Working at the coal face: The contribution of Programme Tutors in supporting practice-based learning in nursing

This paper reports the findings of a Centre for Excellence in Teaching and Learning-funded project to explore key features of effective support for pre-registration nursing students in practice settings. Background The cultivation of positive practice learning environments for students of nursing, including high quality learning support, has been long established as a thorny issue for nurse educators and practitioners. Indeed it was a key theme for the very first nursing research series, supported by the Royal College of Nursing, in the early 1980’s. This included Fretwell’s (1982) work on ward teaching and learning, Orton’s (1981) work on the ward learning environment and Ogier’s (1982) work on the role of the ward sister. Since then there has been an explosion of research in this area. As a profession we have a responsibility to ensure high quality learning support for students in practice settings. If we do not, there will be wide-ranging implications for the quality of patient care, work-related stress, role satisfaction, retention and attrition and professional reputation. Given the significant investment in nurse education and the need to retain nurses in the workforce, it is unsurprising therefore that the practice learning environment has emerged as a key policy issue in the United Kingdom and internationally. Previous research indicates that relationships between the learner and staff are crucial in supporting learning in practice (Pearcey and Elliott, 2004) and that ‘learning is maximised when the learner is effectively partnered with a clinician and experiences are shared’ (Henderson et al., 2009, p.178). In this context, The Programme Tutor (PT) – a role unique to the pre-registration nursing programme at The Open University (OU) – is crucial in facilitating learning in the practice setting. The purpose of the PT role is to work longitudinally with both students and their mentors to support learning in practice and monitor student progress. The PT therefore plays a pivotal role in facilitating learning in the practice setting, aspects of which may have potential for transfer to the wider health education sector. Objectives The overall aim of the project was to critically examine the experiences of a sample of PTs supporting students and mentors on the pre-registration nursing programme at the OU in order to identify the key features of effective PT practice. These features would then inform the continuing development of the programme. Two PTs were recruited as co-researchers on the project, the objectives of which were to: • Explore PT’s experiences of supporting students and mentors • Explore PT’s views regarding student progression • Identify how PTs ‘grow’ into their role • Identify enabling and disabling factors contributing to role effectiveness • Examine the boundaries between the role of the PT and mentor • Explore variations in the PT role across the UK. Data collection and analysis A sample of 20 PTs working on the final practice module of the pre-registration nursing programme, and located across the nations and regions of the UK, was identified. Following ethical approval, telephone interviews were conducted using an interview guide informed by both a review of the literature and the experience of the PT co-researchers. Telephone interviews were used in preference to individual face-to-face interviews in order to accommodate the dispersed geographical spread of participants. The interviews were recorded using digital recording equipment and following transcription, conventional approaches to qualitative data analysis were used to identify common themes across the data. The ethical principles of confidentiality, anonymity and informed consent were upheld throughout the study. The sample was assured that confidentiality would be maintained at all times throughout the project. Anonymity was protected by using pseudonyms both for PTs and organisations. Informed consent was gained at the start of the project and participants were able to withdraw from the project at any stage. Findings suggest that PTs find their role both rewarding and vital in the context of creating supportive learning environments and ultimately supporting students’ transition to become registered practitioners. Being an effective communicator and establishing and maintaining relationships with students, mentors and service managers was described as crucial to the success of the role. Understanding the pressures within practice environments and being able to acknowledge the realities of ‘working at the coalface’ enabled PTs to support both students and mentors in such settings. Conclusion This paper will elaborate more fully the findings of the project, illustrated with reference to verbatim quotes from the data. Although a role unique to the OU pre-registration nursing programme, there may be aspects of the role which could be transferable to other practice-based learning settings. This will be interactively debated with conference delegates. (word count 800) References Fretwell, J. E. (1982) Ward teaching and Learning, Royal College of Nursing, London. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P. and Lloyd, B. (2009) Creating supportive clinical learning environments: an intervention study, Journal of Clinical Nursing, 19, pp.171-182. Ogier, M. E. (1981) An ideal sister, Royal College of Nursing, London Orton, H. D. (1981) Ward learning climate, Royal College of Nursing, London Pearcey, P. A. and Elliott, B. E. (2004) Student impressions of clinical nursing, Nurse Education Today, 18, pp.29-31

Recent water mass changes reveal mechanisms of ocean warming

Over 90% of the build up of additional heat in the earth system over recent decades is contained in the ocean. Since 2006 new observational programs have revealed heterogeneous patterns of ocean heat content change. It is unclear how much of this heterogeneity is due to heat being added to and mixed within the ocean leading to material changes in water mass properties or due to changes in circulation which redistribute existing water masses. Here we present a novel diagnosis of the ‘material’ and ‘redistributed’ contributions to regional heat content change between 2006 and 2017 based on a new Minimum Transformation Method informed by both water mass transformation and optimal transportation theory. We show that material warming has large spatial coherence. The material change tends to be smaller than the redistributed change at any geographical location, however it sums globally to the net warming of the ocean, while the redistributed component sums, by design, to zero. Material warming is robust over the time period of this analysis, whereas the redistributed signal only emerges from the variability in a few regions. In the North Atlantic, water mass changes indicate substantial material warming while redistribution cools the subpolar region due to a slowdown in the Meridional Overturning Circulation. Warming in the Southern Ocean is explained by material warming and by anomalous southward heat transport of 118 ± 50 TWdue to redistribution. Our results suggest near termprojections of ocean heat content change and therefore sea level change will hinge on understanding and predicting changes in ocean redistribution

'Ready to hit the ground running': alumni and employer accounts of a unique part-time distance learning pre-registration nurse education programme

Background This study explored the impact of The Open University’s (OU) pre-registration nursing programme on students’ employability, career progression and its contribution to developing the nursing workforce across the United Kingdom. Designed for healthcare support workers who are sponsored by their employers, the programme is the only part-time supported open/distance learning programme in the UK leading to registration as a nurse. The international literature reveals that relatively little is known about the impact of previous experience as a healthcare support worker on the experience of transition, employability skills and career progression. Objectives To identify alumni and employer views of the perceived impact of the programme on employability, career progression and workforce development. Design/Method A qualitative design using telephone interviews which were digitally recorded, transcribed verbatim prior to content analysis to identify recurrent themes. Settings Three geographical areas across the UK. Participants Alumni (n=17) and employers (n=7). Inclusion criterion for alumni was a minimum of two years post-qualifying experience. Inclusion criteria for employers were those that had responsibility for sponsoring students on the programme and employing them as newly qualified nurses. Results Four overarching themes were identified: Transition, Expectations, Learning for and in practice, and Flexibility. Conclusions Alumni and employers were of the view that the programme equipped them well to meet the competencies and expectations of being a newly qualified nurse. It provided employers with a flexible route to growing their own workforce and alumni the opportunity to achieve their ambition of becoming a qualified nurse when other more conventional routes would not have been open to them. Some of them had already demonstrated career progression. Generalising results requires caution due to the small, self-selecting sample but findings suggest that a widening participation model of pre-registration nurse education for employed healthcare support workers more than adequately prepares them for the realities of professional practice

Prevalence of Symptomatic Heart Failure with Reduced and with Normal Ejection Fraction in an Elderly General Population-The CARLA Study

Background/Objectives: Chronic heart failure (CHF) is one of the most important public health concerns in the industrialized world having increasing incidence and prevalence. Although there are several studies describing the prevalence of heart failure with reduced ejection fraction (HFREF) and heart failure with normal ejection fraction (HFNEF) in selected populations, there are few data regarding the prevalence and the determinants of symptomatic heart failure in the general population. Methods: Cross-sectional data of a population-based German sample (1,779 subjects aged 45-83 years) were analyzed to determine the prevalence and determinants of chronic SHF and HFNEF defined according to the European Society of Cardiology using symptoms, echocardiography and serum NT-proBNP. Prevalence was age-standardized to the German population as of December 31st, 2005. Results: The overall age-standardized prevalence of symptomatic CHF was 7.7% (95%CI 6.0-9.8) for men and 9.0% (95%CI 7.0-11.5) for women. The prevalence of CHF strongly increased with age from 3.0% among 45-54- year-old subjects to 22.0% among 75-83- year-old subjects. Symptomatic HFREF could be shown in 48% (n = 78), symptomatic HFNEF in 52% (n = 85) of subjects with CHF. The age-standardized prevalence of HFREF was 3.8 % (95%CI 2.4-5.8) for women and 4.6 % (95%CI 3.6-6.3) for men. The age-standardized prevalence of HFNEF for women and men was 5.1 % (95%CI 3.8-7.0) and 3.0 % (95%CI 2.1-4.5), respectively. Persons with CHF were more likely to have hypertension (PR = 3.4; 95%CI 1.6-7.3) or to have had a previous myocardial infarction (PR = 2.5, 95%CI 1.8-3.5). Conclusion: The prevalence of symptomatic CHF appears high in this population compared with other studies. While more women were affected by HFNEF than men, more male subjects suffered from HFREF. The high prevalence of symptomatic CHF seems likely to be mainly due to the high prevalence of cardiovascular risk factors in this population

Human and mouse essentiality screens as a resource for disease gene discovery

The identification of causal variants in sequencing studies remains a considerable challenge that can be partially addressed by new gene-specific knowledge. Here, we integrate measures of how essential a gene is to supporting life, as inferred from viability and phenotyping screens performed on knockout mice by the International Mouse Phenotyping Consortium and essentiality screens carried out on human cell lines. We propose a cross-species gene classification across the Full Spectrum of Intolerance to Loss-of-function (FUSIL) and demonstrate that genes in five mutually exclusive FUSIL categories have differing biological properties. Most notably, Mendelian disease genes, particularly those associated with developmental disorders, are highly overrepresented among genes non-essential for cell survival but required for organism development. After screening developmental disorder cases from three independent disease sequencing consortia, we identify potentially pathogenic variants in genes not previously associated with rare diseases. We therefore propose FUSIL as an efficient approach for disease gene discovery. Discovery of causal variants for monogenic disorders has been facilitated by whole exome and genome sequencing, but does not provide a diagnosis for all patients. Here, the authors propose a Full Spectrum of Intolerance to Loss-of-Function (FUSIL) categorization that integrates gene essentiality information to aid disease gene discovery

Associations between systolic interarm differences in blood pressure and cardiovascular disease outcomes and mortality

Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We undertook individual participant data meta-analyses to (1) quantify independent associations of systolic interarm difference with mortality and cardiovascular events; (2) develop and validate prognostic models incorporating interarm difference, and (3) determine whether interarm difference remains associated with risk after adjustment for common cardiovascular risk scores. We searched for studies recording bilateral blood pressure and outcomes, established agreements with collaborating authors, and created a single international dataset: the Inter-arm Blood Pressure Difference - Individual Participant Data (INTERPRESS-IPD) Collaboration. Data were merged from 24 studies (53 827 participants). Systolic interarm difference was associated with all-cause and cardiovascular mortality: continuous hazard ratios 1.05 (95% CI, 1.02–1.08) and 1.06 (95% CI, 1.02–1.11), respectively, per 5 mm Hg systolic interarm difference. Hazard ratios for all-cause mortality increased with interarm difference magnitude from a ≥5 mm Hg threshold (hazard ratio, 1.07 [95% CI, 1.01–1.14]). Systolic interarm differences per 5 mm Hg were associated with cardiovascular events in people without preexisting disease, after adjustment for Atherosclerotic Cardiovascular Disease (hazard ratio, 1.04 [95% CI, 1.00–1.08]), Framingham (hazard ratio, 1.04 [95% CI, 1.01–1.08]), or QRISK cardiovascular disease risk algorithm version 2 (QRISK2) (hazard ratio, 1.12 [95% CI, 1.06–1.18]) cardiovascular risk scores. Our findings confirm that systolic interarm difference is associated with increased all-cause mortality, cardiovascular mortality, and cardiovascular events. Blood pressure should be measured in both arms during cardiovascular assessment. A systolic interarm difference of 10 mm Hg is proposed as the upper limit of normal