Development and evaluation of an integrated clinical learning model to inform continuing education for acute care nurses

Background Significant ongoing learning needs for nurses have occurred as a direct result of the continuous introduction of technological innovations and research developments in the healthcare environment. Despite an increased worldwide emphasis on the importance of continuing education, there continues to be an absence of empirical evidence of program and session effectiveness. Few studies determine whether continuing education enhances or develops practice and the relative cost benefits of health professionals’ participation in professional development. The implications for future clinical practice and associated educational approaches to meet the needs of an increasingly diverse multigenerational and multicultural workforce are also not well documented. There is minimal research confirming that continuing education programs contribute to improved patient outcomes, nurses’ earlier detection of patient deterioration or that standards of continuing competence are maintained. Crucially, evidence-based practice is demonstrated and international quality and safety benchmarks are adhered to. An integrated clinical learning model was developed to inform ongoing education for acute care nurses. Educational strategies included the use of integrated learning approaches, interactive teaching concepts and learner-centred pedagogies. A Respiratory Skills Update education (ReSKU) program was used as the content for the educational intervention to inform surgical nurses’ clinical practice in the area of respiratory assessment. The aim of the research was to evaluate the effectiveness of implementing the ReSKU program using teaching and learning strategies, in the context of organisational utility, on improving surgical nurses’ practice in the area of respiratory assessment. The education program aimed to facilitate better awareness, knowledge and understanding of respiratory dysfunction in the postoperative clinical environment. This research was guided by the work of Forneris (2004), who developed a theoretical framework to operationalise a critical thinking process incorporating the complexities of the clinical context. The framework used educational strategies that are learner-centred and participatory. These strategies aimed to engage the clinician in dynamic thinking processes in clinical practice situations guided by coaches and educators. Methods A quasi experimental pre test, post test non–equivalent control group design was used to evaluate the impact of the ReSKU program on the clinical practice of surgical nurses. The research tested the hypothesis that participation in the ReSKU program improves the reported beliefs and attitudes of surgical nurses, increases their knowledge and reported use of respiratory assessment skills. The study was conducted in a 400 bed regional referral public hospital, the central hub of three smaller hospitals, in a health district servicing the coastal and hinterland areas north of Brisbane. The sample included 90 nurses working in the three surgical wards eligible for inclusion in the study. The experimental group consisted of 36 surgical nurses who had chosen to attend the ReSKU program and consented to be part of the study intervention group. The comparison group included the 39 surgical nurses who elected not to attend the ReSKU program, but agreed to participate in the study. Findings One of the most notable findings was that nurses choosing not to participate were older, more experienced and less well educated. The data demonstrated that there was a barrier for training which impacted on educational strategies as this mature aged cohort was less likely to take up educational opportunities. The study demonstrated statistically significant differences between groups regarding reported use of respiratory skills, three months after ReSKU program attendance. Between group data analysis indicated that the intervention group’s reported beliefs and attitudes pertaining to subscale descriptors showed statistically significant differences in three of the six subscales following attendance at the ReSKU program. These subscales included influence on nursing care, educational preparation and clinical development. Findings suggest that the use of an integrated educational model underpinned by a robust theoretical framework is a strong factor in some perceptions of the ReSKU program relating to attitudes and behaviour. There were minimal differences in knowledge between groups across time. Conclusions This study was consistent with contemporary educational approaches using multi-modal, interactive teaching strategies and a robust overarching theoretical framework to support study concepts. The construct of critical thinking in the clinical context, combined with clinical reasoning and purposeful and collective reflection, was a powerful educational strategy to enhance competency and capability in clinicians.

The relationship between building characteristics and the chemical composition of surface films found on glass windows in Brisbane, Australia

Films found on the windows of residential buildings have been studied. The main aim of the paper was to assess the roles of the films in the accumulation of potentially toxic chemicals in residential buildings. Thus the elemental and polycyclic aromatic hydrocarbon compositions of the surface films from the glass windows of eighteen residential buildings were examined. The presence of sample amounts of inorganic elements (4.0–1.2 × 106 μg m−2) and polycyclic aromatic hydrocarbons in the films (BDL - 620.1 ng m−2) has implications for human exposure and the fate of pollutants in the urban environment. To facilitate the interpretation of the results, data matrices consisting of the chemical composition of the films and the building characteristics were subjected to multivariate data analysis methods, and these revealed that the accumulation of the chemicals was strongly dependent on building characteristics such as the type of glass used for the window, the distance from a major road, age of the building, distance from an industrial activity, number of smokers in the building and frequency of cooking in the buildings. Thus, building characteristics which minimize the accumulation of pollutants on the surface films need to be encouraged.

Design of experiments for bivariate binary responses modelled by Copula functions

Optimal design for generalized linear models has primarily focused on univariate data. Often experiments are performed that have multiple dependent responses described by regression type models, and it is of interest and of value to design the experiment for all these responses. This requires a multivariate distribution underlying a pre-chosen model for the data. Here, we consider the design of experiments for bivariate binary data which are dependent. We explore Copula functions which provide a rich and flexible class of structures to derive joint distributions for bivariate binary data. We present methods for deriving optimal experimental designs for dependent bivariate binary data using Copulas, and demonstrate that, by including the dependence between responses in the design process, more efficient parameter estimates are obtained than by the usual practice of simply designing for a single variable only. Further, we investigate the robustness of designs with respect to initial parameter estimates and Copula function, and also show the performance of compound criteria within this bivariate binary setting.

Bayesian methodology for genetics of complex diseases

Genetic research of complex diseases is a challenging, but exciting, area of research. The early development of the research was limited, however, until the completion of the Human Genome and HapMap projects, along with the reduction in the cost of genotyping, which paves the way for understanding the genetic composition of complex diseases. In this thesis, we focus on the statistical methods for two aspects of genetic research: phenotype definition for diseases with complex etiology and methods for identifying potentially associated Single Nucleotide Polymorphisms (SNPs) and SNP-SNP interactions. With regard to phenotype definition for diseases with complex etiology, we firstly investigated the effects of different statistical phenotyping approaches on the subsequent analysis. In light of the findings, and the difficulties in validating the estimated phenotype, we proposed two different methods for reconciling phenotypes of different models using Bayesian model averaging as a coherent mechanism for accounting for model uncertainty. In the second part of the thesis, the focus is turned to the methods for identifying associated SNPs and SNP interactions. We review the use of Bayesian logistic regression with variable selection for SNP identification and extended the model for detecting the interaction effects for population based case-control studies. In this part of study, we also develop a machine learning algorithm to cope with the large scale data analysis, namely modified Logic Regression with Genetic Program (MLR-GEP), which is then compared with the Bayesian model, Random Forests and other variants of logic regression.

Exploration and optimization of user experience in viewing videos on a mobile phone

Compared with viewing videos on PCs or TVs, mobile users have different experiences in viewing videos on a mobile phone due to different device features such as screen size and distinct usage contexts. To understand how mobile user’s viewing experience is impacted, we conducted a field user study with 42 participants in two typical usage contexts using a custom-designed iPhone application. With user’s acceptance of mobile video quality as the index, the study addresses four influence aspects of user experiences, including context, content type, encoding parameters and user profiles. Accompanying the quantitative method (acceptance assessment), we used a qualitative interview method to obtain a deeper understanding of a user’s assessment criteria and to support the quantitative results from a user’s perspective. Based on the results from data analysis, we advocate two user-driven strategies to adaptively provide an acceptable quality and to predict a good user experience, respectively. There are two main contributions from this paper. Firstly, the field user study allows a consideration of more influencing factors into the research on user experience of mobile video. And these influences are further demonstrated by user’s opinions. Secondly, the proposed strategies — user-driven acceptance threshold adaptation and user experience prediction — will be valuable in mobile video delivery for optimizing user experience.

A pilot study assessing the feasibility of a home-based progressive resistance exercise program and trend toward healing rates for patients with venous leg ulcers

Venous leg ulceration is a serious condition affecting 1 – 3% of the population. Decline in the function of the calf muscle pump is correlated with venous ulceration. Many previous studies have reported an improvement in the function of the calf muscle pump, endurance of the calf muscle and increased range of ankle motion after structured exercise programs. However, there is a paucity of published research that assesses if these improvements result in an improvement in the healing rates of venous ulcers. The primary purpose of this pilot study was to establish the feasibility of a homebased progressive resistance exercise program and examine if there was any clinical significance or trend toward healing. The secondary aims were to examine the benefit of a home-based progressive resistance exercise program on calf muscle pump function and physical parameters. The methodology used was a randomised controlled trial where eleven participants were randomised into an intervention (n = 6) or control group (n = 5). Participants who were randomised to receive a 12-week home-based progressive resistance exercise program were instructed through weekly face-to-face consultations during their wound clinic appointment by the author. Control group participants received standard wound care and compression therapy. Changes in ulcer parameters were measured fortnightly at the clinic (number healed at 12 weeks, percentage change in area and pressure ulcer score healing score). An air plethysmography test was performed at baseline and following the 12 weeks of training to determine changes in calf muscle pump function. Functional measures included maximum number of heel raises (endurance), maximal isometric plantar flexion (strength) and range of ankle motion (ROAM); these tests were conducted at baseline, week 6 and week 12. The sample for the study was drawn from the Princess Alexandra Hospital in Brisbane, Australia. Participants with venous leg ulceration who met the inclusion criteria were recruited. The participants were screened via duplex scanning and ankle brachial pressure index (ABPI) to ensure they did not have any arterial complications. Participants were excluded if there was evidence of cellulitis. Demographic data were obtained from each participant and details regarding medical history, quality of life and geriatric depression scores were collected at baseline. Both the intervention and control group were required to complete a weekly exercise diary to monitor activity levels between groups. To test for the effect of the intervention over time, a repeated measures analysis of variance was conducted on the major outcome variables. Group (intervention versus control) was the between subject factor and time (baseline, week 6, week 12) was the within subject or repeated measures factor. Due to the small sample size, further tests were conducted to check the assumptions of the statistical test to be used. The results showed that Mauchly.s Test, the Sphericity assumptions of repeated measures for ANOVA were met. Further tests of homogeneity of variance assumptions also confirmed that this assumption was met. Data analysis was conducted using the software package SPSS for Windows Release 17.0. The pilot study proved feasible with all of the intervention (n=6) participants continuing with the resistance program for the 12 week duration and no deleterious effects noted. Clinical significance was observed in the intervention group with a 32% greater change in ulcer size (p= 0.26) than the control group, and a 10% (p = 0.74) greater difference between the numbers healed compared to the control group. Statistical significance was observed for the ejection fraction (p = 0.05), residual volume fraction (p = 0.04) and ROAM (p = 0.01), which all improved significantly in the intervention group over time. These results are encouraging, nevertheless, further investigations seem warranted to examine the effect exercise has on the healing rates of venous leg ulcers, with a multistudy site, larger sample size and longer follow up period.

Recognition of expertise : an important concept in the acquisition of nephrology nursing expertise

The present article, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept of recognition of expertise. The study used grounded theory methodology and involved 17 registered nurses who were practising in a metropolitan renal unit in New South Wales, Australia. Concurrent data collection and analysis was undertaken, incorporating participant observations and interviews. According to nurses in this study, patients, doctors and other nurses recognized that some nurses were experts while others were not. In addition, being trusted, being a role model and teaching others were important components of being recognized as an expert nephrology nurse. Of importance for nursing, the results of the present study indicate that knowledge and experience are not sufficient to ensure expert practice; recognition of expertise by others is an important function of expertise acquisition.

Producing the magnum opus : A metaphor for nephrology nursing expertise acquisition

Aim. This paper elucidates the nature of metaphor and the conditions necessary to its use as an analytic device in qualitative research, and describes how the use of metaphor assisted in the analytic processes of a grounded theory study of nephrology nursing expertise. Background. The use of metaphor is pervasive in everyday thought, language and action. It is an important means for the comprehension and management of everyday life, and makes challenging or problematic concepts easier to explain. Metaphors are also pervasive in quantitative and qualitative research for the same reason. In both everyday life and in research, their use may be implicit or explicit. Methods. The study using grounded theory methodology took place in one renal unit in New South Wales, Australia between 1999 and 2000 and included six non-expert and 11 expert nurses. It involved simultaneous data collection and analysis using participant observation, semi-structured interviews and review of nursing documentation. Findings. A three stage skills-acquisitive process was identified in which an orchestral metaphor was used to explain the relationships between stages and to satisfactorily capture the data coded within each stage. Conclusion. Metaphors create images, clarify and add depth to meanings and, if used appropriately and explicitly in qualitative research, can capture data at highly conceptual levels. Metaphors also assist in explaining the relationship between findings in a clear and coherent manner. © 2005 Blackwell Publishing Ltd.

Implicit online learning

Online learning algorithms have recently risen to prominence due to their strong theoretical guarantees and an increasing number of practical applications for large-scale data analysis problems. In this paper, we analyze a class of online learning algorithms based on fixed potentials and nonlinearized losses, which yields algorithms with implicit update rules. We show how to efficiently compute these updates, and we prove regret bounds for the algorithms. We apply our formulation to several special cases where our approach has benefits over existing online learning methods. In particular, we provide improved algorithms and bounds for the online metric learning problem, and show improved robustness for online linear prediction problems. Results over a variety of data sets demonstrate the advantages of our framework.

Measurement of total body water (TBW) and total energy expenditure (TEE) using stable isotopes

Understanding the relationship between diet, physical activity and health in humans requires accurate measurement of body composition and daily energy expenditure. Stable isotopes provide a means of measuring total body water and daily energy expenditure under free-living conditions. While the use of isotope ratio mass spectrometry (IRMS) for the analysis of 2H (Deuterium) and 18O (Oxygen-18) is well established in the field of human energy metabolism research, numerous questions remain regarding the factors which influence analytical and measurement error using this methodology. This thesis was comprised of four studies with the following emphases. The aim of Study 1 was to determine the analytical and measurement error of the IRMS with regard to sample handling under certain conditions. Study 2 involved the comparison of TEE (Total daily energy expenditure) using two commonly employed equations. Further, saliva and urine samples, collected at different times, were used to determine if clinically significant differences would occur. Study 3 was undertaken to determine the appropriate collection times for TBW estimates and derived body composition values. Finally, Study 4, a single case study to investigate if TEE measures are affected when the human condition changes due to altered exercise and water intake. The aim of Study 1 was to validate laboratory approaches to measure isotopic enrichment to ensure accurate (to international standards), precise (reproducibility of three replicate samples) and linear (isotope ratio was constant over the expected concentration range) results. This established the machine variability for the IRMS equipment in use at Queensland University for both TBW and TEE. Using either 0.4mL or 0.5mL sample volumes for both oxygen-18 and deuterium were statistically acceptable (p>0.05) and showed a within analytical variance of 5.8 Delta VSOW units for deuterium, 0.41 Delta VSOW units for oxygen-18. This variance was used as “within analytical noise” to determine sample deviations. It was also found that there was no influence of equilibration time on oxygen-18 or deuterium values when comparing the minimum (oxygen-18: 24hr; deuterium: 3 days) and maximum (oxygen-18: and deuterium: 14 days) equilibration times. With regard to preparation using the vacuum line, any order of preparation is suitable as the TEE values fall within 8% of each other regardless of preparation order. An 8% variation is acceptable for the TEE values due to biological and technical errors (Schoeller, 1988). However, for the automated line, deuterium must be assessed first followed by oxygen-18 as the automated machine line does not evacuate tubes but merely refills them with an injection of gas for a predetermined time. Any fractionation (which may occur for both isotopes), would cause a slight elevation in the values and hence a lower TEE. The purpose of the second and third study was to investigate the use of IRMS to measure the TEE and TBW of and to validate the current IRMS practices in use with regard to sample collection times of urine and saliva, the use of two TEE equations from different research centers and the body composition values derived from these TEE and TBW values. Following the collection of a fasting baseline urine and saliva sample, 10 people (8 women, 2 men) were dosed with a doubly labeled water does comprised of 1.25g 10% oxygen-18 and 0.1 g 100% deuterium/kg body weight. The samples were collected hourly for 12 hrs on the first day and then morning, midday, and evening samples were collected for the next 14 days. The samples were analyzed using an isotope ratio mass spectrometer. For the TBW, time to equilibration was determined using three commonly employed data analysis approaches. Isotopic equilibration was reached in 90% of the sample by hour 6, and in 100% of the sample by hour 7. With regard to the TBW estimations, the optimal time for urine collection was found to be between hours 4 and 10 as to where there was no significant difference between values. In contrast, statistically significant differences in TBW estimations were found between hours 1-3 and from 11-12 when compared with hours 4-10. Most of the individuals in this study were in equilibrium after 7 hours. The TEE equations of Prof Dale Scholler (Chicago, USA, IAEA) and Prof K.Westerterp were compared with that of Prof. Andrew Coward (Dunn Nutrition Centre). When comparing values derived from samples collected in the morning and evening there was no effect of time or equation on resulting TEE values. The fourth study was a pilot study (n=1) to test the variability in TEE as a result of manipulations in fluid consumption and level of physical activity; the magnitude of change which may be expected in a sedentary adult. Physical activity levels were manipulated by increasing the number of steps per day to mimic the increases that may result when a sedentary individual commences an activity program. The study was comprised of three sub-studies completed on the same individual over a period of 8 months. There were no significant changes in TBW across all studies, even though the elimination rates changed with the supplemented water intake and additional physical activity. The extra activity may not have sufficiently strenuous enough and the water intake high enough to cause a significant change in the TBW and hence the CO2 production and TEE values. The TEE values measured show good agreement based on the estimated values calculated on an RMR of 1455 kcal/day, a DIT of 10% of TEE and activity based on measured steps. The covariance values tracked when plotting the residuals were found to be representative of “well-behaved” data and are indicative of the analytical accuracy. The ratio and product plots were found to reflect the water turnover and CO2 production and thus could, with further investigation, be employed to identify the changes in physical activity.

Assessment policy change in relation to English language teaching and learning in China : a study of perspectives from two universities

In response to concerns about the quality of English Language Learning (ELL) education at tertiary level, the Chinese Ministry of Education (CMoE) launched the College English Reform Program (CERP) in 2004. By means of a press release (CMoE, 2005) and a guideline document titled College English Curriculum Requirements (CECR) (CMoE, 2007), the CERP proposed two major changes to the College English assessment policy, which were: (1) the shift to optional status for the compulsory external test, the College English Test Band 4 (CET4); and (2) the incorporation of formative assessment into the existing summative assessment framework. This study investigated the interactions between the College English assessment policy change, the theoretical underpinnings, and the assessment practices within two Chinese universities (one Key University and one Non-Key University). It adopted a sociocultural theoretical perspective to examine the implementation process as experienced by local actors of institutional and classroom levels. Systematic data analysis using a constant comparative method (Merriam, 1998) revealed that contextual factors and implementation issues did not lead to significant differences in the two cases. Lack of training in assessment and the sociocultural factors such as the traditional emphasis on the product of learning and hierarchical teacher/students relationship are decisive and responsible for the limited effect of the reform.

Teachers’ and parents’ perspectives of digital technology in the lives of young children

The pervasiveness of technology in the 21st Century has meant that adults and children live in a society where digital devices are integral to their everyday lives and participation in society. How we communicate, learn, work, entertain ourselves, and even shop is influenced by technology. Therefore, before children begin school they are potentially exposed to a range of learning opportunities mediated by digital devices. These devices include microwaves, mobile phones, computers, and console games such as Playstations® and iPods®. In Queensland preparatory classrooms and in the homes of these children, teachers and parents support and scaffold young children’s experiences, providing them with access to a range of tools that promote learning and provide entertainment. This paper examines teachers’ and parents’ perspectives and considers whether they are techno-optimists who advocate for and promote the inclusion of digital technology, or whether they are they techno-pessimists, who prefer to exclude digital devices from young children’s everyday experiences. An exploratory, single case study design was utilised to gather data from three teachers and ten parents of children in the preparatory year. Teacher data was collected through interviews and email correspondence. Parent data was collected from questionnaires and focus groups. All parents who responded to the research invitation were mothers. The results of data analysis identified a misalignment among adults’ perspectives. Teachers were identified as techno-optimists and parents were identified as techno-pessimists with further emergent themes particular to each category being established. This is concerning because both teachers and mothers influence young children’s experiences and numeracy knowledge, thus, a shared understanding and a common commitment to supporting young children’s use of technology would be beneficial. Further research must investigate fathers’ perspectives of digital devices and the beneficial and detrimental roles that a range of digital devices, tools, and entertainment gadgets play in 21st Century children’s lives.

Understanding the phenomenon of IS success in China through the lens of the IS-Impact model

This study is conducted within the IS-Impact Research Track at Queensland University of Technology (QUT). The goal of the IS-Impact Track is, “to develop the most widely employed model for benchmarking information systems in organizations for the joint benefit of both research and practice” (Gable et al, 2006). IS-Impact is defined as “a measure at a point in time, of the stream of net benefits from the IS, to date and anticipated, as perceived by all key-user-groups” (Gable Sedera and Chan, 2008). Track efforts have yielded the bicameral IS-Impact measurement model; the “impact” half includes Organizational-Impact and Individual-Impact dimensions; the “quality” half includes System-Quality and Information-Quality dimensions. The IS-Impact model, by design, is intended to be robust, simple and generalizable, to yield results that are comparable across time, stakeholders, different systems and system contexts. The model and measurement approach employ perceptual measures and an instrument that is relevant to key stakeholder groups, thereby enabling the combination or comparison of stakeholder perspectives. Such a validated and widely accepted IS-Impact measurement model has both academic and practical value. It facilitates systematic operationalization of a main dependent variable in research (IS-Impact), which can also serve as an important independent variable. For IS management practice it provides a means to benchmark and track the performance of information systems in use. The objective of this study is to develop a Mandarin version IS-Impact model, encompassing a list of China-specific IS-Impact measures, aiding in a better understanding of the IS-Impact phenomenon in a Chinese organizational context. The IS-Impact model provides a much needed theoretical guidance for this investigation of ES and ES impacts in a Chinese context. The appropriateness and soundness of employing the IS-Impact model as a theoretical foundation are evident: the model originated from a sound theory of IS Success (1992), developed through rigorous validation, and also derived in the context of Enterprise Systems. Based on the IS-Impact model, this study investigates a number of research questions (RQs). Firstly, the research investigated what essential impacts have been derived from ES by Chinese users and organizations [RQ1]. Secondly, we investigate which salient quality features of ES are perceived by Chinese users [RQ2]. Thirdly, we seek to answer whether the quality and impacts measures are sufficient to assess ES-success in general [RQ3]. Lastly, the study attempts to address whether the IS-Impact measurement model is appropriate for Chinese organizations in terms of evaluating their ES [RQ4]. An open-ended, qualitative identification survey was employed in the study. A large body of short text data was gathered from 144 Chinese users and 633 valid IS-Impact statements were generated from the data set. A generally inductive approach was applied in the qualitative data analysis. Rigorous qualitative data coding resulted in 50 first-order categories with 6 second-order categories that were grounded from the context of Chinese organization. The six second-order categories are: 1) System Quality; 2) Information Quality; 3) Individual Impacts;4) Organizational Impacts; 5) User Quality and 6) IS Support Quality. The final research finding of the study is the contextualized Mandarin version IS-Impact measurement model that includes 38 measures organized into 4 dimensions: System Quality, information Quality, Individual Impacts and Organizational Impacts. The study also proposed two conceptual models to harmonize the IS-Impact model and the two emergent constructs – User Quality and IS Support Quality by drawing on previous IS effectiveness literatures and the Work System theory proposed by Alter (1999) respectively. The study is significant as it is the first effort that empirically and comprehensively investigates IS-Impact in China. Specifically, the research contributions can be classified into theoretical contributions and practical contributions. From the theoretical perspective, through qualitative evidence, the study test and consolidate IS-Impact measurement model in terms of the quality of robustness, completeness and generalizability. The unconventional research design exhibits creativity of the study. The theoretical model does not work as a top-down a priori seeking for evidence demonstrating its credibility; rather, the study allows a competitive model to emerge from the bottom-up and open-coding analysis. Besides, the study is an example extending and localizing pre-existing theory developed in Western context when the theory is introduced to a different context. On the other hand, from the practical perspective, It is first time to introduce prominent research findings in field of IS Success to Chinese academia and practitioner. This study provides a guideline for Chinese organizations to assess their Enterprise System, and leveraging IT investment in the future. As a research effort in ITPS track, this study contributes the research team with an alternative operationalization of the dependent variable. The future research can take on the contextualized Mandarin version IS-Impact framework as a theoretical a priori model, further quantitative and empirical testing its validity.