Assessment of Practice in Pre-Registration Undergraduate Nursing Programmes. Phase 2 Evaluation: Survey of students’ and mentors’ experiences of grading student competence in practice.

Executive Summary Context Local and national concerns regarding competency in newly qualified practitioners provided the impetus for the undergraduate nursing programme team at Bournemouth University to radically change the practice assessment tool as part of a curriculum rewrite in 2005. Alongside the introduction of the new practice profile, an evaluation strategy was implemented with two stages; Phase One focused on year one of implementation and reported at the end of that year (2005-6). These findings were used to inform mentor education and to amend the tool for new students and those moving into year two. This phase used a qualitative approach to collect data from focus groups with students and mentors (Adult Branch only), and practice/HEI educators concerning their experiences of using the grading practice assessment scheme. Phase Two utilised the qualitative findings to develop a questionnaire survey. Questionnaires were selected as the research tool in order to access greater numbers of students and mentors from across all branch programmes. Education staff was not surveyed in this phase. Purpose and project aim The purpose of the project was to evaluate the impact of the new practice assessment scheme from the perspective of the users and to make suggestions to key stakeholders for quality improvement where necessary. Phase One of the evaluation involved small numbers and only Adult branch students; whilst the findings were informative, it seemed important to test these out on a wider sample. The aim of Phase Two of the grading practice evaluation was to explore: • mentor and student experiences of using the assessment tool across all nursing branches • the impact of quality assurance processes Pertinent literature An overview of the historical and current context of practice assessment for nurses in the UK was provided, including the policy literature from the statutory body. Research on practice assessment in nursing was found to be relatively limited particularly concerning the grading of practice. Key studies include Bondy (1983; 1984) and Hillegas & Valentine (1986) from the USA, Glover et al. (1997) from Australia; from the UK, Burns (1992) and Scammell et al. (2007). All studies had limitations but generally the notion of grading practice was well received by users; however there were concerns about quality assurance processes particularly around reliability as well as issues concerning mentor/practice assessor preparation. In light of an increased national emphasis on nurses’ competency in practice, empirical work that evaluates a new practice assessment initiative is timely. Whilst of value locally in terms of reviewing and improving processes, the findings may also interest colleagues elsewhere. Project design A questionnaire survey of mentors and year two and three nursing students was undertaken to investigate their experiences of using the grading practice assessment tool. All branches of nursing were successfully targeted for inclusion using convenience sampling, but no learning disability students opted to participate. Mentors were accessed via an annual mentor conference; students were accessed via tutor groups. 112 (86%) of the 130 mentors available, completed and returned the questionnaire. The branch representation was adult nursing (62.5%; n=70), Mental Health (21.4%; n=24), Child Health (17%; n=19) and Learning Disability (1.8%; n=2). Questionnaires were distributed to 210 students; 107 were completed (51% response). The sample comprised Adult branch (72%; n=77), Mental Health (19.6%; n=21) and Child Health students (8.4%; n=9). The response rate broadly reflected the proportion of students enrolled within each branch of the targeted cohorts. Most student respondents were undertaking year 3 of their programme (70.1%; n=73); the exception was Child Health where all students were undertaking year 2. As an evaluation study, formal ethical approval was not sought; however permission was granted to conduct the evaluation by the Associate Dean for Nursing, and the educational leads within placement areas. There was a project steering group with representatives of all parties including students and mentors; their role was to oversee the project process and to liase with colleagues within their organisations. Quantitative data was coded and inputted into the Statistical Package for the Social Sciences (SPSS for Windows version 15.0); where possible chi-square analysis was undertaken to explore whether the results were significant. Qualitative aspects of the questionnaire were transcribed and a content analysis was undertaken. Given the sample size, it is not possible to generalise from this evaluation. Others may judge transferability to other settings. In reviewing the findings, a number of limitations must be acknowledged. The most significant limitations are that no Learning Disability students opted to participate and the response rate generally from students was not as high as anticipated (51%). This is however a reasonable response rate for a questionnaire survey but if time had permitted, an extension to the convenience sampling may have been beneficial. Other limitations include the fact that findings were generated from reported practice and, as such, may be subject to distortions of memory. Findings Five key areas emerged from the findings: questions around mentor education indicated that participation in updates was high although the sampling process may have introduced some bias. Indeed poor uptake was identified in Phase One, reflecting other studies and anecdotal evidence for the programme team. The findings around support for practice education were mixed; mentors appeared to want more support than was available. Student experience varied according to branch – Mental health students feeling most supported and Child Health the least. However the use of neutral grades was high in both mentor and student groups indicating some cause for concern. Perception on use of the profile in terms of whether it was fit for purpose indicated positive responses overall but some confusion from both students and mentors as to the status of the written sections in comparison with skills performance; the latter was perceived as the top priority. The fourth area focused on how grading ‘worked’ and yielded some valuable perceptions. Generally respondents liked and wanted to grade or be graded in practice. Whilst the majority of mentors claimed to use the descriptors and found them useful, the number who did not use them was of concern. There were mixed perceptions of the appropriate use of second marking, some students perceiving that they were given middle grades due to logistical problems in accessing second markers, although this was not supported by the mentor data. The vast majority of mentors expressed confidence in grading students. However a significant minority responded neutrally or negatively or did not answer the question when asked whether they felt confident to fail a student. This finding is important when considered alongside the neutral response to feeling supported. Finally accountability within the assessment process appeared strong, although at times profiles were signed by staff who had not worked with the student. It is unclear however whether these mentors were primary mentors or those functioning as second markers. Overview of discussion The Phase Two evaluation was broadly supportive of the Phase One findings but extended these to other nursing branches and has provided more useful detail on some of the issues underpinning the grading practice scheme. Quality assurance is a prime issue: the evaluation has shown that reliability of the tool could be improved if the descriptors are clear and robust processes are in place to ensure these are consistently applied. Second marking is another feature of reliability and perceptions varied as to whether this was utilised as much as required and is an issue for programme and placement staff to consider, particularly in the light of inter-branch discrepancies. Students and mentors should be encouraged to constructively make any concerns known. Education around grading and support for mentors was another key area; there perhaps can never be enough support but if any staff have concerns around failing students, this needs to be addressed. The reasons for differing perceptions of support across branches, needs to be explored further. Overall the grading of competency in nursing practice yields far more benefits than problems. It is an innovative scheme, not without challenges; both evaluation phases provide valuable data to focus quality improvement effectively. Conclusion The evaluation captured the views of mentors and students representing all nursing branches, with the exception of Learning Disability students. The issues raised across the branches were broadly similar, notably that the notion of grading practice was welcomed as a means of valuing the practice element of the programme, although implementation was not without challenges. These are reflected in the focus on the quality assurance processes and in fact this is where the branch experience differs most. Mental Health students felt the most supported in placement, were the most likely to receive grades that required to be second marked (indicating full use of the grading range) and were most satisfied that mentor comments matched the grades awarded. In contrast Child Health students were the least satisfied in all these parameters. Adult branch students gave mainly neutral responses which indicate some underlying issues worthy of further investigation. It can be concluded from the mentor data that experience across branches did not differ markedly. The sample accessed updates and most felt confident in grading practice. However almost 18% did not feel confident about failing students and almost another 20% gave a neutral response to this question, indicating a need for further staff development in this area as well as a review of processes designed to support mentors in making these judgements. Recommendations • Explore ways of engaging learning disability students in sharing their perspective on the practice assessment tool and processes. • Increase transparency of communication channels between placement providers and the university regarding practice assessment. - Flowcharts or algorithms for mentors and students might be useful - Include these on the back of each practice profile • Review support mechanisms for students within placements. Identify best practice and include minimal standards on the clinical audit documentation to increase parity between placements and branches. • Investigate peer support schemes for students in practice which include preparation and support for those undertaking this role. • Child Health programme team should review support for students with practice partners to identify specific issues for improvement. • Review level descriptors with students, mentors as well as programme teams to ensure clarity of language and processes. • Re-emphasise the use of descriptors in mentor education as well as student preparation for placement • Review criteria and processes for second marking and emphasise within mentor education. • Disseminate HSC audit of practice profiles on a placement provider organisation basis and include a focus on quality of feedback in relation to grade awarded. • Review current practice around preparing and supporting mentors in failing students and develop an action plan for implementation over the next academic year

Choice of speed under compromised Dynamic Message Signs.

This study explores speed choice behavior of travelers under realistic and fabricated Dynamic Message Signs (DMS) content. Using web-based survey information of 4,302 participants collected by Amazon Mechanical Turk in the United States, we develop a set of multivariate latent-based ordered probit models participants. Results show female, African-Americans, drivers with a disability, elderly, and drivers who trust DMS are likely to comply with the fabricated messages. Drivers who comply with traffic regulations, have a good driving record, and live in rural areas, as well as female drivers are likely to slow down under fabricated messages. We highlight that calling or texting, taking picture, and tuning the radio are distracting activities leading drivers to slow down or stop under fictitious scenarios

Differential regulation of TNF-α and IL-1β production from endotoxin stimulated human monocytes by phosphodiesterase inhibitors

The effect of selective PDE-I (vinpocetine), PDE-III (milrinone, CI-930), PDE-IV (rolipram, nitroquazone), and PDE-V (zaprinast) isozyme inhibitors on TNF-α and IL-1β production from LPS stimulated human monocytes was investigated. The PDE-IV inhibitors caused a concentration dependent inhibition of TNF-α production, but only partially inhibited IL-1β at high concentrations. High concentrations of the PDE-III inhibitors weakly inhibited TNF-α, but had no effect on IL-1β production. PDE-V inhibition was associated with an augmentation of cytokine secretion. Studies with combinations of PDE isozyme inhibitors indicated that PDE-III and PDE-V inhibitors modulate rolipram's suppression of TNF production in an additive manner. These data confirm that TNF-α and IL-1β production from LPS stimulated human monocytes are differentially regulated, and suggest that PDE-IV inhibitors have the potential to suppress TNF levels in man

Heritage and well-being: Therapeutic places past and present

Ancient sites such as Stonehenge, UK, and Santiago de Compostela, Spain, have long been directly associated with healing and the promotion of well-being. It is a dimension of heritage that continues into the present day. This chapter contextualizes public perceptions and aspirational public policies in relation to heritage and well-being by reviewing the development of interest in therapeutic places, and summarizing the achievements of projects that promoted physical and mental well-being through access to heritage landscapes, encounters with museum collections, participation in archaeological fieldwork, and journeys around ancient monuments. Three dimensions are common to many successful projects: the idea of journeying; structured engagements between people and places; and the opportunities offered for human interaction and making sense of empirical experiences

Learning about the complexity of humanised care: findings from a longitudinal study of nurse students’ perceptions

Background, including underpinning literature and, wherever possible, the international relevance of the research The rise in elderly populations with complex long-term conditions is a global phenomenon (World Health Organisation, 2011). However evidence has emerged internationally around concerns about quality of care, particularly for older people (Katz 2011; Organisation for Economic Cooperation and Development, 2013). It has been argued that in target-driven care environments, there is the potential for care professionals to lose sight of the person receiving the care and focuses on task-completion, resulting in dehumanising care cultures (Galvin and Todres 2013). Educating nurse students to effectively as well as compassionately deliver complex care to vulnerable people represents considerable challenges. Following a number of high profile examples of poor quality care in the United Kingdom (UK) (Francis 2013), health profession education providers now follow professional body guidelines that mandate that values for compassionate practice clearly underpin curricula. Limited evidence exists however, concerning the impact of this initiative over time. This paper reports on a study that evidences the impact on students of an education programme based on a humanising care philosophy in shaping the students’ value base as they progress through their education programmes. Aim(s) and/or research question(s)/research hypothesis(es) . This paper reports on a five-phase longitudinal study exploring the impact of an undergraduate-nursing curriculum based on a humanising care philosophy on the values of individual students. Research methodology/research design, any ethical issues, and methods of data collection and analysis The study uses a qualitative longitudinal approach to understanding the beliefs and values of student nurses from the day of entry, through their education programme to completion. Focusing on two cohorts of students one year apart, data were collected by individual interview at commencement and completion and by focus groups at the end of their first placement and at the end of their first and second years. This presentation reports up to the end of the programme for the first cohort and end of second year for the second cohort. Ethics approval was gained for the entire project. At each stage of the process, students were formally invited to participate and on-going individual consent was gained. The audio-recordings were transcribed verbatim and analysed thematically. Key findings and recommendations By the end of their first placement, both groups were very similar in the expression of their values and to some extent presented a rather negative view of their experiences. However students from both groups became more articulate in expressing their values particularly in relation to their placement experience, as they moved through their programme. Four on-going and developing themes emerged from the data: personal journey, impact of the curriculum, impact of practice and values development. Overall, although each cohort followed two distinct curricula, there were few differences between the groups at each stage. Reasons for this will be discussed. Both groups felt they had become less judgmental, that the curriculum had empowered them to challenge practice and enhanced their confidence. Students also reported that their mentors (placement supervisors) role modelled authentic compassionate care in practice. Over time students’ insight into the complexity of caring developed and their understanding of the importance of practice that respected patient individuality deepened. This study has evidenced the strong link between curriculum and its impact on the evolving values of nursing students. Whilst this paper reports on a local study from one university in the UK, transferability of findings to other settings can be judged; it is argued that the insights will have resonance for nurse educators more widely as well as other health professional disciplines. References Commissioning Board Chief Nursing Officer and Department of Health Chief Nurse Advisor (2012). Compassion in Practice: Nursing, Midwifery and Care Staff. Our vision and strategy. Retrieved 22nd January 2016 from: http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf Francis Inquiry, (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary. Crown Copyright: London. Galvin, K., Todres, L. (2013). Caring and Well-Being: A Lifeworld Approach. Routledge: Abingdon, Oxon. Katz, P.R. (2011). An International Perspective on Long Term Care: Focus on Nursing Homes. Journal of American Medical Directors Association. 12 (7): 487-492 OECD (2013) OECD Reviews of Health Care Quality: Denmark. Retrieved 7th Retrieved 22nd January 2016 from: http://www.oecd.org/els/health-systems/ReviewofHealthCareQualityDENMARK_ExecutiveSummary.pdf WHO (2011) Global Health and Ageing. Retrieved 22nd January 2016 from: http://www.who.int/ageing/publications/global_health.pdf Key words: (5) • Nurse education • Professional values • Humanising care • Curriculum • Longitudinal qualitative research 3 key points to indicate how your work contributes to knowledge development within the selected theme • Nursing students were able to clearly articulate values that underpin humanised care • This study provides evidence for the strong link between curriculum and its impact on the evolving values of nursing students • The curriculum is one factor in embedding humanised values in nursing students; further research is required

A method to improve size estimates of walleye pollock (Theragra chalcogramma) Atka mackerel (Pleurogrammus monopterygius) consumed by pinnipeds: digestion correction factors applied to bones and otoliths recovered in scats

The lengths of otoliths and other skeletal structures recovered from the scats of pinnipeds, such as Steller sea lions (Eumetopias jubatus), correlate with body size and can be used to estimate the length of prey consumed. Unfortunately, otoliths are often found in too few scats or are too digested to usefully estimate prey size. Alternative diagnostic bones are frequently recovered, but few bone-size to prey-size correlations exist and bones are also reduced in size by various degrees owing to digestion. To prevent underestimates in prey sizes consumed techniques are required to account for the degree of digestion of alternative bones prior to estimating prey size. We developed a method (using defined criteria and photo-reference material) to assign the degree of digestion for key cranial structures of two prey species: walleye pollock (Theragra chalcogramma) and Atka mackerel (Pleurogrammus monopterygius). The method grades each structure into one of three condition categories; good, fair or poor. We also conducted feeding trials with captive Steller sea lions, feeding both fish species to determine the extent of erosion of each structure and to derive condition-specific digestion correction factors to reconstruct the original sizes of the structures consumed. In general, larger structures were relatively more digested than smaller ones. Mean size reduction varied between different types of structures (3.3−26.3%), but was not influenced by the size of the prey consumed. Results from the observations and experiments were combined to be able to reconstruct the size of prey consumed by sea lions and other pinnipeds. The proposed method has four steps: 1) measure the recovered structures and grade the extent of digestion by using defined criteria and photo-reference collection; 2) exclude structures graded in poor condition; 3) multiply measurements of structures in good and fair condition by their appropriate digestion correction factors to derive their original size; and 4) calculate the size of prey from allometric regressions relating corrected structure measurements to body lengths. This technique can be readily applied to piscivore dietary studies that use hard remains of fish