A central part of the nursing profession is the performance of practical skills. In order to provide adequate care, maintain patient-safety, and feel comfortable in the profession, registered nurses (RNs) need to be equipped with requisite skills. Overall aim: To explore and describe how learning and development of practical skills occurs during the preparatory phases and within the nursing profession. Method: Qualitative (I, III, IV) and quantitative methods (II) were used. Data were collected through individual interviews (I, IV), questionnaires (II) and participant observations, including informal talks (III, IV). Results: Both students and new RNs expressed a need to learn and develop practical skills (I, II, III, IV). Less than half of the new RNs had access to a clinical skill laboratory (CSL), where they could learn and practice practical skills (II). The students described that learning at a CSL had been meaning for their clinical practice. They also expressed a great need for continuing learning in real patient situations (I, III, IV). During clinical practice, preceptors and students took different approaches which affected student’s learning processesö (I, III, IV). There was a tension between learning at a CSL and learning in clinical practice sites because students perceived differences in the performance of skills. Students described that they understood that performance of skills could be done in different ways without injuring patients. However, the data also showed deviations in performances that could jeopardize patientsafety. In these situations, student’s behavior differed (I, IV). One third of new RNs deviated from evidence based guidelines when they performed practical skills which they were unfamiliar with (II). Both students and new RNs reported that reflection in connection with the performance of practical skills was not common (I, II III, IV). Conclusions: Cooperation between university CSLs and clinical settings must be intensified in order to enhance the understanding of learning processes regarding practical skills. A consensus regarding academic approaches should be reached. Universities need to support preceptors in educational issues where the importance of reflection is clarified and exemplified. Increasing patient-safety requires that new RNs receive opportunities for training in artificial environments, and that a culture that reinforces the use of guidelines and a reflective stance is cultivated.

The purpose of this study is to determine the possible relationship between post-doctoral research productivity of doctorally prepared nurses and instructional experiences of doctoral study, conditions of employment and other factors that may be related to research productivity. The design of the study is causal comparative.

‘First line healthcare’ is offered via telephone in many Western countries. The overall aim of this thesis is to describe Telephone Nursing (TN) from three viewpoints: telenurses, parents calling for their children, and operation managers. Four empirical studies were conducted. Telenurses described their work in five different ways: ‘Assess, refer and give advice to the caller’, ‘Support the caller’, ‘Strengthen the caller’, ‘Teach the caller’ and ‘Facilitate the caller’s learning’, which all constitute a TN ‘work map’. Authentic paediatric calls between parents and telenurses revealed that 73% of callers were mothers and children were aged between 5 days and 14.5 years. The top three contact reasons were ear and skin problems, and fever, with a median call length of 4.4 minutes. More than half of the calls resulted in referrals and 48% received self-care advice. The likelihood of fathers being given referrals as a result of their call was almost twice as high as that for mothers, while mothers were almost twice as likely to receive self-care advice as fathers. Parents described their degree of worry and trust that influenced their decisions whether to contact SHD or not. Their calls were carefully prepared, and the parent calling often depended on family routine. Parents reported to follow recommendations. Most relied upon their own intuition if further worried, but some indicated they would never seek healthcare unless it was recommended. Operation managers described four main goals of TN work: ‘create feelings of trust’, ‘achieve patient safety’, ‘assess, refer and give advice’, and ‘teach the caller’. Equitable healthcare was regarded as important, whereas health promotion was not considered as part of the goals. Conclusion: The studied TN viewpoints present concordance and discrepancies. Paediatric health calls appear mostly to be a woman-to-woman activity. Telenurses’ increased gender competence might increase TN safety. For that matter, telenurses’ collaboration with parents and making parents aware of holding the ultimate responsibility for their child’s condition is important. Goals of TN work and their relationship with healthcare obligations such as equitable healthcare and health promotion need further clarification. The viewpoints described in this thesis may contribute to the development of TN.

Experienced nurses depart the workforce in significant numbers; therefore, it is critical to understand how those departures affect patient care and safety. The focus of this systematic review included appraisal of recent research to provide an understanding of strategies used in acute care settings to retain experienced nurses. Guided by Benner's model of skill acquisition, the purpose of this systematic review was to identify factors that influence the decision of nurses with experience to leave or remain working in acute care work settings. The 19 articles selected for this review were limited to those pertaining to experienced registered nurses who have worked in the acute care setting for 2 years and longer. The review excluded articles pertaining to registered nurses with fewer than 2 years of experience, who were considered at the novice or proficient level of nursing. The results of this literature review showed that management conflicts, lack of support, work environments, work schedules, and disproportionate staffing levels were among the factors leading to morale distress and burnout in experienced nurses. These findings have the potential to contribute to positive social change by guiding administrative efforts to retain experienced nurses and improve mentoring of newer nurses and, ultimately, improve patient outcomes.

The purpose of this research was to discover the extent to which practising registered nurses in the ACT undertake physical assessment. It was also organized to discover the perceived reasons why, in appropriate instances, it was not undertaken and the extent to which certain variables may have influenced its practice or non-practice. It was directed also at discovering the extent to which the practising registered nurse would be prepared to undertake workshops on the subject, so that, if appropriate, a core of registered nurses could be provided to act as the role-models and to create the necessary learning environment in the ACT hospitals and agencies where most of the Canberra College's graduates would find employment. Since the first undergraduate course in nursing was introduced in the tertiary sector, nurse academics have placed significant emphasis on the teaching of the nursing process. It is within the first phase of this process, the assessment phase, that the physical assessment of the patient/client is conducted. Discussions with practising registered nurses and observations, led to some uncertainty as to the extent to which physical assessment was actually being used. A review of the literature showed that no investigation of the matter had been reported in the Australian literature. It was, therefore, proposed to make good this deficiency and to resolve any uncertainty about the extent of use of physical assessment in the ACT. This study was restricted to registered nurses in the ACT where all beginning nurses are educated at the CCAE with a curriculum which includes a comprehensive study of physical assessment. Even so, it is recognized that such studies will only reach a beginning level of competency. In order to ensure that the graduates of these courses extend their competency in physical assessment they need to be able to use these skills in every day nursing practice. This research, therefore, was conducted using a questionnaire which incorporated questions about the use of 36 physical assessment skills. The survey, on a onetime participation basis, was conducted for all registered nurses rostered on a fortnightly period in April 1987. A 66.7% response rate was achieved. The responses were analyzed and the findings, results and recommendations are included in the appropriate sections of this thesis.

Bakgrund: Yrkesrelaterad stress har ökat markant under de senaste tio åren. Vårdyrken anses vara bland de arbeten som är mest tyngda av stress. Långvarig stress kan ge individen fysiska såväl som psykiska problem och kan leda till utbrändhet. För att kunna fastställa en god och säker vård krävs stressförebyggande åtgärder, eftersom kraven på sjuksköterskor höjs allt mer. Syfte: Syftet med litteraturstudien var att beskriva sjuksköterskors strategier för att hantera arbetsrelaterad stress. Metod: Litteraturstudie inkluderande nio kvalitativa studier varav en studie som även bestod av kvantitativa resultat, men endast de kvalitativa resultaten behandlades i denna litteraturstudie. Artiklarna analyserades med inspiration av kvalitativ innehållsanalys. Resultat: Två huvudkategorier identifierades; ”Stressreducering på arbetsplatsen” och ”Stressreducering utanför arbetet”. Den första huvudkategorin utgjordes av underkategorierna ”Kollegialt stöd”, ”Prioriteringar”, ”Att påverka sin egen arbetstid”, ”Att distansera sig”, ”Att stärka sig själv” samt ”Tro och andlighet”. Den andra huvudkategorin bestod av underkategorierna ”Att lämna arbetat bakom sig”, ”Fritidsaktiviteter”, ”Sömn” samt ”Tobak och alkohol”. Slutsats: Sjuksköterskor kan ta till flertalet strategier för att reducera stress kortsiktigt. Däremot krävs organisatoriska förändringar på högre nivå för att på lång sikt reducera arbetsstressen hos sjuksköterskor. / Background: Work related stress has increased greatly during the past decade. Healthcare workers are considered having among the most stressful working conditions. Long term stress may cause physical as well as psychological harm on the individual, which may lead to burnout. In order to be able to secure a good and safe healthcare for the patients, it is essential to find long term stress reducing solutions. This is especially important in today’s healthcare, since the demands on the registered nurse are getting even higher. Aim: The aim of this literature study is to describe the strategies used by registered nurses for manage work related stress. Methods: This literature study included nine qualitative articles, of which one also consisted of quantitative results. However, only qualitative results were included in this literature study. All nine articles were analysed with inspiration from qualitative content analysis. Results: Two main categories were identified; ”Stress Reduction at the Workplace” and ”Stress Reduction Outside of the Workplace”. The main category first mentioned consisted of the subcategories “Collegial Support”, “Priorities”, “Influencing One’s Own Working Hours”, “To Distance Oneself”, “To Strengthen Oneself” as well as “Belief and Spirituality”. The second main category consisted of the subcategories “To Leave Work Behind”, “Spare Time Activities”, “Sleep” and also “Tobacco and Alcohol”. Conclusion: Registered nurses may use several strategies in order to reduce stress momentarily. However, organisational changes on a higher level are needed to reduce work related stress in the long term among registered nurses.

The purpose of this study was to explore and describe the knowledge that a cohort of 40 intensive care unit nurses had of evidence-based practice. It was assumed that they lacked the knowledge to locate, evaluate understand and apply research findings. Quantitative, non-experimental descriptive research was conducted to explore their knowledge and to formulate recommendations for promoting it. Data collection involved administering a structured questionnaire administered to the cohort in an intensive care unit. The findings revealed that, although they were familiar with the basic concept of evidence-based practice, they were reluctant and lacked the skills to adopt it in their practice. It is recommended that they be trained and empowered to develop research expertise from within their own ranks. Finally it is recommended that nursing management should play a more proactive role in identifying cost-effective strategies in overcoming barriers to finding, promoting and integrating evidence-based practice / Health Studies / M.A. (Health Studies)

The study was a descriptive quantitative survey which endeavoured to identify challenges experienced by IMCI trained registered nurses in implementing the guidelines and procedures of the strategy when tending children under 5 years in Gaborone health district. The study also solicited for recommendations on how to address the identified challenges. The research population comprised of all the IMCI-1 trained registered nurses and systematic sampling was employed to randomly select study participants. Data were collected using a questionnaire and was analysed using Excel Advanced software package. Study findings identified challenges related to political support, cost of IMCI training, training coverage, health systems and features of the IMCI strategy. Recommendations for improving use of the strategy included garnering for more political support, adopting short duration training courses, scaling up both pre-service and in-service training as well as addressing the challenges related to health systems and the unique features of the strategy / Health Studies / M.A. (Public Health)

Successful triage is the basis for sound emergency department (ED) care, whereas unsuccessful triage could result in adverse outcomes. ED triage is a rather unexplored area in the Swedish health care system. This thesis contributes to our understanding of this complex nursing task. The main focus of this study has been on the organisation, performance, and decision making in Swedish ED triage. Specific aims were to describe the Swedish ED triage context, describe and compare registered nurses’ (RNs) allocation of acuity ratings, use of thinking strategies and the way they structure the ED triage process. In this descriptive, comparative, and correlative research project quantitative and qualitative data were collected using telephone interviews, patient scenarios and think aloud method. Both convenience and purposeful sampling were used when identifying the participating 69 nurse managers and 423 RNs from various types of hospital-based EDs throughout the country. The results showed national variation, both in the way triage was organised and in the way it was conducted. From an organisational perspective, the variation emerged in several areas: the use of various triageurs, designated triage nurses, and triage scales. Variation was also noted in the accuracy and concordance of allocated acuity ratings. Statistical methods provided limited explanations for these variations, suggesting that RNs’ clinical experience might have some affect on the RNs’ triage accuracy. The project identified several thinking strategies used by the RNs, indicating that the RNs, amongst other things, searched for additional information, generated hypotheses about the fictitious patients and provided explanations for the interventions chosen. The RNs formed relationships between their interventions and the fictitious patients’ symptoms. The RNs structured the triage process in several ways, beginning the process by searching for information, generating hypotheses, or allocating acuity ratings. Comparison of RNs’ use of thinking strategies and the structure of the triage process based on triage accuracy revealed only slight differences. The findings in this dissertation indicate that the way a patient is triaged, and by whom, depends upon the particular organisation of the ED. Moreover, the large variation in RNs triage accuracy and the inter-rater agreement and concordance of the allocated acuity ratings suggest that the acuity rating allocated to a patient may vary considerably, depending on who does the allocation. That neither clinical experience nor the RNs’ decision-making processes alone can explain the variations in the RNs triage accuracy indicates that accuracy might be influenced by individual and contextual factors. Future studies investigating triage accuracy are recommended to be carried out in natural settings. In conclusion, Swedish ED triage is permeated by diversity, both in its organisation and in its performance. The reasons for these variations are not well understood.

Abstract The purpose of this study was to synthesize the existing evidence of working time use and division of labour among nurses and healthcare workers in hospitals. In addition, the purpose was to describe and analyse the interface between registered nurses’ and practical nurses’ work in adult hospital wards and to determine challenges and barriers related to the development of division of labour. The systematic review data consisting of 16 articles was analysed narratively. The quantitative data consisted of practical nurses’ (n = 121), registered nurses’ (n = 472) and nurse managers’ (n = 67) perceptions of practical nurses’ work activities which were analysed statistically. The qualitative data consisted of the above-mentioned groups’ perceptions (n = 260) of the challenges and barriers regarding the development of division of labour. All working groups spent less than half of their working time in direct care duties. Registered nurses spent one-fifth of their working time on documentation. All nurses also had a lot of non-nursing tasks. The quantitative data results revealed that practical nurses performed a wide range of tasks, but the groups’ perceptions of the content of the work differed significantly. The qualitative data showed that challenges and barriers in developing the division of labour were related to individual experiences and know-how and organisational factors. Both practical nurses and registered nurses should concentrate on the tasks they have competence on based on their training. Full expertise is used to benefit nursing work while non-nursing tasks should be delegated to lower educated staff. The role of nurse managers is to help to develop the division of labour and to influence the various challenges and barriers of division of labour. Nurse managers, education planners and health educators may utilise the results. They provide an evidence-based tool for competence development, resource planning and development of education. / Tiivistelmä Tutkimuksen tarkoituksena oli kuvailla ja analysoida työnjakoa välittömään potilashoitoon osallistuvan hoitohenkilökunnan välillä. Lisäksi tarkoituksena oli kuvailla ja analysoida nimikesuojattujen ammattihenkilöiden ja laillistettujen ammattihenkilöiden työnjaon rajapintaa sekä työnjaon kehittämisen haasteita ja esteitä. Työnjaolla tarkoitetaan sitä tapaa, jolla toiminta ja tehtävät järjestetään tarkoituksenmukaisella tavalla hoidon kokonaisuuden ja eri ammattiryhmien välisen osaamisen näkökulmasta. Tutkimuksen ensimmäisessä vaiheessa tehtiin synteesi työnjakoon liittyvästä tutkimuksesta systemaattisen kirjallisuuskatsauksen avulla. Tutkimusartikkelit (n = 16) analysoitiin narratiivisesti. Toisen vaiheen tutkimusaineisto sisälsi kyselylomakkeen avulla saatuja nimikesuojattujen ammattihenkilöiden (n = 121), laillistettujen ammattihenkilöiden (n = 472) sekä esimiesten (n = 67) tuottamia vastauksia sekä saman lomakkeen avoimeen kysymykseen tuotettuja vastauksia (n = 260). Aineistot analysoitiin tilastollisesti ja sisällönanalyysillä. Nimikkeestä riippumatta kaikki hoitajat käyttivät välittömään potilashoitoon alle puolet työajasta. Kirjaamiseen kului noin viidennes työajasta ja lisäksi kaikilla ammattiryhmillä oli paljon ei-hoidollisia tehtäviä. Laillistettujen ammattihenkilöiden ryhmä arvioi lähes säännönmukaisesti nimikesuojattujen tekevän kyselylomakkeessa mainittuja tehtäviä useammin ja esimiehet harvemmin kuin nimikesuojatut itse arvioivat. Ryhmien väliset erot olivat merkitseviä yli puolessa tehtävistä. Työnjaon kehittämisen haasteet ja esteet liittyivät yksilön kokemuksiin, yksilön tieto-taitoon ja organisaatioon liittyviin tekijöihin. Tavoitteena on, että työntekijäryhmät keskittyvät niihin tehtäviin, joihin ovat saaneet koulutuksen perusteella osaamisen. Koko osaaminen käytetään hyödyksi ja ei-hoidolliset tehtävät siirretään pois hoitotyöntekijöiltä. Hoitotyön johdon tehtävänä on edesauttaa työnjaon kehittämistä ja vaikuttaa erilaisilla interventioilla työnjaon esteisiin ja haasteisiin. Tutkimuksen tuloksia voivat hyödyntää hoitotyön johtajat, koulutuksen suunnittelijat ja terveysalan opettajat resurssien kohdentamisessa, muutosten johtamisessa ja läpiviemisessä sekä koulutuksen ja osaamisen kehittämisessä.