Nursing - Theses
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ItemSelf-treatment of wounds: a mixed methods study( 2016)A chronic wound is a disruption of the structure and function of the skin associated with protracted healing. Chronic wounds affect 2% of Australians and cost US$2.85 billion per annum. Chronic wounds have a negative effect on the physical, emotional, social, lifestyle and financial domains of quality of life. Wound treatment involves wound assessment, wound cleansing, debridement of devitalised tissue and the application of wound dressings. Individuals often seek professional services for wound treatment, however the researchers experience and some published evidence suggests that patients sometimes self-treat. Successful self-treatment of chronic wounds has the potential to improve wound healing and the individual’s well-being. A self-care approach to wound treatment may also help to relieve pressure on healthcare services and reduce the economic burden of this condition. The aim of this research was to investigate self-treatment of chronic wounds among people living in the community to inform the development of educational resources and supports for this group. The objectives of this research were to describe the characteristics of people who self-treat, to determine their self-treatment practices and to explore the effect of self-treatment on quality of life. A sequential explanatory design mixed methods study was conducted in Australia and Wales. Data collection involved participants completing one survey (n=113), and a sub-group of the sample completed one in-depth interview (n=25), and one observation of their self-treatment (n=8). The sample was 63.6 years of age on average, self-treated wounds that were 109 weeks duration on average and more than three quarters (n=89, 78.8%) had a leg wound. Health-related quality of life was sub-optimal, 6/10 (ave.) according to the Cardiff Wound Impact Schedule. The majority of self-treaters reported conducting wound cleansing (n=103, 91.2%), wound dressing removal (n=101, 89.4%), wound dressing application (n=100, 88.5%), and wound assessment (n=94, 83.2%). Wound imaging (n=38, 33.6%) and wound debridement (n=46, 40.7%) were conducted by less than half of the sample. The most common reasons for self-treating were to be independent (n=66, 58.4%) and to do the treatment at a time that suited (n=62, 56.6%). Few self-treaters reported receiving structured education to assist them to self-treat (n=6, 5.3%). Self-treaters had spent on average AU$2475 on wound dressing products since the wound started, and AU$121.82 in the most recent 4 weeks which represented 12% of their disposable income. Observations of self-treatment identified that participants conducted the above mentioned self-treatment activities however often not in the most effective manner. The interviews conducted in this study suggested that the effect of self-treatment on quality of life was mainly positive, in particular it improved pain, reduced worry about infection, had financial benefits, and allowed the individual to recapture time lost when receiving professional care. This research has demonstrated the need to develop educational resources and supports for people who self-treat chronic wounds. These resources should include a tool to appraise self-treatment capacity and an e-learning education program to teach patients and their significant other how to self-treat. These resources also have the potential to guide and standardise the practices of healthcare professionals who educate and support self-treaters, and encourage a shared care approach to this self-treatment practice.
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ItemMissed nursing care - a nurse's perspective: an exploratory study into the who, what and why of missed care( 2016)BACKGOUND: Exploration of missed or delayed nursing care has become increasingly prevalent in international nursing literature over the past ten years. Evidence demonstrates that missed nursing care, or care that is left undone or passed on to the following shift, is common and the factors that lead to missed care are complex and numerous. Critically, patients report poorer experiences of care in hospitals where more nursing care is left undone. Despite strong international evidence, there has been little research to explore missed nursing care in Australia, and no papers focusing specifically on missed nursing care in the cancer setting. The aims of this study were to (i) explore nurses’ perceptions of what care is missed in one haematology/oncology in-patient setting in Victoria, Australia, and (ii) to identify factors contributing to missed care. METHODS: This study employed an exploratory mixed-methods approach that included an on-line survey of nurses’ views of missed care and factors leading to missed care, a description of the environment of care during the data collection period, and focus groups to explore, in depth, factors nurses believe result in missed care. RESULTS: Survey data were collected from 17 of 50 eligible nurses (34%) working on a haematology/oncology ward over a three week period in September, 2015. During the data collection period, 103 patients were cared for on the ward. The most common areas of missed care reported were: talking to patients (n=15, 88.2%), developing and updating nursing care plans (n=13, 76.5%), and educating patients and family (n=11, 64.7%). Data from the focus groups indicated acute awareness of missed care and multiple factors leading to missed care were identified. These included staff skill mix, organisation of nursing work, and non-nursing duties that detracted from time with patients. During the focus groups, nurses described considerable discomfort at being unable to provide emotional care they wanted to deliver to patients and their families. They also talked about the inability to take care of themselves. CONCLUSION: This preliminary, exploratory study offers an insight into missed nursing care and its consequences on patients and nurses in one Australian cancer setting. Data reflect the findings of earlier international studies and indicated potentially modifiable factors for reduction of missed nursing care. Multi-site research is needed to further explore missed care in cancer settings to better understand and make recommendations for optimal environments of care, caring and staff wellbeing.
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ItemHow do patients with lung cancer experience radiation induced oesophagitis?( 2016)Patients with lung cancer who receive radiotherapy to their chest may experience the specific treatment toxicity of radiation induced oesophagitis (RIO) if the oesophagus is included in the radiotherapy treatment field. RIO causes significant pain and distress to patients. There is a lack of evidence to guide appropriate management. There is also a lack of information on how patients experience this toxicity. This qualitative, exploratory study examined the experience of RIO described by patients with lung cancer who received RT to the chest, either alone or in combination with chemotherapy. The aims of this project were to: • identify the properties and characteristics of RIO as experienced by the patient having radiotherapy to the chest for lung cancer, • understand how these properties and characteristics change over time, • understand the patient experience of ongoing symptoms following completion of radiotherapy, • identify aspects of the RIO experience amenable to nursing interventions that will assist in the management of RIO and, • establish research questions to test specific nursing interventions for RIO. The Theory of Unpleasant Symptoms (TOUS) was chosen as the conceptual framework for the development of the semi-structured interviews and analysis. Two cohorts of patients were recruited to address the research questions used in this study. Cohort 1 consisted of patients who were actively receiving cancer treatment and experiencing RIO. This cohort provided insight into the experience of RIO in the acute setting, including onset and progression. Cohort 2 consisted of patients who completed treatment for primary lung cancer within the last six months and who experienced Grade 3 RIO at some stage during their treatment. Cohort 2 provided insight into the recovery trajectory following RIO, including long term changes. Semi-structured patient interviews were used to capture the patients experience and recovery of RIO. The interviews sought to identify the properties and characteristics of the pain and swallowing difficulties as described by all patients as well as other relevant features of the experience. Content analysis was used to analyse interview data. Four patient stories were chosen from the interviews to illustrate the overall experience of RIO and recovery as a means of providing context to the findings of this study. These vignettes illustrate the increasing impact on daily life as the severity of RIO increased. The extracted statements identified from the interviews were organised into the four central predetermined categories to describe the experience of RIO: (1) pain, (2) swallowing, (3) management and (4) the impact or bother of the experience of RIO. TOUS provided a framework to capture the symptom dimensions of quality, intensity, duration and associated distress of RIO for each of these categories as experienced by the patients. The patient statements extracted from the interviews were organised into four categories to describe the experience of recovery from Grade 3 RIO. The four categories were (1) memory of pain and swallowing difficulties, (2) time to recovery, (3) long term effects on swallowing and (4) advice for future patients. New knowledge of RIO gained from this study shows that experience changes across the trajectory of RIO, that pain and swallowing are inter-related and require combined therapeutic approaches and that while healing occurs, some swallowing difficulty can persist for some patients.
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ItemEffectiveness of Primary Health Care Services in New Zealand for Minority Refugee Populations: A Case Study of Bhutanese Refugee Women( 2016)A significant number of people have been displaced from their country of origin and become refugees, mostly due to armed conflicts, political violence and human rights abuse. Refugees’ traumatic past and uncertain future, together with complex health needs, present significant challenges for resettlement in their host country. Bhutanese refugees are Bhutanese citizens of Nepali origin. During 1991–1992, more than 100,000 Nepali- Bhutanese became refugees. After spending more than 18 years in refugee camps in Nepal, most of these refugees have now been resettled in various countries including New Zealand and Australia. The aim of this thesis is to examine the effectiveness of primary health care services in meeting the health needs of Bhutanese refugee women resettled in New Zealand. The conceptual framework of this study was guided by the globally accepted philosophy and principles underpinning the Declaration of Alma-Ata for Primary Health Care and the Ottawa Charter for Health Promotion. This qualitative exploratory study was conducted in two phases; the first phase comprised focus group discussions with 32 Bhutanese women and eight Bhutanese men; and the second phase involved individual interviews with 12 health service providers including four general practitioners, five nurses and three midwives. All focus groups with the Bhutanese sample were completed in Nepali, and were later transcribed in Nepali and translated to English. Phase one of the study revealed that resettlement in New Zealand had mixed impacts on Bhutanese women’s health. In general, there had been an improvement in physical health, however, their self-esteem and overall mental health status had deteriorated due to compounding stressors related to their traumatic refugee journey as well as resettlement challenges that they had been enduring. In addition, these women faced a number of barriers in accessing and utilising health services in New Zealand. In phase two of the study, health professionals identified common attributes of Bhutanese women that could impact positively or negatively in addressing their health needs and articulated a number of challenges and some enablers in addressing their health needs. Overall, the findings of this study have revealed that there have been inadequacies and constraints in the provision of culturally safe and effective primary health care services to Bhutanese refugee women and provide evidence for recommendations to address these inadequacies. These findings demonstrated that although New Zealand has had a powerful and enduring primary health care policy commitment, there are limitations in the implementation of this policy in practice. While this study was undertaken with one specific group of people, the results are likely to be transferrable to other minority refugee populations. It is anticipated that the results of this study will contribute in planning and implementing future strategies to better address the health needs of minority refugee populations in New Zealand.
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ItemAn evaluation of violence risk screening at triage in one Australian emergency department( 2015)Background: There is an increasing focus in the published literature on the problem of patient violence in hospital emergency departments (ED). Patient violence negatively impacts staff safety and ultimately the quality of care provided to patients. Research and clinical practice guidelines indicate that the prevention of patient violence in hospital EDs requires a systematic process for identifying patients who are at risk; however the evidence supporting the implementation of risk screening processes in practice is limited. This research was conducted to evaluate the processes and outcomes of a violence risk screening decision support process at triage in one Australian ED. A decision support process for identifying patients at risk of becoming violent was developed and integrated into usual patient assessment practices at point of entry (triage). An evaluation of the risk screen process was then conducted to measure its influence on staff, patient, and organisational outcomes. Design : A mixed methods design incorporating both qualitative and quantitative approaches was utilised. Three studies were sequentially conducted to; explore the feasibility and need for a risk screening process, implement a brief risk screening process and evaluate its influence on the use of security and clinical responses to incidents of patent violence (Code Grey events). Setting: The study site was a level one trauma centre located in Melbourne, Australia. This ED has an annual census of 60,000 presentations with a 40% admission rate. Methods: Study One was conducted to explore the need for, and feasibility of, violence risk screening in practice. Semi-structured observations of triage nurses conducting routine patient assessments were made at the study site. In addition, a retrospective analysis of Code Grey responses matched with demographic and clinical information was performed to characterise the patients and situations in which Code Grey responses were activated. Patient and carer interviews were performed to explore the public perceptions and acceptability of violence risk screening at triage. In Study Two, the violence risk screening decision support process was developed and pilot tested. Levels of agreement between independent raters was determined using the risk screening process for a series of triage assessments. In Study Three, a before and after evaluation was conducted of the risk screening process for its influence on Code Grey responses and access to clinical care. Analysis of the predictive ability of the risk screening process including estimates of its sensitivity and specificity, likelihood ratios and predictive values were performed. Matched pair analysis compared triage nurse self-efficacy before and after the intervention. Results : In Study One structured observations of routine patient assessment at triage (N=167) found nurses used the existing triage process to identify at risk individuals. Based on their assessments the nurses identified a small number of patients requiring risk assessment (6%:10/167) This integrated approach to determining risk was observed to be used in all cases and deviated from standard operating procedure that recommended the use of pre-scripted questions. The 12-month retrospective review of Code Grey responses (N= 1959) identified a high risk group of patients who attended the ED on more than one occasion and required a Code Grey response for violence. Although this group represented 12% (105/857) of patients, they accounted for 32% (577/1796) of all Code Grey events audited. Of the 950 presentations requiring a Code Grey, 67% (639/950) were male, 66% (623/950) arrived by ambulance and 36% (350/950) were referred for a mental health assessment. Factors such as arriving escorted by police and requiring a mental health assessment significantly increased the risk of an individual having a Code Grey response while in the ED (OR=18.88; 95%CI=12.9,27.97; OR=11.68, 95%CI=9.13,14.94 respectively). Analysis of the Code Grey data showed that 25% (500/1959) of events occur at entry points to ED and 50% of a Code Grey responses occurred within the 77 minutes of arrival to the ED. Patient and carer interviews found there is a community expectation that patients at risk of violence are identified to allow an opportunity for prevention and improve safety (N=19). In Study Two, pilot testing of the risk screening process showed that triage nurses correctly identified 52% (122/233) of the patients who required a Code Grey response. Emergency department nurses (n=6) reviewed the triage notes for a sample (n=29) of patients not correctly identified at risk of violence. There was an acceptable level of agreement between triage nurses 69-82%, (kappa .25-.65). Of the 29 presentations of patients who required a Code Grey but were not identified at triage, 45% (13/29) did not have warning signs for violence at triage. In Study Three following the introduction of the violence risk screening decision support process, the proportion of Code Grey response at triage reduced from 29% before (258/904) to 22% after (200/897) implementation p<.001. The median duration of Code Grey events decreased from 14 to 13 minutes p<.009. The proportion of planned Code Greys increased from 52% (468/904) before to 62% after (556/897) p<.001. The sensitivity of the risk screening process was estimated at 56% and the specificity 97%. The total number of coercive interventions (physical restraint, medication given during the Code Grey and mechanical restraint) increased from 822 before to 1007 after p<.001. The median time from triage to first Code Grey increased from 71 minutes before (IQR=7-226) to 124 after (IQR=21-304) p<.001. Patients who required a Code Grey response were seen more quickly by medical staff (Median= 47, IQR=19-106) compared to baseline data (Median=51, IQR=14-114) p<.002. The revised violence risk screen resulted in ED nursing and medical staff being alerted to risk of violence by the electronic alert symbol for 61% (494/817) of Code Grey responses. Conclusion : On arrival to ED, the risk for violence was determined by the triage nurse using clinical judgement. This process was found to be feasible, acceptable to clinical staff, integrated into current triage processes, and reflected the public’s expectations of care. Communication of risk was facilitated using the existing clinical information system and normal work flow within the ED. High risk patient groups and locations were identified. Not all patients who require a Code Grey response were found to have observable warning signs at triage. Following the intervention there was an overall reduction in time staff engaged in emergency responses for aggression. Access to care was unchanged following the introduction of the risk screening; however the increase in the use of coercive practices following implementation of the risk screening process is of concern and warrants further exploration.
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ItemDevelopment of a guideline to inform the content of a summarized patient information form regarding cancer clinical trials( 2014)Ethical review processes support the need to present comprehensive information to enable patients with cancer make informed decisions about whether or not to participate in a clinical trial. However, evidence indicates that patients do not always understand information given to them about the requirements and purpose of clinical trials, raising concerns about the status of consent given. Researchers have attempted to enhance patients’ understanding through implementation of diverse interventions, but these have had mixed outcomes. The thesis started with a systematic review to explore the efficacy of interventions developed to improve patient understanding of clinical trials. The findings of the systematic review suggested limited impact of the interventions on patient understanding. Likely reasons for the limited success were: 1) only a small element of the communication process was addressed by the studies; 2) studies lacked a theoretical framework; 3) studies lacked a detailed description of the intervention development process; 4) studies did not draw on evidence to inform the inclusion of essential information as part of interventions being tested to enable informed consent; and 5) studies lacked reliable and valid outcome measures to measure the impact of interventions on patients’ knowledge of trial purposes and requirements. This PhD set out to develop a guideline for health professionals to inform the creation of the Summarized Patient Information Forms (SPIFs); a document designed to complement the lengthy and often complex Participant Information and Consent Forms (PICFs) given to patients eligible for cancer clinical trials. The purpose of the PhD was to develop a resource to help address documented limitations in patients’ understanding of cancer clinical trial consent forms. Habermas’ Theory of Communicative Action (TCA) was chosen as the theoretical framework to inform the study design. In Stage I, a Delphi process was adopted to generate an exhaustive list of information regarded as important to support informed clinical trial participation and then to reduce this information, through a consensus process, to essential items for inclusion in a SPIF. The Delphi consensus process produced 14 statements regarded as essential information to be included in a SPIF. Stage II involved the development of a guideline for health professionals to inform the production of a SPIF to support patients’ understanding of cancer trial participation requirements during the informed consent process. The SPIF also has the potential to support patients to ask questions or voice concerns during the informed consent process as a result of providing information in an accessible and familiar language. This PhD has produced a robust guideline for health professionals with which to inform the development of a SPIF; a short and concise document as an adjunct to the full PICF to enhance the informed consent process. Once developed, a SPIF can be used to enhance communication of essential information between health professionals and patients. The SPIF has the potential to help professionals share information in an understandable way, to ensure patients understand what clinical trial participation involves and thus, address international concerns about the status of consent currently being achieved with patients recruited to cancer clinical trials.
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Item‘SEEKING BALANCE’ Australian consumer experiences of antipsychotic discontinuation: a mixed methods study( 2014)Despite well-publicised high rates of antipsychotic discontinuation, to date little research has been conducted into the lived experience of stopping. This study uses a dialectic mixed methods approach to explore how people make sense of their attempts to stop antipsychotic medication and the societal conditions framing these attempts. In the context of an increasingly taken for granted biomedical mental illness discourse, this thesis problematises the ‘non-compliant’ consumer identity and brings into focus the complex decisional influences that underlie many discontinuation decisions. The thesis does not seek to assert a position on the value or use of antipsychotic medication, but instead tries to understand different medication related choices made by participants. This thesis responds to calls from within the consumer community for robust discussion around antipsychotic discontinuation that is framed by curiosity rather than paternalism. It is timely in light of increasing antipsychotic prescription rates, known high discontinuation rates and a lack of investment by the larger research community, to date, into peoples lived experiences during this time. The decision to focus exclusively on consumer voices reflects the transformative intent of the thesis to counterbalance both historical and contemporary experiences of consumer marginalisation from the research agenda. While the idea of this thesis sprung initially out of my work as a psychiatric nurse, I hope that its findings may be of interest to a broad range of consumers, clinicians, family members and policy makers. A dialectic mixed methodology is used to investigate both broad patterns and particularities of antipsychotic discontinuation. The preliminary self-administered survey tool, completed by 98 participants, elicited both qualitative and quantitative data relating to the context, experience and outcomes of past discontinuation attempts. In-depth interviews were then conducted with 20 of the survey respondents to develop a deeper explanatory and contextual understanding of their experiences. An Adornian critical theory approach to identity and dialectics informed the data analysis. Contrary to familiar portrayals of people who discontinue their antipsychotics as ‘lacking in insight’ or ‘non-compliant’, the majority of participants in this study described antipsychotic discontinuation as a conscious choice and were able to articulate contextualised and personally meaningful drivers behind this decision. These drivers included: problems in the therapeutic alliance; alternative mental health paradigms and treatment preferences; and the subjective balancing of cons above pros when assessing the impact of antipsychotics on life quality. Other key findings from the study included the strong secrecy and isolation that surrounded many discontinuation attempts, experiences of antipsychotic discontinuation syndromes and polarised discontinuation outcomes. The gaps between expected stereotypes of the ‘non-compliant’ or ‘insightless’ consumer and participants lived experiences are explored in terms of societal expectations of ‘proper’ patient and clinician roles, and contrasting ontological understandings of the nature of mental distress. I argue the following points in relation to practice improvement around antipsychotic discontinuation: - The widespread implicit policy of ‘zero tolerance’ to antipsychotic discontinuation described in this study may be contributing to a culture of consumer secrecy around discontinuation. - Adopting a more collaborative, transparent and consumer driven approach to discontinuation may help to decrease consumer isolation during discontinuation and mitigate potential harms. In order for such a shift to take place, however, the capacity of our mental health system to tolerate risk and support consumer choice will need to be re-imagined. - Greater research attention could be placed on antipsychotic discontinuation syndromes, and clinicians should begin to routinely provide consumers with access to this information from the point of prescription onwards. This thesis suggests that clinical focus on ‘compliance’ may not be an effective model for respectfully approaching decisions relating to antipsychotic medication. Clinicians and policy makers are invited to seek more genuinely transparent, collaborative and value-neutral pathways to support consumers who are contemplating or undertaking antipsychotic discontinuation.
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ItemIdentifying patients at high nutritional risk and assessing the feasibility of medical nutrition therapy in patients receiving radiotherapy for lung cancer( 2014)Radiotherapy to the thoracic region is associated with acute toxicities including radiation-induced oesophagitis, anorexia and fatigue which may impact on the ability to achieve an adequate nutritional intake and subsequently lead to malnutrition. Malnutrition is associated with poorer quality of life, treatment interruptions, reduced functional capacity and is an independent prognostic indicator in patients with lung cancer. The aim of this thesis was to identify the factors associated with weight loss during radiotherapy for lung cancer and to assess the feasibility and preliminary effect of an intensive, individualised nutrition intervention on nutritional, functional and fatigue outcomes. The aims of the thesis were investigated over five studies. The first two studies retrospectively analysed the prevalence and predictors of greater than or equal to 5% weight loss in patients with non-small cell (NSCLC) and small cell lung cancer (SCLC) treated with radiotherapy in two patient cohorts. Two cohorts were studied due to the availability of different clinical parameters in each cohort. These studies identified that treatment with concurrent chemotherapy (NSCLC and SCLC patients), stage III or more disease (NSCLC patients), and multiple radiotherapy dosimetric factors (NSCLC patients) were associated with greater than or equal to 5% weight loss. Of the dosimetric factors, absolute and relative length of the oesophagus receiving 60Gy to the partial circumference, were more strongly related to weight loss. The three predictive variables identified in the retrospective studies were used in the third study, the pilot validation of a model to predict nutritional risk in NSCLC patients at the commencement of radiotherapy. In NSCLC patients treated with high dose palliative or radical intent radiotherapy, stage III or more disease (model 1) had 91% sensitivity and 41% specificity for predicting greater than or equal to 5% weight loss. While in patients treated with radical intent only, the combination of stage III or more disease and concurrent chemotherapy was able to predict greater than or equal to 5% weight loss with a sensitivity of 94% and specificity of 55%. Having established a high nutritional risk associated with thoracic radiotherapy, the fourth study involved a systematic review to determine the effective methods of nutrition intervention in this population. Systematic reviews have previously been completed investigating the effect of novel agents such as omega 3 fatty acids in patients with lung cancer with the results largely inconclusive. This systematic review therefore focused on dietary counselling or oral supplements, previously found to be effective in other tumour types, and identified that insufficient evidence was available regarding the effect of dietary counselling or oral supplements during radiotherapy for lung cancer. Therefore, the final study was a pilot randomised controlled trial to assess the efficacy and feasibility of intensive, individualised dietary counselling in lung cancer patients receiving radiotherapy. The intervention arm of the study demonstrated clinically important benefits at the end of radiotherapy for nutritional, functional and fatigue outcomes compared to patients receiving usual care. High patient satisfaction with the intervention supported the feasibility of the intervention, while acceptable recruitment, consent and attrition rates supported the feasibility of the study. The studies conducted within this thesis have provided evidence that a substantial proportion of patients with lung cancer are at high nutritional risk during radiotherapy. The factors predictive of weight loss during radiotherapy for lung cancer have been identified and supported the pilot validation of models to predict nutritional risk in both high dose palliative and radically treated NSCLC patients. In the pilot randomised trial, dietary counselling improved nutritional, fatigue and functional outcomes in lung cancer patients receiving radiotherapy which is consistent with previous randomised trials of a similar intervention in other tumour types. These studies have provided insight into the lung cancer patients at highest nutritional risk and indicate these patients should be prioritised for nutritional services along with other high risk tumour types. The results indicate that further research in a larger sample is warranted, including external validation of the predictive model and a phase III trial of the intensive nutrition intervention.
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ItemA framework for developing competence( 2014)A competent healthcare workforce is essential to ensuring quality care. There are strong professional and societal expectations that nurses will be competent. Despite the importance of the topic, the most effective means through which competence develops and is assessed, remains elusive. The aim of this study was to evaluate a framework intended to promote competence in nurses new to paediatric practice. Applying the principles of program theory evaluation, a two phase, mixed method design was employed. In Phase One, a qualitative exploratory method was applied. Documents related to the Nursing Competency Framework were audited. Twelve focus groups were conducted to gain understanding of the theory thought to underpin the development of nursing competence. Phase Two enabled a subsequent evaluation to be undertaken that was informed by Phase One. Phase Two was conducted as an explanatory sequential mixed method design. In the first strand of Phase Two, a quantitative method was applied to measure the extent to which competence develops over the first six months of a graduate nurse program (GNP). A tool to measure nurse competence, the Nurse Competence Scale (NCS), was administered to 47 graduate nurses at three time points during their GNP. The second strand of Phase Two employed a qualitative design. Twenty one graduate nurses were interviewed to explain the variations in competence development in light of their results from the NCS. The Phase One findings generated a far more complicated program theory than had arisen from the preliminary audit of documents. Focus group participants articulated a range of processes that support the development of competence, created a comprehensive picture of contextual factors to be taken into consideration and drew attention to the many standards that inform competency development. Results from the NCS indicated nurses made statistically significant gains in competence in the first six months of paediatric nursing practice. The findings from the interviews, considered in combination with the theory that had emerged from Phase One and the NCS results, enabled the conceptualisation of the Framework for Developing Competence. Key elements within the Framework for Developing Competence include; the individual within the team, identification and interpretation of standards, asking questions, guidance, and engaging in endeavours, all taking place in a particular context of practice. Competence is recognised as a combination of knowledge, skills, abilities and attributes. Excellence is identified as the hoped for outcome from which nurses return back through various processes to continuously improve. Much time, energy and resources are directed at supporting the development and assessment of competence, with little evidence as to the most effective means. This study led to conceptualisation of a theory thought to underpin development of competence. The findings of this study will contribute to local, national and international knowledge related to competence both in nursing and other health professions.
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ItemFamily function and congenital heart disease( 2013)Introduction: Congenital heart disease (CHD) is one of the most common birth defects, and the most complex defects often require cardiac surgery in early infancy. Cardiac surgery typically requires intensive care unit admission. The ongoing effect on the family from having a baby with CHD that requires surgery in early infancy has been incompletely defined. Aim: To describe family function and the burden of having an infant with operated CHD, in the families of two year-olds who underwent surgery for CHD in early infancy. Method: The primary caregivers (n = 99) of young infants (less than 8 weeks of age) that required cardiac surgery in Melbourne, Australia and Auckland, New Zealand completed a series of psychosocial questionnaires assessing family function, family burden, significant life stress, and coping style when their child with CHD was 2 years old. Initial surgery complexity (RACHS-1), need for reoperation, maternal education, timing of diagnosis, and intensive care length of stay was also collected. Results: Healthy family function was found in the majority (79%), Unhealthy family function related to significant life stress (p < 0.02) and avoidance coping style (p < 0.02). Unhealthy family function did not relate to complexity of surgery, diagnostic class, need for reoperation, intensive care length of stay, or maternal education. There was a greater family burden for those with more complex lesions (single ventricle physiology with initial palliation) compared to less complex lesions (biventricular physiology requiring corrective surgery) (p < .02). Conclusion: The majority of families of two year-olds with operated CHD had healthy family function. Unhealthy family function was not related to surgical complexity, reoperation, or diagnostic class, but was related to significant life stress and coping style. Families that indicated a higher level of maternal education were more likely to utilise an adaptive style of coping. However those with a lower level of maternal education were more likely to utilise a less adaptive style of coping. Maternal education per se did not influence family function or family burden however coping style did. Family burden was greater for those that required reoperation and had a greater surgical complexity and significant life stress.