Putting knowledge to work in clinical practice: understanding experiences of preceptorship as outcomes of interconnected domains of learning

Aim: To understand newly qualified nurses’ learning during the preceptorship period. Background: Newly qualified nurses’ learning during their transition to confident professional practice is facilitated by effective and supportive preceptorship. Several studies have alluded to, but not directly investigated or addressed contextual factors which may prevent the delivery of effective and supportive preceptorship. Design: Two-phase ethnographic case study design in three hospital sites in England from 2011-2014. Methods: Phase One included participant observation, interviews with 33 newly qualified nurses, 10 healthcare assistants and 12 ward managers, the design of a tool to develop newly qualified nurses’ delegation skills during their preceptorship period. This tool was piloted in Phase Two with thirteen newly qualified nurses in the same sites. Data were analysed using thematic analysis. Findings: Constraints on available time for preceptorship, unsupportive ward cultures, and personal learning styles may limit effective preceptorship if time for learning and knowledge recontextualisation is restricted. For newly qualified nurses in supportive ward cultures, limited access to formal preceptorship can be bolstered by team support. Newly qualified nurses in less supportive ward cultures may have both a greater need for preceptorship and have fewer compensatory mechanisms available to them when formal preceptorship is not available. We argue that organisational learning contexts and individual learning styles which facilitate recontextualisation of knowledge in this group of nurses are key to understanding effective preceptorship. Conclusions: This study reports constraints to effective preceptorship which affect newly qualified nurses in their early careers. We recommend a need for greater prioritisation and ‘ring-fencing’ of time for formal preceptorship to ensure newly qualified nurses are appropriately supported in their transition to confident professional practice. Relevance to clinical practice: We discuss ways to improve preceptorship at ward and organizational level through policy, practice and education and suggest future research in this are

Delegation and supervision of health care assistants’ work in the daily management of uncertainty and the unexpected in clinical practice: invisible learning among newly qualified nurses

The invisibility of nursing work has been discussed in the international literature but not in relation to learning clinical skills. Evans and Guile’s (2012) theory of recontextualisation is used to explore the ways in which invisible or unplanned and unrecognised learning takes place as newly qualified nurses learn to delegate to and supervise the work of the health care assistant. In the British context, delegation and supervision are thought of as skills which are learnt ‘on the job’. We suggest that learning ‘on-the-job’ is the invisible construction of knowledge in clinical practice and that delegation is a particularly telling area of nursing practice which illustrates invisible learning. Using an ethnographic case study approach in three hospital sites in England from 2011-2014, we undertook participant observation, interviews with newly qualified nurses, ward managers and health care assistants. We discuss the invisible ways newly qualified nurses learn in the practice environment and present the invisible steps to learning which encompass the embodied, affective and social, as much as the cognitive components to learning. We argue that there is a need for greater understanding of the ‘invisible learning’ which occurs as newly qualified nurses learn to delegate and supervise

'Doing the writing' and 'working in parallel': how 'distal nursing' affects delegation and supervision in the emerging role of the newly qualified nurse

Background: The role of the acute hospital nurse has moved away from the direct delivery of patient care and more towards the management of the delivery of bedside care by healthcare assistants. How newly qualified nurses delegate to and supervise healthcare assistants is important as failures can lead to care being missed, duplicated and/or incorrectly performed. Objectives: The data described here form part of a wider study which explored how newly qualified nurses recontextualise knowledge into practice, and develop and apply effective delegation and supervision skills. This article analyses team working between newly qualified nurses and healthcare assistants, and nurses' balancing of administrative tasks with bedside care. Methods and Analysis: Ethnographic case studies were undertaken in three hospital sites in England, using a mixed methods approach involving: participant observations; interviews with 33 newly qualified nurses, 10 healthcare assistants and 12 ward managers. Data were analysed using thematic analysis, aided by the qualitative software NVivo. Findings:Multiple demands upon the newly qualified nurses' time, particularly the pressures tomaintain records, can influence how effectively they delegate to, and supervise, healthcare assistants. While some nurses and healthcare assistants work successfully together, others work ‘in parallel’ rather than as an efficient team. Conclusions: While some ward cultures and individual working styles promote effective team working, others lead to less efficient collaboration between newly qualified nurses and healthcare assistants. In particular the need for qualified nurses to maintain records can create a gap between them, and between nurses and patients. Newly qualified nurses require more assistance in managing their own time and developing successful working relationships with healthcare assistants

Interactional Structure Applied to the Identification and Generation of Visual Interactive Behavior: Robots that (Usually) Follow the Rules

Peer reviewe

Non-equilibrium dynamics in an interacting nanoparticle system

Non-equilibrium dynamics in an interacting Fe-C nanoparticle sample, exhibiting a low temperature spin glass like phase, has been studied by low frequency ac-susceptibility and magnetic relaxation experiments. The non-equilibrium behavior shows characteristic spin glass features, but some qualitative differences exist. The nature of these differences is discussed.Comment: 7 pages, 11 figure

Body fatness and physical activity at young ages and the risk of breast cancer in premenopausal women

We examined the relationship between body fatness, sports participation and breast cancer risk in 1560 premenopausal cases and 1548 controls, from three related population-based case–control studies in the UK. Half of the women with breast cancer were aged less than 36 years at diagnosis. Women who perceived themselves as plump at age 10 years had a relative risk of 0.83 (95% confidence interval 0.69–0.99, P=0.03) as compared with those who perceived themselves as thin. Self-reported obesity compared with leanness at diagnosis was associated with a relative risk of 0.78 (95% confidence interval 0.56–1.06, P=0.11). Women who reported having been plump at age 10 years and overweight or obese at diagnosis had a relative risk of 0.75 (95% confidence interval 0.56–1.01, P=0.06) as compared with those who reported being thin at age 10 years and at diagnosis. Findings for three related measures of body fatness suggested that obesity is associated with a reduced risk of premenopausal breast cancer. There was no association between sports participation and breast cancer risk in these premenopausal women. The relative risk for spending an average of more than 1 h per week in sports compared with less from ages 12 to 30 years was 1.00 (95% CI 0.86–1.16, P=0.98)

Memory and chaos in an Ising spin glass

The non-equilibrium dynamics of the model 3d-Ising spin glass - Fe$_{0.55}$Mn$_{0.45}$TiO$_3$ - has been investigated from the temperature and time dependence of the zero field cooled magnetization recorded under certain thermal protocols. The results manifest chaos, rejuvenation and memory features of the equilibrating spin configuration that are very similar to those observed in corresponding studies of the archetypal RKKY spin glass Ag(Mn). The sample is rapidly cooled in zero magnetic field, and the magnetization recorded on re-heating. When a stop at constant temperature $T_s$ is made during the cooling, the system evolves toward its equilibrium state at this temperature. The equilibrated state established during the stop becomes frozen in on further cooling and is retrieved on re-heating. The memory of the aging at $T_s$ is not affected by a second stop at a lower temperature $T'_s$. Reciprocally, the first equilibration at $T_s$ has no influence on the relaxation at $T'_s$, as expected within the droplet model for domain growth in a chaotic landscape.Comment: REVTeX style; 4 pages, 4 figure

Influence of acetaminophen and ibuprofen on in vivo patellar tendon adaptations to knee extensor resistance exercise in older adults

Millions of older individuals consume acetaminophen or ibuprofen daily and these same individuals are encouraged to participate in resistance training. Several in vitro studies suggest that cyclooxygenase-inhibiting drugs can alter tendon metabolism and may influence adaptations to resistance training. Thirty-six individuals were randomly assigned to a placebo (67 ± 2 yr old), acetaminophen (64 ± 1 yr old; 4,000 mg/day), or ibuprofen (64 ± 1 yr old; 1,200 mg/day) group in a double-blind manner and completed 12 wk of knee extensor resistance training. Before and after training in vivo patellar tendon properties were assessed with MRI [cross-sectional area (CSA) and signal intensity] and ultrasonography of patellar tendon deformation coupled with force measurements to obtain stiffness, modulus, stress, and strain. Mean patellar tendon CSA was unchanged (P > 0.05) with training in the placebo group, and this response was not influenced with ibuprofen consumption. Mean tendon CSA increased with training in the acetaminophen group (3%, P < 0.05), primarily due to increases in the mid (7%, P < 0.05) and distal (8%, P < 0.05) tendon regions. Correspondingly, tendon signal intensity increased with training in the acetaminophen group at the mid (13%, P < 0.05) and distal (15%, P = 0.07) regions. When normalized to pretraining force levels, patellar tendon deformation and strain decreased 11% (P < 0.05) and stiffness, modulus, and stress were unchanged (P > 0.05) with training in the placebo group. These responses were generally uninfluenced by ibuprofen consumption. In the acetaminophen group, tendon deformation and strain increased 20% (P < 0.05) and stiffness (−17%, P < 0.05) and modulus (−20%, P < 0.05) decreased with training. These data suggest that 3 mo of knee extensor resistance training in older adults induces modest changes in the mechanical properties of the patellar tendon. Over-the-counter doses of acetaminophen, but not ibuprofen, have a strong influence on tendon mechanical and material property adaptations to resistance training. These findings add to a growing body of evidence that acetaminophen has profound effects on peripheral tissues in humans

Menopausal hormone therapy and other breast cancer risk factors in relation to the risk of different histological subtypes of breast cancer: a case-control study

INTRODUCTION: Breast cancers of different histology have different clinical and prognostic features. There are also indications of differences in aetiology. We therefore evaluated the risk of the three most common histological subtypes in relation to menopausal hormone therapy and other breast cancer risk factors. METHODS: We used a population-based case-control study of breast cancer to evaluate menopausal hormone therapy and other breast cancer risk factors for risk by histological subtype. Women aged 50 to 74 years, diagnosed with invasive ductal (n = 1,888), lobular (n = 308) or tubular (n = 93) breast cancer in Sweden in 1993 to 1995 were compared with 3,065 age-frequency matched controls randomly selected from the population. Unconditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for ductal, lobular, and tubular cancer. RESULTS: Women who had used medium potency estrogen alone were at increased risks of both ductal and lobular cancer. Medium potency estrogen-progestin was associated with increased risks for all subtypes, but the estimates for lobular and tubular cancer were higher compared with ductal cancer. We found OR 5.6 (95% CI 3.2–9.7) for lobular cancer, OR 6.5 (95% CI 2.8–14.9) for tubular cancer and OR 2.3 (95% CI 1.6–3.3) for ductal cancer with ≥5 years use of medium potency estrogen-progestin therapy. Low potency oral estrogen (mainly estriol) appeared to be associated with an increased risk for lobular cancer, but the association was strongest for short-term use. Reproductive and anthropometric factors, smoking, and past use of oral contraceptives were mostly similarly related to the risks of the three breast cancer subtypes. Recent alcohol consumption of > 10 g alcohol/day was associated with increased risk only for tubular cancer (OR 3.1, 95% CI 1.4–6.8). CONCLUSION: Menopausal hormone therapy was associated with increased risks for breast cancer of both ductal and lobular subtype, and medium potency estrogen-progestin therapy was more strongly associated with lobular compared with ductal cancer. We also found medium potency estrogen-progestin therapy and alcohol to be strongly associated with tubular cancer. With some exceptions, most other risk factors seemed to be similarly associated with the three subtypes of breast cancer