Impact of a novel nurse-led prechemotherapy education intervention (ChemoEd) on patient distress, symptom burden, and treatment-related information and support needs : results from a randomised, controlled trial

Background: High levels of distress and need for self-care information by patients commencing chemotherapy suggest that current prechemotherapy education is suboptimal. We conducted a randomised, controlled trial of a prechemotherapy education intervention (ChemoEd) to assess impact on patient distress, treatment-related concerns, and the prevalence and severity of and bother caused by six chemotherapy side-effects. Patients and methods: One hundred and ninety-two breast, gastrointestinal, and haematologic cancer patients were recruited before the trial closing prematurely (original target 352). ChemoEd patients received a DVD, question-prompt list, self-care information, an education consultation ≥24 h before first treatment (intervention 1), telephone follow-up 48 h after first treatment (intervention 2), and a face-to-face review immediately before second treatment (intervention 3). Patient outcomes were measured at baseline (T1: pre-education) and immediately preceding treatment cycles 1 (T2) and 3 (T3). Results: ChemoEd did not significantly reduce patient distress. However, a significant decrease in sensory/psychological (P = 0.027) and procedural (P = 0.03) concerns, as well as prevalence and severity of and bother due to vomiting (all P = 0.001), were observed at T3. In addition, subgroup analysis of patients with elevated distress at T1 indicated a significant decrease (P = 0.035) at T2 but not at T3 (P = 0.055) in ChemoEd patients. Conclusions: ChemoEd holds promise to improve patient treatment-related concerns and some physical/psychological outcomes; however, further research is required on more diverse patient populations to ensure generalisability.

Exploring a functional approach to attitudinal brand loyalty

What psychological function does brand loyalty serve? Drawing on Katz’s (1960) Functional Theory of Attitudes, we propose that there are four functions (or motivational antecedents) of loyalty: utilitarian, knowledge, value-expressive and ego-defensive. We discuss how each function relates to the three dimensions of loyalty (i.e. emotional, cognitive, and behavioural loyalty). Then this conceptualisation of brand loyalty is explored using four consumer focus groups. These exploratory results demonstrate that the application of a functional approach to brand loyalty yields insights which have not been apparent in previous research. More specifically, this paper notes insights in relation to brand loyalty from a consumer’s perspective, including the notion that the ego-defensive function is an orientation around what others think and feel. This creates the possibilities for future research into brand loyalty via social network analysis, in order to better understand how the thoughts of others affect consumers’ loyalty attributes. --------------------------------------------------------------------------------

High-resolution imaging of ordered mixed-layer clays

HRTEM has been used to examine illite/smectite from the Mancos shale, rectorite from Garland County, Arkansas; illite from Silver Hill, Montana; Na-smectite from Crook County, Wyoming; corrensite from Packwood, Washington; and diagenetic chlorite from the Tuscaloosa formation. Thin specimens were prepared by ion milling, ultra-microtome sectioning and/or grain dispersal on a porous carbon substrate. Some smectite-bearing clays were also examined after intercalation with dodecylamine hydrochloride (DH). Intercalation of smectite with DH proved to be a reliable method of HRTEM imaging of expanded smectite, d(001) 16 A which could then be distinguished from unexpanded illite, d(001) 10 A. Lattice fringes of basal spacings of DH-intercalated rectorite and illite/smectite showed 26 A periodicity. These data support XRD studies which suggest that these samples are ordered, interstratified varieties of illite and smectite. The ion-thinned, unexpanded corrensite sample showed discrete crystallites containing 10 A and 14 A basal spacings corresponding with collapsed smectite and chlorite, respectively. Regions containing disordered layers of chlorite and smectite were also noted. Crystallites containing regular alternations of smectite and chlorite were not common. These HRTEM observations of corrensite did not corroborate XRD data. Particle sizes parallel to the c axis ranged widely for each sample studied, and many particles showed basal dimensions equivalent to > five layers. -J.M.H.

Does legal heritage affect obesity? The channel of motor vehicle dependence

We find a robust relationship between motor vehicle ownership, its interaction with legal heritage and obesity in OECD countries. Our estimates indicate that an increase of 100 motor vehicles per thousand residents is associated with about a 6% point increase in obesity in common law countries, whereas it has a much smaller or insignificant impact in civil law countries. These relations hold whether we examine trend data and simple correlations, or conduct cross-section or panel data regression analysis. Our results suggest that obesity rises with motor vehicle ownership in countries following a common law tradition where individual liberty is encouraged, whereas the link is small or statistically non-existent in countries with a civil law background where the rights of the individual tend to be circumscribed by the power of the state.

Health service pathways for patients with chronic leg ulcers : identifying effective pathways for facilitation of evidence based wound care

Background: Chronic leg ulcers cause long term ill-health for older adults and the condition places a significant burden on health service resources. Although evidence on effective management of the condition is available, a significant evidence-practice gap is known to exist, with many suggested reasons e.g. multiple care providers, costs of care and treatments. This study aimed to identify effective health service pathways of care which facilitated evidence-based management of chronic leg ulcers. Methods: A sample of 70 patients presenting with a lower limb leg or foot ulcer at specialist wound clinics in Queensland, Australia were recruited for an observational study and survey. Retrospective data were collected on demographics, health, medical history, treatments, costs and health service pathways in the previous 12 months. Prospective data were collected on health service pathways, pain, functional ability, quality of life, treatments, wound healing and recurrence outcomes for 24 weeks from admission. Results: Retrospective data indicated that evidence based guidelines were poorly implemented prior to admission to the study, e.g. only 31% of participants with a lower limb ulcer had an ABPI or duplex assessment in the previous 12 months. On average, participants accessed care 2–3 times/week for 17 weeks from multiple health service providers in the twelve months before admission to the study clinics. Following admission to specialist wound clinics, participants accessed care on average once per week for 12 weeks from a smaller range of providers. The median ulcer duration on admission to the study was 22 weeks (range 2–728 weeks). Following admission to wound clinics, implementation of key indicators of evidence based care increased (p<0.001) and Kaplan-Meier survival analysis found the median time to healing was 12 weeks (95% CI 9.3–14.7). Implementation of evidence based care was significantly related to improved healing outcomes (p<0.001). Conclusions: This study highlights the complexities involved in accessing expertise and evidence based wound care for adults with chronic leg or foot ulcers. Results demonstrate that access to wound management expertise can promote streamlined health services and evidence based wound care, leading to efficient use of health resources and improved health.

Were intercalated komatiites and dacites at the Black Swan nickel sulphide mine, Yilgarn Craton, Western Australia, emplaced as extrusive lavas or intrusive bodies? The significance of breccia textures and contact relationships

Intercalated Archean komatiites and dacites sit above a thick footwall dacite unit in the host rock succession at the Black Swan Nickel Mine, north of Kalgoorlie in the Yilgarn Craton, Western Australia. Both lithofacies occur in units that vary in scale from laterally extensive at the scale of the mine lease to localized, thin, irregular bodies, from > 100 m thick to only centimetres thick. Some dacites are only slightly altered and deformed, and are interpreted to post-date major deformation and alteration (late porphyries). However, the majority of the dacites display evidence of deformation, especially at contacts, and metamorphism, varying from silicification and chlorite alteration at contacts to pervasive low grade regional metamorphic alteration represented by common assemblages of chlorite, sericite and albite. Texturally, the dacites vary from entirely massive and coherent to partially brecciated to totally brecciated. Strangely, some dacites are coherent at the margins and brecciated internally. Breccia textures vary from cryptically defined, to blocky, closely packed, in situ jig-saw fit textures with secondary minerals in fractures between clasts, to more apparent matrix rich textures with round clast forms, giving apparent conglomerate textures. Some clast zones have multi-coloured clasts, giving the impression of varied provenance. Strangely however, all these textural variants have gradational relationships with each other, and no bedding or depositional structures are present. This indicates that all textures have an in situ origin. The komatiites are generally altered and pervasively carbonate veined. Preservation of original textures is patchy and local, but includes coarse adcumulate, mesocumulate, orthocumulate, crescumulate-harrisite and occasionally spinifex textures. Where original contacts between komatiites and dacites are preserved intact (i.e. not sheared or overprinted by alteration), the komatiites have chilled margins, whereas the dacites do not. The margins of the dacites are commonly silicified, and inclusions of dacite occur in komatiite, even at the top contacts of komatiite units, but komatiite clasts do not occur in the dacites. The komatiites therefore were emplaced as sills into the dacites, and the intercalated relationships are interpreted as intrusive. The brecciation and alteration in the dacites are interpreted as being largely due to hydraulic fracturing and alteration induced by contact metamorphic effects and hydrothermal alteration deriving from the intrusion of komatiites into the felsic pile. The absence of autobreccia and hyaloclastite textures in the dacites suggest that they were emplaced as an earlier intrusive (sill?) complex at a high level in the crust.

The influence of neighbourhood disadvantage on smoking cessation and its contribution to inequalities in smoking status

Introduction and aims: Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking. Design and methods: A multilevel longitudinal study of mid-aged (40-67 years) residents (n=6915) of Brisbane, Australia, who lived in the same neighbourhoods (n=200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation. Results: After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0%-12.8%) than their counterparts in more advantaged neighbourhoods (20.7%-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (p≤0.001) and in 2009 it was 0.260 (p≤0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% CrI 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98 95% CrI 1.48-2.66). Conclusion: Fundamentally, social and economic inequalities at the neighbourhood and individual-levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded, and targeted tobacco control efforts and equity based policies that address the social and economic determinants of smoking.

A randomized controlled pilot study comparing aqueous cream with a beeswax and herbal oil cream in the provision of relief from postburn pruritis

Postburn itch is reported to affect up to 87% of the burn population. Although treatments for postburn itch are multimodal, they remain consistently ineffective. However, recent anecdotal evidence from several outpatients at a tertiary referral hospital suggests that a cream combining beeswax and several herbal oils may be effective in the minimization of postburn itch. The aim of this study was to test the efficacy of beeswax and herbal oil cream against the standard treatment of aqueous cream in the provision of relief from the symptoms of postburn itch. A randomized controlled trial compared two groups using a visual analog scale, frequency of cream application, itch recurrence after cream application, use of antipruritic medications, and sleep disturbance to determine the effect of itch severity and duration. Fifty-two participants were enrolled in the study (84% male) with a mean age of 35 years (SD = 16) and mean burn TBSA of 7.2% (SD = 7.7). Study results found that the beeswax and herbal oil cream reduce itch after application more frequently than aqueous cream (P = .001). In addition, when managed with beeswax and herbal oil cream, participants found that their itch recurred later (P ≤ .001) and their use of antipruritic medications was lower (P = .023). Findings of this study suggest beeswax and herbal oil cream to be more effective in the minimization of postburn itch than aqueous cream. Given this, a larger study examining the efficacy of beeswax and herbal oil cream appears warranted.

Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first 3-4 months of life (‘The Possums Approach’) : effects on cry-fuss behaviours and maternal mood

Problem crying in the first few months of life is both common and complex, arising out of multiple interacting and co-evolving factors. Parents whose babies cry and fuss a lot receive conflicting advice as they seek help from multiple health providers and emergency departments, and may be admitted into tertiary residential services. Conflicting advice is costly, and arises out of discipline-specific interpretations of evidence. An integrated, interdisciplinary primary care intervention (‘The Possums Approach’) for cry-fuss problems in the first months of life was developed from available peer-reviewed evidence. This study reports on preliminary evaluation of delivery of the intervention. A total of 20 mothers who had crying babies under 16 weeks of age (average age 6.15 weeks) completed questionnaires, including the Crying Patterns Questionnaire and the Edinburgh Postnatal Depression Scale, before and 3-4 weeks after their first consultation with trained primary care practitioners. Preliminary evaluation is promising. The Crying Patterns Questionnaire showed a significant decrease in crying and fussing duration, by 1 h in the evening (P = 0.001) and 30 min at night (P = 0.009). The median total amount of crying and fussing in a 24-h period was reduced from 6.12 to 3 h. The Edinburgh Postnatal Depression Scale showed a significant improvement in depressive symptoms, with the median score decreasing from 11 to 6 (P = 0.005). These findings are corroborated by an analysis of results for the subset of 16 participants whose babies were under 12 weeks of age (average age 4.71 weeks). These preliminary results demonstrate significantly decreased infant crying in the evening and during the night and improved maternal mood, validating an innovative interdisciplinary clinical intervention for cry-fuss problems in the first few months of life. This intervention, delivered by trained health professionals, has the potential to mitigate the costly problem of health professionals giving discipline-specific and conflicting advice post-birth.

Combined expression of KLK4, KLK5, KLK6, and KLK7 by ovarian cancer cells leads to decreased adhesion and paclitaxel-induced chemoresistance.

OBJECTIVE: Chemoresistance is a critical feature of advanced ovarian cancer with only 30% of patients surviving longer than 5 years. We have previously shown that four kallikrein-related (KLK) peptidases, KLK4, KLK5, KLK6 and KLK7 (KLK4-7), are implicated in peritoneal invasion and tumour growth, but underlying mechanisms were not identified. We also reported that KLK7 overexpression confers chemoresistance to paclitaxel, and cell survival via integrins. In this study, we further explored the functional consequenses of overexpression of all four KLKs (KLK4-7) simultaneously in the ovarian cancer cell line, OV-MZ-6, and its impact on integrin expression and signalling, cell adhesion and survival as contributors to chemoresistance and metastatic progression. METHODS: Quantitative gene and protein expression analyses, confocal microscopy, cell adhesion and chemosensitivity assays were performed. RESULTS: Expression of α5β1/αvβ3 integrins was downregulated upon combined stable KLK4-7 overexpression in OV-MZ-6 cells. Accordingly, the adhesion of these cells to vitronectin and fibronectin, the extracellular matrix binding proteins of α5β1/αvβ3 integrins and two predominant proteins of the peritoneal matrix, was decreased. KLK4-7-transfected cells were more resistant to paclitaxel (10-100 nmol/L: 38-54%), but not to carboplatin, which was associated with decreased apoptotic stimuli. However, the KLK4-7-induced paclitaxel resistance was not blocked by the MEK1/2 inhibitor, U0126. CONCLUSIONS: This study demonstrates that combined KLK4-7 expression by ovarian cancer cells promotes reduced integrin expression with consequently less cell-matrix attachment, and insensitivity to paclitaxel mediated by complex integrin and MAPK independent interactions, indicative of a malignant phenotype and disease progression suggesting a role for these KLKs in this process.

Timed Up and Go Tests in cardiac rehabilitation : reliability and comparison with the 6-minute walk test

PURPOSE: To test the reliability of Timed Up and Go Tests (TUGTs) in cardiac rehabilitation (CR) and compare TUGTs to the 6-Minute Walk Test (6MWT) for outcome measurement. METHODS: Sixty-one of 154 consecutive community-based CR patients were prospectively recruited. Subjects undertook repeated TUGTs and 6MWTs at the start of CR (start-CR), postdischarge from CR (post-CR), and 6 months postdischarge from CR (6 months post-CR). The main outcome measurements were TUGT time (TUGTT) and 6MWT distance (6MWD). RESULTS: Mean (SD) TUGTT1 and TUGTT2 at the 3 assessments were 6.29 (1.30) and 5.94 (1.20); 5.81 (1.22) and 5.53 (1.09); and 5.39 (1.60) and 5.01 (1.28) seconds, respectively. A reduction in TUGTT occurred between each outcome point (P ≤ .002). Repeated TUGTTs were strongly correlated at each assessment, intraclass correlation (95% CI) = 0.85 (0.76–0.91), 0.84 (0.73–0.91), and 0.90 (0.83–0.94), despite a reduction between TUGTT1 and TUGTT2 of 5%, 5%, and 7%, respectively (P ≤ .006). Relative decreases in TUGTT1 (TUGTT2) occurred from start-CR to post-CR and from start-CR to 6 months post-CR of −7.5% (−6.9%) and −14.2% (−15.5%), respectively, while relative increases in 6MWD1 (6MWD2) occurred, 5.1% (7.2%) and 8.4% (10.2%), respectively (P < .001 in all cases). Pearson correlation coefficients for 6MWD1 to TUGTT1 and TUGTT2 across all times were −0.60 and −0.68 (P < .001) and the intraclass correlations (95% CI) for the speeds derived from averaged 6MWDs and TUGTTs were 0.65 (0.54, 0.73) (P < .001). CONCLUSIONS: Similar relative changes occurred for the TUGT and the 6MWT in CR. A significant correlation between the TUGTT and 6MWD was demonstrated, and we suggest that the TUGT may provide a related or a supplementary measurement of functional capacity in CR.

Utility of an alternative bicycle commute route of lower proximity to motorised traffic in decreasing exposure to ultra-fine particles, respiratory symptoms and airway inflammation - a structured exposure experiment

Background: Bicycle commuting in an urban environment of high air pollution is known as a potential health risk, especially for susceptible individuals. While risk management strategies aimed to reduce motorised traffic emissions exposure have been suggested, limited studies have assessed the utility of such strategies in real-world circumstances. Objectives: The potential of reducing exposure to ultrafine particles (UFP; < 0.1 µm) during bicycle commuting by lowering interaction with motorised traffic was investigated with real-time air pollution and acute inflammatory measurements in healthy individuals using their typical, and an alternative to their typical, bicycle commute route. Methods: Thirty-five healthy adults (mean ± SD: age = 39 ± 11 yr; 29% female) each completed two return trips of their typical route (HIGH) and a pre-determined altered route of lower interaction with motorised traffic (LOW; determined by the proportion of on-road cycle paths). Particle number concentration (PNC) and diameter (PD) were monitored in real-time in-commute. Acute inflammatory indices of respiratory symptom incidence, lung function and spontaneous sputum (for inflammatory cell analyses) were collected immediately pre-commute, and one and three hours post-commute. Results: LOW resulted in a significant reduction in mean PNC (1.91 x e4 ± 0.93 x e4 ppcc vs. 2.95 x e4 ± 1.50 x e4 ppcc; p ≤ 0.001). Besides incidence of in-commute offensive odour detection (42 vs. 56 %; p = 0.019), incidence of dust and soot observation (33 vs. 47 %; p = 0.038) and nasopharyngeal irritation (31 vs. 41 %; p = 0.007), acute inflammatory indices were not significantly associated to in-commute PNC, nor were these indices reduced with LOW compared to HIGH. Conclusions: Exposure to PNC, and the incidence of offensive odour and nasopharyngeal irritation, can be significantly reduced when utilising a strategy of lowering interaction with motorised traffic whilst bicycle commuting, which may bring important benefits for both healthy and susceptible individuals.

Is chrysocolla (Cu,Al)2H2Si2O5(OH)4·nH2O related to spertiniite Cu(OH)2? - a vibrational spectroscopic study

Chrysocolla (Cu, Al)2H2Si2O5(OH)4·nH2O is a hydrated copper hydroxy silicate and is commonly known as a semi-precious jewel. The mineral has an ill defined structure but is said to be orthorhombic, although this remains unproven. Thus, one of the few methods of studying the molecular structure of chrysocolla is to use vibrational spectroscopy. Chrysocolla may be defined as a colloidal mineral. The question arises as to whether chrysocolla is a colloidal system of spertiniite and amorphous silica. The main question addressed by this study is whether chrysocolla is (1) a mesoscopic assemblage of spertiniite, Cu(OH)2, silica, and water, (2) represents a colloidal gel or (3) is composed of microcrystals with a distinct structure. Considerable variation in the vibrational spectra is observed between chrysocolla samples. The Raman spectrum of chrysocolla is characterised by an intense band at 3624 cm−1 assigned to the OH stretching vibrations. Intense Raman bands found at 674, 931 and 1058 cm−1 are assigned to SiO3 vibrations. The Raman spectrum of spertiniite does not correspond to the spectrum of chrysocolla and it is concluded that the two minerals are not related. The spectra of chrysocolla correspond to a copper silicate colloidal gel.

What relationships exist between general self efficacy, locus of control and the nursing practice environment and caring efficacy and job satisfaction?

Research Question: What relationships exist between general self efficacy, locus of control and the nursing practice environment and caring efficacy and job satisfaction? Background: Important characteristics of current nursing practice include nurses having the ability to develop and continue therapeutic relationships with patients, nurses having autonomy and control over the practice environment and nurses having more involvement in decision making. In addition, employee satisfaction is enhanced when organisations offer access to authority. Despite this, nurses continue to complain of feeling powerless in their ability to make decisions. Sample: The study population and criteria for selection included Registered Nurses in Australia who were at the time members of an Australian professional and industrial organisation. Methods: A cross-sectional survey was undertaken. Data analysis was conducted using descriptive and bivariate statistics, and structural equation modeling. Results: The model fit the data well (χ² = 2.3594, χ²/df = 2.3594 and CFI = 0.9987). Twenty four percent of variation in caring efficacy (CE) can be accounted for by general self-efficacy (GSE); work locus of control (WLC) and practice environment (PE) and 62% of the variation in job satisfaction (JS) can be accounted for by GSE, WLC and PE. All pathways were found to be significant except PE to CE. GSE positively explained CE (β = 0.38). WLC was negatively related to CE i.e., as CE scores increased WLC scores decreased (β = -0.23). Further testing of the model found CE was positively related to GSE (βZ = 0.38, p < 0.001) and negatively related to WLC (βZ = - 0.23, p = 0.001). PE was not significantly associated with CE (βZ = - 0.01, p = 0.85). JS was explained by PE, which was positively related (βZ = 0.69, p = < 0.001); GSE which was negatively related (βZ - 0 .09, p < 0.001) and WLC, which was also negatively related (βZ = - 0.20, p < 0.001). Implications for Practice Nursing and organisational leaders should ensure the development of strategies for professional development and orientation programmes which may enhance nurses’ ability to develop caring relationships and express caring behaviours to their patients and as a result improve organisational and patient outcomes. Nursing shortages and turnover rates are associated with job satisfaction and the nursing practice environment. Improving the nursing environment can produce benefits to the health system such as better job satisfaction, improved workforce retention and better patient outcomes.

Examination of factors affecting caring efficacy, job satisfaction in Australian registered nurses

Research Question: What relationships exist between general self efficacy, locus of control and the nursing practice environment and caring efficacy and job satisfaction? Background: Important characteristics of current nursing practice include nurses having the ability to develop and continue therapeutic relationships with patients, nurses having autonomy and control over the practice environment and nurses having more involvement in decision making. In addition, employee satisfaction is enhanced when organisations offer access to authority. Despite this, nurses continue to complain of feeling powerless in their ability to make decisions. Sample: The study population and criteria for selection included Registered Nurses in Australia who were at the time members of an Australian professional and industrial organisation. Methods: A cross-sectional survey was undertaken. Data analysis was conducted using descriptive and bivariate statistics, and structural equation modelling. Results: The model fit the data well (χ² = 2.3594, χ²/df = 2.3594 and CFI = 0.9987). Twenty four percent of variation in caring efficacy (CE) can be accounted for by general self-efficacy (GSE); work locus of control (WLC) and practice environment (PE) and 62% of the variation in job satisfaction (JS) can be accounted for by GSE, WLC and PE. All pathways were found to be significant except PE to CE. GSE positively explained CE (β = 0.38). WLC was negatively related to CE i.e., as CE scores increased WLC scores decreased (β = -0.23). Further testing of the model found CE was positively related to GSE (βZ = 0.38, p < 0.001) and negatively related to WLC (βZ = - 0.23, p = 0.001). PE was not significantly associated with CE (βZ = - 0.01, p = 0.85). JS was explained by PE, which was positively related (βZ = 0.69, p = < 0.001); GSE which was negatively related (βZ - 0 .09, p < 0.001) and WLC, which was also negatively related (βZ = - 0.20, p < 0.001). Implications for Practice Nursing and organisational leaders should ensure the development of strategies for professional development and orientation programmes which may enhance nurses’ ability to develop caring relationships and express caring behaviours to their patients and as a result improve organisational and patient outcomes. Nursing shortages and turnover rates are associated with job satisfaction and the nursing practice environment. Improving the nursing environment can produce benefits to the health system such as better job satisfaction, improved workforce retention and better patient outcomes.