Clinical risk management and patient safety education for nurses : a critique

Nurses have a pivotal role to play in clinical risk management (CRM) and promoting patient safety in health care domains. Accordingly, nurses need to be prepared educationally to manage clinical risk effectively when delivering patient care. Just what form the CRM and safety education of nurses should take, however, remains an open question. A recent search of the literature has revealed a surprising lack of evidence substantiating models of effective CRM and safety education for nurses. In this paper, a critical discussion is advanced on the question of CRM and safety education for nurses and the need for nurse education in this area to be reviewed and systematically researched as a strategic priority, nationally and internationally. It is a key contention of this paper that without ‘good’ safety education research it will not be possible to ensure that the educational programs that are being offered to nurses in this area are evidence-based and designed in a manner that will enable nurses to develop the capabilities they need to respond effectively to the multifaceted and complex demands that are inherent in their ethical and professional responsibilities to promote and protect patient safety and quality care in health care domains.

The emotional context of self-management in chronic illness: A qualitative study of the role of health professional support in the self-management of type 2 diabetes

Background: Support for patient self-management is an accepted role for health professionals. Little evidence exists on the appropriate basis for the role of health professionals in achieving optimum self-management outcomes. This study explores the perceptions of people with type 2 diabetes about their self-management strategies and how relationships with health professionals may support this.

Methods: Four focus groups were conducted with people with type 2 diabetes:  two with English speaking and one each with Turkish and Arabic-speaking. Transcripts from the groups were analysed drawing on grounded hermeneutics and interpretive description.

Results: We describe three conceptually linked categories of text from the focus groups based on emotional context of self management, dominant approaches to self management and support from health professionals for self management. All groups described important emotional contexts to living with and self-managing diabetes and these linked closely with how they approached their diabetes management and what they looked for from health professionals. Culture seemed an important influence in shaping these linkages.

Conclusion: Our findings suggest people construct their own individual self-management and self-care program, springing from an important emotional base. This is shaped in part by culture and in turn determines the aims each  person has in pursuing self-management strategies and the role they make available to health professionals to support them. While health professionals'  support for self-care strategies will be more congruent with patients' expectations if they explore each person's social, emotional and cultural circumstances, pursuit of improved health outcomes may involve a careful balance between supporting as well as helping shift the emotional constructs surrounding a patient life with diabetes.

Relationship of heart failure patients' knowledge, perceived barriers, and attitudes regarding low-sodium diet recommendations to adherence.

The purposes of this study were to describe heart failure patient perceptions regarding instructions received for following a low-sodium diet and the benefits, barriers, and ease and frequency of following the diet. A total of 246 patients with heart failure referred from academic medical centers in the United States and Australia participated in the study. A subset of 145 patients provided 24-hour urine samples for sodium excretion assessment. While most (80%) patients reported receiving recommendations to follow a low-sodium diet, their recall of specific instructions was poor. Although the majority (75%) reported following a low-sodium diet most or all of the time, 24-hour urine sodium excretion indicated that only 25% of patients were adherent. Patients who reported being more adherent, however, had lower urine sodium excretion levels. Attitudes regarding difficulty in and perceived benefits of following the diet were not related to sodium excretion. Data on attitudes and barriers provided guidance for strategies to improve adherence.

New teachers, professional knowledge and educational reform in New Zealand

This thesis examines the professional knowledge of new secondary school teachers in New Zealand, their negotiation of multiple discourses encountered in policy and practice, and their processes of professional identity formation. It is also a study of policy reform. In New Zealand, as elsewhere, recent educational and social reforms have brought about major changes to the way education is managed and implemented. These reforms emphasise market ideologies promoting consumer choice and responsibility, while measuring and monitoring quality and effectiveness. At the same time, the reforms attempt to alleviate social inequality. Teachers' negotiation of an accountability culture and the dominant equity policies is a major focus of this study. The study draws upon group interviews held with nine new teachers during the first two years of their teaching careers. The group interviews were designed to elicit extended narratives from individual teachers, as well as promote more interactive dialogue and reflections within the groups. Because the interviews were conducted at different points in their early careers, the study also has a longitudinal element, allowing insight into how teachers' views are formed or changed during an intense period of professional learning. Analysis of the teachers' narratives is informed by poststructural and feminist understandings of identity and knowledge and by a methodological orientation to writing as a method of enquiry. The thesis develops three main types of discussion and sets of arguments. The first examines new teachers' negotiation of the 'macro' context of teacher knowledge formation that is, their negotiation of an educational policy environment that juxtaposes an equity agenda with accountability controls. In order to historically situate these dilemmas, the particular political, social and educational context of New Zealand is examined. It is argued that teachers negotiate competing political and conceptual debates about social justice, equity and difference, and that this negotiation is central to the formation of professional knowledge. The analysis illustrates ways in which teachers make sense of equity discourses in educational policy and practice, and the apparent contradictions that arise from placing tight accountability standards on schools and teachers to achieve associated equity goals. The second type of discussion focuses on teachers' negotiation of the 'micro' dimension of professional knowledge, looking closely at the processes and practices that form professional identity. Against stage or developmental models of teacher identity, it is argued that professional identity is formed in an ongoing, uneven and fluid manner and is socially and discursively situated/embedded. It is further argued that professional knowledge and identity are entwined and that this relationship is most usefully understood through analysis of the discursive practices that frame teachers' working lives and through which teachers work out who they are or should become and what and how they (should) think. This analysis contributes new perspectives to debates in teacher education about teacher preparation and the knowledge required of teachers in current 'new times'. The final cluster of arguments brings together these macro and micro aspects of professional knowledge and identity with a case study of how new teachers negotiated a recent educational reform of senior secondary school qualifications in New Zealand. This reform has had a significant impact on secondary schools and on the way teachers, and New Zealanders in general, think about education, achievement and success. It was found that this reform significantly challenged new teachers to question their beliefs about assessment and justice in education, and what counts as success. This case study draws attention to the tensions between equity, academic excellence and standards-based assessment, and contributes to understanding how teacher professional knowledge forms both in the context of a specific educational policy reform and in relation to educational reform in general. This study contributes new knowledge to the formation of teacher professional knowledge and identity in an educational climate of change in New Zealand. The findings offer new insights for teacher educators, policymakers and schools into how teachers build, shape and sustain professional knowledge; how they juggle contradictions between a desire for justice, policy imperatives and teacher education rhetoric; the self-constructed, but contingent nature of professional knowledge and identity; and the urgency to address identity formation as part of teacher education and to take account of the dynamic ways in which identities form. These matters need to be articulated in teacher education both pre-service and in-service in order to address teacher retention and satisfaction, and teachers' commitment to equity reform in education.

Patient assessment of medication information leaflets and validation of the Evaluative Linguistic Framework (ELF)

Objective : To obtain patient feedback about the structure and quality of medication information leaflets and validate the usefulness of the Evaluative Linguistic Framework (ELF) for improving written communication with patients.
Methods : Triangulated feedback about a set of rheumatoid arthritis (RA) medication leaflets, some developed with knowledge of the ELF, was obtained from 27 people with RA from interviews, focus group discussion and self-administered questionnaires. The principal elements of the framework were investigated: overall generic structure and functions of each stage, interpersonal relationship between writer and reader, technicality of language and density of information.
Results : Participant assessments of the leaflets aligned with the framework in terms of what constituted a good leaflet. While the main purpose of the leaflets was identified as being information provision, participants also wanted clear instructions, benefits to be highlighted and side effects to be comprehensively listed. For comprehensiveness and user-friendliness, leaflets developed with guidance of the ELF were consistently preferred.
Conclusion : According to people with RA, leaflets generated from a linguistic framework are clearer and more effective in communicating information about medications.
Practice Implications : The ELF is a user-friendly, structured analytic system that can assist with the development of effective high quality patient information materials.

Perspectives of a nurse, a social-worker and a psychiatrist, regarding patient assessment in acute inpatient psychiatry settings : a case study approach

This case study explores what informs and organizes the assessment of patients, as undertaken by a nurse, a social worker and a psychiatrist in public, metropolitan, acute mental health service settings. The research data are the transcripts of in-depth interviews with three experienced practitioners, one from each of the three disciplines. The analysis draws on Foucauldian concepts: discourse as constructed through practices of discipline and the gaze. We explored examples of taken-for-granted assessment practices and their interplay with discourse. The findings suggest that participating practitioners use language in assessment in ways that support the powerful discourses of the professional disciplines. The competing discourse of management, associated with industry and economics, is evident in hospital admission processes, dictating the times and places of assessment. Professional and management discourses both effectively marginalize the perspective of another player in assessment, the patient.

Technology education, science and science education : exploring the relationship

In this paper the nature of technology education in relation to science and science education is explored. Ways forward are indicated for both technology and science in the curriculum so that the two areas can be mutually supportive. In the 1990s, when curriculum writers were attempting to provide technology a unique place in the curriculum, they tended to downplay the relationship between technology and science. One reason for this tendency derives from a perception that science is an academic and elitist discipline and technology is well served by emphasizing the distance between the two. The other reason is perhaps political, that science, by virtue of its status in the community, and the status of its special type of knowledge, would be in a position, if allowed, to subsume the new subject. There are philosophical and historical precedents that justify such a concern. In tracing the historical relationships between science and technology, in professional practice, in philosophical positioning, and in school curriculum, we inevitably need to deal with the politics of school subjects.

The position taken in this paper is that science and technology are different, both in their epistemological foundations, and in the nature of the professional communities and the concerns of individual practitioners within the two areas. In clarifying these differences the essential nature of technology and of science are illuminated. The paper also explores ways in which the two areas can benefit from each other’s existence in the curriculum, and ways of approaching teaching that both clarifies the special nature of each type of knowledge, and allows them to be mutually supportive. This may necessitate a reconstruction of the nature of school science.

The relationship between stress and the symptomatology of fibromyalgia

Fibromyalgia is an unexplained but often debilitating syndrome, characterised primarily by widespread pain. This thesis provides direct evidence that physical and emotional stress exacerbates pain, fatigue and other symptoms of Fibromyalgia and supports the assertion that symptoms may be related to disordered stress-response mechanisma in the human brain. The professional portfolio presents four clinical case studies that demonstrate the utility of Acceptance and Commitment Therapy (ACT) in the psychotherapeutic treatment of people with chronic illness.

Technology effecting interorganisational relationship formation

This thesis examined the effect of emerging broadcasting technology on the formation of interorganisational relationships (IORs) between Australian-based professional football clubs and sport broadcasters. While six preconditions for IOR formation were identified, the clubs and sport broadcasters seek to retain a league-regulated environment.

Interpersonal features of talk in interpreted medical consultations

This linguistic study examined the interpersonal features of the talk between doctors and patients in consultations where a professional medical interpreter was required for them to communicate. Such features affect the relationship between doctor and patient and can impact on medical outcomes. The findings will assist interpreters and doctors in talking to patients and forms part of a larger project to develop a theory of medical interpreting.

The relationship between characteristics of context and research utilization in a pediatric setting

Background
Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.

Methods
A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses` self-reported research use and their perceived context.

Results
A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.

Conclusions
Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.

The dynamics of brand equity, co-branding and sponsorship in professional sports

Globalisation has been one of the most significant determinants of growth in the sports industry worldwide, especially with the increasing importance of brand creation, brand awareness, brand image, brand identity and brand equity. Professional sports teams have become top sports brands through leverage with major company sponsors. Sports marketers have had to become much more entrepreneurial to create competitive advantage for sports organisations and deliver relationship value to consumers. Company sponsorships are prominent drivers of brand strategy around the world. They help create an extended consumer experience and are becoming a strategic vehicle for creating co-branding partnerships between sports organisations and multinational companies. This study reports data from a survey of the top marketing and communications executives in sports and company organisations in New Zealand and as well as a qualitative content analysis of core documents and websites. The study provides insights for sports marketers seeking to: use sponsorship as a prominent driver of brand strategy; employ co-branding as a strategy to create an extended consumer experience; build strong brands through efficient co-branding articulation strategies. The study also provides recommendations for sports organisations and companies to formulate their marketing communications and brand strategies from the perspective of a co-branding relationship.

Nursing and justice as a basic human need

This paper explores the idea that justice is a basic human need akin to those famously depicted in Maslow’s hierarchy of human needs and, as such, warrants recognition as a core element in representative ideas about nursing. Early nurse theorists positioned the principles and practice of nursing as having their origins in ‘universal human needs’. The principle of deriving nursing care from human needs was thought to provide a guide not only for promoting health, but for preventing disease and illness. The nursing profession has had a longstanding commitment to social justice as a core professional value and ideal, obligating nurses to address the social conditions that undermine people’s health.The idea of justice as a universal human need per se and its possible relationship to people’s health outcomes has, however, not been considered. One reason for this is that justice in nursing discourse has more commonly been associated with law and ethics, and the legal and ethical responsibilities of nurses in relation to individualized patient care and, more recently, changing systems of care to improve health and health outcomes. Although this association is not incorrect, it is incomplete.A key aim of this paper is to redress this oversight and to encourage a broader conceptualization of justice as necessary for human survival, health and development, not merely as a professional value, or legal or ethical principle for guiding human conduct.

Conceptualising health literacy from the patient perspective

Objective : A person's health literacy, i.e., their ability to seek, understand and use health information, is a critical determinant of whether they are able to actively participate in their healthcare. The objective of this study was to conceptualise health literacy from the patient perspective.

Methods : Using comprehensive qualitative methods 48 individuals were interviewed across three distinct groups in Australia: those with a chronic condition, the general community and individuals who had recently presented to a metropolitan public hospital emergency department. Purposeful sampling was employed to ensure a range of experiences was captured.

Results : Seven key abilities were identified: knowing when to seek health information; knowing where to seek health information; verbal communication skills; assertiveness; literacy skills; capacity to process and retain information; application skills.

Conclusion : This study identifies key abilities patients identified as critical to seek, understand and utilise information in the healthcare setting. These abilities are not reflected in existing measures for health literacy. Future measures of health literacy could consider incorporating abilities identified in this study and may provide guidance in developing health interventions to assist patients to participate effectively in their health.

Practice implications : More comprehensive measures to assess patient's health literacy are needed.

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.