Crossing Bowen Street : mapping interventions in the classed subject

Synopsis: Crossing Bowen Street Crossing Bowen Street is an extended novel set in Melbourne, Australia. The protagonist, Meg Flanagan, is accepted to teachers' college. Meg is 24 years old and has worked, and lived out of home, since 17. Having completed her year 12 studies part time while working, she has applied to the Melbourne State College for a Bachelor of Education. Melbourne State College is subsequently 'amalgamated'A into Philip University, the original 19th century sandstone institution which borders MSC. Meg has worked as a medical secretary prior to commencing her studies. An only child, she is the first member of her family to go to university, indeed to finish high school. Tertiary study is exciting for Meg and the novel explores the psychic journey as well as the intellectual one, as Meg experiences challenges to the possibilities for her life and the trajectory along which she once assumed it would flow. The narrative is told through episodic and epistolary forms, with particular periods in Meg's cultural and academic life forming the focus, picking up the integral elements of her journey and examining the psychic context and action. Characters in the undergraduate chapters of the novel are somewhat transient, although very important to Meg's rapidly developing, changing sense of herself. The constant 'trying out' of ways of being and even lifestyles sees Meg losing old 'friendships' and making new, even temporary, ones all the time. This allows the opportunity for Meg to explore her feelings about connecting to others and the nature of her relationships. The Meg reflected back to her by others is of constant interest to her, particularly as she is frequently reminded that others see a very different Meg than she does. The novel commences at the outset of Meg's tertiary career, as she initially articulates the extent of her aspiration, of her sense of the possibility of her own life. Each vignette deals, chronologically, with an aspect of Meg's expanding sense of possibility, socially, emotionally, intellectually. Certain vignettes explore her relations with friends and acquaintances in the course, which in turn provide A In 1988, Federal Labor Minister for Education John Dawkins, devised a plan to end the streaming of Australian tertiary institutions and created what is called the Unified National System. This meant that colleges of advanced education and institutes of technology were either created universities in their own right, or more commonly, merged with an appropriate existing university. This process allows a fascinating insight into the class dimensions of hierarchies and stratifications. The need of universities and their members for status has been profoundly underscored. the background and context for her sexual relationships. That aspect of her developing subjectivity provides a marked contrast, which Meg uses as leverage, when set against her sense of herself as a scholar and her growing notion of entitlement, which allows her to 'choose', where previously she believed she had no choice; the choice is a scholarly career. Within all this, Meg discovers and is deeply empowered by certain political left, and feminist, discourses within the university community. She is equally dismayed and alienated by other feminist practices; her growing engagement with her own agency sees her quickly abandoning feminist subject positions previously dear to her, which served a particular purpose and are now superseded. This notion of feeling betrayed by the promise of a value system (or rather, its practitioners) will recur throughout the action of the novel, as Meg moves into an academic role, first as doctoral student and then as academic, seeking to live her values as practice and to remain true to what her trajectory has taught her. This is crystallised in the novel as the role played by the place she came from, and how that informs, and complicates, who she becomes. The novel seeks to explore the fundamental contradictions in doing so, through Meg's increasing awareness that the academy is not the harmonious, class aware institution she has idealised, but a world driven by status and hierarchies. This realisation must be reconciled in the light of Meg's anxieties about her working-class background. Meg's doctoral training at an elite university underscores her developing sense of what constitutes excellence and the role played by highly influential conservative institutions in maintaining social arrangements. As her academic career unfolds, the holding of a Cambridge PhD allows Meg opportunities to make change as certain privileges are afforded her by virtue of her Cambridge status. Yet it is this very notion that she seeks to challenge. Her growing passion for the State University of Victoria, an institution developed for the education of working-class people, informs her activism within the academy. Why are excellence and equity polarised? Why does the institution matter more than the scholarship? Why is so much practice within universities contrary to the values scholars often claim? These questions are explored through the dynamics of academic working life as student and later as a teacher at a university with an explicit equity agenda. The Start of the End (2003): The action commences on a late Friday after at SUV, when the Department of Communication & Cultural Studies has just been advised of Meg's promotion to Associate Professor. This vignette sees the initial soiree and celebrations and allows Meg to reflect on her experience. As her colleagues and friends are congratulating her, a particular student comes looking for Meg. It is clear that Angela Watson needs course advice particularly from Meg. Their discussion seems a straightforward one on the face of it, but it underscores many things; that Meg has come the full circle in her academic life, and what it is that her journey has really been about. The route to professorial appointment is considered, as is the source of Meg's greatest professional joy and fulfillment; is it scholarship, followed by leadership, in her discipline? It is knowing she has continued to speak and act to change the life chances of all students, wherever possible? Or is it the subtle distilling of both of these, along with the knowledge which emerges from the nexus of teaching and research. That scholarship, new knowledge, surely must be taking us somewhere specific in relation to others? The more we know, the more we can do...to what end? From this reflection, we see the action of the novel unfold. We return to this scene at the end of the novel, as Meg considers the trajectory of her life and its themes in her work. The novel ends as she is faced with the next challenge. Arrival (1989): Acceptance sees Meg as she is attempting to transform her life and create a new one. She has just been advised of her admission to an undergraduate Bachelor of Education program, at the major Melbourne teachers' college. Meg shares her rented home with her high school best friend, Anna, and her fiance, Jason, who appears to be superfluous in her life. Meg is aware he is a partner for who she used to be. We see Meg in her job as a medical secretary and this allows the mapping of Meg's sense of her own world, as she travels between home and work. This first stage of seeking her aspiration- to be an English teacher-evolves. As Meg considers the meaning of what she is about to do and how she knows it is right. This involves a consideration of what work means in our lives and how this is different for jobs according to how they are classed. Her relationship with the life she has known, the person she has been, is changing and this change is represented through her relationship with Jason. Meg's first day at teachers' college demonstrates that she is in a constant, often painful, dialogue with herself. The difficulties she encounters in making sense of the relation between her two 'lives' are thrown into sharp relief. The preparation for college sees Meg interrogating herself about how she can be different. Her initial experiences at the College resonate with her highest expectations of the life that awaits her, of the multiple possibilities currently being authored for her. Her first attendance at classes offers the opportunity to try out some of those possibilities, to test them against those she meets and to map the ways she could discover to 'be'. There is much tension and fear, but also endless excitement and these conflicting emotional states parallel and marble each other. It is on this day that she meets Jennifer Wren, her first real friend at university, who offers so many challenges to Meg. Their friendship involves a constant exhausting shift of subject positions, which Meg is able to look back on with affection in years to come. Going Bowling (1989): within a few weeks of commencing at university, Meg is socializing with some of her new friends, having neatly segmented her home and college lives. Meg has already realised that her friendships fall into separate groups; her friendship with Jennifer and the people Jennifer knows does not find its way into this group. They meet in the city to go bowling and have a meal. While Meg really enjoys these new people, already tensions are developing in relations between the group. Their unofficial leader, Rosemary Marshall, has a tendency to seek control and already resistance is showing. Rosemary particularly does not like Jennifer. Meg is enjoying her flirtation with Pete Danville, whom she has assumed to be gay. His very flattering attention has already developed Meg's confidence and stoked her ego, which has eroded in her stagnating relationship with Jason. Rosie has developed a crush on Pete and seems to take the flirtation with Meg personally. Dynamics in the group become slightly uncomfortable but Meg has grown quickly fond of her new friends, especially flamboyant Marina, another whom Rosemary seems to dislike. The discussions which occur during their evening deepen both the relationships and the tensions between them and draw lines which will determine the outcome of their various friendships. The Ball (1990): In the third year of her degree, much has happened to Meg. She is married to Jason, although she omits him from much of her psychic (and practical) life. Meg and her friends attend the Faculty's annual formal dinner dance. Meg has so far managed to balance the competitiveness which occurs between all of them, both academically and personally. The negotiation of her respective friendships with Jennifer and Marina requires a great deal of diplomacy; the subtext in this is very disturbing to Meg. What exactly is the conflict about? She can't be sure why they don't like each other; it could be Marina's smoking, or Jennifer's confidence to spare, but these things also annoy her, yet she does not fight with either girl as they do with each other. Rose has always insisted that the problem is Jennifer's private school background, but Marina went to a catholic girls' school, so what could the difference be? The ball is initially a happy occasion; the girls dress up and they dance and drink champagne together with the boys. But dynamics operating beneath the surface force their way up. Rosie is ready to force Pete to confront her continuing crush on him; Pete confronts Meg about their ongoing flirtation. Meg gives in and admits to herself for the first time that she does want to be with Pete. He is grown up and exciting and strong. He offers her something she has never had with Jason. Married less than a year, she pushes her husband out of her thoughts. The events of the ball force Meg to confront the differences between all her friends and the discomfort this affords everyone. Rosie's continued need for control over the group is acknowledged. Future Present (1991): Meg lives in Carlton with Pete. This is the busiest year thus far in her academic career and the financial, academic and emotional pressure is showing. This vignette gives us the range of Meg's academic activities and the way her life has fallen since the events at the ball eight months earlier. We see Meg grappling with her own evaluation of the changes in her 'way of being'; trying on different ways of living that she has idealised and finding them just as wanting as the last. Meg faces some key existential questions in this vignette and seeks answers which she finally discovers only she can give. Her relationship with Pete, the values and goals they share (and don't share) are thrown into sharp relief and provide a touchstone for the clearer determination of Meg's aspiration and future. Her relationship with various female friends is also revisited and this offers insight into Meg's constant checking of herself against idealised female templates. There is a crisis of identity and strength which constitutes an important fork in Meg's road. Beyond (1992): Beyond sees Meg determinedly seeking ways she can progress towards her goal, while still constantly checking against herself that postgraduate study (let alone a scholarly life) is available to her. We accompany Meg as she seeks and locates the academic path she wants; this is the backdrop for her further psychic exploration of the women who intimidate yet fascinate her, particularly Heloise Waul, who is a significant influence through Meg's postgraduate career. The sites in which Meg's personal struggles manifest are highlighted in this vignette, particularly in terms of dress and cultural pursuit. The conversations between Meg and Heloise also allow an exploration of the feminist politics of that milieu and the class tensions which operate tacitly within those politics. Bound to the Caucus (1992); Meg has now nearly completed her undergraduate degree and has been active for some time in university life and student politics. Her feminist and socialist education is well advanced. Bound to the Caucus shows us Meg in her student politics world for the first time, where the segue of her activism and academic life have taken her. Meg has found female friends who understand that part of her which struggles with inadequacy, although at this point in the novel this common struggle is not well understood or articulated. It is in this vignette that Meg admits her growing attraction for a Liberal student activist, Stuart Noble; this proscribed liaison raises many questions about values and aspiration, as well as the dominant sexual politics of the time and place. Bound to the Caucus also offers insight into the student activism occurring at universities like Philip in the early 1990s. Divergence (1993): Set in 1993, Meg is now in the early weeks of her honours program, although she has been at work on her thesis on the poet William Blake for some months. Living unhappily in a share household near the University, her relationship with Stuart Noble continues to develop, reaching a crisis point in this period. These events occur in the context of Meg's activist career in the Student Left, particularly as she encounters issues of identity around her class, feminism and difference amongst Left women. While Meg fights these battles passionately in an intense milieu, she considers them emotionally in terms of her changing sense of herself. Meg is increasingly aware that the personal impact of her class is changing for her. Additionally, she explores her relation with a 'boyfriend' of right wing political affiliation; Meg comes to recognise that this relationship is undermining her sense of herself in a way that her relationships with women in the left previously did. Honour Roll (1993): Meg is now undertaking honours and this vignette opens with Meg seeing the honours coordinator, Professor Michaela Moore, who approximates all those apparently middle-class traits to which Meg has such a push-pull relation. We see the return of a chapter of the honours thesis, discussion of the content and the constantly shifting subject positions these experiences offer Meg. This vignette also directly introduces Agnes. Mia and Agnes meet Meg after her supervision and this conversation allows very distinct if tacit class themes to develop. Meg has warmed quickly to Agnes, who is unlike anyone she has known; they have much in common in relation to their work and this binds them. Mia continually presents a viewpoint which irritates Meg, in relation to entitlement: to academic life, to funding, even to questioning how these things are enabled. Honour Roll allows us to see Meg's flourishing theoretical and intellectual life and its role in assisting her emotionally as she re-frames the same conundrums that previously constituted obstacles. The Cusp (1993): Meg's developing friendship with Agnes offers her enormous insights into difference and her developing sense of self and aspiration. While the girls come from diametrical backgrounds, they are united by their passion for their research and scholarly work. Meg is increasingly self-conscious through their discussions in terms of how she has seen herself and allowed herself to dream and seek. Cusp is set at the end of the honours year, prior to the release of results. Meg and Agnes explore their feelings about academia and this leads to discussions of purpose and the role of class within that. This vignette also documents Meg's growing social confidence and those aspects of herself which have become so sure to her, that she no longer considers them at all. Whom (1996): [Not included in this abridged edition]. Set at Cambridge, two thirds into Meg's doctorate, Whom shows Meg in the mental space which will take her back to Melbourne and the State University of Victoria. Having risen to the challenge of doctoral study, she is confronted now by deeper demons, and the need to explore and challenge them in the ambivalent context of Cambridge, which so excites her still, but which has proved empty of the profoundly held higher ideals she expected to see reflected. Set in the midst of Meg's doctoral study, this vignette is dramatically abridged in the submission novel. The importance of Whom lies in its concern with Meg's rapidly shifting sense of herself and her own scholarly subjectivity and the changes to these that the culture of Cambridge has wrought. By the second year of her PhD Meg is crystal clear about her goals and decides to spend the long break at home, rather than travelling, because she wishes to 'touch base' with her future. The action described segues into that in Courting the Enemy. Whom describes Meg's ambivalent and contradictory but passionate feelings about Cambridge. Whom demonstrates Meg's increasing anger at the status and privilege to which her education now automatically admits her, and her need to find some sort of stasis and safety in her emotional life. In this vignette, Meg meets her life partner, Jeremy McCallum (I have intentionally reduced the attention in the novel to Meg's romantic life as she matures into her career). Courting the Enemy (late 1990s): By this time, Meg is a senior lecturer in English at the State University of Victoria, which was established in the nineteenth century as the Worker's College. This vignette starts with Meg's attendance at a University Committee which is considering a transformation in relation to equity in admissions policy. Meg was drawn to SUV because of its transparent and determined commitment to educate the children of working-class people. An attack on the equity admission policy of her university galvanizes Meg and some of her colleagues. The action of the vignette considers the role of the scholar, and of such an institution as SUV, in the light of daily academic life. This vignette is primary in its demonstration of the themes of the novel. In the unabridged version, I took the opportunity to illustrate some of the vast range of administrative, intellectual and even physical demands on a senior scholar in the routine of academic life. In placing Meg in this context, I sought to highlight how a scholar of her values and commitment makes sense of the constantly shifting terrain of her working world and how this continually informs her practice. This vignette is also significant for its retrospective description of Meg's employment at SUV some years earlier. Locus: (1995). This piece of writing stands apart from the rest of the novel. I wished to write in a reflective voice, which might be from Meg's journal, were it not in the (omniscient) third person, in order to consider the headspace and meaning-making which occurs as Meg settles into Cambridge, and the lifestyle her situation allows her. Locus is a deeper engagement with Meg's sense of her identity. It considers the impact on her of the physical journeys she must make to match those of her psyche. These are thoughts too personal for a letter, even to Anna. Meg is exploring her ever shifting self and the growth in her self-belief allows her to explore what is rage; that she was bounded by illusions about her worth. Locus seeks to allow some context for Meg's anger at the role Cambridge plays. I seek to create the space in which Meg's dawning self understanding will lead her to her next, driven, purpose. Letters: throughout the novel letters are used to reveal and inform Meg's relationship with her family. This is an intentional device to distance the birth family in an attempt to blur and muddy an assessment of Meg's class through traditional measures. The letters between Meg and Aunty Jean particularly reveal much of the classed emotional antecedents of Meg's life. There are also letters exchanged with Meg's high school best friend, Anna, who has moved to the country and a very different lifestyle. Meg writes to Anna often, using the acceptance she feels in the friendship and her sense that Anna understands her, to touchstone her own emotional growth. Formal letters from institutions ring changes in settings and mark significant points in the geographical and academic trajectory of the character. All the letters serve to introduce time and event changes consistent with the episodic style of the narrative.

Impact of the extended family on microenterprise growth in Ghana : a case study of Accra

This study examines the extended family's impact on microenterprise growth at the individual level, where microenterprise operators have some control over constraints affecting their operations. Beyond the individual level, microenterprise operators have little control over constraints such as government policies and regulations, competition from import-substitution industries and exploitation by corrupt officials. Therefore, it is at the individual level that the extended family serves as a crucial parameter of microenterprise growth and the success with which MEs graduate from the informal sector into the mainstreams of small business. Within this domain, this author has examined the extended family and found that there is a need for policy makers and MED administrators to adopt a more culturally sensitive approach to microenterprise growth if the extended family is to be engaged as a partner in their efforts to support microenterprises as a source of income and employment generation, A central question posed is why most writers on microenterprise activities in Ghana have neglected the extended family as a factor that should be considered in the design of microenterprise growth strategies and policies? The answer to this question was explored in the process of data gathering for this thesis and the results are presented here, especially in chapter 3 below. Suffice it to note here that this neglect has many roots, not least of which is the proclivity of mainstream economics, modern administration practice and the objectivity of double entry accounting based documentation procedures to focus on measurable growth in the formal sectors of the economy and structural constraints such as the lack of finance, lack of market demand, lack of access to technology and government regulations. Consequently, a noticeable trend among these writers is that they rightly advocate finance be made accessible to microenterprises, however, few question whether the finance is effectively used towards microenterprise growth. This issue is crucial in the face of evidence from this study which shows that finance accessed towards microenterprise growth is often put to other uses that negate growth thus keeping microenterprises within the bounds of the informal sector as against graduating out of the informal sector. As a result, these writers have neglected the intimate relations between the extended family and microenterprises, and most importantly, the constraint that the extended family inflicts on microenterprise growth at the individual level of activity. This study, by targeting the growth of the individual microenterprise in the socio-cultural context in which this growth must be achieved, has highlighted the constraint that the extended family does pose on MED. However, the study also shows that these constraints are important not because there is anything inherently wrong with the extended family, but because the socio-economic and policy environment is not consistent with the positive role that the extended family can and should play in the graduation of microenterprises from the informal to the formal sector of the economy in Ghana.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

An evaluation of a community aged care nurse practitioner service

Evaluation aims: An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team.

Background: In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities.

Design: An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken.

Method: All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi-structured interviews.

Results: Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients' physical and psychological symptom management, enhance clients' quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision.

Conclusions: Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting.

Relevance to clinical practice: Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.

Implementation of clinical practice guidelines using simulation in education

Background: Underpinning the Department of Human Services (DHS) “Future directions for Victoria’s maternity services” strategy in Victoria, are the principles of achieving the right balance between primary level care and access to appropriate levels of medical care by making the best use of the complementary skills of midwives, GPs and obstetricians. Planning new models of care have exposed a need to upskill many clinicians in providing evidence based pregnancy care. A statewide education program conducts 1 day workshops to multidisciplinary forums in Victoria. The program content is developed with each service and simulation activities are incorporated in the workshop to provide a realistic environment for practising skills related to the implementation of clinical practice guidelines.

Method: Post workshop surveys are completed anonymously by participants using a five point Likert scale to evaluate their experiences in peer learning, the use of simulation, reflective practice and communication skills training. Open ended responses were analysed thematically.

Results: In 2007, 14 workshops were conducted with 254 clinicians attending. The survey response rate was 80%. Participants responded ‘strongly agree’ or ‘agree’ that the workshop: enhanced their ability to access current pregnancy care research and information 193/ 204(95%), challenged them to think more broadly 192/204(94%), provided an opportunity to reflect on their communication skills during the simulation actives 197/201 (96%) and provided a valuable opportunity for observing the communication skills of their peers 197/ 201(98%).

Conclusion: Providing opportunities for peer learning in pregnancy education is valuable and the use of simulation can play an important role in overcoming barriers to implementing guidelines.

Revolt and discovery : towards an understanding of practice as research through Kristevan aesthetics

This paper will examine Kristeva’s conceptions of revolution and revolt to demonstrate the significance of her work for practitioners and researchers working in the emerging field of creative arts practice as research, a field of research that is burgeoning in the UK, Australia, Canada and Scandinavia. I will argue that Kristeva’ thought elaborates the aesthetic underpinnings of discovery and provides a rationale for the methodologies used in artistic research.

In her later work on interpretation, Kristeva places a greater emphasis on the need for analysis or theory, since the art and culture of revolt produce unfamiliar or mutant meanings that are difficult for audiences to grasp in terms of their potency for engendering social change and individual empowerment. However, she places the responsibility for this analysis and interpretation on the art critic. But what if (as is the case with the advent of artistic practice as research), the maker and the “critic” become one and the same? Can this shift in the status of artistic practice within the knowledge economy, be understood in terms of Kristeva account of the sense and nonsense of revolt? I will address these questions by revisiting aspects of Kristeva thinking on experience-in practice and examining her more recent and extended elaboration of revolutionary practice. The paper will explore how her thinking can provide practitioners with a framework for understanding creative arts research as the production of new knowledge. If as Kristeva argues, that art and literature are amongst the few means of revolt and renewal, it seems appropriate to turn to her thinking in order to articulate a rationale and argument for claiming that practice as research can operate as a driver of change and innovation in contemporary culture.

The first part of this task will involve tracing what Kristeva sees as three forms of revolt made possible through aesthetic experience. This will involve a closer examination of the notions of transgression and art as experience. Following on from this discussion, I will discuss how Kristeva’s work constitutes both an implicit and explicit critique of science allowing us to conceive of artistic research as an alternative and performative production of knowledge. Finally in this paper, I will apply and illustrate these ideas through an analysis of a selection of a number of research projects successfully completed by artistic researchers in Australia. I hope to show that artistic practice as a mode of enquiry, reveals the inextricable and necessary relationship between practice and theory, interpretation and making, art and life. I suggest that it is this interrelationship, that underpins what Kristeva describes as creative and revolutionary practice. In the context of creative arts practice as research, Kriteva’s account of experience–in-practice indicates that interpretation and analysis must fall to the practitioner-researcher himself or herself - rather than to another person who has been external to the procedures of making - to trace the significant experiential, subjective and emergent processes involved in the production of the work that allows it to reveal the new. This is necessary if the generative and revolutionary impact of artistic research is to be fully understood in the wider research arena.

Medical error and decision making : learning from the past and present in intensive care

Background : Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

Purpose : The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

Data source : Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

Findings : Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

Conclusion : It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

Review : nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding.

Background. The literature reports varying nutritional practices in intensive care.

Design. Systematic review.

Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria.

Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under- and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes.

Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re-evaluation of energy recommendations and improved delivery of enteral nutrition.

Relevance to clinical practice. This review supports the multi-disciplinary development and implementation of an evidence-based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.

The delivery of a telephone coaching programme to people with type 2 diabetes by practice nurses in Victoria, Australia : a qualitative evaluation

Aim.  To evaluate telephone coaching undertaken by practice nurses in a randomised controlled trial of self-management support for people with type 2 diabetes.

Background.  Qualitative evaluation of the processes that take place in randomised controlled trials has the advantage of providing information on those variables that contribute to the success or failure of the randomised controlled trial. This additional information can be used to improve or modify chronic disease management programme designs.

Methods.  Grounded theory was used to analyse transcriptions of telephone coaching sessions between practice nurses and patient participants in the randomised controlled trial.

Findings.   Analysis of transcriptions found that patient participants had complex multiple medical conditions to manage, as well as maintaining their daily lives. Two approaches to working with this complexity by practice nurses emerged. We characterised one as ‘treat to target’ and the other as ‘personalised care’. While each approach shapes identities available to patients within the relationship with the practice nurse, the impact or effectiveness of these approaches on outcomes has yet to be reported.

Conclusions.  Telephone coaching takes place in complex social contexts as well as complex medical conditions. People with type 2 diabetes must manage their diabetes care and their care of other conditions within their social contexts. This means a constant negotiation of priorities.

Relevance to clinical practice.  Awareness of how health professional support for patients’ self-management becomes a relationship and element of the negotiated identity of patients is important in adapting clinical guideline-based protocols to achieving targets in the management of chronic illness.

How is the diagnosis of asthma in older people established in clinical practice?

What we need to know
• How is breathlessness perceived and defined in older people?
• What impact does breathlessness have on quality of life?
• Can history taking and physical examination be tailored to efficiently cover all the organ systems associated with
breathlessness?
• Can a self- or carer-rated questionnaire be used to identify asthma in patients with breathlessness?
What we need to do
• Develop self- and carer-rated questionnaires that measure change in function and quality of life before and after
treatment.
• Validate objective measures of physical function and airflow that are sufficiently sensitive to measure change with
treatment.
• Develop a diagnostic guideline in general practice that includes measures of mood and cognitive function and
involves carers where necessary.
• Provide rehabilitation and restorative care services.

Assessment of variation in the alberta context tool : the contribution of unit level contextual factors and practice specialty in Canadian pediatric acute care settings

Background: There are few validated measures of organizational context and none that we located are parsimonious and address modifiable characteristics of context. The Alberta Context Tool (ACT) was developed to meet this need. The instrument assesses 8 dimensions of context, which comprise 10 concepts. The purpose of this paper is to report evidence to further the validity argument for ACT. The specific objectives of this paper are to: (1) examine the extent to which the 10 ACT concepts discriminate between patient care units and (2) identify variables that significantly contribute to between-unit variation for each of the 10 concepts.

Methods: 859 professional nurses (844 valid responses) working in medical, surgical and critical care units of 8 Canadian pediatric hospitals completed the ACT. A random intercept, fixed effects hierarchical linear modeling (HLM) strategy was used to quantify and explain variance in the 10 ACT concepts to establish the ACT’s ability to discriminate between units. We ran 40 models (a series of 4 models for each of the 10 concepts) in which we systematically assessed the unique contribution (i.e., error variance reduction) of different variables to between-unit variation. First, we constructed a null model in which we quantified the variance overall, in each of the concepts. Then we controlled for the contribution of individual level variables (Model 1). In Model 2, we assessed the contribution of practice specialty (medical, surgical, critical care) to variation since it was central to construction of the sampling frame for the study. Finally, we assessed the contribution of additional unit level variables (Model 3).

Results: The null model (unadjusted baseline HLM model) established that there was significant variation between units in each of the 10 ACT concepts (i.e., discrimination between units). When we controlled for individual characteristics, significant variation in the 10 concepts remained. Assessment of the contribution of specialty to between-unit variation enabled us to explain more variance (1.19% to 16.73%) in 6 of the 10 ACT concepts. Finally, when we assessed the unique contribution of the unit level variables available to us, we were able to explain additional variance (15.91% to 73.25%) in 7 of the 10 ACT concepts.

Conclusion: The findings reported here represent the third published argument for validity of the ACT and adds to the evidence supporting its use to discriminate patient care units by all 10 contextual factors. We found evidence of relationships between a variety of individual and unit-level variables that explained much of this between-unit variation for each of the 10 ACT concepts. Future research will include examination of the relationships between the ACT’s contextual factors and research utilization by nurses and ultimately the relationships between context, research utilization, and outcomes for patients.

Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context

Background and Aims: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care.

Approach: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n = 30). Observations focused on nurses’ interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses.

Findings: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration.

Implications: Nurses’ abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error.

Conclusions: Nurses displayed behaviours that increased medication administration quality and safety; however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.

An evaluation of a national program to implement the cornell scale for depression in dementia into routine practice in aged care facilities

Background: Screening tools have been recommended for use in aged care to improve the detection and treatment of depression. This study aimed to evaluate the impact of a program for the routine implementation of the Cornell Scale for Depression in Dementia in Australian facilities, to determine whether use of the instrument by nurses led to further monitoring of depressive symptoms, medical referral, and changes in treatments prescribed for depression.
Methods: A file review was completed for 412 participants out of a total of 867 older people (47.5%) who resided in ten aged care facilities. The review examined Cornell Scale assessment data, medication charts, medical history, nursing progress notes, and resident care plans. Nursing staff who administered the Cornell Scale to each participant were also interviewed, and ten facilitymanagers took part in an interview to determine barriers to the effective implementation of the instrument.
Results: The Cornell Scale had been administered to 46.8% of the sample in the previous 12 months, with 25% of these participants scoring 9–13 and 27% scoring 14 and above. Less than one third of the residents with high scores were monitored by the staff following the assessment. Only 18% of residents with high scores were referred for further assessment of depression, while 10% received a treatment change.
Conclusions: The absence of a protocol for responding to high Cornell Scale scores limited the potential of this program to result in widespread improved treatment of depressed older people. The use of the Cornell Scale by aged care nurses with limited training raised concern.