT9 7BL Tel 02890272645 Email address:[email protected] As the proportion of older people in the population increases and more live alone (WHO,2002),the problem of social isolation among this age group is of growing concern. Health workers practising in rural communities are often confronted with circumstances of social deprivation and poverty similar to those found within the inner cities (Hughes and Keady,1996). Such problems are compounded further in areas such as that of the proposed study, by geographical isolation. Aims: This study will focus on older people (60years and over) and within the culture and geographical context of the isolated border areas aim to: 1. Develop a definition of isolation 2. Identify the determinants of isolation 3. Develop a screening tool that will be used by community nurses to measure the impact of isolation on the health and well-being of older people. The study will use Participatory Rapid Appraisal as a theoretical framework, and as a result, both qualitative and quantitative methods will be used.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

NURSE-MIDWIVES KNOWLEDGE AND BELIEFS ABOUT INFORMED CONSENT Laniece Coleman, MSN, CNM Doctor of Nursing Practice Student Case Western Reserve University Frances Payne Bolton School of Nursing Cleveland, Ohio USA Clinical Nurse-Midwife Drexel University College of Medicine Department of Obstetrics and Gynecology 245 North 15th Street, Mail Stop 495 Philadelphia, Pennsylvania 19147 USA Email: [email protected] Patricia Higgins, RN, PHD Assistant Professor of Nursing Case Western Reserve University Frances Payne Bolton School of Nursing 10900 Euclid Avenue, Cleveland, Ohio 44106 USA Barbara Daly, RN, PHD, FAAN Associate Professor of Nursing Case Western Reserve University Frances Payne Bolton School of Nursing 10900 Euclid Avenue, Cleveland, Ohio 44106 USA Clinical Ethics Director University Hospitals of Cleveland Cleveland, Ohio USA

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Background Informed consent is the cornerstone of contemporary health care practice. When health care providers succeed in their efforts to convey sufficient information about a medical condition or intervention to a patient, the likelihood of the patient choosing a course of action most consistent with his or her lifestyle and values is increased. This respect for an individual’s right to make autonomous decisions regarding his or her health care is the basis of informed consent. Unfortunately, despite the importance of informed consent, inconsistencies in consent routines are prevalent in all areas of the healthcare setting. This may be particularly true in the labor and delivery setting in which a high number of decisions are made at a time when a woman may be experiencing pain, fear, and/or a desire for assistance; there are emergent situations, and/or there are maternal-fetal conflicts. Consequently, health care providers in the labor and delivery setting often have a great deal of control and influence over many aspects of the informed consent process. Thus, they must possess both knowledge about the informed consent process and a conviction that they need to maintain a patient’s rights. In the United States, Certified Nurse-Midwives attend up to 10% of births nationally in the labor and delivery setting. Knowledge about informed consent is required by the American College of Nurse-Midwives’ Standards for the Practice of NurseMidwifery and Code of Ethics; therefore it is information for which the nursemidwife is held accountable. Purpose The specific aim of this study was to assess Certified Nurse-Midwives’ knowledge and beliefs regarding informed consent. Currently, there is no information about this topic in the literature. The study addressed the following questions: 1. What are the knowledge and beliefs of the certified nurse-midwife regarding the informed consent process? 2. Are there differences in the knowledge of the certified nurse-midwife based on years of experience and level of education? 3. Are there differences in the knowledge of certified nurse-midwives based on confidence in their own knowledge about informed consent? Design Using a mailed questionnaire, this descriptive, comparative study surveyed a random sample of 240 members of the American College of Nurse Midwives in 2005. For a relatively homogenous population, such as the 7000 members of the ACNM, Dillman (2000) calculated a sample size of 240 to achieve a sampling error of + / -5 %. The questionnaire is a 34-item Informed Consent Knowledge and Belief Scale adapted by the investigators from their previous work. In addition to demographic information, 9 questions assess the midwife’s knowledge about different aspects of the informed consent process and 11 questions assess beliefs about the process. Results Participants returned one hundred forty-seven surveys, an overall response rate of 59 %. Five of the surveys were excluded from data analysis because respondents indicated that they were retired. One hundred thirty-six surveys were available for data analysis. Participants in the survey were overwhelmingly female (n = 134, 99 %)

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

and Caucasian (n = 121, 89 %). Sixty percent (n = 81) of respondents indicated that they had 10 or more years of experience as a certified nurse-midwife. Seventy-five percent (n = 102) of the sample indicated that they currently attend births. The demographic data of this sample closely resemble ACNM membership in a 2003 membership survey (Durnell-Schuiling, Sipe & Fullerton 2005). Survey respondents indicated that they had varying degrees of education about ethics and informed consent. Thirty-eight percent (n = 51) reported receiving an ethics class during their education. Sixty-three percent (n = 86) reported receiving an informed consent class during their education. For those midwives attending births, 30 % (n = 41) reported receiving training about informed consent from their employer. Nineteen percent (n = 26) reported receiving no education about informed consent during their education or employment. To assess knowledge about informed consent, subjects were asked nine questions about midwifery care. The first multiple-choice question was not scored. Subjects were asked eight additional true-false questions related to informed consent and usual care in nurse-midwifery practice. The subject’s correct answers were scored ‘1’. Correct answers were summed for a “total knowledge” score, with a range of 0 - 8. Two categories of knowledge scores were created: “low to moderate” knowledge (score of 0 - 5) and “high knowledge” (score of 6 - 8). Total knowledge scores (N = 136) ranged from 3 - 8, with a mean of 5.7 (SD = .97), median of 5.5, and mode of 6. Fifty-seven percent (n = 78) of overall respondents scored in the “high knowledge” category; 40 % of respondents scored in the “low to moderate” knowledge category. To determine what beliefs the certified nurse-midwives had regarding informed consent, subjects were asked to rate their agreement/disagreement with 11 statements on a Likert-type scale. Subjects that disagreed with a statement scored a ‘1’ or ‘2’; subjects with neutral feelings about a statement scored a ‘3’; and subjects that agreed with a statement scored a ‘4’ or ‘5’. To determine whether a relationship existed between level of education or years in practice to informed consent knowledge, an analysis of variance (ANOVA) was computed. Results from the ANOVA found no statistically significant differences between certified nurse-midwive’s knowledge about informed consent and their years of practice. Post-hoc Chi square analysis did not reveal significant findings, but did identify a trend. The group of respondents with the largest percentage (n = 7, 78%) of ‘high’ knowledge scores were the certified nurse-midwives with the least amount of experience (0 - 4 yrs). Results from the ANOVA found no statistically significant differences between subject’s knowledge about informed consent and their level of education. The data gathered in this study were used to determine if a relationship between certified nurse-midwives confidence in their knowledge about informed consent and their actual knowledge. An ANOVA was conducted comparing certified nursemidwives ‘total knowledge’ scores on the ICKBS and their response to the belief item “I am confident that my knowledge about informed consent is sufficient for my practice as a CNM”. Sixty-one percent (n = 83) of certified nurse-midwives

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

agreed with the statement, 25 % (n = 34) were neutral about the statement, and 17 % (n = 13) disagreed with the statement. Results of the ANOVA found no statistically significant differences in knowledge scores based on certified nursemidwives self-reported confidence in their knowledge about informed consent. Implications 1. There is a need for further research into certified nurse-midwives knowledge about informed consent. Particular research needs to focus on the trend of those midwives with the least experience scoring in the ‘high’ knowledge category more often. 2. Educators and employers need to examine their courses and training programs to ensure that informed consent is being addressed adequately, as 19% of respondents reported receiving no education or training. 3. Education and training about informed consent needs to be more comprehensive. The majority of respondents were able to answer basic knowledge questions, but only 57% scored in the ‘high’ knowledge category, which required a more sophisticated understanding of the process.

American College of Nurse-Midwives, 2004. Code of Ethics for Certified NurseMidwives. Washington, D.C.: author. American College of Nurse-Midwives, 2003. Standards for the Practice of NurseMidwifery. Washington, D.C.: author. Dillman, D., 2000. Mail and Internet Surveys (2nd ed.). New York: John Wiley & Sons, Inc. Durnell-Schuiling, K., Sipe, T., & Fullerton, J., 2005. Findings from the analysis of the American College of Nurse-Midwives’ Membership Surveys: 2000 – 2000. Journal of Midwifery & Women’s Health, 4 (2), 8 – 15.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

A LIVING CURRICULUM - DEVELOPING A NURSING CURRICULUM FOR OLDER PERSON CARE AT MASTERS LEVEL IN FOUR EUROPEAN STATES Ms. Rita Collins MEd., PGDip(Computers in Education), BNS, RGN, RM, RNT – Lecturer School of Nursing & Midwifery, University College Dublin. Ph: 7166406, email: [email protected], Fax: 7166450. Mr. Michael Connolly MSc (Nursing), BA(Phil), RGN, RNT - Lecturer School of Nursing & Midwifery, University College Dublin. Ph: 7166474, email: [email protected], Fax: 7156450. Mr. Tom O’Connor MSc(Advanced Nursing), PGDip (Education), BNS, DipN, RGN, RNT - Lecturer School of Nursing & Midwifery, University College Dublin - Lecturer School of Nursing & Midwifery, University College Dublin. Ph: 7166430, email: [email protected], Fax: 7156450. ABSTRACT ‘A Living Curriculum’ for older person care is currently being developed to provide an innovative, diverse and contemporary curriculum, which meets the needs of the older person and their carers. The development of this curriculum was supported by EU grant assistance from the Socrates programme and was a collaborative project by the School of Nursing & Midwifery, University College Dublin, The School of Nursing & Midwifery, University of Sheffield England, The College of Nursing Studies, Moribor Slovenia, and The Institute for Basic and Continuing Education of Health Workers, Budapest Hungary. The number of people in the older age group (65 years and greater) across the European Union is increasing. This is particularly noted in the partner states involved in this development. In Ireland the census of 2002 (CSO 2002) puts the number of older people at 11.1% of overall population with an estimate of this figure rising to 20.6% by the year 2016 and climbing further to 35.9% by 2036. Based on statistics from national census in the years 2001-2003 this trend seems to be reflected in the United Kingdom where older people account for 16% of the overall population, while in Slovenia they account for 8.9% and in Hungary 20.8%. One of the major challenges in building such a curriculum was to make it dynamic. To this end the curriculum is called ‘A Living Curriculum’, denoting the needs of the older person as emerging from that population and their carers. The primary concern of such a development is to ensure that the needs of the older person as perceived by this group provide the content of the curriculum. The direction for content selection on the basis of ‘person-centeredness’ (Nolan 2004) was underpinned by a philosophy that would create an ethos of respect and autonomy while at the same time meeting the needs of the older population as expressed by this group. This paper will focus on the process of engaging in a collaborative European project.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Nolan M, Davies S., Brown J., Keady J., Nolan J. (2004) Beyond ‘person-centred’ care: a new vision for gerontological nursing. Journal of Advanced Nursing, 13(3a) 45-53 Population Statistics for Ireland available from cso.ie/statistics/popnbyage2002.htm. Accessed on April 12th 2005 Population Statistics for Hungary available from www.ksl.hu Accessed on April 12th 2005 Population Statistics for Slovenia available from www.sigov.si/zrs/ Accessed on April 12th 2005 Population Statistics for the United Kingdom available from www.statistics.gov.uk Accessed on April 12th 2005

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

ERACARE: THE IRISH EXPERIENCE OF EUROPEAN COLLABORATION TO PROMOTE NURSING AND MIDWIFERY RESEARCH.

Sarah L. Condell, RGN RM RNT BNS MA Nursing Research Advisor Health Research Board, 73 Lwr Baggot Street Dublin 2

This paper describes the experience of collaboration between a number of partners that aimed to promote nursing and midwifery research at a European level. The paper covers the process of initial engagement with strategic partners, the collaborative working required to gain a successful application to the 6th Framework Programme of the European Union, and the roll out of such an international project from the Irish perspective.

The challenges encountered in the project and the lessons of

collaborative working that were learnt, will be outlined. A reflective assessment of the contribution of the Irish partner to the project will be made.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

POSTGRADUATE EDUCATION NEEDS ANALYSIS FOR SPECIALIST NURSING AND MIDWIFERY PRACTICE IN THE HSE MID-WESTERN AREA AUTHORS Magnus Conteh BSc. Agric. Ed, RMN, ENB 997/8, DMS, MA Project Manager for the Development of Postgraduate Education in Specialist Practice Cora Lunn RGN, ENB 249/870, H. Dip, MSc Assistant Project Manager for the Development of Postgraduate Education in Specialist Practice ADDRESS OF PRESENTERS NMPDU Project Office, 5TH. Floor, Bank House, 106 O’Connell House, Limerick, County Limerick BACKGROUND A postgraduate education needs analysis was an essential undertaking by the Postgraduate Education Project in order to ensure that the development and implementation of postgraduate education programmes for nurses and midwives within the HSE Mid-Western Area was based on actual need and took into consideration those factors that influence programme appropriateness and uptake. METHODOLOGY In undertaking this study, a mixed methods approach was adopted with both qualitative and quantitative methodologies employed. Between Mid-December 2003 and March 2004, 24 focus groups were conducted with a total of 175 participants attending. The groups were organised by division of practice and held with three categories of staff. Participants were selected from employees of the HSE Mid-Western Area, the voluntary hospitals and GP services within the Mid-West area. Each discussion group lasted approximately one to one and half hours with a question guide used to focus the discussion around predetermined topics. A semi-structured interview was conducted with 3 Directors of Care Services to capture the strategic view within the HSE Mid-Western Area on the postgraduate education needs of the nursing/midwifery workforce. The themes generated in the focus groups and semi-structured interviews provided the basis for the seven questions asked in a postal survey that was conducted. The survey consisted of a close-ended questionnaire and was distributed to a sample of 400 participants. This sample was randomly selected from the HSE Mid-Western Area -

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Pay, Personnel, and Related Systems (PPARS) database containing 2790 (at that time) of nursing and midwifery staff names, after removing the names of staff who participated in the focus groups. 126 questionnaires were returned, resulting in a response rate of 31.5%. FINDINGS The study identified a number of national and international drivers considered to influence the development of nursing/midwifery postgraduate education in specialist practice. It also showed an overwhelming support for the proposed postgraduate education framework and continuum of awards, as they support flexibility, accessibility, user friendliness and continuing professional development. A number of key themes emerged around important factors that would support or hinder the delivery/participation in postgraduate nurse/midwifery education. Furthermore, it identified a number of areas where staff considered postgraduate education would make a significant contribution to their personal and professional development within the organisation. Finally, the study identified a number of postgraduate education programmes that need to be developed within the region. REFERENCE Conteh, M. and Lunn, C. (2005) Postgraduate Education Needs Analysis Report. Project for the Development/Implementation of Postgraduate Education Programmes in Specialist Practice. Nursing and Midwifery Planning and Development Unit., HSE Mid-Western Area.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

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Name: Edel Conway [email protected] Job Title: Assistant director of PHN & Project Officer CHISP, Qualifications: M. Soc. Sc; B. Sc. (nursing studies); H. Dip PHN; Dip.health service management; RGN; RM; Cert. O.T. For more details contact Edel Conway, HSE-South Eastern Area, 21, Mary Street, Clonmel, Co. Tipperary 052-77143

CHILD HEALTH INFORMATION SERVICE PROJECT (CHISP) This supporting parents / child health project is piloted in the Health Services Executive- South Eastern Area from 2002-2006. It is led by Edel Conway, Assistant director of public health nursing / project officer and guided by a multi disciplinary child health steering committee as well as in consultation with ranges of stakeholders and end users. Project Background The Child Health Information Service Project (CHISP) compliments the Health Service Executive- South Eastern Area service’s planning objective of undertaking a demonstration project to support parents’ information needs during their early year’s parenting role, as recommended by Denyer, Thornton and Pelly, (1999). A second objective of this project is to contribute to ongoing research and development of quality child health and surveillance services at area level with a view to complimenting national child health service development. An analysis of the research of Stage 1 of the project identified child health information as a crucial area of parent and family support (Conway, 2003). Following on from this the CHISP project focused on empowering parents by enhancing their knowledge capacity on aspects of child rearing and holistic development through developing appropriate information in various formats (Conway, 2004,a; 2005). Purpose of the project 1. Supporting and empowering parents in their parenting role in the formative years of childrearing by determining and addressing their child health information needs. 2. To inform providers of the needs and preferences of parents when tailoring and furnishing timely information to meet parents’ unique needs.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Structure of the Project Stage 1 Identify parents and carers child health and related support service Complete information needs. Establish current and best practice of service providers. Stage 2 Design and produce products that fill the identified gaps in health information. Current ‰ Booklet and audio CD 1 - Caring for Your Baby: Birth to Six Months

Stage 3 Current

Old. ‰ Booklet and audio CD 2 - Caring for Your Child: Six Months to Two Years Old. ‰ Booklet and audio CD 3 - Caring for your Child: Two to Five Years Old. Set up structures to communicate this health information to our client groups, factoring in evaluation. Address any additional training needs of service providers & evaluate the project.

Aims of the project 1. Identify what information parents need to support them in parenting their children thus helping them to: promote their child’s health and well-being; identify possible problems; and access appropriate services. 2. To communicate this information to parents in the most appropriate way. Objectives of the project 1. To identify and evaluate current child health information available and the information systems in use. 2. To identify best and effective practice in relation to service provision. 3. To identify the child health information needs of parents from ante-natal to preschool years. 4. To establish the needs of service providers in relation to the information they share with parents. 5. To develop formats such as written, audio CD and Internet based information resources where they do not currently exist or enhance and complement those already available. 6. To source or develop training packages for service providers and for other key informants in relation to communication of this information. Principles underpinning the project 1. The information needs of parents and carers of children are at the core of this project. This includes information on child health and allied social service support. 2. Key stakeholders, including parents will continue to be consulted with at each stage of the project. 3. Parents require different levels of detail on various aspects of information according to their unique needs. 4. The information is layered so that what is initially presented communicates a broad outline and conveys access to the next layer or contact link.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

5. Co-ordination and process evaluation is incorporated to ensure each layer is accessible to those who most need it. 6. Parents will have the information when they need it in user-friendly formats. 7. There will be and increased awareness among the health service professionals of the information needs and delivery preferences of parents. 8. The final packages will be readily and easily shared and incorporated into the front line child health service provision in each Community Care Service. The first evaluated information package (Conway, 2004a&b) is endorsed by the Programme of Action for Children as a health promoting resource tool when working in partnership with parents. This first pack has been incorporated by the HSESouthern and Mid-Western areas as well as the South Eastern Area and there are expressions if interest from other areas to roll out these evaluated qualitysupport packs. Evaluation Evaluation is conducted right through the time frame of the project including process and outcome measures. References Conway, E. (2005). Caring for Your Child: Six Months to Two Years Old Kilkenny: HSE-South Eastern Area. Conway, E. (2004, a). Caring for Your Baby: Birth to Six Months Old. South Eastern Health Board.

Kilkenny:

Conway, E. (2004, b). Evaluation of the pilot information resource pack: Caring for Your Baby: Birth to Six Months Old. Kilkenny: South Eastern Health Board (Unpublished). Conway, E. (2003). Identifying the child health and related support service information needs of parents/carers from the antenatal to pre school years. Kilkenny: South Eastern Health Board (Unpublished). Denyer, S., Thornton, L., and Pelly, H. (1999). Best Health for Children: Developing a Partnership with Families. Dublin: National Conjoint Child Health Committee.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

NURSES’ MOTIVATIONS FOR STUDYING THIRD LEVEL POSTREGISTRATION NURSING COURSES AND THEIR EXPERIENCES OF STUDYING ON THEIR PERSONAL AND THEIR WORK LIVES By: Clodagh Cooley, RGN, Higher Diploma in Nursing Studies, Bachelor of Nursing Degree, Diploma of Higher Education in Nursing Studies. Lecturer, Centre for Nursing Studies, National University of Ireland Galway, Galway. Tel: 091-495274/ [email protected]

ABSTRACT Nationally, in Ireland since the late 1990s, a plethora of post-registration nursing courses have been developed (Department of Health, 2002). Numerous nurses have embraced the opportunity to study these courses (McCarthy, 1999). To date no contextual information is known about what motivates so many nurses to study these courses or their experiences of studying. The aim of this study was to explore and to describe nurses' motivations for studying third level post-registration nursing courses and their experiences of studying on their personal and work lives. A descriptive, exploratory qualitative research design was utilised. Permission to undertake the study was sought and gained from the course directors in a third level institution. A total of eighteen nurses participated in this study. Data was collected using three focus groups and a one-to-one interview. The data was analysed using Ritchie and Spencer’s (1994) “Framework.” Three themes were identified: "I want to keep up and I want to keep in there" and "It's about juggling and getting the balance" and "I'm looking at things differently." The findings concluded that the nurses’ motivations to study were influenced by many factors. A unique finding of this study is that the free fees initiative influenced their motivations. Their experiences of studying were broader in scope than their motivations. To attend their course and to study, the nurses had to organise both their home and their work lives. Family support facilitated them to study. The support that they received from their nursing managers, nursing colleagues and the third level institution varied. Finally, it was found that studying enlightened the nurses’ professional and personal perspectives.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THE USE OF PARTICIPATORY ACTION RESEARCH AS A METHODOLOGY FOR THE IMPROVEMENT OF INTERPROFESSIONAL PRACTICE DEVELOPMENT ANDREA M. CORBETT BN, PG Dip HSc (Managed Care), PG Dip HSc (Rehabilitation), M Phil (Nursing) PhD candidate, Monash University. Western Institute of Technology at Taranaki, PO Box 2030, New Plymouth, New Zealand. 064 6 757 3100 [email protected] PARTICIPATORY ACTION RESEARCH What is it? Stringer and Genat (2004), define action research as: “a systematic, participatory approach to inquiry that enables people to extend their understanding of problems or issues and to formulate actions directed towards the resolution of those problems or issues.” The linking of the terms “action” and “research” highlights the essential features of the approach: trying out ideas in practice as a means of improvement and as a means of increasing knowledge. This linking originates from Kurt Lewin’s work, the acknowledged pioneer of action research, who had a firm belief that the two ideas of group decision and commitment to improvement were inextricably linked. He believed that those affected by planned changes had the primary responsibility for deciding on courses of critically informed action which seemed likely to lead to improvement, and for evaluating the results of strategies tried out in practice. Origins Whilst Kurt Lewin is acknowledged as the pioneer of action research as a distinct research methodology by many writers, others actually attribute the concept to American philosopher, John Dewey, (Greenwood, D.J. & Levin, M., 2000) who wrote extensively in the 1930’s regarding the education system and the need to reform it by democratisation. Dewey analysed and wrote about reflective thinking in which practical problems demanded practical solutions, and the solution could only be regarded as viable when it was shown that it produced the desired outcome in actual practice. The actual term ‘action research’ is credited to two men, Lewin and John Collier. Collier was the Commissioner of Indian Affairs in the United States between 1933 and 1945. He used the term ‘research-action’ to describe social research that was cyclical in its nature: ‘action research and research action’. Collier held firm beliefs that ethnic relationships between the Indian and the white man could only be improved by a programme of collaborative research in which both parties came together and participated to develop acceptable solutions to problems.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Participatory action research has its origins in community development approaches in underdeveloped countries whereas action research developed from the work of Kurt Lewin and has been applied to education and management research in developed countries such as the USA, Australia and England. Early PAR projects were concerned with marked inequalities in the distribution of resources and power between the privileged and dominant and those who were marginalised and oppressed in Latin America, Africa and Asia (Kemmis and McTaggart, 2000). There are six trends that converged to contribute to the concepts of participatory action research. Tandon (1996) states that in these trends can be seen the theoretical principles, methodology and epistemology of PAR. They are: The debate about the sociology of knowledge and its implications for epistemological development throughout civilisation. The writings of Habermas (1971) led this debate and had an emphasis on the concept that knowledge of human civilisation was conditional on its historical context. Adult educators in South America (among them Brazilian Paulo Friere) believed that the learner should have control over their own learning processes and evolved a methodology of teaching and learning to effect this. Their view of research came to reflect their view of the practice of adult education as it was practiced and they were the first to disseminate the term ‘participatory research’ in 1974-75. Freire’s (1982) contribution to educational practice came about as a result of his pedagogy which led to the third trend and this was the support for the idea and practice of PAR as an educational process within the framework of conventional education. The process of knowing and of education were shown to be interlinked which gave support to the arguments promoted by adult educators in support of PAR. Friere believed that reality was not an objective truth or facts to be discovered but includes the ways in which people involved with facts perceive them (Minkler and Wallerstein, 2003). A parallel trend in the development of PAR was the contribution of action research which challenged the existing concept of research as a static process. From Lewin’s day, action research has argued the basis of action as a basis of learning and knowing. This concept is at the heart of PAR. Phenomenology made the next significant contribution to the development of PAR according to Tandon (1996) as the work of phenomenologists legitimated experience as a basis of knowing. Human emotions and feelings were able to be recognised as genuine ways of knowing. Further work by phenomenologists led to the recognition of experiential learning as a legitimate form of knowledge that could inform practice. The question of participation in research by the persons whose development was being attempted was seen as a critical variable and received undeniable evidence of its necessity with the failure of top-down expert designed projects and programmes.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Feminisms: Tandon also acknowledges that the enrichment of the theory and practice of PAR can be attributed to feminist perspectives. He believes that feminist ways of knowing and changing reality as expressed by Maguire (1987) have strengthened the use of PAR in a contemporary context. In attempting to define “feminisms” one encounters the difficulty that there is no one feminist view point or feminist method of exploring an issue. However there are some commonalities and Maguire (1996) states these as being: That all women face some form of oppression and exploitation, and this oppression and exploitation is experienced differently depending on race, class, culture, religion, sexual preference, age, physical abilities, and nationality. All feminisms have a commitment to uncover and understand the forces that cause and sustain oppression; and finally that feminisms work to obtain individually and collectively, a commitment to end all forms of oppression. Participatory research has highlighted the centrality of power in the social construction of knowledge however only feminist research has pointed out the centrality of male power as a factor in the construction of knowledge (Maguire, 1987). Paulo Freire certainly made a major contribution through his work in adult education to the development of PAR however he does present in his writings male bias. He writes of man in the world suggesting that it is man that makes culture not women. That he took androcentricity as the norm may well explain why he ignores man’s domination of women in the social world. Feminist critique and influence on participatory action research asks questions regarding terminology: who is the ‘poor’, who are the ‘marginalised’, who are the ‘oppressed’; words often used in PAR projects as many of the major PAR projects have had the primary aim of empowering the ‘poor’, the ‘marginalised’ or the ‘oppressed’. There is a danger however in using such terminologies, as there is the implication that the persons to who they refer are homogenous. Maguire (1996) in her writings brings the relevance of feminist theory and its initial emphasis on the issues of the power and dominance of men over women to PAR with her reflections that feminisms are about attempting to bring together the many voices and visions of a more just, loving and non-violent world. In the sense that feminisms and PAR share emancipatory and transformative intentions, it is noted that often PAR has ignored the gender factor in oppression. During the 1970’s PAR centred on male power, perceptions and problems. Maguire argues that feminist perspectives have shifted since then and that instead of being man-centred, feminisms now talk of human-centred which automatically includes woman on the agenda. This is stated as being a good development as it strengthens the PAR approach where there are inequalities in class, ethnicity and gender. Participatory Action Research and the Health Sector: It was but a short step to adapt action research as a practitioner-friendly research methodology that could be used by nurses, physicians, and other health professionals to formulate appropriate service delivery practices, and appropriate health strategies.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Its very practitioner-friendly qualities made it a suitable methodology to use when attempting to understand the ways lay people might contribute to the development of appropriate service delivery strategies (Stringer and Genat, 2004). In relationship to nurses and health care delivery Koch, Selim, and Kralik (2002) report that during a PAR project the reflection phase creates a self awareness which enables participants to give voice to topics that were important to them. This has the potential to improve and change practice to enhance the sense of belonging, involvement, and empowerment of those involved. These changes in individuals then enable group reflection to lead to a reconstruction of the meaning of a particular practice situation and to enable understanding and a sense of clarity of what might be possible. It is further pointed out that the ability to have a voice or an opinion, to raise an issue and have it heard, is potentially empowering. The experience of some participants is that they feel validated as it is the first time they have been heard in their lives. To achieve its results PAR requires that people engage in three different activities: inquiring into the nature of a problem; getting together as participant units; and mobilising for action by raising awareness of what needs to be done. These activities shared in an interprofessional forum make PAR a very suitable methodology for change in the health sector. The appeal for nurses and other health professionals of PAR according to Koch, Selim, and Kralik (2002) are: a recognition of power relationships; recognition of the value of the lived experience of people; and the empowerment of people through the process of constructing and using their own knowledge. Using these principles participants are able to develop a sense of unity and create a safe environment where their individual constructions and interpretations can be compared and contrasted, facilitating negotiated action. It has been shown that PAR is able to be effectively used in health research in a formalised structured health care system such as the United Kingdom where PAR has been used within the National Health Service. The NHS is a bureaucracy that is stated to be one of the largest in Europe, it is hierarchical in nature and practice, and there are huge implications in any attempt to make structural and/or operational changes. Whilst it is indeed difficult to change structures and practices in a nonparticipatory, hierarchical organisation such as the NHS, it is possible (Dockery, 1996) using PAR. PAR is a research methodology that is having success in achieving improvements in clinical practice. It is producing change for the betterment of service delivery to the patient in a number of different sectors and in almost every country in the world. Some examples cited include the work of Jones (2004) who used the method in Wales to introduce a care pathway for patients with schizophrenia. Bryant-Lukosius and DiCenso (2004) used PAR to introduce Advanced Practice Nurses for prostate cancer

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

care in Ontario, Canada. Johnsen and Normann (2004) have written of the use of the method on a much larger scale to introduce improvement on a regional basis in rural Norway. Stringer and Genat (2004) write extensively on the use of the method and give examples ranging from continence management with patients with multiple sclerosis, community medical practice, physiotherapy practice and in public health areas. The most pleasing thing to note in these and other examples of practice development is that they nearly all are interprofessional in their scope and application. PRACTICE DEVELOPMENT – A DESCRIPTION: The key elements of Practice Development are variously stated as being those of: •

the development of knowledge, skills and values to provide good quality patientfocused care. This is the examining of care issues at the micro level, at the level of the individual health care practitioner

•

a process of continuous improvement that furthers the effectiveness of patientcentred care. This relates to care delivered at the macro level, at the level of the interprofessional team.

It is acknowledged that practice development processes impact directly on the recipients of care, our patients. However it is also acknowledged that practice development activities can also be aimed at the way nurses and fellow health care colleagues work with patients, which can result in an impact on practice, without directly involving the recipients, the patients, in the process. PAR is a methodology that is gaining increasing acceptance among health professionals as a means of furthering the aims of practice development and in particular health service delivery. This paper seeks to link the concepts of practice development and the methodology of PAR by using explanations from a study in progress. The goals of the study in progress are to develop a more seamless approach to the management of people with physical disability from their acute admission through to and beyond discharge in rural areas of New Zealand. When analysing the literature McCormack, Manley and Garbett (2004) found a range of activities that are practice development. Seventy one activities were identified and following a comparative analysis reduced to six descriptive categories. These were: • promoting and facilitating change • translation and communication • responding to external influences • education • facilitating and implementation of research into practice • audit and quality. At the macro/service delivery level these categories of practice development are readily identified as the realms of practice of the participatory action researcher.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The four basic steps of participatory action research compliment one another and flow in a cyclical manner and ultimately into a series of sequential cycles. These steps also fit perfectly into the descriptors of practice development as defined by McCormack, Manley and Garbett (2004). Plan:

A plan is developed that will inform action to improve an action (practice) that is already happening. It should be forward looking. It recognises that to some degree all social action is unpredictable and therefore risky. The plan needs to be flexible to be able to adapt to unforeseen effects or constraints.

Action: This is deliberate and controlled. It is a careful and thoughtful variation on existing practice. It is critically informed. It uses action as a platform for future development and later action. Action is flexible and open to change in the light of changing circumstances. Observation: In participatory action research this process is planned It looks forward, providing the basis for reflection. Observation is responsive, open-minded and open-eyed. Researchers observe the action process, the effects of the action, both intended and unintended; the circumstances of, and the constraints on action; how circumstances and constraints change planned action; and any other issues that may arise. Reflection: This seeks to make sense of the processes, problems, issues and constraints that have appeared during strategic action. Reflection is aided by discussion among participants and provides the basis for a revised plan/cycle. BACKGROUND TO THE STUDY IN PROGRESS In 2003 a study was completed that explored the whanau (family) experience of people who had suffered CVA in Taranaki. Of the seven whanau groups involved in this study five of them lived in rural areas. The results revealed, among other issues, a ‘hit and miss’ system of service delivery. Evidence showed that there was an uncoordinated, quite disjointed system of care management at all levels. It varied from very effective management, in a small clinically focused area, to non-existent in others. The analysis of the data showed that the expectations of the whanau of these patients were no different than any other family who also suffered a stroke or other physical disability. They wanted and needed information about those services to assist them to care. They wanted and needed access to services to assist them to care. The whanau would readily respond to the requirement to care but needed teaching, and ongoing education and supervision to enable them to care more comprehensively. The study concluded with 10 recommendations being made to the local District Health Board (DHB). If actioned these could result in a lessening of the deficits in service delivery and support for rural communities. It was initially to be left to the DHB to progress the aims of the 2003 study however when an opportunity presented

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

to develop a new research project the exploration of existing service delivery methods was put forward and adopted as the topic for a new study which began in April 2004. Care delivered to those needing health and disability services in New Zealand does not come under one umbrella. In broad terms there are three separate funding streams. Acute services are provided by the local DHB under funding from Vote Health. When the patient moves from an acute to non acute classification they then have to be diagnosed as medical or injury. If diagnosed as injury, their care needs are then the responsibility of the Accident Compensation and Rehabilitation Corporation. This includes the remainder of their time in hospital and on after discharge. If the patient’s health needs are due to a non accident cause such as CVA, cancer, or degenerative illness, their care is funded out of the Disability and Health Support Services (DHSS) funding pool until discharge when it is then administered by a local Needs Assessment, Service Coordination (NASC) agency whose operational funding also comes from the local DHB under contract negotiation. To further add to this confusing mix is the recent development of Primary Healthcare Organisations which are intended to play a far greater role in health service delivery to communities than previously provided by general practitioners. The DHB’s funding now derives mainly from a population based funding model that was introduced by Central Government in 1993. District Health Boards that serviced rural areas received less than the larger urban based DHB’s which had larger populations to serve. There has been some attempt to compensate DHB’s with higher payments for the additional costs that accrue in servicing a rural based population, however inevitable rationalisation and centralisation of health service delivery has occurred that disadvantages people because of their geography. In examining the issues that derived from the 2003 study it became obvious that the problems being encountered by patients with health service delivery arose across disciplines and across services. In some areas there was active ‘patch protection’ activities evident. There were gate keeping activities in some instances, lack of the provision of information or of information transfer regarding services, and there were issues that arose across service provider boundaries related to the consequences of differing funding streams. Upon careful reflection a PAR methodology was decided upon to guide the new study into alternative methods of service delivery to persons with physical disability living in rural areas of New Zealand, but Taranaki in particular. The study has wide ramifications and to be completed in its entirety will necessitate the development of alternative service delivery models across service provider boundaries. This will probably require legislative change. There will also be required a retrospective prospective comparative study to examine the effects of the alternative service delivery model. This first phase is designed to gather the views from the collective experiences of participants, analyse these experiences and suggest changes that could or should be made. The initial semi-structured interviews are conducted in a one on one setting in which confidentiality and anonymity are guaranteed to the participant. It is intended to follow these interviews with a thematic analysis, return this summary to

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

participants along with their edited interview transcript for their comment. Following this sequence the participants will be brought together in one or two PAR groups to allow the process to proceed. PRACTICE DEVELOPMENT DESCRIPTORS: McCormack, Manley and Garbett (2004) list several descriptors of practice development and the first four of these fit well into the stages described as part of the method of PAR. Promoting and facilitating change: Activities here are concerned with supporting, raising awareness, and helping create a culture to support change based on the perceptions of need as identified by the staff themselves. In the study in progress the researcher is required to facilitate an examination of philosophical attitudes across interprofessional disciplines and the changes that may be required to generate a change and therefore effect practice development for an improvement in service delivery. Having a professional outsider viewpoint, and therefore not consciously or subconsciously tied to a particular service delivery strategy, the researcher has been able to guide the participants to a position where they are able to examine the service delivery issues raised from their own perspectives and begin the process of identifying potential changes. Participants enrolled in the study may be classified as: management/administration x 6; health professionals in the clinical setting x 16. This process parallels the reflection stage of the action research cycle which enables the plan to inform practice development. Issues identified to date have included the lack of a co-ordinated approach to service delivery; a lack of information sharing across service providers; and constraints placed on more effective co-operation because of differing funding streams. Translation and communication: In planning for successful change and practice development activities, McCormack, Manley and Garbett (2004) refer to the generation of interest for the project among managers and opinion leaders in the broader organisation. This was an essential part of the preparatory work of the study and the enrolment of participants into it. When the results of the 2003 study were presented to staff of the DHB, many took the recommendations and findings of that research study as a personal criticism of their activities in service delivery. These persons were unable to accept or acknowledge that the 2003 study was merely a relating of the experiences of a group of patients and their families with service delivery. The study told in simple terms their experiences. There was no criticism of individuals or services, and tragically in taking it thus, health professional missed a golden opportunity to examine the tales of the participants and then look at their practice/s. The result for the researcher was that participants were reluctant to enrol in this study. This reluctance was overcome by first talking to key service delivery co-ordinators, the opinion makers and middle managers of the organisation, and then having one of this group act as a liaison between the researcher and potential participants.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Responding to external influences: The external influences that affect the delivery of health and disability services in New Zealand have to be considered and contemplated as we try to develop improved systems of service delivery. However external influences do not just relate to service delivery providers such as the ACC and PHO’s, but also to those influences related to and as a consequence of Government policies, funding allocations, and prioritisation of services. The present study hopes that in implementing the action step of the PAR cycle that the relationships between existing services, inside and outside the hospital, and between policy and practice development may be strengthened to further develop and enhance service delivery. Education: In the context of practice development it is noted that professional development refers to the skills of the individual health professional while practice development is about creating those conditions where such skills and knowledge can be applied. When one considers all the ramifications of change in implementing practice development strategies then the educative activities that will be needed to spread and enable the implementation of such change cannot be overlooked. CONCLUSION This paper has sought to demonstrate that nurses and health professionals can collaboratively and successfully use the methodology of Participatory Action Research as a means to successfully implement improvements in health service delivery by way of practice development. The study underway in Taranaki is demonstrating how the principles of Participatory Action Research can enhance and compliment the concepts of practice development. Ultimately it is believed that the lessons being learned in Taranaki will be able to be applied across all New Zealand and perhaps to offer guidelines for those responsible for service delivery in other rural communities in other countries. Thank you.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References: Bryant-Lukosius, D. and DiCenso, A. (2004) A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48 (5). Dockery, G. (1991). Power and process in development theory, decentralisation and primary health care. M Ed dissertation, University of Manchester. Friere, P. (1992). Pedagogy of hope: Reliving pedagogy of the oppressed. New York, Continuum. Greenwood, D.J. & Levin, M. (2000). Reconstructing the relationships between universities and society through action research, in Denzin, N.K. & Lincoln, Y.S. (eds), Handbook of qualitative research (2nd ed). Thousand Oaks, Sage. Habermas, J. (1971). Towards a rational society. London, Heinemann. Johansen, H.G., Normann, R. (2004). When research and practice collide: The role of action research when there is a conflict with stakeholders. Systemic Practice and Action Research, 17 (3), pp207-235. Jones, A. (2004). Perceptions on the standardization of psychiatric work: development of a care pathway. Journal of Psychiatric and Mental Health Nursing, 11. Kemmis, S. & McTaggart, R. (2000). Participatory action research, in Denzin, N.K. & Lincoln, Y.S. (eds), Handbook of qualitative research (2nd ed). Thousand Oaks, Sage. Lewin, K. (1946). Journal of Social Issues, 2, 34-46, cited in McNiff, J. (2003), Action Research: Principles and Practice, (2nd ed). London, Routledge/Falmer. Koch, T., Selim, P., Kralik, D. (2002). Enhancing lives through the development of a community based participatory action research programme. Journal of Clinical Nursing 11. Maguire, P. (1987). Doing participatory research: A feminist approach. Centre for International Education, Amherst, Massachusetts. Maguire, P. (1996). Proposing a more feminist participatory research: knowing and being embraced openly, in de Koning, K. & Martin, M., Participatory research in health: Issues and experiences. London, Zed Books. McCormack, B., Manley, K., Garbett, R. (eds), (2004). Practice Development in Nursing. Oxford, Blackwell Publishing. Minkler, M. and Wallerstein, N. (eds) Community based participatory research for health. San Fransisco, Jossey-Bass. Stringer, E. & Genat, W.J. (2004) Action research in health. Ohio, Pearson.

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Tandon, R. (1996). The historical roots and contemporary tendencies in participatory research: implications for health care, in de Koning, K. & Martin, M., Participatory research in health: Issues and experiences. London, Zed Books.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AN EXPLORATORY STUDY OF THE TRANSITION EXPERIENCES OF RECENTLY QUALIFIED GENERAL DIPLOMATE NURSES Philip Corcoran, R.G.N; R.N.T; PG.Dip. CHSEd; MSc. Nursing Lecturer in Nursing & Health Studies, Institute of Technology, Letterkenny, Co. Donegal. ABSTRACT This paper will present the findings from a qualitative study, conducted at a general hospital site in the Republic of Ireland in 2003. The aim was to explore the transition experiences of a sample of recently qualified diplomate nurses, and the findings are considered in the context of making changes for a better future. Literature review revealed that the transition from student to staff nurse had been widely studied in the UK since Project 2000 was introduced in 1989. Many changes were recommended there and structures were put in place to support Project 2000 graduates postqualification. Pre-registration nurse education in Ireland subsequently moved to higher education diplomas in 1996, and quickly advanced with degree programmes commencing in 2002. There was no published evidence that this topic was studied in Ireland by 2003. The focus of this paper is therefore on exploring the transition experiences of Irish diplomate nurses who had undergone this transition from student to staff nurse. An exploratory qualitative design was adopted, and purposeful sampling used to recruit twenty participants, who were qualified between five and eighteen months. Ethical approval was granted, and informed consent obtained from all participants who took part in four focus group interviews. Data analysis was guided by Miles & Hubermans’(1994) analytical framework, and Nicholsons’ (1990) role transition theory. Following analysis of the data, four main themes were identified: 1. 2. 3. 4.

Encounter: The First Experiences Adjustment: Facing Reality Stability: Achieving Role Satisfaction The Future: Suggestions For Improvement

Recommendations for change involve the pre-registration curriculum, development of the rostered placement experience, and formal transition programmes and support for the first four to six months of registered practice. While the findings and recommendations from this small-scale study only relate to the twenty nurses who participated at one site, they are largely supported by previous research elsewhere, and may therefore be relevant to other similar populations. Miles, M. & Huberman, M. (1994) Qualitative Data Analysis. (2nd Ed.) London: Sage. Nicholson, N. (1990) The Transition Cycle: causes, outcomes, processes and forms. In: Fisher, S. & Cooper, C. (1990) On the Move: The Psychology of Change and Transition. Chichester: John Wiley & Sons.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

FACILITIES FOR RELATIVES OF TERMINALLY ILL PATIENTS IN THE ACUTE CARE SETTING Anne – Marie Corroon RGN, RNT, PGDip Ed., MSc Adv Nursing Nurse Lecturer, Course Co-Ordinator School of Nursing & Midwifery Studies, 24 D’Olier Street, Dublin 2. Caring for relatives is an integral aspect of patient care (Costello, 2001; Holden et al, 2002; McIntyre, 2002; Duhamel & Dupuis, 2003). Dying is recognised as a family event (Wong et al, 2001; Mok et al, 2002) rather than an individual concern. The terminal phase of the patients’ illness often results in considerable psychological and social difficulty for the patients’ relatives and friends (Thomas & Morris, 2002). It is widely noted that relatives of terminally ill patients are often critical of their experiences during the patients’ illness and death (Dunne & Sullivan, 2000; Eriksson et al, 2001; Keegan et al, 2001; McIntyre 2002; Isaksen et al, 2003). Given the current emphasis on quality assurance and the inclusion of the family, in the present Health Strategy (Department of Health & Children, 2001) it is essential that nurses be facilitated to deliver a quality service. Caring for relatives of terminally ill patients represents a source of considerable stress for nurses (Rittman et al, 1997; Rasmussen et al, 1997; Costello, 2001; Kristjanson et al, 2001; Yang & Mcilfatrick, 2001; Main, 2002; McIntyre, 2002). Exploration of the phenomenon is necessary to ensure that the educational needs of staff are identified and met that appropriate supportive mechanisms and resources are introduced to facilitate the provision of this care. No research exists detailing this phenomenon in the Irish healthcare setting. Therefore this study was undertaken to explore nurses’ lived experiences of caring for relatives of terminally ill patients on oncology wards. A hermeneutical phenomenological methodology was employed in this study. Purposive sampling was used and the sample was limited to nurses working in oncology with at least two years post registration experience. Seven nurses were interviewed using in-depth open audiotaped interviews, to explore their experience of this phenomenon. The analysis of the transcripts was influenced by Gadamerian philosophy. The concepts of the hermeneutic circle and the fusion of horizons were utilised to analyse the data. The findings revealed that there were difficulties in caring for the relatives that were inherent in the acute care area, in which the facilities available for relatives were inadequate. This lack of appropriate resources was noted to be a stressor for the participants, in that it constrained them from providing the level of care that they aspired to provide. The participants found it difficult to work with such constraints. The participants spoke of the need to facilitate relatives to be with the patient and that it was not uncommon for relatives to sleep on the floor in the patients’ room. Furthermore it was evident that there is little or no provision for privacy for relatives and terminally ill patients due to the physical constraints of the acute setting. It is apparent that the designation of a room for use by relatives would considerably reduce some of the stress experienced by staff and relatives. The low priority afforded to this client group, at an organisational level and at ward level, is apparent. Given that the patient and family comprise the unit of care, this has implications for practice and service planning. Further research is warranted to further address this issue.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Developing the Evidence for Wound Cleansing (This paper will present the process and findings of a systematic review) Ms Zena Moore Lecturer & Professor Seamus Cowman Head of Department Faculty of Nursing & Midwifery Royal College of Surgeons in Ireland 123 St Stephen's Green Dublin 2 Ireland Background: Pressure ulcers (also called pressure sores, bed sores and decubitus ulcers) are areas of tissue damage that occur in the very old, malnourished or acutely ill, who cannot reposition themselves (Robertson et al, 1990). Pressure ulcers impose a significant financial burden on health care systems and negatively affect quality of life (EPUAP, 2002; Bader et al, 2004) Wound cleansing is considered an important component of pressure ulcer care. Therefore, this systematic review sought to answer the following question: What is the effect of wound cleansing solutions and wound cleansing techniques on the rate of healing of pressure ulcers? Search Strategy: We searched the Special Trials Register of the Cochrane Wounds Group (up to August 2005), and the Cochrane Central Register of Controlled Trial (The Cochrane Library Issue 3, 2005). We Searched bibliographies of relevant publications retrieved. We contacted drug companies and experts in the field to identify studies missed by the primary search. Selection criteria: Randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or different wound cleansing solutions, or different cleansing techniques, were eligible for inclusion if they reported an objective measure of pressure ulcer healing. Data Collection and Analysis: Two authors extracted data independently and resolved disagreements through discussion and reference to the Cochrane Wounds Group editorial base. A structured narrative summary of the included studies was conducted. For dichotomous outcomes, relative risk (RR), plus 95% confidence interval (CI) were calculated; for continuous outcomes, weighted mean difference (WMD), plus 95%CI were calculated. Meta analysis was not conducted because of the small number of diverse RCTs identified. Main Results: No studies compared cleansing with no cleansing. Two studies compared different wound cleansing solutions: a statistically significant improvement in Pressure Sore Status Tool scores occurred for wounds cleaned with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) compared to isotonic saline solution (P value = 0.025), but no statistically significant change in healing was seen when water was compared to saline (RR 3.00, 95%CI 0.21-41.89). One study compared cleansing techniques, but no statistically significant change in

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

healing was seen for ulcers cleansed with, or without, a whirlpool (RR 2.10, 95% CI 0.93-4.76). Conclusion: We identified only three studies addressing cleansing for pressure ulcers. One noted a statistically significant improvement in pressure ulcer healing for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) compared to isotonic saline solution. Overall there is no good trial evidence to support the use of any particular wound cleansing solution or technique for pressure ulcers.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

‘Challenging the theoretical basis of the philosophy of ‘partnership with parents’. Presenter 1 Name / Title Job title: Qualifications: Workplace: Mailing address: Post code: Country Day time telephone: Mobile number: E-mail address:

Dr. Imelda Coyne BSc Programme Director / Lecturer PhD, BSc(Hons) with Education, Dip N, RSCN, RGN, RNT School of Nursing, Dublin City University School of Nursing, Dublin City University, Dublin 9, Ireland Dublin 9 Ireland 01-7008504 0879512495 [email protected]

Presenter 2 Name / Title Job title: Qualifications: Workplace: Mailing address: Post code: Country Day time telephone: Mobile number: E-mail address:

Miss Joy Conlon Nurse Tutor BSc. MSc. R.G.N. R.S.C.N. (H. Dip) R.N.T. School of Nursing, Our Lady’s Hospital For Sick Children School of Nursing, Our Lady’s Hospital For Sick Children, Crumlin, Dublin 12 Dublin 12 Ireland 01-409 6606 086 3299050 [email protected]

Parent participation is a key issue in children’s health care both here in Ireland and internationally. Although nurses are expected to enter into partnership with families in the provision of care (Commission Report, 1998), research on parent participation from the UK (Darbyshire, 1992; Callery, 1995), from Sweden (Kristensson-Hallstrom and Elander, 1994), from Australia (Keating and Gilmore, 1996) and from the USA (Knafl et al, 1988 and Brown and Ritchie, 1989;1990) indicates that parent participation is a complex, multi-dimensional and problematic concept that nurses find the concept difficult to understand and apply in practice. There has been no research to date in Ireland which has explored parent participation from the perspective of all three participants – parent, child and nurse. There is also a paucity of research from the child’s perspective on the issue of parent participation. Therefore this research project will focus on developing an understanding of parents and children's experiences of consultation and involvement in care during periods of hospitalization. The project will provide information on the practice and application of parent participation in the Irish context and will also build on the knowledge base for nursing in general by uncovering how roles and relationships are negotiated within the clinical setting. Previous research on parent participation has primarily been

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

descriptive thus indicating a need to develop a theoretical perspective on parent participation in order to explain the underlying process. The data collected during this study will contribute to the theoretical framework which Dr. Imelda Coyne developed in her PhD study, which in turn should enhance the applicability and generalisability of the theory across many paediatric settings. The study aims to (a) research parents, children's and nurses experiences of participation and negotiation of care in the hospital setting, (b) to understand how parents, their children and nurses negotiate roles and relationships within the hospital setting, (c) to explore the conditions, effects and management of participation and (d) to generate a theory explaining the process of participation. References: Bradshaw, M ., Coleman, V., Cutts, S., Guest, C and Twigg, J (2001) Family centred care: a step too far. Paediatric Nursing 12(10), 6-7 Lee, P (1998) An analysis and evaluation of Casey’s conceptual framework. International Journal of Nursing Studies 35, 204-209 Smith, L., Coleman, V and Bradshaw, M (editors) (2002) Family-centred care: Concept, theory and practice. Hampshire: Palgrave

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Breach Avoidance Facilitator Mr Gerard Cronin RN ENB 199, BSc(Hons) Nursing MA Healthcare Management, FFEN A & E Senior Nurse & Modern Matron A & E Department Basildon Hospital Foundation Trust Nerthermayne Basildon Essex SS16 5NL England + 44 1268 533911 [email protected] Miss Julie Wright RN ENB 199, Diploma in Research Emergency Services Project Facilitator Basildon Hospital Foundation Trust Nethermayne Basildon Essex SS16 5NL England The publication of the NHS plan (2000) has created a climate of change and opportunity within the National Health Service (NHS) of the United Kingdom. It has challenged managers and clinicians to provide a visionary transformation on how health care is delivered and managed. It has challenged both practitioners and recipients of health care. The Department of Health drive to introduce the 4-hour emergency care target has been based on the recommendations of the Reforming Emergency Care document (DOH 2001). Many acute trusts have attempted to initialise a myriad of programmes to improve the patients experience and meet the governments target in this sector. This presentation aims to explore the concept of the Breach Avoidance Facilitator (BAF) within the A&E department of an acute Foundation Trust. The background to the introduction of the BAF role was an acute examination of the issues affecting the A&E performance against the 4-hour target. Our April 2003 performance was 64.83%. It was clear that a programme of radical change would have to be introduced. We decided to introduce the role of BAF and place our most senior A&E sisters in this role. We wanted to capitalize on their extensive clinical experience; organizational excellence and positive established working relationships within the organization. The objective of the BAF is to assist the department to meet the 4-hour target The BAF is supernumerary, completely clinically based and takes pre-emptive managerial action to avoid patients breaching the 4-hour target. The role of the BAF include: • Supervising junior staff • Coordination of resources

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

• • • • • •

Monitoring of departmental activity Accounting for all breaches of the A&E 4-Hour target Chasing practitioners in relation to delayed decision-making Chasing support services such as imaging and pathology when delays are encountered Completion of an electronic handover form Liaison with the bed managers re bed allocation

A number of challenges were identified when the role was first introduced. These include: problems in relation to role definition and the perceived loss of clinical skills. It is our vision that the role of the BAF will evolve to improve the patient experience of A&E services, include more formal clinical supervision and increasing amounts of clinically based teaching. References Department of Health (2000). The NHS Plan. London. Crown Copyright. Department of Health (2001). Copyright.

Reforming Emergency Care.

London.

Crown

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Why do newly qualified Registered Nurses choose to work in an Accident & Emergency department? Mr Gerard Cronin RN ENB 199, BSc(Hons) Nursing MA Healthcare Management, FFEN A & E Senior Nurse & Modern Matron A & E Department Basildon Hospital Foundation Trust Nerthermayne Basildon Essex SS16 5NL England + 44 1268 533911 [email protected] Mrs Camille Cronin RN Bsc(Hons) Nursing, MSc, MEd, PGCE Teaching Fellow University of Essex Southend [email protected] The recruitment of Registered Nurses (RN) to all specialities in the health care sector is now a global business and an international problem (Kennedy 1999, Buchan and O’May 1998, Buchan 1994). Nursing staff working in demanding areas such as emergency care are likely to spend considerable time working and being involved in intense interactions with people all day (Gillespie and Melby 2003). The nature of emergency care is physically demanding and nursing staff are faced with significant demands ranging from meeting patient care needs, coping with persistently high turnover of patients and high degree of work pressure (Malach-Pines 2000). The recent introduction of the Accident & Emergency (A&E) 4 hour target (DOH 2000) has changed the boundaries of A&E work. The staff involved in service delivery are now working in a performance-managed environment. When staff work under such circumstances this can lead to chronic stress and eventual burnout. This would suggest that the A&E department could be an unattractive care environment to work in. Locally Basildon A&E department has a strong reputation in employing, retaining and developing newly qualified staff nurses within the A&E setting. Encouraging newly qualified RNs to work in the A&E speciality has not been previously examined. There is a paucity of research in this area. Only a minority of UK A&E departments will consider accepting applications from this group of staff. Many departments have a policy of not accepting newly qualified RNs. Reasons for this include a perceived lack of acute experience and skills, poor interpersonal skills and turnover that remains the highest among younger staff (Gray and Phillips 1994, McCarthy et al 2002). The presentation will outline the results of a study that was carried out to identify the key reasons why newly qualified registered nurses choose to work in an A&E environment.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

A qualitative approach was used in order to identify the reasons why newly qualified staff nurses choose to work in an A&E. Focus group interviews were used to collect and validate data. In total a convenience sample of 25 newly qualified staff nurses participated. Focus group interviews took place on three occasions over a period of 18 months as each wave of the induction programme was introduced. On each occasion between 8-10 participants took part in the interviews that lasted approximately one to one and half hours Five main themes from each group were identified and then each participant had the opportunity to rank the themes in relation to importance (i.e. what they felt were important reasons for choosing to work in A&E). The presentation will explore the results of the study. This information will be attractive to Nurse Managers and Nurse Practitioners working in the field of Emergency Care. It will also be relevant to workforce planners with particular responsibility for recruitment in Emergency Care References Buchan J (1994) Where do your staff go? Nursing Management. 1(4). 16-17 Buchan J, O’May F (1998). Nursing supply and demand: reviewing the evidence. Nursing Times,94(26),167-178. DOH (2000). The NHS Plan. A plan for investment. A plan for refrom. Crown Copyright HMSO. London. Gillespie M, Melby V (2003). Burnout among nursing staff in accident and emergency and acute medicine: a comparative study. Journal of Clinical Nursing, 12:842-851 Gray M, Phillips VL. (1994). Turnover, age and length of service: a comparison of nurses and other staff in the National Health Service. Journal of Advanced Nursing. Vol 19 819-27. Kennedy A (1999). A problem shared. The World of Irish Nursing. July/August,1415. Malch-Pines A (2000). Nurse’s burnout, an existential psychodynamic perspective. Journal of Psychosocial Nursing, 38:23-31. McCarthy G, Tyrrell MP, Cronin C (2002). National Study of Turnover in Nursing and Midwifery. Dublin: Department of Health and Children.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Using the Patchwork Text as a vehicle for promoting interprofessional health and social care collaboration in Higher Education. Jayne Crow. MSc, BA(Hons), RGN, Cert. Ed. (Senior Lecturer. APU) Shirley Jones. M.Ed. MCSP. DipTP. (Senior Lecturer. APU) Lesley Smith. MSc, BSc(Hons), Cert. Ed. (Senior Lecturer. APU) Contact address: School of Community Health and Social Studies. Anglia Polytechnic University. Bishop Hall Lane, Chelmsford, Essex. CM1 1SQ 01245 493131 ext: 4822 e-mail: [email protected] fax: 01245 495708 pager: 07654 317802 Abstract The promotion of effective interprofessional collaboration is very high on the UK government’s agenda for reform and modernisation of the Health and Social Care Services. How to educate toward effective interprofessional collaboration between professionals and between professionals and service users in the Health and Social Care arena is a thorny issue and one with which lecturers in Higher Education in the field are currently grappling. We and our colleagues have been developing our curriculum and teaching in this subject over a number of years and have researched this process using an Action Research framework. This presentation shares our work to date and in particular our use of the Patchwork Text as an innovative form of teaching, learning and assessment. We describe the Patchwork Text process and our experience of using it with our students. We report the findings of a small exploratory study examining the student experience of the Patchwork Text on module focussing on interprofessional collaborative practice in health and social care. We collected data from students via open-ended questionnaires and a focus group discussion. The findings that emanate from thematic analysis of the data indicate that the iterative process of the Patchwork Text reflects the skills that facilitate interprofessional collaboration in the practice setting and we will discuss the potential of the Patchwork Text to facilitate such collaboration. References Crow, J. Smith, L. and Jones, S. (2005) Using the Patchwork Text as a vehicle for promoting interprofessional health and social care collaboration in Higher Education. Learning in Health and Social Care 4.3.117-128.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Crow, J. Smith, L. (2003) Using co-teaching as a means of facilitating interprofessional collaboration in health and social care. Journal of Inter-professional Care. Vol 17.No.1.45-55. Crow, J. Smith, L. (Accepted for publication in 2005) ‘Co-teaching in Higher education: Reflective Conversation on shared experience as CPD for lecturers and health and social care students’. Reflective Practice. Smith, L. & Winter, R. (2003) Applied Epistemology for Community Nurses: Evaluating the Impact of the Patchwork text. The Patchwork Text: A Radical Reassessment of coursework Assignments. A Special Issue of Innovations in Education and Teaching International. Vol. 40 No. 2, p. 161-179. Winter , R. (2003) Contextualizing the Patchwork Text: Addressing Problems of Coursework Assessment in Higher Education. The Patchwork Text: A Radical Reassessment of coursework Assignments. A Special Issue of Innovations in Education and Teaching International. Vol. 40 No. 2, p. 112-122.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

A STUDY TO INVESTIGATE THE INCIDENCE OF DIASTASIS RECTI ABDOMINIS OF PRIMIPAROUS WOMEN DURING THE THIRD TRIMESTER OF PREGNANCY S. Downey (BSc (Hons) Physio), M. Russell (BSc (Hons) Physio), E. CulletonQuinn¹ (MEd, BSc (Hons) Physio) ¹School of Physiotherapy, TCD, e-mail: [email protected], Ph: 00353 1 6082123 Diastasis recti abdominis (DRA) is a condition in which the rectus abdominis muscle separates in the midline at the linea alba. Where this condition occurs antenatally it may potentially contribute to back pain during pregnancy and an ineffective push during the second stage of labour. The primary aim of this study was to identify the incidence of DRA during the third trimester in a primiparous population. Aetiological factors were also investigated. One hundred and one women who took part in antenatal classes at a large Dublin maternity hospital during November and December 2002 were invited to participate in the study. Out of these, 62 women were eligible for and agreed to take part in the study. Measurements of the distance between the rectus bellies, rectus abdominis distance (RAD), were taken using dial callipers. An RAD of greater than 25mm was considered to be a diastasis. The women were measured while performing a gentle curl up in the crook lying position. A questionnaire was administered to collect data concerning maternal demographic characteristics and self – reported exercise histories. These were then examined in relation to the incidence of DRA. Results showed an incidence of DRA of 66% in the subject group. The incidence of DRA was higher among women with above average weight gains in pregnancy (p < 0.01) and above average BMI at the time of measurement (p < 0.05). The performance of abdominal muscle exercises during the first and second trimesters of pregnancy appeared to decrease the incidence of diastasis (p < 0.001). In conclusion DRA appeared to be relatively common in the third trimester. Factors such as weight gain, BMI and abdominal exercise appeared to influence the incidence of diastasis. A large scale prospective studies would be needed to adequately examine the incidence of and aetiological factors influencing diastasis recti abdominis in the childbearing year.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Infertility, Ethnicity and Health Professionals Lorraine Culley BA MA PhD Reader in Health Studies Faculty of Health and Life Sciences De Montfort University Leicester LE1 9BH Email: [email protected] Nicky Hudson BA MA Research Fellow Faculty of Health and Life Sciences De Montfort University Leicester LE1 9BH Within the UK, approximately one in six couples seek specialist help at some time in their lives because of fertility problems and the demand for infertility services is increasing, largely due to raised public awareness of treatment possibilities. Infertility can lead to considerable distress. An extensive collection of studies show that involuntary childlessness can be a devastating experience for many, with significant consequences for social and psychological well-being (Monach 1993, Inhorn & Van Balen 2002). However, most research has been carried out with white, middle class, treatment seekers and has ignored those from minority ethnic communities (Greil 1997). This paper reports on one aspect of the first major study of infertility and ethnicity carried out in the UK (Culley et al 2004). The project aimed to explore the social meanings of infertility within four main South Asian communities (Bangladeshi and Pakistani Muslims, Gujarati Hindu and Punjabi Sikh communities) in three English cities and to examine the experiences of infertility service users from these communities. Although there are many similarities between the experiences of minority ethnic patients and couples from the majority population who access infertility treatment, this study suggests a number of key issues which are of particular relevance for minority ethnic communities and the significance of these will be outlined. The main focus of the presentation however, will be a discussion of the data generated from individual, semi-structured interviews and group interviews with health professionals (n=23) working with South Asian infertility patients. It outlines their perceptions of ethnicity and diversity, perceptions of patients’ knowledge of fertility and infertility; their role and experiences in communication support and counselling of South Asian infertility patients and their assessment of educational needs in relation to delivering healthcare appropriate to the needs of minority ethnic communities. Providing health services in a diverse society is often a challenge for professionals and patients (Culley 2000). This paper also discusses key recommendations for health professional practice in infertility care and presents a resource developed for professionals working in this field.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Culley, L. (2000) Working with diversity: Beyond the factfile. In C. Davies, L. Finlay & A. Bullman (Eds) Changing practice in health and social care. Sage (pp.131142.). London Culley, L. A., Rapport, F., Katbamna, S., Johnson, M. & Hudson, N. (2004). A Study of the Provision of Infertility Services to South Asian Communities. Leicester: De Montfort University. Greil, AL. (1997). Infertility and psychological distress: a critical review of the literature. Social Science and Medicine, 45 (11), 1679-1704. Inhorn, MC & Van Balen, F. (2002) (eds) Infertility around the Globe. New thinking on Childlessness, Gender and Reproductive Technologies. California: University of California Press Monach, J. H. (1993) Childless: No Choice: The experience of involuntary childlessness. Routledge: London.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

IN SEARCH OF A THEORY: USING A FOCUS GROUP INTERVIEW DEVELOPMENTALLY Ms Elizabeth A Curtis Lecturer School of Nursing & Midwifery The University of Dublin, Trinity College 24 D'Olier Street Dublin 2 Ireland This presentation is an excerpt from a large study on job satisfaction among nurses in the Republic of Ireland. A key task within this study was to select a theory of job satisfaction that could be incorporated into the study’s framework. Such a task could easily be achieved by reviewing the theoretical literature. This researcher, however, wanted to avoid selecting a theory that was based solely on a review of the literature, or for that matter, on her personal preference. In this researcher’s opinion, a more appropriate approach to selecting a theory is to do so after exploring the views and opinions of a sample of nurses through the use of a focus group interview. A focus group interview can be used in a number of different ways. In the present study, however, it was used as part of a mixed-method study on job satisfaction. The purpose of the focus group interview was twofold. Firstly, to explore nurses’ views and experiences about (a) their work, (b) the organisation where they worked and (c) the factors that contributed to their job satisfaction. Secondly, to use the focus group developmentally, wherein the data would be used to assist this researcher in selecting a suitable theory of job satisfaction and also in planning a questionnaire survey. The focus group interview was conducted in April 2002. The interview commenced at 10.00 and continued for two and a half hours. The participants were selected using a purposive sampling strategy. The original number of participants recruited to form the group was seven but only six participated. One participant had to withdraw due to work commitments (night duty). A facilitator was selected by this researcher to conduct the interview. A semi-structured format was used and the interview guide was designed using questions rather than a set of discussion topics. It is important to stress, however, that although a semi-structured format was used the interview was not a facilitator-dominated discussion. All research is based on trust and cooperation between the researcher and respondents. For this reason, ethical considerations were paramount not only with regard to the focus group interview, but throughout the entire study. Information packs were prepared for every participant in the focus group. Each pack contained the following information: (a) a copy of the ethical protocol developed by this researcher and used to guide the entire study - this protocol included a statement on how anonymity and confidentiality were to be upheld, (b) a copy of the consent form, (c) information outlining the research problem, purpose of the research study, justification for the study, and purpose of the focus group interview. In addition, participants were

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

reminded at the beginning of the interview that as volunteers, they were free to withdraw from the study if they so wish. An independent observer was recruited for the interview. The role of the independent observer was to ensure that the interview was conducted according to the procedures prepared for the study and that ethical guidelines were adhered to. Finally, this study was granted ethical approval from the University of Dublin, Trinity College. The data from the focus group was analysed using ‘note-based analysis’. The findings indicated that a specific set of factors were responsible for job satisfaction while a different set of factors contributed to job dissatisfaction. Factors such as “working in a self selected speciality”, “knowing patients are satisfied with their care”, and “autonomy” contributed to nurses’ job satisfaction. Factors, such as “lack of control over staff shortages”, “increased workload”, and “inadequate working conditions” and “not having management support” led to job dissatisfaction. These findings would appear to be similar to the principles described in Two-Factor theory. Consequently, Two-Factor theory was incorporated into this study’s framework.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AN EVALUATION OF A CARERS SUPPORT SERVICE IN A RURAL AREA: PILOT STUDY Mary Rose Day, MA (Social Service Administration) BSc (Nursing) Hdip PHN Dip Manag RPHN RM RGN College Lecturer Catherine McAuley School of Nursing and Midwifery Brookfield Health Science Complex, University College, Cork. Recent policy documents in Ireland have recognised that health systems must become more people-centred with the interest of public patients clients and carers being given greater prominence and influence in decision making at all levels. Family carers are being required to provide increasingly complex care for their relatives in the community so it is important they have access to a wide range of good quality services and supports. The aim of this project was to evaluate the work of a Carers Support Group in a rural area that includes peninsulas and inhabited islands. The objectives were to assess the service delivery model that is in place to support Carers; the usage benefits and satisfaction levels of Carers with the support services and the perception of health professionals and their knowledge, awareness and linkages with the group. Both a qualitative (focus groups carers) and quantitative (questionnaires carers and health professionals) approach was selected to carry out the evaluation. The pparticipants included Carers who were on the register of the support group and health professionals providing services in the region. In the findings Carers described the support services as a valuable resource to acquire up to date accurate, relevant and reliable information. The establishment of the service gave Carers recognition and a voice to work collectively to improve the lives of Carers in this rural area. Support Group sservices helped reduce feelings of isolation and facilitated connections to be made with other carers in the region. The service model in operation recognised Carers as key partners, had structured involvement of Carers and worked in partnership with both statutory and voluntary agencies in the region. Overall, the nurses and health professionals who were involved in the evaluation were positive about the services and felt it played a key role in supporting Carers as well as reducing their sense of isolation. They were aware of several of the services provided by the support group yet only 54% of health professionals who participated in the study had made referrals to the service. To conclude the results add support to the value of offering a range of interventions to support Carers in their role. Support services play a key role in supporting individuals to remain in the community, however nurses and health professionals may not be sufficiently aware of the importance of certain types of support services for carers and

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

this could have implications. Primary health care staff need to develop systems, which engage them in identifying and supporting carers.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

SUPPORTING CARERS Mary Rose Day, MA (Social Service Administration) BSc (Nursing) Hdip PHN Dip Manag RPHN RM RGN College Lecturer Catherine McAuley School of Nursing and Midwifery Brookfield Health Science Complex, University College, Cork. The majority of older people and people with disabilities people are cared for in their own homes (Department of Health and Children (DOH & C), 20001a, b) this has put increased pressure for care on families and carers. There is increased recognition of the importance of supporting carers in maintaining their health and well-being (Department of Health (UK) 1999, Levine, 1999, Southern Health Board, 1999). Banks, Cheesman and Maggs (1999) identified eight key areas as important to meeting carers needs. They are a voice, recognition, information, time off, quality services, emotional support, training and support to care and financial security. The Carers Unit was set up in 2000 in the Southern Health Board (SHB) (now the Health Service Executive, Southern Region) to support carers. It took an innovative and wide-ranging approach in supporting carers. The type of supports developed include a Newsletter “The Carers Voice” with the support of the Department of Social and Family Affairs (DSFA), booklet “The Importance of Supports and Networks for Carers” in partnership with the SHB, DSFA and Cork City Partnership, training courses, support groups, support line, as well as information sessions. The Carers Unit in partnership with the Community Dieticians developed a video on ‘Eat Well to be Well’ and volunteers have trained and are delivering workshops on nutrition to groups in the community. Service model is person-centered, works in partnership with key stakeholders to address the social, economic and environmental influences on the health of carers, and recognizes that improving the health of populations is impossible for any one organization on its own (DoH & C, 2001a). Sharing best practice and audit has been a key part in the development of supports. References Banks, P. Cheeseman, C. Maggs, S. (1998) The Carers Compass: Directions for improving support to Carers Kings Fund UK Department of Health and Children (2001a) Quality and Fairness: a Health system for You Dublin: Stationery Office Department of Health and Children (2001b) Primary Health Care A new Direction Stationery Office Department of Health (1999) (UK) Caring About Carers: A National Strategy for Carers Department of Health: London Levine, C. (1999) Home sweet hospital: the nature and limits of private responsibilities for home health care Journal of Ageing and Health 11, 341-359 Southern Health Board (1999) Ageing with Confidence Southern Health Board: Cork

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Mental Health Nurse perspectives on membership within multidisciplinary teams. Rick Deady College Lecturer, UCC MSc Nursing, Bsc (Hon) Psychology, Dip Child Psychology, Cert Ed (FE), Cert Health Ed, RNT, RPN, RGN. Catherine McAuley School of Nursing & Midwifery, Brookfield Health Science Complex, University College Cork, Cork. During recent research (Deady, 2002) that investigated whether there currently existed amongst Irish mental health nurses a collective set of attitudes, values or beliefs, a number of issues were identified that enlightened upon their perceived role within the multidisciplinary team. The study supported Cowman et al's (1997) findings of a multifaceted role and Rogers et al's (1993) suggestion that the quality of the nurseclient relationship as perceived by the client, distinguishes Mental Health Nursing from other care disciplines. However, although the study suggested that these nurses support the need to emphasis the caring aspect of their role, this practice was perceived by the nurses as being undervalued within the multidisciplinary team. In addition, the nurses felt that they were used in a “Jack of all trades” manner that hindered the development of therapeutic roles and resulted in an ad hoc and reactive nature to their practice. This style of practice is now being perceived by clients as unsatisfactory (Cork Advocacy Network, 2001, Focusing Minds, 2002). This paper suggests that a clear delineation of what the role of psychiatric and mental health nursing should involve would enhance the professional status of the discipline within the multidisciplinary team and would positively impact on client care. Cork Advocacy Network (2001) Inaugural Forum: theirs got to be a better way, Dury's Hotel, Cork: CAN, Dromina, Charleville, Co.Cork. Cowman, S., Farrelly, M. and Gilheaney, P. (1997) The role and function of the psychiatric nurse in clinical practice, Dublin: St. Vincent's Hospital Fairview and The School of Nursing Dublin City University. Deady, R. (2002) A phenomenological investigation into how the attitudes, values & beliefs of Irish trained psychiatric nurses influence their lived experience of nursing practice. Psychiatric Nursing, Dublin: PNA, Vol 3, Issue 1. Focusing Minds (2002) Developing mental health services in Cork and Kerry, Cork: Southern Health Board. Rogers, A. Pilgrim, D. & Lacy, R. (1993) Experiencing psychiatry: users views of service, London: MacMillan.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Guiding students through reflective practice - the preceptors' experiences Anita Delaney Duffy RGN, BSC Nursing Management, RNT, M.Sc Nursing. Faculty of Nursing and Midwifery, RSCI, Dublin 2.

Background: Reflective practice and preceptorship have attracted substantial discussion in the in the field of nursing over recent years. This study took place during an era of significant change in Nurse education in Ireland. Nurse education is in a transition stage having evolved from certificate to diploma level, with current students undertaking a degree level of education. The students who trained under the apprenticeship style programme are presently working as preceptors with today’s students. Whilst the preceptor’s role exists, a problem arises due to the lack of a recognised framework of support. Recent Nursing strategies recognize there is a need to support and develop staff where students are assigned. Guided reflection, as a model of clinical supervision, may be a convention for nurses to consider the eminence of their actions. There is a paucity of Irish research in relation to the factors, which impede or facilitate guided reflection through clinical supervision Methodology: This study utilises a qualitative descriptive approach to illuminate qualified nurses' experiences relating to the process of facilitating student nurse’s guided- reflections. The actual research approach and design placed an emphasis on internal validity rather than external, therefore any claims to generalisability are unlikely. Analysis of the data revealed that preceptors had little or no experience of using guided reflection within the preceptorship process. Factors, which contributed to these findings, included the training and development of preceptors, the critical relationships within the preceptorship process and the preceptor’s experiences of reflection in the past, the present and the anticipated future benefits of the process Conclusion: Currently anecdotal evidence suggests that the application of reflection to practice is poorly developed in the practice area, with further research strongly recommended. Guided reflection is a catalyst for professional development and life long learning. It is hoped that the consequence of this study will be considered to embrace recommendations for practice, education and further research

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Educational Needs of Nurses Providing Sexual Health Care in Ireland Ms. Sandra Delamere Advanced Nurse Practitioner MSc, BNS, SCM, SRN GUIDE Clinic, St. James’s Hospital, James’s St, Dublin 8. Ms. Bróna Mooney Lecturer in Nursing Studies MSc. Nursing (Education), B.N.S. (Hons.) R.G.N., R.N.T. Certificate in Critical Care Nursing. School of Nursing and Midwifery, Trinity College Dublin, 24 D’Olier St, Dublin 2. The Commission on Nursing (1998) recognised the need for a coherent approach to the progression of specialisation and the development of a clinical career pathway for nurses. Specialist nursing is highly valued as a clinically focused professional activity which enables nurses to deliver competent/expert care to clients in a variety of healthcare settings. Once such area is that of sexual healthcare. A national survey was carried out to gain an understanding of the educational needs of nurses working in sexual health services in the Republic of Ireland. Data was collected using an anonymous questionnaire and results suggest that in order to meet the challenges of nurses working in sexual healthcare a need exists to develop an academically accredited course that will prepare and enable nurses to deliver research based, holistic and innovative specialist nursing care in the area of sexual health. Government of Ireland (1998) Report of the Commission on Nursing: A blueprint for the future. Dublin: Government of Ireland.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

FIGHTING FALLS WITH ACTION RESEARCH: A PRACTICE DEVELOPMENT PROJECT Authors Names: Dempsey Jennifer Doctor of Nursing, Master of Nursing Studies, Graduate Diploma of Nursing, Graduate Certificate of Emergency Nursing, Registered General Nurse, Registered Psychiatric Nurse. Contact Address: Jennifer Dempsey Clinical Nurse Consultant Medical Stream Central Coast PO. Box361 Gosford NSW 2250 Australia. Contact Email: [email protected] ABSTRACT Nurses espouse a caring ethic and demonstrate effectiveness in prevention of patient falls but are often observed taking risks with patients’ safety. These actions reflect poor congruence between espoused values and behaviours. Attitudes, values and involvement in decision-making are factors that influence work behaviours. Nurses’ attitudes are held to be a definitive factor in prevention work; however, few studies have focused on adherence with best practice principles of fall prevention. Yet nurses claim no authority to change their work. It was assumed that increased adherence would be achieved by improving nurses’ attitudes through participation in decisionmaking surrounding fall prevention practice. This study aimed to test this assumption by empowering nurses working in two medical wards with high numbers of patient falls to improve their ownership of practice by utilising critical social theory and action research. Nurses’ attitudes, including self-esteem, professional values and work satisfaction were established before and after a practice development project using action research. Mixed methods were employed by praxis groups meeting fortnightly for a year reflecting on, and re-engineering practice. Action research occurred in cycles focusing on assessment, communication, everyday work, and performance. Nurses’ work was re-organised to gain time to spend in prevention work. Patients’ environments were made safer and more patient-centred. New and effective ways of assessing risk to fall, communication of risk and monitoring nurses’ performance of prevention work were created and evaluated. Analysis demonstrated that nurses had good self-esteem and professional values but were not satisfied with their work. Self-esteem and professional values were unaffected by participation in work-related decisions however, nurses expressed increased sense of ownership, more satisfaction and were observed to engage in more prevention work. In conclusion, manipulation of attitudes and values is not warranted if attitudes and values are good. However, participation in work-related decision-making engages practitioners and leads to greater congruence between values and behaviour. The “unspoken rules” constraining practice that were exposed in the action research oblige nurses to assume authority, confronting and dispelling these constraints to enable more therapeutic care to emerge. Recommendations include promoting practice development as the preferred means for cultural change and improving person-centred care whilst recognising its fragile nature and dependence on clinical leadership.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Role Transition from Clinical Nurse to Nurse Lecturer Laura Dempsey RGN, RNT, Dip NS, BNS, Pg Dip CHSE, MSc. Lecturer Centre for Nursing Studies NUI, Galway

Phone : 091 492013 E mail: [email protected] Aim of the Study: To investigate a select cohort of nurse lecturers in Ireland who have undergone a role transition from clinician to educator. Background of the study: Nurse education in Ireland has undergone dramatic changes over the last ten years with schools of nursing relinquishing its former close association with health boards and hospitals and moving into third level education. The role of the nurse tutor has evolved to meet these educational demands. A review of current literature pertaining to the topic of interest revealed an abundance of international literature on the subject of interest however the researcher failed to uncover any empirical Irish literature on the experiences of nurse novice lecturers in this country. This absence of Irish research posed the research question, what are the experiences of novice nurse lecturers who have undergone a role transition from clinician to educator? Methodology: The methodological approach selected for this study is a qualitative descriptive study. Six research participants were selected through the utilisation of purposeful sampling. After ethical approval, and conducting a pilot interview, research data was obtained utilising semi structured interviews. A comprehensive manual analysis of the data was conducted using the data analysis tools of highlighter pens and a scissors to identify emerging codes. In addition, a series of sequential conceptual steps from Leininger (1985) was followed to thematically analyse the transcribed interview dialogue. Findings: Participants reported to have encountered a negative experience during the initial stage of the role transition, with reports of feeling frightened, daunted and stressed during this transition period. The educational preparation that participants received was extremely beneficial for their role as nurse lecturer however inadequacies were reported in the setting and marking of exam papers and underpreparation for the administrative role of the nurse lecturer. Collegial support was the main facilitating factor that participants had available to them. The need for obtaining feedback from their senior colleagues and having a mentor available to them to aid their transition was further highlighted. A low self-confidence in their ability to adequately perform their role further hindered participant’s transition, in addition to a heavy workload and not enough time to perform their role satisfactorily. In addition, all participants expressed that they did not receive an acceptable orientation to their working environment and new role. However despite criticisms of their role transition, participants found the evolution from clinician to educator to have been a positive event.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Conclusion: This study highlights the experiences of novice nurse lecturers who have undergone a role transition from clinician to educator. The findings from this study highlight that all participants have experienced a similar transition process despite geographical and organisational differences. Initially, participants found the transition difficult and despite having completed an educational course prior to commencement of their role, participants still found themselves under-prepared for certain aspects of their new role. Concluding that despite the initial fears and anxieties experienced, participants expressed an overall positive attitude for their role transition. Reference: Leininger, M.M. (1985) Qualitative Research Methods in Nursing. Philadelphia: W.B. Saunders Company

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Exploring Multiple Intelligence Theory In The Context Of Teaching And Learning In Undergraduate Nurse Education In Ireland. Margaret Denny ,RPN,RBT,RNT,DipProSt,BSc,PGDipCHSE., M.Phil.Applied Psychology. Lecturer, School of Health Sciences, Department of Nursing, Waterford Institute of Technology, College Street Campus, Waterford. Ireland. Phone No: 00-353-51-302816 E-Mail: [email protected] The abstract is taken from on going research for a PhD. in Applied Psychology at the National University of Ireland, University College Cork under the supervision of Professor Maxwell Taylor, Head of Applied Psychology, University College Cork. This presentation reports on the first year preliminary findings of this ongoing research. Abstract On exploring the Irish literature to date, no data were found ascertaining the potential of Multiple Intelligence (MI) or the adoption of such teaching approaches in nurse education. MI theory suggests the presence of a number of recessive intelligences in addition to the dominant intelligences, that is, verbal linguistic and logical mathematical (Gardner 1993). Gardner’s (1993) theory proposes that individuals have multiple intelligences rather than a single intelligence and the potential to harness and develop all intelligences is possible. These differences clearly illustrate why it is imperative for educationalists to expand the definition of intelligence from its singular status to its plural coexistence. Gardner (1993) described seven equal and autonomous intelligences in 1983 and eight intelligences in 1995. The MI’s that he proposed are linguistic, spatial, logical mathematical, musical, naturalistic, bodily kinaesthetic, intrapersonal, and interpersonal. What Gardner (1993) is suggesting is that people learn in different ways and by different approaches and lecturers need to employ specific learning and teaching methods during the learning process. MI facilitates instructional environments where student’s and lecturer’s multiple intelligences can be exemplified, thereby, allowing both parties to become actively engaged in the learning process. Kershaw (2004) highlights the importance of identifying and nurturing individual skills and aptitudes in students. Teaching for learning using brain-based approaches is one means through which the individualised educational needs of students’ can be transformed. Many gaps remain in the evidence base pertaining to conceptual and educational aspects of learning. The current research study examines how an MI teaching technique such as Multiple Intelligence Teaching Approach (MITA- Weber, 1999) is a means of initiating change within an integrated studies context. It

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

exemplifies multiple ways of knowing content and explores performance-based assessment as part of the active learning process (Weber, 1999). Arguably this departure will contribute to the present post-technocratic model of education, and to the conceptual understanding of MITA application together with brain-based approaches to teaching and learning in third level education. An across method triangulated approach is used to address the research objectives. This involves mutual collaborative action research and as part of the quantitative component of the research study a general quasi-experimental approach known as a ‘Simple Interrupted Time Series’ and ‘Interpretable Non-Equivalent’ group design approach, is used (Heppner 1992; 1999). This involves two samples (Simple interrupted time series group- year 2 BSc in Intellectual Disability Nursing) and Interpretable non-equivalent group –(BSc in Psychiatry year 2). This allows for a comparison of observations before and after interruption and a comparison between both groups (Heppner 1992; 1999). It requires multiple observations over time and the introduction of interruption (Multiple intelligence teaching approaches- treatment group) at specified points during the theoretical component of the students’ year. Data analysis will involve performing an independent t-tests and a two-way ANOVA, and ANCOVA on first year findings. The research is currently undertaken in an academic institution in the South East of Ireland. The target population is twenty one second year nursing students undertaking the BSc in Intellectual Disability Nursing and twenty six second year nursing students undertaking the BSc in Mental Health Nursing. Students’ and lecturer MI profiles were identified through the administration and analysis of the ‘Multiple Intelligence Development Assessment Scale’ (MIDASShearer, 1996). The researcher, as part of the study, has undertaken a certification course for MITA, level one, at the Brain Based Renewal Centre in Rochester, New York. It is proposed that the research outcomes will contribute to the conceptual understanding of MI and MITA brain based approaches, raise awareness, and impart a more in-depth understanding of the significance of MI and MITA approaches to teaching and learning in contemporary nurse education. Key words: Multi-method Research; Brain Based Approaches; Nurse Education. Gardner H. (1993) Frames Of Mind. New York: Basic Books. Kershaw B. (2004) Educating nursing students as individuals. Guest Editorial. Journal of Advanced Nursing. London: Blackwell Publishing. Shearer B. (1996) Multiple intelligence development and assessment scales. Ohio: Multiple Intelligences Research and Consulting Inc. Weber E. (1999) Student Assessment That Works. A Practical Approach. Needham Heights, MA: Allyn And Bacon.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Evidence-based clinical practice guidelines for midwifery-led care: Challenges and strategies in their development. Devane D,1 Begley CM,1 McCann C,2 Hughes P,3 Maguire R,4 Molloy K,3 Finan A,3 Higgins S,2 Ahmed S,3 Vaughan D,2 Clarke M.5 Clinical practice guidelines are integral to linking best available evidence with best clinical practice. International interest in these stems from a desire to improve the quality of care for health care users, concerns regarding variations in clinical practice and the increasing availability of evidence on the effectiveness of different forms of care. Clinical practice guidelines are systematically developed statements, which assist practitioners and health care users to make well-informed decisions about the most appropriate health care for specific circumstances. Guidelines have the potential to increase the use of effective care and reduce the use of ineffective or harmful forms of care. Although there is an abundance of information on the importance of, and the process for, developing clinical practice guidelines, there is little information on the practical difficulties and challenges encountered and strategies employed in their development. This paper aims to redress this balance, and focuses on the lessons learned in the collaborative process of developing evidence-based, clinical practice guidelines for midwifery-led care in the first midwifery-led units in the Republic of Ireland. The prevalence of medical-led models of care and the cultural, political and economic challenges in the Republic of Ireland, mean that the lessons learned will be relevant to other individuals and organisations involved in guideline development. We will address issues such as project management (philosophy, project sponsorship, development group composition, topic selection), method of reviewing evidence (searching the literature, assessment of quality); generating recommendations (interpretation of evidence, balancing risks and benefits, issue of lack of evidence on certain components of care, separating science from opinion) and intra and interprofessional collaboration. We will provide examples of actual guidelines developed using this process and specific challenges faced and overcome in their production. 1

School of Nursing and Midwifery, Trinity College Dublin, Ireland. Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland. 3 Cavan General Hospital, Cavan, Ireland. 4 Louth County Hospital, Dundalk, Co. Louth, Ireland. 5 UK Cochrane Centre, Oxford, England. 2

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Screening for mental health problems in people with learning disabilities in Northern Ireland using the Mini PAS-ADD Interview (Moss 2003) Authors Mr Maurice Devine RNLD, RGN, DN, CNLD, BSc Hons, Community Nursing, Adv Diploma Nurse Education Nurse Consultant Thompson House Hospital 19/21 Magheralave Road Lisburn BT28 3BP Northern Ireland + 44 28 92673913 [email protected] Dr. Laurence Taggart Lecturer University of Ulster Background: There is strong empirical evidence that people with learning disabilities have a higher incidence of developing mental health problems compared to their nondisabled peers. Individuals not recognised cannot be fully assessed and more importantly treated effectively resulting in distress for the individual, their carers and service providers. Despite the availability of screening instruments designed specifically for this population, no studies have been undertaken to identify the prevalence rates of mental health problems in this population in Northern Ireland. Aim of project: This project will focus upon the recognition of mental health problems in adults with mild/moderate learning disabilities residing within the community within Down/Lisburn Trust. In ascertaining such prevalence figures the appropriate diagnostic and therapeutic interventions can be developed before the persons’ problems become established and thereby preventing crisis responses that often occur at present. Proposed Methodology Participants: The project will be based in one Community Health and Social Services Trust with an estimated learning disabled population of approximately 650 aged between 18- 65 years, who are known to Learning Disability services. Of these 650 people it is anticipated that approx 150-200 people with a mild/moderate learning disability and who attend a day care facility within the Trust, and who give their consent will be enrolled on this project. Design: Members of the community learning disability team (Social Workers and Learning Disability Nurses) will receive training in the use of this screening instrument. After training, these staff will complete a Mini PAS-ADD Interview for each participant, in conjunction with the relevant day care worker. To ensure the reliability of the community personnel ratings, a psychiatrist specialising in learning disabilities has been employed to undertake 30 comprehensive

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

psychiatric assessments on a random sample of the participants and will compare her clinical diagnosis with that of the community personnel using the Mini PAS-ADD Interview. Outcomes of Study: It is anticipated that by undertaking this study service planners will become more cognisant of the unmet needs of those who are susceptible to, or suffer from Dual Diagnosis, and of the urgent need to develop more community based and specialist services. From a participant perspective, it is hoped that there will be a more proactive approach to intervention, more emphasis given to mental health promotion, early detection, and fewer crisis responses, ie. hospitalisation. Completion date: Feb 2006 Reference : Moss S. (2003) “The Mini PAS-ADD Interview Schedule” Pavilion Publishing.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

REPEAT INTERVIEWING IN A HERMENEUTIC STUDY OF NURSEPATIENT INTIMACY: EXPECTATIONS VERSUS REALITIES. Maura Dowling MSc (Nursing), BNS (Hons), RNT, RGN, RM, Cert.Oncology. Lecturer. Centre for nursing studies, St Anthony’s campus, National University of Ireland, Galway 091 493833 [email protected] This paper discusses the realities of repeat interviewing in a three-site philosophical hermeneutic study on nurse-patient intimacy in oncology care guided by the work of Gadamer (1989). Initially, it was planned to conduct two and possibly three interviews with each study participant (oncology nurses and patients receiving treatment for cancer). This fits with Gadamer’s (1989) assumption that understanding is dependent on the particular historic situation. Moreover, the understanding of participants’ subject matter and my understanding as researcher changes over time (Fleming et al 2003). Furthermore, repeated interviewing fits with a feminist view of interviewing adopted for this study. In philosophical hermeneutics, understanding is derived from personal involvement by the researcher in a reciprocal processes on interpretation that are inextricably related with one’s being-in-the-world (Spence 2001). The interview style adopted for this study has therefore a strong feminist orientation, and the reciprocal nature of the researcher-participant relationship is evident in this ‘positioning’. Although repeat interviewing with nurses proved valuable to the study; repeat interviewing of patients with a chronic disease such as cancer proved to be an unrealistic endeavour; therefore, plans to re-interview patients were abandoned. The main reason for not pursuing with this strategy of interviewing was that patients’ physical and mental conditions had often altered considerably when I went to reinterview them. For instance, one patient receiving treatment for breast cancer described herself as “too giddy” (as a result of starting steroids) to be interviewed when I returned to her a few weeks after the first interview, and the condition of another patient deteriorated significantly the week I had scheduled to re-interview him. My difficulties with re-interviewing sent me on a search of the literature for the views and experiences of others. However, a literature search on the issue of repeat interviewing revealed a dearth of information. I did find out general information such as their use in ethnographic studies similar to that by Moore (2004) and grounded theory research as that discussed by Maijala et al (2003). However, these authors did not discuss reasons for, or issues arising with this interviewing strategy. Nevertheless, Wimpenny and Gass (2000) do address the issue of similarities between repeat interviewing in grounded theory and phenomenology, which I did find helpful. In addition, a grounded theory approach was evident in aspects of my interviewing, as the first interview impacted on the second one which is reflective of a grounded theory approach (Wimpenny and Gass 2000).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The second interview with nurses in the study proved a valuable methodological exercise in most cases. The nurses were given the whole transcriptions of their first interview and my interpretation in the form of themes emerging. The emerging themes proved particularly useful as it offered a prompt for reminding participants of what they had discussed in the first interview. This strategy of reminding study participants of their previous interview is also discussed by Birch and Miller (2000). It was decided to focus the repeat interview by using an interview guide developed following analysis and interpretation of the first interview. This strategy proved very useful in facilitating elaboration of the issues raised in the first interview. Hirsch (1967) recommends that at a micro level, “further (isolated) parts of the text can be subjected to renewed investigation in order to ascertain which interpretation would explain them best” (cited in Alvesson and Skoldberg 2000: 59). Repeat interviewing allowed for such a process. Moreover, the focused nature of the repeat interview resulted in less “dross”, as an attempt was made to focus on the phenomenon of interest to the study. However, I deliberately did not just focus on the obvious themes related to intimacy emerging from the first interview, but also considered aspects of the cancer trajectory relayed by nurses. This was because I wanted to remain “open” to the meaning of intimacy in oncology settings. Furthermore, the main argument of hermeneutics from its origin has been that “the meaning of a part can only be understood if it is related to the whole” (Alvesson and Skoldberg 2000: 53), and I decided that intimacy in the nurse-patient relationship in cancer care settings cannot be considered in isolation from the cancer experience itself. The repeat interview also acted as a credibility check for my analysis and interpretation; a strategy of validating impressions in a second interview also employed by Hinds (2004). Moreover, returning to participants also presented an opportunity for the informants to share additional information with me. This dual purpose of repeat interviewing is also highlighted by Catanzaro (1988). Moreover, for some nurses the repeat interview was what could be described as a therapeutic experience as it offered them the opportunity to delve deeper on a topic that was raised in their awareness as a result of the first interview. Birch and Miler (2000: 190) also discuss this outcome of interviewing where “…an individual reflects on, and comes to understand previous experiences in different-sometimes more positive- ways that promote a changed sense of self”. Another unexpected challenge of repeat interviewing was the need for prompt analysis and interpretation of the first interview in order to re-interview nurses within a reasonable time frame. In the early stage of the study, this need for a quick turnaround was a bit demanding. However, mid-way through the study, I began using Atlasti to help manage the coding process and this provided very useful assistance with managing and retrieving the data. In conclusion, a dearth of discussion on the process of repeat interviewing has resulted in my reliance for direction from dialogue with my supervisor and colleagues and readings from my reflexive diary. My reflexive diary has proved particularly valuable for direction as it offers transparency to why decisions were made in the interviewing strategies employed in this study. References

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Alvesson M, Skoldberg K (2000) Reflexive methodology. New vistas for qualitative research, Sage Publications, London Birch M, Miller T (2000) Inviting intimacy: the interview as therapeutic opportunity. International journal of social research methodology. 3, 3, 189-202 Catanzaro M (1988) Using qualitative analytical techniques, in Woods, NG & Cantanzaro, M. (Eds) Nursing research. Theory and practice, St Louis: The CV Mosby company. 437-456 Fleming V, Gaidys U & Robb Y (2003) Hermenuetic research in nursing: developing a Gadamerian-based research method. Nursing Inquiry, 10, 2, 113-120 Gadamer GH(1989) Truth and Method (2nd ed) (Translation revised by Weinsheimer J and Marshall DG) Sheed & Ward, London Hinds PS (2004) The hopes and wishes of adolescents with cancer and the nursing care that helps, Oncology Nursing Forum, 31(5), 927-934 Hirsch ED Jr (1967) Validity in interpretation, New Haven, CT: Yale University Press. Cited in: Alvesson M, Skoldberg K (2000) Reflexive methodology. New vistas for qualitative research, Sage Publications, London Maijala H, Paavilainen E & Astedt-Kurke P (2003) The use of grounded theory to study interaction, Nurse Researcher, 11(2), 40-57. Moore D (2004) Beyond “subculture” in the ethnography of illicit drug use, Contemporary Drug Problems, 31, 181-212 Spence D (2001) Hermeneutic notions illuminate cross-cultural nursing experiences. Journal of Advanced Nursing. 35, 4, 624-630 Wimpenny P, Gass J (2000) Interviewing in phenomenology and grounded theory: is there a difference. Journal of Advanced Nursing. 31(6), 1485-1492

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

DESCRIPTIVE STUDY OF THE CONTINUING PROFESSIONAL EDUCATION OF REGISTERED CHILDREN’S NURSES IN IRELAND Author Name: Carmel Doyle Address; Lecturer in Nursing, School of Nursing & Midwifery, University of Dublin, Trinity College, 24 D’Olier Street, Dublin 2. Qualifications: RNID, RCN, RNT, PgDip CHSE, BNS (Hons), MSc Nursing Aim: The aim of this study was to explore the continuing professional education (CPE) of Registered Sick Children’s Nurses (RCN’s) in Ireland. Background: In Ireland at present, there is no formal structure for the CPE of registered nurses. CPE is evidently an essential component of professional competence (National Council for the Professional Development of Nursing and Midwifery, 2003). Within the searched literature there is a lack of specific studies relating to the CPE of RCN’s. Therefore this study was important in exploring the CPE of RCN’s. Furthermore, this will assist in the development of CPE for RCN’s in Ireland. Methodology: A non-experimental quantitative research design was adopted using a descriptive survey technique. Permission was sought from the ethics committee within the Faculty of Health Sciences, University of Dublin, Trinity College. A stratified random sample of 500 RCN’s in Ireland completed a questionnaire. The adopted method of sampling was aided by the assistance of An Bord Altranais. The results were analysed using a quantitative and qualitative approach. Quantitative data was analysed using version eleven of the Statistical Package for the Social Sciences while qualitative data was thematically analysed. Data was presented through both descriptive means and tabular and graphical form. Findings: The findings revealed that RCN’s in Ireland use a variety of methods to keep up to date, the most popular being journal reading. Only 12 of the sampled nurses believed that the 2 days leave for CPE per year, as recommended by the Report of the Commission on Nursing (Government of Ireland, 1998) is sufficient. The majority believed that more than 3 days study leave per annum should be provided, while also indicating that all CPE should be undertaken on employer-funded time. Conclusions: RCN’s in Ireland strongly believe that CPE is essential if nursing is to develop as a profession. However, they need to be supported in their endeavours through a fair and equitable system. This system should allow for flexibility in work practices to facilitate study as well as financial and other practical supports. The results of this study confirm the need for a comprehensive review of CPE for RCN’s in terms of both structure and content. Several subject areas of importance to RCN’s were identified. The issue of providing appropriate and accessible education for all, particularly those working outside the capital city is one, which must be urgently addressed.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References: Government of Ireland (1998) Report of the Commission on Nursing – A Blueprint for the Future. Dublin: Stationary Office. National Council for the Professional Development of Nursing and Midwifery (2003) Agenda for the Future Professional Development of Nursing and Midwifery. Dublin: National Council for the Professional Development of Nursing and Midwifery.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The design and implementation of a clinical competency tool for a Post Graduate Paediatric Nursing Programme. Carmel Doyle, Lecturer in Nursing, University of Dublin (RNID, RCN, RNT, PgDip CHSE, BNS, MSc) Maryanne Murphy, Paediatric Nurse Tutor, AMNCH, Tallaght, Dublin 24 (RGN, RCN, BSc, MSc) Geraldine Kyle, Paediatric Nurse Tutor, AMNCH, Tallaght, Dublin 24 (RGN, RCN, MSc) Abstract Quality in nurse education may be seen in a number of ways including the attainment of academic excellence, practical competence or a combination of both. With this in mind a Clinical Competency Document (CCD) was designed by an expert panel of paediatric nurse tutors. The design process also included collaboration with experts in the clinical area. The design and content of the C. C.D. was complemented by the available literature. The structure of the C.C.D. is based on the domains of competence outlined by An Bord Altranais. The domains of competence represent the level the student must reach on completion of the educational programme. The aim of the domains of competence is to ensure that the students acquire the skills of critical analysis, problem solving and abilities essential to the art and science of nursing. The structure of the C.C.D. is also based on Benner's (1984) five stages for the development of expert practice. The purpose of the CCD is to ensure that the student is equipped with the knowledge and skills necessary to practice as a competent Registered Children's Nurse. Benner's (1984) five stages for the development of expert practice was deemed a suitable framework to achieve this. Following approval by the link university, implementation of the CCD began in April 2005. Evaluation of the process is ongoing.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

CONTROLLING RESPONSE SHIFT BIAS IN EVALUATION RESEARCH: THE USE OF THE RETROSPECTIVE PRETEST METHODOLOGY IN THE EVALUATION OF A MASTER’S IN NURSING PROGRAMME Jonathan Drennan RNMH, RPN, RGN, RNT, BSc, Med School of Nursing & Midwifery, University College Dublin Introduction Student self-report measures of change are widely used in evaluation research to measure the impact and outcomes of an educational programme or intervention. Traditionally the design used to measure outcomes is the measurement and comparison of the student’s pretest-posttest scores. Traditional pretest-posttest measures work on the assumption that the respondent’s assessment of the measurement will not change from the pretest to the posttest. However, the respondent’s perception of the constructs under evaluation may change as a result of the educational intervention leading to an underreporting by the respondent of any real change occurring between pretest and posttest, this change in perception is known as response shift. One method that has been suggested as reducing the confounding effect of this response-shift is the use of retrospective pretests. The Study Design: This paper discusses the use of the retrospective pretest as a means of controlling response shift bias in the evaluation of a Masters in Nursing programme. Instruments:. The retrospective pretest instrument, the Masters in Nursing Outcomes Evaluation Questionnaire (MNOEQ), was developed to measure student self-reports of change and the impact of the programme on graduates. Outcomes and behaviours measured included the development of professional communication, the facilitation of the development of leadership and teaching roles, the development of critical thinking skills, research practice and utilisation, initiating positive change in the profession, and development of advanced specialist practice competencies. The scales that compose the MNOEQ were tested using factor analysis and classical test statistics. Procedure: The process of undertaking the retrospective pretest consisted of firstly asking respondents to report their level of ability at present on each item following completion of the master’s programme (called a posttest) and then asked to think back and rate themselves on each item before the programme commenced (called a thentest). Findings The collection of thentest and posttest ratings at the same time led to a reduction of response shift bias due to the fact that the respondent was making the ratings at time 1 (thentest) and time 2 (posttest) from the same perspective. The results showed significant differences between the posttest and thentest on a number outcomes. The overall value of the retrospective pretest method was that respondents were less likely to overestimate their ability at the pretest phase of the study due to the fact that this evaluation was taken at the same time as the posttest phase.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

LONELINESS AND SOCIAL ISOLATION AMONG OLDER IRISH PEOPLE Presenter: Jonathan Drennan RNMH, RPN, RGN, RNT, BSc, MEd School of Nursing & Midwifery, University College Dublin, Belfield, Dublin 4 Research Team: Professor Pearl Treacy, Dr. Michelle Butler, Ms Anne Byrne, Dr. Gerard Fealy, Ms Kate Frazer, Dr. Kate Irving Aims of the Study • Record the prevalence of loneliness amongst older people and examine and compare the prevalence of loneliness amongst older groups. • Provide a profile of those older people experiencing loneliness. Methods: Design: The study design was a descriptive cross-sectional survey of loneliness and social isolation in older people in the Republic of Ireland. Survey Instruments: Loneliness was assessed using the Social and Emotional Loneliness Scale for Adults – Short Form (SELSA-S) and social isolation was measured using the Network Assessment Instrument. The SELSA-S measures two types of emotional loneliness – family loneliness and romantic loneliness. A number of population characteristics of older people were also measured in the survey. The aim was to identify social predictors that are related to loneliness and social isolation. Procedure: Currently in Ireland, there is no sampling frame that specifically identifies older people. Respondents were therefore randomly contacted by telephone using a technique known as Random Digital Dialling. Sample: A random sample of 874 older people were contacted with 683 agreed to take part in the study resulting in a response rate of 78%. Data Analysis: Data was analysed using descriptive and inferential statistics. Descriptive statistics described the demographic profile of the sample and their experience of loneliness and social isolation. Inferential statistics were used to identify differences between various categories of older people, for example area of residence, marital status and access to transport. Relationships (correlation coefficients) between various demographic characteristics and levels of loneliness and social isolation were also explored. Findings: A number of factors were found to be associated with different levels of loneliness including; increasing age (social and romantic loneliness),limited access to transport (social loneliness), living in a rural area or rented accommodation (social loneliness), poor health (social, family and romantic loneliness), having no children (family loneliness), being female (family and romantic loneliness) and being single or widowed (family and romantic loneliness). The majority of older people in the survey were found to be living in socially supported networks; however 10% of the sample were socially isolated with reports of minimal social contacts or social networks.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

TITLE: THE USE OF THE DELPHI TECHNIQUE IN THE DEVELOPMENT OF A NURSING MINIMUM DATA SET FOR GENERAL NURSING Presenters: Jonathan Drennan RNMH, RPN, RGN, RNT, BSc, MEd Anne Byrne RGN, BSc, MSc School of Nursing & Midwifery University College Dublin Belfield Dublin 4 Research Team: Pearl Tracey, Anne Scott, Abbey Hyde, Padraig. MacNeela, Kate Irving, Michelle Butler. Summary: The purpose of this paper is to describe the use of a Delphi survey as part of the process to develop a Nursing Minimum Data Set for Ireland (NMDS-I). The aim of the NMDS-I is to provide minimum data that can maximally demonstrate the contribution of nursing to patient/client care. This will allow the complexity of care provided by nurses to be directly measured in a variety of healthcare settings and to justify the contribution of nursing to patient care. This paper will discuss the process of the Delphi survey as a method of achieving consensus among a panel of experts including methods of sampling and data analysis. The results identified a number of items that are emerging as the core elements of nursing to be included in an Irish Nursing Minimum Data Set. Aim and objectives: The aims of the study were (a) to identify the core elements of nursing, (b) to identify items that would be included in a Nursing Minimum Data Set for Ireland (c) to achieve consensus on items for inclusion in a Nursing Minimum Data Set. Method: A three-round Delphi survey was used to achieve consensus on items that would be included in a Nursing Minimum Data Set. The Delphi survey was administered to clinical nurses working in a variety of clinical settings. Sample: The sample was identified in 4 hospitals in the Republic of Ireland. Three were in predominantly urban areas and one in a rural area of the country.. This resulted in a total of 250 nurses identified as eligible to take part. Analysis: Consensus was deemed to have been achieved for each item in rounds 1 and 2 when 75% of respondents rated an item 4 or above on a 7-point scale. In the final round further analysis was undertaken of responses over the three rounds. Findings: A number of items are emerging from the data as core items in the areas of physical, psychological and social problems, physical, psychological and social interventions, organisation and co-ordination roles, and outcomes of nursing care. Conclusion: The Delphi technique was identified as an effective method for identifying the core items of nursing. These items can then be developed for inclusion in a Nursing Minimum data Set.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Title : Intellectual

Primary Caregiver Attitudes to Sexuality for People with Disability: A Quantitative and Descriptive Pilot-Study.

Author: Elaine Drummond, BSc, H.Dip, Cert Behaviour Therapy, RNID. Position: Lecturer – Intellectual Disability Address: Catherine McAuley School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork. Telephone No: 021-4901453 Email Address: [email protected] _____________________________________________________________________ ___ Abstract: This pilot-study sought to investigate the attitudes of primary caregivers (PCs’) to sexuality for people with intellectual disability (ID) who attend two-day service sites within one service provider organisation in Southern Ireland. A thorough review of the literature indicated that whilst attitudes towards sexuality for the ID have become more open in the past three decades, considerable barriers remain for those with ID in experiencing their sexuality positively. In effect they remain socially excluded from wider society in that they are powerless to access their full rights with respect to intimate personal relationships and sexuality education. Throughout the last century people with ID have been perceived as social threats that must be segregated to protect the social order or as socially vulnerable without the skills to survive in a society that marginalizes them (Meera 2000, Walmsley 2000 and Wolfe 1997). The advent of the ‘civil rights’ concerns and the normalization movement in the 1960’s, further impacted on beliefs about sexuality and despite advances made in securing these rights, it is unclear if attitudes of PCs’ and wider society have adjusted accordingly (Aunos & Feldman 2002). Difficulties and barriers for people with ID in experiencing their sexuality positively have been clearly identified in studies by Hamilton (2002), Johnson et al (2000) and Evans et al (2003) and are linked to culture, religion, history, risk, service providers, staff and parents. This is confirmed by the views of adults with ID themselves who when asked have demonstrated an understanding of personal relationships and sexuality (Caffrey 1992, Murray et al 2001, and Christian et al 2002). The researcher adopted a quantitative and descriptive study design in exploring these attitudes through the use of a self-administered postal questionnaire. Attitudes of a sample of PC (n= 45) were assessed in parents, siblings and staff of adults with ID attending rural and urban day services. Attitudes were measured by the SAQ-ID (the adapted GSAQ-LD developed by Karellou 2003a); it comprised 59 closed-ended questions where questions 1-10 sought demographic information. The remaining 45 Likert-type questions (15 to 59) asked participants to choose a statement from a menu of responses that most reflect their present attitude. Statements were expressed in both positive and negative forms and their order was randomized. Each item on the scale is scored from 1 to 5 on a 5-point agree – disagree continuum and are coded to show a

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

high score indicating a more open attitude and a low score a more conservative attitude towards sexuality of people with and without ID. The instrument demonstrated good internal consistency and test retest reliability. Results indicated that age, level of education, marital status and religious attendance significantly influenced attitudes of PCs’ in this pilot-study. PCs’ who are younger and have a higher level of education tend to hold more open attitudes to sexuality generally and for people with ID specifically. However respondents tended to discriminate between groups and PCs’ who were single (n = 12) were less likely to discriminate than their non-single counter-parts (n = 33). A clear relationship was also found between attitudes and religious attendance where more open attitudes are associated with lower levels of religious attendance. PCs’ in this study were also found to vary in their overall acknowledgement of the sexuality of the ID as compared to the general population and did differ in their attitudes towards same sex relationships for people with ID as compared to the general population. Contrary to findings in some studies gender, level of ID and geographical location were generally found to be insignificant. The overriding concern seems to be that unless those who support people with ID are included in discussions about sexuality then the possibility of addressing the issue with people with ID is lost. However the development of appropriate frameworks on which to build a best practice approach to the concept of sexuality will only be accomplished by additional research in the area. The overall conclusion drawn is that an inclusive approach where the views of all stakeholders are represented is the only way forward in addressing the sexuality needs of Irish people with ID. References: • Aunos, M. & Feldman, M.A. (2002) Attitudes towards Sexuality, Sterilization and Parenting Rights of Persons with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities, 15, 285-296. • Caffrey, S. (1992) S.A.M & S.U.E.- Sexual Attitudes Measures and Sexual Understanding Explored: An exploration of the sexuality of People with mental handicap, their parents’ awareness of, and attitudes towards that sexuality. PhD. Thesis, Trinity College Dublin. • Christian, L.A.; Stinson, J. & Dotson, L.A. (2002) Staff Values Regarding the Sexual Expression of Women with Developmental Disability. Sexuality and Disability, Vol.19, No. 4, 283-291. • Evans, D.S.; Healy, E.; & McGuire, B. (2003) The Development of Personal Relationships and Sexuality Guidelines for People with Learning Disabilities. Paper presented at the Conference ReSpeCt hosted by The National Federation of Voluntary Bodies, on Wednesday, 5th November 2003, Galway, Ireland. • Hamilton, C (2002) Doing the Wild Thing: Supporting an Ordinary sexual Life for people with Intellectual Disability. Disability Studies Quarterly, Vol. 22, No.4, 40-59. • Johnson, K.; Frawley, P; Hillier, L. & Harrison, L. (2002) Living Safer Sexual Lives: Research and Action. Tizard Learning Disability Review, Vol. 3, No.3, 4-9. • Karellou, J. (2003a) Development of the Greek Sexuality Attitudes Questionnaire – Learning Disabilities (GSAQ-LD). Sexuality and Disability, Vol 2, No. 2, 113 – 135.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

•

• • •

Meera, R. (2000) “Sexuality and People with Learning Disabilities". Mitchell, L.; Doctor, R.M. & Butler, D.C. (1978) Attitudes of caretakers towards the sexual behaviour of mentally retarded persons. American Journal of Mental Deficiency 83 (3), 289-296. Murray, J.; MacDonald, R. & Levenson, V.L. (2001) Sexuality: Policies, Beliefs and Practice. Tizard: Learning Disability Review, Vol.6, No. 1, pp. 2935. Walmsley, J. (2000) Women and the Mental Deficiency Act of 1913: citizenship, sexuality and regulation. British Journal of Learning Disabilities, 28, 65-70. Wolfe, P.S. (1997) The Influence of Personal Values on Issues of Sexuality and Disability. Sexuality and Disability, Vol. 15, No.2, pp. 69-89.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Hear No Lesbian, Speak No Lesbian, See No Lesbian: Literature Review on Lesbian Healthcare Ms Mel Duffy BA, MA Lecturer in Sociology School of Nursing Dublin City University Dublin 9 Ireland + 353 1 7005833 [email protected] Abstract This paper will review the literature on lesbian healthcare with particular reference to the experiences of lesbian women within the healthcare environment. Research indicates that lesbian women attend health care providers less often than heterosexual women. Some researches allude to the fact that this may arise out of lesbian women’ ambivalence to their wellbeing and health status or indeed poor economic conditions. The American Medical Association, Council for Scientific affairs (1996) reiterates these concerns, implying that lesbian women may not feel that health issues are of concern to them. Gochras & Bidwell (1996:2) suggest other factors at play such as “isolation, fear, violence and the requisites of day-to-day survival”. Isolation and fear may be factors to consider when lesbian women are seeking health care whether in actual reality or the fear that this may be the reality, which stops them from seeking health care. As Plummer (1996:65) indicates, lesbian concerns “rests with processes, reactions, and subjective realities”. The reality of lesbian women’s experience of health care professionals informs them when they seek health care.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

FROM THE EMERGENCY DEPARTMENT TO HOME: A STUDY EXPLORING DIMENSIONS OF DISCHARGE PLANNING FOR OLDER PEOPLE AND COMMUNICATION OF INFORMATION - A SUMMARY PAPER Mary E. Dunnion, R.G.N.; BSc in Nursing; PgDipEd; MSc in Advanced Nursing Lecturer in Nursing, Nursing Department, Letterkenny Institute of Technology, Letterkenny, Co. Donegal, Ireland. Tel: 00353 74 9186395 Email: [email protected] Billy Kelly, RGN; RNT; BA; MSc; M.Res; Associate Head of School, School of Nursing, University of Ulster, Jordanstown, Co. Antrim, Northern Ireland. Tel: 028 903 68490 Email: [email protected] Introduction For the purpose of this study older people have been defined as those over 65 years of age. Demographics worldwide show a continuing rapid increase in the number of older people aged 65 years and over and this trend is also evident in the Republic of Ireland (ROI) (Department of Health & Children 1999). It is recognized that older people discharged home directly from the emergency department are a vulnerable group. Older people are more vulnerable than younger adults to being acutely ill (Crosbie 1999, Spilsbury et al. 1999, Bridges et al. 2000) and are particularly at risk when discharged home directly from the emergency department (Runciman et al. 1996, Ferguson 1997, Cherry & Reid 2001). Hendriksen and Harrison (2001) report that many older patients attend the emergency department out of standard office hours. Over 50 % of older patients are unable to carry out basic activities of daily living following discharge form the emergency department (Runciman et al. 1996, Hendriksen and Harrison 2001). This suggests a picture of functional incapacity, vulnerability, and the need for additional support. Emergency departments have a significant role to play in the care of older people. Effective communication and liaison are seen to be keys to the provision of high quality care for older people in the emergency department and in ensuring a seamless care between sectors. The Research Problem A need for research on this specific area exists because of a gap in the research in relation to the specific problem of discharge planning and communication of information following discharge of older people from emergency departments and due to the importance of this client group in future planning and delivery of health care services. Aim The purpose of this study was to explore dimensions of the management of the older person following care in an emergency department located in a 320-bed rural general hospital in the ROI and in the surrounding primary care catchment area. Aim of this study was to identify the preparation for discharge home by identifying perceptions and attitudes of staff in both care sectors in relation to current levels of discharge planning and communication between these two care areas and to examine the views

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

of all staff on the needs of older people following discharge from the emergency department. Methods Methodology used was that of a survey approach of nursing and medical staff in both the emergency department and primary care services. A purposeful sample was collected that comprised the total population (n=222) of all grades of medical (n=34) and nursing (n=27) staff in both the emergency department and all nursing (Public Health Nurses (n=59) & Practice nurses (n=34)) and medical staff (General Practitioners (n=68)) in the primary care area. Standardized questionnaires were employed which comprised both open and closed questioning style. The questionnaires (one for acute and one for community care areas) incorporated those from an exploratory study on discharge planning in the setting of hospitalized patients undertaken by McKenna et al. (2000). These questionnaires were adapted to make them emergency care specific and in order to meet the specific needs of this study. Of the questionnaires distributed 135 were returned and the overall response rate for staff participating in the study was 61%. Raw statistical data were analysed using SPSS for Windows Version 11.0 while the qualitative data arising from the open-ended questions were content analysed for themes. Main Results Procedures undertaken when discharging an older person from the emergency department • • •

Of the PHN respondents, 56.4% (n=31) reported referral to all relevant agencies as “Never” being undertaken 34.4% of GPs (n=1) and 44.4% (n=8) of practice nurse respondents reported being unsure as to whether this was undertaken 73.7% of nurse and 36.4% (n=4) of doctor respondents in the emergency department reported that this was “sometimes” undertaken

Discharge Planning • •

A common response from PHN respondents was that of never being notified of discharges form the emergency department GP respondents received “little if any” or no notification of discharge

Communication • •

Results in this section were variable between sectors with hospital staff reporting the level of communication to be much greater than that perceived by their colleagues in primary care The current discharge planning documentation and the level of information received was reported as being unsatisfactory by all groups

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Problems That Exist For Older People • • • • • • • •

Respondents reported the following problems that exist for older patients discharged from the emergency department when no particular discharge planning procedures exist: Decreased continuity of care At high risk Unable to manage at home Confused re management of problem “They tend to be readmitted for similar problems” “Over/under dose of medication, improper management of patient at home” “Referrals and follow ups are hit and miss depending on staff on duty and the departments workload”

Usefulness of a discharge liaison nurse for older people in the emergency department •

Many respondents described a discharge liaison service in the emergency department as being “extremely useful” and “useful”

Discussion The findings in this study are very similar to those reported by McKenna et al.’s (2000) study on discharge planning in an acute hospital setting that identified a lack of synchrony between hospital and community nurses in relation to the level of communication between the two sectors. Older patients discharged home from the emergency department are a vulnerable group (Runciman et al. 1996, Hendriksen and Harrison 2001) and this study supports these earlier findings with respondents identifying serious problems present for older people when discharged from the emergency department when no particular discharge planning procedures exist. Hospital nurses can reduce admission rates by ensuring appropriate preparations are completed prior to discharge (Bridges et al. 2000, Elgie, 2000) however findings here show that although staff respondents may document such arrangements, documentation may not always reach the intended population. Poor communication between the hospital and community interface has been highlighted in previous studies (Tierney et al. 1993, Closs & Tierney 1997, Cox, 2000) and this research supports earlier findings with primary care responses highlighting a definite need to increase the level of referral and communication between sectors. Main Recommendations further studies such as action research zMore collaborative interactions between care sectors zThe development of new documentation forms, set discharge criteria and discharge planning protocols zDischarge planning could be incorporated into nursing care plans in use in emergency departments zDiscussion with management regarding the perceived usefulness of a liaison service zUndertake

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Conclusion Previous research highlights communication difficulties when patients are discharged from hospital. Findings from this study indicate that this problem can also be applied to the emergency department. It is evident that it is necessary to develop, audit and evaluate referral criteria and guidelines, accurate documentation and prompt referral to the primary care sector following discharge from the emergency department. References Bridges, J., Meyer, J., McMahon, K., Bentley, J. & Winter, J. (2000) A health visitor for older people in an accident and emergency department. British Journal of Community Nursing, 5(2), 75-80. Cherry, J. & Reid, J. (2001) Fast-tracking older people through A&E. Nursing Standard, 15(16), 42-4. Closs, J. & Tierney, A. (1997) The complexities of using a structure, process and outcome framework: the case of an evaluation of discharge planning for elderly patients. Journal of Advanced Nursing, 18, 1279-1287. Cox, S. (2000) Improving communication between care settings. Professional Nurse, 15(4), 267-271. Crosbie, B. (1999) Discharge Planning. British Journal of Community Nursing, 4(7), 320. Department of Health & Children (1999) Building Healthier Hearts The Cardiovascular Strategy. The Stationery Office: Dublin Elgie, C. (2000) Chasing the Dollars. Nursing Management, 7(3), 12-15. Ferguson, A. (1997) Discharge planning from A&E: Part 1. Accident and Emergency Nursing, 5, 210-14. Hendriksen, H. & Harrison, R.A. (2001) Occupational therapy in accident and emergency departments: a randomised controlled trial. Journal of Advanced Nursing, 36(6), 727-732. McKenna, H., Keeney, S., Glenn, A. & Gordon, P. (2000) Discharge planning: an exploratory study. Journal of Clinical Nursing, 9(4), 594-601. Runciman, P., Currie, C.T., Nicol, M., Green, L. & McKay, V. (1996) Discharge of elderly people from an emergency department: evaluation of health visitor follow-up. Journal of Advanced Nursing, 24, 711-718. Spilsbury, K. & Meyer, J., Bridges, J. & Holman, C. (1999) Older adults’ experiences of A&E care. Emergency Nurse, 7(6), 24-31.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Tierney, A.J., Closs, S.J., King, C., Worth, A. & Macmillan, M.S. (1993) A national survey of current discharge planning practice in acute hospital wards throughout Scotland. (1st Supplementary Report to the Report on “Discharge of Patients from Hospital”). Department of Nursing Studies: University of Edinburgh.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Judgement or prejudice: Ageism in students of the caring professions Dr Suzanne Egan Lecturer Department of Psychology Mary Immaculate College University of Limerick South Circular Road Limerick Ireland & Dr Kerry Greer The aim of this research is to contribute in general to the our knowledge about attitudinal factors that influence decision making, and in particular, to attitudinal factors that influence decisions made by health trainees and professionals about elderly patients. In the course of a typical day, health care trainees and professionals make many decisions about their behaviour towards, and treatment of, patients. These decisions/behaviours may be influenced by factors of which they are unaware. This study will investigate the predictive power of three different attitude measurement tools in order to identify the most effective tool for subsequent research on the impact of ageism in health care personnel.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EXPLORING THE NATURE OF THE PATIENT-PODIATRIST RELATIONSHIP -learning about research through the Professional Doctorate programme Mairghread JH Ellis Lecturer in Podiatry Faculty of Health and Social Sciences Queen Margaret University College Edinburgh [email protected] Background The Professional Doctorate in Health and Social Care of the University Brighton offers a programme of research based development for experienced practitioners. Stage 1 of this programme allows for analysis of one’s own practice, the development of inquiry skills, and the evaluation of research designs. It is assessed by 3 pieces of submitted work; • Assignment 1 comprises the development of a research question • Assignment 2 comprises a critique of possible methodological approaches • Assignment 3 comprises the report of a small scale study, with the aim of trialling a methodology appropriate to the research topic. The research question True evidence based practice encompasses not just best evidence and clinical expertise, but also patient preference. Much is made now of the ‘empowered’ patient, the ‘informed’ patient, the expert patient (Muir Gray, 2002; Stubblefield and Mutha, 2002; Coulter, 2003). I entered the doctoral programme with a research area from M level study which I intended to progress within this programme. Having researched the availability and accessibility of www based health information (Ellis and Thomson, 2003); I intended (naively) to attempt to measure the impact of the ‘WWW informed patient’ on the therapeutic relationship. Undertaking assignment 1 showed me that this was not possible, as in reflecting and reading for this piece of work, it occurred to me as an experienced practitioner, that I did not fully understand the nature of my relationships with my patients. Are podiatrists ‘carers’ or ‘curers’? Or are we a mixture of both? I realised that only if podiatrists can fully understand the relationship they hold with their patients, will both partners in the therapeutic relationship be fully empowered to embrace evidence based care. Therefore, I had to step back and first explore a basic feature of clinical practice - the nature of the patient-practitioner relationship. Study design The study was undertaken with the aim of allowing this novice researcher to trial the qualitative methodology. The researcher aimed, through focussed conversations to generate data which would give insight into practitioners’ relationships with their patients. Purposive sampling identified 3 experienced podiatrists (1 private

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

practitioner, 1 NHS practitioner, and one with mixed experience). A review of models of qualitative analysis was undertaken, and the model of Leonard in Benner (1994) was chosen to allow the data to illustrate emergent themes, with narrative excerpts used to demonstrate examples. One aspect of the Professional Doctorate is the emphasis placed on transparency of the researchers’ reflection and reflexivity. Finlay (2002) has commented that reflexivity involves a positive evaluation of the researchers’ own experience to help understand something of the fusions of horizons between subject and object. Because there are sources of commonalities between individuals, constituted by similar cultures in terms of dialogue and understanding, we can glean meaning. This belief is developed from the writings of H-G Gadamer (1900-2002) who believed that the ‘horizon of the present’ could not be formed without accepting the past experiences of both researcher and participant (Crotty, 1998). This is only credible and trustworthy however, if reflection and reflexivity are demonstrable elements of the research process. Literature searching identified no published literature in the area of patientpractitioner relationship specific to podiatry, therefore literature in the fields of nursing and medical practice were utilised to help set the findings in context. Findings Data analysis resulted in 4 themes emerging – • Issues around professionalism, power and status – participants felt that how they were perceived by patients and fellow professionals could affect how they interacted with their patients. Issues such as the wearing of uniform and professional titles could affect how the podiatrist felt they were perceived by their patients. • Patient podiatrist interaction – the largest theme, this showed that participants had an ability to adopt styles to match individual patients. In private practice especially, participants felt that they fulfilled both a social and a professional role. ‘Emotional involvement’ was seen to be different from ‘familiarity’ as over-familiarity from the patient could be perceived as threatening and unwelcome by the practitioner, whereas emotional involvement came from the practitioner as a result of length/depth of therapeutic relationship. ‘Empathy’ came across as an essential characteristic for successful relationships. • Educating; and the ‘educated patient’- Educating the patient was seen to be not only an integral and fundamental part of practice, but also a tool to justify extending treatment intervals or to facilitate discharge. Patients often did not comply with education, and this could negatively affect the relationship as viewed by the podiatrist. The ‘educated’ patient, especially with WWW information, could be perceived as intimidating. • The system – this theme arose from the NHS podiatrists, and showed issues around the conflict of delivering single episodes of care, and focussed discharge policies – both of which challenged and tested existing patientpractitioner relationships. Podiatrists spoke of these tensions with their patients as a source of stress. Discussion This very small pilot study generated much valuable data. The importance of empathy as an essential quality, and the personal context of practice are features

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

which emerged also from research by Rosa and Hasselkus (1996) who researched therapist–patient relationships in Occupational Therapy. Adopting different styles for different patients has also been discussed by Aranda and Street (1999). Their research suggested that nurses can be both authentic and ‘a chameleon’ where necessary to meet individual patient’s needs. The perceived challenges of ‘the system’ are of great interest, especially when set against the NHS Improvement Plan document, Creating a Patient-led NHS (DH/NHS, 2005). Finally, in the current Internet age, it seems that while patients are actively encouraged to seek information, this can result in the practitioner feeling challenged both personally and professionally. The Way Ahead It is evident this is a new area of research to podiatry, and it is hoped that the main study with both NHS podiatrists and private practitioners as participants, will generate findings to cause debate and reflection within the profession. It is also intended that future publications from this doctoral research will enhance and promote the qualitative research approach within podiatry – Promoting and effecting change in practice is, after all, a major objective of this professional doctorate programme. References Aranda SK., and Street, AF., (1999) Being authentic and being a chameleon: nursepatient interaction revisited, Nursing Inquiry, 6 75-82 Benner, P (ed.) 1994, Interpretive Phenomenology- Embodiment, caring and Ethics in Health and Illness, Sage Publications, Inc. Thousand Oaks, USA. Coulter, A. 2003, The Autonomous Patient - Ending paternalism in medical care, The Stationery Office, London, UK. Crotty, M. 1998, The Foundations of Social Research – Meaning and perspective in the research process, Sage Publications Inc., Thousand Oaks, USA. DH/NHS, 2005, Creating a Patient-led NHS – delivering the NHS Improvement Plan, ROCR ref. Gateway reference: 4699 Ellis, MHJ. and Thomson, CE. (2003) Consumer health information on the WWW: an evaluation of information on verrucae, The Foot, 13 130-135 Finlay, L. 2002, “Outing” the Researcher: The Provenance, Process and Practice of Reflexivity, Qualitative Health Research, 12 (4) 531-545 Muir Gray, JA. 2002, The Resourceful Patient, eRosetta press, Oxford, UK. Stubblefield, C. & Mutha, S. 2002, "Provider-Patient Roles in Chronic Disease", Journal of Allied Health, 31 (2) 87-92.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Organisational Communication, Communication Audit, Organisational Effectiveness and Organisational Development. Professor Roger Ellis OBE DSc, MSc, BA (Hons), C Psychol, AFBPS, T Cert Director of Research School of Health and Social Care University of Chester Dr Elaine Hogard PhD MSc MEd BSc (Hons) Reader in Evaluation Research University of Chester Parkgate Road Chester Cheshire CH1 1AB England [email protected] Whilst communication is a well-researched topic in Nursing, the concentration tends to be on face-to-face and, particularly, dyadic communication between, for example, nurse and patient; and student and mentor. Organisational communication, defined as communication between a number of individuals not necessarily in face to face to face contact but members of a single organisational entity, is comparatively neglected. It is argued that organisational communication is a crucial factor in determining the effectiveness of an organisation and its capacity to meet its goals. For example the delivery of effective nursing care is affected by organisational communication at ward, directorate and trust levels. This paper describes an approach to the study of organisational communication known as communication audit. Various techniques for communication audit are described with a particular emphasis on the survey questionnaire tool developed by the authors. This tool encourages participants to identify the quantity and quality of communication received on a number of key topics, from a number of individuals and positions and using a range of media and to compare this with the amount of information desired. Differences between amount received and desired highlight problems and points for improvement and development. The tool also allows for evaluation of speed of response and trust between participants and the identification of strengths and weaknesses in communication. Finally participants are able to identify critical incidents of good and bad communication. The use of o this method to study organisational communication in two contexts is described one concerning practice education in pre= nursing and the other interprofessional communication in an early years ‘Sure Start’ scheme. The results of the audits are described and related to effectiveness and developmental objectives.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Stressors which impact on Registered Nurses undertaking a Bachelor of Science Degree in the Republic of Ireland. An Explorative Study. William Evans, RGN, RSCN, HDip. Paeds, RNT, PG Dip in Educ., BNS (Hons), MSc Lecturer, Department of Nursing and Health Studies, Institute of Technology, Tralee. Honor Nicholl, RN, RSCN, RM, RCT, JBCNS 160, RNT, BSc, MEd, PGDip G&C, Ad.Dip Teaching Studies, lecturer/Course Cordinator, School of Nursing, Trinity College Dublin. Fiona Timmins, RGN BNS BSc RNT FFNRCSI NFESC MSC Acting Director BSc (Cur), School of Nursing, Trinity College Dublin. Gary Brown, Head of Department, RGN, RNT, Dip Nurs (A), MSc, PhD Head of Department, Department of Nursing and Health Studies, Institute of Technology, Tralee. Significant change is evident at both undergraduate and postgraduate level nurse education in the Republic of Ireland. Increased emphasis professionally on the provision of continuing professional development and life long learning has imposed new challenges on registered nurses. Despite a significant amount of evidence on stress and potential stressors in nursing (Lindop 1991, Thyer and Bazeley 1993, Jones and Johnston 1997 and Lo 2000), there is little documented evidence on stressors that impact on part-time nursing students, undertaking post registration education programmes. The aim of this study is to compare the levels and types of stress experienced between two groups of part time students who are completing a Bachelor of Science in Nursing in two Third Level institutions in the Republic of Ireland (n=140). The research question guiding the study is: what are the predominant stressors isolated amongst registered nurses studying at Degree level in two Third Level institutions in the Republic of Ireland? An explorative design is employed and the data collection tool is a stress questionnaire constructed for a previous study. Reliability and Validity of the research tool has been documented. Results indicate significant stressors associated with assessments, course workload and balancing attendance at the course with participants work commitments. An increased awareness of the age related stressors of this population is required. In addition, support mechanisms need to be in place for these students at both the workplace and the university. References Lindop, E. (1991) individual stress among nurses in training: why some leave and others stay. Nurse Education Today 2,110 - 120. Thyer, S.E. and Bazeley, P. (1993) Stressors to student nurses beginning tertiary education: an Australian study. Nurse Education Today 13,5,336 - 42. Jones. M.C. and Johnston D.W. (1997) Distress, stress and copying in first-year student nurses. Journal of Advanced Nursing 26,3,475 - 482.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Lo, R. (2002) Experience before and throughout the nursing career A longitudinal study of perceived level of stress, coping and self-esteem in undergraduate nursing students: An Australian Case Study Journal of Advanced Nursing 39, 2, 119-126.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

ILLUMINATING THE ESSENTIAL ELEMENTS OF THE COMPETENCEBASED APPROACH TO NURSE EDUCATION THROUGH AN EXPLORATION OF STAFF NURSES' EXPERIENCES OF ITS IMPLEMENTATION WITHIN THE PRACTICE PLACEMENT. A PHENOMENOLOGICAL STUDY. Name of Author: Miriam Farrell Job Title: Clinical Placement Co-ordinator Qualifications: RPN, RGN, BSc. (Hons) Nursing, MS.c (Hons) Nursing Education, RNT Address: 18 The Lawns, Collegewood Park, Clane, Co. Kildare This qualitative study adopted a phenomenological design and attempts to uncover the essential elements of the competence-based approach to nurse education through an exploration of staff nurses’ experiences of its implementation within the practice placement. The literature relating to competence and competence-based approaches to nurse education is reviewed and serves to contextualise this new approach to nurse education in Ireland today. Judgmental purposive sampling was used thereby ensuring that the staff nurses as co-researchers had experienced the phenomenon of interest. Five staff nurses were interviewed to establish the essence of the competence-based approach as they experienced it. Ethical approval was sought and granted and ethical considerations were adhered to throughout the research process. The approach and methodological choices used are consistent with phenomenological assumptions developed by the German philosopher Edmund Husserl (1859-1938). This study attempts to address some of the recent critiques regarding the use and understanding of Husserlian and mainstream phenomenology by nurse phenomenologists (Crotty 1996, Paley 1997, Yegdich 2000). The use of a stepwise method for phenomenological research facilitated engagement in phenomenological processes consistent with the chosen design (Crotty 1996). The data gleaned from the interviews were transcribed and analysed using Moustakas’s (1994) adapted version of Van Kaam (1959, 1966). Textural-structural descriptions were constructed for each individual co-researcher. Schemas are presented and serve to illustrate and summarise the main findings within this study and form the basis for the discussion chapter. Findings revealed many changes experienced by staff nurses due to the transition to the competence-based approach within practice settings. While the infancy of the competence-based approach is acknowledged within this study and issues are raised surrounding the competencebased approach and its implementation, an overall sense of positivity emerged towards the potential of this approach for the future of nurse education. The need however, for adequate, appropriate preparation, ongoing support and recognition of staff nurses as vital stakeholders is central for its successful implementation in the future. Recommendations are made for future research, education and practice.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Crotty M. (1996) Phenomenology and Nursing Research. Churchill Livingstone. Melbourne. Moustakas C. (1994) Phenomenological Research Methods. Sage Publications, London. Paley J. (1997) Husserl, phenomenology and nursing. Journal of Advanced Nursing 26,187-193. Van Kaam A. (1966) Application of the phenomenological method. In Van Kaam A. Existential Foundations of Psychology. Cited in Moustakas C. (1994) Phenomenological Research Methods. Sage Publications, London. Yegdich T. (2000) In the name of Husserl: nursing in pursuit of the things themselves. Nursing Inquiry 7, 29-40.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

DEPRESSION – WHAT’S IN A NAME – EXPERIENCES AND CARE Author: Malachy Feely, RPN, Cert.C, Dip.N, MA, Nurse Practice Development Co-ordinator – Mental Health Services, St. Brigid’s Hospital, Ardee, Co. Louth. Summary explanation: The development and delivery of an interactive and responsive educational programme (Choices Programme) that promotes and fosters decision-making and choice for people who experience depression is the scope of this initiative, completed within the context of an ongoing practice development and PhD research study. Depression, what it means, how it is experienced and responses have been central to this work. Clear planning and qualitative confusion reign, as responsiveness to experience was paramount in design. Issues relating to research in mental health and mental health services, including identifying a responsive and ethical approach that adequately captures the multifarious experience a.k.a. ‘depression’ and gender issues relating to scope of experience and researcher sex, were addressed. Key learning outcomes: Participant feedback and experience identified that the development, delivery and participation in the Choices Programme has empowered clients to take a more active role in their care relative to their experience of depression. Additional learning, in relation to programme development, delivery, participation and initial review includes identifying: what it means ‘I’m depressed’; what to include in developing the programme; delivery of Choices Programme – the facilitators’ experience and client participation in Choices Programme – client experience. Further, depression was found to be an individually lived multifaceted, disconnecting and imprisoning experience. The application of the label is simultaneously helpful and unhelpful. Those who experience it have difficulty in responding to the enormity of actual experience. It is concurrently individualised and collectivised in context and experience. Implications for practice: Care experience and depression are inextricably linked, with relational responses of caregiver significant both in what is said and the manner in which it is delivered. The changing nature of depression knowledge and experience as an individually based occurrence requires internal and external personal reflective responses (in the context of those living with depression) and from service providers in care delivery. The use of educationally and experientially focussed approaches to care has the potential to positively facilitate this journey – a process that requires further examination in the context of care and experience. Additional implications include potential consequence of the running of additional programmes vis-à-vis the pragmatics of the process, for: Participants; Facilitators; and Services – both clinical and academic.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Rape & Sexual Assault in Ireland: Project Overview Ms Anne Flood MSc, BSc (Hons),RGN Director & Anne McHugh CNM2, Nursing Practice Development Unit Centre for Nursing and Midwifery Education, Donegal St Conals Hospital Letterkenny Co Donegal Ireland + 353 74 9188851 [email protected] Overview of Project In 1997 the A&E Department and the Nursing Practice Development Unit had concerns regarding the reception of rape victims within the A&E Department. This led to the commissioning of a CARE Suite at Letterkenny General Hospital. This suite is purposely designed to receive such victims in a non clinical environment. Through this development and networking with other units within Ireland it was noted that there were several issues affecting the development of care for rape victims throughout the country and indeed throughout other countries. One of the major issues is access to a forensic examiner in a timely manner. A national conference was held in Letterkenny. At this conference a need emerged to investigate this issue more systematically at a national level. This has led to the commissioning of an interprofessional, interagency steering group within the Department of Health and Children and the development of national guidelines for care. Funding from the national council for nursing and midwifery has enabled us to investigate the role of the clinical nurse specialist as forensic examiner which is now being discussed within the steering group. Needs Identification In 2003 a needs analysis was undertaken to uncover the picture on a national basis. All Emergency Departments listed in the Irish Medical Directory were asked to complete a questionnaire (n=34). There was a 65% (n=22) response rate. Concerns related to Gardai, Personnel, Accommodation, Training and Guidelines. The least concern was around access to Gardai (86%). The highest concern was around suitably qualified personnel (57%) & staff training (57%) with guidelines for practice causing most concern (71%). This demonstrated that there is a need: • • • •

To ensure equity of access to this service throughout Ireland To provide a service which responds to the needs of rape victims - person centredness To ensure the service is of the best quality firmly based on evidence To ensure the nurse can maintain accountability in a court of law

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Proposals to address these issues include the development the Clinical Nurse Specialist role, the development of a Higher Diploma programme to Support the role and the development of Guidelines for Practice. The role of the CNS as determined by the National Council for Nursing and Midwifery should encompass this criteria • Registered nurse/midwife – 5yrs minimum • Extensive experience/expertise. • Evidence of continuous professional development. • Education - Higher Diploma or above. • Must be within their scope of practice. In response to this the Forensic nurse would gain authority from the National Steering Committee, education from the Higher Diploma in Forensic Nursing –Rape/Sexual Assault and competence from both the clinical component of the higher diploma programme and continued engagement in clinical practice and assessment of competence. The higher diploma clinical modules would include The law and forensic nursing, Principles of forensic nursing and Holistic care of victims of sexual assault The national guidelines are now complete and ready for publication

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Rape & Sexual Assault in Ireland: Review of the Literature Ms Anne Flood MSc, BSc (Hons),RGN Centre for Nursing and Midwifery Education, Donegal St Conals Hospital Letterkenny Co Donegal Ireland + 353 74 9188851 [email protected] The World Health Organisation states that rape is ubiquitous and occurs in every culture, in all levels of society and in every country in the world. Data from country and local studies indicate that, in some parts of the world one woman in every five has suffered an attempted or complete rape by an intimate partner during her lifetime. Although the vast majority of victims are women, men and children of both sexes also experience sexual violence. Sexual violence can thus be regarded as a global problem, not only in the geographical sense but also in terms of age and sex (WHO, 2003). Ireland has been active in promoting research to address the issues faced in providing a service to meet the needs of victims of rape and sexual assault. Many reports have influenced the development of services throughout the country. (Report On The Task Force On Violence Against Women, Office Of The Tánaiste, (1997), The Legal Process And Victims Of Rape (Bacik et al, 1998), A Framework For Developing An Effective Response To Women And Children Who Experience Male Violence In The Eastern Region (2001), Attrition In Sexual Assault Offence Cases In Ireland (Leane et al, 2001), The SAVI Report - Sexual Abuse And Violence In Ireland (McGee et al, 2002). The Dublin Rape Crisis Centre commissioned The Royal College of Surgeons of Ireland to undertake research and produce a report on Sexual Abuse and Violence in Ireland in 2002. The resulting publication was the SAVI Report (McGee et al, 2002). Minister Michael Martin, TD Minister for Health & Children introduced this report with “ …the impact of rape and sexual assault can have a traumatic effect on victims, and services must be in a position to respond appropriately”. and Minister John O’Donoghue, TD Minister for Justice, Equality and Law Reform stated that “..research projects give us important information to help all involved respond better to the special needs of victims.” One concern voiced in this report was the silent majority of victims not reporting rape and sexual assault. “We knew that those people who sought help were a minority of those sexually victimised and there was no way to establish the number of people who do not seek help.” (Allen, 2002 cited by McGee et al, 2002). Following the presentation of the literature in the Irish context there can be no doubt that “the question arises, as to whether a need exists for the establishment of additional specialised units throughout the country. In this context, the Task Force recommends that this issue be specifically examined by the Department of Health” (Oifig an Tánaiste, 1997).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Bacik I., Maunsell C., Cogan S. (1998) The Legal Process And Victims Of Rape, Cahill Printers Ltd: Dublin. Leane M., Ryan S., Fenell C., Egan E. (2001) Attrition In Sexual Assault Offence Cases In Ireland : A Qualitative Analysis, The Stationery Office: Dublin McGee H., Garavan R., deBarra M., Byrne J., Conroy R. (2002) The SAVI Report. Sexual Abuse And Violence In Ireland. A National Study of Irish Experiences, Beleifs and Attidutes Concerning Sexual Violence. Dublin: Liffey Press. Office Of The Tánaiste, (1997) Report of the Task Force on Violence Against Women, Government Publications: Dublin. World Health Organisation (2003), Guidelines For Medico-Legal Care For Victims of Sexual Violence, WHO: Geneva.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

CARING TO TOUCH: HOW NURSES FEEL Dr E Gale, Lecturer in Nursing, PhD MA RNT RMNH School of Nursing and Midwifery, Keele University, Keele, Staffordshire, ST4 6QG Dr J Hegarty, Senior Lecturer in Psychology PhD, School of Psychology, Keele University, Keele, Staffordshire, ST5 5BG Background Touch rarely occurs when people with are being cared for. When it does, it tends to be functional in nature, rather than therapeutic. Why? Carers could have an important role in engendering emotional well-being in patients if they used touch in a professionally therapeutic way. This study aimed to discover what staff perceived were the barriers to their use of touch in nursing. Method 96 staff participated in 11 focus groups. The groups comprised trained and untrained nurses. They were asked to consider issues that had been identified in a literature review concerning staff attitudes to the use of touch in caring. Results Views and feelings about touch were varied, but participants generally felt that touch did benefit clients Qualified staff did not feel the need for further training in the use of touch but non-qualified staff felt the need for training in all aspects of touch. Conclusions Training may be a key reason why therapeutic touch is not used more. More work should be done to train staff in using touch as one way to increase emotional wellbeing.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EXPLORING THE PSYCHOLOGICAL IMPACT OF A RECONFIGURED BODY: THE EXPERIENCE OF AMPUTATION AND SUBSEQUENT PROSTHETIC FIT

Pamela Gallagher, BA Mod., DipStat, PGCE, PhD Lecturer in Psychology, Faculty of Science and Health, School of Nursing, Dublin City University, Dublin 9, Ireland. Tel: +353-7008958 E-mail: [email protected] Many challenges arise from losing a limb, most notably the process of being fitted for and learning to use a prosthesis. Central to this is the idea of providing the person with more effective body functioning and ensuring ‘successful’ prosthetic use. Consequently, the majority of research concerns itself with the ensuing physical adjustment, the prosthesis and physical or technical factors that impede or facilitate this adjustment process. This is an obvious and inherently required aspect of the process. However, as a result, the psychosocial aspects of adjusting to the prosthesis remain comparatively unresearched and poorly understood (Desmond and MacLachlan, 2002). Psychoprosthetics explore the psychological factors at play in the adaptation to prosthetic devices. This paper will report on a series of studies that investigates the psychological perspective on prosthetic use and adjustment in adults with a lower limb amputation. In particular, it will review the role of meaning attributed to limb loss and prosthetic use, and quality of life in people with a lower limb prosthesis, and their relationship to subsequent adjustment. It will also discuss the development and ongoing use of the Trinity Amputation and Prosthesis Experience Scales, a multidimensional self-report questionnaire designed to better understand the experience of amputation and adjustment to a lower limb prosthesis. The findings present a backdrop against which to explore the issues facing a person who has had an amputation and is being fitted with a prosthesis; the ways in which a person deals with the complex loss and gain that accompanies an amputation and the impact this has on our sense of self; the way in which the person relates and adjusts to the prosthetic technology that now is part of the reconfigured body; and the role of positive psychology and the impact of this perspective for the way we view illness and disability. Overall, the findings from these studies advocate the promotion of a user centred approach and the importance of interdisciplinary inputs. References Desmond D, MacLachlan M. (2002). Psychosocial issues in the field of prosthetics and orthotics. Journal of Prosthetics and Orthotics, 14(1), 19-22.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

THE INTRODUCTION OF AN IMMEDIATE LIFE SUPPORT COURSE TO THE UNDERGRADUTE NURSING SCIENCES PROGRAMME. Authors: (1)Patrick Gallagher BSc, Post Grad Diploma (Distinction),RGN Address: Teaching Fellow School of Nursing and Midwifery Queen’s University, Medical Biology Centre, 97, Lisburn Road, Belfast [email protected] (2) Billiejoan Rice MSc, BSc, RGN (3) Debbie Rainey MSc, BSc, RGN (4) Trevor Mc Nulty Senior Resuscitation officer Resuscitation Services, First Floor, Bostock House Royal Group of Hospitals, Belfast BT12 6BA (5)Niall Mc Kenna BSc, RN (6)Marian Traynor EdD, MEd, BSc, RGN [email protected]

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Background The purpose of this study was to pilot the introduction of an Immediate Life Support (ILS) course to the undergraduate nursing sciences programme. Aim and objectives of the study The aim of this study was to deliver and evaluate an ILS course to third year nursing students. The objectives were to promote the requirement for newly qualified nursing staff to be competent to deal with the acutely ill patient and to promote the development of a practitioner with the ability to think critically and analytically. Design of the study Third year Adult Branch nursing students (n= 225) were invited to take part in the study. The study was designed over a nine-day period: twelve students participated per day, total number of students = 89. Students were randomly assigned to the study and were asked to access the web for details of the date and time of their session. The ILS course was delivered in the nursing and midwifery clinical education centre in the school of nursing and midwifery at Queen’s University. Students were provided with the ILS manual in advance of their attendance at the course. (The course was run in keeping with the guidelines from the UK resuscitation council) Students were informed in advance that provided they passed the course they would receive a certificate from the UK resuscitation council. The course was delivered by nurse teachers who are recognised Advanced Life Support (ALS) instructors. Data Collection and Analysis Each participant completed a 24-item questionnaire. Participants could choose one of five options, from “strongly agree” to “strongly disagree” when responding to each item. The responses were scored 1 to 5 with a score of 3 being assigned to the “undecided” group. Results: The questionnaires were analysed using SPSS. Results indicate that students strongly support the view that the ILS course should be part of the undergraduate nursing sciences programme.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EDUCATIONAL NEEDS ANALYSIS – A TRIANGULATION OF APPROACHES Colette Gibbons-Twomey MSc, PGDip Ed. BSc(Hons),SpDipCMNH, RPN, RNT. Specialist Co-ordinator of Postgraduate Education Anne Flood Catherine Cannon ADDRESS OF AUTHORS: Centre of Nurse and Midwifery Education, St. Conal’s Hospital, Letterkenny, Co. Donegal NAME OF PRESENTER: Colette Gibbons-Twomey The Donegal Centre for Nurse and Midwifery Education (C.N.M.E) aims to provide practice-based nursing and interdisciplinary education. Thus ensuring continued professional development of healthcare staff. Therefore contributing to the development of effective and equitable health care in accordance with local and national policy Training and development is a cyclical process of which the identification of learning needs is the first step. Identifying needs is crucial to the whole context of learning and development because it ensures that training and development occurs when it is most needed, resulting in the most efficient and effective use of resources (The Office For Health Management, 2002) The Donegal Centre for Nurse and Midwifery Education analysed and identified the training and educational needs of staff in 2004-2005 utilising the Office For Health Management Toolkit (2002). This involved an analysis of the organisation and it’s strategies, an analysis of the staff to be trained and thirdly, an operational analysis of the level of jobs for which the target group is used (Blanchard and Thacker, 1999). The findings from this comprehensive and highly effective study continue to reflect the pertinent training needs of staff and service, therefore its findings will be utilised in the 2005-2006 training and educational needs analysis.A triangulation of approaches was used in the 2005-2006 training needs analysis. Campbell and Fiske (1959) identified that the validity of research is not only be enhanced through the utilisation a mixed method approach but the data also would be rich in quality and depth. They also cited triangulation as a valuable strategy to ensure the rigour, breadth and depth of an investigation. Data was collected in four phases, 1. A critical review of the 2004-2005 needs analysis. 2. A short confidential questionnaire, distributed randomly to nursing staff within each nursing discipline. 3. An A3 poster was distributed to each unit/ward manager outline five educational themes. They were requested to display the poster on the staff notice board for a two-week period. Staff were encouraged to discussion and complete the poster, identifying the educational courses that they would like to attend and which reflected the needs of their service plan. 4. Discipline specific focus

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

groups with nursing staff to assist in clarifying that data from the questionnaires correctly reflected the organisational needs. The Q.U.A.S.A.R. audit tool was used to analyse data. This comprehensive educational needs analysis is ongoing at present and comprehensive results will be available in early August 2005 for dissemination. Blanchard, P.N. and Thacker, J.W (1999) Effective Training: Systems, Strategies and Practices. New Jersey : Prentice Hall. Campbell, D.T. and Fiske, D.W. (1959) “Convergent and discriminant validation by multi-trait, multi-dimensional matrix.” Psychological Bulletin 56, 81-105. Office For Health Management (2002) Learning and Development Needs: Identification and Planning Toolkit. Dublin : Office For Health Management.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

PROFESSIONAL DEVELOPMENT COURSE FOR CLINICAL PLACEMENT COORDINATORS – AN OUTLINE AND EVALUATION Colette Gibbons-Twomey Specialist Co-ordinator of Postgraduate Education MSc, PGDip Ed. BSc(Hons),SpDipCMNH, RPN, RNT. Centre of Nurse and Midwifery Education, St. Conal’s Hospital, Letterkenny, Co. Donegal Clinical Placement Coordinator (CPC) posts were established in response to the development of the pre registration diploma programme c1994. The report of the commission of nursing (1998) the CPC was a pivotal factor in the success of the pre registration degree programme. Their role is to advise, empower and facilitate students to achieve maximum outcomes from clinical placements. They also facilitate students in their application of competencies, ensuring the student demonstrates proficiency within practice. Those in post are skilled clinical practitioners and are required to demonstrate expert management, leadership and negotiation skills; all of which influence on only student education but patient care. The Department of health and Children (1996) stipulated that the Clinical Placement Coordinator requires to undertake a training course by the health board / hospital in conjunction with the third level institution to support their competence development. This was also highlighted by Drennan (DOH) (2001) This course therefore proposed to provide the course candidates with the theoretical knowledge and competencies required to fulfil the role of Clinical Placement Coordinator. The course was developed using a similar model to that successfully employed by the Practice Development Team in St. Vincent’s Fairview, Dublin. Eight Nurses accross three divisions of the nursing register participated in the course. Four were existing CPCs and four were on a relief bank of CPCs. The course was conducted over a fourmonth period and consisted of 117 Theoretical Hours (6.5hr x 18 days) and 35 Clinical Practice Hours (7hr x 5 days). The course content was taught at level 8. Liaison was established with Letterkenny Institute of Technology to accredit the course as a minor award within a major award. All participants completed a 5000word course assessment. The theoretical course content was delivered under nine themes: 1.Enhancing and sustaining a learning environment. 2. Developments in nurse education. 3. Contemporary professional issues. 4. Facilitation of learning and supporting the student. 5.Developing and measuring competence. 6.Leadership and management. 7. Practice development. 8 Research in practice and 9. Accountability. The course also consisted of five supervised clinical placement days. Participants were encouraged to engage in peer supervision with each other on one occasion. The course participants utilised learning plans and reflective diaries during their placement. In order to ascertain the participants’ experiences to date and gain an insight into their motivations and educational needs they completed pre and midpoint questionnaires. The course content and timetabling of content was adapted slightly to tailor their

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

requirements. A triangulation of approaches was utilised to evaluate the course on completion using an in-depth evaluation questionnaire, a semi structured focus group and the course assignment. The course assessment will give a valuable insight into the depth and learning that took place on the course. The theoretical and clinical components of the course have been completed and assignments are in the process of being marked and moderated.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

LEARNING FROM SERVICE USERS – AN EXPLORATION OF STUDENTS’ EXPERIENCE OF LEARNING IN PRACTICE Janice Gidman MEd, PGCE, BSc (hons), ONC, RGN Head of Education Centre School of Health and Social Care University of Chester Parkgate Road Chester, CH1 4BJ There is increasing recognition of the need for effective strategies to promote learning during the practice aspects of health and social care education programmes. Indeed, this is gaining increasing recognition within formal quality monitoring and enhancement procedures (Quality Assurance Agency (QAA), 2000; 2004). Patients and clients are at the heart of the government’s agenda for health and social care reform (DOH, 2000; 2003) and this is an issue of increasing significance for those involved both in care and professional education. This paper argues that all professionals involved in health and social care education need to value and promote the important role that service users play in respect of this learning. This paper will report on a qualitative research study, which explores students’ perceptions of learning during their practice placements. A purposive sample was identified, to include students from all four branches of nursing, and from midwifery and social work programmes. Students were interviewed and the data was analysed using Giorgi’s descriptive phenomenological method (Giorgi, 1989). The data indicate that students perceive that they learn from experiences with service users in a range of practice settings; students report, however, that this learning is often ‘ad hoc’ in nature. The research findings will be discussed in relation to service user involvement in the education of health and social care students and in respect of the value of reflection as a strategy to promote this learning. References Department of Health (2000) The NHS Plan. London: D.O.H. Department of Health (2003) Patient and Public Involvement in the New NHS. London: D.O.H., Giorgi A (Ed.) (1989) Phenomenology and Psychological Research. Pittsburgh, Duquesne Press. Quality Assurance Agency (2000) Code of Practice: Practice-based Learning, London: QAA Quality Assurance Agency (2004) Prototype document for the approval and ongoing quality monitoring and enhancement process. London: QAA

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AN EVALUATION OF OCCUPATIONAL THERAPY SPECIFIC TREATMENT/INTERVENTION PLANS WITHIN INTERPROFESSIONAL CLINICAL SETTINGS AILSA GILLEN MSC, DIPCOT,PGCE, CERTED,ILTM SENIOR LECTURER DEPARTMENT OF ALLIED HEALTH, CANTERBURY CHRIST CHURCH UNIVERSITY, NORTH HOLMES ROAD, CANTERBURY, CT1 1HU ENGLAND Government policy advocates that quality of care is assured through interprofessional working and client centred care (DOH 1997, DOH 1998, DOH 2000). Clearer and closer communication is set as the means by which this is addressed (DOH 2000, DOH 2002). The evidence within OT literature demonstrates agreement that specific and client centred working can help achieve the desired outcome of the intervention (Trombly, Vining, Radomski & Scold Davis (1998, Missiuna & Pollock 2000, Melville, Baltic, Bettcher & Nelson 2002). However there is no identification of how this intervention can best be recorded to communicate the uniqueness of the OT role in client centred care. In light of this, this exploratory evaluative study aims to identify the goal setting and treatment planning practice of occupational therapists within health settings in and around the Canterbury area. Focus groups were used to gather the perception of experiences of practicing OTs in relation to goal setting and writing treatment plans. In addition, participants submitted anonymous written treatment plans for analysis. Results of the study demonstrated that, from the participants’ perspective, goals were set for the client and were service driven. In addition, they felt that goal setting and treatment planning required non-OT specific working and that they felt undervalued. The analysis of the submitted treatment plans substantiated these perceptions, except in the case of them feeling undervalued. There was no evidence of this within the documentation. This study raises the question of how OTs can highlight their unique contribution to the quality assurance agenda. Bibliography Department of Health Department of Health Department of Health Department of Health HMSO

1997 1998 2000 2002

The New NHS: Modern, Dependable London HMSO A First Class Service London HMSO The NHS Plan London HMSO Shifting the Balance of Power: Communication London

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Melville L.L., Baltic T, Bettcher T.W. & Nelson D.L. 2002 Patients’ Perspectives on the Self-identified Goals Assessment American Journal of Occupational Therapy Vol56 No.6 p650-659 Missiuna C & Pollock N 2000 Perceived efficacy and goal setting in young children Canadian Journal of Occupational Therapy Vol 67 Issue 2 p 101-109 Tromby C.A,Vining Radomski M & Schold Davis E.S 1998 Achievement of SelfIdentified Goals by Adults With Traumatic Brain Injury: Phase I American Journal Of Occupational Therapy Vol 52 No,10 p810-818

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

BEREAVEMENT AND INTELLECTUAL DISABILITIES: A QUALITATIVE STUDY EXPLORING THE PERCEPTIONS OF SUPPORT GIVEN BY FORMAL CARERS AT THE TIME OF AND FOLLOWING BEREAVEMENT Author: Ursula Gilrane-Mc Garry Job Title: Lecturer in Nursing Qualifications: MSc. (Advanced Nursing), PGDip. (Nurse Education), B.A. (Health Management), R.N.I.D. Address: Dept. of Nursing and Health Studies St. Angela's College Lough Gill Sligo Contact details: Email: [email protected]. Tel no:071-9142051 (ext.286) Name of presenter: Ursula Gilrane-Mc Garry.

ABSTRACT Little is known about the service user’s perception of the supports provided by formal carers around the time of bereavement for people with intellectual disabilities. This paper investigates the perceptions of the types of supports provided to this population at the time of, and following, bereavement by formal carers. In total eleven participants took part in a series of semi-structured interviews. Practical supports (i.e. involvement in events surrounding the death and access to the rites of passage) provided to these individuals were reported to be positive interventions, whereas, the provision of emotional supports (i.e. formal and informal supportive counselling) by staff were cited by the participants to be sporadic. The use of alternative approaches (i.e. reminiscence work; the creation of a life story book/family tree, the use of art therapy and pictorial material) were also reported to be lacking. These findings highlight the need for education and training to provide staff with the insights, knowledge and skills necessary to practically and emotionally support people with intellectual disabilities who are facing loss and bereavement. In addition, these training needs should be aligned with ongoing managerial and specialist organisational support so that the specific needs of this bereaved population can be fully addressed.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

RESEACHING GAY AND LESBIAN POPULATIONS Author: Qualifications: Current Position:

Michèle Glacken* PhD; BSc; RGN; RM. Head of Department of Nursing & Health Studies St. Angela’s College Lough Gill Sligo

Daytime telephone Number: 00 353 719135646 Correspondence address: As above E-mail address:

[email protected]

Author: Agnes Higgins Qualifications: MSc, BNS RNT, RPN RGN Current Position: PhD Student Daytime telephone Number: 01 8451100 Correspondence address: School of Nursing & Midwifery Studies University of Dublin, Trinity College Dublin 2 Ireland E-mail address:

[email protected]

ABSTRACT: Loss of a spouse/partner is recognized as one of the most stressful losses with the sense of loss intensified because the grief is not only for the person who has died but for the connection to the spouse, as well as for the bereaved person’s plans, hopes, and dreams for a future with the spouse/partner. Although all bereaved partners, whether hetro-sexual or homosexual, need to make sense of the loss and fit it into their assumptive world, to date most research on bereaved spouses has emerged from the heterosexual community. The advent of AIDS in the 1980s witnessed a shortlived surge of research interest in the bereavement experience of the gay community. It is evident from the aforementioned research that gay partner loss can be related to the literature on disenfranchised loss (Wallbank, 1992). As Shernoff (1998: 27) explains when a ‘gay man’s partner dies, his trauma is often exacerbated by the lack of mainstream culture’s recognition of his relationship, his loss, and his being a widower’. However, it is clear that not all bereaved gay partners experience disenfranchised grief. Unfortunately, the findings of the research carried out with the gay community at this time are limited in terms of generalisability to the wider gay community for a number of reasons, namely many participants were experiencing multiple losses leading to a chronic state of mourning; experiencing survivors’ guilt and because AIDS often afflicted young men whose life experience was limited in terms of emotions related to the meaning of life, sickness and death thus affecting their response to the loss. Similarly, there is a severe lack of literature on lesbian women who have lost their partners through death. There loss is said to be particularly acute as lesbian women tend to establish relatively long term relationships. Indeed,

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

lesbian women who have lost a partner are truly silent grievers (Walter, 2003). This paucity of empirical literature on the bereavement experience of members of the gay community means that palliative care practitioners have no ready source of information available to inform them of the specifics of how gay widows/widowers mourn and what is required for them to adjust to their bereaved state in an adaptive way. Palliative care professionals’ are thus compromised in their ability to provide evidence base care for this population. The authors of this paper sought to address this dearth through a qualitative study with the specific aim of identifying and describing the bereavement experience of gay persons following the death of their partner. The study is ongoing with the mode of data collection being unstructured interviews. Thematic analysis will be employed. The aim of this paper is to discuss some of the ethical and methodological challenges faced by the researchers undertaking the study. Researching all populations poses certain methodological challenges in relation to recruitment and sampling. However, researching the experiences of gay and lesbian people creates further challenges as they could be considered to be a ‘hidden population’ within the Irish context. Issues to be addressed will include the maintenance of confidentiality/ privacy; achieving informed consent and trust; recruiting and sampling a ‘hidden’ population and issues that emerged in relation to defining the sexuality status of the participants and researchers. The manner in which these challenges were addressed will be discussed. Shernoff, M. (1998) Gay widowers: Grieving in relation to trauma and social supports Journal of the Gay and Lesbian Medical Association 2 (1): 27-33 Wallback, S. (1992) The empty bed. Bereavement and the loss of love. London: Darton, Longman & Todd Walter,C.A (2003) The loss of a life partner: Narratives of the bereaved New York: Columbia University Press

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

An Exploratory Study of Psychiatric Nurses’ Perceptions of Physical Touch with People who Experience Acute Mental Health Problems Madeline Gleeson RPN RGN BNS (Hons) MSc.N Nurse Lecturer School of Nursing & Midwifery Trinity College 24 D’Olier Street Dublin 2 Background Physical touch is a fundamental part of the nurse patient relationship in virtually all nursing situations. Despite the fact that numerous writers have advocated the importance of physical touch as a therapeutic intervention and a fundamental part of the nurse patient relationship, physical touch does not appear to have been a major topic for research. The majority of studies on physical touch are from general nursing. The lack of attention paid to touch in psychiatric nursing is probably related to the fact that touch in psychiatry has been traditionally taboo (Autton, 1989) and because psychiatric patients are self-caring to a degree and therefore require minimal attention (Tommasini, 1990). The primary concern in healthcare delivery is the fear that physical touch will be misinterpreted as a sexual behaviour (Hunter and Struve, 1998). On reviewing the literature, only four studies on physical touch and psychiatric nursing were found and all were from the USA (De Augustinis, Isani and Kumler, 1962 as cited in Burd and Marshall, 1963, Aguilera, 1967, Cashar and Dixson, 1967 and Tommasini, 1990). There is a distinct lack of published research regarding psychiatric nurses’ perceptions of physical touch in the Irish context. This paper reports on psychiatric nurses’ perceptions of physical touch with people who experience acute mental health problems. Methodology A descriptive exploratory qualitative research design was used as it allowed the perceptions of the participants to be described in their own words (Robson, 2002). Ten registered psychiatric nurses were randomly selected from one psychiatric hospital in Ireland, to participant in the study. Data was collected by semi-structured interviews based on the analysis of the literature reviewed. Burnard’s (1991) 14 stage-by stage process of coding and categorization was used to analyse the data. The criteria for establishing trustworthiness for qualitative studies were employed. Approval for conducting the study was granted by the relevant research ethics boards. The Director of Nursing of the research site granted access and permission to recruit the sample. Findings As an outcome of the data analysis six main categories were identified, the meaning of physical touch, using physical touch in clinical practice, factors that influence the use of physical touch, effects of physical touch, cultural context and learning about physical touch. The findings indicated that physical touch is used in psychiatric nursing and is only considered to be therapeutic to patients if used judiciously with effective interpersonal skills. The use of physical touch is dependant on certain factors, the patient’s health status, diagnosis, age, gender, culture and the nurse patient relationship. Male nurses have a heightened awareness of using physical touch with

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

female patients because of the fear of sexual allegations. Both male and female nurses had concerns about touching people who had a diagnosis of psychosis, paranoia, mania and personality disorders. The use of physical touch in the form of restraint was described as a way of providing safety and protection to patients and staff and emphasis was placed on the effective use of verbal and non-verbal communication before during and after a restraint. Physical touch was not addressed as a separate topic in the participants’ nurse education but was incorporated into modules on communication and psychomotor skills. Participants in the main learned how to use physical touch by observing exemplar role models in the clinical area. The use of physical touch was described by some of the participants and suggestions were given for the need for greater educational preparation for nurses because of the increase in different cultures in Ireland today. Conclusion The findings tentatively add to the existing empirical research on physical touch in nursing. The findings serve to highlight the use of physical touch as complex and multidimensional within psychiatric nursing. Through the use of description in this study, greater meaning and understanding of physical touch can now be shared and can possibly reinforce the importance of a behaviour that is used every day by nurses, touch. References Aguilera, D. C. (1967) Relationship between physical contact and verbal interaction between nurses and patients. Journal of Psychiatric Nursing. 5(1): 5-21. Autton, N. (1989) Touch An Exploration. London: Darton, Longman and Todd Ltd. Burd, S. F. and Marshall, M. A. (1963) Some Clinical Approaches to Psychiatric Nursing. New York: The Macmillian Company. Burnard, P. (1991) A method of analyzing interview transcripts in qualitative research Nurse Education Today. 11: 461-466. Cashar, L. and Dixson, B. K. (1967) The Therapeutic Use of Touch. Journal of Psychiatric Nursing. September-October: 443-451. Hunter, M. & Struve, J. (1998) The ethical use of touch in psychotherapy. London: Sage Publications. Robson, C. (2002) Real World Research. 2nd Edition. United Kingdom: Blackwell Publishing. Tommasini, N. R. (1990) The use of touch with the hospitalized psychiatric patient. Archives of Psychiatric Nursing. 4(4): 213-220.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EXPLORING LIVED EXPERIENCE OF OCCUPATIONAL STRESS IN NHS PODIATRISTS-AQUALITATIVE INQUIRY - Developing new research methods through the professional doctorate. Donna Glover Podiatrist Community Centre For Health Dumbarton Road Partick Scotland [email protected] Background To date there has been only limited research into occupational stress in podiatry. There has been no qualitative inquiry attempting to better understand the experience of stress in daily practice, or allowing practicing NHS podiatrists to discuss, without limitation their own experiences of stress in practice. The current research aims to address this shortfall. For the purposes of the current research occupational stress will be defined as “the adverse reaction people have to excessive pressure or other types of demand placed on them (HSE, 2001) Current evidence suggests that burnout rates are higher across the UK podiatric workforce than that of other health care professions (Mandy and Tinley, 2004). Key sources of stress for podiatrists have been identified as including, too much work, isolation, lack of patients understanding of the podiatrists job and dealing with patients emotional problems (Mandy and Tinley, 2004). Having come on board the professional doctorate programme naively thinking myself to be a quantitative researcher and aiming to ‘measure’ stress in some way, my journey caused me to explore the question ‘what do I really want to know about occupational stress?’ and ‘how can I best find this out?’. Therefore, I begun to question my motives for choosing this as my research topic and came to realise that my aim was not in fact to measure stress, but to better understand the experience of stress in practice (for podiatrists) in order that we can utilise this knowledge to; • • • •

empower clinicians to play an important role in their workplace to minimise excessive stresses where possible increase our awareness of stress and its effects and implications both in our selves and our colleagues to begin to understand perceptions of stress within the profession to provide new knowledge within the profession about stress and its impact on daily practice

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Methods This study was a small pilot study to enable testing of new methods of data generation in this area of podiatric practice. Participants were randomly selected practicing podiatrists from a large primary care trust. The methods chosen were collage and semi-structured interviewing. The aim in both of these techniques was to allow participants to have the lead in the generation of data whilst acknowledging the role the researcher plays in the process. Collage is defined as an artistic composition of materials and objects pasted over a surface, often with unifying lines and colour (Dictionary.com). In this research participants in a small group of five where asked to browse through a selection of magazines choosing images which stimulated a memory or helped to symbolise an experience or view on occupational stress. The participant then glued images on to a large A3 sheet of card to produce their own individual collage. Such projective techniques are sometimes used as ice-breakers in various settings (Parsell et al, 1998). However, when this activity is carried out with a specific question as the central focus (e.g. a research question), and then to combine this with an additional research method (such as an interview), this type of technique can successfully be adapted as a useful and flexible qualitative research technique. Following this, each participant was offered an individual interview. In each interview, the collage was used as the focus for discussion. This enabled participants to choose the most relevant or significant experiences for them and reduced the risk of the researcher leading the discussion. The interviews did not consist of any pre-set questions and are semi-structured in that the researcher had prepared for the interview itself but had not imposed questions across the board. This combination of methods was influenced by my participation in the professional doctorate programme where exposure to other clinical researchers and participation in action learning sets, along with a structured programme of education, I was able to experiment with new ideas and receive continual support and feedback in a variety of settings. Early Findings and Discussion Analysis of the preliminary data emerging from this small pilot study has resulted in the production of new knowledge in the field of podiatry. The methods chosen were successful in practice and will therefore be carried into the final study. Initial findings suggest that stress is an important topic in practice but that this is both a positive and a negative experience. Previous research has not discussed the positive impacts of stress in practice. Previously identified sources of stress such as too much work (Mandy and Tinley, 2004), have been further developed by exploring what aspects of workload have such an impact on stress. The current research suggests that clinical workload (e.g. patient numbers) is not problematic. However, a lack of dedicated time for other non-clinical activities’ is stressful. Therefore this small study has demonstrated how the new methods can be used to both expand and deepen our current understanding of stress in podiatric practice.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Conclusion My journey as a professional doctorate student has allowed me to explore an area in which I have great interest, namely occupational stress in podiatry. It has however, through its encouragement to question ones practice both as a clinician and a researcher encouraged me to trial new methods to generate this data. To date, following a small pilot study, these new techniques have proven successful, exiting and challenging and will now be used in my thesis where my aim is to explore the experiences of occupational stress for practicing NHS podiatrists. References Health and Safety Executive. 2001, Tackling Work Related Stress, A Guide For Employees. Mandy, A. and Tinley, P. 2004, ‘Burnout’ and Occupational Stress. A Comparison Between UK and Australian Podiatrists, Journal of American Podiatric Medical association Vol 94(3) pp282-291 Parsell, G. Gibbs, T. and Bligh, J. 1998, Three Visual Techniques To Enhance Interprofessional Learning, Postgraduate Medical Journal Vol 74 pp387-390

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Conundrum of Consent for Young Adolescents Ms Mary Godfrey RGN, RM, RCN, BNS (Hons), RNT, MA Principal Nurse Tutor School of Nursing Our Lady's Hospital for Sick Children Crumlin Dublin 12 The purpose of consent is to facilitate choice and decision-making, protect and promote individual autonomy and ensure a person is neither coerced, persuaded, manipulated, nor deceived in any way. However, when the individual is an adolescent between the ages of 12 and 16 the issue of consent becomes problematic in healthcare. This is compounded by the prevailing belief that young people have a right to have their autonomy respected, their voice heard, and engage in decisionmaking in matters which affect them concerning their own health and well-being. The reality is very different, especially when a young person’s perspective is contrary to that of their parents, and or healthcare professionals, or where a young mother can consent for her infant but not for herself. The dilemma poses a conundrum for the nurse in clinical practice in determining what are the young person’s rights and the nurses ethical responsibilities. “Walking this tightrope is not an easy task” (Madden 2002:446), but one that must be addressed. A disparity exists between the legal age of consent and the actual ability and the competency to do so. In Ireland young people under sixteen years have no definite right to give consent for treatment in healthcare. They are presumed to be legally incompetent to make such decisions of this nature and thus require parental consent. However, young people often have the competency of adults to make decisions, but this goes unrecognised and is underestimated. Alderson and Montgomery (1996) children should be presumed competent from the age of five, with the onus on the healthcare professionals to demonstrate a young person’s incompetency as opposed to him/her having to prove this capacity. Whilst competency has been considered in the English courts and is referred to as ‘Gillick competence’, it has not yet been considered in this jurisdiction. It is within these parameters that this paper will explore the nurses’ responsibilities in ensuring the young person’s right to consent is protected and where necessary to advocate on their behalf. The complexity of competence will be addressed including the variety of influencing factors and the means of determining competence. Whilst there is no substantial agreement on either the characteristics of a competent individual or how competency should be measured (Johnstone 1999), nurses have a significant contribution to make in promoting the ethical considerations of actively engaging young people under sixteen in the consent process.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Alderson P. and Montegomery J. (1996) Health Care Choices. Making Decisions with Children. (Participation and Consent series, number 2) London: Institute for Public Policy Research. Johnstone M.J. (1999) Bioethics. A Nursing Perspective. 3rd edn. Sydney: Harcourt Saunders. Madden D. (2002) Medicine, Ethics and the Law. Dublin: Butterworth (Ireland).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

NEW EDUCATIONAL METHODS – CHALLENGES AND OPPORTUNITIES OF E-LEARNING IN NURSING EDUCATION Vida Gönc, Helena Blažun, Dušanka Mičetić-Turk, Peter Kokol University College of Nursing Studies University of Maribor Tel. nb. ++ 386 2 300 47 29 Fax. nb. ++ 386 2 300 47 47 e-mail:[email protected]

Introduction Nowadays we are facing with rapid growth of new technologies with which we are collecting and delivering information. In the last decade we are facing with a development of new techniques of education such as e-learning, simulations, virtual reality etc. Quick changes on the field of informational communication techniques and technologies forces institutions to think about different ways of teaching and learning. It is well known that our knowledge gained in school is getting out-of-date so its modernization is necessary. Computer based training and e-learning have brought a revolution to learning and instruction. But in general the empirical results of e-learning studies are somewhat disappointing. They cannot prove the superiority of e-learning processes over traditional learning in general nor in specific areas like nursing. Distance education Distance education is known for almost 200 years (Holmberg, 1995), first just as correspondence education. When we speak about distance education we thing about teaching and learning in where students are not required to be physically present at a specific location during the term and it is the process of providing instructions when students and instructors are separated by physical distance and technology. Most often, regular mail is used to send written material, videos, audiotapes, and CD-ROMs to the student and to turn in the exercises; nowadays e-mail and the Web are used as well(en.wikipedia.org/wiki/Distance_education,distance.nmsu.edu/support/glossary.ht ml). Initiation of life long learning in educational process and importance of knowledge leads us (SURS, 1999), as well as abroad (Vasquez Bronfman, 2000), to increasing of different educational forms and programs. Educational institutions follow new forms of education, which are often supported by informational communication techniques, mainly Internet. In the field of education, Internet is a media for information (Ploenes, 2000) and material transmission. With rapid development of informational communication technology and fast life style, distance education is more and more attractive and interesting form of education, mainly because of globalization as consequence of global development of Network (Kurbel, 2000). Usage of informational communication technology in distance education change organization and way of realization of distance education and also the role and method of work of professors and students.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Distance education in nursing care Study of nursing care demands a lot of theoretical and practical knowledge. Students and professors can use Internet and different bases for gaining proper literature which they need for study and teaching. Other forms as: e-mail, videoconferences, virtual classrooms are nowadays already a part of educational process. Because nursing care is very specific science (Yom, 2004; Davis, Sollecito, Shay, Williamson, 2004) verbal interpretations and conversations must be combined with computer supported education. Malow and Gilje (Mallow, Gilje, 1999) stress the importance of critical judgment of professors in introduction and influence of information technology. However, a lot of people have doubts about technology and humanity, especially in nursing profession. Internet offered options for nurses which were a few years ago only a dream (Cowell, 2000). In USA distant education for nurses at different levels is developing all the time. That kind of education is offered by many educational institutions (such as Regents College, Graceland College, The State University of New York at Stony Brook, The University of Phoenix). At University College of Nursing Studies University of Maribor we had an idea that we have to support nursing care – special fields of nursing care with information technology. We started with preparations within the subject Gynaecology, following the basic goals of education, larger flexibility of education and the importance of qualifying student for active use of knowledge (Gönc, 2004). We were very aware of the students' needs as well as their expectations. We believed that by utilizing the variety of learning media that are available to educators we can improve the learning process and outcomes while exposing students to innovative technologies that they will be exposed to in their future careers. Here we have to point out that we have to realize the importance of knowledge of Information Technology (IT) and that IT is not something to be afraid of, but represents a challenge to all of us. If used properly, IT, both in education and patient care, can be a great advantage. From this point of view we can start creating better learning tools for nursing students to gain the necessary skills to excel in information intensive environments. Distance education model, which was developed at Faculty for electronics, informatics and computer science (Lenič et al., 2000) is designed for students of University College of Nursing Studies University of Maribor. Model has two separate approaches: first is for students and their usage of information technology, second is destined for professors, their lectures and other educational activities. The purpose of distance education model is presentation of fundamental knowledge in specific fields of nursing care. Content is divided on thematic complex and it can be included in other fields of nursing care. The content is equipped with audio-visual means which thematically supplement theoretical contents.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Picture: Example of distance education modul for breastfeeding Goals of distance education model in nursing care If we want to create a distance education model for nursing care, it is very important to know theoretical and practical contents of subjects in nursing care. Computer supported information system is designed for planning, execution and evaluation of educational content. Computer designed information system enables: o Improving of quality of educational process with different results of information technology; o Clear presentation of nursing problems; o Better preparedness of students for application of theoretical content in clinical practice; o Possibility of multidisciplinary usage; o Bigger creativity, motivation and quality of work of students in nursing care; o Accessibility of educational contents regardless time; o Development of student ability for analyzing, synthesis and critical thinking; o Simple upgrading and changing in compliance with professional cognition. Students' opinion about distance education At University College of Nursing Studies University of Maribor we performed a qualitative study aiming to research the reasons why e-learning is not yet successful in nursing and how to improve the situation. It is not only important to create and prepare the materials, but also to present the model of e-learning to students and make the instructions for students, tutors and teachers how to use online courses. For better understanding of theoretical contents and improved application in clinical practice we support the lectures with information technology. The model represents informatics system which enables better and easier communication between students and lecturers (tutors) and also covers the entire educational process. It also includes educational instruments for performing distance education. We think that the main problem for teachers is how to create complicated knowledge presentations, providing text files, scanned text or self made explanations to topics. In

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

aspects of online courses, teachers want to rely on reliable authors, reliable and tested knowledge providers, as they do with the use of paper based books. Contrary, the students are supporting the e-learning as and addition to ordinary but much shortened courses especially as an asynchronous way of learning. An additional problem we encountered was that e-learning requires different pedagogical approaches for both teaching and learning and that nor teachers nor students are aware of it. Recent research found out that knowledge based systems can support different learning styles supporting individualized learning and teaching. Some other studies showed that learner models representing learning styles can be built and used with success in intelligent tutoring systems. In general such learning’s called self regulative and it has been shown that the level of self-regulation is highly correlated with the learning performance. Another very important recent finding is that till recently it was assumed that an individual’s ability to learn is fixed. But current research showed that this assumption may be wrong. Learning may be a skill, not a hard-wired trait and people can improve their capacity to learn at any age. Our idea is to create an e-learning model, which will enable teachers and tutors to learn how to prepare and manage course materials easily and efficiently. Our project goes another way and tries to implement new tools into the elearning environment to come to better results. This is especially important because of the importance of e-learning in special fields like nursing where in addition to nurses also patients (including disabled persons, elderly, hard to reach persons) have to be instructed and educated. We performed research among 10 full time and 26 part time students. The questions were similar for both groups. On questions related to possessing computer and using the Internet we got similar answers. 90% of students posses computer and use it. We perceive a little difference in frequence of usage the Internet, part time students daily use Internet only in 69%, full time student in 90%. On the question in which purposes they use Internet, part time students answered in educational purpose (47%), entertainment (43%) and work (10%), of course full time students use Internet more for educational purpose (62%) and entertainment purpose (38%). At questions regarding distance education we were very surprised that full time students don’t have many experiences about using or knowing distance education. Majority of students heard about distance education but never used it. We gained much more interesting answers from part time student that had some experiences in using distance education (7%), a lot of them heard about it and never used it (27%) and there are a lot of those who never heard about distance education (32%). It was very interesting what students think are advantages and disadvantages of distance education. Both groups thinks that main advantage is time and money saving (57%), learning whenever, whatever and wherever (22%). What surprised us is the fact that selfdiscipline, motivation and isolation are disadvantages for full time students and advantages for part time students. Part time students have a lack and fear of technology (15%) but both groups thinks that one of the main disadvantages is no direct contact with professors (30%). Students would like to gain knowledge through Power point presentations (30%), visual presentations (36%), word documents (7%), simulations (4%), etc. Both groups think that distance education could be very useful in their future professional carriers. From the data of our research we collected much useful information that gives us directions for our further development of distance education modules. In the next future we will prepare distance education modules in Informatics and Pediatrics and other fields of nursing.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

We believe open source to be the best technology strategy for the development of shared knowledge and learning.We are at a critical moment in the evolution of elearning. After many years of development, e-learning has become an important process for educational institutions who are now exploring how to educate for students needs and expectations.Despite all the recent activity, models for how people teach and learn online are still immature. The cause of this problem is the separation of people in time and space; but it can be overcome by building environments where people talk to one another, build relationships, and teach one another (http://www.samizdat.com/otter.html). We have to enable students and already employed nurses acquisition of up to date knowledge which they will need in contemporary working area. There is no doubt that students who are educated in modern education process based on information technology will be better prepared for working environment (Mičetić-Turk, 2005). Literature: Holmberg, B. The Evolution Of the Character and Practise of Distance Education, Open Learning, 1995. Vol. 10, No. 2: 45-53. en.wikipedia.org/wiki/Distance_education distance.nmsu.edu/support/glossary.html SURS – Statistični urad Republike Slovenije, (1999): » Statistični letopis Republike slovenije1999«, Avilable:http://www. sigiv.si/zrs/leto99. Vasquez Bronfman, S. Linking Information Tehnology and Pedagogical Innovation to Enchance Management Education, 2000. V ECIS 2000- A Cyberspace Odyssey, vol. 2., Wirtscaftsuniversität, Wien. Ploenes, P. (2000) Internet Use at the University: A Comparative Analysis between Students of the Pennsylvania State Universty (USA) and the University OF Colonge (Germany), v ECIS 2000 - A Cyberspace Odyssey, vol.2., Wirtscaftsuniversität, Wien. Kurbel, K. A Completely Virtual Distance education Program Based on the Internet – Case and Agenda Of the International MBI Program, V ECIS 2000- A Cyberspace Odyssey, 2000. Vol. 2., Wirtscaftsuniversität, Wien. Yom, Y. Interration of Internet-based learning and traditional face- to- face learning in an RN-BSN course. CIN: Computers, Informatics, Nursing, 2004 May-Jun, 22(3), 145-52. Davis, M. V. Sollecito, W. A. Shay, S. Williamson, W. Examining the impact of a distance education MPH Program: a one year Follow – up survey of graduates, Journal of Public Health Management and Practice, 2004 Nov-Dec, 10(6), 556-3.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Malow, G.E. Gilje, F. Technology based nursing education, Nursing Education, 1999, Vol. 38, No.6, pp. 248-252. Cowell, K. Distance learning presents new opportunities for busy nurses, 2000 http://www.cinahl.com/cgi-bin/refsvc?jid=237 Gönc, V. Model študija zdravstvene nege na daljavo, magistersko delo, Univerza v Mariboru, Fakulteta za organizacijske vede, 2004. Lenič, M. Brest, J. Avdičauševič, E. Mernik, M. Žumer, V. Informacijski sistem za vodenje računalniških vaj. Zbornik devete Elektrotehniške in računalniške konference ERK 2000 (Zajc, B., ur.), Portorož 21. – 23. september 2000, pp 347-350, IEEE Region8, Slovenska sekcija IEEE, Ljubljana. http://www.samizdat.com/otter.html Mičetić-Turk, D. Nove možnosti in načini izobraževanja zdravnikov ter medicinskih sester. Isis (Ljubl.), 2005, letn. 14, št. 5, str. 52-54.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

AN EVALUATION OF BREASTFEEDING SUPPORT GROUPS Author: Noreen Goonan, (RGN,RM,Hdip.PHN B.Arts., MSc.), PHN, Tuam Health Centre, Tuam, Co. Galway. Background to study: There has been intensive research documenting the importance of breastfeeding for mother and child, family and society (Lewis 2003). The global strategy on infant feeding recommends exclusive breastfeeding for the first 6 months of life and to continue up to two years and beyond with adequate complementary feeding. Breastfeeding rates in Ireland are one of the lowest in the developed world. The National Health Promotion Strategy (DoH & C, 2000) highlighted that the previous breastfeeding targets set were not being achieved. They reported that only 29% of mothers breastfed their last child. It was in the context of these low incidences of breastfeeding and the desire to engage community members, that the Western Health Board developed breast feeding support groups. These initiatives aimed to encourage and promote breastfeeding in the community by rebuilding and revitalising support networks for mothers utilising the skills of local volunteer peer supports. In this study the author evaluated the support groups and examined the impact the group had on mothers who attended. Design of the study & sample selection: The study population was a census sample of 180 mothers who attended the 6 breastfeeding support groups, within a 16 month time-frame in Galway Community Care Area. A quantitative research methodology was utilised in which a self-completed questionnaire was designed, piloted and delivered to those mothers in June 2004. Data analysis: The responses from the completed questionnaires were entered in a database for analysis in SPSS (Version 12). The strategy for analysing the data collected consisted of two main approaches, descriptive statistics (frequency and percentages) in addition to inferential comparative analysis by means of statistical testing. The findings were then presented in the form of descriptions supported by tables, charts and graphs. Results: There was a 79% response rate from the postal questionnaire. Results from the research showed that mother’s primary reasons for attended were social/company, breastfeeding advise, childcare advice and to see the Public Health Nurse. When asked about the impact that the breastfeeding support group had on the length of time they breast for, 54.4% reported that it had helped to extend the duration. 98.5 % of mothers rated the groups as very good or good. The majority of participants rated most aspects of the group very positively, with the enthusiasm of those running the group being identified by the highest number of individuals (95.6%) and being able to talk about breastfeeding problems came close behind at 94.9%. Overall there was a high level of satisfaction with the service and the research lead to recommendations. Department of Health & Children (2000). The National Health Promotion Strategy 2000/2005. Dublin: The Stationary Office Lewis, C. (2003) HHS Blueprint to boost breastfeeding. Consumer Health Journals, May-June, 37(3),12-7.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

A Professional Narrative on Performance Management: De-Constructing the Reciprocal Acts of Managing and Performing in the Workplace Presenter Evelyn Gordon, Lecturer, School of Nursing, Dublin City University, Glasnevin, Dublin 9. Qualifications M.Sc., RPN. Contact Details Tel: 353-1-7007704 Email: [email protected] Abstract In recent years there have been considerable changes in the direction of increased accountability and transparency in public bodies (O’Neill, 2002), which have permeated the health sector. This has lead to the establishment of performance initiatives at local, national and international levels. As a result Performance Management (PM) is gaining increasing attention within the public health services. Drawing upon a qualitative study and literature review this paper discusses the challenges that PM poses for clinicians and managers within a mental health setting. The study, utilising a grounded theory methodology (Glaser, 1998), explored the unique responses of professionals to the phenomenon of PM. The sample included clinicians (n=6) and non-clinicians (n=3), from a range of professional backgrounds, with different levels of managerial responsibility. A literature review facilitated emerging themes to be compared and contrasted with traditional and contemporary perspectives on PM. A narrative evolved that highlights some of the dilemmas experienced by clinicians and managers in responding to rapidly changing expectations of professionals and services. Key themes centred on the challenges associated with transforming existing views about clinical practices and professional identity as situated within the contextually bound and reciprocally influencing acts of managing and performing in the workplace. Glaser, B. G. (1998) Doing Grounded Theory: Issues and Discussion. California: Sociology Press. O’Neill, O. (2002). A Question of Trust. Cambridge: Cambridge University Press.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

PRIMARY CARE PATIENTS’ VIEWS ON EPILEPSY TREATMENT AND SERVICES – A LITERATURE REVIEW Sandra Gormley RGN, BSc (Nursing) Staff Nurse Sligo General Hospital The Mall Sligo Epilepsy is the most common serious neurological condition, with a prevalence rate ten-fold higher than that of multiple sclerosis and one-hundred-fold higher than that of motor neurone disease (Brodie et al, 1997). It is estimated that at least 1% of the population has epilepsy with 5% of individuals experiencing a seizure at some point in their lifetime (Delanty, 2002). Like diabetes, with which it shares similar prevalence, epilepsy also requires long-term drug treatment and monitoring and may have a large impact on the quality of life of the individual and their families. An effective service provides a framework, which helps people to deal with the physical, psychological and social consequences of epilepsy, from initial diagnosis right throughout their patient careers. The literature review presented here would lead one to suspect that existing services may fall short of ideal service provision for various reasons. Primarily U.K. based studies were located with one Irish study focusing on services for children with epilepsy (Senior, 2002) and one Swedish study Chaplin et al (1998). It can be gleaned from the literature that there is empirical evidence to suggest that there is a lack of coordination between primary care, secondary care and specialist centres in the area of services for epilepsy. The studies generated similar findings of perceived deficiency in organisation of services, problems with access to specialist clinics, lack of continuity of care and clarity of responsibility, lack of follow-up support services, deficiencies in information provision, poor interpersonal skills of doctors and concerns about clinical competence. (Buck et al, 1996, Chaplin et al, 1998, Chappel and Smithson, 1998, Wallace and Solomon, 1999, Poole et al, 2000, Senior, 2002 and Elwyn et al, 2003). A research proposal to examine user views on epilepsy services in primary care in the HSE-NorthWest Area is the background to this review and it is hoped that findings from this study could potentially help to inform service needs planning for the region within the context of the existing plans for a neurology service for the area. References • • •

Brodie, M.J., Shorvon, D., Johanessen, S.,Halasz, P., Reynolds, E.H., Wieser, H.G. and Wolf, P. (1997) Appropriate standards of epilepsy care across Europe. Epilepsia.38 pp. 1245-50. Buck, D., Jacoby, A. , Baker, G., Graham-Jones, S. and Chadwick, D. (1996) Patients’ Experiences of and Satisfaction with care for their epilepsy. Epilepsia 37(9):pp. 841-849 Chaplin, J., Wester, A., and Tomson, T. (1998) The perceived rehabilitation needs of a hospital based outpatient sample of people with epilepsy. Seizure 7: pp. 329-335

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

• • • •

• •

Chappell, B., and Smithson, H., (1998), Patient views on primary care services for epilepsy and areas where additional professional knowledge would be welcome. Seizure 7: pp.447-457 Delanty, N. (2002) (Video recording) Leaving the Shadows-A Video on Epilepsy. Wicklow, Ireland: Sherwin Media Group. Elwyn, G., Todd, S. Hibbs, R. Thapar, A., Edwards, P., Webb, A., Wilkinson, C. And Kerr, M. (2003) A ‚real puzzle’: the views of patients with epilepsy about the organisation of care. BMC Family Practice 4: 4 Poole, K., Moran, N., Bell, G., Solomon, J., Kendall, S., McCarthy, M., McCormick, D., Nashef, L., Johnson, A., Sander, J., and Shorron, S. (2000), Patients perspectives on services for epilepsy: a survey of patient satisfaction, preferences and information provision in 2394 people with epilepsy. Seizure 9: pp.551-558 Senior, J. (2002) Educational, Medical and Advisory Provision for Children with Epilepsy in the Republic of Ireland. Brainwave, The Irish Epilepsy Association (CD-ROM) Wallace, H.K. and Solomon, J.K., (1999) Quality of epilepsy treatment and services: the views of women with epilepsy. Seizure 8: pp81-87

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

‘Facilitating communication skills laboratories with first year general nursing degree students’ Margaret Graham, RGN, RM, RNT, CCU Cert, BNS, MSc. in Nursing. Lecturer, Department of Nursing and Midwifery, University of Limerick. Irene Cassidy Lecturer RGN, RM, BNS, RNT, MSc. In Nursing. Lecturer, Department of Nursing and Midwifery, University of Limerick. Dympna Tuohy RGN, RNT, Grad. Dip. In Med.-Surg. Nursing, ICU Cert, BNS, MSc. In Nursing. Lecturer, Department of Nursing and Midwifery, University of Limerick. ABSTRACT Enormous changes have occurred within the education of pre-registration nurses in Ireland. Central to nurse education remains the acquisition of clinical skills. Within the education programme offered at the University of Limerick, clinical skills laboratories (CSLs) have been designed in association with various modules. This poster presents an evaluation of the CSLs associated with the “Communication and Therapeutic Relationship” module delivered to first year general nursing degree students. Areas explored within the laboratory sessions are outlined, as well as the breadth of teaching and learning strategies utilised. The evaluation process involved a thematic analysis of students’ retrospective reflective comments. Four themes emerged: personal and professional development, strategies, relaxation and theory to practice and making it real. Additionally students’ responses to a summative evaluation questionnaire were collated. Students found that experiential strategies encouraged linking of theory to practice, learning through interaction with peers and developing a deeper understanding of the importance of interpersonal skills within nursing practice. The benefits of a framework and the team approach used by the facilitators to ensure the smooth running of the sessions are given. Evaluation of any learning process presents challenges as to when and how to evaluate and hopefully this poster will stimulate further debate. Recommendations from our experience of facilitating CSLs related to communication skills are offered. Keywords: Communication and interpersonal skills; Laboratory skills; Teaching and learning skills; Student nurses.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

New Perspectives in Nursing communication-reflecting on communication across the nursing disciplines. Mr Colin Griffiths RNID, MSc, RNT, PGDip CHSE Lecturer + 353 1 6083115 [email protected] Ms Catherine McCabe RGN, BNS, RNT, MSc Research Fellow + 353 1 6083019 [email protected] School of Nursing & Midwifery The University of Dublin, Trinity College 24 D'Olier Street Dublin 2 Ireland Abstract. Client-centred communication is an integral part of nursing and is the foundation stone for the provision of high quality nursing care. The success and effectiveness of the nurse-client relationship lies in the words and body language that nurses choose to use when providing client care. Increasingly attention is being given to the therapeutic relationship between the nurse and the client, rather than a discrete set of communication skills for given situations, it is proposed that client-centred communication is an integral part of nursing and is the foundation stone for the provision of high quality nursing care. The impetus for the study arose due to similarities arising between four independent research studies conducted by the authors, and the resultant need to share these key themes with a view to ultimately improving nursing practice. The aim of this paper is to present a novel examination of a core aspect of nursing across four strands of the profession with a view to eliciting key communication skills that underpin the profession of nursing. These four conjoint studies demonstrate how the deployment of finely honed communication skills is important in the development of the nurse client relationship and ultimately the achievement of high quality nursing care. The paper further aims to use the combined results of these four studies to demonstrate important characteristics of nurse/client

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

An Education Needs Analysis of Medical and Surgical Nurses in the HSE North Eastern Area Myles Hackett MSc, BSc (Hons), RPN, RGN, RNT, Specialist Co-ordinator, Centre of Nurse and Midwifery Education, HSE North Eastern Area. + 353 41 9874771 [email protected]

Medical and surgical nurses together represent the largest group of general nurses. Their care affects the lives of a large number of patients. However at present, in the HSE North Eastern Area, there are no specialist courses available which specifically relate to their area of practice. Therefore, the Centre of Nurse and Midwifery Education, HSE North Eastern Area, proposes to conduct and education needs analysis of medical and surgical nurses to identify their needs and develop continuing professional development programmes based on these needs. A descriptive, quantitative design will be used for this study. Data will be collected from medical and surgical nurses throughout the HSE North Eastern Area using an anonymous questionnaire. Analysis of the data, using the SPSS (Statistical Package for the Social Sciences) computer programme, will allow the researchers to identify the local and regional education needs of medical and surgical nurses. Following data analysis consultation will take place with Nurse Practice Development Co-ordinators to formulate an action plan based on the needs identified by respondents. It is hoped that the education needs analysis will form the basis of continuing professional development programmes facilitated by the Centre of Nursing and Midwifery Education.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

UNDERSTANDING STUDENT MIDWIVES VIEWS OF BIRTH THROUGH CREATIVE EXPRESSION Jennifer Hall MSc RN RM ADM PGDip(HE) & Mary Mitchell RGN, RM, ADM, CERT Ed Med Senior Midwifery Lecturers University of the West of England Bristol Contact Address: 20 Claremont Ave Bishopston Bristol BS7 8JE [email protected] Or [email protected] Background The nature of midwifery being both an art and a science requires exploration of methods of teaching students that will enhance this understanding. A philosophy of holistic care of women should underpin courses and these concepts should be put across to the students in ways that will be meaningful to them. This presentation will describe innovative sessions that endeavour to explore spirituality within the context of midwifery practice. Within the nursing framework there is valuing of spiritually based care, especially in the context of the end of life. (eg Cobb & Robshaw 1998, McSherry 2000). In the formal midwifery curriculum this has been a neglected aspect (Hall 2001) despite the belief by some women and midwives that birth is a powerful, spiritual event. It is a paradox that there is so little appreciation of the value of recognizing the spiritual potential of life at its beginnings. The teaching approaches for the session have included theory and research, however, by recognising that students are also ‘spiritual’ beings it was felt appropriate to develop sessions that allows them to explore their feelings about their spiritual selves. A creative approach has been used, using mediums of video, music, aroma and storytelling, combined with an opportunity for the students to express their selves through art. (Cameron 1993). Study The study aimed to develop an understanding of student’s views on the meaning of birth by examining the creative pieces and written explanations produced by 5 students in the spirituality session, using a framework devised from Rose (2001). Further exploration was made of the effectiveness and value of the activity as a teaching method through open-ended questionnaires. This presentation will describe the innovative methods used and present the views of birth we established from the students art and their views of the teaching session. References Cameron J (1993) The Artists Way- a course in discovering and recovering your creative self London: Pan MacMillan

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Cobb M Robshaw V (eds) The spiritual challenge of health care London: Churchill Livingstone Hall J (2001) Midwifery Mind and spirit: emerging issues of care Oxford: Books for Midwives

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Reflection: a coping strategy for student nurses? Ms Anne M. Hardie Lecturer Napier University Canaan Lane Campus Edinburgh EH9 2TB Scotland Aim: to explore the benefits of reflection on the psychological well being of student nurses. Learning Outcomes Describe the emotional impact of clinical experience on student nurses. Explain the effect of this on psychological well being of student nurses. Explore the use of reflection as a means of coming to terms with feelings engendered by clinical practice. A study of critical incident assignments submitted over a period of 5 years was undertaken to identify the effects of clinical practice on student nurses. Students were asked to describe critical incidents and to reflect on the incident as the final assignment in the Higher Education Diploma in Adult nursing course. A sample of 30 scripts was taken from 8 cohorts, of these 218 were found to be suitable for the study. Students were asked to follow a recognised cycle of reflection eg (Atkins Sue 1993) to structure the work. These essays were analysed and student feelings identified most often were: guilt, fear, anger, frustration and inadequacy, of 218 only 4 reported feeling competent and fulfilled. The effect of this on self-esteem is explored. The next stage of the work called for students to identify what they considered the key issues and to review the literature pertaining to the issues. To complete the reflective cycle the students then had to apply what they had learned to the incident and discuss how it could have been handled and how the student would behave if a similar incident were to arise in the future. An unexpected finding from this study was that feelings of guilt anger and inadequacy were resolved following reflection. Further research is called for to verify this finding. Atkins Sue, M. K. (1993). "Reflection: a review of the literature." Journal of Advanced Nursing 18: 1188-1192. Randle, J. (2003). "Changes in self esteem during a 3 year pre registration diploma in higher education (nursing) programme." Learning in Health and Social Care 2(1): 5160. Smith, A. (1998). "Learning about reflection." Journal of Advanced Nursing” 28 (4) 891-898

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

MENTAL HEALTH PROBLEMS AND PEOPLE WITH LEARNING DISABILITIES: A NURSING PERSPECTIVE Steve Hardy RNLD, MSc Training and Consultancy Manager Estia Centre 66 Snowsfields London United Kingdom SE1 3SS The presence of mental health problems in people with learning disabilities is a relatively new concept. Historically it was not recognised that people with learning disabilities could suffer from the same psychiatric disorders as the general population (Gravestock, 1999). Though studies over the last thirty years have generally found higher rates of mental health problems in this population (Taylor et al, 2004, Borthwick-Duffy, 1994, Corbett, 1979). This increased prevalence is due to a combination of complex vulnerability factors including biological, psychological, social and developmental. The assessment of mental health problems fraught with difficulties. These difficulties suggestibility, acquiescence and third party often needs to be adapted to the particular ability.

in people with learning disabilities is including communication impairments, reports. Care planning and treatment needs of the person and their level of

The mental health care of this vulnerable and complex group is challenging and their needs are best met within an interdisciplinary framework, of which nurses are an integral part. This presentation will explore the above issues in relation to the role of the nurse. Borthwick-Duffy S.A. (1994) Epidemiology and prevalence of psychopathology in people with mental retardation. Journal of Consulting and Clinical Psychology, 62 (1), 17-27. Corbett J.A. (1979) Psychiatric morbidity and mental retardation. In: James F.E. and Snaith R. (eds) Psychiatric Illness and Mental Handicap. London, Gaskell. Gravestock S. (1999) Adults with Learning Disabilities and Mental Health Needs: Conceptual and Service Issues. Tizard Learning Disability Review 4, 2, 6-13. Taylor J.L., Hatton C., Dixon L. and Douglas C. (2004) Screening for psychiatric symptoms: PAS-ADD Checklist norms for adults with intellectual disabilities. Journal of Intellectual Disability Research 48, 1, 37-41.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

INFORMING FAMILIES: DEVELOPMENT OF NATIONAL BEST PRACTICE GUIDELINES AND TRAINING FOR INFORMING FAMILIES OF THEIR CHILD’S DISABILITY. Alison Harnett, BSc. Comm., Informing Families Project Co-ordinator. Maria Walls BSc., CQSW, MEd., Director of Research & Membership Services. National Federation of Voluntary Bodies, Oranmore Business Park, Oranmore, Galway. Aim: To develop national best practice guidelines, education and training in appropriate procedures to inform families of details of their child’s disability, at the first stage of communication of a diagnosis or concern. Background: The manner in which parents are informed that a child has a disability can have an important bearing on the attitude of parents throughout their child’s life (Needs and Abilities 1990). Good disclosure practice prevents much distress for parents, and can form the beginning of positive parent-professional relationships, facilitates the attachment process, and when combined with family support services over the first years, reduces levels of anxiety and stress (Cunningham 1994). It is essential that staff responsible for disclosing the news are supported in this sensitive task, through training, support and clear guidelines (Right From the Start 2003). Currently in Ireland there is a lack of consistent policy, guidelines, and best practice recommendations in place in this area (ERHA 2004). As a result, the National Federation of Voluntary Bodies and the Health Services National Partnership Forum initiated a project to develop, through research and consultation, national best practice guidelines for informing families of their child’s disability, with the support of the Department of Health and Children. Design of Study: There is a lack of comprehensive research into current practice in informing families in Ireland and very little has been reported of parents’ experiences in hearing the news. Therefore, qualitative and quantative research will be undertaken in order to develop evidence-based best practice guidelines that validate international recommendations for the Irish context. Eighteen focus groups will take place; six with parents of children with disabilities between 0 and 6 years, and twelve with staff members from key disciplines involved in disclosure; encompassing maternity, paediatric, community, and disability service settings. Each will examine current practice and recommendations for improved practice. A wider representative sample of parents (using figures from the NIDD and the NPSDD databases) and professionals will be surveyed through a postal questionnaire, to provide further quantative evidence of current experiences. The data from the focus groups, questionnaires, and a national and international literature review, will be analysed and cross-referenced to develop draft guidelines which will undergo a comprehensive consultation process with key stakeholders. The intended outcome will be the development of agreed multidisciplinary national guidelines, leading to enhanced communication with families, and increased support for professionals delivering the news.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Doyle, A. (2004). Report of the Maternity and Intellectual Disability Review Group on Integrated Patient Care, Dublin: ERHA Cunningham, C. (1994). Telling Parents their Child has a Disability. In Mittler, P. & Mitter, H. (Eds), Innovations in Family Support for People with Learning Disabilities. Lancashire, England: Lisieux Hall Government of Ireland (1990). Report of the Review Group on Mental Handicap Services. Needs and Abilities. Dublin: The Stationery Office Right From The Start Working Group. (2003) Right From The Start, Template – Good practice in sharing the news. London: SCOPE

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

NEW ROLES, NEW WAYS OF WORKING: DEVELOPING PRACTICE BASED EDUCATION IN PRIMARY CARE Nigel Harrsion Acting Associate Head MA PgDipCogTh PGDipPC Couns PGdEd BA(Hons) DPSN RGN RMN Department of Nursing Faculty of Health Brook Building University of Central Lancashire Preston Lancashire PR1 2HE Tel.: 01772 89 3714 E-Mail Address: [email protected] Christina Lyons Post Doctoral Senior Research Fellow PHd MSc Teachers Certificate DPSN RNT RMN Department of Nursing Faculty of Health Brook Building University of Central Lancashire Preston Lancashire PR1 2HE Tel.: 01772 894595 E-Mail Address: [email protected]

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

New Roles, New Ways of Working: Developing Practice Based Education in Primary Care The NHS Plan (DoH 2000) set out a strategy to modernise the NHS in England. This included development of mental health services in primary care. Graduate Mental Health Workers are amongst the first wave of new roles and new ways of working in mental health and are part of the wider NHS modernisation agenda (DoH 1998; DoH 1999). It is intended that Graduate Mental Health Workers help provide services for the large number of people presenting to general practitioners with mild to moderate depression and anxiety. This paper reports on the role of clinical mentors and supervisors in the delivery of practice based education to Graduate Mental Health Workers, essential to the development of this new assistant practitioner role and reshaping of primary care mental health services. The introduction of Graduate Mental Health Workers in the North West of England has been supported by a post graduate certificate that has been developed through a partnership involving the University of Central Lancashire, the University of Manchester, Liverpool John Moores University, the neighbouring Primary Care Trusts and Service User Organisations. Each university has validated a programme with the same structure, content, assessment and award. The programme design provides learning opportunities, 50% of which are offered by the University and 50% in practice. The role of practice based mentors and supervisors is integral to the delivery of the programme. Although there are established quality monitoring processes for university based learning and assessment, evaluation of practice based learning and assessment is less robust. In preparation for their role, mentors attended a one day workshop and supervisors attended a three day workshop with the option of four half day follow-up workshops divided over a year. Postal questionnaires, together with an explanatory letter, were sent to all supervisors and mentors who have supported students from the 3 universities collaboratively involved in the North West of England. This captured information relating to. Analysis of feedback focused on: • Characteristics of mentors / supervisors • Future development and management of the curriculum • Preparation and support of mentors and supervisors • Development of a methodology to monitor the quality of practice based learning within the Post Graduate Certificate Course • Development of a methodology to monitor the validity and reliability of practice based assessments. Feedback from Primary Care Trusts (PCTs) in the North West of England that are linked to the 3 university programmes, provides insights into the role of the mentors and supervisors and how their preparation and support may be improved. References Department of Health (1998) Modernising Mental Health Services: Safe, Sound and Supportive. London: Department of Health [online]

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

http://www.publications.doh.gov.uk/nsf/mentalh.htm Department of Health (1999) National Service Framework for Mental Health. Modern Standards and Service Models. London: Department of Health [online] http://www.publications.doh.gov.uk/nsf/mentalh.htm Department of Health (2000) The NHS Plan: A Plan for Investment; A Plan for Reform. London: Department of Health [online] http://www.publications.doh.gov.uk/nsf/mentalh.htm

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The Role of the Social Model of Disability in Irish Intellectual Disability Nursing, the Nursing Perspective. Author –Liz Hartnett RNID, MSc. Lecturer in Intellectual Disability Nursing School of Nursing Dublin City University Dublin 9. This study aimed to explore the role of the social model of disability in Irish intellectual disability nursing from the perspective of ten Irish Registered Nurses in Intellectual Disability. To generate the deep rich data required in-depth interviewing was used and constant comparative analysis was used to analyse the data. The results of this study highlighted that evidence of aspects of the social model in participants’ outlooks and work practices was very apparent although the term ‘the social model’ is not one that the majority of participants use. Although limitations of the social model were described by participants they equally described ways in which the social model could further enhance intellectual disability nursing. Adopting aspects of the social model could facilitate Irish intellectual disability nursing to address some of the challenges it faces such as role confusion and maximize its contribution to disability service provision through a clear language, clear underlying values and networking with organizations supporting the social model (including the National Disability Authority). Valuable and useful information could be generated through further research relating to this focus of inquiry.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

BIRTH TECHNOLOGY: INDUCTION OF BIRTH AND ITS IMPACT ON MATERNAL AND FETAL MORBIDITY AND MORTALITY IN NORTHERN JORDAN

Reem Hatamleh PhD student in Midwifery at the Institute of Nursing Research University of Ulster (Holder of the VCRS research bursary, BSc in Nursing, Post graduate Diploma in Midwifery, Post graduate Diploma in Advanced Midwifery

Marlene Sinclair PhD, MEd DASE BSc (Hons) RM RN RNT Senior Lecturer in Midwifery, Institute of Nursing Research University of Ulster George Kernohan BSc PhD Professor of Health Research, Institute of Nursing Research University of Ulster Brendan Bunting BSc PhD Professor of Psychology, University of Ulster *A Full version of this paper has been submitted to Evidence Based Midwifery and permission for an abridged version to be submitted for the conference proceedings has been granted.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Abstract Birth technology: Induction of birth and its impact on maternal and fetal morbidity and mortality in Northern Jordan Introduction: The inappropriate use of technology in childbirth has become an issue of international concern. The literature demonstrates that routine birth technology for induction of birth has a negative impact on maternal and infant physical and psychological wellbeing (Kiersi et al, 1995; Crowely, 1998; Enkin et al, 2000, Sinclair, 2000; Maslow& Sweeny, 2000). Rates of induction of birth ranging from 10%-30% have been reported with wide variations between countries and institutions (Boulvain et al, 2001). Aim. This paper reports on a study conducted in Jordan where there is no national data available on the induction rate or the infant/maternal mortality morbidity rate. Most obstetric units in Jordan do not have official guidelines or policies for induction and the majority of births take place in hospital under the direction of a medical doctor. Design. A prospective cohort study was used to explore the impact of birth technology (induction of labour in particular) on the lives of women and babies in Jordan using a convenience sample of 200 primigravida women who gave birth in 2004. -A data abstraction form was used to collate data from women themselves within three days of birth and repeated again at six weeks postnatal. Data extraction was confirmed by examining the casenotes. Findings: All of the women were married and the majority were dependant on their husband to keep them on a minimal family income of £360 per month. The age range was17 to 37years and the majority had school education but only 10% were working. Descriptive statistics indicated that the majority of the women experienced technological birth, (161, 80.5%) were induced, 27 (13.5%) had planned caesarean section and only 12 (6%) had spontaneous labour. The mean gestational age for the sample was 39 weeks. A range of technological interventions were recorded 144 (72%) of women having an artificial rupture of membranes 46(73%) receiving oxytocin infusion, 166 (83%) monitored by continuous fetal monitor, and 166 (83%) were recorded as showing signs of fetal distress. Episiotomy was performed on 133 (66.5%) of women. They gave birth to 204) babies (four sets of twins) and five infant deaths occurred but no maternal deaths were reported. Almost half of the babies were admitted to the special baby unit for resuscitations (45%) and 19 required admission to the hospital in the first six weeks.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Introduction In 1985, the World Health Organization (WHO) Consensus Conference on the Appropriate Use of Technology made 21 recommendations about the use of technology in childbirth. This conference was called because of an increase in the routine use of birth technology. The conference concluded that the national and international induction rate was to be no more than 10%. This was based on the evidence available at the time on the incidence of post term reported at 4%-6% (Crowley, 1989). Furthermore, the use of electronic fetal monitoring was to be governed by evidence that women were ‘high risk’. Defining birth technology Birth technology has been defined as a ‘complex chain of interventions that are closely related to each other, and which are conducted by obstetricians or midwives for women during the antenatal, intranatal and postnatal periods’ (Wagner, 1994). According to the Royal College of Gynaecologist and Obstetricians, (RCOG, 2001) induction of birth is an intervention designed to ‘artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix and culminating birth of the baby. This includes both women with intact membranes and women with spontaneous rupture of membranes, but who are not in labour’. The drive behind induction was the potential to decrease the perinatal and maternal mortality rate, reducing the number of post-term births and intervening in cases of maternal toxaemia. However, the evidence does not appear to support the effect of medical interventions during labour on improving infant outcomes (Hall, 1998). The technological cycle of birth has been described as part of routine midwifery practice involving antenatal monitoring, induction of labour, oxytocin infusion, continuous electronic fetal monitoring, increased likelihood of episiotomy, giving birth in the lithotomy position, and the use of epidural and other forms of systemic analgesia (Sinclair and Crozier 2004) Literature review The literature identifies a number of possible risks for mothers and babies from induction such as an increase in the incidence of both instrumental deliveries and caesarean sections, more perineal trauma, greater requirement for analgesia, neonatal admission to special baby unit, lower Apgar score (Maslow & Sweeny, 2000; Boulvain et al, 2001), and increased chance of haemorrhage, anaemia, low gestation age, low birth weight (Sinclair and Duff, 2000; Enkin et al, 2000). Induction by using amniotomy is associated with increase rate of caesarean section for fetal distress, and lower Apgar score (Fraser et al, 2001). Induction by using sweeping of membranes has been associated with bleeding, irregular contractions and discomfort during vaginal examination (Boulvain et al, 2001). Induction by using oxytocin is associated with increased use of pain relief and continuous fetal heart monitor (Tan and Hannah, 2001), and unsuccessful vaginal delivery within 24 hours (Kelly and Tan, 2001). Continuous electronic fetal monitoring is associated with increased risk of operative delivery and caesarean section for fetal distress (Vintzileos et al, 1995). (Thaker et al, 2002) carried out a meta analysis to compare the efficacy of CEFM with intermittent auscultation, using the results of nine published randomised controlled trials and found that there was a statistically significant drop in the number of neonatal seizures associated with routine continuous electronic fetal monitoring, in the view of the

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

increase in the rate of caesarean section and instrumental deliveries. The challenge to EFM is that the rate of operative delivery has increased dramatically since the use of EFM began, without a concomitant decrease in the incidence of cerebral palsy and mental retardation (Haggerty, 1999). Study Setting Jordan is a developing country with limited natural resources, chronic water shortage and limited arable land (5%), requiring virtually all energy resources to be imported (Ministry of Administrative and Development, 1999). The last updated health statistics about Jordan in 2003 showed that the crude birth rate per 1000 population was 29, the total fertility rate 3.7, and the maternal mortality rate is 4.1 per 10000 live births and the infant mortality rate is 22.1 per 1000 live births. However, there is no available data on maternal and infant morbidity (Jordan, 2004). The major causes of neonatal deaths and their proportional mortality were respiratory distress syndrome (40%), sepsis (14%), and asphyxia (12%). In Jordan, strategies for maternal and child health development have helped in changing the nature of knowledge about the birth process. These include moving birth to hospitals, replacing traditional low-technology with sophisticated technology (without proper training) technologies, the domination of medical model in the care for pregnancy and childbirth, importing obstetric technology, absence of spontaneous normal vaginal delivery and high rates of induction of labour, high rate of caesarean section birth, and the care of premature and sick infants in intensive care units. The estimated the rate of induction in Jordan is between 15%-20% but there are no statistics to support this and obstetricians have no official guidelines or policies for induction. Study Aim The main aim of this study was to provide baseline data about birth technology outcomes for women and their infants who gave birth in one major maternity hospital in Northern Jordan. Design A prospective cohort study was used to explore the impact of birth technology (induction of labour in particular) on the lives of women and babies in Jordan using a convenience sample of 200 primigravida women who gave birth in 2004. Instrument The questionnaire, a self-designed instrument, was developed to collect data about maternal and infant outcomes during antenatal, intranatal and postnatal period. It focused on demographic and social data, antenatal histories of women, perinatal, maternal, fetal and postnatal outcomes, as well as women’s perceptions about the use of technology in childbirth. Validity and reliability The instrument was constructed after an extensive review of the literature with special attention to item generation that would provide qualitative and quantitative data that could be analysed using SPSS and content analysis. It also was subjected to extensive pre-testing by conducting three pilot studies to enhance the validity and reliability. Ethical approval

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Approval to conduct the study was given by the Human Subject’s Committee at the Jordan University of Science and Technology. In order to obtain access to all governmental hospitals, a letter was sent to the Ministry of Health and permission was granted to collect the data. Sample size Power analysis was used to estimate the sample size and a total of 370 women were recruited to the study but only 200 agreed to participate. Convenience sampling was used to recruit women booking for the first time between February and August 2004. Access The project was advertised on posters were placed in the postnatal clinic at the major teaching hospital in Northern Jordan. Women who were willing to participate in the study and who met the inclusion criteria, primi and aged between 17-38 years old were approached. Data analysis A total of 200 women completed the initial research and all data were analysed using the SPSS version 11.0 statistical package (SPSS Inc, Chicago, USA). RESULTS Demographic Profile of Participants: All of the women were married and aged between 17 and 36. The majority (64%) had school education of at least 12 years, less than half (n=71, 35.5%) had obtained graduate education, and only one woman had no education (illiterate). The majority were housewives (72.5%), with only (n=55, 27.5%) working. Most women n=180 (90%) were on a family income of 2500gm), 12 were born prematurely and 159 were born at term. Apgar scores at 1 minute ranged from 2 to 8 with a mean of 6.86 (SD= 1.201), and at 5 minutes ranged from 5 to 9 with a mean of 8.3 (SD= 1.041). Thirty-seven percent of the sample (n=74) had lower Apgar scores at the first minute, and 10.5% (n=21) had lower Apgar scores at the fifth minute. Of the 74 infants of lower Apgar scores at first minute, 21 were lower Apgar scores at fifth minute. None of women had umbilical cord prolapse or ruptured uterus. Almost half of babies were admitted to the special baby unit for resuscitation 47.5% (n=95), and the length of stay ranged from 1 to 432 hours with a mean of 21 hours (SD= 62.559). Further break down of data show that almost all babies who had lowered Apgar scores at 1 minute 91% (n=67 out of 74) and 5 minutes needed resuscitation and admission to the special baby unit. Hospital Re-admission Nineteen babies (10%) were admitted to hospital in the early weeks of birth and 24 women (12%) were readmitted to the hospital after giving birth. Urinary tract infection (7.5%), blood transfusion (7.5%), mastitis (7%), and wound infection (6.5%), were the major reasons for readmission to hospital. Discussion The discussion deals with the research aims in the light of the research evidence and the specific findings from this study. Information about birth technology for induction of birth in Northern Jordan This study provides evidence of the routine use of birth technology in Northern Jordan and the rates of induction are contrary to those recommended by the WHO in 1985. The majority of women had been induced at 38-39 gestation weeks. The common method was by artificial rupture of membranes followed by artificial oxytocin 78.4% (n=102). While the minority were induced by amniotomy, followed by oxytocin, prostaglandin and sweeping of membranes 16% (n=32). The rates of different method of induction are shown in table 2. All women who had vaginal delivery n=132 gave birth lying flat on back with legs in stirrups, and mediolateral episiotomy was performed on 67% (n=133) as a routine policy, out of 132 (66%) suffered perineal tear. The third stage of birth is managed by the active method (syntocinon or syntometrin) as a routine policy, however, syntometrin is not used for women with high blood pressure. As a routine policy women who had vaginal delivery were given oral antibiotics and analgesics, and women who had caesarean section were given intravenous antibiotics, voltarol, analgesics and oral paracetamol. None of the women died.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Table 2:Methods of induction Method PGE2 followed by amniotomy alone PGE2 followed by amniotomy with oxytocin PGE2 followed by amniotomy, amniotomy with oxytocin and sweeping of membranes Amniotomy alone Amniotomy with oxytocin Sweeping of membranes

Number and percentage 4(2%) 13(6.5%) 11(5.5%)

132(66%) 1(.5%)

Indication of induction Induction of labour is indicated for women with pregnancy complications. In this study, only 16% (n=32) were induced for pregnancy complications such as post-term pregnancy 7% (n=14), pre-eclampsia and pre-labour rupture of membranes, 3%, and 3%, respectively. Suspected fetal compromise was present in 1.5% (n=3) and abnormal antepartum testing in 1.5% (n=3). None of women who were 42 weeks gestation had suspected fetal compromise, or pre-eclampsia, or pre-labour rupture of membranes. Indications of caesarean section Reasons of emergency caesarean section was examined, it was noted that fetal distress 11% and failed induction 7.5% were the major reasons in the sample as reported in the case notes while shoulder dystocia, failed forceps, arrest, and failed vacuum were the other reasons. Elective caesarean section was carried out on 13% (n=27) and the major reasons were prim breech 6% (n=12), eclampsia 3% (n=6) and possible fetal distress 1% (n=2); others such as premature separation of placenta, and placenta praevia were other reasons. Further break down of data showed that (6 out of 12) of primi breech women had elective caesarean section at 38-39 gestation age and six had elective caesarean section at 40 weeks. Impact of birth technology for induction of birth on maternal and infant mortality and morbidity This study assessed the impacts of birth technology for induction of birth on maternal and infant morbidity and mortality and compared them between the two groups (Induced and spontaneous). The literature frequently mentions that induction of birth is associated with the incidence of both instrumental deliveries and caesarean sections. However, the results of observational studies are controversial, with some suggesting an increased rate of caesarean section and instrumental delivery among induced women (Hannah et al, 1996; Sinclair, 1999; Maslow and Sweeny, 2000; Bouvlain et al, 2001, Jennifer et al, 2002), whereas others suggest the opposite (NICHHD, 1994; and James et al, 2001). In this study results show that 20.5% (n=41) of participants went into emergency caesarean section. Further breakdown of data show that the induced group accounted for the high proportion 18.5% (n=37) and accounted for all instrumental vaginal delivery 2% (n=4). These findings are keeping with (Maslow and Sweeny, 2000),

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

they found that induction associated with high risk of caesarean section, long hospital stay, and higher costs. The reasons given for caesarean section were examined. It was noted that in addition to 15 mothers being delivered by caesarean section following failed induction 7% of all the inductions were for post-term pregnancy. There were significant higher incidences in the induced group of caesarean section for fetal distress 10%, abnormal antepartum testing 1.5%, suspected fetal compromise 1.5%, arrest .5%, and failed vacuum .5%. Fetal distress and failed induction were the major reasons for emergency caesarean section (10%, and 7.5%, respectively) in the induced group. Further breakdown of the data showed that the induced group accounted for a high proportion of the different signs of fetal distress. 26% (52 out of 161). Induction of birth associated unsuccessful vaginal delivery within 24 hours (Kelly and Tan, 2001; Fraser et al, 2001; Bouvlain et al, 2001). Increased incidence for postpartum haemorrhage has also been linked with induction of labour, both by ARM and intravenous infusion of oxytocin (El-Torkey & Grant, 1992). There were 12.5% (25) women who had postpartum haemorrhage, out of which 10% (n=20) had primary postpartum haemorrhage and 2.5% (n=5) had secondary haemorrhage. In this sample, the induced group accounted for the higher proportion 12% (24). Induction associated with perineum trauma, in this sample there was 66% (132) of the sample had different type of perineum trauma. Further break down of data show that the high proportion of women who had perineal trauma was in the induced group 61.5% (n=123) compared to 1.5% (n=3) in the spontaneous group. These findings are keeping with Bouvlain et al (2001), who reported induction of labour to be associated with a higher risk of caesarean section (RR=2.4, 95% CI 1.8, 3.4). Resuscitation (RR=1.2 95% CI 1.0, 1.5), and admission to NICU (RR=1.6, 95% CI 1.0, 2.4) were most frequent after induction of labour. Induction of labour is also associated with a requirement for pain relief and continuous fetal heart monitor (Tan and Hannah, 2001; Bouvlain et al, 2001; Sinclair & Crozier, 2004). Many investigators suggest that the use of continuous electronic fetal monitoring rather than intermittently listening to the fetal heart, was found to increase the risk to women of unnecessary instrumental and operative deliveries, and pain relief (Neilson et al 1996; Enkin et al, 2000; Thacker et al 2002). Others suggest that use of continuous electronic fetal monitor lower perinatal mortality related to fetal hypoxia (Neilson and Mistry, 2002; Vintzileos et al 1995; Thacker et al 2002). In this sample, the use of EFM was on 178 (89%) of the sample. There were 41 women went into emergency caesarean section, and four women went into instrumental deliveries, there was 88% (176) of sample required pain relief (pethidine 100mg). Further break down of data showed that the high proportion of emergency caesarean section was for fetal distress (n=26 out of 41). These findings are keeping with (Vintzileos et al, 1995), continuous electronic fetal monitoring is associated with increased risk of operative delivery and caesarean section for fetal distress. Conclusion In Jordan there is no clear policy for pregnancy and childbirth therefore, induction of labour is not monitored or policy led. This research portrays a grim picture of the outcomes of ‘inappropriate use of birth technology’ on women and babies in Northern Jordan. Whilst the authors acknowledge the low proportion of women giving birth

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

spontaneously and the problems associated with statistical power, the overwhelming use of induction technology is such that one can state categorically that induction is the ‘norm’ and spontaneous birth is the ‘abnormal’ and the outcomes demonstrate increased morbidity for mothers and babies. References Boulvain, M; Marcoux, S; Bureau, M; Fortier, M; &Fraser, W. (2001) risks of induction of labour in uncomplicated term pregnancies. Paediatric and prenatal epidemiology, 15, 131-139. Boulvain, M; Stan, C and Irion, O (2001) Membrane sweeping for induction of labour. [ Update of Cochrane Database Syst Rev. issue (2) Crowley, P. (1989) Post term pregnancy: induction or surveillance? In Effective Care in Pregnancy and Childbirth, (Eds) Chalmers, I, Enkin, M; & Keirse, Oxford University Press, Oxford. Duff, C& Sinclair, M. (2000) exploring the risks associated with induction of labour: a retrospective study using the NIMATS database. Journal of advanced nursing, 31 (2), 410-417. Enkin, M. Kierse, M; Neilson, J; Crowther, C; Duely, L. Hodnett, E &; Hofmeyr, J. (2000) A guide to effective care in pregnancy and childbirth. (third edition). Oxford: Oxford University Press. El-Torkey, M. & Grant, J.M. (1992) Sweeping of membranes is an effective method of induction of labour in prolonged pregnancy: a report of a randomised trial. British Journal of Obstetric and Gynaecology 99, ,455-458. Fraser, W. Turcot, L. Krauss, I, Brisson- Carrol, G. (2001) Ammniotomy for shortening spontaneous labour (Cochran Review). In: The Cochran librabry, 1 Oxford: Update Software. Hall, R. (1998) Management of labour. In: Rosen’s (ed) Physician jugement and patient care. NewYork: Chapman and Hall. Hannah, M.E, Huh, C, Hewson, S.A, Hannah, W.J (1996) Post-term pregnancy putting the merits of a policy of induction of labour into perspective. Birth, 23 (1),1319. Haggerty, L. (1999) Continuous electronic fetal monitoring: Contradictions between practice and research. Journal of Obstetrics and Gynecology, 28, 409-416. Jordan (2002) Results from population and family health survey available @http://www.measuredhs.com Jordan (2004) available @http://www.emro.who.int/Jordan/ access on 16 Aug.2005

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

James, C; George, S; Gaunekar, N; & Seshadri, L. (2001) Management of prolonged pregnancy: A randomised trial of induction of labour and antepartum foetal monitoring, the national medical journal of India, 14(5). Jennifer, L. Bailita, Stephen, M. Downs and John, M. Thorp (2002) Reducing the caesarean delivery risk in elective inductions of labour: A decision analysis, Blackwell Science Ltd. Paediatric and Perinatal Epidemiology, 16, 90-96. Kelly, A.J. Tan, B (2001). Intravenous oxytocin alone for cervical ripening and induction of labour The Cochran library (Oxford) issue (3). Software, research, Systematic review. Kierse, M, Enkin, M.; & Chalmers, I. (1995) A guide to effective care in pregnancy and childbirth. (2nd edition). Oxford: Oxford University Press. Maslow, A; & Sweeny, A. (2000) elective induction of abour as a risk facltor for caesarean delivery among low-risk women at term. Obstetrics and Gynaecology, 95(6),1, 917-922. Ministry of Administrative and Development (1999). Plan of Public Administrative Sector. Amman: Jordan. NICHHD (National Institute of Child Health and Human Development) (1994) A clinical trial of induction of labour versus expectant management in post-term pregnancy. American Journal of Obstetrics and Gynaecology,170,716-723 Neilson, K.B; Dambrosia, J.M; Ting, T.Y; & Grether, J.K. (1996). Uncertain value of electronic fetal monitoring in predicting cerebral palsy. The New England Journal of Medicine, 334, 613-618. Neilson, J.P, & Mistry, R.T. (2002) Fetal Electrocardiogram Plus Heart Rate Recording For Fetal Monitoring During Labour (Cochran Review). In: The Cochran Library issue (1), 2002. Update Software Oxford. Royal College of gynaecologists and obstetricians (2001). Available at http://www.rcog.org.uk/resources/public/rcog_induction_of_labour.pdf Sinclair, M.K. (1999) “High Technology in the Labour Ward: Implications for Education and Training” PhD thesis, Medical Library, Queen’s University, Belfast Sinclair, M.K. (2001) Birth Technology: Observations of High Usage in the Labour Ward All Ireland Journal of Nursing & Midwifery 1 (3) 83-88 Sinclair, M.K., Crozier, K. (2004) Medical Device Training in Maternity Care: Part 2 British Journal of Midwifery 12 (8): 509-513 Tan, B, &,Hannah, M (2001) Oxytocin for pre-labour rupture of membranes at or near term (Cochran Review). In: The Cochran library, Issue 2. Update Software, Oxford. Thacker, S.B; Stroup, D; Chang, M (2002) continuous Electronic Heart Rate Monitoring For Fetal Assessment During Labour (Cochran review) In: The Cochran Library, issue (1) Update software: Oxford.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Vintzileos, A.M; Nochimson, D.J; Guzman, E.R; Knuppel, R.A; Lake, M;& Schifrin, B.S. (1995) Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: A metal-analysis. Obstetrics and Gynecology, 85,149-155. Wagner, M. (1994) Pursuing The Birth Machine: The Search for Appropriate Birth Technology. Australia: ACE Graphics. (Pp5-23). Wagner, M. (2000) General situation of obstetrics in the World: How the scientificmedical power helps to perpetuate the concept: They shall deliver with fear. Paper presented at First International Congress on Home delivery and childbirth, Jerez de la Frontera, Spain. World Health Organization (1985) Appropriate technology for birth. The Lancet, 2, pp436-347. WHO (2001) caesarean section delivery, an increasingly popular option, Bulletin of the World Health Organization 79 (12), Genebra WHO (1999) Appropriate technology for birth British Journal of Midwifery (7),9

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

EVALUATION STUDY OF A RESOURCE FOR DEVELOPING EDUCATION, AUDIT AND TEAMWORK IN PRIMARY CARE Dr Elaine A Haycock-Stuart PhD Lecturer, School of Nursing Studies, The University of Edinburgh 31 Buccleuch Place, Edinburgh. EH8 9JT Tel 0131 650 8442 Fax 0131 6503891 Email: [email protected] Dr Neil M Houston MBChB, MRCGP General Practitioner, Dollar Medical Practice, Dollar, Central Scotland (Honorary Senior Lecturer affiliated to the Department of postgraduate Medicine, University of Glasgow) An evaluation of the views of primary health care team members’ participating in an intervention programme of a Resource for Education, Audit and Teamworking (CREATE) is presented. The pilot CREATE programme comprised of a series of nine educational and team building workshops delivered in protected time to all clinical and administrative staff in seven General Practices in one Health Board locality, within a twelve month period. The content of the programme was developed in response to an educational needs assessment undertaken by the CREATE steering group. The purpose of the evaluation study was to identify if the CREATE programme altered participants' views of teamwork, education and audit and to ascertain the suitability of the CREATE programme for more extensive implementation in Scotland. The evaluation study utilised a combination of quantitative and qualitative survey methods. Quantitative questionnaires devised specifically as evaluation tools for the project, were manually distributed and collected at the first and last CREATE workshops to all participants present on each occasion. Following the first and last CREATE workshop, key informants from each practice subsequently participated in qualitative, in-depth interviews. The combined results of the quantitative and qualitative analysis reveal that the CREATE project is highly valued by the majority of primary health care team members who participated in the programme, particularly clinical staff and to a slightly lesser extent administrative staff. The findings indicate that a relatively simple but inclusive programme delivering appropriate education to primary care teams within protected time is able to overcome barriers to teamwork and this may lead to the staff delivering improved quality of health care services. Areas where teamwork and quality improvement were perceived as developing most significantly included; developing objectives, meeting as a Practice and communication so people were more involved in discussions and decision making. As a result of the findings from the pilot, the key elements of CREATE are being replicated elsewhere in Scotland. Key words Teamwork, Education, Quality

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Full title of concurrent paper: ‘An Exploration of Palliative Care Nurses’ Educational Needs in the Practice of Spiritual Care’ Person presenting: Deborah Hayden Home Address: 129 Wogansfield Leixlip Co Kildare Work Address: Department of Education & Research, Our Lady’s Hospice Harold’s Cross Dublin 6 W Qualifications: RGN, RNT, H Diploma Nursing Studies (Palliative Nursing), MSc (Nursing) Contact numbers: Work: 01 4068702 Home: 01 6244638 Mobile: 086 1052598 Email Address: [email protected]

Abstract Education is the foundation of quality palliative care (DoHC, 2001a) and the cornerstone to improving palliative care (Macleod and James, 1994; DoHC, 2001b, Kenny, 2001, 2003; Reb, 2003; De Vlieger et al, 2004). However, it is widely accepted that nurse educationalists hold a poor record in preparing nurses adequately for providing spiritual care (Piles, 1990; Ross, 1997; Greenstreet, 1999;

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Narayanasamy, 1993,1999; McSherry and Draper, 1998) despite the prominence of spiritual care within the philosophy of palliative care (O’Rawe Amenta, 1997; Byrne, 2002; Hunt et al, 2003; Souter, 2003). Therefore, the need exists for improved educational input (Ross, 1996; Bradshaw, 1997; McSherry and Draper, 1997; McSherry, 1998; Hunt et al, 2003). However, deficient evidence exists as to how spiritual care should be taught best (Bradshaw, 1997) especially to hospice nurses (Highfield, Taylor and Amenta, 2000). The purpose of this study is to remove the ignorance, fear, and misconceptions surrounding spiritual care; arouse curiosity in the practice of spiritual care; and render the learning of spiritual care as more memorable, understandable, and relevant to practice. Utilising a descriptive-exploratory qualitative approach, data was collected using semi-structured interviews. Eight purposefully sampled Palliative Care Clinical Nurse Specialists answered the research question ‘what are palliative care nurses’ educational needs in practicing the spiritual dimension of palliative nursing care?’ By posing this question, the study aimed to explore what palliative care nurses consider as important when learning about the spiritual dimension of palliative nursing care. The objectives of this study were to contribute towards ascertaining palliative care nurses’ educational needs in the practice of spiritual care; to contribute towards developing a curriculum outlining the spiritual dimension of palliative nursing care; and most importantly, to contribute towards indirectly enhancing the spiritual aspect of palliative nursing practices. Data analysis was facilitated by an adaptation of Burnard’s (1991) method of thematic content analysis. The findings recommend that educators should develop palliative care nurses’ awareness of the attributes of the ‘special’ spiritual dimension of palliative care. Embedded in the attributes, are ‘special’ skills and qualities that are essential to spiritual practice, which educators should awaken. Reflecting on and generating simplistic talk about the practice of spiritual care will result in the practice being recognised. This involves educators facilitating exploration of the aforementioned areas safely and supportively. All of this is dependent upon the ‘giving of time’. The findings also encourage educators to promote the imbibing of a philosophy that appreciates the provision of spiritual care, and to highlight the privilege of learning about spiritual care from clinical exemplars. However, a personal willingness derived from a sound moral and ethical ethos to provide spiritual care, is essential to the delivery of what is plainly ‘good’ palliative care. References Kenny L. (2001) Education in palliative care: making a difference to practice? International Journal of Palliative Nursing 7 (8): 401-407. Kenny L. (2003) An evaluation-based model for palliative care education: making a difference to practice. International Journal of Palliative Nursing 9 (5): 189-194. Macleod R. & James C. (1994) The context of education in palliative care In: Teaching Palliative Care Issues and Implications. Patten Press, London.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Reb A. (2003) Palliative and end-of-life Care: Policy analysis. Oncology Nursing Forum 30 (1): 35-50. De Vlieger M., Gorchus N., Larkin P., Porchet F. (2004) A Guide to the Development of Palliative Nurse Education in Europe. Palliative Nurse Education: Report of the EAPC Task Force. Available: www.eapcnet.org Department of Health and Children (2001a) Report of the National Advisory Committee on Palliative Care. The Stationery Office, Dublin. Department of Health and Children (2001b) Quality and Fairness. A Health System for You. The Stationery Office, Dublin. Available: http://www.doh.ie/hstrat/index.html (2004, July 22) Bradshaw A. (1997) Teaching spiritual care to nurses: an alternative approach. International Journal of Palliative Nursing 3 (1): 51-58. Burnard P. (1991) A method of analysing interview transcripts in qualitative research. Nurse Education Today 11: 461- 466. Byrne M. (2002) Spirituality in palliative care: what language do we need? International Journal of Palliative Nursing 8 (2): 67-74. Greenstreet, W. (1999) Teaching spirituality in nursing: a literature review. Nurse Education Today 19: 649-658. Highfield, M., Taylor, E. and Amenta, M. (2000) Preparation to care: the spiritual care education of oncology and hospice nurses. Journal of Hospice and Palliative Nursing 2 (2): 53-63. Hunt J., Cobb M., Keeley V.L. and Ahmedzai S. (2003) The quality of spiritual caredeveloping a standard. International Journal of Palliative Nursing 9 (5): 208-215. McSherry W. & Draper P. (1997) The spiritual dimension: why the absence within nursing curricula? Nurse Education Today 17: 413-417. McSherry W. (1998) Nurses perception of spirituality and spiritual care. Nursing Standard 13 (4): 36-40. McSherry W. and Draper P. (1998) the debates emerging from the literature surrounding the concept of spirituality as applied to nursing. Journal of Advanced Nursing 27: 683-691. Narayanasamy A. (1993) Nurses awareness and preparedness in meeting their patients’ spiritual needs. Nurse Education Today 13: 196-201.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Narayanasamy A. (1999a) ASSET: a model for actioning spirituality and spiritual care education and training in nursing. Nurse Education Today 19: 274-285. O’Rawe Amenta, M. (1997) Spiritual care: the heart of palliative nursing. International Journal of Palliative Nursing 3 (1): 4. Piles C. (1990) Providing spiritual care. Nurse Educator 15 (1): 36-41. Ross L. (1997) The nurses’ role in answering and responding to patients’ spiritual needs. International Journal of Palliative Nursing 3 (1): 37-41. Souter J. (2003) Using a model for structured reflection on palliative care nursing: exploring the challenges raised. International Journal of Palliative Nursing 9 (1): 612.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

FATHERS’ PERSPECTIVES ON THE EMOTIONAL IMPACT OF MANAGING THE CARE OF THEIR CHILDREN WITH CYSTIC FIBROSIS.

Claire Hayes RGN, RM, RCN, BSc Nursing, MSc Nursing Cystic Fibrosis Clinical Nurse Specialist/ Lecturer 23 Gate Lodge, Castle Road, Blackrock, Cork (086) 3492667 [email protected] Background: Although life shortening, increasing numbers of children with cystic fibrosis (CF) are surviving into adulthood due to advances in nutritional and pulmonary management (Orenstein et al, 2002). This can largely be attributed to parents’ participation in all aspects of CF care. To date, existing knowledge on the impact of providing care for children with chronic illness on parents has predominately originated from mothers’ perspectives. Fathers’ perspectives in their own right has been little researched despite the increase in dual earner families (Department of Enterprise and Employment, 1996) and the growing recognition of the role of fathers in caregiving (Pruett, 1998). There is little known about the emotional toll of caregiving on fathers’ mental health and it was the subject of an exploration of fathers’ experiences of managing the care of their children with CF. Study Design: An ethnographic design was chosen to explore the meanings that fathers attach to their experiences in their daily involvement in the CF care of their children. Sample Selection Methods: Following ethical approval and permission from the specialist paediatrician, a list of 15 names and addresses of participants that fulfilled the inclusion and exclusion criteria were provided by the CF clinical nurse specialist. Eight Irish fathers who resided with their pre-school children with CF and diagnosed at least one year, gave consent to take part. Data Collection and Analysis: Fathers took part in audio-taped interviews, using a topic guide developed from the literature, in their own homes, lasting 45-60 minutes. Data were analysed using thematic content analysis. Rigour of the study was enhanced by the use of verbatim quotations, reflexivity and a decision trail of the research process. Results: Fathers described living with CF as a constant worry owing to the incessant and unpredictable nature of the disease. They spoke of their fear of their children missing treatment or developing complications. Although they reported that they spoke to their wives about CF they indicated that talking about CF was difficult as it caused them to think about it. Their accounts indicated, however, that it was impossible not to think about CF as constant reminders surrounded them. They tried to maintain a positive outlook by living from day to day and changing their priorities to make the best of the time they had together as a family.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References Department of Enterprise and Employment (1996). Growing and sharing our employment: strategy paper on the labour market. Dublin: Stationary Office Orenstein,D.M., Winnie,G.B. and Altman,H. (2002). Cystic Fibrosis: a 2002 update. The Journal of Pediatrics, 140(2), 156-164. Pruett,K.D. (1998). Research perspectives, role of the father. Pediatrics, 102(5), 1253 -1261

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

STAFF NURSES PERCEIVED AND ACTUAL METHODS OF COMMUNICATION WHEN INERACTING WITH SERVICE USERS WHO COMMUNICATE NON - VERBALLY AND FUNCTION WITHIN THE SEVERE TO PROFOUND RANGE OF INTELLECTUAL DISABILITY Denise Healy Nurse Lecturer MSc. in Developmental Disabilities, Higher Diploma in Learning Disability Studies, Diploma in Management, R.G.N., R.N.I.D. St. Angela’s College, Lough Gill, Sligo. For all people, developing and maintaining interpersonal relationships is vital. Individuals with severe/profound intellectual disabilities are likely to experience communication difficulties that impede such relationships. Investigators studying staff – service user interactions in settings for people with intellectual disability have generally found very low rates of interaction between individuals and staff members (Hile & Walbran, 1991). In addition, very little information is available about how staff nurses in day and residential services typically communicate with adults who have an intellectual disability. An exploratory research design was employed with purposive sampling being the sampling strategy of choice. Nurses perceived by the researcher to be knowledgeable about communication with persons with a severe to profound intellectual disability were invited to participate with ten nurses eventually participating. The participants were asked to choose a service user with whom they were familiar. The service users communicated non - verbally and functioned within the severe to profound range of intellectual disability. A combination of data collection tools were used, namely structured observation, individual interviews and focus group interviews. Thematic content analysis was used to analyse the individual and focus group data and SPSS (Scientific Package for Social Sciences) was used to analyse the observational data. The key findings identified were as follows. The majority of staff felt continuing education and training in the area of communication would increase their confidence and competence. Staff when interacting with service users used similar amounts of verbal and non - verbal methods of communication. Interestingly, some staff members were able to predict their method of communication however, their actual use of communication appeared to be strongly influenced by the use of a ‘teaching strategy’. In addition, the majority of staff failed to recognise their use of some verbal and non verbal signs of communication and also failed to adjust their language to meet service users’ needs. Environmental factors were highlighted as having an impact on communication and negative and positive aspects of communication were identified. Alternative methods of communication were examined and many participants suggested that these methods could be used in addition to verbal means of communication. Hile, M. and Waldran, B. (1991) Observing staff-resident interactions: What staff do, what residents receive. Mental Retardation, 29, pp.35-41.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

POSTNATAL CARE – HOW IMPORTANT IS IT? A REVIEW OF THE LITERATURE Ms Maria Healy Ph.D student, MSc (Health Promotion), RNT, PGDip Health Promotion, RM, RGN College Lecturer School of Nursing and Midwifery Health Sciences Building University College Dublin Belfield Dublin 4 Ireland [email protected] The period immediately following childbirth is a time, in most women’s lives were there is tremendous emotional and physical change (Levitt et al. 2004). Across the globe in both, the developed and developing countries this critical transitional period for the women, her newborn and her family is often over-shadowed by the attention given to pregnancy and birth (WHO 1998). This trend towards paying limited attention to the overall provision of postnatal care has been referred to in the literature as the ‘Cinderella’ of the maternity services (Evans 2001). Postnatal care is also stated as being positioned at the ‘End’ of the maternity service process (Dowswell et al. 2001). Research highlighting the neglect of postnatal care and the lack of research in this area has been documented since the early 1990’s (House of Commons Health Committee 1992). Women themselves have also reported continued dissatisfaction with postnatal services claiming that their ordinary postnatal needs after birth are overlooked ( Audit Commission 1997, Ockleford et al. 2004). In addition, postnatal care has recently been judged to be ineffective in meeting women’s postnatal care needs (Singh and Newburn 2000). Although the birth of a baby is normally a joyful occasion, this tremendous change can leave new mothers experiencing poor health as a result of giving birth and becoming a mother (Liamputtong and Naksook 2003). Psychological morbidity has been widely documented since the late 1960’s with recent evidence linking postnatal depression to physical postpartum health problems (Brown and Lumley 2000). An extensive literature review of postnatal care will be presented. This literature review informs research which aims to develop a novel framework of postnatal care primarily based on phenomenological accounts of Irish women’s experiences. A thesis of the research findings will be presented towards the degree of Doctor of Philosophy, to the Midwifery Studies Research Unit, Department of Midwifery Studies, University of Central Lancashire. Audit Commission (1997) First Class Delivery: Improving Maternity Services in England and Wales. London: Audit Commission. Brown, S., Lumley, J., (2000) Physical health problems after childbirth and maternal depression at six to seven months postpartum. British Journal of Obstetrics and Gynaecology, 107, 1194-1201.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Dodswell, T., Renfrew, M. J., Gregson, B., Hewison, J., (2001) A review of the literature on women’s views on their maternity care in the community in the UK. Midwifery, 17, 194-202. Evans, J., (2001) Woman-centred postnatal care: the personal view of an independent midwife. MIDIRS Midwifery Digest, 11 (supplement 1), s7-s8. House of Commons Health Committee (1992) Report: Maternity services. Vol 1. London Levitt, C., Shaw, E., Wong, S., Kaczorowski, J., Springate, R., Sellors, J., Enkin, M., McMaster University Postpartum Research Group (2004) Systematic review of the literature on postpartum care: Methodology and literature search results. Birth, 31,3. Liamputtong, P., Naksook, C., (2003) Perceptions and experiences of motherhood, health and the husband’s role among Thai women in Australia. Midwifery, 19, 27-36. Ockleford, E.M., Berrymany J.C., Hsu, R., (2004) Postnatal care: what new mothers say. British Journal of Midwifery. 12, (3), 166-171. Singh, D., Newburn, M., (2000) Women’s experiences of postnatal care. London: National Childbirth Trust. World Health Organisation (1998) Postpartum care of the mother and newborn: a practical guide. Report of a Technical Working Group. Maternal and Newborn Health/Safe Motherhood Unit. Division of Reproductive Health. Geneva: World Health Organisation.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Discharge Criteria used in Post Anaesthetic Care Units in the Republic of Ireland. Dr Josephine Hegarty & Ms Aileen Burton College Lecturers Catherine McAuley School of Nursing & Midwifery Brookfield Health Sciences Complex University College Cork Abstract Discharge readiness of patients from the Post Anaesthetic Care Unit (PACU)/recovery is often determined by specific discharge criteria (Aldrete & Kroulik 1970; Chung 1993). The aim of discharge criteria is multi-faceted: firstly, to ensure haemodynamic stability of patients, secondly to promote patient safety and comfort and finally as guidance for nurses and anaesthetists to use in conjunction with their clinical judgement. This descriptive national study aimed to survey discharge criteria(s) utilised in the Post Anaesthetic Care /Recovery Unit. This quantitative, descriptive study used a postal self-administered researcher developed questionnaire for the collection of data from 44 hospitals nationally. A response rate of 73% (n=32) was elicited. 78% (n=25) utilised specific discharge criteria(s) within their Post Anaesthetic Care Units. The majority of hospitals utilised varied criteria in the determination of fitness of patients for discharge from the PACU. Interestingly many units responded to the questionnaire stating that they were in the process of developing specific criteria for the discharge of patients from the PACU. References Aldrete, J.A., Kroulik, D. (1970). A Post Anaesthetic Score. Anesth Analg. 49, 924934. Chung, F. (1993). Are Discharge Criteria Changing? Journal of Clin. Anesth. 5, 64s68s. Key words: discharge criteria, recovery, post anaesthetic care unit

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

‘THE UNSPOKEN SIDE EFFECTS’: PSYCHIATRIC DRUGS AND SEXUAL FUNCTION Agnes Higgins MSc; BNS; RNT; RPN; RGN, PhD student/Health Research Board Fellow, Cecily M. Begley RGN, RM, RNT, FFNRCSI, MSc, PhD, Professor of Nursing and Midwifery/Director, School of Nursing and Midwifery, The University of Dublin, Trinity College, 24, D’Olier St, Dublin 2 Background: Sexuality is a quality of life issue for all people and a healthy enjoyment of one’s sexuality is an integral part of the human experience and a basic right of all. However, when it comes to people with disability, and more specifically, with people who are experiencing mental health problems, sexual expression is one aspect of quality of life that is often ignored or forgotten. One area where this is reflected is in the area of drugs and sexual function. Neuroleptic and antidepressant medication can have a significant negative effect on the person’s sexual function, with consequential effects to self esteem and relationships. Design: The focus of this paper is on presenting the literature on the effects of the drugs on sexual function followed by preliminary findings in relation to nurses’ views on educating clients about the sexual side effect of drugs. These findings are part of a larger qualitative study that aimed to explore how psychiatric nurse respond to issues of sexuality in practice. Ethical approval was obtained from the Faculty of Health Sciences and the relevant health service provider. Data collection and analysis: Using an unstructured interview, data were collected from 25 psychiatric nurses working in a mental health service in an urban area. Data were analysed using a grounded theory approach. Findings: The findings suggest that nurses do not educate clients about sexual sideeffects and do not actively enquire about their experience of these side-effects. Possible reasons for nurses engaging in what they term ‘protectively withholding of information’ will be explored. In a world where medication forms part of the treatment of people with mental distress, nurses need to respond to their request for information in a more comprehensive manner; not because they wish to increase ‘compliance’, or because the statutory or state body states that it is part of our role, but because they truly believe in the right of people to be informed and make informed decisions.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

INFORMED CHOICE AND DECISION MAKING AND INTRAPARTUM FETAL MONITORING IN WOMEN AT LOW OBSTETRIC RISK: MIDWIVES VIEWS. Carol Hindley BA, MSc, RN, RM, ADM, Cert Ed Lecturer (Midwifery) School of Nursing, Midwifery and Social Work University of Manchester 5th Floor, Gateway House Piccadilly South Manchester M60 7LP Tel: 0161-237- 2081 E mail: [email protected] Ann M Thomson BA, MSc, RN, RM, MTD Professor in Midwifery University of Manchester School of Nursing, Midwifery and Social Work Coupland III Building Oxford Road Campus Manchester E mail: [email protected] Abstract Background: Over recent years in the United Kingdom (UK), the National Health Service (NHS) has adopted health care initiatives which explicitly advocate “partnerships” between practitioners and their clients (NHS Executive, 1996 and DoH 2003). More importantly, the NHS has been committed to the improvement of information which is paramount in facilitating client choice around the options of care available to them (NHS Executive, 1995). Contemporary policy documents have also focused on the unique needs of the client when facilitating the principles of informed choice (DoH 1997). The often used slogan “informed choice” is, therefore, not new to midwifery professionals, indeed it was eulogised in the well publicised “Changing Childbirth” report which stressed the importance of providing unbiased information so that women could make informed decisions about their care (DoH, 1993). Nearly a decade later, the doctrine of informed choice in maternity care appears not to have been embraced in its entirety as researchers have since demonstrated that attaining informed choice is more of a challenge for some decision points in maternity care than others, particularly where intrapartum fetal monitoring is implicated (O`Cathain et al, 2001 ). Design: Qualitative. Sample: Convenience sample of 58 Registered Midwives in two NHS Trusts in one region in the north of England.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Method: Semi-structured interview schedule, taped interviews, data collection by midwifery researchers in clinical sites. Transcripts analysed verbatim by a general thematic approach (Aronson, 1994), categories, themes and sub-themes identified. Results: Midwives favoured informed choice and shared a unanimous consensus on the definition. The midwives` idealistic perception of informed choice, which included contemporary notions of empowerment and autonomy for women expressing an informed choice, was not reportedly translated into practice. Midwives often had to implement informed choice within a competing set of health service agendas, which included medically driven protocols, a political climate of actively managed maternity care and the fear of litigation. References

Aronson J (1994) A Pragmatic View of Thematic Analysis. The Qualitative Report 2, (1): 1-4 DoH (1993) Changing Childbirth: Report of the Expert Maternity Group. London: Department of Health DoH (1997) The new NHS: Modern and Dependable London: Department of Health. DoH (2004) NHS Improvement Plan: Putting people at the heart of public services. London: Department of Health. National Health Service Executive (1995) Corporate Governance in the NHS. London: NHS Executive National Health Service Executive (1996) Clinical guidelines: using clinical guidelines to improve patient care within the NHS. Leeds: NHS Executive. O`Cathain A et al (2002) “Women’s perceptions of informed choice in maternity care”. Midwifery 18 (2): 136-144

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

An investigation of the Internet as a resource for nurses working in Ireland and its role in supporting their clinical practice and promoting their professional development. A dissertation submitted and accepted (2004) to the University of Dublin, in partial fulfilment of the requirements for the degree of Master of Science in Health Informatics. Author: Geraldine Hiney. MSc Health Informatics., BNS (Hons.)., RSCN., RGN., Diploma in Asthma Care. Contact Details: Informatics Nurse, Nurse Practice Development Department, AMNCH, Tallaght, Dublin 24. Ireland. Telephone: 01 4144085 email: [email protected] 1.0 Introduction Research has shown that nurses will always strive to get the job done and avail of all resources to deliver the best patient care (Gilder et al, 1999). In order to deliver effective, efficient and quality patient care, the onus is on the nursing profession to utilise Information and Communications Technology (ICT) effectively (Travis & Brennan, 1998). With the changing and evolving nursing profession there is an emphasis for nursing to provide Evidence-Based practice (EBP) (Commission on Nursing, 1998). To do so, the nursing profession requires effective tools to support their developing roles, Clinical Practice (CP) and promote Professional Development (PD). The question is whether the Internet is such a tool for nurses working in Ireland. With the rapidly changing healthcare service and evolving nursing profession the Internet is often presented as an innovative resource which supports the delivery of a quality healthcare service. But is this true? Can the Internet provide such resources? Evolving roles for nursing has lead to a demand for EBP to support CP (Farmer et al, 1999, and Sackett et al, 1996) and nursing as a profession aims to deliver the highest possible healthcare (An Bord Altranais, 2000). The Irish nursing profession has changed rapidly over the last five to ten years with the Commission of Nursing Report (Commission on Nursing, 1998) and the move to third level education leading to an increased focus on PD and EBP. In order to evaluate the Internet as a resource for these necessary activities a number of elements need to be assessed including assessing it as a resource for supporting continuous life long learning (Russell, 2003). Learning, e-learning, specific issues with the Internet, evaluation of the Internet, skills and training required and challenges also need to be assessed in relation to the Internet. To address this, research was conducted and then utilised in the development and maintenance of a new nursing website (Nursing Information Research Exchange www.nire.ie.). A full copy of this dissertation may be viewed on the website at: http://www.nire.ie/members/index.asp?locID=342&docID=-1

1.1

Research Objectives and Aims

The objectives of the research was to: ƒ Using literature, research and analyse the Internet as a resource for nurses in relation to supporting CP and promoting PD, both nationally and internationally.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

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Survey and Nurses working in Ireland and analysis the results to ascertain their patterns of Internet use, their experiences, access issues, skills and training issues and evaluation issues. Make recommendations on how to provide Internet resources for Nurses working in Ireland which meets their needs for supporting CP and promoting PD.

Therefore does the Internet provide effective and useful resources for nurses working in Ireland to support their clinical practice and promote their professional development? 2.0 Methodology The author conducted a literature review, internationally and nationally. Due to the naturally occurring independent variable the author chose a quantitative nonexperimental methodology (Cormack, 1996, and LoBiondo-Wood & Haber, 2002). In order to facilitate easy participation from diverse service settings the author utilised a survey postal questionnaire (LoBiondo-Wood & Haber, 2002). The information required was determined by the aims of this project and informed by the detailed literature review carried out. The survey evaluated: ƒ patterns, motivation, purpose and extent of Internet use, ƒ access issues encountered, ƒ experiences of using the Internet, ƒ barriers encountered, ƒ skills & training issues, ƒ evaluation methodology issues, ƒ potential Internet use, in light of the service, area of practice and elapsed time since the participant first registered. 2.1 Sample For the purpose of this research the population was identified as nurses working in Ireland and the study aimed to target nurses: ƒ From all levels of nursing and who have varied ICT skills and Internet access. ƒ Who do not utilise ICT and the Internet routinely or only do so on a limited basis. It was not possible or practical for the purpose of this research to evaluate all of the population of 58,987 active registered nurses. A sampling decision was made to obtain a convenient sample of the population. A stratified sampling frame was developed and participants were then randomly selected. This elicited a diverse selection and gave each of the groups equal opportunities of selection. The total number of questionnaires distributed was 520 with two cohorts of respondents who were further sub divided into homogeneous groups which considered all variables and included participants from: ƒ A major Dublin academic teaching hospital (AMNCH). ƒ Public Health nurses in the Health Service Executive (HSE) South Western Area. ƒ Nurses working in a community nursing home in the HSE South Western Area. ƒ Mental Health nurses working across the in the HSE South Western Area. The limitations and ethical considerations of the study were addressed. A pilot study was conducted to test the suitability of the instrument chosen (Cormack, 1996, and Parahoo, 1997). Minor changes were initiated with the addition of a number of

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

additional explanations e.g. definition of warehousing. The questionnaire was deemed to be suitable and the instrument was carried forward into the main study. Necessary permission was sought and obtained from all the sites and the questionnaire was distributed along with an explanation letter. All of the questionnaires were returned directly to the author via post. An Excel spreadsheet was utilised to collate and analysis the data obtained along with the generation of graphs and charts to illustrate results. 3.0 Statistical Analysis Of the 520 questionnaires issued, 138 were returned yielding a response rate of 26.53%. Analysis was conducted on: ƒ Respondent profiles. ƒ Impact of length of service. ƒ What is the current Internet use? ƒ What motivators exist for using the Internet for CP and PD? ƒ What current activities and services respondents used the Internet for? ƒ What specific CP and PD activities that the Internet is used for? ƒ What was the access issues, routes and the frequency of use? ƒ What were their experiences of the Internet? ƒ How they rated the Internet in relation services and tools? ƒ What were their experiences of learning tools on the Internet? ƒ What were their experiences of learning tools educational frameworks? ƒ What barriers they encountered when using the Internet? ƒ What are the potential services which respondents might use? ƒ How they would rate the Internet as a resource? ƒ Internet literacy. ƒ What type of skills and training were received and how they rated them? ƒ How they rated their confidence in using the Internet? ƒ How they evaluated Internet sites and content? 4.0 Discussion A detailed discussion of the results in light of the literature review can be found in the dissertation but a number of interesting points were found: ƒ That the academic teaching hospital scored a higher probability for Internet use of p=0.96,whereas the second group of comprising of diverse care settings and multiple locations has a probability rating for Internet use of p=0.69. This indicates that the teaching hospital nurses are more likely to use the Internet. ƒ Use of the Internet to support CP was scored the lowest, but conversely activities, which would support CP such as communication, education and research, were scored much higher. ƒ Email communication was identified as the most utilised with a probability of p=0.94 followed by web browsing p=0.83. But as elements considered necessary for supporting CP and PD e.g. online journals, discussion forums all have a low probability rating this poses a question for providers on how to promote and support their use by nurses working in Ireland. ƒ Respondents who identified that they used Internet dimensions rated them with a probability rating of p=0.21 for obtaining feedback to p=0.60 for obtaining and or sharing of: evidence / research / expert knowledge and skills. This is significant, as obtaining feedback is an essential dimension to using the Internet to support clinical practice.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

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The highest motivator for Internet use is education. Conversely email communication which was deemed necessary for supporting clinical practice was rated the lowest. They also identified that CP and PD activities produced a high result at 65% (p=0.65) in comparison to other activities at 26.66% (p=0.26). This indicates that these activities are motivators to promoting the use of the Internet. Nurses with less work experience are more probable to use the Internet ranging from p=1.0 to a probability rating of p=0.60 for nurses with a length of service of greater than 20 years. This drop from 100% to 60% is significant (SD=11.43) and requires consideration when providing Internet sites for nurses working in Ireland. 93.63% (p=0.93) of the identified users accessed the Internet from home with 71.18% (p=0.71) accessed via the workplace. The remaining routes ranged from a probability of p=0.50 to p=0.45. When the results were further evaluated for the frequency of their access the results for access via home and the workplace remained unchanged. But when workplace access was compared to other routes the probability rating dropped to p=0.28. This demonstrates that there is a need to facilitate access via the workplace considerably. Positive experiences overall of using the Internet were gained by nurses working in Ireland. Learning via the Internet produced the highest satisfaction rating followed by ease of use, research, using online databases, warehousing, navigation of Internet sites, self-assessment and competency assessment, telemedicine and lastly video linking. The majority was highly rated by the respondents but self- assessment and competency assessment, telemedicine and video linking were rated significantly lower. At most 50% of the identified Internet users used the Internet as a learning tool. 50% of these respondents found it appropriate for the content and tool followed by 48% identifying that it followed an educational framework. Conversely only 29% identified that the tool allowed for feedback. This is an important issue as feedback has already been identified as been essential to providing sites which can support CP and promote PD via learning. Barriers encountered were identified by a significant number of respondents (p=0.60). The lowest probability rating was indicated at p-0.47 for lack of user support but this is still quiet a significant probability that nurses would encounter this barrier. This indicates that there is a need for providers to produce solutions to these barriers. 38.18% indicated that they received formal skills training with on-the-job training been the most common. Acquiring skills via the Internet was the second lowest at 14.28%. Training was identified as adequate by 52.38% but the remaining found it inadequate. The most common reason inadequate training was the lack of opportunity to practice their skills. 60.87% of respondents received no formal training which reflects also the negative rating of the respondents in relation to their confidence in their Internet skills. Respondent’s confidant in their Internet literacy skills still indicated a need to provide training. 77.27% identified that they did not evaluate sites but 54.54% did evaluate the content found. This implies that the information is somewhat evaluated but as it is required that both the content and sites need evaluation a higher probability is required.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

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89.13% of respondents have identified that they would avail of training in Internet evaluation methodology. Nurses would avail of Internet based training was found with a high probability rating of p=0.89. A high probability rating indicates that nurses working in Ireland are willing to use the Internet and also to a greater extent and to support CP and promote PD.

5.0 Recommendations To provide an Internet site which can effectively support the CP and promote the PD of nurses working in Ireland both the literature review and survey identified that providers when designing and developing Internet sites for nurses working in Ireland should: ƒ Adhere to guidelines and standards consider and include user perspectives in the site design and develop specific rules, guidelines, and standards for the provision of content for the site. ƒ Promote awareness of their Internet sites and the tools provided and elicit support from users from both diverse locations and varying length of work experience. ƒ Enable elements that support education and daily work to be promotes as they were identified as being motivators for using the Internet. This includes email, discussion forum, evidence-based content, research, and online journals etc. This motivation should also include how to use their site effectively and efficiently as well as the content provided. ƒ Provide access near to the point of care and therefore in the workplace no matter the diverse locations. This will enable access to resources which will support the CP and PD of nurses working in Ireland. ƒ Provide a number of Internet services and tools along with the dimensions required as seen in figure 5.1. Figure 5.1: Services & Tools with Dimensions

Services/Tools ƒ Email. ƒ Online journals. ƒ Bulletin Boards. ƒ Newsgroups. ƒ Discussion Forums. ƒ Chat Rooms. ƒ Evidence-based content. ƒ Research elements. ƒ Self-assessment and assessment tools. ƒ Educational tools. ƒ Web browsing.

Dimensions ƒ Convenient use. ƒ Flexible use. ƒ Ease of navigation. ƒ Information exchange. ƒ Interaction. ƒ Access to expert knowledge. ƒ Learning. competency

self-

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

ƒ Supply online educational and instruction tools which are interactive, self-

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directive, problem based with educational frameworks and which allow access to evidence, research, expert knowledge, policies, feedback, guidelines and standards. They should consider users working in divers locations and setting when proving these learning tools. Provide online courses to enable and enhance Internet skills and Internet literacy which in turn will increase nurse users confidence in their utilisation of Internet resources. This will have the effect of increasing their efficiency in using the Internet to support CP and promote PD. Provide online courses to enable users to evaluate and validate sites and content. Provide solutions for accessing, and connecting to the Internet, searching and navigating the Internet, retrieval of information, user and technical support and lack of training. Provide a solution which is simple and easy to use with user-friendly technology, that provides appropriate and sufficient training that enables the development of the necessary skills, that reflects the chosen learning style to meet the needs of the users. These solutions should include interactive tools to meet requirements and which are flexible to suit all levels. The should be browser-based?

6.0 Conclusion This research based dissertation aimed to investigate the Internet as an effective tool to support the nursing professions evolving roles, evidence-based clinical practice and promote their professional development, all of which are identified in the Commission on Nursing as being required (Commission on Nursing, 1998). This is in order that the nursing profession may utilise ICT effectively to deliver effective, efficient and quality care (Travis & Brennan, 1998). The current Irish health strategy - Quality and Fairness: A Health System for You- prioritises the need to use available resources effectively and efficiently to provide a quality service which is based on evidence, standards and protocols (Department of Health and Children, 2001). The strategy goes on to specifically identify the use of ICT resources in order to do so (Department of Health and Children, 2001). The National Health Strategy identified as one of its main objectives utilisation of ICT effectively to share information and support care delivery, in order to enable the delivery of a quality health service (Department of Health and Children, 2004). Therefore to deliver this care nurses need to engage in PD, and life long learning, using evidence-based practice to support their CP and in turn achieve competence, accountability and autonomy (An Bord Altranais, 2000). To achieve this the nursing profession in Ireland needs to be supported and facilitated with appropriate tools. The author has concluded from the literature that the Internet is capable of delivering resources to support clinical practice (CP) and promote professional development (PD). With the research study the author went on to evaluate what is the current situation for nurses working in Ireland in order to ascertain: ƒ If they utilise the Internet to support their CP and promote their PD and to what extent this occurs? ƒ To what extent would nurses working in Ireland use the Internet to support their CP and promote their PD? ƒ What would be required to provide Internet sites for nurses working in Ireland to support their CP and promote their PD?

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Overall the study produced a positive outlook to the Internet as such a resource but it identified a number of issues and areas, which require addressing. As a result, in evaluating these outcomes in light of the literature review, the author identified a number of recommendations for the provision of these Internet resources. It should also be noted that both the literature and the study identified that management support and organisational support are required in order that nurses can effectively utilise these resources. This is required at organisational level rather than from the providers but the provider has an important role to play by providing the tools and resources that are required and also promoting their availability to both nurses and management alike. The author went on to utilise these findings in the development of a new nursing Internet site the Nursing Information Research Exchange (NIRE) www.nire.ie, which aims to utilise web technology effectively and efficiently. References An Bord Altranais. (2000) Review of Scope of Practice for Nursing and Midwifery. Final Report. Dublin: An Bord Altranais. Commission on Nursing. (1998) Report of the Commission on Nursing – A Blueprint for the Future. Dublin: Commission on Nursing. Cormack. D. F. S. (1996) The Research Process in Nursing. (Third Edition). Oxford: Blackwell Science. Department of Health and Children. (2001) Quality and Fairness: A Health System for You. Dublin. Department of Health and Children. Department of Health and Children. (2004) Health Information: A national Strategy. Dublin: Department of Health and Children. Farmer. J., Richardson. A., Lawton. S. (1999) Improving access to information for nursing staff in remote areas: the potential of the Internet and other networked information resources. International Journal of Information Management. Vol. 19: pg. 49-62. Gilder, R. E., Koch, F., McBride, S. (1999) Enhancing Perioperative Nursing Effectiveness Through Informatics. AORN Journal. Vol. 69(5): pgs. 978, 981-982, 984-987, & 989-990. LoBiondo-Wood. G., Haber. J. (2002) Nursing Research: Methods, Critical Appraisal, and Utilization. (Fifth Edition). St Louis: Mosby, Inc. Parahoo. K. (1997) NURSING RESEARCH. Principles, Process and Issues. New York: Palgrave. Russell. S. S. (2003) Professional Nursing Development: Improving the Way Dermatology Nurses learn. Dermatology Nursing. Vol. 15 (5): pg. 438-440.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Sackett. D.L., Rosenburg. .W.M.C., Gray. J.A.M., Hayes. R.B., Richardson. W. (1996) Evidence-based medicine: What it is and what it isn't. British Medical Journal. Vol. 312: pg. 71-72. Travis. L., Brennan. P. F. (1998) Information Science for the future: an innovation nursing informatics curriculum. Journal of Nursing Education. Vol. 35 (4): pg. 162168.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Nurse teachers' contribution to the clinical learning environment Ms Susan Hourican RGN, AAS, BSc, MEd Lecturer in Nursing School of Nursing Dublin City University Dublin 9 Ireland + 353 1 7008528 [email protected] The nurse education forum report 2000 recommends that nurse teachers should develop their links with clinical practice, as it is essential to the success of the preregistration nurse education programme. This study examines the complexity of the nurse teachers’ facilitation role in clinical practice. A grounded theory approach was selected as the research methodology for this study. Semi-structured interviews were used to collect data from nurse teachers in one school of nursing. Data collected were analysed using Strauss and Corbin’s framework. A dichotomy of opinions exists among nurse teachers as to how to support and teach student nurses in clinical practice. In view of these findings, recommendations are made for an approach to clarify and maintain nurse teachers facilitation role.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Title of Paper: "Facilitation of Learning in Clinical Practice" - The experiences of Children's Nurses. Author: Rachel Howe, RGN, RSCN. Clinical Facilitator - Child Health, The Adelaide & Meath Hospitals incorporating The National Children's Hospital, Tallaght, Dublin 24. Co-Author: Judith Foley, RGN, RSCN, RNT, BNS, MSC Ed. Education Officer, An Bord Altranais, 31/32 Fitzwilliam Square, Dublin 2. Summary: This paper describes the experiences of Children’s Nurses who facilitate learning for student nurses in clinical practice. A qualitative descriptive design was the research process that guided the researcher in obtaining the participant’s experiences of the phenomenon. A computer-assisted qualitative data analysis software (CAQDAS) package was used to help the researcher caryy out the content analysis stage of this study. The researcher will present a synopsis of the study’s findings and make tentative recommendations for the future. Background: Although there is a plethora of literature about the clinical learning environment, there is very little research available in relation to the experiences of Children's Nurses who facilitate learning for both undergraduate and postgraduate student nurses in Ireland. It is important for managers, educators and clinical facilitators to be aware of the staff nurse’s needs, so that they can support them in their role of assessing student competence for professional registration (Ogier, 1986; An Bord Altranais, 2003). Design of Study: The aim of this research study is to accurately report the real life experiences of Children's Nurses, who facilitate students in clinical practice, by using their own rich descriptions of events. Therefore the researcher was drawn to qualitative descriptive research, as it is used to describe people’s perceptions or experiences of the world (Burnard & Morrison, 1994). Sample Selection: Posters calling for volunteers to take part in the research study were placed in each of the Children's Hospitals in Dublin. A purposive sample was required for this study, because the researcher needed to capture data from a specialised group of staff that had experienced the phenomenon (Coyne, 1997; Polit & Beck, 2004). Therefore a purposive sample of ten Children's Nurses were recruited for an interview with the researcher. One participant was recruited for a pilot test prior to embarking on further interviews. Data Collection & Analysis: The researcher carried out Semi-structured interviews with ten participants. Interviews were held in coffee shops or empty offices in convenient locations for the participants. The researcher used an interview guide that was developed from the themes in the literature and gentle probing techniques to elicit responses from the participants. Each interview was tape-recorded and transcribed verbatim by the researcher. Analysis of the transcripts was aided by CAQDAS NUD*IST 6. The researcher selected a content analysis approach to guide the data analysis stage of this study, which is consistent with the values of qualitative descriptive methods (Brink & Wood, 1998; Ritchie & Lewis, 2003).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Results: The results of this study have yet to be determined, however the researcher hopes to make tentative recommendations with regard to the future implication for nursing education, management and practice development. References: An Bord Altranais (2003) Guidelines on the key points that may be considered when developing a quality clinical learning environment. Dublin: An Bord Altranais. Brink, P.J. and Wood, M.J. (1998) Advanced design in nursing research. London: Sage Publications. Burnard, P. and Morrison, P. (1994) Nursing Research in Action. Developing Basic Skills. 2nd Edition. Great Britain: Macmillan Press LTD. Coyne, I. T. (1997) Sampling in qualitative research: Purposeful and theoretical sampling; merging or clear boundaries? Journal of Advanced Nursing 26(3): 623630. Ogier, M.E. and Barnett, D.E. (1986) Sister/staff nurse and the nurse learner. Nurse Education Today 6: 16-22. Polit, D.F. & Beck, C.T. (2004) Nursing Research: Principles and Methods. Seventh Edition. London: Lippincott Williams & Wilkins. Ritchie, J. and Lewis, J. (2003) Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: Sage Publications.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Understanding children’s Nurses’ Experiences of Advocacy: A Hermeneutic Study Ms Frances Howlin Nurse Teacher RSCN; RGN; Diploma in Management and Industrial Relations; BNS; Registered Nurse Tutor; Masters in Science in Nursing Address: 7 Grange Manor Ave; Rathfarnham, Dublin 16. Abstract The role of the nurse as advocate has been endorsed by An Bord Altranais (2000) and the International Council of Nurses (2000). Despite its endorsement advocacy has proven to be a complex concept leading to difficulties in its definition and application to practice (Grace, 2001). Few research studies have explored registered children’s nurses’ experiences of advocacy (Fetsch, 1991; Raines, 1993; Mallik, 1997) and none have taken place in the context of Irish paediatric nursing. It was, therefore, appropriate that the purpose of this hermeneutic study was to describe how children’s nurses understand and interpret the experience of being an advocate. The study utilised a qualitative approach based on Gadamer’s (1976; 1989) hermeneutical philosophy. Data collection took place in an Irish paediatric hospital between December 2004 and March 2005. The sample was purposive and consisted of six registered children’s nurses that had an advocacy experience that they were willing and able to describe. The main methods of data collection included: the collection of some biographical information, identification of the researcher prejudices, twelve hermeneutic interviews and the compilation of the researchers reflexive diary. Rigour was addressed by asking the participants to verify the interview transcripts and the findings for their interview, by identifying the researcher prejudices and via compilation of an audit trail. Measures to ensure that the research was ethical were implemented. Benner’s (1994) method of data analysis was utilised and the findings consisted of paradigm cases, exemplars and a thematic analysis. The main themes identified included: advocacy as protection, advocacy as representing the expressed wishes of the parent/child, advocacy as enabling the voice of the child and the work of advocacy. The themes, illustrated the complexity of advocacy and its ability to support various models and differing ethical principles. Implications for practice, education and research were presented. References An Bord Altranais (2000) Review of Scope of Practice for Nursing and Midwifery Final Report. Dublin: An Bord Altranais. Benner, P.E. (1994) Interpretative Phenomenology: Embodiement, Caring and Ethics in Health and Illness. Thousand Oaks, California: Sage Publications Ltd. Fetsch, F. H. (1991) Advocacy in Pediatric Nursing: a Qualitative Study. University of Kansas: Unpublished PhD Thesis.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Gadamer, H-G. (1976) Philosophical Hermeneutics. (Translated and edited by David E. Linge) Berkley: University of California Press. Gadamer, H-G. (1989) Truth and Method. 2nd Edition. (Translated by Weinsheimer, J. and Marshall, D. G.) London: The Crossroad Publishing Company. Grace, P. J. (2001) Professional advocacy: widening the scope of accountability. Nursing Philosophy 2(2):151-162. International Council of Nurses (2000) Code of Ethics. Geneva: International Council of Nurses. Mallik, M. (1997) Advocacy in nursing- perceptions of practising nurses. Journal of Clinical Nursing 6(4): 303-313. Raines, D. (1993) Deciding what to do when the patient can’t speak. Neonatal Network 12(6): 43-48.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

REGISTERED MENTAL HANDICAP NURSES AND INTERDISCIPLINARY WORKING WITH PEOPLE WITH INTELLECTUAL DISABILITIES IN THE REPUBLIC OF IRELAND CHRISTINE HUGHES, M Sc, M Ed, H Dip, BA (Mod), RNID, RGN, RNT NATIONAL COUNCIL FOR THE PROFESSIONAL DEVELOPMENT OF NURSING AND MIDWIFERY, 6-7 MANOR ST BUSINESS PARK, MANOR ST, DUBLIN 7 T: (00 353) – (0)1 – 885300 F: (00 353) – (0)1 – 8680366 E: [email protected] Introduction This research was carried out in partial fulfilments of the requirements of the M Sc in Developmental Disabilities, Centre for Disability Studies, University College Dublin. The relevant literature was reviewed in order to understand (1) the context in which intellectual disability nursing (formerly mental handicap nursing) and disability policy have developed in the Republic of Ireland and (2) the implications of interdisciplinary working in health services advocated by the Department of Health and Children (DoHC). The research questions were concerned with Registered Mental Handicap Nurses’ (RMHNs) 3 (now Registered Nurses – Intellectual Disability) contribution to intellectual disability (ID) services, their understanding and experience of interdisciplinary working and how they can enhance their contribution to interdisciplinary working. ID service provision since 1950s - Policy Intellectual disability nursing was established as a division of the register in 1959. Since that time service provision in Ireland for people with intellectual disabilities (ID) has developed in accordance with the recommendations or findings of various documents and reports, for example, Report of the Commission on Mental Handicap (1965), Education and Training of Severely and Profoundly Mentally Handicapped Children in Ireland: Report of a Working Party to the Minister for Education, Minister of Health and Minister of Social Welfare (1983), Towards a Fuller Life. Green Paper on Services for Disabled People (1984), Needs and Abilities: A Policy for the Intellectually Disabled (1991) and Report of the Commission on the Status of People with Disabilities: Strategy for Equality (1996). The National Disability Authority (NDA) developed person-centred standards for disability services (NDA 2003a, 2003b), but these had not been confirmed by the DoHC at the time that the present study was undertaken. 4 Prior to this the DoHC had advocated mainstreaming of services for all people with disabilities (DoHC, 2001a). 3

Now titled Registered Nurses – Intellectual Disability (RNs – ID). A disability strategy was published in September 2004 after the completion of the present study. A strategic review of disability services was announced in the summer of 2005.

4

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Interdisciplinary working Health and social care professionals have been urged by the DoHC (2001a, 2001b) to work in an “interdisciplinary” manner to “extend the range of skills available to patients, improve the deployment of scarce professional skills and provide greater continuity in the care of patients and clients” (DoHC, 2001a, 119). A lack of integrated care was noted “between and even within” some services, but no clear definition of “interdisciplinary” was provided, nor were supports and structures required for successful interdisciplinary identified. Interdisciplinary working implies three or more practitioners from different disciplines working in an interdependent work relationship and working for a common goal, namely the benefit of the clients and their families; appropriate for ID services (Rokusek, 1995). Each member of an interdisciplinary team (IDT) is viewed as an equal in all decision-making and consensus-building. Features of interdisciplinary working include: mutual respect for the expertise of all disciplinary professionals, paraprofessionals, families and consumers; decreased control of work boundaries; and open and effective communication with peers and others in and outside of the professional work environment. The outcomes and benefits of interdisciplinary working include: • The effective use of resources (Harkness et al, 2003) • Countering reductionism and fragmentation of care (Gyamartin, 1986) • Improved patient/client care (Harkness et al, 2003; While & Barriball, 1999) • Successful implementation of policies and the creation of a more flexible workforce (Barr, 2001). Interdisciplinary working can be hindered by too many organisations attempting to work together with inadequate linkages between them, and by inadequate information technology systems and data and information sharing. Professional barriers and structures may hinder the integration of services for patients and clients, as may job specialisation (DoHC, 2001). Individual practitioners may define their scope of professional practice within the confines of the agency in which they work (Luongo, 2000). Areas of conflict between disciplines can arise which stem from power imbalances (Kramer & Schmalenberg, 2003). Øvretveit (1996) has suggested that organisations should ensure new practitioners understand different types of teams and types of interdisciplinary working. Strategies include interdisciplinary case conferences, meetings, team-working and networking (Barr, 2001), appropriate continuing professional education that promotes such ways of working, and role modelling by senior professionals of equal power relationships and socialisation of new employees into collaborative practice structures (Kramer & Schmalenberg, 2003). Intellectual disability nursing in Ireland In 1998 the Commission on Nursing stated that ID nursing roles needed “to be clearly defined in a diverse and increasingly complex service” (Government of Ireland,

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

1998). The aim of the pre-registration syllabus for ID nursing was to enable newly qualified nurses to work with clients in “a diversity of roles, from intensive physical nursing of profoundly handicapped individuals to supportive guidance in the management of habilitation of children, adolescents and adults” (ABA, 2000). 5 It is difficult to assess the contribution of ID nurses to the ID services in Ireland for various reasons. There are difficulties in identifying numbers of RMHNs employed in nursing roles or non-discipline specific roles in ID services and there is a lack of published evidence around outcomes of the role, which has also been overlooked in policy and other documents (DoHC, 2001; NDA, 2003c) ID nursing and interdisciplinary working – research questions Effective team-working is effected by ensuring understanding of different types of interdisciplinary team working (Øvretveit 1996) and ways of working (Barr 2001), and understanding of team-members’ roles, thus the study was undertaken in order to determine: • What are ID nurses’ views on their contribution to ID service provision? • What is their understanding of interdisciplinary working? • What are their views on how they can contribute to interdisciplinary working? The study A qualitative approach was taken, given the lack of previous research in this area (Morse, 1994). Semi-structured open-ended interviews were held with ID nurses working in Irish ID services. A pilot study was conducted in January 2004 with three RMHNs at two locations, resulting in some revision of the interview schedule. Letters were sent to the managers of four different services requesting their assistance. Participation was entirely voluntary and participants indicated their willingness to participate by completing consent forms. Interviews were transcribed and their content analysed manually in order to identify themes and sub-themes. The target population comprised all RMHNs working in all Irish ID services. Four services in four different locations were selected at random. These included two voluntary and two statutory services, two of which catered for more than two hundred clients and two for fewer than two hundred clients. Fourteen RMHNs participated (eleven women and three men), half of whom worked in either of the voluntary services and half in the statutory services. Similarly, half worked in larger services and half in smaller services. Five worked in residential services only, two in residential and community or day services, five in the community only and two in day services. Themes that emerged from the data were: • • • 5

Meaning of being an ID nurse Distinguishing ID nurses from other nurses working in ID services Understanding of interdisciplinary working

This syllabus was updated in 2005.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

• • • • • • • •

Understanding of the roles of other disciplines Requirements for successful interdisciplinary working Benefits of interdisciplinary working Drawbacks of interdisciplinary working ID nurses as equal members of IDT Pre-reg preparation for interdisciplinary working Contribution of ID nurses to interdisciplinary working Enhancing this contribution

A number of sub-themes associated with each theme also emerged. Discussion 6 More than half of the participants in the present study alluded to having a wide range of particular skills suited to assessing the needs of people with ID and to providing holistic care. The diversity of the roles of RMHNs and role components were commented on and this was reflected by the composition of the sample of participants, their respective backgrounds, work experience and settings in which they were currently working and had worked previously. However, it cannot be stated that the participants articulated unequivocally the contribution that RMHNs have made to ID service provision. Similarly, there were very few substantive comments about what distinguished RMHNs from other nurses working with people with ID, even though most of the participants indicated they had worked with other nurses at some point in their respective careers. Most participants understood interdisciplinary working to mean different health and social care professionals working together: some identified the professionals and nonprofessionals with whom they actually worked or envisaged as potential members of an IDT; with one exception, none spontaneously included the client. The interchangeable use of the terms interdisciplinary and multidisciplinary by several participants, may indicate ignorance of the differences in meaning. Many of the participants appeared to understand interdisciplinary working to include or to be synonymous with interdisciplinary team-working. However, formalised teamworking structures and other strategies for promoting interdisciplinary working (Barr, 2001) did not seem to be in place in some of the services where the participants were working, or were in place within particular settings within a service but not in others. It also appeared that the participants had few opportunities to work directly alongside other professionals or grades of staff apart from care staff, especially those participants working in residential settings. Nevertheless, more than half of the participants stated that different opinions and expertise had enhanced the holistic, person-centred approach of current service provision. Implications of the study There is clearly a need to enhance interdisciplinary working in ID services. This may be achieved by enabling staff in such services to become more familiar with the 6

Due to the time restrictions imposed on the presentation, only a small number of points will be discussed here.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

terminology and concept of interdisciplinary working; formalised team-working structures and other strategies for promoting interdisciplinary working should be considered (Barr 2001). Increased opportunities to work with and participate in continuing education/training activities with other disciplines may help to achieve mutual understanding of others’ roles and develop skills of interdisciplinary working. RMHNs (now RNs – Intellectual Disability) should consider how they can better articulate their role: this may be achieved through the development of assertiveness and confidence. At a policy level, there is a need to develop an agreed definition of interdisciplinary working, and further research to be undertaken into existing interdisciplinary working practices, if any. Third-level education providers could examine aspects of under/post-graduate curricula relating to preparation for interdisciplinary working. Future Research Some areas for future research are more or less implicit in the recommendations that emerged from the study (but not outlined here). In the light of the findings of the present study concerning the participants’ lack of experience of interdisciplinary working a useful starting point would be to undertake an exploratory case study of interdisciplinary working within an individual ID service. This would allow an intensive exploration of the service (Polit & Hungler, 1999; Burns & Grove, 2001) over a sustained period of time (Creswell, 2003). Multiple methods would be used to collect data for the case study (Yin, 1994).

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

References An Bord Altranais (2000a) Requirements and Standards for Nurse Registration Education Programmes (2nd ed). Dublin, An Bord Altranais. Barr, H (2001) Interprofessional Education: Today, Yesterday and Tomorrow. Learning and Teaching Support Network Centre for Health Sciences and Practice. Available from www.health.ltsnl.ac.uk/miniprojects/HughBarrFinal.htm [Accessed 16 April 2003]. Burns, N, Grove, S K (2001) The Practice of Nursing Research: Conduct, Critique and Utilization (4th ed) Philadelphia, W B Saunders Company. Commission on Mental Handicap (1965) Report of the Commission on Mental Handicap Dublin. Commission on the Status of People with Disabilities (1996) Report of the Commission on the Status of People with Disabilities: Strategy for Equality Dublin, Stationery Office. Creswell, J G (2003) Research Design: Qualitative, Quantitative and Mixed Methods Approaches (2nd edn). Thousands Oaks, Sage. Departments of Education, Health and Social Welfare (1983) Education and Training of Severely and Profoundly Mentally Handicapped Children in Ireland: Report of a Working Party to the Minister for Education, Minister of Health and Minister of Social Welfare. Dublin, Stationery Office. Department of Health (1984) Towards a Fuller Life. Green Paper on Services for Disabled People. Dublin, Stationery Office. Department of Health & Children (2001a) Quality and Fairness: A Health Strategy for You. Dublin, Stationery Office. Government of Ireland (1991) Needs and Abilities: A Policy for the Intellectually Disabled. Dublin, Stationery Office. Government of Ireland (1998b) Report of the Commission on Nursing – A Blueprint for the Future. Dublin, Stationery Office. Gyamarti, G (1986) The Teaching of the Professions: An Interdisciplinary Approach. Higher Education Review, 18(2), pp33-43. Harkness, J L, Smith, A L, Waxman, D M, Hix, N V (2003) Balancing Personal and Professional Identities: The Art of Collaborative Practice. Families, Systems and Health, 21(1), p93-99. Kramer, M, Schmalenberg, C (2003) Securing “Good” Nurse-Physician Relationships. Nursing Management, 34(7), pp34-38. Luongo, P F (2000) Partnering Child Welfare, Juvenile Justice and Behavioral Health with Schools. Professional School Counseling, 3, pp.308-314. Morse, J M (1994) Critical Issues in Qualitative Research. London, Sage. National Council for the Professional Development of Nursing and Midwifery (2001a) Clinical Nurse/Midwife Specialists – Intermediate Pathway. Dublin, NCNM National Council for the Professional Development of Nursing and Midwifery (2001b) Framework for the Establishment of Advanced Nurse Practitioner and Advanced Midwife Practitioner Posts. Dublin, NCNM.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

National Disability Authority (2003a) Draft National Standards for Disability Services. Dublin, National Disability Authority. National Disability Authority (2003b) Draft National Standards for Health Services. Dublin, National Disability Authority. National Disability Authority (2003c) Review of Access to Mental Health Services for People with Intellectual Disabilities. Dublin, National Disability Authority. Øvretveit, J (1996) Five Ways to Describe a Multidisciplinary Team. Journal of Interprofessional Care, 10(2), pp163-171. Polit, D F, Hungler, B P (1999) Nursing Research: Principles and Methods (6th ed). Philadelphia, Lippincott Company. Rokusek C (1995) An Introduction to the Concept of Interdisciplinary Practice. In Thyer, B A, Kropf, N P (Eds) Developmental Disabilities: A Handbook for Interdisciplinary Practice. Cambridge, Mass., Brookline Books, pp1-12. While, A, Barriball, K L (1999) Qualified and Unqualified Nurses’ Views of the Multidisciplinary Team: Findings of a Large Interview Study. Journal of Interprofessional Care, 13(1), pp77-89. Yin, R K (1994) Case Study Research: Design and Methods (2nd ed). Newbury Park, CA, Sage Publications.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

DEVELOPING A SIMULATED COMMUNITY TO SUPPORT INTERPROFESSIONAL EDUCATION IN HEALTH AND SOCIAL CARE Maggie.Hutchings, Senior Lecturer: Education, BA, MA, CertEd, ILTM Janet Scammell, Head of Learning and Teaching, BA, MSc, Dip NEd, ILTM, RGN, SCM Michael Martin Senior Web Developer, BSc Institute of Health and Community Studies, Bournemouth University, UK Institute of Health and Community Studies (IHCS) Bournemouth University R310 Royal London House Christchurch Road Bournemouth Dorset BH1 3LT [email protected] Inter-professional education (IPE) in health and social care has been strongly advocated as a means of encouraging collaboration between professional groups to help improve the quality of care delivery. The UK Centre for the Advancement of Interprofessional Education (CAIPE) defines IPE as: ‘Occasions when two or more professions learn from and about each other to improve collaboration and the quality of care’ (Barr 2001). Inter-professional education is being developed at Bournemouth University for nurses, midwives, occupational therapists, physiotherapists, operating department practitioners and social workers. The challenge is to enable meaningful inter-professional learning for students and teaching staff working in a context of diversity of professions represented and student differences in entry criteria, ability, and prior experience. Student numbers are large and group sizes differ widely across professions. Furthermore students are located across a wide geographical area for clinical experience and across three academic bases for face-to-face teaching and tutorial support. The curriculum team, tasked with developing collaborative learning as opposed to simply shared teaching within this complex framework of logistical and diversity considerations, proposed a blended learning solution, a key element of which is a webbased ‘simulated community’ peopled by health and social care users, living and working in a number of urban and rural settings. The ‘simulated community’ is designed to facilitate realistic student inquiry and effective learning within a safe but challenging inter-professional environment (Brown et al 1989, Jonassen & Land 2000, Savin-Baden 2000). It includes: • • • •

An interactive web-based simulated community consisting of practice-situated individuals as ‘live’ and changing learning resources Case scenarios developed by health and social care practitioners using material from practice situations for analysis and problem-solving Discussion boards and chat rooms for debating issues and sharing interprofessional perspectives on scenarios, client news bulletin updates, and role plays Learning resources - professional codes of conduct, legislation, standards, policy documents.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

The purpose of the paper is to explore the design and development of the ‘simulated community’ and case studies, the integration of a Personal and Academic Development common skills unit to facilitate student engagement and confidence in using e-learning and developing IT, information literacy and study skills, and the role of staff development in promoting, supporting and evaluating this innovation. The evaluation approach adopted is iterative and formative using an action research framework to facilitate the enhancement of learning (Kember 2000). Staff experiences are being evaluated by means of staff development tutorials and feedback from students will be used to identify potential changes and enhancements. The intention is to share initial findings and reflections from the evaluations with the academic and professional practice communities.

References Barr, H (2001) Interprofessional education: Today, yesterday and tomorrow. London, CAIPE Brown, J.S. Collins, A. & Duguid, P. (1989) Situated cognition and the culture of learning. Educational Researcher 18(1) 32-41. Jonassen, D. H. & Land, S.M. (eds.) (2000) Theoretical foundations of learning environments. New Jersey: Lawrence Erlbaum. Kember, D. (2000). Action learning and action research: improving the quality of teaching and learning. London: Kogan Page. Savin-Baden, M. (2000). Problem-based learning in higher education: untold stories. Buckingham: SRHE and Open University Press.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

TRAUMATIC BRAIN INJURY: ACUTE AND LONG TERM CONSEQUENCES DR PATRICIA JANSEN SCHOOL OF NURSING AND MIDWIFERY TRINITY COLLEGE DUBLIN Information on factors of recovery following TBI are multifaceted. However, TBI is a significant public health problem so that the duration of the recovery after a traumatic brain injury is an important factor in planning health care services. This study explores this issue with a sample of mild and moderate cases that were seen at a Johannesburg hospital. Patients who were identified as having suffered TBI were followed over time and seen again. Although all had recovered physically. psychological recovery in terms of well-being, mood states and changes in family relationships was far from complete. Unlike severe TBI cases, these cases are less likely to seek the help and support they clearly require.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

ATTITUDES OF HEALTH CARE PROFESSIONALS TOWARDS END OF LIFE CARE Dr Kathleen Ahern PhD, RN Director of Graduate Nursing Wagner College 24 David Street Staten Island New York 10308 USA [email protected] Frank J. Forte MD Paula McAvoy MPA, RN Dr Giovannie Jean-Baptiste MD Department of Medicine Staten Island University Hospital 401 Mason Avenue Staten Island New York 10305 USA Background: About half of all Americans die in hospitals and many do so in pain and subjected to treatments that neither improve their quality of life nor are desired. Generally, there is a loss of dignity and excess use of high technology procedures, wasted resources and little symptom relief. Large expenditures on end of life care benefits no one. Major national initiatives have been launched to address end of life care. A large number of states require that health care institutions to inform patients about advance care planning. Despite these efforts in the U.S., only about 20% of hospitalized patients have an advance care plan. Experts have suggested that influencing health care professionals’ attitudes and knowledge about end of life care may improve the care of terminally ill patients. Purpose: The purpose of this study is to explore the attitudes of health care professionals towards end of life care. Design and Methods: A survey design was used with 119 nurses and 132 physicians recruited from several health care institutions located in a borough of New York City as well as from a medical society and a professional nurses’ organization. The surveys were directly distributed and collected by study assistants on site. The survey consisted of six demographic items and 10 Likert response items. The Likert response items dealt with issues such as communicating with dying patients and families and the care at end of life including appropriateness of withholding treatment such as resuscitation. The survey was psychometrically tested previously by the researchers and had documented validity and reliability. The total desired number of subjects that will be recruited is 500. The study will continue until this end point.

School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings A-K

Results: Overall, only about 25% of the health care professionals had an advance care plan. Older subjects were significantly more likely to have a plan than younger ones ( p,