Autism : an introduction to behavioural therapy models used for autism and nursing the person with autism in the primary care setting

Childhood autism falls under the guise of autism spectrum disorders and is generally found in children over two years of age. There are of course variations in severity and clinical manifestations, however the most common features being disinterest in social interaction and engagement in ritualistic and repetitive behaviours. In Singapore the incidence of autism is on the rise as parents are becoming more aware of the early signs of autism and seek healthcare programmes to ensure the quality of life for their child is optimised. Two such programmes, Applied Behaiour Analysis and Floortime approach have proven successful in alleviating some of the behavioural and social skills problems associated with autism. Using positive behaviour reinforcement both Applied Behaviour Analysis and Floortime approach reward behaviour associated with positive social responses.

Pulmonary embolism in the emergency department : a Singaporean nursing case review

Introduction The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism. Method We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats—a single case report or a series of case reports; in this case we opted to report on a single case. Discussion The gentleman in question was an ambulance admissionto the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents. Conclusion We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.

Advanced arterial blood gas analysis in septic shock : a Singaporean nursing case review.

Introduction The admission to the Intensive Care Unit with a diagnosis of sepsis and/or septic shock is not uncommon. The aim of this article is to present a nursing case review of a patient admitted to the intensive care unit with a diagnosis of septic shock and the use of bedside acid–base formulae to inform clinical decision making. Method We chose to use a case review. This method is useful in reporting unusual or rare cases and is typically seen more in medicine than in nursing. Discussion The gentleman in question was a self-presentation with a short history of fever and worsening shortness of breath. His condition worsened where he required admission to the intensive care unit. The use of ‘advanced’ acid–base interpretation to guide his nursing care provided a platform from which to advance a deeper understanding of the intricacies the critically ill patient often presents. Conclusion The use of case review is enlightening in understanding the disease process and the decision-making that accompanies this. The lessons learnt are applicable to a wider nursing audience because understanding acid–base physiology is beneficial in supporting and advancing critical care nursing practice.

Mixed venous oxygen saturation monitoring revisited : thoughts for critical care nursing practice

Background Less invasive methods of determining cardiac output are now readily available. Using indicator dilution technique, for example has made it easier to continuously measure cardiac output because it uses the existing intra-arterial line. Therefore gone is the need for a pulmonary artery floatation catheter and with it the ability to measure left atrial and left ventricular work indices as well the ability to monitor and measure a mixed venous saturation (SvO2). Purpose The aim of this paper is to put forward the notion that SvO2 provides valuable information about oxygen consumption and venous reserve; important measures in the critically ill to ensure oxygen supply meets cellular demand. In an attempt to portray this, a simplified example of the septic patient is offered to highlight the changing pathophysiological sequelae of the inflammatory process and its importance for monitoring SvO2. Relevance to clinical practice SvO2 monitoring, it could be argued, provides the gold standard for assessing arterial and venous oxygen indices in the critically ill. For the bedside ICU nurse the plethora of information inherent in SvO2 monitoring could provide them with important data that will assist in averting potential problems with oxygen delivery and consumption. However, it has been suggested that central venous saturation (ScvO2) might be an attractive alternative to SvO2 because of its less invasiveness and ease of obtaining a sample for analysis. There are problems with this approach and these are to do with where the catheter tip is sited and the nature of the venous admixture at this site. Studies have shown that ScvO2 is less accurate than SvO2 and should not be used as a sole guiding variable for decision-making. These studies have demonstrated that there is an unacceptably wide range in variance between ScvO2 and SvO2 and this is dependent on the presenting disease, in some cases SvO2 will be significantly lower than ScvO2. Conclusion Whilst newer technologies have been developed to continuously measure cardiac output, SvO2 monitoring is still an important adjunct to clinical decision-making in the ICU. Given the information that it provides, seeking alternatives such as ScvO2 or blood samples obtained from femorally placed central venous lines, can unnecessarily lead to inappropriate treatment being given or withheld. Instead when using ScvO2, trending of this variable should provide clinical determinates that are useable for the bedside ICU nurse, remembering that in most conditions SvO2 will be approximately 16% lower.

Advancing nursing practice : redefining the theoretical and practical integration of knowledge

Aim The aim of this paper is to offer an alternative knowing-how knowing-that framework of nursing knowledge, which in the past has been accepted as the provenance of advanced practice. Background The concept of advancing practice is central to the development of nursing practice and has been seen to take on many different forms depending on its use in context. To many it has become synonymous with the work of the advanced or expert practitioner; others have viewed it as a process of continuing professional development and skills acquisition. Moreover, it is becoming closely linked with practice development. However, there is much discussion as to what constitutes the knowledge necessary for advancing and advanced practice, and it has been suggested that theoretical and practical knowledge form the cornerstone of advanced knowledge. Design The design of this article takes a discursive approach as to the meaning and integration of knowledge within the context of advancing nursing practice. Method A thematic analysis of the current discourse relating to knowledge integration models in an advancing and advanced practice arena was used to identify concurrent themes relating to the knowing-how knowing-that framework which commonly used to classify the knowledge necessary for advanced nursing practice. Conclusion There is a dichotomy as to what constitutes knowledge for advanced and advancing practice. Several authors have offered a variety of differing models, yet it is the application and integration of theoretical and practical knowledge that defines and develops the advancement of nursing practice. An alternative framework offered here may allow differences in the way that nursing knowledge important for advancing practice is perceived, developed and coordinated. Relevance to clinical practice What has inevitably been neglected is that there are various other variables which when transposed into the existing knowing-how knowing-that framework allows for advanced knowledge to be better defined. One of the more notable variables is pattern recognition, which became the focus of Benner’s work on expert practice. Therefore, if this is included into the knowing-how knowing-that framework, the knowing-how becomes the knowledge that contributes to advancing and advanced practice and the knowing-that becomes the governing action based on a deeper understanding of the problem or issue.

From expert to tasks, expert nursing practice redefined?

Aim The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

The pathophysiology of emphysema : considerations for critical care nursing practice

Emphysema is caused by exposure to cigarette smoking as well as alpha1-antitrypsin deficiency. It has been estimated to cost the National Health Service (NHS) in excess of £800 million per year in related health care costs. The challenges for Critical Care nurses are those associated with dynamic hyperinflation, Auto-PEEP, malnutrition and the weaning from invasive and non-invasive mechanical ventilation. In this paper we consider the impact of the pathophysiology of emphysema, its effects on other body systems as well as the impact acute exacerbations have when patients are admitted to the Intensive Care Unit.

Empowerment in nursing : paternalism or maternalism?

The aim of this article is to explore whether patient empowerment flourishes in the wake of current health reforms or if there is a power struggle between nursing and medicine as to what is in the patients' best interest. Shifting the balance of power from healthcare professionals to patients has become a key element of healthcare policy in England. The RCN's definition of nursing places patient empowerment as a central remit of nurses. However, achieving genuine patient empowerment is not easy and requires individuals and organizations to alter their beliefs, values and behaviours. To empower patients nurses must be in a position to share power and this may require a realignment of the traditional power base within health care. Although empowerment is often viewed on a one-to-one level between professionals and patients, for true patient empowerment to occur, issues of power and control must also be addressed at a national and political level.

Homophobia in nursing : a concept analysis.

It could be argued that the term homophobia may have an array of meanings, which makes it difficult to truly define. Therefore, the purpose of this article is to explore homophobia in nursing using concept analysis as described by Walker and Avant (1995). Definitions of homophobia in general terms will be identified together with a working definition of homophobia in nursing in order for the critical attributes to be explored and identified. The formation of model, borderline, and contrary cases will exemplify the key characteristics of what homophobia in nursing is and is not. The examination of the antecedents, consequences, and empirical referents allows for further refinement of the key attributes, which define homophobia in nursing.

Advancing Nursing Practice in Pain Management

This book showcases the development and evaluation of innovative examples of pain management initiatives by advanced practitioners. It considers each service development or community initiative both in terms of advanced practice nursing and pain management. There is a wide range of examples of innovation in pain management included - from the introduction of ketamine use in one trust, to wider issues around meeting the needs of pain management in the community. The book considers issues including use of research, education and interprofessional working in the advanced practitioner role. Each chapter looks at development of the service, challenges of implementation, evaluation of the service's success and justifying the importance of the advanced nurse in the service's achievements.

Developing a culture to support peer review of teaching in higher education

This presentation addresses issues related to leadership, academic development and scholarship of teaching and learning, and highlights research funded by the Australian Office of Learning and Teaching (OLT) designed to embed and sustain peer review of teaching within the culture of 5 Australian universities: Queensland University of Technology, University of Technology, Sydney, University of Adelaide, Curtin University, and Charles Darwin University. Peer review of teaching in higher education will be emphasised as a professional process for providing feedback on teaching and learning practice, which if sustained, can become an effective ongoing strategy for academic development (Barnard et al, 2011; Bell, 2005; Bolt and Atkinson, 2010; McGill & Beaty 2001, 1992; Kemmis & McTaggart, 2000). The research affirms that using developmental peer review models (Barnard et al, 2011; D'Andrea, 2002; Hammersley-Fletcher & Orsmond, 2004) can bring about successful implementation, especially when implemented within a distributive leadership framework (Spillane & Healey, 2010). The project’s aims and objectives were to develop leadership capacity and integrate peer review as a cultural practice in higher education. The research design was a two stage inquiry process over 2 years. The project began in July 2011 and encompassed a development and pilot phase followed by a cascade phase with questionnaire and focus group evaluation processes to support ongoing improvement and measures of outcome. Leadership development activities included locally delivered workshops complemented by the identification and support of champions. To optimise long term sustainability, the project was implemented through existing learning and teaching structures and processes within the respective partner universities. Research outcomes highlight the fundamentals of peer review of teaching and the broader contextual elements of integration, leadership and development, expressed as a conceptual model for embedding peer review of teaching within higher education. The research opens a communicative space about introduction of peer review that goes further than simply espousing its worth and introduction. The conceptual model highlights the importance of development of distributive leadership capacity, integration of policies and processes, and understanding the values, beliefs, assumptions and behaviors embedded in an organizational culture. The presentation overviews empirical findings that demonstrate progress to advance peer review requires an ‘across-the-board’ commitment to embed change, and inherently demands a process that co-creates connection across colleagues, discipline groups, and the university sector. Progress toward peer review of teaching as a cultural phenomenon can be achieved and has advantages for academic staff, scholarship, teaching evaluation and an organisation, if attention is given to strategies that influence the contexts and cultures of teaching practice. Peer review as a strategy to develop excellence in teaching is considered from a holistic perspective that by necessity encompasses all elements of an educational environment and has a focus on scholarship of teaching. The work is ongoing and has implication for policy, research, teaching development and student outcomes, and has potential application world-wide.

Linking research and practice

Understanding the key factors that influence the evidentiary basis for practice and using skills in retrieving evidence that informs practice change are essential to the development of a health professional's career, regardless of the discipline. This chapter focuses on the key links between research and practice, particularly how health professionals use various sources of evidence and new knowledge to inform and improve the effectiveness of their practice in order to benefit the health of clients. Evidence-based practice and research utilisation are two major global research/practice initiatives that form the basis for this chapter. Examples that illustrate the real-world application of these initiatives are included in the Research Alive and Case Study sections. How practice change can be facilitated within health organisations is also briefly introduced.

Good practice report : clinical teaching

Clinical experience, or experience in the ‘real world’ of practice, is a fundamental component of many health professional courses. It often involves students undertaking practical experience in clinical workplace settings, typically referred to as clinical placements, under the supervision of health professionals. Broadly speaking, the role of clinical supervisors, or teachers, is aimed at assisting students to integrate the theoretical and skills based components of the curriculum within the context of patient/client care (Erstzen et al 2009). Clinical experience also provides students with the opportunity to assimilate the attitudes, values and skills which they require to become appropriately skilled professionals in the environments in which they will eventually practise. However, clinical settings are particularly challenging learning environments for students. Unlike classroom learning, students in the clinical setting frequently find themselves involved in unplanned and often complex activities with patients and other health care providers, being supervised by a variety of clinical staff who have very different methods and styles of teaching, and negotiating bureaucratic or hierarchical structures in busy clinical workplaces where they may only be spending a limited amount of time. Kilminster et al (2007) also draw attention to tensions that may exist between the learning needs of students and the provision of quality care or need to prevent harm to the patient (e.g. Elkind et al 2007). All of these factors complicate the realisation of clinical education goals and underscore the need for effective clinical teaching practices that maximise student learning in clinical environments. This report provides a summary of work that has been achieved in relation to ALTC projects and fellowships associated with clinical teaching, and a review of scholarly publications relevant to this field. The report also makes recommendations based on issues identified and/or where further work is indicated. The projects and fellowships reviewed cover a range of discipline areas including Biology, Paramedic Practice, Clinical Exercise Physiology, Occupational Therapy, Speech Pathology, Physiotherapy, Pharmacy, Nursing and Veterinary Science. The main areas of focus cover issues related to curriculum, particularly in relation to industry expectations of ‘work-ready’ graduates and the implications for theoretical and practical, or clinical preparation; development of competency assessment tools that are nationally applicable across discipline-specific courses; and improvement of clinical learning through strategies targeting the clinical learning environment, building the teaching capacity of clinical supervisors and/or enhancing the clinical learning/teaching process.