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The ability to reflect on, and learn from, practice experiences is essential for nurses when seeking to provide effective person-centred care. This article outlines the various types of reflection that nurses can use, such as reflection-in-action and reflection-on-action. It also details some of the main models of reflection and explains how nurses might develop their skills in reflection to enhance the quality of patient care. The article provides examples of cases and reflective activities to demonstrate how nurses can use reflection in their practice., Competing Interests: None declared, (© 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Authentic leadership is a relatively new concept in nursing in which authentic leaders are anchored by their deep sense of self, and know where they stand on important issues, values and beliefs. While there is considerable literature available on authentic nurse leadership, little has been written regarding its effect on newly qualified nurses. Therefore, the author undertook a scoping review of the literature on authentic leadership and newly qualified nurses. A total of 12 articles were found through database searches and included in the review. Thematic analysis of the articles identified two primary themes of 'well-being at work' and 'work environment', and two lesser themes of 'transition from student to nurse' and 'retention'. The scoping review found that authentic leadership has a positive effect on newly qualified nurses and that authentic leaders can develop genuine and trusted relationships, thereby promoting a supportive work environment for newly qualified nurses., Competing Interests: None declared, (©2020 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Background: E-professionalism is a term used to describe the behaviours of healthcare professionals, including nurses, in the online environment. While a range of professional guidance on the use of online social media platforms is available, there has been little research into the perspectives of patients and the public more generally on nurses' e-professionalism., Aim: To explain what, how and why the public make decisions about the acceptability of nurses' online behaviours and e-professionalism, and to make recommendations for nurses on managing the information they share online., Method: This was a mixed-method critical realist study. Participants in a survey ( n =53) and two focus groups ( n =8) discussed and rated the acceptability of five vignettes related to nurses' online behaviours based on real-life examples., Findings: The participants generally thought that nurses are entitled to have a personal life and freedom of speech and to promote causes they believe to be important, even if these were not aligned with their own beliefs. Participants unanimously considered the use of profane language against any individuals or groups to be unacceptable., Conclusion: The public make decisions on the acceptability of nurses' online behaviours based on a range of complex factors, including social and individual values, attitudes and beliefs, as well as their intent and consequences. Recommendations for nurses on how to manage the information they share online include: using separate platforms for personal, educational and professional purposes; using functions that control who can 'tag' and share their posts; and ensuring any information they share that relates to healthcare or nursing practice is up to date and evidence based., Competing Interests: None declared, (©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Aim: The aim of this concept analysis is to clarify the meaning of professional nursing values., Background: In a time of increasing ethical dilemmas, it is essential that nurses internalize professional values to develop and maintain a professional identity. However, nursing organizations and researchers provide different conceptions of professional nursing values, leading to a lack of clarity as to the meaning and attributes of this construct., Design: Walker and Avant's (2011) method was used to guide an analysis of this concept., Data Source: Resources published from 1973 to 2016 were identified via electronic databases and hand-searching of reference lists., Review Methods: A review of the literature was completed and the data were analyzed to identify uses of the concept; the defining attributes of the concept; borderline, related, contrary, and illegitimate examples; antecedents and consequences; and empirical referents., Results: Professional nursing values were defined as important professional nursing principles of human dignity, integrity, altruism, and justice that serve as a framework for standards, professional practice, and evaluation., Conclusions: Further research is needed in the development and testing of professional nursing values theory, and the reassessment of values instruments. Core professional values that are articulated may help unify the profession and demonstrate the value of nursing to the public., (© 2017 Wiley Periodicals, Inc.)

Background: The study aims to assess the situational judgment capability of students in various professions, including medicine, surgical nursing, anesthesia nursing, and emergency medical technology, using a validated and adapted Situational Judgment Test (SJT). Methods: The cross-sectional study was conducted at Qom University of Medical Sciences in 2023–2024. The study consisted of two steps: (1) adaptation and validity assessment of the SJT in various health professions, and (2) evaluation of students' situational judgment capability using the adapted SJT. Participants included 207 students from surgical nursing, anesthesia nursing, medicine, and emergency medical technology departments, selected through stratified random sampling. The SJT included 10 constructed-response scenarios developed by Alkhuzaee and colleagues in 2022. The validation and adaptation process utilized consensus methods, and the SJT was modified to a selected response format based on a knowledge-based approach. Scores ranged from 0 to 30. Cohen's method and norm-referencing standard deviation were used to calculate a cut-off score. Data were analyzed using descriptive statistics (frequency, mean, standard deviation) and inferential statistics (independent t-test, ANOVA, and ANCOVA). Results: The face and content validity of the adapted SJT with a selected-response format was confirmed by expert agreement. The reliability of the SJT was approved, with a Cronbach's Alpha of 0.81. The mean score of students' situational judgment in professionalism was 11.90 (SD 4.54). Students' professions significantly impacted their situational judgment scores (F (3.201) = 3.67, p = 0.01, Partial Eta Squared = 0.052). Conclusion: The adaption and validation of SJT with a selected response format were confirmed by experts who evaluated the situational judgment capabilities of students in different clinical professions. The reliability of the SJT was acceptable—Cohen's method as a standard-setting approach assisted in identifying students needing support and training. The moderate level of situational judgment capacity confirmed the development of the educational program for the improvement of non-cognitive and non-technical skills such as judgment and decision-making in the field of professionalism. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your understanding of the stigma associated with personality disorders • To find out how the narrative around personality disorders is evolving • To recognise the need for comprehensive staff training and education about personality disorders. Individuals with a personality disorder diagnosis experience high levels of stigma within society generally and healthcare services specifically. This narrative review analyses the recent literature exploring the stigma associated with personality disorders. The findings offer insights into the ongoing contentious nature of personality disorder as a diagnosis, the issues around misdiagnosis and the prevailing attitudes of healthcare professionals. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware that orofacial clefts are the most common facial congenital abnormalities in humans • To read a case study presenting an overview of the care provided for an infant born with a cleft palate • To recognise the vital role of children’s nurses in supporting family-centred care. Orofacial clefts are the most common facial congenital abnormalities in humans. Their management is complex due to a range of immediate and ongoing challenges. These include breathing, feeding, speech, hearing and dental issues. This article uses a case study approach to outline these challenges for a patient who was born with a cleft palate. The case is followed by a discussion of contemporary evidence-based care. The article focuses on family-centred care and multidisciplinary teamwork, and the author also details the central role of the children’s nurse. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the importance of recognising the specific healthcare needs of children and young people • To be aware of the concerns that have been raised in response to the potential move towards a generalist approach in nursing • To learn about some of the suggestions for protecting the field of children and young people’s nursing and optimising care for this patient group. At certain points in nursing history, it has been necessary to make a case for children and young people to be cared for by specialist nurses educated to meet their specific needs. However, in 2018 the updated Nursing and Midwifery Council (NMC) standards of proficiency for registered nurses adopted a generic rather than field-specific approach. This article reiterates that children, young people and their families have unique needs that are best met by nurses who are trained specifically to care for them. The case is made from a historical and legal perspective, concluding with a proposal that in the best interests of children, young people and their families, the NMC should embed specific competencies for children’s nurses into its standards of proficiency to future-proof this field of practice. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To learn about a project that aimed to support teams caring for children and young people to reflect on their experiences and the effects of the coronavirus disease 2019 (COVID-19) pandemic • To recognise the need to ensure staff are adequately prepared to manage any future surges in respiratory illness effectively • To be aware of the potential long-term effects of the COVID-19 pandemic on emotional health and well-being. The coronavirus disease 2019 (COVID-19) pandemic was a challenging experience for children and young people’s services, and the workforce. The Valuing All Staff Together programme was a one-year project hosted by the North West Paediatric Critical Care, Surgery in Children, Long Term Ventilation Operational Delivery Network to support teams caring for children and young people to reflect on their experiences of the COVID-19 pandemic. Using an online survey, focus groups and interviews, it gave staff the opportunity to explore and understand the effects of the pandemic and the subsequent surge in demand, including how these affected services and the emotional health and well-being of staff. This would enable better preparation for future surges in respiratory illness in terms of learning, training and development. This article describes the programme’s aim, method and findings, and the main recommendations for practice. [ABSTRACT FROM AUTHOR]

Background: Many nurses join the profession because they have altruistic intentions, but some nurses experience barriers to acting on altruistic intentions which may be a source of job dissatisfaction or burnout. Objective: The purpose of this study was to evaluate construct validity, internal consistency, and convergence reliability of the Nursing Altruistic Execution Scale (NAES), a novel instrument assessing the perceived ability to help others through work. Methods: The NAES was developed based upon a literature review examining altruistic behavior as a motivator for nursing work, with expert feedback for instrument refinement. Participants completed the NAES, Copenhagen Burnout Inventory Work-Related Burnout Scale, and Satisfaction of Employees in Health Care Survey. Exploratory factor analysis examined construct validity and factor loadings. Confirmatory factor analysis verified consistency in factor structure. Linear regression assessed for convergence reliability with burnout and job satisfaction. Results: The sample included 843 acute care hospital nurses surveyed in January-March 2023. Exploratory factor analysis revealed a two-factor solution, named altruistic engagement with work and workplace barriers to altruism. Nine instrument items were retained and demonstrated strong internal consistency (Cronbach's alpha 0.79). There was a significant relationship between both factors of the NAES and both burnout and job satisfaction, demonstrating that greater altruistic execution is associated with lower burnout and greater job satisfaction. Conclusion: Preliminary findings support the use of the NAES as a valid and reliable scale. Findings show there is correlation between altruistic intentions and burnout. Interventions aimed at enhancing altruistic execution may reduce nurse burnout and thereby improve retention. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the challenges of managing diabetes mellitus alongside dementia • To learn about the importance of sharing patient information among healthcare professionals in various settings • To consider how the use of IT might promote more effective communication between specialties. Background: Managing diabetes mellitus alongside the onset and development of dementia poses many challenges for those living with these conditions as well as their families, carers and service providers. Aim: To describe nurses’ positive experiences when managing adults with diabetes and dementia, as well as the issues and challenges. Method: Qualitative, semi-structured focus group interviews were conducted with community and diabetes specialist nurses drawn from five health and social care trusts. Findings: Four themes were identified: whose responsibility is it?; community and diabetes specialist nurses – the pivot point; education to manage comorbidities; and interprofessional communication. Conclusion: Community and diabetes specialist nurses experience many challenges when supporting individuals living with diabetes and dementia. Sharing patient information among practitioners in different settings is critically important. IT could overcome the limitations of note-keeping ‘silos’, but further education is recommended to establish more effective communication and partnership working. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To refresh your knowledge of what critical reflection entails and its potential benefits • To enhance your understanding of some of the reflective models that nurses can use to support them • To consider how you could use critical reflection to enhance your practice. Reflection is an essential aspect of nursing practice that facilitates continuing professional development and practice improvement. Critical reflection is a more in-depth form of reflection and can be described as a creative, dynamic and transformative learning process that enhances practice by promoting self-awareness and critical thinking. Older adults often present with complex and multiple healthcare needs. Engaging in critical reflection can assist nurses to provide the high-quality, person-centred care required to meet those needs, support older people to retain their independence and enhance their well-being. This article discusses critical reflection within the context of nursing older people and describes various models that can be used to support the reflective process. The authors use a practice example to illustrate how using critical reflection in practice can enable nurses to develop a deeper understanding of themselves and use what they have learned to enhance their delivery of person-centred care. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your understanding of the training needs of ward nurses who manage major trauma patients • To read about the development and evaluation of a bespoke major trauma course for ward nurses • To identify potential challenges in quality improvement projects and how they can be addressed. Nurses working with major trauma patients in ward environments in the UK are expected to evidence their knowledge and skills in a set of national competencies. This article describes a bespoke major trauma course and a coaching and portfolio development programme designed to enhance ward nurses’ knowledge and skills, help them evidence their competence and support their professional development. Evaluation of the course showed an overall improvement in nurses’ self-rated competence and confidence in a range of relevant major trauma topics and clinical skills. Evaluation of the coaching and portfolio development programme showed that nurses believed their knowledge and skills had improved after taking part and that they valued the opportunity for professional development. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the link between severe mental illness and suboptimal physical health • To enhance your knowledge of the complex and multifaceted causes of diagnostic overshadowing • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). People with severe mental illness (SMI) often have suboptimal physical health and associated outcomes. An important issue for mental health nurses to be aware of is diagnostic overshadowing, which occurs when healthcare professionals misattribute a person’s physical health symptoms to their existing mental illness. This misattribution increases the likelihood of delays in treatment, potentially giving rise to complications that further negatively influence health outcomes. While the causes of diagnostic overshadowing are complex and multifaceted, mental health nurses need to ensure that their practice is not a contributing factor, which requires ongoing self-reflection on their knowledge, skills and attitudes. This article defines diagnostic overshadowing, proposes potential explanations for why it may occur and offers practical strategies to prevent it. Raising awareness of diagnostic overshadowing could help to improve physical health outcomes for people with SMI. [ABSTRACT FROM AUTHOR]

Emergency nurses are the first clinicians to see patients in the ED; their practice is fundamental to patient safety. To reduce clinical variation and increase the safety and quality of emergency nursing care, we developed a standardised consensus-based emergency nurse career pathway for use across Australian rural, regional, and metropolitan New South Wales (NSW) emergency departments. An analysis of career pathways from six health services, the College for Emergency Nursing Australasia, and NSW Ministry of Health was conducted. Using a consensus process, a 15-member expert panel developed the pathway and determined the education needs for pathway progression over six face-to-face meetings from May to August 2023. An eight-step pathway outlining nurse progression through models of care related to different ED clinical areas with a minimum 172 h protected face-to-face and 8 h online education is required to progress from novice to expert. Progression corresponds with increasing levels of complexity, decision making and clinical skills, aligned with Benner's novice to expert theory. A standardised career pathway with minimum 180 h would enable a consistent approach to emergency nursing training and enable nurses to work to their full scope of practice. This will facilitate transferability of emergency nursing skills across jurisdictions. [ABSTRACT FROM AUTHOR]

Background: Midwifery emergencies can be managed by providing effective and quality care through a skilled workforce. Improving the quality of midwifery care requires the professional development of midwives, especially those who are novice, to maintain their capabilities and enhance their performance. This study was designed to develop a professional development program in the management of midwifery emergencies for midwifery graduates. Materials and Methods: This mixed-method study was conducted in two phases. In the first phase, a qualitative study was conducted to investigate the program needs, facilitators, and barriers to the management of midwifery emergencies in midwifery graduates. Further, the initial version of the program was developed based on the results of the qualitative study and literature review. The Analysis, Design, Development, Implementation, and Evaluation (ADDIE) model was used to develop a professional development program for the management of midwifery emergencies. The developed program was then evaluated and approved by a panel of experts. In the second phase, the developed professional development program is implemented, and its impacts are evaluated. Finally, the final professional development program in the management of midwifery emergencies for midwifery graduates is provided. Results: In total, 2,360 primary codes were extracted and merged into 210 codes. After extracting the sub-categories and categories, a review of the texts was conducted, and the final program was developed. Conclusions: Using a professional development program for newly graduated midwives is an effort to improve the health of mothers and infants who receive these services.

Rationale and key points: Why you should read this article: • To understand the necessary preparation required before triaging a patient • To familiarise yourself with the steps required when triaging a patient in the emergency department • To learn about the scales and algorithms used by nurses when triaging patients. Triaging patients can be a complicated process, with multiple modes of assessment taking place simultaneously, and nurses need to be confident and competent in their assessment skills. This article explains the necessary preparation for triage and outlines the steps that nurses need to take when triaging a patient in the emergency department. • Triage requires a targeted patient assessment, using both clinical judgement and triage tools to determine appropriate acuity categories. • Different scales and algorithms are used in triage, so it is essential to clearly communicate the acuity categories assigned to patients. • A structured approach to patient assessment can guide decision-making and identify issues. • Various diagnostic tests can be used to facilitate the triage process, but care needs to be taken to ensure the process is not prolonged by their use. Reflective activity: ‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when assessing the acuity of patients in triage. • How you could use this information to educate nursing students or your colleagues on the appropriate technique and evidence base regarding the triaging of patients in the emergency department. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the complexity of the needs of people with delirium superimposed on dementia • To enhance your knowledge of second-generation activity theory • To recognise the consequences of the separation of physical health and mental healthcare. Background: Delirium superimposed on dementia (DSD) affects the physical, mental and cognitive well-being of the person. The separation of physical health and mental health means that the care of people with DSD is at odds with the multifaceted aetiology and presentation of the condition. There is a lack of research on DSD from a mental health perspective. Aim: To explore UK mental health nurses’ experiences of providing care for people with DSD. Method: Individual semi-structured interviews were conducted with seven mental health nurses from one NHS trust in England. Participants’ experiences were considered through the lens of second-generation activity theory. Data were analysed using framework analysis. Findings: Six themes were identified: awareness of guidance and tools; guidance or tools as ‘paper exercises’; knowing the patient; the multidisciplinary team; care burden; and mental health versus physical health. Conclusion: When providing care for people with DSD, mental health nurses use their skills in knowing patients as individuals. However, this aspect of ‘knowing’ cannot be readily translated into the use of a numerical scoring tool. An integrated approach is required to support the care of people with DSD. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To gain a greater understanding of key specialist nursing roles in children’s cardiology • To delve into the guidance and standards on nursing roles and competences in children’s cardiac services • To recognise the need for nursing teams to collaborate across congenital heart disease (CHD) networks. Background: Children’s cardiac nursing roles have changed over the past decade. Royal College of Nursing (RCN) guidance and NHS England standards have been published with the aim of standardising and enhancing nursing care for children and young people with congenital heart disease (CHD) and their families. Aim: To explore the breath of implementation of key nursing roles in children’s cardiac services across the UK and Ireland and to determine whether the roles met the RCN guidance and the NHS England standards. Method: A cross-sectional survey design was used. The 150 members of the Congenital Cardiac Nurses Association (CCNA) were invited via email to participate and were sent a link to an online survey. Findings: Of the 150 potential respondents, 31 completed the survey. Overall, respondents believed that the RCN guidance had been implemented effectively and that children’s cardiac nursing roles matched the RCN’s example job descriptions. Respondents’ comments suggested that implementation of the NHS England standards had been challenging and that progress in setting up key roles such as lead nurse, cardiac nurse educator and children’s cardiac nurse specialist had been slow. Respondents felt that political and financial factors adversely affected recruitment. Conclusion: Since publication of the NHS England standards there has been some progress in the implementation, in children’s cardiac services, of key nursing roles such as lead nurse and innovative nursing roles such as advanced nurse practitioner and research nurse. The findings of this study have informed the latest edition of the RCN guidance, which now includes the role of senior research nurse. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To increase your awareness of the growing importance of personalised medicine in cancer services • To enhance your understanding of the support needs of patients who undergo genomic testing • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Knowledge of genomics and genetic testing is increasingly being used to inform cancer diagnosis, prognosis and effective treatment, known as personalised or precision medicine. The NHS aims to embed genomics into diagnostic pathways, meaning that it is becoming a routine aspect of cancer care. Therefore, it is important that cancer nurses have an understanding of genomics and personalised medicine so that they can provide appropriate information and support to patients and families. This article is designed to equip nurses with the skills to start essential genomic conversations with patients to support them through their cancer pathways. It focuses on Lynch syndrome, an inherited condition that increases the risk of developing certain cancers, and explains the genetics, testing, surveillance and psychological aspects of care for patients and families affected by this syndrome. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To appreciate that the gradual and uncertain trajectory in frailty can be a barrier to advance care planning • To recognise the importance of the early recognition of frailty in prompting conversations on end of life care • To acknowledge the need for all healthcare professionals to receive better education on frailty and its effects. Background: Older people with frailty are susceptible to sudden and rapid deterioration, so discussing their wishes and preferences for care at the end of life should be a priority. However, frailty is often not considered or recognised, which impedes patient-centred decision-making. Aim: To explore the views and perceptions of senior healthcare professionals regarding the usefulness of the Clinical Frailty Scale (CFS) in identifying frailty; whether a CFS score of severe frailty leads senior healthcare professionals to recognise that the person is likely to be approaching the end of life; and whether a CFS score of severe frailty prompts senior healthcare professionals to have conversations about advance care planning and end of life care with patients. Method: Semi-structured individual interviews were undertaken with seven senior healthcare professionals at one hospital in England. Data were analysed using thematic analysis. Findings: Frailty appeared to be complex, multifaceted and at times difficult to identify. A diagnosis of severe frailty did not necessarily prompt advance care planning and end of life care conversations. Such conversations were more likely to happen if the person had comorbidities, for example cancer. Prognostication appeared to be challenging, partly due to the gradual and uncertain trajectory in frailty and a lack of understanding, on the part of healthcare professionals, of the condition and its effects. Conclusion: People with severe frailty may be disadvantaged in terms of receiving appropriate end of life care. Better education on frailty for all healthcare professionals would facilitate conversations about advance care planning and end of life care with patients diagnosed with severe frailty. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your understanding of the relationships between workplace stressors and job performance • To familiarise yourself with validated scales that can be used to measure stress, resilience and job performance • To consider measures that could be implemented to mitigate stressors, increase resilience and foster effective coping mechanisms among nurses. Background: Nurses are a crucial part of healthcare organisations, constituting around half of the global healthcare workforce. Therefore, it is important to examine the factors that may affect their job performance, which is central to the delivery of effective healthcare services. Aim: To examine the relationships between stress, resilience and job performance within the nursing context in Jordan. Method: A cross-sectional descriptive correlational design was used. A self-administered questionnaire comprising stress, resilience and job performance scales was completed by a convenience sample of 207 nurses working in five hospitals in the northern and middle regions of Jordan. Results: Overall, respondents self-reported moderate stress levels, normal resilience levels and moderate job performance. The study identified: a moderate positive correlation between stress and resilience; a weak negative correlation between stress and job performance; and a weak positive correlation between resilience and job performance. Conclusion: It is essential that nurse managers, leaders and policymakers implement measures to mitigate the stressors encountered by nurses, increase resilience and foster effective coping mechanisms. Such measures could enhance nurses’ resilience and job performance, ultimately improving patient care. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your awareness of the importance of digital literacy among nurses • To recognise that data from electronic patient systems can be used to improve patient care • To read about a data-driven education model implemented at one NHS trust to improve digital literacy. A digitally literate nursing workforce can support the delivery of safe, effective care and improve patient outcomes. However, digital literacy among nurses is variable. Electronic patient records (EPRs), which require the digital documentation of all patient encounters, can be used to generate data that will inform strategies to improve patient care and patient safety. Nurse leaders at Imperial College Healthcare NHS Trust acknowledged that although ward nurses were providing excellent patient care, there were gaps in their digital documentation of that care. To address the issue, the trust implemented a model of education informed by data analytics and aimed at developing nurses’ digital skills and increasing their engagement with digital workflows. This article describes how applications extracting data from the EPR system are used to identify nurses’ digital literacy training needs and how a team of digital clinical practice educators delivers targeted educational strategies to meet those needs. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To familiarise yourself with what nursing associate apprenticeships involve • To read about apprentice nursing associates’ experiences of home placements in primary or social care • To explore factors that may support or hinder apprentice nursing associates’ professional development. Background: An increasing number of apprentice nursing associates undertake their home placement in primary care or social care, but there is limited understanding of apprentice nursing associates’ experiences in these settings. Aim: To explore apprentice nursing associates’ experiences of a home placement in primary care or social care and provide initial insight into what may support or hinder their professional development in these settings. Method: A mixed-methods study design was used with qualitative interviews complemented by a quantitative survey. Participants were recruited among 27 current or former apprentice nursing associates studying at one London university. Eleven current or former apprentices were interviewed and 15 completed the survey. Findings: Participants’ motivations for applying to become nursing associates were to develop professionally and advance their careers. They experienced supportive learning environments where they felt part of the team, but also unsupportive learning environments where they were denied protected learning time and supervised practice. Several participants experienced unfair treatment and abuses of power, including non-payment for university days and external placements, sexual harassment and marginalisation. Conclusion: Apprentice nursing associates can have suboptimal experiences of home placements in primary care or social care and be subjected to unfair treatment and abuse. Urgent action is required from higher education institutions and employers to ensure apprentice nursing associates are adequately supported. [ABSTRACT FROM AUTHOR]

Background: Mutual rights in the medical system have always been considered an important component of medical ethics. Observance of midwives' rights could affect the quality of their services. This study was conducted to determine the methods for improving the observance of midwives' rights from the perspective of midwives and related managers. Methods: This cross-sectional study was performed on 346 midwives and 19 hospital managers in 9 hospitals in Isfahan (Iran) 2018 -2019. The sample was selected from the midwives using the census method and from the managers using the purposive method. Data were collected using a questionnaire containing demographic, managerial-organizational, and individual methods to improve the observance of midwives' rights. Findings were analyzed using descriptive/inferential statistics (T- test) in SPSS v. 18 software. Results: Managerial-organizational and individual methods from the perspective of midwives and managers (total view) were not significantly different (P>0.05). The most important managerial-organizational method to improve the observance of midwives' rights included "increasing the level of awareness of midwifery staff about their rights and their recognition" with a mean and standard deviation (SD) of 4.32 ± 0.78, and one of the most important individual methods was to "improve work conscience" with a mean and SD of 4.35 ± 0.80. Conclusion: Managerial-organizational and individual methods are important to increase the observance of midwives' rights in the hospital. In order to improve midwifery services and midwives' health, hospital managers must make the necessary efforts to increase the observance of midwives' rights by considering related factors.

Abstract Introduction The clinical practices of nurses should be in accordance with the principles of professional ethics. Respecting professional ethics principles depends on several factors. The present study was conducted to investigate the effective inhibitors and facilitators in compliance with professional ethics and their importance from the nurses’ perspective. Methods During this cross-sectional descriptive study, 452 nurses were included by the census sampling method. The data were collected via the “inhibitors of compliance with professional ethics standards by the nurses’ perspective” and “facilitators of compliance with professional ethics standards by the nurses’ perspective” questionnaires. Additionally, by designing the “open-ended question” section, other inhibiting and facilitating factors of professional ethics standards from the nurses’ perspective were investigated. The data were analyzed using descriptive and inferential statistics (Wilcoxon signed ranks test). Results The individual care-related dimension as a facilitator had the highest mean score compared to the other dimensions (76.62 ± 4.92). Furthermore, seven items in the inhibitor section, 19 items in the facilitator section had higher scores. Among them, there were seven items in common. Strong or weak belief in compliance with ethical issues had the highest mean scores in the role of facilitator and inhibitor (90.54 ± 12.13 and 89.54 ± 14.88, respectively). Conclusion Strong or weak belief in compliance with ethical issues was the most important inhibitor and facilitator from the nurses’ perspective, which makes it necessary to examine individual beliefs about ethical issues among applicants to enter the nursing profession.

ObjectivesFew surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic.DesignCross-sectional survey using four validated instruments.SettingSixty-two sites in Canada and the United States.SubjectsAttending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs.InterventionNone.Measurements and main resultsWe analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures.ConclusionsDespite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

BackgroundPhysician burnout and wellbeing are an ongoing concern. Limited research has reported on the impact of the COVID 19 pandemic on burnout over time among U.S. physicians.MethodsWe surveyed U.S. frontline physicians at two time points (wave one in May-June 2020 and wave two in Dec 2020-Jan 2021) using a validated burnout measure. The survey was emailed to a national stratified random sample of family physicians, internists, hospitalists, intensivists, emergency medicine physicians, and infectious disease physicians. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Responses were weighted to account for sample design and non-response bias. Random effects and quantile regression analyses were used to estimate change in conditional mean and median PFI-BC scores, adjusting for physician, geographic, and pandemic covariates.ResultsIn the random effects regression, conditional mean burnout scores increased in the second wave among all respondents (difference 0.15 (CI: 0.24, 0.57)) and among respondents to both waves (balanced panel) (difference 0.21 (CI: - 0.42, 0.84)). Conditional burnout scores increased in wave 2 among all specialties except for Emergency medicine, with the largest increases among Hospitalists, 0.28 points (CI: - 0.19,0.76) among all respondents and 0.36 (CI: - 0.39,1.11) in the balanced panel, and primary care physicians, 0.21 (CI: - 0.23,0.66) among all respondents and 0.31 (CI: - 0.38,1.00) in the balanced panel. The conditional mean PFI-BC score among hospitalists increased from 1.10 (CI: 0.73,1.46) to 1.38 (CI: 1.02,1.74) in wave 2 in all respondents and from 1.49 (CI: 0.69,2.29) to 1.85 (CI: 1.24,2.46) in the balanced panel, near or above the 1.4 threshold indicating burnout. Findings from quantile regression were consistent with those from random effects.ConclusionsRates of physician burnout during the first year of the pandemic increased over time among four of five frontline specialties, with greatest increases among hospitalist and primary care respondents. Our findings, while not statistically significant, were consistent with worsening burnout; both the random effects and quantile regressions produced similar point estimates. Impacts of the ongoing pandemic on physician burnout warrant further research.

INTRODUCTION AND AIMS: Professionalism provides for an obligation for nurses in carrying out nursing care in hospitals and this is obtained from continuing professional development (CPD). The aim of this research is to review the benefits of CPD in nursing practice. MATERIAL AND METHODS: This paper is a literature review using several databases, namely Scopus, PubMed, Science Direct. Searching for articles were with the keywords/MeSh vocabulary - "[Continuing Professional Development]" OR "[CPD]" AND "[Nursing]"AND [Professional]. RESULT: Based on the search results, nine articles were found which had used mixed (n=2), qualitative n= 2 and quantitative (n=5) methods. CONCLUSION: CPD impacts nurses' knowledge, skills, job retention, patient safety and quality of care. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To refresh your knowledge of holistic needs assessments (HNAs) • To consider how HNAs can be effectively delivered to patients with cancer as and when required • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Holistic needs assessments (HNAs) are interventions used by clinical nurse specialists (CNSs) and other members of the cancer team to deliver personalised care to people living with cancer. HNAs have been used since the launch of the National Cancer Survivorship Initiative in 2007, with many cancer services embedding them in routine patient care. However, shortcomings in HNA delivery remain, notably in terms of the number of people who receive them. This article prompts nurses to reflect on how HNAs can be effectively delivered to all patients with cancer as and when they need them. The author discusses the principles of personalised cancer care, the benefits of HNAs and when, where, how and by whom HNAs should be carried out. Recommendations to support nurses in cancer settings to increase and improve HNA delivery include CNSs, cancer support workers and allied health professionals joining forces and collaboration between secondary and primary care teams. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To familiarise yourself with the professional nurse advocate role • To learn how restorative clinical supervision can support nurses to enhance the care of older people • To acknowledge handovers or debriefs as complementary sources of support for nurses. The professional nurse advocate (PNA) role is the key enabler of delivery of the NHS England Advocating and Educating for Quality Improvement (A-EQUIP) model of professional nursing leadership and clinical supervision. The aim of the PNA role is to provide clinical, educational and well-being support to nurses through restorative clinical supervision. This article describes the PNA role and the A-EQUIP model and discusses some of the challenges experienced by nurses in relation to delivering care to older people and current workforce pressures. The author suggests that restorative clinical supervision may support nurses to manage these challenges and enhance their practice in the care of older people, and describes part of a workforce improvement project to illustrate this in practice. Finally, the author considers some of the barriers to implementation of restorative clinical supervision. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise the importance of exercise in older people in preventing falls • To enhance your confidence in promoting exercise programmes suitable for older people • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Older people who sustain a fall may experience a range of adverse outcomes, such as distress, injury and loss of independence. Falls increase the risk of frailty and frailty increases the risk of falls. Regular exercise is a pillar of falls prevention and can have extensive benefits for older people’s health, well-being and ability to undertake activities they enjoy. As part of the multidisciplinary team, nurses have a pivotal role in implementing exercise-based falls prevention strategies for older people and in encouraging their patients to exercise. This article discusses exercise as a falls prevention strategy in hospital and in the community and supports nurses to develop their knowledge and confidence in promoting exercise in older people. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the main characteristics of master’s degree programmes and the expectations of master’s students • To learn about the benefits of a master’s degree for patient outcomes • To consider the relationship between critical thinking and critical reflection. Undertaking a master’s degree has become an integral part of nurses’ continuing professional development. However, there can be uncertainty among nurses about the requirements and expectations of this level of education, and about the benefits for patients and nurses. This article describes the main characteristics of master’s degree programmes and the expectations of master’s students. It also explores the literature on the benefits of a master’s degree in relation to patient outcomes, nurses’ clinical competence and professional autonomy and nurses’ career development. The author considers the concepts of, and relationship between, critical thinking and critical reflection and how nurses’ ability to apply these concepts in practice can be enhanced through undertaking master’s level education. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand why nurse-patient communication in the emergency department (ED) can be challenging • To consider a range of practical ways in which to enhance nurse-patient communication in the ED • To recognise the role of audit, education, mentorship and reflection in maximising nurse-patient communication. Effective communication in the emergency department (ED) is vital for ensuring safe patient care and supporting optimal patient outcomes and satisfaction. However, such settings are often noisy, fast paced and unpredictable, which can make nurse-patient communication challenging. Effective communication requires the appropriate knowledge and skills underpinned by clarity, mutual understanding, respect and empathy. However, maximising nurse-patient communication requires various practical and strategic measures, ranging from addressing the environmental challenges of the ED and meeting patients’ individual communication needs, to implementing quality control measures and supporting mentorship, reflection and education in practice. This article offers an overview of some of the practical and strategic measures nurses of all levels and experience can apply to maximise nurse-patient communication in the ED. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand how simulation can create a safe environment conducive to deep and meaningful learning • To recognise the importance of enhancing the communication and clinical skills of children’s hospice staff • To learn about a quality improvement project conducted to test simulated learning at a children’s hospice. Simulated learning has well known positive effects but its use in palliative care education is limited. A quality improvement project was undertaken at a children’s hospice to develop and evaluate simulation workshops. The aim was to increase the knowledge, skills and confidence of nurses and healthcare assistants in managing challenging situations commonly experienced when caring for children with life-limiting conditions and their families. The Plan, Do, Study, Act (PDSA) model for improvement was used to test simulation workshops on a small scale using a post-workshop questionnaire and reflective diaries. Despite some initial anxiety, participants felt that the workshop had enhanced their confidence, knowledge and skills, particularly in relation to conducting challenging conversations. The project has provided insight and evidence to develop simulated learning at the children’s hospice and further afield. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your knowledge of the elements of neurological assessments in children • To improve your understanding of when to perform neurological observations and when to escalate them • To contribute towards revalidation as part of your 35 hours of CPD (UK readers) • To contribute towards your professional development and local registration renewal requirements (non-UK readers). Neurological observations are a vital part of the assessment of infants, children and young people with a suspected or confirmed acquired brain injury (ABI). They are designed to identify neurological deterioration and inform the management of ABIs. Children’s nurses may perform many of these neurological observations, including by using tools such as the AVPU scale, the Glasgow Coma Scale, pupillary response and limb assessment. This is the second of two articles that aim to encourage accuracy and consistency when performing neurological observations in infants, children and young people with a suspected or confirmed ABI to optimise their care. The article explains how to undertake various elements of a neurological assessment, how often to perform neurological observations, when to escalate concerns and why it is important to use family-centred care. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To enhance your awareness of adultification and which groups are most at risk of it • To understand the risk factors and harmful effects associated with adultification • To identify strategies that you could use in your practice to prevent adultification. Adultification, whereby children and young people are perceived as older or more mature than they actually are, disproportionately affects those from minority ethnic backgrounds. It can also occur in other contexts, for example when children and young people are placed in a position of adult responsibility. Nurses have a duty to support and protect children and young people, which includes protecting them from adultification and the negative effects it can have on health and well-being. This article discusses strategies nurses can use to prevent adultification – such as developing awareness, avoiding adultifying language and listening to children and young people – and actions to take when suspecting adultification from colleagues. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To refresh your knowledge of pubertal development in children • To identify the contributory factors for early, or precocious, puberty and how they may be prevented and managed • To recognise the role of nurses in supporting children experiencing precocious puberty and their families, with a focus on girls. Puberty is an important marker of health and development in a child’s life. Complex neuroendocrine factors contribute to the onset of puberty. While pubertal changes usually occur between the ages of 12 and 13 years, some children may attain puberty before the age of eight years for girls and nine years for boys, which is termed precocious puberty. A literature review was conducted to explore the incidence and prevalence of precocious puberty, identify contributory factors, and recognise management and preventive measures. In addition, the effects on the child and family and the role of nurses were considered. The incidence and prevalence of precocious puberty are increasing. Obesity, early childhood stressors, environmental toxins, increased access to the internet and socioeconomic status are contributory factors. Pharmacological and psychological interventions may be used to manage precocious puberty. Lifestyle modifications such as healthy eating are important preventive measures. Nurses have an important role in preparing children and families, and supporting their psychological and social well-being. [ABSTRACT FROM AUTHOR]

Objective: to identify teaching-learning strategies for professional nursing care: consequences of COVID-19. Methods: a qualitative study with a phenomenological theoretical approach. The population was made up of 11 teachers and 10 students on the Bachelor of Nursing course at a public university, who were interviewed in-depth and audio-recorded for later transcription. Open categorization was used; content analysis enabled the identification of categories: Teaching-learning strategies, Acquired learning, and professional skills. Results: the most relevant teaching and learning strategies are active methodologies and collaborative work. The adaptability of students and teachers is the most important thing to highlight, enhancing the development of skills through the link between theory and practice. Conclusion: it is clear that the actors agree that the strategies have better application and results in learning care through the face-to-face education modality, facilitating the approach of real scenarios to generate meaningful learning. Contributions to practice: the complete panorama of the educational transition that teachers and students have gone through during the pandemic has supported the identification of teaching-learning strategies that promote meaningful learning.

Why you should read this article: • To gain insight into the views and perceptions of nurses regarding digital technology and digital skills • To recognise that using digital technology is likely to have both advantages and drawbacks for patient care • To acknowledge the need for nurses to receive appropriate and accessible digital literacy training. Background: Digital technology has an increasing role in healthcare, but staff lack opportunities to develop their digital skills and there is a lack of research on education and training in digital technology for staff. Aim: To explore nurses' perceptions of the use of digital technology in their practice and to identify the digital skills required by newly registered nurses to work in a digitally enabled environment. Method: Individual semi-structured interviews were conducted on an online communication platform with nine participants – four newly registered nurses and five senior nurses working in clinical and/or management roles. Inductive thematic analysis was used to analyse the data. Findings: Several barriers and facilitators to the use of digital technology were identified, including around infrastructure, time, skills, training, support, leadership, familiarity and confidence. The use of digital technology may enhance care consistency and increase patient autonomy, but it may also erode nurse-patient relationships. Conclusion: Digital technology can enhance patient care but organisational barriers, notably in relation to digital literacy training, need to be addressed for nurses to fully adopt it. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To improve your knowledge of systemic anticancer therapy (SACT) and its administration • To increase your awareness of the need for thorough systematic safety checks before SACT administration • To read about a project at a haematology unit designed to help nurses conduct pre-SACT safety checks Systemic anticancer therapy (SACT) is a high-risk procedure with the potential for medication errors at every stage, from prescribing and dispensing to administration. Pre-administration checks carried out by nurses are the last opportunity to detect any discrepancies or potential errors before the patient receives their planned treatment. It is therefore crucial that nurses use a consistent, comprehensive and systematic method of conducing pre-SACT administration checks. In 2020-21, the practice education team on the haematology unit at a specialist cancer hospital in London developed, trialled and evaluated a pre-SACT administration checklist. The checklist has provided nurses with a consistent and systematic order of checks to follow before SACT administration and practice educators with a tool for training nurses and assessing their competence in administering SACT. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware of communication challenges often experienced by people with learning disabilities • To recognise how communication challenges for people with learning disabilities may be compounded by the growing use of digital technology • To consider various communication strategies and tools that you could use to support people with learning disabilities Healthcare provision relies on effective communication, since this can enable information to be shared, develop therapeutic relationships and improve health outcomes. However, many people with learning disabilities experience significant issues with expressive and receptive communication, and these issues are likely to be compounded by the growing use of digital technology. This article outlines factors that affect communication for people with learning disabilities during healthcare encounters, including communication challenges they may experience in relation to accessing health information and using digital technology. The article also explores strategies and tools nurses can implement to address these challenges and ensure effective communication with individuals. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To increase your awareness of the challenges of pressure ulcer assessment in patients with darker skin • To acknowledge the lack of representation of darker skin tones in healthcare education, literature and tools • To enhance your understanding of how to assess patients with darker skin tones for pressure ulcers Standards of education and practice require nurses to respect and value the principles of equality and diversity. However, even though the UK is an ethnically diverse society, nurse education, teaching resources, textbooks and clinical tools do not adequately consider or represent darker skin tones, which is likely to negatively affect the quality of care and compound health inequalities. This article highlights the importance of skin tone diversity in education, literature and resources to ensure optimal education for nurses and optimal pressure ulcer care for patients. The author reflects on the challenges involved and raises awareness of resources that can support nurses in the early detection of skin changes in people with darker skin tones. [ABSTRACT FROM AUTHOR]

Purpose: The degree of caring behavior of oncology nurses is a crucial factor in the care provided to patients with cancer. In this study, we aimed to investigate factors related to oncology nurses' caring behavior, including their resilience and professional quality of life. Methods: A cross-sectional descriptive study was conducted with 107 oncology nurses at an urban tertiary hospital from May 18 to 24, 2015. We used a self-report questionnaire to measure resilience, professional quality of life, and degree of caring behavior. Data analysis included descriptive statistics, correlations, and multiple regression analysis using SPSS/WIN 20.0. Results: Oncology nurses presented with low levels of resilience and caring behavior, and high levels of compassion satisfaction, burnout, and secondary traumatic stress. There was a statistically significant relationship between the degree of caring behavior, resilience (r = .43, p < .001), compassion satisfaction (r = .51, p < .001), and burnout (r = - .42, p < .001), as well as between secondary traumatic stress and burnout (r = .34, p < .001). Factors associated with oncology nurses' degree of caring behavior were compassion satisfaction (t = 6.00, p < .001) and educational level (t = 3.45, p = .001). Conclusion: This study demonstrates that oncology nurses' degree of caring behavior is related to their professional quality of life and education. These findings suggest that enhancing oncology nurses' healthy coping strategies at both the individual and organizational levels can further develop holistic nursing care. Additionally, it is necessary to examine the factors affecting nurses' compassion satisfaction and to try to promote this aspect. [ABSTRACT FROM AUTHOR]

ProblemCompassion Fatigue (CF) in healthcare professionals has been explored in multiple studies, but few focused on hospital-based pediatric nurses. The purpose of this integrative review is to synthesize the evidence about CF prevalence in nurses caring for pediatric patients, and to describe its effects on retention and job satisfaction.Eligibility criteriaIncluded studies were in English from any date describing research or quality improvement studies about CF in pediatric nurses.SampleAn integrative review of nine electronic databases yielded 13 articles about 1921 nurses. Data were synthesized from four qualitative and nine quantitative studies separately before integrating results. A risk of bias analysis was included for evidence level and quality.ResultsOverall CF prevalence was low, but 14% of nurses were at high risk of burnout and 10% were at high risk for secondary traumatic stress. Studies examining the effects of CF on retention found no significant relationship. Most studies were about critical care or oncology nurses.ConclusionsA subset of pediatric nurses is highly vulnerable to CF, but more high-quality evidence is needed to fully address this topic. Leaders should study CF prevalence, protective and exacerbating factors, relationships between CF and retention, and targeted strategies to resolve CF in high-risk nurses.

The abstract is often the first text that people read before starting to read the entire article. Therefore, a great effort and attention should be paid in writing it. Since summarizing an article in a few sentences is difficult and requires professional skills, we aimed to address the importance and impact of an abstract and its function and types, and provide a practical guide to writing an effective and accessible scientific abstract.

Nurse, Midwives and Allied Health Professionals (AHPs), along with other health and social care colleagues are the backbone of healthcare services. They have played a key role in responding to the increased demands on healthcare during the COVID-19 pandemic. This paper compares cross-sectional data on quality of working life, wellbeing, coping and burnout of nurses, midwives and AHPs in the United Kingdom (UK) at two time points during the COVID-19 pandemic. An anonymous online repeated cross-sectional survey was conducted at two timepoints, Phase 1 (7th May 2020-3rd July 2020); Phase 2 (17th November 2020-1st February 2021). The survey consisted of the Short Warwick-Edinburgh Mental Wellbeing Scale, the Work-Related Quality of Life Scale, and the Copenhagen Burnout Inventory (Phase 2 only) to measure wellbeing, quality of working life and burnout. The Brief COPE scale and Strategies for Coping with Work and Family Stressors scale assessed coping strategies. Descriptive statistics and multiple linear regressions examined the effects of coping strategies and demographic and work-related variables on wellbeing and quality of working life. A total of 1839 nurses, midwives and AHPs responded to the first or second survey, with a final sample of 1410 respondents -586 from Phase 1; 824 from Phase 2, (422 nurses, 192 midwives and 796 AHPs). Wellbeing and quality of working life scores were significantly lower in the Phase 2 sample compared to respondents in Phase 1 (p