1.0 Introduction

Complexities in assignments and projects have facilitated the adoption of team approaches to problem solving. In many learning institutions and places of work, team approach has led to different people being brought together in order to benefit from their varying but combined experience and manpower. Studies by Pokras (2002) have revealed that team members perform to their best standards if a common target or goal had been readily identified before the formation of the team. Identification of the common goal in initial stages is the key to team success since every team has its own defined roadmap for achieving the identified goal. Achievement of the target also involves each team member identifying his role in the team and doing his best to achieve it. Team members are likely to encounter challenges when working on achieving their common goals. To ensure success in their teams, they need to understand overall issues that affect the performance of their members.

In line with the above, this written report seeks to reflect on the overall team experience as was displayed by Team 4 members when they undertook tutorial preparation and tutorial discussion assignments. The report identified the observations on team experience; dynamics and development. The varying characteristics of Team 4 members were also noted and are also described in this report.

The report goes ahead to link the observations of Team 4 members to the various academic theories on team experience. Secondary literatures addressing team experience themes are consulted for the proposed academic theories. The report then concludes with reasons on why Team 4 experiences were as observed and noted. Recommendations are the provided on how best Team 4 members can improve their future team spirits and experiences. It is our desire that any team reading this report will find it interesting and valuable for their future use.

2.0 Observations of Team Experience

As the name suggests, Team 4 was constituted by 4 members; 1 female and 3 males. To hold each member accountable on his/her role in the group, Team 4 members decided to nickname each member. As such, the following members made up Team 4; Member 1, Member 2, Member and Member 4. The observations below have adopted this naming.

During their first meeting, Team 4 members unanimously agreed on the use of face to face, Skype, and mobile phone services of voice and short messaging services (sms) as avenues of carrying out the discussion. Amongst the 3, face to face communication was the most frequently used method of carrying out the team work since members consented to the idea that immediate feedbacks were easily passed between them when using this method.

Most observations were therefore noted during the face to face sessions. The overall rating for the observations made can be summarised as 70% positive and 30% negative. The following is a presentation of some of the major observations as displayed by Team 4 members. The presentation involved identification of key variables and the observations made on members.

2.1 Leadership Roles

Though it was earlier on agreed that leadership role at Team 4 was to rotational, it was observed that some members feared the responsibility of assuming leadership roles when it came to their turns. The creation of the tutorials for presentation in class called for each team member to assume a leadership role on a rotational basis. This was considered key to success of any team since each team was to be later on required to successfully present their tutorials before the class. The presentations required every member of the group to take a leadership role at the time of presentation and therefore the reluctance by Member 2 and Member 4 to assume leadership roles caused a lot of worries to Member 1 and Member 3 since it was projected that it would impact negatively on the overall performance of Team 4. During the initial meetings, Members 2 and 4 would faithfully request any of their colleagues to volunteer by taking up the leadership roles on their behalf. Reasons put forward in their defence were that they deemed themselves less skilled when it came to creating slides and providing the logical structure upon which discussion topics were to be handled. One member, Member 2, was even bold enough to state before the other members that he lacked the courage to articulate issues before a group of people.

To correct on this, Members 1 and 3 had to assume guidance and encouragement roles. In encouraging the two to improve on their courage, Members 1 and 3 borrowed Topchik (2007) motivational quote that called on fearful people to focus on by speaking up and listening openly for them to built trust (p.10). As time wore on and more meetings were held, Members 2 and 4 were able to develop their courage and lead the discussions to the best of their understanding. They could usher in members to give out their suggestions as well as interrupt them to allow their colleagues to seek clarifications in areas where they felt dissatisfied.

2.2 Knowledge on Topics Discussed

It was observed that the four members experienced variations when it came to understanding the topics under discussion. For instance, in one session Member 1 emerged as the most knowledgeable in identifying and linking the relationships between various sub-topics. In the succeeding session, Member 3 assumed this role. These variations helped the sharing of knowledge amongst Team 4 members.

2.3 Contributing Towards Discussion Topics

Though Members 2 and 4 had initially shown fearful factors, it was observed that all Team 4 members took an active role in contributing towards topics at hand. Everybody would seek an opportunity to express his ideas, and his colleagues would either agree or disagree on the particular member’s points.

2.4 Conflicts and Disagreements

As every member became active in the discussions, it was observed that Team 4 members could not hold to each other’s opinions and wishes. A practical case emerged one Saturday when Member 1 proposed and insisted that every member was to present to the class the section which he or she oversaw as the leader of the team. In sticking to his view, Member 1 claimed that it was common sense that as a leader of the session, each leader stood a better chance of presenting the section to the class. However, his colleagues completely objected to his opinion on the view that teamwork and team spirit called on all members to have an even understanding of all the issues discussed by the team, and as such, each had an equal understanding of the sections. To them, anyone could comfortably present any section. The disagreement arising from this varied opinions boiled to the extent that all members had to unanimously agree to call off the session to avoid on the impending physical fights. However, on a positive note, Member 1 had to drop his hard line stance and adopt other members’ suggested random selection.

2.5 On the Issue of Time

It was observed that members attended to sessions on time. Only one chance of late arrival was observed when Member 3 arrived 30 minutes late into the discussion. However, she had written a phone message to every member of the team to inform them of her late arrival since she was held up on traffic at the time of the meeting.

3.0 Theoretical Evaluation

Institutions of learning and business organizations have continued with their adopted norm of using team approach as the tool for achieving specific tasks. Teams continue to gain increasing attention as potentially important organization assets (Zayed and Kamel, 2005, p.1). The increased adoption of team approach or team experience across these institutions has called for the need to provide information on the themes and dynamics involved in teamwork to help them achieve or attain their set targets. These may include amongst others;

3.1 Definition of Teams

Teams are groups of individuals who accomplish designated objectives by working independently, communicating effectively, and making decisions that affect their work (Topchik 2007, p.7). On their part, Zayed and Kamel (2005) defined teams as two or more independent individuals who interact with and influence one another in order to accomplish a common purpose (p.1). From his research, Pokras (2002) summarised team chemistry as consisting of the following three parts; communication, consensus and contracting (11).

From the definitions above it can be deduced that Team 4 comprised of the four individuals who worked to achieve a common goal of preparing tutorials on selected topics for presentation. They interacted through face to face, Skype or messaging and talking on phone. Zayed and kamel (2005) noted that many people across business fields had come to replace the term group with team. To such people, the two words mean the same and can therefore be used interchangeably.

3.2 Succeeding as a Team: Levels Involved

The joining together of members to form a team does not guarantee the success of the particular team. The formation stage may bring together quiet, cautious or tentative members who may take a while before starting to go through the storming stage (Zayed & Kamel, 2005, p.10). The storming process may involve team members studying each others’ tensions, differences as well as conflicts. After learning of members characteristics, team members advance into the second stage where they actively concentrate on solving their problems. Teams achieve their goals when members start interacting smoothly. At this level, each member is energetic, dynamic and productive leading to the team attaining success by achieving their set common goal.

3.3 Characteristics of a Good Team

According to RIC Publishers (2003), good team members listen to each other, cooperate, have clear team goals and allow each member to freely express his or her opinions (p.24). On his part, Topchik (2007) went on to postulate that best team experiences had roles of each member clearly defined, had members who were open and honest in communication, had a supportive and knowledgeable manager, allowed members to freely make decisions and rewarded or recognized its members when they successfully achieved its goals (p.6).

4.0 Conclusion

Though little disagreements were observed in Team 4’s meeting sessions, the team successfully achieved its goal of creating presentation tutorials. This was reflected in the comprehensive and detailed tutorials that were successfully presented to the class on the presentation day. The ability of the all Team 4 members to respond confidently and accurately presentation questions also contributed in highlighting the team’s success.

In assessing the hard line stands taken by some team members, it was concluded that the decision by the teacher not to give due attention to members characteristics at the time of forming the teams may have played a facilitation role. As Topchick (2007) notes, when forming a team, the individual’s skills, knowledge and experience should constitute the number one criteria for team membership (p10).

5.0 Recommendation

Best on Team 4’s achieved results; the following recommendations stand to be made.

Team 4 members should learn the importance of recognizing each other’s contributions. This makes every team member to feel that his/her work is very meaningful and important. As such more contributions are likely to be forwarded by the motivated team members.

The rotational team leaders should know that their leadership roles involve coordinating member activities. They should therefore not get discouraged or shy away from assuming these leadership roles based on their inferiority complex. Drawing from Dan and Lane (2008) works, team members who initially declined to take up their leadership roles are informed that effective team leaders are tasked with enabling everyone to contribute their unique skills (p.307).

Members should be in a position to accommodate the views of other members by dropping their hard line stands. Team works are intended to avail avenues for their colleagues to share their opinions and arrive at common stands.

Lastly and as Exley and Dennick (2004) opine, in cases where members are handling complex topics, several discussion sessions should be created to help members to research more on the topic at hand. This will help them to develop and accumulate knowledge on these topics.

Psychedelics as Treatment for Depression in Patients with Dementia

Literature Review

Older adults

Aging is an inevitable part of life. Approximately 20% of the population in developed countries is comprised of adults over 60 years old (Wick, et al., 2000). The average life expectancy continues to grow meaning the risk of an individual developing an age-related disease also continues to grow (Clarfield, 2017). Future research should investigate how to prevent or cure age-related diseases.

Depression in older adults.

The American Psychiatry Association (APA) defines major depressive disorder as when at least five of the following nine symptoms are present: sadness, disinterest, weight changes, sleeping pattern changes, delayed cognition, tiredness, self-loathing, inability to concentrate, or reoccurring thoughts of suicide (2013a). Depression is not a normal part of getting older, although aging increases the risk of an individual developing depression (Blazer, 2003). Depression in older adults should be treated as any other mood disorder because complications may arise if the depression is left untreated. The Geriatric Depression Scale (GDS) serves to quantify the severity of depression in older persons by assessing mood, self-esteem, and energy (Sheikh & Yesavage, 1986). The shorted version of the GDS is used for patients with poor attention-spans such as those with dementia. This scale is not specifically for older persons with cognitive impairment. Consequently, it may not be a completely accurate assessment for patients with dementia.

Dementia in older adults.

Dementia can be the result of several medical conditions such as Alzheimer’s disease, Parkinson’s disease, and Lewy-body dementia (Gale, Acar, & Daffner, 2018). The World Health Organization estimates that 50 million people live with some form of dementia with 60-70% of cases attributed to Alzheimer’s disease (World Health Organization [WHO], 2019). Slightly different symptoms are present depending on the disease. The APA defines dementia as a neurocognitive disorder diagnosed when the following symptoms are present: poor attention-span, mal-orientation, fluctuation in disturbances, cognitive decline, and evidence of a physiological cause (2013b). The Global Deterioration Scale (GDS) defines stages that correlate with the severity of a patient’s cognitive decline by assessing memory, mood, behaviors, and activities of daily living (Reisberg, et al., 1982). Severe cognitive decline significantly decreases a person’s quality of life and complicates preexisting mental disorders. The comorbidity of dementia and depression can have severe and complex outcomes.

Depression and dementia.

Depression in older adults is a strong indicator of the early stages of dementia (Kaup et al., 2016). The symptoms of depression often continue while the dementia disease progression. An estimated 10-30% of people living with dementia also suffer from depression (Devanand et al., 1997). The Cornell Scale for Depression in Dementia (CSDD) scores the severity of depression specifically for patients with dementia by assessing mood-related signs, behavioral disturbances, physical signs, cyclic functions, and ideational disturbances (Alexopoulos, et al., 1988). The combination of depression and dementia often manifests into agitation and hostility (Volicer, 2018). These behaviors can make it difficult for caregivers to provide proper care to older adults suffering from both depression and dementia. Trials of antidepressants are currently the recommended treatment for older adults with depression and dementia despite the high risk of adverse effects (Ford & Almeida, 2017). A new depression symptom-relief medication could allow caregivers to provide proper care without the adverse effects of current antidepressants.

Psychedelics

Psychedelics are a class of drugs that increases serotonin levels and consequently alters mood, perception, and cognitive processes (Nichols, 2016). The side-effects of increased serotonin levels make psychedelics desirable to some people. Psychedelics are commonly consumed either religiously or recreationally (Luna, 2011), but small doses can improve cognitive abilities (Prochazkova et al., 2018). Future research may reveal the full potential of using psychedelics to treat mood disorders. The general use of psychedelics is controversial: some religious groups view psychedelics as a way to enhance their spirituality (Luna, 2011) while other religious groups condemn all recreational drug use (McNamara, 2011). This is the basis for the debate on the legality of psychedelics. Many countries, including the United States, classify psychedelics as illegal controlled substances (United States Code, 2016). Research is greatly limited due to the legal status of psychedelics.

History.

Some American religious groups in the early twentieth century encouraged the association of drugs with immoral behaviors (McNamara, 2011). The Harrison Anti-Narcotic Act of 1914 constitutionally enabled the federal government to regulate controlled substance (Terry, 1915), state legislations began classifying psychedelic-related crimes as felony offenses in 1966 (Lee & Shlain, 1987), and the 1970 Control Substances Act categorized psychedelics as schedule I drugs (United States Code, 2016). All of this legislation restricted the accessibility of psychedelics. Additionally, controlled substances with no medicinal benefit and a high risk for abuse are classified as schedule I drugs (United States Drug Enforcement Administration [DEA], n.d.), so psychedelic research was significantly reduced for a few decades (Carhart-Harris & Goodwin, 2017). The United States Drug Enforcement Administration (DEA) significantly increased the approval rate for research regarding schedule I drugs in 2017 (2018). The increased accessibility to psychedelic research could develop clinical use for medicinal benefits.

Dimethyltryptamine (DMT).

DMT is a psychedelic associated with strong hallucinogenic effects (Cakic, Potkonyak, & Marshall, 2010). Some people recreationally use DMT for a powerful psychological experience with a low risk of adverse effects (Davis, et al., 2018). The production of the spiritual brew, ayahuasca, commonly includes the plant

Psychotria viridis

which contains DMT (Domínguez-Clavé et al., 2016). Ayahuasca has been used in religious ceremonies throughout the upper Amazon for centuries (Luna, 2011). This sacred view of DMT’s psychological effects suggest a higher benefit to risk ratio.

Case studies have shown that, while uncommon, DMT can induce psychosis (Dobkin de Rios & Rumrrill, 2018) (Paterson, Darby, & Sandhu, 2015). The possibility of dramatic adverse effects is reason to proceed research with caution. Many observational studies have been conducted to investigate the current uses of DMT. A fewer number of controlled experiments have been performed to directly test the effects of DMT in a monitored setting.

Microdosing psychedelics for depression.

The term

microdosing

refers to the regularly scheduled consumption of very small dosages of some drug. Microdoses of psychedelics are typically ten to twenty times smaller than a recreational dose (Kuypers, et al., 2019). A microdose is usually too small to cause noticeable hallucinogenic effects. The microdose will cause an increase in serotonin levels resulting in some less intense side-effects. Approximately 20% of microdosers have experienced some acute adverse effects (Hutten, et al., 2019). The risks and benefits of any drug must be assessed before clinical usage. Microdoses of DMT had an antidepressant effect on rats without increasing anxiety (Cameron, et al., 2019). This evidence suggests that microdoses of DMT could be used clinically to ease symptoms of depression.

Current antidepressants may take up to several weeks before becoming fully effective (Otte et al., 2016). Waiting several weeks for symptom relief may feel distressing for a person with depression. Additionally, the first antidepressant trial fails for about 30% of depression cases leading to a long trial-and-error period (Conway et al., 2017). Being subjected to many failed medications may be disheartening for people suffering from chronic depression. Ayahuasca can be utilized as a fast-acting medication for treatment-resistant depression (Palhano-Fontes et al., 2019). Utilizing psychedelics as antidepressants could change the way psychiatrists treat depression.

Psychedelics effect in older adults.

There is not much evidence that psychedelics are beneficial specifically for older adults. Small doses of cannabis do not cause any significant effects in older adults with dementia (Van den Elsen, et al., 2015). The absence of any results includes the absence of adverse results. The clinical use of psychedelics has proven to be safe enough to begin research with larger doses.

Current Study

The recent increase in studies concerning the medicinal benefit of psychedelics could lead to a breakthrough in how depression is treated. This potential medication could also be useful in specifically treating depression in older adults with dementia. This experimental study explores the direct effect that microdoses of DMT have on treating depression in older adults with dementia. Prior studies suggest that microdoses of DMT can relieve symptoms of depression (Cameron, et al., 2019) (Palhano-Fontes et al., 2019). Some case studies warn researchers of the risk of psychedelic induced psychosis (Dobkin de Rios & Rumrrill, 2018) (Paterson, Darby, & Sandhu, 2015). Another study demonstrated the low risk of adverse effects of microdoses of psychedelics in older adults with dementia (Van den Elsen, et al., 2015). These studies together suggest the potential benefit of microdoses of DMT on depression symptom relief for older adults with dementia.

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Utilising Evidence Based Care

This essay endeavours to investigate hand hygiene, and feel I need to gain more knowledge in this field by utilising the available evidence effectively. I also intend to discuss nurse held traditions, customs and rituals.

The common method of handwasing is usually with unmedicated soaps, whist an anti-bacterial soap may be used for total hand decontamination. (Hugonnet & Pittet 2000). As nursing staff can wash their hands up to forty times per hour, it may be one of the most frequently practiced nursing skills (National Patient Safety Agency, 2004). According to Pittet (2000) healthcare professionals barely reach fifty per cent compliance with handwashing. Holland, Jenkins, Soloman et al (2003) point out that hands are the primary factor is spreading bacteria, especially as they come into contact with body fluids, furniture, dressings and equiptment.

During a placement on a surgical ward I witnessed poor hand hygiene and felt I needed to deepen my knowledge of effective and appropriate hand washing to be a competent, safe practitioner. Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure against transmission of hospital acquired infection between patient to patient (Gould et al (2007). As a health care professional I am aware I must work within the guidelines of the Nursing and Midwifery Council (NMC) and the government body, the Department of Health (DoH). Within this essay I intend to utilise two sources of research, critique them, and use the findings accordingly.

The Nursing and Midwifery Council Code of Conduct (2008) states that ‘care and advice to patients must be based on the best available evidence’ (NMC 2008 p4). Fitzpatrick (2007) states ‘healthcare professionals must demonstrate effective integration of evidence, including findings of research into their decision making.

‘Evidence based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available clinical evidence from systematic research ‘Sackett et al (1996).

Within evidence available for utilisation is an evidence hierarchy. At the top of the hierarchy are well designed randomised controlled trials. The UK Cochrane Centre specialises in random controlled controlled trials (RCTs). The Cochrane centre operates globally to maintain and publish up to date reviews of randomised controlled tests for health care. (Sheldon and Chalmers 1994). Hamer (1999a) also states that randomised controlled trials (RCTs) are frequently called the gold standard of research evidence. The Cochrane Centre work out the validity of research by grading them. Grading starts at A-C, A being the highest score, and showing it has met all the quality requirements (Mulrow & Oxman, (1997). Hierarchies are also used in clinical guidelines, graded by both standard of evidence and recommendations. The highest standard of evidence grade, matched by the highest recommendation grade, suggests superior validity and ought to be considered to be implemented in practice (Cook et al, 1992)

Research evidence appropriateness can be based on how the data was collected. Examples of different research designs are RCTS, case-controlled studies, cohort studies, professional, or qualitive. The two research paper I am examining use a mix of methods.

Lockett (1997) claims evidence-based practice is a combination of scientific and professional practices. The ‘evidence -based’ aspect refers to scientific rationale and the ‘practice’ part refers to behaviour of the healthcare professional (Lockett 1997). The importance of evidence -based practice is highlighted by Hamer (1999b), stating the primary aim is to aid professionals in effective decision making to reduce ineffective, inappropriate possible hazardous practices. This would suggest, as with guidelines set out by the NMC that the use of evidence-based practice has much rationale. The American Nurses Association (2003) points out that in order to enable nurses to tally with the expectations of society, a strong evidence base for practice is essential. Furthermore, for nursing to be recognised a genuine profession, it is essential to have all of its practices based on evidence (Royal College of Nursing 1982).

Once a topic had been chosen to explore I conducted a search via databases. I found initially to use solely the term handwashing, which yielded a surplus of data.

I set the date parameters on the search to the last 5 years to maximise the validity of the research, which not only provided more suitable data, but narrowed the search to yield less results. This facilitated the search for relevant research. I added other words to the search, such as compliance and the word and/or. Also truncation was used, this maximised the search further. Especially as there are many variations of the work handwashing. Furthermore, handwashing was not the only term used to describe handwashing, hand hygiene was also used. This too, yielded successful results. The term nurse was also added, this too was truncated to nurs*, which allowed terms such as nursing, nurses, nursed to be detected, thus increasing the probability of locating the desired results. I set the parameters to detect full text and on the English language.

As I am not accustomed to using databases I sought the advice of the librarian, EBSCO, CINAHL and BNI were recommended resources. Also the Cochrane library has been praised as the gold standard in randomised controlled studies. As randomised controlled studies are at the top of the hierarchy of evidence I decided to seek a randomised controlled study. I found located the primary piece of evidence from the Cochrane library.

On this occasion I did not use main stream search engines, although I would consider using a search engine in the future to find research. Fitzpatrick (2007) claims internet searches engines can yield credible results.

My second piece of research was discovered on Ovid. Once selected, Ovid requires users to select databases within that database. I excluded paediatrics as this was not relevant to the search.

|Interventions to improve hand hygiene compliance in patient care conducted by Gould (2007) is the selected primary source.

The quality of the abstract was clear, with sub heading, and reflected the aim of the paper and its content. The objectives were to assess the long term success and improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene can lower hospital infections. This was relevant to my search as this is an area I wanted to increase my knowledge on, and utilise in practice, if the research is deemed valid and credible.

The types of studies used were randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITSs) meeting the requirements of the Cochrane Effective Practice and Organisation of Care Group (EPOC).The research is a systematic review. According to Mulrow (1995) systematic reviews do the ‘hard work’ of critiquing the research so time limited health care workers can access valid data. Systematic reviews are the gold standard of research (NHS Centre for reviews and Dissemination, p.1 1996):

‘Systematic reviews locate, appraise and synthesis evidence from scientific studies in order to provide informatative, empirical answers to scientific research questions.’

Muir & Gray (1997) and Sackett et al (1997) claim randomised controlled trials are thought to be the most dependable and trustworthy source of evidence.

I interpret the above as indicting the research may be of a high standard to meet the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC). Although the research paper is not yet fully critiqued, this is a positive validity indicator.

The participants were target groups, of doctors and nurse. Theatre staffs were excluded due to different hand hygiene techniques being used. To exclude theatre staff was relevant as hand hygiene is part of the ‘scrubbing in’ ritual, and if included may have caused inaccurate results.

Data collection and analysis was conducted by two reviews, and they accessed the data quality. All of the data they had gathered was via databases searches, and two studies out of over seventy five met the criteria review.

The author concluded no implications for practice, as the review had not been able to provide enough evidence. The implications for research were more studies are urgently needed to evaluate improvements to hand hygiene. The biasness of the paper is not easy to find out as I could not discover the professions of the researchers. It could be suggested that if they were nurses, this could create a potential for bias.

When searching for this primary piece of research I did not need to be concerned about UK and American spellings are the words used did not have UK & American versions. However in future I would chose to look for both to show abundant data. The keywords used for finding this particular piece were, hand*, hygiene, wash*, comlianc*, concordanc* and nurs*.

Quantitive research sample sizes normally exceed one hundred participants. Interviews or questionnaire have set questions. Data is usually recording statistically (Siviter 2005). The data within this research was presented in tabular form. The CASP (2006) quantitive tool was utilised in the critiquing of this research. Had the research paper been qualitive, I would have used the CASP quantitive tool. This is a valuable and effective tool in analysing the research for strengths and weaknesses (Hek & Moule 2006). Although on this occasion I used CASP to critique the paper I would in future consider using other critiquing frameworks, such as Bray and Rees (1995) and Benton and Cormack (2000) or Popay et al (1998).

As to if the research was ethical or not is indistinguishable as no consent issues arose as all evidence was found via databases. Although, consensual issues are not the only ethical issues to be considered. Beauchamp & Childress (1994) claim healthcare ethics is when moral issues and questions are raised within the healthcare realm. Respect to an individual values and beliefs are a part of being ethical. However in terms of the primary research paper there are no visible signs of a breach of ethics.

The results show that both the randomised controlled trials were poorly controlled. One trail shows an increase in hand washing compliance four months after interventions. The second trail has shown no post intervention increase in hand hygiene. The author found both samples were of low quality and was conducted over a too small time frame.

The author concludes there is not any strong evidence to make an informed choice to better hand washing. According to the author, one off teaching sessions will not expected to make any lasting changes to compliance. Further robust research is recommended by the author. Therefore, currently from this research there is inadequate data that could be utilised in evidence-based practice.

‘Hand hygiene practices: student perceptions’ is the second piece of research chosen. This is a qualitive piece of research.

The aim of the research was clear from the abstract and the title. Student nurses were interviewed to gain depth of data. Student nurses were also guaranteed anomity, which may have assisted the researcher gain rich data. Had the researcher chose a quantitive methodology, it would have been complex to achieve student’s perspectives. The NMC (2008) praises qualitive research methods as they respect patient’s individuality and feelings in the way nursing staff are presumed to, and is suitable for nursing research. According to Parahoo (2006), qualitive research may be considered to be of less value than quantitive research. Another positive aspect of qualitive research is the broad picture it provides, history, context, and the causes ( Blaxter, Hughes & Tight, 2006). Siviter (2005) defines the average qualitive research sample size as fairly small, with an average of fifteen to twenty. Data is usually gathered through semi-structured interviews and open ended questions.

The researchers who conducted the research are both nurses and have a professional interest in the paper, and it is noted that the possibility of bias could occur. This was recognised by the nurse researchers.

Evan (2003) Hierarchy of evidence concludes case studies lack validity in comparison to random controlled trials and systemic reviews.

A barrier to utilising research to support evidence-based practice may be lack of knowledge and skill. Hundley et al (2000) noted that although attempts are being made to incorporate research education into current nurse curriculum, poor analysis skills are still a barrier to reading research. Hundley et al (2000) also states time is a primary barrier to utilising evidence-based practice. Retsas (2000) offers advice in conquering the time barrier, advising organisations need to increase time to study in order for evidence-based practice to be achieved. Issues with autonomy, or lack of, have been suggested as potential barriers in the implementation of nursing research. Doctors were named as a potentially obstructive (Lacey 1994). Shaw et al (2005) suggest that to know and understand possible barrier and enablers to utilising evidence is critical in the identification of evidence-practice gaps. Grol and Wensing (2004) discuss the many different enablers and barriers that might be found when change is attempted to be implemented. These range from awareness, knowledge, motivation to change and behavioural routines (Grol and Wensing 2004).

Traditional rituals within nursing are a barrier to implementing evidence -based practice. Walsh and Ford (1990) define rituals as:

‘Ritual action implies carrying out a task without thinking it through in a problem-solving way. The nurse does something because this is the way it has always been done. The nurse does not have to think about the problem and work out an individual solution, the action is a ritual’.

Billy and Wright (1997) defend rituals, claiming some are healing, and have some positive outcomes. Parahoo (2006b) argues that rituals are when practice rationale is forgotten. Thompson (1998) discusses the research-practice gap, claiming there is a gap between knowledge and practice. This would indicate there is a gap between producers and users of research (Caplan 1982).Larsen et al (2002) argues that the research-practice gap does not exist in nursing as it is not an evidence-based profession. One way of passing on the message of evidence-based practice is through clinical guidelines. Woolf et al (1999) clinical guidelines improve quality of decisions made by healthcare professionals, although a downfall may be recommendations are wrongly interpreted.

A First Class Service (Department of Health, 1998) summarizes the government ideas for improving evidence base, and how to implement the findings. This indicates the government’s recognition of the benefits to quality of care, and its links to evidence-based practice. Since then the government has included evidence-based practice in its strategies, such as NHS Research and Development in 1992 and Making a Difference in 1999. Evidence-based healthcare was at the core of these strategies (Department of Health, 1992). In the North Bristol Trust the ‘Clean your Hands’ campaign is in use. This was implemented by The National Patient Safety Agency; Alcohol gels were put all around the trust, in an attempt to make hand hygiene facilities more accessible. Nursing staff also wore ‘it’s ok to ask badges’; encouraging patients to remind busy staff to wash their hands (Infection Control Policy and Manual North Bristol Trust, 2006).

In conclusion I have learnt there is a colossal sum of research to be potentially be utilised in practice. From accessing valid data, to having the time to critique research once in practice, to trying to implement change when in practice, I have realised there are many obstacles to achieving evidence-based practice.

Research should always be analysed to establish whether or not the data it produces is valid and if it ought to be implemented in practice or not. From the two research papers I have analysed I found that neither were valid enough to consider implementing in practice. I have also learnt that change within health care is not as easy to implement as I have previously thought, many parts of the interprofessional team must be involved. Managers are key to helping change take place. I do still believe that effective handwashing is definitely one of the most effective measures in the role of infection control. A valid, robust research paper on this essential nursing skill would aid effective hand hygiene, as currently many research paper out there do not make the grade for them to be implemented in practice.

From this I have learned a valuable lesson that just because research is there, does not necessarily make it credible and valuable.

Reference

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The World Health Organization (2011) advocates exclusive breastfeeding for six months to provide nutritional, immunologic and other health benefits. Breastfeeding mothers stroke their babies more frequently which helps in mother-child interaction and baby’s physical and cognitive development (Field et al., 2010). In Singapore, however, a national survey demonstrated that only 21% of mothers were breastfeeding at six months postpartum when 95% attempted to breastfeed but most stopped due to feeding problems (Deurenberg-Yap, Foo, Lim, Ng, &Quek, 2005). Incorrect techniques causes complications like breast engorgement, sore nipples and low milk supply, which in turn leads to cessation of breastfeeding (Tully, & Payne, 2003). The purpose of learning of this teaching plan is to impart breastfeeding skills to new mothers to empower them to breastfeed correctly and prevent common feeding problems that lead to premature weaning.

First breastfeeding experience affects a mother’s breastfeeding outcomes for future children (Deurenberg-Yap et al., 2005). This finding emphasizes the importance in supporting breastfeeding in new mothers.

2. Target Learners

The teaching plan aims to teach a first-time mother in the hospital on the proper practical techniques of breastfeeding. Mothers, who do not breastfeed because they cannot, their baby cannot or they choose not to, are not selected as target learners. Contraindications of nursing include maternal use of certain drugs (Ito, Lee, & Moretti, 2000), untreated maternal tuberculosis, human immunodeficiency virus infection, herpes lesions on the breast (Eglash, Montgomery, &Wood, 2008) and galactosemic baby (Eglash et al., 2008).

3. Assessment of the Learner

a) Learning Needs

The nurse would assess the client’s learning needs by asking her questions that reflect her level of breastfeeding knowledge. London (2009) suggested that the nurse may appear disrespectful if she fails to acknowledge what the client knows and insists on teaching something she knows very well. The nurse will arrange another teaching session for the client to acquire breastfeeding knowledge if she lacks it. Deurenberg-Yap et al. (2005) demonstrated that awareness of the benefits of breastfeeding significantly prolong breastfeeding. In addition, theories on adult education consistently state that adults are more motivated to learn things they perceive as relevant and important (Wingard, 2005). Hoddinott and Pill (2000) supported that mothers prefer to be facilitated to make their own decision to breastfeed rather than being told to do it. Acquiring breastfeeding knowledge allows the client to make informed decision so she will be motivated to learn.

b) Educational Level

The nurse would evaluate the client’s literacy level to judge the literacy level of the teaching plan to ensure that she will be able to comprehend and apply what is taught.

c) Readiness to Learn

The client’s emotional state and physical comfort is assessed as an indicator of her readiness to learn. Kendall-Tackett (2004) stated that postpartum depression causes atrophy of hippocampus, leading to impact learning and memory and Spear (2008) indicated that mothers with negative childbirth experience and complications experienced difficulties in breastfeeding due to emotional distress and medication effects. For these mothers, the nurse will give extra support, administer prescribed pain medications or refer them to counselling service before the sessions.

d) Cultural Background

The nurse would factor in cultural considerations specific to the client so that she can interact with the client effectively without offending her. For example, shaking head can mean “yes” or “no” in different cultures (cited in Manson, Leavitt, & Chaffee, 2007). A mother is allowed to practice breastfeeding using a doll substitutes if she does not feel comfortable breastfeeding in front of the nurse.

e) Dominant Learning Style

The nurse will determine the client’s dominant learning style and teaches in a manner that favours the style. Vance (2003) stated the choice of teaching style would affect a learner’s learning outcome.

4. Planning

a) Time Management

A survey conducted revealed that 36.7% of nursing students identified lack of time as a barrier to patient education (Dal, Demir, & Bulut, 2009). To save time, the nurse has to be organized and prepared the teaching tools beforehand. The nurse should not delegate teaching to a healthcare assistant because of staff shortage. London (2009) contended that patient education should be done by healthcare professionals who are well-aware of the content and the rationales.

b) Time Frame

The teaching sessions will not be conducted in the first few hours following childbirth. A mother should start breastfeeding within an hour of birth to ensure successful breastfeeding and promote mother-infant relationship (Tully, & Payne, 2003). As such, the nurse’s priority in the first few hours is to assist client in initiating breastfeeding rather than teaching.

The teaching plan consists of 2 short sessions that take place over two days. Redman (2004) indicated that short teaching sessions are more constructive than one lengthy session. Moreover, labour is an energy-draining process, short sessions caters to the client’s fatigue and increased need for rest.

Postpartum perineal pain has been reported to affect 92% of mothers for the first 2 months of delivery (Andrews, Thakar, Sultan, & Jones, 2007). In view of that, teaching sessions will be scheduled after morning medicine round when the client experiences less pain and thus most receptive to learning.

c) Teaching Resources

The nurse will show two videos by Howcast (2009) and Parents (2008). The nurse will ensure that the information in the videos is accurate and reliable before showing to the client.

Lactessa doll which is specifically designed for breastfeeding education will be used for demonstration. The doll resembles a real newborn with realistic weight, flexible limbs and head as well as a three-dimensional mouth that allows realistic demonstration of positions, latch-on and feeling of the hard palate. If the doll is not available in the ward, the nurse can propose to purchase one or use a pillow as a substitute (Birth International).

d) Teaching Venue

In adult learning theories, teaching is not just about imparting knowledge and skills, it also involves setting the optimum environment for learning (Hutchinson, 2003).

Breastfeeding- friendly environment is required to promote breastfeeding (Mitra, 2003). The teaching sessions will be conducted in teaching room. The nurse will book the room after assessing the client. She will arrange the seats, prepare the resources required and ensure that the physical environment is not noisy, not cold or overheated. The factors that are beyond the nurse’s control are the size of the room and whether the room is well-equipped with the audiovisual equipment. If the equipment is not available, the nurse will borrow it from other wards before the session.

Hutchinson (2003) stated that it is necessary for the student to feel secure in order to experiment, verbalize concerns and raise questions. Mitra (2003) also identified embarrassment as one of the barriers to breastfeeding. To respect client’s dignity, the nurse will ensure that the door is locked during the sessions.

e) Method of implementation

The nurse would adjust the plan according the client’s characteristics identified in the assessment process. This is made possible by incorporating other teaching sessions into the teaching plan based on individual needs.

One-to-one teaching is used to provide the mother with a private space to breastfeed as many mothers feel uneasy breastfeeding in front of others (Johnson, Williamson, Lyttle, & Leeming, 2009).

Vance (2003) identified that people learn better and faster with their dominant learning style. As such, this teaching plan incorporates several ways of learning which include video watching, story sharing, demonstration with explanation and return demonstration

Visual learners need to see images in order to learn effectively (Vance, 2003). Hoddinott, Pill (2000) and Su et al., (2007) demonstrated that women preferred practical demonstrations of breastfeeding rather than being told how to. Therefore, the nurse ensures that the teaching sessions are not just facts but also action-orientated by showing videos and providing demonstration and describing each step as she performs it.

To get the attention of auditory learners, the nurse would repeat important points. After demonstration, the nurse would ask the client to repeat the explanation as Vance (2003) stated that auditory learners remember better when they verbalize it. Also, the nurse will share successful breastfeeding stories. Literature review has demonstrated that storytelling is increasingly used in patient education to transmit human experiences, knowledge and skills (Haigh, & Hardy, 2010). Storytelling is not only cost-effective (Silver, 2001), mothers have learned effectively from other mother’s experiences and challenges (Spear, 2008).

Kinesthetic learners have short attention span and learn best through hands-on practice (Vance, 2003). Therefore, the client will be encouraged to hold a doll and follow along nurse’s actions during demonstration to keep her engaged.

f) Expected Outcome

The primary expected outcome is that at the end of the 2 sessions, the client will be able to correctly demonstrate and describe a variety of breastfeeding positioning, latching-on and burping techniques.

The secondary expected outcome is that the client will not develop complications of breastfeeding and continue to breastfeed independently for 6 months and beyond as advocated by World Health Organization (2011). As a result, the baby achieves optimum health and client loses maternal weight (World Health Organization, 2011).

The nurse will clearly state the expected outcomes in the first session. Tully and Payne (2003) reported that mothers with goals tend to breastfeed for a longer duration of time. The nurse and the client will negotiate on common appropriate objectives as adult learners are motivated when they are involved in objective setting (Schwenk, 1987).

5. Implementation

Day 1: March 17, 2011 at 9:00am – 9:20am

Activity

Time Frame

Learning Content

Teacher’s Role

1. Introduction

5 minutes

Self introduction

Discuss expected outcomes.

Remember client’s name and address her by her name to build mutual trust (Hutchinson, 2003).

2.Video showing

10 minutes

Proper positioning, latching-on and burping

Start the video

Remain in the room to observe if the client is receptive.

3. Story sharing

5 minutes

Learn from other mother’s experience and challenges.

Narrate true breastfeeding stories

Day 2: March 18, 2011 at 9:00am – 9:30am

Activity

Time Frame

Learning Content

Teacher’s Role

1. Demonstration

10 minutes

Demonstration of skills with description of the steps while client follows along.

Demonstrate proper techniques and provide description.

2. Return demonstration

10 minutes

Patient performs return demonstration on her baby

Provide brief instant oral feedback

2. Debrief & feedback session

10 minutes

Evaluate progress

Provide feedback on client’s performance.

Determine if client is competent to breastfeed independently

6. Evaluation

During return demonstration, the nurse assess client’s proficiency of breastfeeding techniques and gives frequent brief instant feedback on the client’s performance so the client is aware of her progress and able to correct her mistakes on the spot.

During debrief and feedback session, the nurse provides summative feedback on the client’s overall performance. Adult learners appreciate feedbacks and use it to evaluate their progress (Schwenk, 1987). Descriptive feedback is more effective than evaluative feedback because it provides suggestions for improvement (Schwenk, 1987). For example, the client accidentally dropped the doll. An evaluative statement would be, “You’re really clumsy.” A better descriptive statement would be, “You were not positioning the baby correctly. You should support the head with your forearm.” The nurse should provide specific feedback (Schwenk, 1987). A general statement such as, “You’ve done well”, can be replaced with “I noticed that you’ve demonstrated the breastfeeding positions very well, especially for the cradle hold”, to reinforce the specific positive behaviour. Feedback is given immediately after client’s demonstration to allow her to remember her performance and adjust her behaviour accordingly.

2000 wordsEvaluation continues after the sessions ended. The baby may not be feeding whenever its mouth is at the breast so the nurse will assess the mother and her baby for signs of milk transfer during each feeding (Tully, & Payne, 2003). She will assess the client for breast softening and lightening and signs of oxytocins release during feeding. She will assess the baby for rhythmic suck and audible swallows during feeding, moist mouth after feeding, at least two stools and six wet diapers in a day as well as absence of hunger cries between feeds (Tully, & Payne, 2003).