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This is an article published in Nursing Times. It is a personal opinion feature.

Quality assured clinical learning environments, including evidence shared across boundaries, will support a globally prepared Medical and Allied Health Professionals (AHP) international workforce to transfer skills and practice to enhance patient treatment.\ud HEALINT4ALL provides Medical and AHP educators, clinician and students an audit system to assure and determine quality of EU clinical learning environments. Students can be confident that they will obtain an increased number and varied safe learning placements through extensive partnerships whilst fostering inclusivity. This project additionally contributes to global citizenship, professional health and well-being though promoting optimal standards and best practice.\ud \ud This publication summarises and presents project progress around completion of the first output (IO1).

Objective: To compare dietary intake and lifestyle behaviour in women with polycystic ovarian syndrome (PCOS) and healthy women.\ud \ud Methods: 160 healthy women (partner with male infertility) were recruited to a control group; 168 women with PCOS (diagnosed on ultrasound) were recruited to a case study group for this cross-sectional comparative study. The case group was classified into three phenotypes based on presence or absence of menstrual disorder (M), hyperandrogenism (HA), and polycystic ovary according to sonography (PCO): HA+PCO (n=53), PCO+M (n=57) and M+HA+PCO (n=66). Dietary intake and lifestyle behaviour were measured using a food frequency questionnaire (FFQ) and a lifestyle questionnaire (LQ).\ud \ud Results: The mean energy (P

Objectives: Assisted reproductive technologies (ARTs) give hope to some infertile couples; however, in vitro fertilization (IVF) is expensive and not subsidized by the Iranian state. More than 75% of IVF cycles in Iranian couples are unsuccessful. The aim of this paper is to describe the experiences of Iranian infertile couples after unsuccessful treatment.\ud \ud Materials and Methods: In this descriptive qualitative study, 36 participants including 29 Iranian infertile couples recruited after unsuccessful ART treatments, five infertility treatment team members and 2 relatives of infertile couples were interviewed at an Infertility Center in Northeastern Iran from April 2016 to June 2017. Data were collected using semi-structured, face-to-face interviews. Data analysis was carried out following Sandelowski.\ud \ud Results: Iranian infertile couples’ experiences following failed ART cycles are described. The findings presented here show that Iranian infertile couples experience stressors during treatment cycles and systemic challenges which may be unique to the Iranian cultural context.\ud Conclusions: Iranian infertile couples face particular challenges related to the cultural context in which ARTs are delivered. Further exploration of the effects of culture on the experiences of failed ARTs needs to be considered by infertility clinics in Iran

Introduction: Infertility is a major medical issue. Investigations and treatment of infertility are the beginning of a complex, time-consuming and stressful process for couples that may fail well. The present study explored the needs of infertile couples following treatment failure with Assisted Reproductive Technologies (ARTs). Methods: A descriptive qualitative study was conducted in an Iranian infertility center, in the Northeast of the country between April 2016 and June 2017. The researchers recruited 29 individuals including 9 couples, 9 women and two men with primary infertility through purposive sampling. The data were collected using semi-structured interviews and analyzed iteratively, using conventional content analysis with MAXQDA software. Results: The main concepts obtained from the data were classified into one theme titled: ""The need for support"" and four main categories along with their subcategories, and included the need for psychological support, the need for more useful information, the need for social support and the need to access to supplementary services. Conclusion: The findings show that following treatment failure, the infertile patients’ expressed needs and preferences were not met. Identifying and meeting their needs may help the infertile couples to deal with ARTs failure and to reach a decision about future treatment.

Aim: To report the findings from an evaluation of the impact of the Compassion in Practice Vision & Strategy (CiPVS) (National Health Service England (NHSE), 2012) on nursing, midwifery and care staff.\ud \ud Background: The CiPVS was a programme of work to highlight the importance of compassionate care following the Francis Report in 2013 into the deficits in care in an NHS hospital trust. It was launched by NHS England in 2012 at a time when fiscal cuts were introduced by the Department of Health in England. \ud \ud Design and setting: Mixed methods. \ud \ud Results: Inferential statistics were used to test whether there were significant differences between staff at different levels of seniority with regard to awareness and involvement in CiPVS and their attitudes to it. Awareness and involvement of staff in CiPVS was high amongst middle and senior management but limited at ward level. Staff were not involved in CiPVS due to a lack of awareness. Ward level staff who were aware and involved perceived a lack of support and communication from senior leadership to deliver CiPVS.\ud \ud Discussion: Results reveal professional anger, distress and resistance to CiPVS and a view of the programme as a top down initiative which did not sufficiently recognise structural constraints on nurses’ ability to deliver compassionate care. We discuss the implications of our findings for global nursing. \ud \ud Conclusion: Participants emphasised that compassion for patients is only sustainable where there is compassion for staff and many participants felt that they were not being treated with compassion.\ud \ud Relevance for practice: NHSE should strongly affirm that nurses and midwives in general provide compassionate care. Trust leadership should provide support for ward level staff who deliver compassionate care in difficult circumstances.

Background: Universities in the United Kingdom (UK) are required to incorporate values based recruitment (VBR) into their healthcare student selection processes. This reflects an international drive to strengthen the quality of healthcare service provision. This paper presents novel findings in relation to the reliability and predictive validity of multiple mini interviews (MMIs); one approach to VBR widely being employed by universities.\ud \ud Objectives: To examine the reliability (internal consistency) and predictive validity of MMIs using end of Year One practice outcomes of under-graduate pre-registration adult, child, mental health nursing, midwifery and paramedic practice students.\ud \ud Design: Cross-discipline evaluation study. Setting: One university in the United Kingdom.\ud \ud Participants: Data were collected in two streams: applicants to A) The September 2014 and 2015 Midwifery Studies programmes; B) September 2015 adult; Child and Mental Health Nursing and Paramedic Practice programmes. Fifty-seven midwifery students commenced their programme in 2014 and 69 in 2015; 47 and 54 agreed to participate and completed Year One respectively. 333 healthcare students commenced their programmes in September 2015. Of these, 281 agreed to participate and completed their first year (180 adult, 33 child and 34 mental health nursing and 34 paramedic practice students).\ud \ud Methods: Stream A featured a seven station four-minute model with one interviewer at each station and in Stream B a six station model was employed. Cronbach’s alpha was used to assess MMI station internal consistency and Pearson’s moment correlation co-efficient to explore associations between participants’ admission MMI score and end of Year one clinical practice outcomes (OSCE and mentor grading).\ud \ud Results: Stream A: Significant correlations are reported between midwifery applicant’s MMI scores and end of Year One practice outcomes. A multivariate linear regression model demonstrated that MMI score significantly predicted end of Year One practice outcomes controlling for age and academic entry level: coefficients 0.195 (p = 0.002) and 0.116 (p = 0.002) for OSCE and mentor grading respectively. In Stream B no significant correlations were found between MMI score and practice outcomes measured by mentor grading.\ud \ud Internal consistency for each MMI station was ‘excellent’ with values ranging from 0.966–0.974 across Streams A and B.\ud \ud Conclusion: This novel, cross-discipline study shows that MMIs are reliable VBR tools which have predictive validity when a seven station model is used. These data are important given the current international use of different MMI models in healthcare student selection processes.

Objective: To evaluate a simple acupressure protocol in LIV3 and LI4 acupoints in women with primary dysmenorrhea.\ud \ud Methods: This paper reports a randomized, single blinded clinical trial. 90 young women with dysmenorrhea were recruited to three groups to receive 20 minutes acupressure every day in either LIV3 or LI4, or placebo points. Acupressure was timed five days before menstruation for three successive menstrual cycles. On menstruation, each participant completed the Wong Baker faces pain scale, and the quality of life short form -12 (QOL SF-12).\ud \ud Results: Intensity and duration of pain between the three groups in the second and third cycles during the intervention (p

Clinical commissioning groups (CCGs) were set up under the Health & Social Care Act (2012) in England to commission healthcare services for local communities. Governing body nurses (GBNs) provide nursing leadership to commissioning services on CCGs. Little is known about how nurses function on clinical commissioning groups. We conducted observations of seven formal meetings, three informal observation sessions, and seven interviews from January 2015 to July 2015 in two CCGs in the South of England. Implicit in the GBN role is the enduring and contested assumption that nurses embody the values of caring, perception and compassion. This assumption undermines the authority of nurses in multidisciplinary teams where authority is traditionally clinically based. Emerging roles within CCGs are not based on clinical expertise but on well-established new public management concepts which promote governance over clinically based authority. While GBNS claim an authority located in clinical and managerial expertise, this is contested by members of the CCG and external stakeholders irrespective of whether it is aligned with clinical knowledge and practice or with new forms of management, as both disregard the type of expertise nurses in commissioning embody.\ud Key words: case study; clinical commissioning groups; governing body nurses; leadership; authority; observation.

Editorial

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

This paper explores how reflexive practices enabled researchers to achieve a more complex analysis of qualitative data generated from focus groups. Drawing upon our experiences as two White British researchers, conducting\ud a study with internationally educated nurses from Black, Asian and Minority Ethnic backgrounds, we consider how our analysis led us to a more nuanced understanding of the data than might have occurred without reflexivity. We identified our respective standpoints, confronted our feared biases, particularly in relation to social stereotyping and prejudice, and located ourselves as co-producers of the data. This enabled us to consider how we might be representing, holding and paralleling, systemic patterns of discrimination, leading to several new insights. Reflexive practice is often referred to in theory, less often in application. We hope that sharing\ud our reflexive process will benefit other researchers navigating the complex waters of identifying themselves in their research.

Aims and objectives. To explore factors influencing exercise adherence among women with breast cancer while following an exercise programme.\ud Background. Earlier research shows that women with breast cancer decrease physical activity following the cancer diagnosis and that adhering to exercise interventions can be a challenge. Research is needed to identify motivational factors and barriers for exercise adherence among women during treatment for\ud breast cancer.\ud Design. This was a qualitative study to explore patient’s perceptions of the challenges to exercise adherence during a randomised, controlled trial.\ud Methods. Twenty-seven women with early-stage breast cancer were purposively sampled for focus group interviews during 2011–2012 from their participation in the exercise intervention group during 2010–2012. Five focus groups were performed,\ud and data analysis was completed using the systematic text condensation method.\ud Results. During the focus group study, five main themes were identified, which described factors participants perceived to influence their adherence to exercise during chemotherapy: ‘side effects of breast cancer treatment as a barrier to exercise’, ‘restoring and maintaining normality in daily life motivates exercise’, ‘other valued activities compete with exercise’, ‘constructive support enhances exercise’ and ‘positive beliefs about efficacy and outcomes motivate exercise’.\ud Conclusion. Adherence to exercise in women with breast cancer is challenged by internal and external conditions and may be improved by attention to the impact of treatment side effects and by supporting patient self-efficacy towards changing\ud health behaviour.\ud Relevance to clinical practice. Nurses should be aware that exercise adherence could be a challenge among women with breast cancer. They should help identify obstacles to exercise for women and ways to overcome them, as well as support them in their beliefs that they are capable of changing their health behaviour

From the perspective of preventive medical discourse, early interventional screening is one of the most important ways to intervene with developmentally delayed children and an important service for children’s public health. This paper details an historical perspective of early developmental screening in the United States and reexamines the concepts of early screening in widespread use in children’s populations to expose undisclosed facts. These facts remind us that early developmental screening might not be totally based on children’s needs, but on both the government’s desires and political activities. As a result, a certain population was identified as subjects that required developmental screening resulting in very large numbers studies. Under these circumstances, developmental screening instruments were used in conjunction with pediatricians’ individualized appraisals. The approach to developmental surveillance was to expand from the children to the parents’ concern. The instrument not only legitimately recruited parents and facilitated parents’ surveillance of their children’s development, but was also was a platform for highlighting parent-child interactions. This discussion may help community health nurses further understand different perspectives of early interventional screening in practice.

Background: Published research has shown the multiple mini interview (MMI) to be a reliable assessment instrument in medical and nursing student selection internationally.\ud Objectives: To develop, pilot and examine the reliability of MMIs in pre-registration student midwife selection in one Higher Education Institution a UK setting. \ud Design and setting: BSc (Hons) Midwifery Studies students at a Higher Education Institution in the UK volunteered to participate in ‘mock’ MMI circuits during the first week of their programme. DeVellis’s framework for questionnaire development underpinned the generation of interview scenarios. Participants’ responses to scenario questions were rated on a 7 point scale. Internal consistency was calculated for each station.\ud Results: An eight station model was piloted. Communication skills were assessed at each station as a generic attribute. Station specific attributes assessed included compassion and empathy, respect for difference and diversity, honesty and integrity, intellectual curiosity and reflective nature, advocacy, respect for privacy and dignity, team working and initiative, the role of the midwife and motivation to become a midwife. \ud Cronbach’s alpha scores for each station ranged from 0.91 – 0.97. \ud Conclusion: The systematic development of the MMI model and scenarios resulted in ‘excellent’ reliability across all stations. These findings endorse the MMI technique as a reliable alternative to the personal interview in informing final decisions in pre-registration student midwife selection.

Internationally, system-wide changes to the structures and systems governing health care aim to improve outcomes for patients, quality of care and access to services. The introduction of top-down centrally driven solutions to governance of health care, at the same time as increasing policy emphasis on greater ‘bottom up’ patient and public involvement in all aspects of health care, has set up complex tensions for policy implementation and health care practice. This paper explores the interplay of these agendas in the context of changes in primary health care services provided by the National Health Service (NHS) in England. Specifically, it looks at an example of service user involvement in a study (the PEGI study) of professional response to changes in the governance and incentives in the care of people with long-term conditions. This qualitative study was conducted in three Primary Care Trust sites in England. Service users influenced and guided the study throughout. In-depth interviews with 56 health and social care professionals engaged in the development of local policies and the delivery of care for people with complex long-term illness drew on vignettes developed by 32 members from three Service User Reference Groups (SURG). Themes generated by the cross case analysis were validated through these SURG groups. The findings presented here focus on four themes about risk and comparison of professionals’/service users’ perspectives of the issues: managing risks/consistent support, the risks of letting go/feeling in control, professionalism/helping people to help themselves, and managing expectations/professionals losing out. Service user involvement added value by: validating understandings of governance, framing debates to focus on what matters at the point of care, and enabling perspective sharing and interaction. We suggest that more collaborative forms of governance in health care, that take account of service user perspectives and enable interaction with professional groups, could help to validate processes of quality assurance and provide motivation for continuous quality improvement. We offer a model for ‘opening up’ collaborative projects to evaluation and appraisal and a process for critical reflection of the interrelationships between the PEGI study context, researcher issues, methods/approach and outcomes/impact of service user involvement.

Executive summary\ud This report presents the findings from the 2015 online survey of nurses working in commissioning roles either as Governing Body nurses (GBNs) and nurses working for Commissioning Support Units (CSUs) which support CCGs. The survey was undertaken in collaboration with the Commissioning Nurse Leaders’ Network (CNLN). We present the results from the online survey in the context of current policy developments and some recommendations.\ud Data collection was carried out using an online survey of all commissioning nurse members of the CNLN between 11th June and 6th July 2015. All of the sample provided by NHS England (n=238) were sent a personalised email (addressed to them by name) which included an information sheet about the survey and a link to the online survey. The response rate was 40.7% (n=97) which was similar to the response rate for the survey of CCG nurses carried out in 2014 by NHS England (41%, n-=69).\ud Findings included in this report refer to all respondents in the survey (GBNs and nurses working in CSUs) unless otherwise indicated. \ud Demographic profile and previous experience \ud 92.8% of respondents worked for one or more CCGs; 7.25% of respondents were employed by a CSU.\ud \ud Respondents were mostly female, over 50 years of age, of White or White British ethnicity, with substantial clinical, managerial and Board experience.\ud \ud Working patterns\ud 75% of the respondents had worked within CCGs or CSUs for more than two years; a relatively small proportion (7.8%) had been in their post for less than one year.\ud \ud 79.7% of respondents worked full-time (37.5 hours a week or more) and the majority (82.2%) worked within one CCG or CSU. \ud \ud Just under 18% of GBNs worked for more than one CCG and a majority of these respondents felt that all their CCGs worked well together (56.3%) but 25% said that only some are working together and 18.8% said that none were working together.\ud A large majority of GBNs (81%) worked in full-time statutory (executive) roles with just 14% working as part- time statutory (executive) roles. \ud \ud Tensions between CSUs and CCGs.\ud Amongst nurses who worked in CSUs, more than half of respondents (57.2%) said that they were fairly or extremely dissatisfied with the impact of their work on the CCG (28.6% in each category). A large minority (42.9%) said that they were fairly satisfied. Comments in open-ended questions suggested that this may be explained by perceptions that CSUs are not respected or valued by CCGs or that CCGs may sometimes make unreasonable demands on CSUs.\ud \ud GBNs‘ motivation, roles and experiences of working in CCGs.\ud The reasons for wanting to be a nurse on a CCG, which GBNs cited most frequently were: having an impact in population health; being an advocate for patient interests and ensuring a nursing influence on commissioning services. \ud \ud GBNs’ perceptions of their influence of their roles on decision-making in CCGs.\ud GBNs were much more satisfied with their impact on CCGs (84% very or fairly satisfied) than were nurses working in CSUs. In addition, more than 90% of GBNs were extremely or fairly satisfied overall with the contribution they made to the work of the CCG. \ud \ud Two-thirds of GBNs said that they chair at least one committee, most commonly the Quality Committee / Quality and Risk Committee or the Safeguarding Committee.\ud \ud Over 90% of GBNs said that their CCG has an executive management board. Of these, 79.7% reported that they were a member of that board. A large majority of GBNs who were on CCG management boards (89.1%) felt that they were extremely or fairly influential on these boards.\ud \ud Amongst those not on executive management boards, the reason most frequently given was that their role was not configured as an executive one and therefore they were not on the board and not able to influence decision making at this level. \ud \ud A large majority of GBNs (85.1%) felt that they were extremely or fairly influential in CCG decision- making generally.\ud \ud Nearly all respondents (92.7%) considered that the statutory nursing role was important (extremely or fairly) to the work of the CCG. \ud \ud GBNs’ views on the perceived purpose of CCGs.\ud Improving the population’s heath was considered to be the most important goal of their CCG by a significant majority of respondents (61.6%); 19.2% felt commissioning was the most important goal of CCG work; 9.6% of respondents believed service redesign and meeting financial targets were the most important goals of their CCG. \ud \ud GBNs’ perceptions of their ability to be leaders in CCGs.\ud 95.8% of respondents felt that that they had a leadership role within their CCG. More than half of respondents (52.9%) said that they were ‘extremely confident’ in carrying out their leadership role and a further 38.2% were fairly confident. \ud \ud Conclusions\ud These are positive, albeit self reported, findings regarding the nursing role in CCGs and CSUs. Some of the findings suggest causes for further investigation: \ud \ud • The open- ended responses show that the influence and impact of the GBN role may in some instances be limited by certain assumptions or ways of working, particularly the perception that the GP is the lead clinician in the CCG. \ud • There is evidence in the findings that GBNs were much more satisfied with their impact on CCGs than were nurses working in supporting commissioning in CSUs. \ud Consequently, achieving the goals of the CCGs, including developing a nursing leadership role in commissioning on CCGs, may therefore be under threat if the contributions of GBNs and other nurses working for CCGS or in CSUs, go unrecognised or are under-utilised.

In this chapter, I draw on fieldwork conducted for my doctorate that explored the lived experiences of people living with HIV (PLWHIV). I was interested in PLWHIV who had accessed fertility treatment and child adoption services. HIV-related infertility and adoption are different to other forms of infertility or experiences of adoption because some of those affected may not be biologically infertile. When untreated, HIV can affect reproduction and increase the risk of HIV transmission during unprotected sexual intercourse to both a non-positive partner and potentially an unborn baby. Consequently, PLWHIV who wish to become parents are generally encouraged to access counselling in order to establish safer methods of having children. Fertility treatment or adoption are possible options that avoid the risk of HIV transmission to the unborn baby and partner (Savasi, Mandia, Laoreti & Certin, 2013). In this chapter, I discuss how I managed professional and personal relationships during fieldwork as I researched a small community of PLWHIV.