"I'm not an investigator and I'm not a police officer" : a faculty's view on academic integrity in an undergraduate nursing degree

In nursing, expectations of honesty and integrity are clearly stipulated throughout professional standards and codes of conduct, thus the concept of academic integrity has even more impetus in preparing students for graduate practice. However, a disparity between policy and practice misses the opportunity to instil the principles of academic integrity, and at its core honesty, a pivotal trait in the nursing profession. This study draws upon the experience of the nursing faculty to explore how academic integrity policy of deterrence operate in nursing education. While participants deplored cheating behaviours, they expressed frustration in having to ‘police’ large numbers of students who had little awareness of the academic standards to meet policy requirements. In addition, they were cynical because of a perceived lack of severity in sanctions for students who repeatedly breached integrity. Participants expressed a moral obligation as educators to meet student learning needs and preferred to engage with students in a more meaningful way to uphold academic integrity. The ambivalence to detect and report breaches in integrity undermines the effectiveness of policy. Therefore, faculty must recognise the importance of their role in detecting and escalating cases of dishonesty and execute deterrence in a more consistent way. To do this, greater support at an institutional level, such as smaller class sizes, inclusion in decision making around sanctions and recognition of additional workload, will enable faculty to uphold policy. Although policing was not their preferred approach, the role of faculty in detecting and reporting cases of misconduct is crucial to increase the certainty of students getting caught, which is essential if policy is to be effective in deterring dishonest behaviour

Death in hospital following ICU discharge : insights from the LUNG SAFE study

Background: To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward. Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments (‘treatment limitations’), and the subpopulations with treatment limitations. Results: 2186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in hospital after ICU discharge were older, more likely to have COPD, immunocompromise or chronic renal failure, less likely to have trauma as a risk factor for ARDS. Patients that died post ICU discharge were less likely to receive neuromuscular blockade, or to receive any adjunctive measure, and had a higher pre- ICU discharge non-pulmonary SOFA score. A similar pattern was seen in patients with treatment limitations that died in hospital following ICU discharge. Conclusions: A significant proportion of patients die in hospital following discharge from ICU, with higher mortality in patients with limitations of life-sustaining treatments in place. Non-survivors had higher systemic illness severity scores at ICU discharge than survivors. Trial Registration: ClinicalTrials.gov NCT02010073

Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure : an analysis of the LUNG SAFE database

Background: Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF). Methods: An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples. Results: Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest. Conclusions: In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS. Trial registration: NCT02010073. Registered on 12 December 2013

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries

Background: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. Methods: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Results: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. Conclusions: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality

Supporting student learning through the use of a sequential case study workbook : an inductive content analysis of student feedback

Background: The use of workbooks to support nursing student learning are not new. Used in a variety of guises and differing delivery formats from printed to electronic, enables nursing students to engage in specific complex patient conditions with the view to enhancing and support learning. However, evaluating the effectiveness of the workbook itself is often overlooked, instead value is expressed in academic success. Aim: The aim of this study was to evaluate the effectiveness of a sequential based workbook to support student learning. Method: Inductive content analysis was used to identify text patterns from end of semester student feedback. In all, three generic themes were identified – Usability, Knowledge and Content and Workload to create a main theme – The Living Workbook. Results: On the whole students found the workbook a user-friendly medium to support learning and importantly being able to apply the knowledge into the practice setting. There were a number of students who disliked the workbook because of the complexity of the case studies being presented and for being content heavy. Conclusions: Despite the challenges of passing the unit, the use of a sequential workbook to enhance the reality of providing nursing care to complex and challenging patient conditions was seen favourably

Connecting generic academic integrity modules to professional integrity through curriculum design

Many higher education providers have introduced online, academic integrity modules to maintain academic standards, control risks to quality, and demonstrate that students are aware of fundamental principles of academic integrity. In Australia, these modules assist providers in meeting regulatory requirements and controlling risks to the credibility of qualifications and institutional reputation. Often developed by academic librarians, generic academic integrity modules demonstrate the expertise librarians contribute to broader educative approaches to academic integrity. They are generally one of a range of institutional strategies to address risks posed by academic cheating services and other emerging challenges to academic integrity. Students are generally required to complete them as a prerequisite to enrollment or within a set period following enrollment. Failure to complete modules can lead to consequences for students, such as preventing them from enrolling in their chosen course, accessing the learning management system or receiving assessment results, or limiting further progression. Providers may benefit from economies of scale derived from centralized online modules and compulsory completion supports compliance. However, a punitive approach to noncompletion may not lead to the outcomes intended when completion is mandated, especially where outcomes are framed in general terms related to increasing awareness of academic integrity, perceptions of misconduct, or, in more specific terms, related to engagement in misconduct. Taking a  “carrot”  approach, where students see the relevance to their chosen discipline and profession, can support meaningful engagement, connecting students with professional standards and values rather than completing modules simply to avoid consequences for noncompletion. As part of an educative approach to academic integrity at the course or program level, this can add value by strengthening or leveraging existing systems of social regulation rather than undermining them. Framing outcomes with reference to professional accreditation standards can support internal quality assurance, overcoming some of the limits of external quality assurance

Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence-based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on-call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on-call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence-based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non-therapeutic laparotomy rates

'Statistical significance' in research : wider strategies to meaningfully interpret findings

Background: The P-value is frequently used in research to determine the probability that the results of a study are chance findings. A value less than 0.05 was once typically considered only to mean that results are ‘statistically significant’, as it indicates the chance they are false positives is less than one in 20 (5%). However, P<0.05 has transcended into meaning a study has had positive findings and its results are true and meaningful, increasing the likelihood it will be published. This has led to researchers over-emphasising the importance of the P-value, which may lead to a wrong conclusion and unethical research practices. Aim: To explain what the P-value means and explore its role in determining results and conclusions in quantitative research. Discussion: Some researchers are calling for a move away from using statistical significance towards meaningful interpretation of findings. This would require all researchers to consider the magnitude of the effect of their findings, contemplate findings with less certainty, and place a greater emphasis on logic to support or refute findings – as well as to have the courage to consider findings from multiple perspectives. Conclusion: The authors argue that researchers should not abandon P-values but should move away from compartmentalising research findings into two mutually exclusive categories: ‘statistically significant’ and ‘statistically insignificant’. They also recommend that researchers consider the magnitudes of their results and report whether findings are meaningful, rather than simply focusing on P-values. Implications for practice: Lessening the importance of statistical significance will improve the accuracy of the reporting of results and see research disseminated based on its clinical importance rather than statistical significance. This will reduce the reporting of false positives and the overstatement of effects

"Integrity is integrity. IT doesn't matter the context" : a qualitative exploratory study of academic integrity in an undergraduate nursing program

Academic integrity is integral to the development of knowledge, clinical skills, and the professional development of nursing students, and provides an inextricable link to the standards for professional nursing practice. A semi-structured interview of 11 nursing academics was undertaken to explore academic integrity in an undergraduate nursing program in a large, Australian metropolitan university. An inductive approach to thematic analysis was used to identify the following themes (1) Graduate attributes: the participants believed academic integrity was important in equipping nurses with the knowledge, skills, critical thinking, and moral integrity necessary to support decision making in clinical practice. They expressed concerns that dishonest behavior may be transferred into clinical practice and threaten patient safety. (2) Gatekeepers: participants viewed themselves as gatekeepers, with vested interest to protect patients and the professional reputation of nursing. (3) Role models: participants instilled integrity in students nurses through dialog and role modeling of discipline-specific values. (4) Curriculum: participants believed that assessment design, course content and the physical environment influenced a student’s ability to maintain integrity. Based on these findings, the participants identified a greater focus on the importance of academic integrity in the development of graduate attributes should be made more explicit to nursing students throughout their studies. A focus to learning with integrity will create notable learning opportunities and better prepare students for future professional practice

Factors associated with similarity index (SI) scores among a large cohort of undergraduate nursing students

Similarity index (SI) generated by text matching software (TMS) on written assessment tasks is routinely collected by universities and used by academics to flag potential cases of plagiarism in an era of prolific electronic information. (Bertram Gallant, 2008). For students, SI provides feedback on how they have paraphrased the work of others in terms of text matching, thus providing the opportunity to restructure text as required to reduce their SI to avoid plagiarism. Therefore paraphrasing is an important academic writing skill that has been adopted by many universities to improve academic integrity