A growing evidence base has demonstrated the value of Forest School as an outdoor learning approach which supports a range of benefits including improved physical, social and mental wellbeing, increased confidence and self-esteem and the development of problem-solving skills. However, critics of Forest School have argued that a lack of theoretical coherence and detail risks the misinterpretation of Forest School and its pedagogy by both practitioners and researchers. This paper responds to these concerns, establishing a comprehensive and detailed theoretical framework for Forest School. Through a thorough examination of evidence supporting Forest School delivery, we examine the theoretical keystones of this pedagogical approach to inform an interdisciplinary theoretical understanding of Forest School. We argue that Forest School is a particular socially constructed approach to outdoor education, which is informed by social constructivist experiential learning theory. This is driven by two core components. First, play-pedagogy, which includes the opportunity to experience risk and be creative. Next, biophilic interaction, which examines the human innate desire to be in nature. This is informed by the cultural origins of Forest School development as underpinned by Nordic notions of friluftsliv and by theories of place attachment. Taken together, this theoretical framework considers the breadth of knowledge that underpins Forest School and recognises its growing evidence base, which positions it as a rich and valuable pedagogical approach.

Problem: The Safewards' model identifies factors that can lead to conflict and addresses these factors, using ten interventions, within inpatient mental health wards aiming to reduce "conflict and containment." The Department of Health (2014) and Care Quality Commission (2017) supported the use of Safewards to reduce restrictive practice across all mental health settings in the UK, but its application to adolescent mental health remains relatively unexplored. This study therefore aims to address the research question: "What are the factors influencing the success of ten Safewards' interventions when implemented onto an acute adolescent ward?" Methods: Eight healthcare assistants and two nurses who had attended Safewards' training participated in semi-structured interviews four months after Safewards was introduced to an acute adolescent ward. The interviews were transcribed verbatim and analyzed using thematic analysis. Data analysis was conducted inductively by developing data-driven themes. Findings: Many of the factors influencing Safewards' success in adolescent mental health (e.g., acuity; dependence on nonregular staffing; lack of leadership and operating procedures) paralleled the evidence found in adult services. Conclusions: This study contributes new information by implementing "mutual help" and "calm down" principles with adolescents, as well as discussing barriers of operational procedures and benefits of patient involvement.

Abstract Introduction Involuntary relocation when care homes close can be detrimental to residents’ health and well‐being and is associated with increased mortality. There is little formal evidence to support whether planning can mitigate the impact of such moves. This study aimed to understand the experiences of a whole care home relocation where staff and residents relocated together using existing published guidance. Methods A longitudinal qualitative research study using individual face‐to‐face semi‐structured interviews was conducted between August 2018 and August 2019. Baseline interviews were conducted 6–8 weeks after relocation with follow‐up interviews 10–12 months later. Interviews were recorded, transcribed and analysed using framework analysis. Results 27 interviews were conducted; 19 baseline interviews (4 residents, 7 family members, 8 staff) and 8 follow‐up interviews (2 residents, 2 family members, 4 staff). Participants’ feelings about the relocation were mixed: some reported apprehension before the move but others excitement. Residents and families felt variably involved in planning the move, whereas staff expressed lack of involvement. Time, family support and continuity of care helped participants settle in. The new environment shaped participants’ experiences and abilities to adjust, especially the lack of a homely feeling with the new home, the larger size and changes in staff organisation and management. Conclusions Despite implementation of existing guidance, relocation was still challenging for residents, staff and family members. Future relocations should increase involvement of staff in the planning and design of the home; offer continuous support to those involved; and ensure continuity of care and management style.

AIMS To provide insight into patient experiences of a general hospital-based alcohol specialist nurse intervention during alcohol detoxification, experiences of alcohol specialist nurse hospital-based follow-up appointments (Pathway A) as well as the experiences of patients who did not have access to this additional help post detoxification (Pathway B). DESIGN A longitudinal qualitative study. METHODS A thematic analysis of semi-structured interviews (2016-2017) with 24 patient participants (N = 12 in each pathway; purposive selection) 1-4 weeks post-detoxification and at 3 and 6 months, to identify patient experiences of these interventions. RESULTS Participants gave accounts of how 'empathic' and 'straight talking' interactions with alcohol specialist nurses during detoxification helped them to 'open up' and orient towards change. After detoxification follow-up, outpatient appointments in the hospital setting were seen as supporting change in early recovery and engagement with a wider range of services. Those with no access to nurse follow-up described experiencing a 'void' in available help. Participants in both groups described barriers to engagement with community alcohol services, peer groups and access to help for mild-moderate mental health problems. CONCLUSION Patient accounts indicate alcohol specialist nurse interventions during and after unplanned detoxification in a hospital setting can help orient patients towards change and support early recovery. IMPACT Providing alcohol specialist nurse interventions in general hospitals offers one route to initiating recovery in alcohol-dependent patients. This has potential to improve the lives of those affected and to reduce related demands on hospital services, but further research is needed.

Background: There has been extensive research of clinical reasoning in health professions, and reflective practice is widely used. However, in the field of osteopathy, clinical reasoning is largely under-researched and the use of structured reflective practice at its early stages. Objective: To understand the broad role of reflective practice on osteopathic clinical reasoning during active delivery of patient care. Method: Using an ethnographic method, the diagnostic and reasoning processes of one osteopath were recorded as they arose. These notes were then expanded to give a description of the interaction with the patient during the clinical encounter. Using autoethnography and reflective practice, the descriptions of the clinical encounters were developed into reflective narratives which were then analysed using elements originating from grounded theory. Results: Reflective practice helps the practitioner become aware of their moment-by-moment osteopathic practice, it triggers the questioning of a practitioner's clinical reasoning, and creates change of practice. Conclusion: This novel study highlights the relevance of reflective practice as a means of monitoring the thinking and reasoning processes in osteopathy. An increase in awareness of clinical reasoning processes could help prevent cognitive and affective biases and possible clinical error. We would argue that reflective practice is a critical tool in maintaining professional competence in osteopathy across a practice lifetime.

Background: Clinical reasoning has been widely researched in the health sciences; however, in osteopathy it is still in its relative infancy. Objective: To explore the moment by moment clinical reasoning processes of an osteopath whilst with patients, to understand the role of perceptual diagnostic judgments, and metacognitive processes. Method: A qualitative interpretive study with a novel narrative method as an organising structure: the moment by moment thought processes of a single osteopath were recorded and transformed into descriptions of the interactions with patients. The descriptive texts were expanded into narratives using autoethnography and reflective practice. Narratives were then analysed using methods originating from grounded theory. Results: Our interpretations indicate that osteopaths establish a multisensory construct during clinical reasoning which enables both analytic and intuitive decision-making strategies. Clinical reasoning was monitored by a variety of metacognitive processes, including intuitive discernments such as feeling that a decision is correct, and the judgment that there is sufficient information to make that decision. Conclusions: This is the first study to explore the subjective moment by moment clinical reasoning and decision-making strategies of an osteopath whilst with patients. It suggests that perceptual diagnostic judgments are multisensory and include mental and visual imagery, and embodied senses. These enable analytic and intuitive diagnostic strategies that are accompanied by persistent metacognitive processes during the consultation, which guide the practitioner's decision strategies. (C) 2018 Published by Elsevier Ltd.

Background: A preceptorship model of clinical teaching was introduced to support the new all-graduate nurse education programme in Ireland in 2002. Little is known about how this model impacts upon the pedagogical practices of the preceptor or student learning in clinical practice leading to question what constitutes effective teaching and learning in clinical practice at undergraduate level.Aim: This study aimed to explore the clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland and identify when best practice, based on current theoretical professional and educational principles occurred.Method: A qualitative research study of a purposively selected sample of 13 students and 13 preceptors, working together in four clinical areas in one hospital in Ireland. Methods were semi-structured interviews, analysed thematically, complemented by documentary analysis relating to the teaching and assessment of the students. Ethical approval was gained from the hospital's Ethics Committee.Findings: Preceptor-student contact time within an empowering student-preceptor learning relationship was the foundation of effective teaching and learning and assessment. Dialoguing and talking through practice enhanced the students' knowledge and understanding, while the ability of the preceptor to ask higher order questions promoted the students' clinical reasoning and problem solving skills. Insufficient time to teach, and an over reliance on students' ability to participate in and contribute to practice with minimal guidance were found to negatively impact students' learning.Conclusions & Implications: Concepts such as cognitive apprenticeship, scaffolding and learning in communities of practice can be helpful in understanding the processes entailed in preceptorship. Preceptors need extensive educational preparation and support to ensure they have the pedagogical competencies necessary to provide the cognitive teaching techniques that foster professional performance and clinical reasoning. National competency based standards for preceptor preparation should be developed. (C) 2017 Elsevier Ltd. All rights reserved,

Objectives: Teenage cochlear implant users’ perceptions of deafness, surgery, fitting of the device and life as a cochlear implant wearer were explored in order to gain a more comprehensive understanding of teenagers’ experiences of living with the device. Methods: Semi-structured in-depth interviews were undertaken and analysed using thematic analysis. Ten teenagers aged 14–16 years with at least one cochlear implant were interviewed. Results: Seven teenagers experienced great pre-operative anxiety and two reported significant post-operative pain. Four of the teenagers described a mismatch between their expectations and the disappointing reality of adjusting to the device. However, all the teenagers reported an enhanced sense of well-being as a result of being able to interact more easily with their world around them. The teenagers differed in the extent to which they identified with the hearing and deaf world. Discussion: Despite the early challenges, over time the teenagers experienced many functional and psychosocial benefits. Most felt their lives were now easier as a result of the cochlear implant(s). They described complex, flexible identities. Conclusions: By giving prominence to the teenagers’ voices this study has added new knowledge concerning their experience of surgery. The findings also more fully revealed the challenges of adjusting to the device and the impact of having a cochlear implant on the teenagers’ identities. Clinical recommendations are made to address the gaps in service highlighted by these findings.

Background: Over 50% of people diagnosed with breast cancer in most African countries present late and report to the hospital with advanced stage III and IV disease, a major reason for the poor survival rate. This study reviewed studies focusing on patient-related factors or reasons contributing to the late presentation or delayed diagnosis of breast cancer in Africa. Method: A rigorous literature search was conducted with search terms “Breast Neoplasms” AND “Late Presentation” OR “Delayed Diagnosis” AND “Africa” OR “the name of any of the African countries” within CINAHL, African Index Medicus, MEDLINE, Web of Science and PsycINFO electronic databases. Additional hand searching of reference lists of included articles was conducted. A thematic synthesis was conducted. Result: Of the eighty-two studies identified, nine were eligible and included in the review. Studies included were conducted in Egypt, Nigeria, Ghana, Kenya and Libya. The factors identified as contributing to late presentation of breast cancer among most African women were negative symptom interpretation, fear, belief in alternative medicine, social relations and networks, lack of trust and confidence in orthodox medicine, and access to healthcare. Conclusion: A complex matrix of factors were identified that contribute to the late presentation or delayed diagnosis of breast cancer among most African women. The orthodox medical system in most African countries is gradually losing their relationship and credibility because of false reassurance, frequent misdiagnosis and strike actions, which is leading to late presentation of breast cancer.

Introduction Little empirical evidence exists to identify the impact that a partner's absence or presence has on the mother's decision-making and her consequential help-seeking behaviour when her child is unwell. Methods This study used a qualitative design in three phases using focus groups and interviews to explore Army mothers’ help-seeking behaviour as a lone parent when their child was unwell during the out-of-hours period. Thirty-one parents from a British Army garrison were interviewed. Results The findings demonstrated that Army life created a combination of stressors for Army mothers, which altered their help-seeking behaviour when their child was unwell. When their partner was available, mothers contacted health services as a last resort, once all other avenues had been exhausted. However, in contrast, in their partners’ absence, they were contacted as a first resort. Conclusion An algorithm was generated from the findings, which illustrates the importance of ascertaining whether the mother is alone at the time of the consultation. Increased emotional vulnerability intensified the need for reassurance and affected a mother's decision-making ability. Primary healthcare staff should ascertain whether mothers are currently lone parents at an early stage of their assessment, as this may influence the entire consultation.

•Service users' reported feedback experiences were positive, without exception.•Students' experiences of feedback were more ambivalent, but ultimately developmental.•Service users' feedback can contribute to student learning and formative assessment.•Mental health user feedback constitutes a good fit with recovery orientated practice.•HEI user involvement policy can include users who students work with in practice.

The study aimed to investigate the process of reflection in professional nurse education and the part it played in a teaching and learning context. The research focused on the social construction of reflection within a post-registration, palliative care programme, accessed by nurses, in the United Kingdom (UK). Through an interpretive ethnographic approach, the organisational, contextual and cultural issues impacting upon teaching and learning interactions, and the use of reflection therein were explored with student and nurse educator participants. Data were collected from observations of teaching and learning, interviews, and extracts from programme documentation and reflective learning contracts (RLCs).Findings contribute new empirical knowledge regarding the process of teaching and learning about reflection, including educator and clinical supervisor facilitation, the emotional work involved in reflection and methods of 'mapping' and 'modelling' to support reflection. The influence of both higher education and practice partner organisations on the use of reflection is also evident and indicates that professional reflective education requires institutional support from both education and practice. Specific findings in this paper are pertinent and transferable to other disciplines, where reflective education is used to develop being critical in order to learn through experience. This research offers valuable insights into the realities of reflective education and has currency for educators committed to developing skills for reflection and learning through experience for students, through the generation of a reflective culture.

DOI: 10.5294/aqui.2013.13.3.2 Objective: The aim of this study was to explore nurses’ and doctors’ perception on using a care bundle as a guideline for the manage- ment of pain in critical care. Despite the development of evidence-based guidelines and protocols on the management of pain in critical care, pain is still a major problem. The introduction of care bundles in critical care has improved the management of ventilated patients. A care bundle in pain management aims to reduce variations in practice. Method: This study employed a qualitative prospective design us- ing a semi-structured, in-depth interview of 23 nurses and doctors in a critical care unit. Result: Four main themes emerged: 1) suitability to the critical care setting; 2) applicability to the critical care setting; 3) ownership of the Pain Care Bundle; and 4) necessity for current practice. The results showed a poor uptake by the healthcare professionals in managing acute pain among critically ill patients. Conclusion: The study found that nurses and doctors did not perceive the pain care bundle as a useful tool for improving pain managment, with evidence pointing to a gap between pain management practice, as described by the care bundle, and actual practice. DOI: 10.5294/aqui.2013.13.3.2

Objetivo: el objetivo de este estudio fue explorar la percepción de las enfermeras y los médicos sobre el uso de un paquete de aten- ción como una guía para el manejo del dolor en cuidados críticos. A pesar del desarrollo de guías y protocolos para el manejo del dolor en cuidados críticos, basados en la evidencia, el dolor sigue siendo un problema importante. La introducción de un paquete de atención para cuidados críticos ha mejorado el manejo de los pacientes ventilados. Un paquete de atención en el manejo del dolor tiene como objetivo reducir las variaciones en la práctica. Método: el estudio tiene un diseño prospectivo cualitativo desarrollado mediante una entrevista en profundidad y semi-estructurada de 23 enfermeros y médicos en una unidad de cuidado crítico. Resultado: cuatro temas principales surgieron: 1 ) la adecuación al escenario de cuidado crítico, 2) la aplicabilidad al escenario de cuidado crítico, 3 ) la propiedad del Paquete de Atención al Dolor, y 4) la necesidad en la práctica actual. Los resultados mostraron una pobre aceptación del paquete por parte de los profesionales de la salud en el manejo de dolor agudo en los enfermos críticos. Conclusión: el estudio encontró que las enfermeras y los médicos no percibieron el paquete de atención al dolor como una herramienta útil para mejorar el manejo del dolor, con pruebas que apuntan a una brecha entre la práctica del manejo del dolor, tal como se describe por el paquete de atención, y la práctica real.

Background Addressing the care needs of people with advanced cancer is often complex, requiring communication between different professional and lay care providers, across different geographical and professional boundaries. Achieving the right balance of support and autonomy can be difficult, needing to be tailored to each patient. Aim Identify and quantify the number of people involved in the care of people with cancer and palliative care needs, and explore the network of communication pathways between these different people. Method Case study methodology was employed, each case involving one patient and the (patient-identified) people involved in their care (PIPCs) within the past 6 months. During indepth interviews with patients (n=24; mean length 65 min) and PIPCs (n=100; mean length 30 min), respondents identified and described the network of communication pathways surrounding the patient's care. A map of each patient's care network was drawn during each interview, and was subsequently redrawn using social networking software. Results Patients (15 female, 9 male; age range: 48–85) had a range of primary tumours (mean time since diagnosis: 9.5 months; range: 0.5–61 months). All were described as receiving or needing specialist or generalist palliative care at the time of recruitment (through General Practice (n=5); Hospital Specialist Palliative Care Team (n=8); Specialist Palliative Care Unit (n=11)). Patients identified 9–45 (mean:26) different people/teams as being involved in their care; an average of six PIPCs per case (range:0–11) were subsequently interviewed about their contribution to the communication surrounding this patient. Conclusion Sample cases and selected communication maps are presented to illustrate the range of possibilities in numbers of PIPCs involved and the complexity of, and patient and PIPC satisfaction with, some patients' communication networks. The methodological utility of the mapping technique, and its potential contribution to achieving the right balance of involvement in palliative care, are considered.