Acting in Time: Transport Nurses optimising critically ill patients for transfer to a regional ECMO centre. A Grounded Theory Study

Regionalisation and centralisation of Intensive Care Units, coupled with demographic changes, have resulted in an increased demand for inter-hospital transport. The Conventional ventilatory support vs Extracorporeal membrane oxygenation for Severe Adult Respiratory Failure Trial (CESAR), validated the use of ECMO in the UK for critically ill adults. The H1N1 Influenza A epidemic in 2009, led to four more adult ECMO centres being designated, and more recently the World Health Organisation (WHO, 2020), recommended ECMO for eligible patients in the COVID-19 pandemic. A critical incident occurred while I was undertaking the transport of a critically ill adult, which led to the unplanned use of mobile ECMO, still in its infancy. Seeking answers to the questions raised from this incident a research proposal was formed in order to investigate what could be learnt from the actions of transport nurses in promoting stability and preventing deterioration of patient acuity during the transport process. A grounded theory approach was used to try and understand the processes and strategies that experienced transport nurses used in optimising their patients’ stability and generate a substantive theory in explaining their timely actions. Under a pragmatic paradigm, this grounded theory study utilised the methods of Retrospective Medical Records Review and Interviews. Quantitative random sampling of 50 patients retrieved to a regional ECMO centre, allowed the collection of vital physiological variables staged over three time points. Data analysis showed that two out of the eight variables demonstrated a statistical significance in deterioration. Qualitative unstructured interviews from six transport nurses revealed a variety of activities, proactive and reactive, cognitive and physical, with overwhelming attention to time constraints, employed to benefit the patient. An explanatory theory was identified. Acting in Time encapsulated extant theory from the Secure Base Model (SBM) in fostering studies, and the Actor-Network Theory (ANT), from sociological literature. Acting in Time made overt the core virtues, practices, and skills of the transport nurse in aiming to reduce the risks associated will transport of the critically ill adult while striving to maintain patient stability. The study identified a growing need for centralisation, coordination, standardisation, audit, education and training for all those involved in transporting critically ill patients to a regional ECMO centre. It recommends that dedicated regional transport centres should be implemented for the transport of the adult critical care patient. A centralised database should be created for the import of data from the regional transport teams. Education for all nurses, not just transport nurses, needs to be available to deliver high quality care at any point of patient retrieval. A curriculum for transport education for nurses is outlined. This research reinforces and adds to the Intensive Care Society and Faculty of Intensive Care Medicine (ICS & FICM, 2019), and standards of education for nurses enhanced

Researching Across Two Cultures: Shifting Positionality

Embodied and creative research methods provoke honesty, emotion, and vulnerability in participants, which add to the richness of the stories they tell and are willing to share. The positionality of the researcher is less of “interviewer” and more “co-producer” or participant in a dialogue. Visual and creative approaches invite participants to share in ways in which they are not able or willing through words alone. The data and outputs they produce, with film, art, or objects, can in turn affect those who see it more than written text and need to be analysed and disseminated along with more traditional transcripts, articles, and presentations. In the context of investigating sensitive issues such as those around embodied identity, these methods, which use embodied methods to explore embodied research questions, may feel the most appropriate. These approaches lie along the boundary of therapy and research, asking much of researchers who are unlikely to have received therapeutic training or ongoing support. Due to this deficit, the researched may find that their experience is not held or contained in a way that the content would demand. Similarly, the data themselves lie on the boundary of art and research, in that they can be seen as more than a tool to facilitate reflection, but as artifacts in their own right. What are the implications in this scenario? Where should we position ourselves and our work along these boundaries? Who holds the space for the researcher and the researched if both are made vulnerable

Designing high fidelity simulation to maximize student registered nursing decision-making ability

The current healthcare environment is a complex system of patients, procedures, and equipment that strives to deliver safe and effective medical care. High fidelity simulation provides healthcare educators with a tool to create safety conscious practitioners utilizing an environment that replicates practice without risk to patients. Using HFS learning opportunities to refine a learner\u27s clinical decision-making skills under time pressure and high stakes outcomes could provide new opportunities for training the healthcare workforce of the future. This design based research project explored how to structure HFS training to facilitate the development of decision-making in second semester Registered Nursing learners. Borrowing from the research base of aviation and the military, a framework of Situation Awareness was used to define decision-making skills. Using a naturalistic decision-making approach, the research sought to understand how the design of the HFS learning event impacted the ability of participants to demonstrate behaviors of Situation Awareness. Findings of this study demonstrated that design based research is a powerful tool to create a rich understanding of the high fidelity simulation learning experience. The results also supported the work of Jeffries (2005) reiterating that HFS simulation design must be created using strong pedagogical principles that support specific learning outcomes. Particular attention should be focused on maintenance of fidelity, understanding complexity and scaffolding learning opportunities through a multi-phased approach that minimally includes debriefing. The research related to this small group suggests that the briefing stage of HFS learning should be further explored for its influence on learning in HFS. The influence of the facilitator/faculty on the HFS was emphasized in this research suggesting that faculty development would be important for use of this new tool. Additional implications of the research suggest that high fidelity simulation has a role in team training and development of communication skills

Learning through the Looking Glass : Anticipation through the Lens of Social and Transformative Learning at a Futures literacy Lab

The emergent phenomena of a complex world produce novel situations and opportunities that are difficult to prepare or plan for. Futures Literacy is proposed as a participatory transformative practice for developing capabilities that help individuals to both sense, and make sense of, novelty, through anticipation for emergence. This dissertation contributes to the empirical basis of how engaging in critical self-reflection as a collective, produces valuable insights into how assumptions form the lenses through which we imagine times later than now. The learnings that occur when individuals encounter simulated emergence in a challenging but supportive and creative environment, and the products of that process in terms of concrete actions, are contextualised within Futures Literacy learning journeys. This dissertation explores the role of transformative learning for understanding the social learning that occurs at a Futures Literacy Laboratory (FLL) through analysis of participant experiences and reflections using the Wenger-Trayner value creation framework. This study articulates that learning through anticipation for emergence is characterised by complexity, impredicavity, and reflexivity, which requires a broad range of cognitive and emotional skills to navigate. Participants of an FLL who are open to the process encounter deeply challenging critiques and insights that come to be understood as significant steps in understanding the inner sources of anticipatory assumptions. If these can then be explored under conditions of psychological safety, then alternative lenses become available that allow for the enhanced perception of the emerging present as well as their own boundaries. This process is cognitively and emotionally demanding and contingent on enabling factors and initial conditions. Weaving the participant experiences of this event into a broader narrative of learning provides opens opportunities for individual insights and practice, but also opportunities for new avenues of research. The results indicate that there is positive evidence that FLLs provoke reconsideration of established assumptions and can foster new lines of thinking. Situating FLLs as Transformative and social learning spaces, allows for the identification of practical implications and the generation of learning narratives than contribute to our understanding of the change processes at play in Futures Literacy capability building

“Focus on the Users”: Empathy, Anticipation, and Perspective-taking in Healthcare Architecture

This dissertation is a phenomenological anthropology of intersubjectivity in the design of healthcare architecture. Based on 12 months of ethnographic fieldwork with architectural designers in the San Francisco Bay Area, this dissertation details how architectural designers derive and enact their understandings of the healthcare professionals and patients for whom they design. Since the 1960s, many architects have taken up an orientation toward design that I herein refer to as “Methodological User-Centricity” (MUC). The premise is simple: better design hinges on better empirical knowledge of the people being designed for, and that knowledge is best acquired by what are often social-science-inspired methods. One of the most influential encapsulations of this orientation in design today (in architecture and beyond) is “empathy”. The healthcare architects in this ethnographic study believed “empathic” knowledge of “users”—including patients, doctors, nurses—was essential to improving healthcare, and sought to develop this understanding of occupants through games, interviews, and other methods for learning about users’ needs, values, and experiences. Situated in this context, this dissertation examines the background premises and methods through which these architectural designers enact their specific forms of constituting others and intervening in the built environment on their behalf. Working from data running the gamut of architectural activities from initial stages of user research and conceptualization, to completion and retrospective evaluation by both designers and end-users, the dissertation analyzes the diverse modalities of experience by which members of architectural project teams orient themselves to users’ needs and possibilities. In doing so, the dissertation approaches architecture as a polymorphous response to others, one ultimately rooted in manifold forms intersubjectivity and degrees of social understanding. Nevertheless, this dissertation also presents a critical analysis of unintentional shortcomings arising through unequal user representation in architectural designers’ research with healthcare institutions

Registered nurses' experiences in nursing of children post cardiac surgery in an academic hospital in Gauteng

Abstract: Paediatric cardiac surgery is performed on children diagnosed with congenital, acquired heart defects. Post cardiac surgery, these children are admitted to the cardio-thoracic intensive care unit where they are nursed by trained registered nurses and experienced registered nurses. Most of the registered nurses are bridging courses nurses who completed training and education under Regulation (R683). The South African Nursing Council’s (SANC) R683 regulation leads to qualification as registered nurse and is known as bridging course in the South African nursing context. Based on the shortage of registered intensive care nurses in South Africa, the registered bridging course nurses are allowed to work in ICU even though they lack the requisite knowledge and skill. The researcher has observed that these registered nurses manage certain situations inappropriately, and they appear to be dissatisfied and unhappy, and that the atmosphere in the CTICU is often tense. The purpose of the study was to understand the registered nurses’ lived experiences in nursing children post cardiac surgery, and to describe recommendations to support them. A qualitative, exploratory, descriptive, and contextual research design was used. Purposive sampling was utilised. The target population comprised registered nurses who have undergone training in terms of the South African Nursing Council/s Regulation R683. Data collection was conducted by means of in-depth individual phenomenological interviews until data saturation...M.Cur. (Medical and Surgical Nursing Sciences

Career and Technical Education Teacher Self-Efficacy of Staff Development as Part of a Beginning Teacher Induction Program: A Qualitative Research of CTE Teacher Externs of a South Texas School District…From the Classroom to the Job Site, and Back Again

Career and Technical Education (CTE) has proven itself through substantial research, to provide a positive impact on the U.S. economy and the job market in its college and career preparedness of high school students. However, the ability of school districts in retaining competent CTE teachers is not as reassuring. The progressive years for any beginning CTE teacher are during their initial tenure in the profession. Teacher self-knowledge is also developed during these years inclusive of the occupational reflection of either removing oneself from or continuing as a teacher. Therefore, it can be stated that it is during this period when professional learning opportunities, or the lack thereof, can formulate a basis of a CTE teacher’s inherent decision to either remain or depart from the profession. From this presumption, the self-efficacy beliefs of beginning CTE teachers towards staff development is important to investigate to recognize if these experiences impact this construct. This qualitative research will seek to explore the experiences of beginning CTE teachers in their participation in a school district-implemented externship as part of their required CTE beginning teacher induction staff development as well as the sentiments of their mentors and principals. It is the goal of this research to establish a connection to current existing theoretical constructs in this field from the data collecting process

An integrated study of earth resources in the state of California using remote sensing techniques

The University of California has been conducting an investigation which seeks to determine the usefulness of modern remote sensing techniques for studying various components of California's earth resources complex. Most of the work has concentrated on California's water resources, but with some attention being given to other earth resources as well and to the interplay between them and California's water resources