Information use in clinical practice: A case study of critical care nurses' enteral feeding decisions

Although registered nurses have a plethora of information sources available to assist them in making clinical decisions, how this information informs such decisions is not well understood. Through the work undertaken in this thesis a deeper understanding of information use in clinical practice is developed. Information use in clinical uncertainty is explored, specifically in the context of making decisions about enteral feeding practices within critical care environments. Instrumental case studies were used to access the information use processes of registered nurses working in an intensive care unit. Two case sites (a Level III intensive care unit in metropolitan teaching hospital and a Level II intensive care unit in a district hospital) were selected for the purpose of theoretical replication. Data were collected to inform specific issues. Concurrent verbal protocols (think aloud), observation and retrospective probing were used to explore documented clinical decisions and the information used to inform those decisions. Q sorting was used to determine the accessibility and usefulness of information available to participants and focus groups were used to explore senior nurse clinician’s perceptions of the authority of the identified information sources. A synthesis of findings from the two case sites highlighted three key issues. First, natural testimony (the use of personal communication to obtain information) was privileged over other, more formal sources of information however the veracity of the information obtained through natural testimony was not explicitly assessed. Registered nurses relied on the credibility of the person providing the information, leaving the information itself unchallenged. The clear reliance on information accessed through natural testimony, but the evident lack of critical evaluation of information obtained in this way, indicates a need for the development of strategies for the critical assessment of the accuracy of this clinical information. Second, the findings highlighted nurses’ use of clinical inquiry. Nurses used clinical inquiry to resolve clinical uncertainty as well as for logistic reasons. Participant’s use of inquiry was influenced by their approach to work, the impact of both organisational and personal perspectives on the perceived value of their work; and by models of clinical leadership where an investment in relational capital was considered a strategy to positively influence a culture of inquiry. Although organisational documents which are designed to ensure quality and consistency of patient care as required by current clinical governance strategies were considered useful, these document were not widely used as a primary source of information. The use of organisational documents, as well as the need to practice in concert with such documents, was identified as a factor negatively impacting on the development and support of nurses’ use of clinical inquiry. Third, findings addressed the usefulness of information for clinical decisions and the resolution of clinical uncertainty. The usefulness of information was influenced by its relevance to a clinical question or information deficit, and by the media used to convey the information. In general, print based media was considered more useful than other forms such as electronic documents. While original research was not considered useful, nurses valued research-based practice and responded positively to incorporating research into practice, particularly if research was pre-appraised by colleagues who were able to disseminate research findings to the clinical area and facilitate its use in clinical practice. This case study indicates that information use is less about individuals and the clinical context in which they are making decisions, and more about the social, cultural and organisational influences that shape decision making, and the information selected to support those decisions. The preference for natural testimony as information in decision making may, on first consideration, be viewed as undesirable in a work context that relies on accurate and consistent documentation. Determining the credibility of the information provider and the accuracy of the information itself is also challenging in an environment where this type of information and the approach to accessing it is selected for its ease of accessibility and the speed at which it can be applied. Yet, the pervasiveness with which nurses rely on others for information suggests verbal testimony is important in the context of clinical practice and highlights the need to develop a clearer understanding of why nurses privilege this information. Therefore verbal testimony must be considered carefully as a strategy for providing information, particularly research-based information and this study therefore highlights the need to develop strategies that enable those providing information to convey their expertise as a clinician as well as a user and provider of information. The organisational culture and work structures currently in place in Australia are unlikely to undergo significant change in the coming years, therefore their impact on information use warrants careful consideration. The nursing profession and the higher education sector aim to foster through inquiry, the independent, evidence-based practice of registered nurses. Health care organisations also highly value independent, evidence-based practice but also promote patient safety through use of current clinical governance strategies. While these two goals can be complimentary they also create tension when clinical governance strategies stifle inquiry and independent decision making of registered nurses. Ultimately, the current health care system in Australia and the wider community expect an evidence base for practice together with clinical governance strategies that promote safe practice. Nurses, as part, of this system must be accountable for both in the context of their clinical practice. We therefore need with some urgency to determine how to best balance these complementary and simultaneously competing ideals

Information use in clinical practice: A case study of critical care nurses' enteral feeding decisions

Although registered nurses have a plethora of information sources available to assist them in making clinical decisions, how this information informs such decisions is not well understood. Through the work undertaken in this thesis a deeper understanding of information use in clinical practice is developed. Information use in clinical uncertainty is explored, specifically in the context of making decisions about enteral feeding practices within critical care environments. Instrumental case studies were used to access the information use processes of registered nurses working in an intensive care unit. Two case sites (a Level III intensive care unit in metropolitan teaching hospital and a Level II intensive care unit in a district hospital) were selected for the purpose of theoretical replication. Data were collected to inform specific issues. Concurrent verbal protocols (think aloud), observation and retrospective probing were used to explore documented clinical decisions and the information used to inform those decisions. Q sorting was used to determine the accessibility and usefulness of information available to participants and focus groups were used to explore senior nurse clinician’s perceptions of the authority of the identified information sources. A synthesis of findings from the two case sites highlighted three key issues. First, natural testimony (the use of personal communication to obtain information) was privileged over other, more formal sources of information however the veracity of the information obtained through natural testimony was not explicitly assessed. Registered nurses relied on the credibility of the person providing the information, leaving the information itself unchallenged. The clear reliance on information accessed through natural testimony, but the evident lack of critical evaluation of information obtained in this way, indicates a need for the development of strategies for the critical assessment of the accuracy of this clinical information. Second, the findings highlighted nurses’ use of clinical inquiry. Nurses used clinical inquiry to resolve clinical uncertainty as well as for logistic reasons. Participant’s use of inquiry was influenced by their approach to work, the impact of both organisational and personal perspectives on the perceived value of their work; and by models of clinical leadership where an investment in relational capital was considered a strategy to positively influence a culture of inquiry. Although organisational documents which are designed to ensure quality and consistency of patient care as required by current clinical governance strategies were considered useful, these document were not widely used as a primary source of information. The use of organisational documents, as well as the need to practice in concert with such documents, was identified as a factor negatively impacting on the development and support of nurses’ use of clinical inquiry. Third, findings addressed the usefulness of information for clinical decisions and the resolution of clinical uncertainty. The usefulness of information was influenced by its relevance to a clinical question or information deficit, and by the media used to convey the information. In general, print based media was considered more useful than other forms such as electronic documents. While original research was not considered useful, nurses valued research-based practice and responded positively to incorporating research into practice, particularly if research was pre-appraised by colleagues who were able to disseminate research findings to the clinical area and facilitate its use in clinical practice. This case study indicates that information use is less about individuals and the clinical context in which they are making decisions, and more about the social, cultural and organisational influences that shape decision making, and the information selected to support those decisions. The preference for natural testimony as information in decision making may, on first consideration, be viewed as undesirable in a work context that relies on accurate and consistent documentation. Determining the credibility of the information provider and the accuracy of the information itself is also challenging in an environment where this type of information and the approach to accessing it is selected for its ease of accessibility and the speed at which it can be applied. Yet, the pervasiveness with which nurses rely on others for information suggests verbal testimony is important in the context of clinical practice and highlights the need to develop a clearer understanding of why nurses privilege this information. Therefore verbal testimony must be considered carefully as a strategy for providing information, particularly research-based information and this study therefore highlights the need to develop strategies that enable those providing information to convey their expertise as a clinician as well as a user and provider of information. The organisational culture and work structures currently in place in Australia are unlikely to undergo significant change in the coming years, therefore their impact on information use warrants careful consideration. The nursing profession and the higher education sector aim to foster through inquiry, the independent, evidence-based practice of registered nurses. Health care organisations also highly value independent, evidence-based practice but also promote patient safety through use of current clinical governance strategies. While these two goals can be complimentary they also create tension when clinical governance strategies stifle inquiry and independent decision making of registered nurses. Ultimately, the current health care system in Australia and the wider community expect an evidence base for practice together with clinical governance strategies that promote safe practice. Nurses, as part, of this system must be accountable for both in the context of their clinical practice. We therefore need with some urgency to determine how to best balance these complementary and simultaneously competing ideals

An Investigation of the Impact of Student Satisfaction on Student Outcomes Among Undergraduate Students in a Blended Learning Environment in University A

The purpose of this study was to examine the impact of student satisfaction on student outcomes among undergraduate students in a blended learning environment in University A. It was a quantitative predictive correlational design, with predictor variables satisfaction with course, sex, age and race/ethnicity, and criterion variable end-of-course score. The Corona Virus pandemic highlighted the central role of blended and online learning in educational processes globally. The technological revolution in education characterized by the infusion of digital technologies in classrooms, indicates that blended learning will continue to feature prominently in educational settings. Student satisfaction in blended learning redounds to the benefit of students and educational institutions since it could contribute to improved pedagogical and curricular practices, goodwill, enhanced reputation, and increased enrollment. Participants for this study were drawn from a convenience sample of 330 undergraduate students enrolled in a blended general education course at University A. Data collection procedures for predictor variables were accomplished through the online administration of the Satisfaction with Blended eLearning Systems (BELS) Questionnaire, while criterion variable data was garnered from student records. Applying multiple linear regression analysis, a statistically significant relationship was found between the linear combination of satisfaction with course, sex, age, race/ethnicity and end-of-course score. However, satisfaction with course emerged as the only significant predictor of the end-of-course score. Course satisfaction in blended learning settings influences performance. Further investigations are needed in other tertiary level institutions in the Caribbean, across different disciplines, and different blended learning delivery methods

User agency as a feminist frame in human computer interaction and information science

User agency within sociotechnical contexts supports both feminist reflexivity in HCI research, and the feminist ethnographic tradition present within Information Science. User agency as a unifying scholarly frame between these two disciplines that in turn expand our understanding of gender identity formation within information and computing environments

Ununfoldable Polyhedra with Convex Faces

Unfolding a convex polyhedron into a simple planar polygon is a well-studied problem. In this paper, we study the limits of unfoldability by studying nonconvex polyhedra with the same combinatorial structure as convex polyhedra. In particular, we give two examples of polyhedra, one with 24 convex faces and one with 36 triangular faces, that cannot be unfolded by cutting along edges. We further show that such a polyhedron can indeed be unfolded if cuts are allowed to cross faces. Finally, we prove that ``open'' polyhedra with triangular faces may not be unfoldable no matter how they are cut.Comment: 14 pages, 9 figures, LaTeX 2e. To appear in Computational Geometry: Theory and Applications. Major revision with two new authors, solving the open problem about triangular face

A centrifuge modelling study of the response of piled structures to tunnelling

Tunnelling beneath piled structures may compromise the stability and serviceability of the structure. The assessment of potential structure damage is a problem being faced by engineers across the globe. This paper presents the outcomes of a series of geotechnical centrifuge experiments designed to simulate the effect of excavating a tunnel beneath piled structures. The stiffness and weight effects of piled structures are examined independently using aluminium plates of varying stiffness (`equivalent beam' approach) and the addition of weights supporteby aluminium piles. Greenfeld displacement patterns and results from pile loading tests are also provided. The variation of structure displacement profiles with plate stiffness, weight, and tunnel volume loss are used to illustrate the main effects of tunnel-pile interaction and the contribution of the superstructure to the global tunnel-pile-structure interaction. Results indicate that piles have a detrimental role in tunnel-structure interaction problems, whereas the superstructure stiffness and weight can, respectively, reduce and increase structure distor-tions and settlements. Finally, the potential for structural damage is evaluated by comparing structure and greenfield deflection ratios as well as resulting modification factors. The paper presents a unique set of results and insights which provide valuable guidance to engineers working across the ground and structural engineering disciplines

Glue: A Technique for Eliminating Fragments and Run-Ons

Many students who are nonnative speakers of English, yet highly proficient, are placed into basic writing or English as a Second Language courses when they enter college. While these students may have advanced oral English proficiency, their writing frequently suffers from a lack of training in academic writing and commonly contains fragments and run-ons, a frustrating sentence-level problem for these students. A review of current writing texts uncovered a general failure to treat these problems as a sentence-boundary issue. The approach taken here is that such students will be able to monitor their writing for incorrectly formed sentences if given a system designed to help them understand English sentence structure. The key concept is Glue, a term used for all clause markers. Working through exercises, in which they label the Glue and systematically identify fragments, run-ons, and complete sentences, students see a system emerging, which brings them to an understanding of English written conventions. Using Glue, the students gain control of their writing and are able to avoid fragments and run-ons

The Dory Fleet of Pacific City: An Annotated Bibliography

This annotated bibliography has been created as part of the Launching through the Surf: The Dory Fleet of Pacific City project. Kathleen Spring, Brenda DeVore Marshall, Andrea Snyder, Mary Beth Jones, Alicia Schnell, and Gabrielle Leif have contributed to the document. Many of the articles and other documents were found in personal scrapbooks and files. In many cases, the bibliographic information is incomplete. Research is ongoing, and the bibliography will be updated as additional information becomes available

Chromatin state changes during neural development revealed by in vivo cell-type specific profiling.

A key question in developmental biology is how cellular differentiation is controlled during development. While transitions between trithorax-group (TrxG) and polycomb-group (PcG) chromatin states are vital for the differentiation of ES cells to multipotent stem cells, little is known regarding the role of chromatin states during development of the brain. Here we show that large-scale chromatin remodelling occurs during Drosophila neural development. We demonstrate that the majority of genes activated during neuronal differentiation are silent in neural stem cells (NSCs) and occupy black chromatin and a TrxG-repressive state. In neurons, almost all key NSC genes are switched off via HP1-mediated repression. PcG-mediated repression does not play a significant role in regulating these genes, but instead regulates lineage-specific transcription factors that control spatial and temporal patterning in the brain. Combined, our data suggest that forms of chromatin other than canonical PcG/TrxG transitions take over key roles during neural development

damidseq_pipeline: an automated pipeline for processing DamID sequencing datasets.

UNLABELLED: DamID is a powerful technique for identifying regions of the genome bound by a DNA-binding (or DNA-associated) protein. Currently, no method exists for automatically processing next-generation sequencing DamID (DamID-seq) data, and the use of DamID-seq datasets with normalization based on read-counts alone can lead to high background and the loss of bound signal. DamID-seq thus presents novel challenges in terms of normalization and background minimization. We describe here damidseq_pipeline, a software pipeline that performs automatic normalization and background reduction on multiple DamID-seq FASTQ datasets. AVAILABILITY AND IMPLEMENTATION: Open-source and freely available from http://owenjm.github.io/damidseq_pipeline. The damidseq_pipeline is implemented in Perl and is compatible with any Unix-based operating system (e.g. Linux, Mac OSX). CONTACT: [email protected] SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.We thank Charles Bradshaw for helpful comments on the software. This work was supported by the BBSRC [BB/L00786X/1] and Wellcome Trust [092545]. The Gurdon Institute is supported by core funding from the Wellcome Trust [092096] and CRUK [C6946/A14492].This is the final published version. It first appeared at http://dx.doi.org/10.1093/bioinformatics/btv38