Critical Analysis of two peer-reviewed research Articles, health and medicine homework help

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NSG 3029 FOUNDATIONS OF NURSING RESEARCH POWERPOINT PRESENTATION RUBRIC CRITERIA Introduction to the research articles • 10 States authors, title, publication of the articles Article #1 • Purpose • Background and significance of the problem • Methodology • Interpretation of findings Article #2 • Purpose • Background and significance of the problem • Methodology • Interpretation of findings Synthesis of information • Compares and contrasts both articles and their components • Synthesize information in both articles to develop and present a unique perspective on the topics Recommendation for the future research • POSSIBLE POINTS Summary of recommendations from both articles 20 20 40 30 EARNED POINTS Application of research articles in nursing practice • 30 Outlines the research findings for the use in nursing practice PowerPoint presentation quality • PowerPoint presentation is organized, wellconstructed, legible, and directed to RNs (classmates) • Presentation is not more than 15 min at length with a maximum of 15 slides • Slides are easy to understand with catchy design and graphics • Reference slide is done per APA guidelines • Slide references are correctly cited on the slide 50 200 TOTAL: Feedback: Critical Analysis of Two Peer-Reviewed Research Articles [Students’ Names] Articles Reviewed •[Article #1 = must be APA format] •[Article #2= must be APA format] Article #1: Purpose •[type purpose here] Article #1: Background and Significance of the Problem •[bullets only] •[bullets only] •[bullets only] •[bullets only] •[bullets only] •[bullets only] •[bullets only] Article #1: Methodology •Sampling Technique –[type here] •Sample Characteristics –[type here] •Setting –[type here] Article #1: Interpretation of Findings •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] Article #2: Purpose •[type purpose here] Article #2: Background and Significance of the Problem •[bullets only] •[bullets only] •[bullets only] •[bullets only] •[bullets only] •[bullets only] •[bullets only] Article #2: Methodology •Sampling Technique –[type here] •Sample Characteristics –[type here] •Setting –[type here] Article #2: Interpretation of Findings •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] •[BULLETS only = type answer here] Synthesis of Information •[Compare and contrast both articles = i.e. compare & contrast the methodology used, between these articles, which research utilized better research technique?; is Article #1’s results similar or different from Article #2’s results; etc.] Synthesis of Information •[Combine, “synthesize,” the information in the research articles to develop an argument or a unique perspective on a topic] Recommendations for Future Research •[recommendations MUST be a summary from BOTH research articles] •Bullets ONLY •Bullets ONLY •Bullets ONLY •Bullets ONLY •Bullets ONLY Application of Research Articles in Nursing Practice 1.[text here] 2.[text here] 3.[text here] 4.[text here] 5.[text here] 6.[text here] 7.[text here] References •Your texts here MUST be written in an APA, 6th ed format. Please refer to your notes and visit the library. Research Stress in hospice at home nurses: a quahtative study of their experiences of their work and wellbeing Karen Tunnah, Angela Jones, Rosalynde Johnstone P alliative care nursing can be a rewarding but emotionally stressful specialty in which to work, and therefore stress and burnout may contribute to issues of staff sickness and retention. Studies have shown that although staff perceive themselves as coping, many nurses do experience compassion fatigue and burnout (Abendroth and Flannery, 2006; Edmunds, 2010). The purpose of this study was to undertake an assessment of hospice at home nurses' experiences and wellbeing while caring for palliative and dying patients. Anecdotal evidence identified a lack of education and training regarding self-help strategies in the local nursing team. Clinical supervision is available for the team but uptake had been poor. The literature includes studies undertaken with palliative care nurses working in a hospice environment, but few published studies have looked specifically at hospice nurses working out in the community. Background Nursing has been described in many studies as a demanding and stressful profession, particularly for those working in direct clinical care (Hawkins et al, 2007; Edmunds, 2010). Compassion fatigue may be triggered by becoming overly empathetic with patients, having unreal expectations of outcomes, and experiencing personal crises (Abendroth and Flannery, 2006). It may affect an individual caring for someone who is experiencing a traumatic event such as dying. A nurse may experience helplessness and react by turning off his or her emotions. Compassion fatigue is also often linked to burnout, which can be defined as: emotional exhaustion, sometimes accompanied by a cynical approach, that can be experienced by individuals in a caring role (Maslach and Jackson, 1991). Burnout may affect the mental and physical health of the nurse, which could ultimately affect the quality of their nursing care (Maslach and Jackson, 1991). Some have also suggested that burnout is contagious International Journal of Palliative Nursing 2012, Voi 18, No 6 Abstract The literature has evaluated studies of hospice nurses and stress but very few studies have focused on community hospice nurses. This study explored hospice at home nurses' experiences of caring for palliative and dying patients. Hospice at home nurses working in the community across North West Wales were interviewed and a grounded theory approach was used to categorise the data into the following themes: job satisfaction, Stressors, coping strategies, and support. Recommendations arising from the study include encouraging the use of clinical supervision, attendance at multidisciplinary meetings, and the provision of stress-awareness training, and raising awareness of the role of hospice at home nurses in primary care. Implementation of these recommendations might be beneficial for staff wellbeing. Further work would identify whether such recommendations can help to prevent sickness and promote staff retention. Key words: Hospice at home nurses # Stress and coping • Dying patients • Qualitative methods and can be communicated from one nurse to another (Bakker et al, 2005). Palliative care nursing is often viewed as a psychologically distressing and stressful specialty (Gambles et al, 2003). Palliative care nurses are fully aware that all the patients in their care have an incurable illness with a life-limiting prognosis and are expected to die. Furthermore, national strategies such as the UK's End of Life Care Strategy (Department of Health, 2008) promote high-quality care for all adults at the end of life, which includes conditions with complex needs. This may pose further challenges and stresses for palliative care staff. However, it is now recognised that the benefits of early intervention and symptom control in the palliative patient help to maintain quality of life (World Health Organization, 2002). Also, studies suggest that palliative care staff report lower levels of burnout than other specialties, including oncology and intensive care nursing (Vachon, 1995). Lower levels of distress have also been reported for hospice nurses than for staff Karen Tunnah is Hospice at Home Nurse; Angela Jones is Clinical Nurse Manager; Rosalynde Johnstone is Project Manager, Betsi Cadwalader University Health Board, Palliative Care Department, Bodfan Eryri Hospital, Caernarfon, Gwynedd LL55 2YE, Wales Correspondence to: Rosalynde Johnstone Rosalynde.johnstone® wales.nhs.uk 283 Research ^Studies have shown that although staff perceive themselves as coping, many nurses do experience compassion fatigue and burnout...* working in other areas, whicb implies that hospices are positive environments in which to work (Payne, 2001). The same study examined Stressors, coping, and demographics in relation to burnout and hospice nurses. It found that Stressors such as conflict with staff made the greatest contribution to burnout. The importance of not labelling an individual as coping 'well' or 'badly' in relation to burnout has also been highlighted, as this can oversimplify the coping/burnout relationship (Payne, 2001). The participants in the study reported here were hospice at home nurses working in the community setting, which is not compatible with the nurses in Payne (2001). The role of the hospice at home nurse embraces the biopsychosocial approach to human functioning, particularly in relation to illness or disease (Engel, 1977). The importance of psychosocial factors in nursing is recognised, and tbe development of a close, holistic relationship with patients is encouraged (Aldridge, 1994; Luker, 1997). This can take a considerable amount of time (Skilbeck and Payne, 2003). Hospice at home nurses can spend between 1 and 2 hours with the patient and their family on a first visit. Subsequent visits may be shorter or longer depending on the needs of the patient and tbe disease progression. Toward the end of life the hospice at home nurse may need to make multiple extended visits on one day. The emotional element of 'getting to know' patients and their families is difficult to define, not least because of the lack of clarity surrounding the terminology. The phrase 'emotional care and support' is used interchangeably with 'psychological care and support' or 'psychosocial care' (Skilbeck and Payne, 2003). However, different meanings can be attributed to each term depending on the contexts and theoretical backgrounds. The term 'emotional labour' draws on a sociological background and is used to represent hard work, and indeed the difficulty of caring for patients at tbe end of life has been acknowledged (Froggatt, 1998; Jones, 2001a). Emotional labour places demands on the individual as tbey are constantly creating and sustaining relationships with patients who subsequently die. Tbe nurse tben has the continuous task of assimilating the loss of the patient and of the relationship. Dealing with the demands of this emotional 'yo-yo' may gradually erode one's resilience and result in stress-related issues for the nurse. However, tbe emotional labour involved in palliative care is often underestimated and undervalued (Henderson, 2001). Mechanisms for coping with this aspect of nursing dying patients are varied and well 284 documented (James, 1993; McNamara et al, 1995; Froggatt, 1998; Jones, 2001b). The benefit of staff training in self-care tbrough counselling sessions and stress inoculation training is recognised (Ablett and Jones, 2007; Desbiens and Fillion, 2007). It bas been suggested that the opportunity for reflective practice in end-of-life care may help staff come to terms with the emotional impact of tbe work (Jones, 2001b). Some researchers suggest that a stress-resistant personality type and personal factors such as hardiness and a sense of stability and structure may enable hospice nurses to be buffered from the stressful effects of palliative care nursing (Ablett and Jones, 2007). Factors that promote resilience and wellbeing in nurses could be developed through training and supervision (Ablett and Jones, 2007). Clinical supervision and reflection are recognised as viable mechanisms for supporting palliative care nurses (Jones, 2001b). However, there is a lack of agreement concerning definitions, models, and use of clinical supervision. Known variously as 'mentorship', 'supervision by manager', and 'reflective practice', clinical supervision was very popular in the late 1990s; however, little is known about how or wbetber it is used by clinical nurse specialists (Yegdicb and Cusbing, 1998; Skilbeck and Payne, 2003; Jones, 2006). Aim The aim of the study was to explore the feelings and experiences of hospice at home nurses when providing palliative nursing care for patients in tbe community. Tbe study sought to identify key issues that contribute toward stress in hospice at home nurses working in primary care. Method Qualitative methodology was used as this is more suited to exploratory studies of people in their natural settings. The potential participants were a team of hospice at bome nurses working in the community across a large rural area in North West Wales. Ethics The study was presented to the North Wales Research Ethics Committee-West and a favourable opinion was awarded subject to management permission being granted. The study was given full management permission in accordance with NHS research governance arrangements. Research team The research team comprised the nursing team leader (with management, clinical, and research International Journal of Palliative Nursing 2012, Voi 18, No 6 Research experience), the project manager (with management and research experience), and a hospice at home nurse (with clinical experience). Items in i-jlics were used as prompts for the inier^iewer in the event that the intervie'Vre had dfficulty responding to th= question. Participants The hospice at home nursing team in North West Wales comprises ten qualified nurses and one health-care assistant. All had worked in the palliatiye care setting for a minimum of 12 months. The nurses deliver 'hands on' nursing care in collaboration with various community nursing teams, providing symptom control and advice for patients and their carers in the community. Their work sometimes necessitates travelling distances between 10 and 110 miles per day. The nurses were informed of the study and invited to participate at the regular nurses' meeting by their colleage, the first listed author. It was made clear that they were under no obligation to take part and that they could withdraw at any time during or after the study without having to provide a reason and without fear of compromising their working relationships. Confidentiality was assured both verbally and in writing, with the usual exception of disclosure of any unsafe, unethical, or illegal practice. Age: Gencer General nursing experience: Hospice njrsing experience: QualificitJDns: Area of v^ork: I a) Can you tell m 2 about a good working day as a. hcspice nurse? /) What wojtd yoL say contributed towards mating it c good day? I b) Can >ou tell me about your worst working day as a hospice nurse? i) Whatwojtd yoL say contributed towards mailing it your worst doy? 2) How do you leel your work affects y /) Woutd yoj soy iz affects you physicatly? In what na/? ii) WouHycu soy i effects you mentally? In what wa/? 3) Hov» do you cope with an emotionally d^mandng day? Data collection /) Woutd yoj soy you totk to work colleagues? Each nurse was asked to participate in a taperecorded semi-structured interview lasting a maximum of 45 minutes. The interviews were conducted by the palliative care project manager. This position has no professional responsibility for tbe nursing team (managerial or otherwise) and is external to the hospice at home nursing service. The interviews all took place in the palliative care department in a quiet designated room at times convenient for the nurses and fitting in with their clinical duties. As the interviews could prove to be emotional or distressing, the nurses were offered the opportunity of counselling. There is currently an arrangement between an independent counselling service and the Health Board to provide free counselling sessions for Health Board employees. ii) Would ycu say »oo talk to family? Tbe interview schedule is provided in Box 1. The interview comprised a list of open-ended questions, guided by tbe interviewer. Interviewer prompts were included to avoid long silences during the interview process. Leading questions were avoided. The questions were managed in a conversational style to maximiseflexibilityand versatility. Data analysis The transcripts of each interview were analysed using the grounded theory approach initially developed by Glaser and Strauss (1967). Tbis International journal of Palliative Nursing 2012, Vol 18, No 6 Hi) VVou.'c jau soy you talk to your mar\ager? iv) VVou.'c jou soy you totk to friends? 4) Hov» w o u l d youi say you cope w i t h t h e p i y s i i a l demands of y o u r w o r k i n g day? /) Woutd yoj soy ycu exercise, watk, cycle or gc to the g/m' ii) Would ycu say »ou relox m a warm both? Hi) Wou.c jrou say yoj switch off in front of the TV? iv) Would ycu soy ."ou catch up with outstandhg househo/d /obs such os ckoning or gardening? 5) Hov" would youi say you cope with the psychological demands oí your working day? i) Would you soy you browse the internet? it) Would ycu say rou discuss your day with others? Hi) Wou,c you say yo j meditate or use any other form z-fmentol exercise.' iv) WOU.Û you soy yoj hove on eorly night? approach :s favoured in nursing and the isodal sciences >wing tc the systematic and structured way that the data are collected and analysed. The term 'grounded theory' refers to the idea that the data are not obtained from tl-.e researchers' preconceived hypothesis but are discovered or derived!. Themes that are repeatedly present or notably ¿bsent in the data are deemed significant enough to be categorised and each aisce oJ data 285 Research 6) How would you say you oope ./vith the demands: put on you by other health professionals? 7) How do you feel your job impacts on your famil/ life? 8) How does continually nursing dying patients affect your daily life? 9) During your time as a hospice at home nurse ha/e there been any training or support events that you felt »vere beneficie ? 10) Is there anything further that you wou d like t o discuss? i) Do you have any suggestions ttiat would improve yoir daily work experience? 11) Is there anything you would '/f:e to see put n place to improve your daily work experience? Thank you for participating in thi; study. is constantly compared with another until no further new data aie discovered. Data analysis was carried out following transcription of all of the interviews. The transcripts were typed verbatim with the exception of participant names, which were omitted. The transcripts v/ere independently read and re-read for familiarity b^ individual members of the research teair, who were blmd to each others' critique of the data until the^ met to discuss the content of the transcripts. The ckta were analysed by an open coding procedure in which the first step of the analysis is conceptúalisaticn of the data. Concepts are identified through analytical procedures such as isking quest.ons about the data and looking for differences £.nd sirüilarities between phenomena, events, and incidents through constant comparison. The common themes that emerged from the data were tl'.en grouped together for identification and labelled with an abstract name to produce categories. Meticulous reccrds of the research process were mainiained with the aim that other researchers would be able to analyse the data and reach the sam; conclusions. Analysis triangularion by the different members of the team was intended to ensure reliability and reduce bias and error. Results and discussion Of the ten registered nurses in the hospice at home nursing team, seven participated in the study. One nurse '^as excluded because she had a rcle in tiie research team, one nurse was 286 absent on maternity leave, and one nurse declined to participate. The reason given for non-participation was that the nurse preferred the interview to be conducted in Welsh. This option was not available to the study without introducing extra financial costs and increasing potential bias. All of the nurses were female, and they had an average age of 54 years (range 41-62 years). All were registered nurses at a minimum, with a mean of 24 years of nursing experience (range 10-39 years). There was unanimous consensus among the research team that four super-ordinate themes emerged from the data: O Job satisfaction O Stressors O Coping strategies O Support. Job satisfaction Job satisfaction was identified as an important determinant of the nurses' stress levels. Several of the nurses discussed the merits of 'making a diffeirence': 'When you've walked in and there's a crisis, the patient is in pain, family in distress, they are not coping, they are frightened. By the time you have left the home, having sorted out the pain, the symptom control issues and you've calmed the waters ... the families are happy.' Nurse 2 'I mean we can make things better. We can't change what's happening but we can make a difference.' Nurse 7 'If you can nurse someone at home and make them as comfortable as possible in their last days of life, it's a privilege to do it ... it's well worth everything you do.' Nurse 1 Similar views from nurses regarding the rewards of nursing dying patients were reported in a study from Taiwan (Wu and Volker, 2009). These Thai nurses acknowledged the job satisfaction and sense of self-worth obtained from helping their patients achieve a good death. However, it should be noted that there are significant differences between the cultures and approaches to end-of-life care between a hospice in Taiwan and the setting of- the present study. Another study that investigated stress in palliative care nurses also identified a theme called 'making a difference' (Ablett and Jones, 2007). In the study reported here the nurses' commitment to their work and the sense of being in control of International Journal of Palliative Nursing 2012, Vol 18, No 6 Research the work situation were indicated as being a source of job satisfaction. Contact with dying patients was also indicated to be a key source of job satisfaction by Grunfeld et al (2005). Prioritising the workload was important for the nurses in the present study to be able to manage their day effectively: 'The distances that you are travelling between patients and the requests for input can be demanding. You've got to be assertive and say 'No, I can't physically do that.' You need to prioritise patient care and then go with that priority.' Nurse 1 The large distances involved in the nurses' daily work and the collaboration with a number of community nursing teams, all with different demands, can result in increased activity and stress for the hospice at home nurses. A study of district nurses found that they had similar experiences when caring for dying patients (Burt et al, 2008). Stressors The nurses identified conflict with colleagues from outside the team and difficulty communicating with the GPs and district nurses as a source of stress: 'The GPs can be difficult to get hold of and they are not always proactive, and without that, then your job is almost impossible to do.' Nurse 2 Nurse 7 identified that district nurses are now also so busy that palliative patients are missing out on visits: 'That's quite stressful, when you tell a colleague that a patient is going down or whatever, they don't hear, because they don't want to hear what you are saying.' In a recent study, 'fellow workers not doing their job' was among the top identified Stressors, along with feelings of isolation (Martens, 2009). Nurse 1 described occasionally feeling lonely and isolated: 'Maybe you don't want to talk so much when you finish your shift. I think it does affect you.' Nurse 7 Conversely, another nurse denied feeling mentally affected by the job: 'I think that it is down to experience, age and maturity. If the work started to worry me ... that's when I stop.' Nurse 4 Sources of emotional labour and occupational stress in female hospice nurses were also identified by Payne (2001). The most frequent Stressor was 'death and dying', then 'inadequate preparation', followed by conflict with doctors and nurses. The least problematic Stressors were 'lack of support' and 'uncertainty of treatment'. However, organisational factors such as a high workload and lack of resources and support have been identified as a significant source of stress for hospice nurses by other studies (Hawkins et al, 2007). Occupational stress is recognised as a major reason for ill health; however, it must also be noted that the stresses experienced are context-dependent (Desbiens and Eillion, 2007; Martens, 2009). Consequently, it is important that the introduction of any coping strategies decreases stress and promotes positivity, encouraging a beneficial response. Coping strategies The nurses identified the need to 'switch off after work: 'It's very sad really, you know when it comes to the end of their life it can hit you emotionally, but I don't take it home and think about it for hours.' Nurse 1 'I can switch off at the end of the day, I've always been able to do it because I don't think you do your patients any good if you're fretting too much and can't do your job properly the following day.' Nurse 3 Many of the nurses said that walking and exercise were means to help them unwind after a difficult day: 'It depends on the patient, on their family, it depends whether your local colleagues are working as well or whether you are on your own.' 'I find exercise helps. I go to the gym twice a week in the morning and I find that really helps.' Nurse 7 Many of the nurses commented that the job was 'mentally draining'—more so than working in a different clinical scenario. Other after-work relaxation methods included watching television, listening to music, and attending craft lessons. International ¡ournal of Palliative Nursing 2012, Voi 18, No 6 nurses identified conflict with colleagues from outside the team and difficulty communicating with the GPs and district nurses as a source of stress...* 287 Research ^Increased use of clinical supervision and reflection is indicated, along with the provision of stress-awareness training.* It has long been established that there is a medium-to-high risk of hospice nurses experiencing compassion fatigue, but also that healthy professional 'distancing' learned from years of nursing experience and 'self-care' can balance out Stressors (Abendroth and Flannery, 2006). However, it has also been reported that the job of dealing with multiple deaths and accompanying the dying does not seem to have a major affect on palliative care nurses (Desbiens and Fillion, 2007). Furthermore, stress levels are similar to or lower than in nurses working in other fields. Support The nurses identified support from colleagues as being important for their coping: 'I chat with my colleague and the district nurses ... make sure we have lunch together in the office so that we can chat and you know say how we feel, so that helps.' Nurse 5 Nurse 3 worked in a particularly isolated rural area and found that: 'Coming and mixing with the other people that you work with in the department weekly, is actually more beneficial probably than anything else.' Other nurses also found support among family and friends: 'My husband and I we do discuss things if I have got something on my mind. I would tell him ... without naming names, that's how I unload properly.' Nurse 6 The majority of the nurses in Wu and Volker's (2009) study identified the importance of seeking peer support, especially if there is a difficult case, and support from colleagues was also recognised in Payne's (2001) study. Social support has been found to be an important coping strategy, and supervision and support groups should be encouraged as an approach to coping with stress (Hawkins et al, 2007). The use of reflection in and on practice for the nurses in the present study takes place both informally among the team and formally at the weekly multidisciplinary team meeting. The team meeting is recognised as being a safe and supportive place to discuss a variety of problems related to practice and complex symptom management (Arber, 2007). 288 nurses. From these, various recommendations can be made. Care providers should promote regular attendance at weekly multidisciplinary team meetings and, where relevant, local monthly team meetings including the palliative care consultant and Macmillan nurses as well as hospice at home nurses. Meetings can be held in the local place of work, supplementary to the weekly multidisciplinary team meeting. Increased use of clinical supervision and reflection is indicated, along with the provision of stress-awareness training. Raising awareness of the role of the hospice at home nurse in the primary care setting is also relevant, as conflict outside the palliative care team and communication difficulties between the hospice at home nurses and primary care teams were identified as a source of stress for the hospice at home nurses. Limitations This study was undertaken in a relatively small team of hospice at home nurses working closely with one another to provide a community palliative nursing service across a wide geographical area of North West Wales. For pragmatic reasons the project manager conducted the study interviews. Although known to the team members, the project manager does not have a clinical relationship with the nursing team members. Using an existing member of the team to undertake the role of interviewer may have had positive and negative effects. Being interviewed by a familiar person may be less threatening, leading to a more relaxed discussion. Alternatively the nurses may have felt inhibited because they knew the interviewer, although during the interview process the interviewer had no sense that the nurses felt awkward in any way. Despite the interview transcripts being anonymised and the order of the transcripts randomised for each researcher, in one or two cases it was still possible for the researchers to identify the interview participant. This familiarity was present to some degree for all three of the researchers; however, each researcher was blinded to their colleagues' critiques of the transcripts. Interestingly, consensus was quickly apparent when the researchers met to discuss the outcomes of the study. During discussion of the transcripts and identification of common themes there was agreement that saturation had been reached and no loss of data was apparent in the conclusions drawn from the transcripts. Recommendations Conclusion The study highlighted a number of factors that contribute to the wellbeing of hospice at home End-of-life care is everyone's business, from generalist to specialist, regardless of care setting. International journal of Palliative Nursing 2012, Voi 18, No 6 Research With increasing emphasis being placed on achieving preferred place of care at time of deatb, tbe hospice at home nurse represents a critical resource tbat is valuable not only to patients but also their families and health professionals. Further studies are needed to ascertain the potential of the recommended interventions to improve the wellbeing of hospice at home nurses. @i Acknowledgments The authors wish to acknowledge the participation of the hospice at home nursing team, without whose contribution this study would not have been possible. Acknowledgment is also due to the NHS organisation R&D department for sponsoring the study. Abendroth M, Flannery J (2006) Predicting the risk of compassion fatigue. / Hosp Palliât Nurs 8(6): 346-56 Ablett JR, Jones RS (2007) Resilience and well-being in palliative care staff: a qualitative study of hospice nurses experience of work. Psychooncology 16(8): 733-40 Aldridge M (1994) Unlimited liability? Emotional labour in nursing and social v/oik. J Adv Nurs 20(4): 722-8 Arber A (2007) "Pain Talk" in hospice and palliative care team meetings: an ethnography. Int J Nurs Stud 44(6): 916-26 Bakker AB, Le Blanc PM, Schaufeli WB (2005) Burnout contagion among intensive care nurses. ] Adv Nurs 51(3): 276-87 Burt J, Shipman C, Addington-Hall J, White P (2008) Nursing the dying within a generalist caseload: a focus group study of district nurses. Int] Nurs Stud 45(10): 1470-8 Department of Health (2008) End of Life Care Strategy: Promoting High Quality Care for All Adults at the End of Life. DH, London Desbiens JF, Fillion L (2007) Coping strategies, emotional outcomes and spiritual quality of life in palliative care nurses. Int] Palliât Nurs 13(6): 291-300 Edmunds MW (2010) Caring too much: compassion fatigue in nursing. 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Nurs Enquiry 8(2): 130-8 James N (1993) Divisions of emotional labour: disclosure and cancer. In: Fineman S (ed) Emotion in Organisations. Sage, London: 94-117 Jones A (2001a) A psychoanalytically informed conversation with a woman and her husband following major surgery for cancer of her neck and torso. ] Adv Nurs 35(3): 459-67 Jones A (2001b) Some experiences of professional practice and beneficial changes derived from clinical supervision by community Macmillan nurses. Eur ] Cancer Care 10(1): 21-30 Jones JM (2006) Clinical supervision in nursing. What's it all about? Clin Supervisor 24(1-2): 149-62 Luker KA (1997) Research and the configuration of nursing services. / Adv Nurs 6(4): 259-67 Martens ML (2009) A comparison of stress factors in home and inpatient hospice nurses. / Hosp Palliât Nurs 11(3): 144-53 Maslach C, Jackson SE (1991) The measurement of experienced burnout. / Occup Behav 2: 99-113 McNamara B, Waddell C, Colvin M (1995) Threats to the good death: the cultural context of stress and coping among hospice nurses. Sociol Health III 17(2): 222-41 Payne N (2001) Occupational Stressors and coping determinants of burnout in female hospice nurses. ] Adv Nurs 33(3): 396^05 Skilbeck J, Payne S (2003) Emotional support and the role of clinical nurse specialists in palliative care. / Adv Nurs 43(5): 521-30 Vachon MLS (1995) Staff stress in hospice/palliative care: a review. Palliât Med 9(2): 91-122 World Health Organization (2002) WHO definition of palliative care, www.who.int/cancer/palliative/definition/ en/ (accessed 7 June 2012) Wu HL, Volker DL (2009) Living with death and dying: the experience of Taiwanese hospice nurses. Oncol Nurs forum 36(5): 578-84 Yegdich T, Cushing A (1998) A historical perspective on clinical supervision in nursing. Aust NZ ] Ment Health Nurs 7(1): 3-24 Call for peer reviewers International journal of Palliative Nursing is very grateful for the advice provided by its pool of dedicated volunteer peer reviewers, and is always appreciative of new offers from experienced clinicians and academics interested in helping out. If you would like to be considered for the peer review team, please send a brief CV and details of your particular areas of expertise or interest to the Editor, Craig Nicholson: craig.nicholsont^markallengroup.com Guidelines for reviewers are available. International lournal of Palliative Nursing 2012, Vol 18, No 6 289 Copyright of International Journal of Palliative Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Research for Practice The Relationship of Burnout, Work Environment, and Knowledge to SelfReported Performance of Physical Assessment by Registered Nurses Anita G. Fennessey etween 210,000 and 440,000 patients die annually from preventable harm that occurred during hospitalization (Allen, 2013). The Joint Commission (2013) identified inadequate patient assessment as a primary cause of sentinel events. Assessment, the first step of the nursing process, is the systematic and ongoing collection of patient data (Nugent & Vitale, 2014). Accurate, ongoing physical assessment must be performed to achieve positive patient outcomes. Thorough physical assessment is the foundation for all planned nursing intervention and provides the framework for comparison of subsequent findings during hospitalization. Several positive outcomes have been attributed to registered nurses’ (RNs) consistent performance of thorough physical assessment. They include improved nurse-physician collaboration, decreased adverse medical events, and better patient outcomes (Giberson, Yoder, & Lee, 2011). However, research also has found nurses do not use even onehalf of the assessment skills they learned in school (Birks, Cant, Ainsley, Chung, & Davis, 2013). Burnout has been identified as a contributor to RNs’ inability to perform assessment skills consistently and thoroughly. High burnout levels also have been linked to lower job satisfaction, increased judgment errors, and decreased work efficiency (Rosales, Labrague, & Rosales, 2013). Because burnout impacts job performance, overall quality of patient care also may be affected B 346 Physical assessment by registered nurses plays a key role in preventing sentinel events. Variables that may affect nurses’ ability to perform physical assessment consistently were examined. (Morse, Salyers, Rollins, MonroeDevita, & Pfahler, 2012; Patterson, 2011). However, no specific studies link burnout to performance of physical assessment skills by RNs. Literature Review A literature review was conducted for 2011-2016 using Medline (OVID), Medline (PubMed), CINAHL, and EBSCO. Keywords included physical assessment skills, work environment, burnout, nursing assessment, and knowledge. The search included only articles written in English. Multiple studies were analyzed and reviewed prior to selecting specific studies relevant to this research. Garrosa, Moreno-Jiménez, Rodriguez-Muñoz, and Rodriquez-Carvajal (2011) discussed the link of role stress to burnout, recognizing the engagement process in relation to role stress had not been studied adequately. The purpose of their crosssectional study was to investigate the relationship of role stress and personal resources to burnout and engagement processes among nurses. Data were obtained from 508 nurses in various general hospitals in Madrid. Role stress was found to be related more to burnout, while personal resources such as emotion- al competence were associated with engagement. These findings helped to link role stress with physical assessment as part of the nurse’s role performance. Woodhead, Northrop, and Edelstein (2016) reported exposure of long-term care nursing staff to increased levels of occupational stress as well as burnout. Using the Job Demands-Resource Model of Burnout, they investigated the relationship among job demands, job resources, and burnout. Data were collected from 250 nursing staff of a long-term care facility. Hierarchical linear regression analyses indicated job demands such as greater occupational stress were linked to higher levels of emotional exhaustion, increased depersonalization, and decreased personal accomplishment. Job resources (e.g., support from supervisors, family members) were linked to higher levels of personal accomplishment and lower levels of emotional exhaustion. Researchers concluded measures to decrease burnout should include focusing on stress and social support outside the work environment. The author of the current study recognized occupational stress can impact job performance negatively. Anita G. Fennessey, DrNP, RN, CNE, is Nursing Instructor/Course Coordinator, Abington Memorial Hospital Dixon School of Nursing, Abington, PA. September-October 2016 • Vol. 25/No. 5 The Relationship of Burnout, Work Environment, and Knowledge to Self-Reported Performance of Physical Assessment by Registered Nurses Mijakoski and colleagues (2015) noted burnout may be related to increased exposure to chronic emotional and interpersonal workplace stressors. They investigated the relationship among burnout, job engagement, job pressures, and workplace culture to demonstrate differences between physicians and nurses working in a general hospital in Skopje, Republic of Macedonia. The Maslach Burnout Inventory and Utrecht Work Engagement Scale were used to measure burnout and job engagement, respectively. Work demands were measured with the Hospital Experience Scale, and workplace culture was measured using the Competing Values Framework. Higher scores of dedication and organizational work demands were found in physicians, while nurses demonstrated higher scores of clan organizational culture. However, burnout correlated negatively for nurses and physicians with clan organizational culture. By arranging sufficient job demandresources interaction, authors concluded burnout could be prevented and improved job engagement achieved. By improving job engagement and decreasing burnout, then, overall job performance (including physical assessment) also may improve. A gap exists in the literature regarding the performance of physical assessment. The researcher for the current study has observed nurses rushing through physical assessment, increasing the risk for possible inaccuracy. Exact variables contributing to RNs’ poor or inaccurate performance of physical assessment skills have not been identified specifically. However, deficiencies in nursing performance have been linked to increased stress, time constraints, nurse-to-patient ratios, and burnout (The Joint Commission, 2012). Research should determine if a relationship exists among RNs’ burnout, knowledge, and organizational attributes, and consistent performance of their physical assessment skills. Purpose The purpose of this study was to explore the relationship of RN burnout, knowledge of physical assessment skills, and work environment to self-reported physical assessment skill performance. Methods Design and Sample This descriptive correlational study used a cross-sectional data collection survey. Descriptive surveys were used to collect interval ratio data. Demographic data enabled the investigator to determine if a link existed between length of experience, types of experience, education, and RNs’ skill in performing physical assessment. A convenience non-probability sample was recruited from two hospitals (one surburban, one urban) comparable in size and number of RNs. Approximately 1,400 RNs at study institutions qualified for the study. Statistical power analysis determined a sample of 100 RNs would be representative of the population to provide scientific basis to calculate power. This calculation was based on a desired power of 80% for a median effect size (r=0.25, p=0.05) (Gaskin & Happel, 2014). Inclusion criteria were RNs practicing for more than 2 continuous years; currently employed on a medical-surgical, telemetry, or critical care unit; currently employed 16 or more hours per week; clinical nurse, including charge nurse; and ability to understand the consent process. Measures Demographic data were collected on an investigator-generated form, to include nurse’s age, sex, hours worked per week, years as an RN, entry level of nursing education, highest level of education, and current RN role. The Oldenburg Burnout Inventory (OLBI) was used to measure the degree of professional nurse burnout (Demerouti, Bakker, Vardokou, & Kantas, 2003). The OLBI assesses September-October 2016 • Vol. 25/No. 5 two core dimensions of burnout: exhaustion and disengagement. Exhaustion is described as an end result of extreme physical and emotional stress. Disengagement is defined as the separation of self from work, indicating possible lack of interest. The OLBI contains 16items (eight each in exhaustion and disengagement subscales) rated on a Likert-scale (1=strongly disagree, 5=strongly agree); a higher rating indicates a higher degree of burnout. Internal consistency was acceptable with Cronbach’s alpha over 0.70 (Reis, Xanthopoulou, & Tsaousis, 2015). The Nursing Work Index Revised (NWI-R) was used to measure organizational attributes that may affect RNs’ ability to perform physical assessment consistently (Aiken & Patrician, 2000). The NWI-R is a 57item instrument rated on a Likert scale (1=strongly agree, 4=strongly disagree). It has overall Cronbach’s alpha of 0.96. The 28-item Physical Assessment Performance Questionnaire (PAPQ) was used to test RNs’ perceived knowledge and ability to perform a complete physical assessment (Yamauchi, 2001). For each of the 28 physical assessment items using a 5-point Likert scale, questions addressed the following: knowledge and ability to perform the skill, frequency of use for each physical assessment item, and extent of respondents’ perceived need for each physical assessment item. At the time of instrument development, content validity, clarity, and item discrimination were confirmed by three nurse educators and three practicing nurses. Each item of the physical assessment questionnaire was independent, so internal consistency among items was not needed. A Physical Assessment Knowledge Test (PAKT) was developed as an attachment to the PAPQ. PAKT included 10 NCLEX-style multiplechoice items to assess RNs’ basic knowledge of assessment physiology. Items were generated from the Logic Extension Resource (LXR) test bank. The LXR program provides 347 Research for Practice statistical analysis for each test question. The average Kuder Richardson-20 correlation statistic for the PAKT was 0.73 to 0.90, with an average item point biserial score from +0.228 to +0.346. Procedures After receiving Institutional Review Board approval from Abington Memorial Hospital (AMH; Abington, PA) and Hahnemann University Hospital (HUH; Philadelphia, PA), the co-investigator distributed information fliers to RNs at study hospitals through e-mail, or by placing fliers in nurses’ mailboxes or randomly handing fliers directly to nurses. RNs were informed participation was completely voluntary. Those who chose to participate accessed a survey link, which opened to an introduction/ consent form explaining the study’s purpose. The form also listed inclusion criteria to allow RNs to determine if they were eligible to participate and continue, or were not eligible or did not want to participate and thus exit the web site. Data Analysis Demographics and study variables were tabulated using descriptive statistics, summary scores, graph displays, and frequency distributions for each consequence and demographic variable. Analysis was based on a multiple linear regression design to explore if the relationship of the independent variables (knowledge of physical assessment skills, nurse burnout, organizational attributes) significantly correlated to the dependent variable (performance of physical assessment skills). Additional correlations were completed to explore relationships of the subconcepts burnout (exhaustion and disengagement), work environment (autonomy, control, nurse-physician collaboration, organizational support), and demographics (years of experience). Results Of 1,100 potential participants from AMH and HUH, only 150 RNs initiated the survey (11% response 348 Variable TABLE 1. Bivariate Correlations Work Environment Composite (1) (1) Physical Exam Performance Composite (2) (2) -0.06 Knowledge Test Composite (3) Burnout Composite (4) (3) 0.11 0.07 (4) 0.21 -0.17 -0.07 Coefficients rounded at second decimal point for convenient presentation. * p = 0.05 rate). Participants were predominantly women (n=134, 93%) and held an associate degree (n=40, 27%) or baccalaureate degree in nursing (n=60, 41%). Most worked in medical-surgical nursing (n=56, 38%) or critical care nursing (n=47, 32%) and had 6-10 years of experience (n=34, 23%). No statistical significance was found in this study. For example, results did not indicate nurses who scored higher on the PAKT performed physical assessment skills more consistently (r=0.07; see Table 1). Also no relationship was found between RN burnout and performance of physical assessment skills (r= -0.17). Additionally, an association was not found between RNs’ perception of the work environment and performance of physical assessment skills (r= -0.06). However, on post-hoc analysis of the demographic data to the PAPQ, subscales of frequency of use and extent of need from the PAPQ were statistically significant for RNs who worked on the critical care and telemetry units compared to RNs who selected “Other” on the demographic data form (e.g., pediatrics, neurology, oncology, geriatrics) (see Table 2). Findings indicated RNs who work in telemetry and critical care settings perceived a need for physical assessment skills and thus may perform physical assessment skills more frequently compared to nurses in other areas. The difference in frequency of performing assessment and extent of need between critical care and telemetry RNs and RNs from pediatrics, neurology, oncology, and geriatrics has clinical significance because patients on these units are considered vulnerable and generally experience more complications (Allen, 2013). Findings indicated these patients were not assessed frequently and thus were at higher risk for adverse events. Another finding emerged from the post-hoc analysis. When expert RNs (defined as prepared at the graduate level with more than 5 years of clinical experience as nurse educators at a program accredited by the National League for Nursing Commission for Nursing Education Accreditation) reviewed the PAPQ and listed the top 10 physical assessment skills to be performed every day, a discrepancy was found between what they viewed as important and what RNs in this study viewed as important. Results of this survey were compared to the frequency-of-use subscale of the PAPQ completed by RNs in this study. Expert RNs and the RNs in this study similarly selected eight skills. Consequently, the significance was in the skills not selected by RNs in this study. RNs in the study believed assessing for pitting edema and observing gait were of higher priority than assessing pupil response and pulse deficit. This discrepancy could impact patient safety, especially if a patient had a pulse deficit which was not assessed before the patient was taken out of bed to observe his or her gait. Discussion This study evaluated self-reported frequency of use, knowledge, and extent of need for physical assessment. Even though no statisti- September-October 2016 • Vol. 25/No. 5 The Relationship of Burnout, Work Environment, and Knowledge to Self-Reported Performance of Physical Assessment by Registered Nurses TABLE 2. Physical Assessment Performance Questionnaire Scores by Group Variable Extent of Knowledge* Other Group** Medical-surgical Critical care Progressive care Telemetry Other Frequency of Use Mean Standard Deviation 38 75.9 7.8 14 35 10 10 79.2 73.4 74.9 9.4 7.1 7.7 6.7 13.9 32 104.0 12.5 Telemetry 10 107.4 15.1 Medical-surgical 37 90.5 8.8 Medical-surgical Critical care Progressive care Critical care Progressive care Telemetry 13 72.9 88.6 Other Extent of Need N 38 9 12 33 9 10 98.2 103.8 82.8 92.4 92.8 94.7 17.7 5.7 14.9 9.0 9.1 6.0 * No significant differences in extent of knowledge among groups. ** The group classified as “Other” was significantly different (p
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Critical Analysis of Two
Peer-Reviewed Research Articles
[Students’ Names]

Articles Reviewed
•[Article #1 = Stress in hospice at home nurses:
A qualitative study of their experiences
Of their work and well-being]
•[Article #2= The Relationship of Burnout, Work
Environment, and Knowledge to Self-Reported
Performance of Physical Assessment by
Registered Nurses]

Article #1: Purpose
•Assess hospice at home nurses’ well-being and
experience in providing healthcare for palliative
and dying patients.

Article #1: Background and
Significance of the Problem
•Nursing is demanding and stressful.
•Nurses suffer compassion fatigue caused by burnout
even without knowledge.
•Burnout affects mental and physical health of
nurses.
•Early intervention helps increase quality of patients’
lives.
•Hospice environments are more friendly than others.
•Factors that foster nurses’ resilience and wellbeing
can be achieved through training and supervision

Article #1: Methodology
•Sampling Technique
–Qualitative methodology

• Sample Characteristics
-Hospice at home nurses working in the community

• Setting
–Rural area in North West Wales

Article #1: Interpretation of
Findings
•Long distances in daily work leads to increased
stress.
•Conflict was identified with nurses outside the team.
•Failure by other nurses to perform their duties
increased stress.
•Nursing profession is mentally draining.
•Support rom colleagues, family and friends is crucial
in the nursing practice.
•Raising awareness on the role of hospice nursing is
required

Article #2: Purpose
•Explore the relationship of registered nurses’
burnout, awareness of physical assessment
skills, and work setting to self-reported
physical assessment skill performance.

Article #2: Background and
Significance of the Problem
•Inadequate patient assessment is the main cause of hospitalized
patient mortality.
•Continuous collection of patient data is necessary for positive
patient outcomes.
•Nurses don’t apply assess...


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