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NURSING JOURNAL The Official Quarterly Journal of the Singapore Nurses Association Volume 38 No. 4 October - December 2011

Season’s Greetings

ISSN 0218-0995

Singapore Nurses Association SNA House, 77 Maude Road Singapore 208353 Tel: (65) 6392 0770 Fax: (65) 6392 7877 Email: Website:

Contents 3

President’s Message

Penny SEET



Sally CHAN


An Analysis of Artwork Representing The Experiences of Colorectal Cancer Survivors

Carol LOI


Meeting the Nutrition Challenge of Stage 3 Kidney Failure: Considerations for Nursing Practice

MOK Wen Qi, Joyce Yee Hui ANG, Martin CHRISTENSEN


Music Therapy in the Palliative Setting: A Systematic Review

Mabel Qi-He LEOW


Migrant Chinese Women and Sexual Health: A Role for the Advanced Specialist Community Nurse In Singapore

Eleanor HOLROYD, William WC WONG


A Book Excerpt: Prescription For Excellence: Leadership Lessons for Creating A World-Class Customer Experience From UCLA Health System

TAN Wee King


Intergration of Simulation-Based Learning in the Nursing Programme: A Reflection

LIAW Sok Ying


The State of Nursing Science

TAN Khoon Kiat


Information for Authors

Singapore Nursing Jour nal

Singapore Nurses Association Executive Council Jan 2010 - Dec 2011 Publisher

Singapore Nurses Association SNA House, 77 Maude Road Singapore 208353 Tel: (65) 6392 0770 Fax: (65) 6392 7877 Email: Website:

Editorial Board Chief Editor Deputy Editor Members

Sally Wai Chi CHAN TAN Khoon Kiat CHAN Moon Fai CHENG Bing Shu HE Hong Gu Eleanor HOLROYD Kumari KALAYPERUMAL Sukhdev KAUR LEE Geok Yian LEE Leng Noey M Kamala Devi SUPPIAH Nagammal Kylie Lee Sung TANG TANG Siew Yeng Eugene TEOH


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President Vice President Hon Secretary Asst Hon Secretary Hon Treasurer Asst Treasurer Member Member Member Member Member Member Member Executive Director

Ms Penny SEET A/Prof LIM Swee Hia Ms KWEK Koon Roan Dr Pearlyii CHIA Mr SAHARI Ani Ms Coreen LOW Prof Sally CHAN Dr Janet CHOO Ms CHUA Gek Choo Ms LEE Yen Yen Ms LIM Siew Geok Ms Shefaly SHOREY Mr Pritpal SINGH Ms Shirley LIM

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Volume 38, No. 4, October - December 2011

PRESIDENT’S MESSAGE on the need to focus on Intermediate and Long Term Care in the community links closely to primary care. The SNA looks forward to working closely in alignment with her office to raise the profile of nursing services in the community.

Time flies! As the year draws to an end, one wonders where time has gone? Even more importantly, what have we done to show for it?

Nearer home, new membership has shown an increase this past year from 2,336 to 2,550 to date. Registrations for the LTU Degree and Masters Programmes continue to show positive increases too. SNA will persevere to initiate the Leadership for Change (LFC) 3G Programme in conjunction with International Council of Nurses (ICN) next year and I look forward to active endorsement and support by the current nursing leaders and the community to ensure the development of a strong leadership for future leadership succession.

The Singapore Nurses Association (SNA) had crossed several milestones this last quarter of 2011. Firstly, a total of 157 nurses graduated from the 13th intake La Trobe University (LTU) Degree program in September. The graduation ceremony was held on 22nd September at the Hyatt Hotel, Singapore attended by the LTU faculty and graced by Dr Pauline Tan, Chief Nursing Officer, Ministry of Health.

The Executive Council (EXCO) has seen several changes in its executive council leadership. New blood is required and inevitable for growth and new perspectives. I strongly believe that when one door closes, another opens. The Singapore Nursing Journal (SNJ) has a vibrant new team with new ideas. I am confident that everyone on the sidelines, is waiting with bated breath, in anticipation for the new face of the SNJ, expected to make an appearance in the new year.

It also saw the first MOH-SNA and 16th Joint SingaporeMalaysia Nursing Conference held in Khoo Teck Puat Hospital attended by more than 500 participants from both sides of the causeway. The co-chair, Ms Chua Gek Choo and her committee worked long and hard on the scientific programme. The topics discussed, ran the gamut of subjects from global leadership, quality, research and innovations in healthcare, the all time favourite evidence-based care and leading change in healthcare to care of the elderly, care in the community and spiritual well-being.

As the next annual general meeting looms, I reiterate the need for willing and active volunteers to give their time and help sustain and manage the professional body. The SNA is growing in leaps and bounds and we need to nurture sufficient successors so that its development can remain continuous and vibrant. The Executive Nurses Chapter forlornly awaits its resurrection but until someone steps forward to resuscitate it, its revival remains a yearning.

The presentation, “It’s a Jungle out there - making ecological sense” by Mr Liak Ting Lit, Chief Executive Officer, Khoo Teck Puat Hospital was well received. Dr Pauline Tan too took the keynote address to outline current enigmas in healthcare – its challenges and opportunities and the implications for Nursing. It was motivating to hear her summary of the integrated, supportive and holistic roles of the current Nursing Leadership (including those of SNA) incorporated into her Collective Nursing Leadership model with emphasis

So, all you young nurses out there, step forward! Be part of the SNA. Penny SEET


Singapore Nursing Jour nal



We all agree that scholarship is hard work. Once you finished writing a manuscript, you would like to submit it to a journal which allows the paper to be easily accessible and preferably cited. One way to ensure this happens is to submit your manuscript to a journal that is indexed in common electronic databases, such as the Cumulative Index of Nursing and Allied Health Literature (CINAHL) (Gennaro, 2010).

Welcome to the Singapore Nursing Journal, the official journal of the Singapore Nurses Association (SNA). The SNA was founded in 1957. The SNA became a full member of the International Council of Nurses in1961, the year seeing the birth of The Nursing Journal of Singapore. This journal was later renamed as Singapore Nursing Journal (SNJ).

The SNJ is indexed in the CINAHL which you may consider for submitting your manuscripts. The SNJ is a professional nursing journal which accepts papers presenting original research, review articles, discussion papers and book reviews. The SNJ published more than 3,000 copies for each issue. It has wide circulations. Apart from members of SNA, the SNJ is sent to Singapore Library Headquarters, all hospitals and institutions in Singapore, as well as overseas nursing professional associations.

What is the function of a professional nursing association? There are many professional nursing associations all over the world, some with smaller, specialty-focused membership. Some countries or regions have more than one nurses groups. The SNA differs from the specialty-focused associations in that it is a broad-based, multipurpose nurses’ organisation. SNA members come from all nursing specialties, all practice sites, and all educational levels. It is generally recognised as the only all-purpose professional organisation of nurses in Singapore, and it is the representative of nurses in Singapore.

From 1961 to the present, the SNJ has sailed through sea of changes. I am happy to inform you that a new editorial team has just been formed in October 2011. With the solid foundation laid down by former editorial teams, we will set sail for even higher goals. We have developed a new set of ‘Information for Authors’ to provide more guidelines to manuscript authors. The SNJ will take on a new design from the January 2012 issue onwards.

Back in 1958, a paper published at The American Journal of Nursing explained the essence of a professional association and stated: ‘The professional association is an organisation of practitioners who judge one another as professionally competent and who have banded together to perform social functions which they cannot perform in their separate capacity as individuals’ (Merton, 1958, p. 50).

The Editorial Board members welcome your feedback and suggestions. Please let us know if you would like to have more information about the SNJ and the ways in which you can be involved in the future. I look forward to your support and working closely with you to bring SNJ to new heights.

Indeed, unity is power. The SNA, by uniting nurses in Singapore, has the vision of promoting nursing as an autonomous and united profession, as leaders in providing quality care, and as key players in influencing policy and decisions.

Sally CHAN Chief Editor

What is the function of a professional nursing journal? A professional nursing journal is usually a peer-reviewed periodical in which scholarship relating to nursing and healthcare is published. Professional journals serve as forums for the introduction and presentation for scrutiny of new knowledge and research, and the critique of existing knowledge and research (Gennaro, 2010). Professional journals are of great importance in the dissemination of knowledge to nurses and nursing students.

References Gennaro, S. (2010). Editorial: Impact and scholarship. Journal of Nursing Scholarship, 42(3), 233. Merton, R. K. (1958). The functions of the professional association. The American Journal of Nursing, 58(1), 50-54.


Volume 38, No. 4, October - December 2011

AN ANALYSIS OF ARTWORK REPRESENTING THE EXPERIENCES OF COLORECTAL CANCER SURVIVORS Carol LOI Genetic Counsellor, Department of Colorectal Surgery, Singapore General Hospital, Singapore Correspondence address: Carol LOI Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169608 Tel: (65) 63213615 Email:

Abstract Objectives: The aim of this paper is to describe an experience of participating in an art therapy session with colorectal cancer survivors to understand their experience in the journey with colorectal cancer. An analysis of the participants’ artwork will be presented and discussed. Method: Four participants who had a diagnosis of colorectal cancer were recruited from a support group centre in Singapore. They were invited to attend an art therapy workshop. During the session, they were asked to draw a picture and then shared their drawings within a group session. An artistic expression approach was used to analyse the data together against the participants’ background. Findings and discussion: The artwork and sharing illustrated the emotional impact of illness to the participants. They expressed grief, concerns, depressed moods, fear, and loneliness. Some tried to cope with their illness positively through using religious or voluntary work. Findings suggested the need to enhance supportive care to help cancer survivor through their difficult illness journeys. Conclusion: Artwork is a form of therapeutic communication. It provides opportunities for cancer survivors to share their feelings and experiences with one another. Art in this situation appeared to be a psychosocially supportive intervention for patients with colorectal cancer. The knowledge generated from this experience can help planning future supportive activities for this group of patients. Key words: Art Therapy; Colorectal Cancer Survivors


for cancer survivors in Singapore. Art therapy involves the therapeutic use of art within the context of a professional relationship with people who have experienced illness, trauma, or challenges in their life. Through creating art and reflecting on the art products and processes, people can increase awareness of self and others, better cope with symptoms, stress, and traumatic experiences; enhance cognitive abilities; and better enjoy the life-affirming pleasures of making art (American Art Therapy Association, 2011).

The number of newly diagnosed colorectal cancer cases has increased in recent years especially in younger age groups (Siegel, Jemal, & Ward, 2009). Colorectal cancer has emerged as the most common cancer in Singapore. It is well established that colorectal cancer patients experience a high level of distress as a result of the cancer diagnosis (Kangas, Henry, & Bryant, 2002). With the advance of medical treatment, patients with cancer survive much longer now. Post-treatment colorectal cancer survivors may suffer from fatigue, insomnia, dyspnoea, constipation, diarrhoea and financial difficulties due to their illness (Arndt, Merx, Stegmaier, Ziegler, & Brenner, 2004; Edward & Clarke, 2004). Studies found that cancer survivors expressed difficulty in coping and adapting to the disease. Furthermore, these survivors present with a variety of concerns of readjustment and readaptation to daily life. Areas of concern for patients include the fear of recurrence, and learning to live with compromise. There is a need to develop sustainable interventions to promote long term psychosocial well-being in cancer survivors (Cotrim & Pereira, 2008).

Art making can assist a person to communicate their emotional or psychological problems through the use of imagery. In cancer survivors, in addition to medical treatment, creative expression through art can be used to address the psychological, social, physical and spiritual issues, which may help to reduce psychological stress, and have a positive influence for the immune system and overall functioning of the body. Furthermore, through artistic expression, healthcare professionals can have a better understanding of the participants’ emotional experiences (Lee, 2010). In this paper, the author will describe an experience of participating in an art therapy session with four cancer survivors.

Over the past few decades health care professionals and patients have begun to explore creative approaches to help cancer survivors. Art therapy is a relatively new intervention 5

Singapore Nursing Jour nal


They were told that they could share those experiences with the group only when they felt comfortable. The four participants took turns to talk about their drawings.

An art therapy workshop was conducted in a weekend afternoon in a support group centre in Singapore for colorectal cancer survivors. The workshop was facilitated by a trained art therapist. There were four colorectal cancer survivor participants conveniently recruited from the existing support group. The author participated in the workshop as a non-participative observer with permission from all participants. Permission was also granted by the participants to take photographs on their artwork and to take field notes on the process of art making and their sharing experiences.

The author used an artistic expression approach (Collie, Bottorff, & Long, 2006; Malchiodi 1999) to analyse their drawings. Artistic expression is a qualitative approach to capture and reveal participants’ experiences or insights, expressed through their artworks on their experiences of living with cancer. The author tried to interpret the participants’ expression from the colours and symbols of their drawings together with their sharing after the drawing. From the analysis, the author tried to understand the impact of cancer on these participants.

The art therapist started the workshop with a brief introduction of the purpose of workshop. She explained that art therapy uses art to communicate, to express, to explore and to discover. She reassured the participants that the workshop was not focused on the aesthetic value of the finished product but on the therapeutic process of drawing.

To ensure anonymity of the participants, all the names used in this paper are pseudonyms. Lee shared his experience in English language. Alice spoke in Mandarin, and John and Ling spoke with a mixture of both English and Mandarin. Mandarin was translated verbatim to English in this paper by the author.

The art therapist provided the participants with art materials and guided them through drawing, colouring and taping throughout the workshop. The four participants used soft pastels to draw and created their artwork on texturised paper. Upon finishing the last touch on their drawings, the art therapist invited the participants to share their experiences.

The participants were at various stages of their cancer and differing stages of their treatments ranging from post-surgery two months to ten years. Two were undergoing chemotherapy during the art therapy workshop. Table 1 summarises the demographic and health status profile of the four participants.

Table 1: Participants’ Profile Post surgery period

Having permanent stoma

Cancer staging



Age when 1st diagnosed with cancer




2 months



Undergoing chemotherapy

2. Alice




3 years



Undergoing chemotherapy

3. John




10 years



Completed treatment

4. Ling




6 months



Undergoing chemotherapy for recurrence

Name (fictitious) 1. Lee



Volume 38, No. 4, October - December 2011

Lee’s Drawing – Four Sunflowers with Butterflies

colours. Perhaps among the dark side of Lee’s illness, he still had a sense of optimism and hope. When the therapist and patient work together in art therapy, it may mobilise healthy forces within a patient’s personality to fight the disease (Lee, 2010). Lee requested for more art therapy workshops to be conducted in the support group and he seemed to be looking forward for another workshop in the future.

Lee was diagnosed with stage III colon cancer two months ago and he was still undergoing chemotherapy. Lee’s drawing consisted of four full bloom sunflowers (Diagram 1), accompanied by two butterflies flying above the sunflowers in a sunny day. Sunflower is considered a happy flower in Western culture. It was once an ancient religious symbol and local people appreciate its beauty and radiant warmth. However, Lee painted his sunflowers in black colour.

Alice’s Drawing – Sailing Boat Alice had been diagnosed of stage I rectal cancer 3 years ago and she had a permanent colostomy stoma. Alice’s drawing was of a sailing boat with a big fish in the ocean in day time (Diagram 2).

Diagram 1: Lee’s drawing

Diagram 2: Alice’s drawing

Lee said: I like drawing during my primary school days. It was 30 years from now. It was the first time I started drawing again. After I started chemotherapy, I didn’t smile until today. I feel that you should organise more classes or more workshops like this …

Alice said: Three years after the operation, I am still feeling depressed. Especially when there are activities but I dare not to participate or go far away from my home … worried about travelling around. I could not have the same lifestyle as I had before the diagnosis of cancer. Keep worrying about recurrence of cancer. … I used to go out a lot but now I dare not to because of the colostomy. ... It is different now compared to before. ... Felt sad. But it is nice to come back here (to the Centre) and happy to see friends are well. I think that this kind of activity is beneficial. … what do you all think?

In working with cancer patients, Malchiodi (1999) has discovered two central themes about the art images cancer patients make which she has termed “hurter” and “healer” images. Hurter images can be about the disease itself, fear, grief, losses, or how life has been changed in some way. Examples of hurter images are: jagged rocks, volcanoes, dark clouds, serpents, barriers and the use of the colours red and black. Healer images seem to help support the person. Examples of healer images include a light source, madalas (circle drawings), mystical figures, and metaphors for God, symbols of love, and the use of the colour yellow or gold (Lee, 2010). It appears in the above testimony that Lee exemplified this theme.

Alice hardly smiled while talking. Alice seemed to be constantly worried about a recurrence of cancer. She appeared socially isolated as she had confined herself at home. Alice used to be active and outgoing, she found the colostomy she had now was inconvenient for her to go out to join her friends in some activities. She expressed the feelings of emptiness and solitude and her fear of recurrence and worries about such uncertainties.

Lee had been newly diagnosed with cancer and expressed that he had not smiled since the diagnosis. The black sunflower might reflect Lee’s sadness, grief and losses because of the cancer diagnosis.

Alice’s drawing was a one-person boat with a tiny sail, which represented freedom. She might miss the freedom that she had in the past. Perhaps she was longing for the freedom like sailing in the ocean. Her drawing also depicts her loneliness or isolation like a fish in the ocean. Though she drew a sunny day, the ocean was dark in colour. It might reflect her fear of recurrent cancer.

During the art session, the author observed that Lee’s face was radiant and his eyes shone when he was actively participating in his drawing. His face lit up when he spoke about his experience in drawing. Though Lee’s sunflowers were in black, he had painted the sun and butterflies with


Singapore Nursing Jour nal

very positive. However, he drew his sunflower in black colour. Would it reflect that he still had fear and uncertainty about his illness? The meaning of symbols, colours and metaphors are defined by the person who made them this and there is a need to explore the meaning of John’s paintings in greater depth.

However, Alice expressed that she found support and comfort in this group art therapy session. She paused in between her talking and looking around the group as if seeking consensus. Art therapy group interventions also provided in this example a socially supportive role.

John’s Drawing – A Big Sunflower Ling’s Drawing – A Self Portrait

John was diagnosed with stage II rectal cancer ten years ago, and he had a permanent colostomy. John was a Christian with very strong faith in God. He said that religion had given him strength to cope with his illness. He was one of the support group patient ambassadors who met newly diagnosed colorectal cancer patients to share experience and support. John was an artist himself. He mentioned that he had put his thoughts and feelings into art. He mentioned that art was therapeutic indeed which allows expression of negativity, overcoming certain restriction imposed by the diagnosis of cancer and surgery.

Twenty years ago, Ling was diagnosed with colon cancer at the age of 29. Six months ago she was diagnosed as having a recurrence of the cancer and she is 49 years old now. She had just commenced her chemotherapy treatment. Ling said: I felt I have returned to childhood, I’m happy as this is my first time drawing in my life. … I have been given an opportunity to express myself in drawing. We have grown up since childhood. We are always busy with work and schedules and have never had a chance to draw. I feel very happy when I was drawing.

John said: I had no toys during my childhood, so I drew and use match sticks to build houses as my toys. Now I am teaching children in origami paper folding … We can express our thoughts and feelings just like a child. For example, in Sichuan province earthquake in China, many children lost their families. They felt sad but did not know how to express their emotions. Some made use of arts to express their feelings. … The use of art is therapeutic and you are able to understand how the children felt through arts. ... You don’t have to be an artist to draw. We can put our thoughts or feelings in the drawing just like children draw picture on what they think. … Another example is school children being bullied by other children. … They also use drawing to express their feelings. We do not have to be talented in art. … I do not judge their art piece but only encourage them to tell their stories. … I put my thoughts into art. It is my feelings. …

Ling painted her self-portrait with candles, stars and moon beside her. It is a colourful portrait. Some artists express their inner self by using colours. The colours Ling used in her drawing were soft. However, she outlined her hair with green. Could it be related to her worry about losing her hair during chemotherapy? The candle in her drawing is still burning. Perhaps she would also want her life to keep on burning (Diagram 4).

Diagram 4: Ling’s drawing

John’s drawing was of a “Big Sunflower” (Diagram 3). The ‘Sunflowers’ name comes about because sunflowers always turn their heads to the sun, representing spirituality. John is a Christian and he used religion to cope with his illness. He was also actively helping other patients. He appeared to be

Diagram 3: John’s drawing

Ling smiled a lot while sharing with the group and she said she was happy to express herself in drawing. She regretted that her life was always preoccupied with work and schedules. Thus, she appreciated the opportunity to draw in the art session and expressed her experiences and feelings through art.


Volume 38, No. 4, October - December 2011

It should be noted that the term ‘art therapy’ is reserved for when a certified art therapist is providing professional guidance to a person, family or group. The process of making art without the presence of an art therapist is referred to as creative self expression or art as therapy (Lee, 2010). Healthcare professional can use creative self expression or art as therapy in helping and supporting patients in their recovery journey.

The experience in this art session showed that colorectal cancer had differing impacts. Lee mentioned that he had not smiled since diagnosis. Alice illustrated her fear and frustration that she was now confined at home and she worried about going out. John relied on religion to help him. Ling regretted that her life was so preoccupied with work that she had left out various life enjoyments. Both Alice and John had a permanent stoma. John actively engaged in arts and he helped other patients as a volunteer and he appeared happy. Alice did not want to go out of home because of the worry related to the stoma. Lee and Ling were still undergoing chemotherapy. Both verbalised their joy and happiness after participating in the art therapy workshop. They felt as if they had returned to their childhood days.

Conclusion In this paper, the author presented a preliminary analysis of the participants’ artwork. Communication through artworks in this case provided an opportunity for the expression of experiences and thoughts not otherwise available. These examples provide encouraging preliminary data to support a possible future role for nurses in the therapeutic use of art as a psychosocial intervention within a Singapore context for colorectal cancer patients or patients with other types of cancer.

Charles and Telis (2009) contended at Vincent van Gogh’s specific patterns and drawings depicted new insights for using drawing to directly express the meaning of his thoughts, and the way he saw the world and himself. In the same way, art allows creativity and free expression of the feelings of cancer survivors and it can be utilised as a valuable tool in the support group. It gives cathartic opportunities for some cancer patients. It should be noted that during the art session, the participants need to focus on the art process rather than on artistic skill.

References American Art Therapy Association. (2011). Definition of art therapy. Retrieved from Arndt, V., Merx, H., Stegmaier, C., Ziegler, H., & Brenner, H. (2004). Quality of life in patients with colorectal cancer 1 year after diagnosis compared with the general population: A population-based study. Journal of Clinical Oncology, 22(23), 4829-4836. Charles, M., & Telis, K. (2009). Pattern as inspiration and mode of communication in the works of van Gogh. American Journal of Psychoanalysis, 69(3), 238-262.

During the art session, the sharing opportunity might give patients the courage to talk about their experience of living with cancer and their worry and fear. The participants in this experience reacted to their illness in different ways. It showed that patients needed support to help them through the difficult treatment journey in various stages of their illness.

Collie, K., Bottorff, J. L., Long, B. (2006). A narrative view of art therapy and art making by women with breast cancer. Journal of Health Psychology, 11(5):761-75. Cotrim, H., & Pereira, G. (2008). Impact of colorectal cancer on patient and family: Implications for care. European Journal of Oncology Nursing, 12(3), 217-226.

Though the numbers of participants in this art session were small, it was encouraging to see that art session can be a potential psychosocial intervention for colorectal cancer patients. The participants’ enthusiasm was evidenced and they would like the support group to conduct more workshops. It is apparent that art has the potential for developing creativity in life, when self-esteem was due to their cancers. Furthermore, artwork encourages vision, hope and imagination, all of which nurture the healing process (Lee, 2010). Artwork is a form of therapeutic communication which provides opportunities for cancer survivors to share with one another to make themselves understood by other people. Art may also help patients to learn how to be more open and how to see things in a different ways.

Edwards, B., & Clarke, V. (2004). The psychological impact of a cancer diagnosis on families: The influence of family functioning and patients’ illness characteristics on depression and anxiety. PsychoOncology, 13(8), 562-576. Kangas, M., Henry, J. L., & Bryant, R. A. (2002). Posttraumatic stress disorder following cancer: A conceptual and empirical review. Clinical Psychology Review, 22(4), 499-524. Lee, C. (2010). The healing qualities of artistic expression: The role of creative process and serious illness. Retrieved from http://www. Malchiodi,K.(Ed) (1999). Medical art therapy with adults. London: Jessica Kingsley Publishers. Siegel, R. L., Jemal, A., & Ward, E. M. (2009). Increase in incidence of colorectal cancer among young men and women in the United States. Cancer Epidemiology Biomarkers & Prevention, 18(6), 1695-1698.


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MEETING THE NUTRITION CHALLENGE OF STAGE 3 KIDNEY FAILURE: CONSIDERATIONS FOR NURSING PRACTICE MOK Wen Qi Year 3 Nursing Student Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine National University of Singapore Joyce Yee Hui ANG Year 3 Nursing Student Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine National University of Singapore Martin CHRISTENSEN Assistant Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine National University of Singapore Correspondence address: Martin CHRISTENSEN Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore 117597 Tel: (65) 66011603 Email:

Abstract Self-care management is needed for effective management of chronic kidney disease. The main aim for treatment or management of chronic kidney disease is to delay the worsening of kidney function, and to prevent or to manage the co-morbidities. Selfcare management is not easy, and patients will face many challenges, especially when they cannot get use to the new treatment plan. One of the challenges they face is dietary restriction, which is a very important aspect in any self-care management programme. Chronic kidney disease patients require a low-protein, low-sodium, low-potassium, and low-phosphorus diet. There are several strategies patients can undertake to ensure adherence, such as self-monitoring their dietary habits and type of food consumed using a food diary; involving social support, such as family members and spouse to help them to adhere to their diet restrictions; setting goals and providing positive reinforcement when they achieved the targeted goals; joining self-management programmes to equip themselves with the necessary skills so that they can better adhere to the treatment regimes, including diet restriction; and lastly, having the knowledge about their regime, and using this knowledge to help them understand and improve their adherence. Key words: Self-Care Management, Chronic Renal Failure, Renal Diet


Therefore in order to effectively manage their condition, healthcare professionals should be able to understand the challenges in self-care management of this patient group and find relevant and effective strategies to help them manage their condition. This paper will focus on exploring various challenges patients with stage 3 CKD face in selfcare management, and more specifically diet restrictions will be discussed in more depth including strategies individuals can adopt in order to support and manage their condition effectively.

Chronic kidney disease (CKD) is defined as either renal damage manifested as structural or functional abnormalities, or estimated glomerular filtration rate (eGFR) less than 60ml/ min/1.73m2 on a minimum of two occasions for more than three months (Thomas, 2010). It is classified into five stages according to level of kidney function present or the glomerular filtration rate (GFR) (Thomas, 2010). Stage 3 CKD reflects a moderate decrease in eGFR of 30- 59ml/min/1.73m2 (Thomas, 2010). The chronic nature of this illness necessitates self-care management which is particularly important during stage 3 CKD to preserve renal function and delays end-stage renal disease (ESRD) progression (Costantini et al., 2008). However, not every patient will advance to stage four or five, and it has been shown that the lack of follow-up and management is a major contributing factor in people having end-stage renal failure (Lameire et al., 2005).

Self-Care Management Self-care management is defined as the behaviour employed by an individual in managing and implementing the treatment regimen within the individual’s lifestyle routine and it recognises an individual’s central role in managing chronic diseases (Costantini et al., 2008). In the process of managing 10

Volume 38, No. 4, October - December 2011

self-care, individuals with stage 3 CKD will face several challenges. Patients with newly diagnosed stage 3 CKD are likely to experience emotional burdens such as fear and anxiety about treatment process and the uncertain prognosis (Jerant, von Griederichs-Fitzwater, & Moore, 2005). Physical constraints of stage 3 CKD such as overwhelming fatigue also affect work life and limit social participation (Jerant et al., 2005). This may cause social isolation which results in lack of social support especially when patients with CKD rely on assistance in managing their condition (Jerant et al., 2005). Financial issues may arise due to hefty cost of treatment and may prevent one from making the necessary adaptations due

to financial constraints (Thorp, Eastman, Smith, & Johnson, 2006). Besides, CKD is a complex and fluctuating condition, thus patients may face difficulties in managing their own condition due to lack of knowledge (Jerant et al., 2005). In addition, patients with stage 3 CKD often have various comorbidities such as hypertension, anaemia and diabetes resulting in them having to adhere to multiple medications, which can be confusing (Thorp et al., 2006). Furthermore, these patients are expected to make lifestyle modifications such as weight and blood-pressure control, increase their level of exercise, reduce alcohol intake, quit smoking and adopt changes in nutritional regimens to slow down disease progression (Thorp et al., 2006) (Table 1).

Table 1: The Psycho-physio-social Burden of Stage 3 Chronic Kidney Disease Stage 3 CKD



• • • • • • •

• • • • • •

Anxiety Fear Denial Sadness Anger Depression Social Isolation


• Diabetes Fatigue Peripheral Oedema • Hypertension Sleeplessness Back pain Urine frequency Urinary colour change

Challenges • • • • • •

Financial burden Polypharmacy Diet & Nutrition Smoking cessation Health literacy Alcohol intake

(Rastogi et al., 2008; Rocco, 2009)

Nutrition and Stage 3 CKD

In susceptible patients, in particular patients with stage 3 CKD who experience shortness of breath as a result of pulmonary congestion, hypocalcaemia may precipitate congestive heart failure (Hall, 2011).

Nutritional therapy is a complex but essential component in managing Stage 3 CKD (Kopple & Massry, 2004). The prime function of the kidney is to excrete waste products of metabolism such as urea and creatinine and excess minerals for example sodium, potassium and phosphate (Clement & Ashurst, 2006). These substances can accumulate in the body if kidney function is impaired and therefore strict adherence to a modified diet regime can reduce this accumulation and the associated effects (Clement & Ashurst, 2006). For patients with CKD there are multiple renal diet parameters such as reduction of phosphorus, sodium and protein (Clement & Ashurst, 2006).

Like phosphorus, salt intake is of a great concern in stage 3 CKD because high sodium intake is likely to cause hypertension in response to an expansion of the extracellular space through fluid retention exacerbated by the kidneys and the thirst centre (Eskridge, 2010). The increased fluid intake will increase contractility, a normal compensatory mechanism in response to fluid loading, which in turn raises blood pressure causing an increased cardiac workload. Over time this will eventually lead to cardiomegaly and congestive heart failure (Eskridge, 2010).

In failing kidneys for example, phosphorus will accumulate in the blood (Clement & Ashurst, 2006). Phosphorus has a negative effect on calcium absorption and secretion. In the presence of high serum phosphate levels, serum calcium levels are typically below normal levels; the opposite occurs with a low serum phosphate. However, in stage 3 CKD the inability of the kidneys to effectively secrete phosphate results in an accumulation of this mineral in the blood effectively making the person hypocalcaemic. In response, parathyroid hormone is secreted to raise serum calcium levels. Unfortunately bones which have the greatest calcium store often resorb, resulting in the patient complaining of muscle aches and pains and the development of osteoporosis; an important consideration especially in female patients. (Clement & Ashurst, 2006). Calcium plays an important role on cardiac muscle contraction and arterial smooth muscle tone. Therefore, hypocalcaemia will effectively reduce cardiac contractility and cause vasodilation.

Like an increased sodium intake, reducing protein intake is essential to prevent an accumulation of its metabolites – urea and creatinine. Urea and creatinine are the prime metabolites needed to be removed from the body. Urea has a very finite excretion factor through the kidneys, that is to say in the normal functioning kidney the nephrons will filter 100% of the urea presented to them. But over the course of the tubular system approximately 70% of this will be actively reabsorbed by specific urea transporters (Seeley, VanPutte, Regan, & Russo, 2011). Unlike urea, creatinine is excreted in the same amounts that it is produced and is effectively 100% secreted; none is reabsorbed. In renal failure, the inability of the remaining glomeruli to filter urea and creatinine is a result of an impaired GFR (Seeley et al., 2011). This effectively means that serum urea and creatinine levels will rise quickly (Clement & Ashurst, 11

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2006). Decreasing the protein intake can successfully reduce the urea and creatinine load the failing nephrons have to filter, thereby reduces the rate of GFR decline and prolongs renal survival (Clement & Ashurst, 2006).

may be further complicated by serial changes in the diet as the disease progresses (Kopple & Massry, 2004). This often leads to dietary non-adherence with increasing duration of the illness. Relationship variables deterring adherence to nutrition will include inconsistencies in the advice provided by HCPs and the ineffective interaction between HCP, and patient and caregiver (Kopple & Massry, 2004). This may lead to confusion in terms of dietary recommendations and may also be seen as relinquishing patient control over the condition in favour of healthcare advice (Thomas, Bryar, & Makanjuola, 2008). The ineffective interaction and communication between HCP and patients may result in inadequacy of dietary instruction and supervision to ensure adherence (Thomas et al., 2008). Inconvenience of the dietary regimen being prescribed by HCP without taking into consideration the patient’s lifestyle is likely to lead to non-adherence to prescribed nutritional regimens (Thomas et al., 2008).

Factors Affecting Adherence to the Renal Diet Multiple factors are involved in the adherence to nutritional advice. Patients with stage 3 CKD often face challenges in adhering to the prescribed renal diet and an understanding of these factors will allow nurses to better promote dietary adherence (Kopple & Massry, 2004). These factors can be broadly categorised into patient variables and relationship variables between patient, caregiver and healthcare professionals (HCP) (Kopple & Massry, 2004). Patient variables in dietary non-adherence include knowledge deficit, hectic lifestyle and lack of decision-making in own dietary outcomes and dissatisfaction with the prescribed renal diet (Kopple & Massry, 2004).

Strategies to Support the Renal Diet

Patients, with stage 3 CKD may lack knowledge on the importance of nutrition in determining their health outcomes (Kopple & Massry, 2004). They may also have little idea on the types of food choices which meet the nutritional recommendations (Kopple & Massry, 2004) and therefore they may not know how to make the necessary adjustments in their current eating habits to fit the prescribed renal diet regimen.

Nutritional therapies for CKD patients are complicated and necessitate multiple, integrated intervention approaches to support adherence. Strategies to improve nutritional adherence fall into three broad categories: patient education, behavioural modification and organisational changes (Kopple & Massry, 2004). Nutrition education is a necessary initial step to achieve dietary change (Kopple & Massry, 2004). Education seeks to increase a patient’s knowledge and change any potential undesirable attitudes (Kopple & Massry, 2004). To facilitate diet adherence, nurses should first review nutritional values of the food types the patient generally eats to increase patient’s awareness of ingredients like salt, sugar and fat (Gillis et al., 1995). In addition, the nurse can provide guidelines for diet modification in accordance to the renal diet prescription by the dietician and in consideration of the identified nutritional values (Gillis et al., 1995). In doing so, patients will be aware of the nutrient contents of the different food groups and specific food choices for CKD and thereby promoting individual choice. To enhance dietary adherence, nurses can highlight the importance of strict dietary regimen in stage 3 CKD and more importantly, the expected benefits that will slow down disease progression (Kopple & Massry, 2004). Whilst it is easy to provide education, it is vital in self-care management programmes to assess a patient’s knowledge and literacy levels first to ensure the information provided will be fully comprehended (Rosal et al., 2001). Furthermore, in instances where the patient’s diet is determined by someone else such as the caregiver, education should then be targeted at the person involved in preparing patient’s diet (Kopple & Massry, 2004).

Hectic lifestyles for example may prevent patients from adhering to the prescribed nutritional regimen (Kopple & Massry, 2004). Patients leading a “fast-paced” life are more likely to eat out. Food prepared at hawker centres and food courts tend to have a higher ratio of saturated fats and salt than home-cooked food. At home, one can control the ingredients and the cooking methods (Kopple & Massry, 2004). Many patients, especially the elderly depend on others for certain aspects of their care including diet (Kopple & Massry, 2004). More often than not, food marketing and preparation lie with the caregiver (Kopple & Massry, 2004). Therefore, resistance to adhering to a “special” diet often precludes patient choice because the decision-making lies with the caregiver instead of the patient. The renal diet tends to be relatively unpalatable and differs from the usual eating patterns of patients (Kopple & Massry, 2004). This may cause patients to be dissatisfied with the prescribed dietary changes, affecting their adherence (Kopple & Massry, 2004). The importance of a patient’s agreement towards eating pattern adherence to maintain nutritional goals is highlighted in one study which demonstrated that patients with higher satisfaction towards the prescribed diet are more likely to adhere to the dietary regimen than those dissatisfied ones (Coyne et al., 1995).

Behavioural modification strategies focus on the behaviours involved in adherence and attempt to influence specific behaviours directly through techniques such as reminders, self-monitoring and positive reinforcement (Kopple & Massry, 2004). Reminders can reduce dietary non-adherence as a result of cognitive decline and forgetfulness (Kopple & Massry, 2004). Various aids such as charts and menus serve to remind patients to limit nutrients such as proteins and sodium (Kopple & Massry, 2004). In addition, nurses can seek to remind patients to adhere

The chronic nature of CKD necessitates lifelong changes in dietary habits. Sustaining dietary change is particularly challenging due to the central role food often plays in many Singaporean social situations (Kopple & Massry, 2004). Changes in lifestyle through dietary modifications often have far greater social consequences than that of other medical interventions (Kopple & Massry, 2004). Moreover, the renal dietary regimen 12

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to nutritional regimens through text-messaging, an important consideration when attempting to maintain compliance.

plan is appropriate (Rosal et al., 2001) so that on-going support for patients throughout the dietary change process maintains motivation and sustains adherence (Kopple & Massry, 2004).

Self-monitoring is a process of observing and recording one’s dietary intake that can aid in promoting dietary change (Kopple & Massry, 2004). One form of self-monitoring is record-keeping where patients are expected to record the nutritional contents of all food eaten (Gillis et al., 1995). This helps patients to assume a more active role in nutritional adherence. Nurses can act as facilitators by instructing on the proper way to selfmonitor, checking patient’s records for accuracy and providing useful feedback (Kopple & Massry, 2004). Self-monitoring also provides nurses with opportunities to give positive reinforcement such as praises to patients for their effort which enhance their self-efficacy, hence promoting adherence (Kopple & Massry, 2004).

Conclusion CKD is a progressive illness that necessitates self-care management. Self-care management in patients with stage 3 CKD plays a critical role in affecting clinical outcomes and in delaying disease progression to end stage renal disease. However, these patients often face numerous challenges such as nutritional adherence and would have to adjust to disruptive and permanent implications of a pervasive illness on various aspects of their lives. The role of nurses is to work closely with patients to promote and sustain adherence to nutritional regimens and other self-care areas so that they can continue to lead active and emotionally gratifying lives in the face of CKD.

From a health care perspective, strategies involving organisational changes can improve the quality of interaction between patients and HCPs so as to enhance dietary adherence (Kopple & Massry, 2004). To reduce complexity of the nutritional regimen, nurses can work collaboratively with dieticians and the patient in an attempt to make the renal diet less complex by prioritising the regimen and breaking the dietary plan into sequential implementable stages (Kopple & Massry, 2004). Moreover, nurses can directly involve the patient in the development of nutrition plan (Kopple & Massry, 2004). This can help to minimise inconvenience by tailoring the diet regimen to the patient’s culture and lifestyle as closely as possible and therefore promoting dietary adherence. Nurses can also act as advocates and translate the recommended nutrient levels by the dietician into an individualised meal pattern for the patient (Kopple & Massry, 2004). One method of creating individualised meal plans is to provide food choices lists (Kopple & Massry, 2004). These lists enable greater variety in the diet and enhance its palatability while preserving the consistency of daily nutrients levels (Kopple & Massry, 2004). Food choice lists and meal patterns can be used to provide written guidance and nutritional goals for patients whilst enabling them to eat as normally as possible (Kopple & Massry, 2004). In addition, nurses can collaborate with dietitians to assist patients to accommodate favourite food in their diets, usually with certain limitations on frequency and portion size (Coyne et al., 1995). Assessment of patient’s satisfaction can be made before dietary modifications are prescribed as there is a positive correlation between satisfaction of prescribed diet and dietary adherence (Coyne et al., 1995). With this, a diet pattern that gives patients satisfaction and pleasure will be likely to support sustained adherence to dietary changes for patients with CKD (Kopple & Massry, 2004).

References Clements, L., & Ashurst, I. (2006). Dietary strategies to halt the progression of chronic kidney disease. Journal of Renal Care, 32(4), 192-197. Costantini, L., Beanlands, H., McCay, E., Cattran, D., Hladunewich, M., & Francis, D. (2008). The self-management experience of people with mild to moderate chronic kidney disease. Nephrology Nursing Journal, 35(2), 147-156. Coyne, T., Olson, M., Bradham, K., Garcon, M., Gregory, P., & Scherch, L. (1995). Dietary satisfaction correlated with adherence in the Modification of Diet in Renal Disease Study. Journal of the American Dietetic Association, 95(11), 1301-1309. Eskridge, M. (2010). Hypertension and chronic kidney disease: The role of lifestyle modification and medication management. Nephrology Nursing Journal, 37(1), 55-59. Gillis, B., Caggiula, A., Chiavacci, A., Coyne, T., Doroshenko, L., Milas, C., & Scherch, L. (1995). Nutrition intervention program of the modification of diet in renal disease study: A self-management approach. Journal of the American Dietetic Association, 95(11), 12881294. Hall, J.E., (2011). Guyton & Hall textbook of medical physiology (12th ed.). New York: Saunders. Jerant, A., von Friederichs-Fitzwater, M., & Moore, M. (2005). Patients’ perceived barriers to active self-management of chronic conditions. Patient Education & Counseling, 57(3), 300-307. Kopple, J. D., & Massry, S. G. (2004). Nutritional management of renal disease. (2nd ed.). (pp. 630-646). Philadelphia: Lippincott Williams & Wilkins. Lameire, N., Jager, K., Biesen, W. V., Bacquer, D. D., & Vanholder, R. (2005). Chronic kidney disease: A European perspective. Kidney International Supplement, 68(99), S30-S38. Rastogi, A., Linden, A., & Nissenson, A. R. ( 2008). Disease management in chronic kidney disease. Advances in Chronic Kidney Disease, 15 (1), 19-28. Rocco, M. (2009). Disease management programs for CKD patients: The potential and pitfalls. American Journal of Kidney Diseases, 53(3 Suppl 3), S56-63. Rosal, M., Ebbeling, C., Lofgren, I., Ockene, J., Ockene, I., & Herbert, J. (2001). Perspectives in practice. Facilitating dietary change: The patient-centered counseling model. Journal of the American Dietetic Association, 101(3), 332-341.

Nurses can model appropriate food choices in several ways (Gillis et al., 1995). For instance, nurses can provide cookbooks with appropriate recipes and offer cooking demonstrations (Gillis et al., 1995). This helps to provide insights for the interpretation and improvement of prescribed dietary plans (Gillis et al., 1995). In addition, nurses should ensure maintenance of dietary changes for patients with stage 3 CKD through follow-up (Rosal et al., 2001). It is essential to evaluate and monitor the patient’s progress and to determine if the diet

Seeley, R., VanPutte, C., Regan, J., & Russo, A., (2011). Seeley’s Anatomy & Physiology. (9th ed.). New York: McGraw-Hill. Thomas, N. (2010). Recognising and managing chronic kidney disease. Practice Nurse, 39(10), 19-22. Thomas, N., Bryar, R., & Makanjuola, D. (2008). Development of a self-management package for people with diabetes at risk of chronic kidney disease (CKD). Journal of Renal Care, 34(3), 151-158. Thorp, M., Eastman, L., Smith, D., & Johnson, E. (2006). Managing the burden of chronic kidney disease. Disease Management, 9(2), 115-121.


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MUSIC THERAPY IN THE PALLIATIVE SETTING: A SYSTEMATIC REVIEW Mabel Qi-He LEOW Master of Science (Nursing) Student Alice Lee Cnetre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore Correspondence address: Mabel Qi-He LEOW Alice Lee Cnetre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore 117597 Tel: (65) 97420543 Email:

Abstract Background: Music therapy is popular in the palliative setting as people have physical, social, emotional, cognitive and spiritual needs arising directly from the disease process. Objectives: This systematic review aims to evaluate quantitative and qualitative studies on patients’ experience with music therapy in the palliative setting. Design: Systematic review. Data sources: A systematic search of the literature was undertaken to identify published research studies from January 1990 to December 2010. A hand search of the reference lists and bibliographies of included articles was also conducted to search for additional published studies not located through electronic database search. Review methods: Studies on the experience of palliative care patients with music therapy were examined. Data were extracted independently by two reviewers. Methodological quality was also assessed by two reviewers against key quality criteria. Findings: Three hundred and sixty three papers were identified from the database search, of which nine met the inclusion criteria for the review. Music therapy was found to improve patients’ quality of life, relief physical symptoms, and provide psychosocial support for patients. Conclusion: The studies reviewed show that music therapy has physical and psychosocial benefits for patients in the palliative setting. The small number of studies included in this review shows the lack of research on the use of music therapy on palliative patients, and that more well-designed studies should be conducted in this area. Key words: Music Therapy, Palliative Care, Systematic Review


disease process (Porchet-Munro, 1995). Hence, music therapy is used to meet the physical needs, such as pain and symptom relief (Gallagher et al. 2006), and psychosocial needs such as their spiritual and communal needs (Aldridge, 2003). Music therapy can help patients to express their emotions as it creates a non-threatening and accepting environment which is calming and thus, enable the patient to “open up” (“Music therapy in palliative care”, 2004).

Music therapy is the “controlled use of music, its elements and their influences on the human being to aid in the physiological, psychological and emotional integration of the individual” (Munro & Mount, 1978). Hence, for music therapy to be considered as a formal therapy, the music therapy session must be conducted by a trained music therapist. Otherwise, it would more commonly be termed ‘music as therapy’, or ‘music intervention’, instead of ‘music therapy’. During music therapy sessions, the music therapist employs music as the primary agent for a therapeutic outcome. A wide range of musical activities including listening to music and music making using improvisation techniques may be used during the sessions (Clements-Cortes, 2004).

Two systematic reviews of quantitative studies on use of music therapy in palliative setting had been conducted. The first review was conducted by Hilliard (2005) on music therapy in hospice and palliative care. The second one was done by Bradt and Dileo (2008) on patients at the end of life. Although both reviews aimed to uncover the literature on music therapy, the use of music without a trained music therapist was also included in some of these studies. The trained music therapist

In the palliative setting, many patients have physical, social, emotional, cognitive and spiritual needs arising from the 14

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IA Calculation of sample size and accurate standard definition of appropriate outcome variables IB Accurate and standard definition of appropriate outcome variables IC Neither of the above

would be the therapeutic agent who does not only offer social support for the patient, but also design and conduct the therapeutic sessions to meet the patient’s needs. There have been no systematic reviews conducted on qualitative studies on music therapy. Such reviews are important as they could help explain the reasons underlying the quantitative evidence, and better understand patients’ experiences during music therapy sessions. Hence, this systematic review aims to evaluate quantitative and qualitative studies on patients’ experience with music therapy conducted by trained music therapists in the palliative setting.

Grade II (Fairly strong evidence) Prospective study with a comparison group (non-randomised controlled trial, good observational study or retrospective study that controls effectively for confounding variables). IIA Calculation of sample size and accurate, standard definition of appropriate outcome variables and adjustment for the effects of important confounding variables IIB One or more of the above

Method A systematic search of the literature was undertaken to identify palliative care patients’ experiences with music therapy from January 1990 to December 2010. Electronic databases (CINAHL, Medline, PsycINFO, and Scopus) were searched. Cochrane databases were also examined. The search terms employed in electronic searches were: palliative care/terminal care/hospice/end of life AND music therapy. A hand search of the reference lists and bibliographies of included articles was also conducted to search for additional published studies not located through electronic database search.

Grade III (Weaker evidence) Retrospective or observational studies IIIA Comparison group, calculation of sample size, accurate and standard definition of appropriate outcome variables IIIB Two or more of the above IIIC None of these Grade IV (Weak evidence) Cross-sectional study, Delphi exercise, consensus of experts The quality of methodology was assessed by two reviewers independently. In the event of disagreement, a third reviewer would be involved.

The inclusion criteria of the papers were as follows: 1) English language publication 2) Patients who were receiving palliative care 3) Patients who received music therapy delivered by a trained music therapist 4) Quantitative or qualitative papers 5) Published between 1990 to 2010

Results Table 2 presents the flow of studies through the review. After the removal of duplicates, 363 papers were identified. One paper was identified through a hand search (Mihara, et al., 2006). A review of the abstracts revealed that most papers described how music therapy is employed in the healthcare facility. Nineteen papers were found to describe patients’ experience with music therapy in the palliative setting, and examined in full detail. Of these, nine were excluded as seven were case studies with the music therapists describing their interaction with the patients (Clements-Cortes, 2004; Dimaio, 2010; Magill-Levreault, 1993; Marom, 2008; O’Callaghan, 1996b; Pawuk & Schumacher, 2010; Salmon, 1993), one was not conducted in a palliative setting (O’Callaghan & McDermott, 2004), one described music therapists’ experience with patients’ incomplete music therapy legacies (Thomas & Crappsley, 2009; O’Callaghan, Petering, Thomas & Crappsley, 2009), and one was written in Japanese (Mihara et al., 2006).

Studies were excluded if they reported the use of music without a trained music therapist. The evidence was graded according to the rigour of study design and analysis (see Table 1). Studies that employed qualitative methods were graded as weak evidence, but were included to understand patients’ experience with music therapy.

Table 1: Grading criteria for review of studies Grade I (Strong evidence) RCTs or review of RCTS


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Table 2: Flow of studies through the review Total number of hits from searches: 620

Removal of duplicates: 258

Total number abstracts appraised: 363 (one hand searched)

Total number of full text articles appraised: 19

Total number identified for data extraction: 10

Total number included in the review: 10

Quantitative papers: 5

Qualitative papers: 5

Methodological Quality

Of the quantitative papers, two were randomised controlled trials (RCT) and were graded at level IB (Hilliard, 2003; HorneThompson & Grocke, 2008). No sample calculation was done for Hilliard (2003). A power calculation was attempted by Horne-Thompson and Grocke (2008), but the recruited sample could not meet the targeted number. Three papers were graded at level IIIC as they employed a pre-post study design with no control group or sample power calculation (Krout, 2001; Gallagher et al., 2006; Nakayama et al., 2009). Sample size for the studies ranged from 10 (Nakayama et al., 2009) participants to 150 participants (Gallagher et al., 2006). Details of the studies are found in Table 3.

Nine papers were included in this review. Five were quantitative papers ( Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006; Hilliard, 2003; Horne-Thompson & Grocke, 2008; Krout, 2001; Nakayama, Kikuta, & Takeda, 2009), and four were qualitative ones (O’Callaghan, 1996a; O’Callaghan & Hiscock, 2007; O’Kelly & Koffman, 2007; Leow, Drury, & Poon, 2010). The studies were conducted in a wide range of countries, such as United States of America (Gallagher et al., 2006; Hilliard, 2003;Krout, 2001), United Kingdom (O’Kelly & Koffman, 2007), Australia (Horne-Thompson & Grocke, 2008; O’Callaghan, 1996a; O’Callaghan & Hiscock, 2007), Japan (Nakayama et al., 2009), and Singapore (Leow et al., 2010).

Table 3: Details of included papers Author/Year/ Country

Gallagher, et al., 2006 Cleveland, Ohio, United States

Study design

Ex post factor, no control

Sample size/ characteristics

150 participants Patients who had terminal illnesses


Survey questionnaire completed by patients and music therapist

Type of music therapy

Individual music therapy sessions


Wilcoxon signed rank test used for statistical analysis Patients rated improvement in pain, anxiety, and mood (p<0.05).Patient rated no improvement in shortness of breath. Music therapist rated improvements in facial expression, movement, sleep, and verbalisations. 16

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Author/Year/ Country

Hilliard, 2003 New York, United States

Study design


Sample size/ characteristics

80 participants Patients who were diagnosed with terminal cancer, with a prognosis of 6 months or less


Survey questionnaire completed by participants

Type of music therapy

Music therapy conducted in participantsâ&#x20AC;&#x2122; home


Music therapy improves patientsâ&#x20AC;&#x2122; quality of life (Repeated measures ANOVA) No significant effect on physical functions and length of life (T-test)

Author/Year/ Country

Krout, 2001 Florida, United States

Study design

Pre-post test with no control

Sample size/ characteristics

80 participants Patients who were receiving regularly scheduled music theray services from the hospice. Patients were terminally ill and had a prognosis of 6 months or less


Survey questionnaire completed by observer (not the music therapist) and the participant

Type of music therapy

Music therapy delivered in home, hospital, nursing home, or in-patient acute care unit


T-test used for statistical analysis Reduction in pain: Rated by observer (p<0.001), Rated by participant (p<0.005) Increase in physical comfort: Rated by observer (p<0.001), Rated by participant (p<0.005) Increased relaxation: Rated by observer (p<0.001), Rated by participant (p<0.005)

Author/Year/ Country

Horne-Thompson, & Grocke, 2008 Melbourne, Australia

Study design


Sample size/ characteristics

25 participants Patients with end-stage terminal disease receiving inpatient hospice services


Survey questionnaire completed by participants. Heart rate taken by independent staff members not involved in the study

Type of music therapy

A single music therapy session


Mann-Whitney test used for statistical analysis Reduction in anxiety for the experimental group on the anxiety measurement of the Edmonton Symptom Assessment System (ESAS) (p=0.005). A post hoc analysis found significant reductions in other measurements on the ESAS in the experimental group, specifically pain (p=0.019), tiredness (p=0.024) and drowsiness (p=0.018). No decrease in heart rate


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Author/Year/ Country Study design Sample size/ characteristics

Nakayama, Kikuta, & Takeda, 2009 Japan Pretest-posttest with no control 10 participants Patients with terminal cancer at an inpatient hospice


Survey questionnaire completed by researcher, based on participant’s response. Cortisol levels measured by participant’s saliva samples

Type of music therapy

Group music therapy, with 40 minute live session of songs of seasons


Wilcoxon signed rank test used for statistical analysis Decrease in saliva cortisol levels (p=0.0316) Decrease in refreshment (p=-0.375) Decrease in depression (p=0.0690) Decrease in anxiety (p=0.0898) Increase in alertness/excitement (p=0.0690) No difference in fatigue (p=0.2527)

Author/Year/ Country

Nakayama, Kikuta, & Takeda, 2009 Japan

Study design Sample size/ characteristics

Pretest-posttest with no control 10 participants Patients with terminal cancer at an inpatient hospice


Survey questionnaire completed by researcher, based on participant’s response. Cortisol levels measured by participant’s saliva samples

Type of music therapy

Group music therapy, with 40 minute live session of songs of seasons


Wilcoxon signed rank test used for statistical analysis Decrease in saliva cortisol levels (p=0.0316) Decrease in refreshment (p=-0.375) Decrease in depression (p=0.0690) Decrease in anxiety (p=0.0898) Increase in alertness/excitement (p=0.0690) No difference in fatigue (p=0.2527)

Author/Year/ Country

O’Callaghan,& Hiscock, 2007 Melbourne, Australia

Study design Sample size/ characteristics Method Type of music therapy


Modified grounded theory 128 participants Oncological patients Anonymous written responses Patients who participated in one or more music therapy sessions 1. Music therapy often elictes varied affective responses that frequently or infrequently recus and polarized affects might be experienced simulaneously. 2. Music therapy or music can be associated with human relationships, characterised by the affirmation of one’s social presence embodied in positive and negative memory association or through community building 3. Cancer and its treatment is endured physically but music therapy can elicit helpful shifts in physical awareness through altering sensory or somatic experience, or through motivating physical movement (real of imagined) 4. Music therapy offers scope for experiencin altered and improved awareness, sometimes elicited by memories, and characterized by diversion, imagery, or transference. 5. Music therapy can transform adversity into a more positive experience, and can elicit rediscovered or new self-awareness and thoughts about one’s musical future. 6. Music therapy or music can be associated with increased well-being, self awareness, and self-expressions. 7. Some do not experience memories in music therapy sessions, and rarely, music therapy does “nothing”.


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Author/Year/ Country

O’Callaghan, 1996 Melbourne, Australia

Study design

qualitative interpretative

Sample size/ characteristics

39 palliative care inpatients. 26 patients had advanced neurological disease, and 13 patients had cancer.


Examine the lyrics of songs written by the patients.

Type of music therapy

Individual of group song writing sessions.


1. 2. 3. 4. 5. 6. 7. 8.

Author/Year/ Country

Leow, Drury, & Poon 2010 Singapore

Study design

Qualitative interpretative

Sample size/ characteristics

5 participants Patients who had attended at least one music therapy session with the music therapist, and were mentally lucid


Face- to- face semistructured interviews

Type of music therapy

Individual music therapy sessions


Four themes emerged: 1. Mirror of the inner feelings: Improve mood and provides a form of distraction. 2. Bridge of connection: Participants felt connected to music, provide a platform for reminiscence and comfort. 3. Music as a therapeutic medium: Enjoyment in music, rapport building, and choice to use music as a therapeutic medium. 4. Barriers to music therapy: Physical barriers, emotional barriers, knowledge barriers, and work demands of therapist.

Author/Year/ Country

O’Kelly, & Koffman, 2007 London, United Kingdom

Study design

Modified grounded theory

Sample size/ characteristics

20 participants Doctors, nurses and allied health professionals in Five UK hospices in suburban areas, providing in-patient and day-care facilities.


Face- to- face semistructured interviews

Type of music therapy

Group music therapy with other patients, and music therapy for patients with their family members


Enable self-reflection Enable patients to write messages to other people, especially their love ones. Enable patients to compliment others. Facilitate life review process. Reflect upon significant others, including pets. Enable self-expression of adversity. Enable diversion of physical symptoms. Enable spiritual expression.

1. Positive influence on: a. Emotional aspect - Allow the expression of emotions b. Physical aspect - Improve phsyical movement of patients c. Social aspect - Improve social interaction with other people d. Environmental aspect – Improve mood of patients and staff e. Spiritual aspect f. Creativity – Promote creative expression 2. Promote holistic care.


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Grocke, 2008). A study by Nakayama et al. (2009) also found that anxiety levels lowered, but results were not statistically significant. This reduction in anxiety could have also led to the relief from their breathlessness as they felt more relaxed.

For the qualitative papers, two papers used the grounded theory (O’Callaghan, 1996a; O’Callaghan & Hiscock, 2007), and two used a qualitative interpretative method ( O’Kelly & Koffman, 2007; Leow, et al., 2010). To obtain the experiences of palliative care patients with music therapy, a myriad of methods were used - one interviewed the patients in an inpatient hospice (Leow, et al., 2010), one analysed the musical lyrics of patients (O’Callaghan, 1996a), one analysed anonymous written responses of patients (O’Callaghan & Hiscock, 2007), one recorded the group discussion with music therapists, and one interviewed the multidisciplinary healthcare team (O’Kelly & Koffman, 2007). The sample size ranged from 5 (Leow, et al., 2010) to 128 (O’Callaghan & Hiscock, 2007)

Qualitative evidence has revealed several other psychosocial benefits of music therapy such as providing a platform for the expression of emotions which have accumulated during their illness trajectory (O’Callaghan, 1996a; O’Callaghan & Hiscock, 2007; O’Kelly & Koffman, 2007), facilitating the life review process and allowing reminiscence of the past (Leow et al., 2010; O’Callaghan, 1996a; O’Callaghan & Hiscock, 2007;), and promoting social interaction (Leow, et al., 2010; O’Kelly & Koffman, 2007). Other benefits of music therapy include promoting creativity (O’Kelly & Koffman, 2007), and allowing spiritual expression to God (O’Callaghan & Hiscock, 2007).

Study findings Quality of life

Limitations of music therapy

Music therapy was found to improve overall quality of life of patients. Using the Hospice Quality of Life Index – Revised (HQLI-R) which measures patients’ physical, relationship, psychological, spiritual, and financial aspects, Hilliard (2003) found that patients from the group which received music therapy experienced better quality of life.

Although most patients have acknowledged the benefits of music therapy, qualitative studies have revealed some limitations to the use of music therapy. The study by O’Callaghan and Hiscock (2007) found that some patients felt that music therapy did not help them in any way. A qualitative study by Leow et al. (2010) also discovered that patients have expressed some barriers to their use of music therapy. These barriers were caused by patients’ increased physical weaknesses, music therapy arousing past memories, patients’ lack of knowledge on music, and heavy workload of the music therapist resulting in patients rejecting music therapy. Despite the benefits of music therapy in pain and symptom management, some patients have expressed that they would choose to use pharmacological methods to relieve their physical discomfort, instead of music therapy (Leow et al., 2010).

Physical symptoms After music therapy, patients reported lower physical discomfort scores (Gallagher, et al., 2006). Qualitative findings showed that music therapy was able to provide a form of distraction for patients (Leow, et al., 2010; O’Callaghan, 1996a; O’Callaghan & Hiscock, 2007; O’Kelly & Koffman, 2007). During music therapy, imagery may be used to distract patients from their physical discomfort. This may have indirectly helped relieve the physical discomfort.


Music therapy provided pain relief for patients (Gallagher, et al., 2006; Krout, 2001;Leow, et al., 2010; O’Callaghan & Hiscock, 2007). Patients reported lower pain scores after music therapy sessions (Gallagher, et al., 2006; Krout, 2001). Qualitative studies also affirmed this finding as patients verbalised having less pain after music therapy sessions (Leow, et al., 2010; O’Callaghan & Hiscock, 2007).

The review on using music therapy in the palliative setting shows that music therapy has become more popular in the last decade. It is found that research on music therapy has been conducted in Western and Asian countries, ascertaining that music therapy is widely used in palliative care in various countries. For the quantitative studies, only two RCTs had been conducted (Hilliard, 2003; Horne-Thompson & Grocke, 2008). Three studies were pre-post studies with no control (Gallagher et al., 2006; Krout, 2001; Nakayama et al., 2009), and thus, were graded at a lower evidence. Despite the lower graded evidence, these studies showed favourable outcomes of the use of music therapy in the palliative setting. Hence, they could provide the basis for developing higher quality studies in future. Studies on music therapists’ case study reflections, and those describing the music therapists’ interaction with the patients, were excluded in this review.

One study also suggested that music therapy could relief shortness of breath (Gallagher, et al., 2006). This relief from breathlessness could be attributed to music therapy promoting relaxation in patients (Leow, et al., 2010; O’Callaghan & Hiscock, 2007).

Psychosocial benefits of music therapy Quantitative evidence has shown that music therapy helped to improve patients’ mood (Gallagher, et al., 2006; Nakayama, et al., 2009). From qualitative narratives, it was found that music therapy improved mood by making the patients feel happy and lively, as patients enjoyed the music therapy sessions (O’Callaghan & Hiscock, 2007; Leow, et al., 2010).

There could be difficulty recruiting participants who are at the end of life as they may be physically weak and unable to participate in the research study. This may have attributed to the small sample size in some studies. Horne-Thompson and Grocke (2008) attempted to do a sample size calculation for their

Two studies found that music therapy was able to help reduce patients’ anxiety (Gallagher et al., 2006; Horne-Thompson & 20

Volume 38, No. 4, October - December 2011

quantitative studies, but were unable to meet the sample size required. For qualitative studies, only one study endeavoured to seek patients’ experience with music therapy by interviewing patients themselves. However, the researchers only managed to recruit five participants into the study (Leow, et al., 2010).

Clements-Cortes, A. (2004). The use of music in facilitating emotional expression in the terminally ill. American Journal of Hospice & Palliative Medicine, 21(4), 255-260, 320, 251p. Dimaio, L.(2010) Music therapy entrainment: a humanistic music therapist’s perspective of using music therapy entrainment with hospice clients experiencing pain. Music Therapy Perspectives, 28(2), 106-115. Gallagher, L. M., Lagman, R., Walsh, D., Davis, M. P., & LeGrand, S. B. (2006). The clinical effects of music therapy in palliative medicine. Supportive Care in Cancer, 14(8), 859-866.

Quantitative studies have largely focused on the physical benefits of music therapy. However, no quantitative studies have ascertain the psychosocial benefits of music therapy, although qualitative studies have described many psychosocial benefits of music therapy, such as providing social interaction and meeting spiritual needs.

Hilliard, R. E. (2003). The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Journal of Music Therapy, 40(2), 113-137. Hilliard, R. E. (2005). Music therapy in hospice and palliative care: A review of the empirical data. Evidence-based Complementary and Alternative Medicine, 2(2), 173-178.

In this review, it is also found that most studies focused on the benefits of music therapy, and the barriers of music therapy had not been deeply explored. Understanding the barriers to music therapy is essential as this will help music therapists deal with the barriers.

Horne-Thompson, A., & Grocke, D. (2008). The effect of music therapy on anxiety in patients who are terminally ill. Journal of Palliative Medicine, 11(4), 582-590. Krout, R. E. (2001). The effects of single-session music therapy interventions on the observed and self-reported levels of pain control, physical comfort, and relaxation of hospice patients. American Journal of Hospice & Palliative Care, 18(6), 383-390, 432, 381p.


Leow, Q. H. M., Drury, V. B., & Poon, W. H. (2010). A qualitative exploration of patients’ experiences of music therapy in an inpatient hospice in Singapore. International Journal of Palliative Nursing, 16(7), 344-350.

The studies in this review have shown that music therapy has physical and psychosocial benefits for patients in the palliative setting. Regarding physical aspects, music therapy can help reduce pain and symptoms caused by the disease process. On the psychological part, music therapy can improve patients’ mood, allow reminiscence, increase social interaction, promote creativity and allow spiritual expression. The small number of studies included in the review shows the inadequate evidence supporting the effectiveness of music therapy on palliative patients, and that more well-designed RCTs and qualitative studies should be conducted in this area.

Magill-Levreault, L. (1993). Music therapy in pain and symptom management. Journal of Palliative Care, 9(4), 42-48. Marom, M. K. (2008). “Patient declined”: Contemplating the psychodynamics of hospice music therapy. Music Therapy Perspectives, 26(1), 13-22. Mihara, B., Mihara, Y., Fujimoto, M., Nagashima, H., Tomita, Y., & Takao, M. (2006). The effect of music therapy for patients with amyotrophic lateral sclerosis - Evaluation by neuropsychological and physiological tests. Japanese Journal of Music Therapy, 6(1), 23-32. Munro, S., & Mount, B. (1978). Music therapy in palliative care. Canadian Medical Association Journal, 119(9), 1029-1034.

Future quantitative studies may attempt to quantify the psychosocial benefits of music therapy in improving social interaction with patients’ family and friends, and meeting spiritual needs of patients. Qualitative studies that focus on understanding patient’s motivations and factors influencing their decision of participating in music therapy may be conducted. Patient’s relatives could also be interviewed to understand their perception on the patient’s use of music therapy.

Music Therapy Association of British Columia (2004). Music therapy in palliative care. Geriaction, 22(1), 23-25. Nakayama, H., Kikuta, F., & Takeda, H. (2009). A pilot study on effectiveness of music therapy in hospice in Japan. Journal of Music Therapy, 46(2), 160-172. O’Callaghan, C. C. (1996a). Lyrical themes in songs written by palliative care patients. Journal of Music Therapy, 33(2), 74-92. O’Callaghan, C. C. (1996b). Pain, music creativity and music therapy in palliative care. Complementary Medicine International, 3(2), 43-48.

Limitations of this review could be attributed to the exclusion of studies not published in the English language. Also, only published studies were included in this review which may have limited the scope of literature search.

O’Callaghan, C. C., & Hiscock, R. (2007). Interpretive subgroup analysis extends modified grounded theory research findings in oncologic music therapy. Journal of Music Therapy, 44(3), 256-281. O’Callaghan, C. C., & McDermott, F. (2004). Music therapy’s relevance in a cancer hospital researched through a constructivist lens. Journal of Music Therapy, 41(2), 151-185.

Conflict of interest

O’Callaghan, C. C., Petering, H., Thomas, A., & Crappsley, R. (2009). Dealing with palliative care patients’ incomplete music therapy legacies: Reflexive group supervision research. Journal of Palliative Care, 25(3), 197-205.

There is no conflict of interest at the point of review.

Acknowledgement The author would like to thank Dr Vicki Drury and Mr Edward Poon for being the second and third reviewer for the papers to be included in the review.

O’Kelly, J., & Koffman, J. (2007). Multidisciplinary perspectives of music therapy in adult palliative care. Palliative Medicine, 21(3), 235-241. Pawuk, L. G., & Schumacher, J. E. (2010). Introducing music therapy in hospice and palliative care: An overview of one hospice’s experience. Home Healthcare Nurse, 28(1), 37-44.

References Aldridge, D. (2003). Music therapy references relating to cancer and palliative care. British Journal of Music Therapy, 17(1), 17-25.

Porchet-Munro, S. (1995). The supportive role of music: The active and passive roles music can play in palliative care. European Journal of Palliative Care, 2(2), 77-80.

Bradt, J., & Dileo, C. (2008). Music therapy for end-of-life care. Cochrane Database of Systematic Reviews(2).

Salmon, D. (1993). Music and emotion in palliative care. Journal of Palliative Care, 9(4), 48-52.


Singapore Nursing Jour nal

MIGRANT CHINESE WOMEN AND SEXUAL HEALTH: A ROLE FOR THE ADVANCED SPECIALIST COMMUNITY NURSE IN SINGAPORE Eleanor HOLROYD1, William WC WONG2, 1. Professor, Asian and Gender Nursing Studies, School of Health Sciences, RMIT University, Melbourne; Visiting Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore 2. Associate Professor, Department of Family Medicine & Primary Care, The University of Hong Kong Correspondence to: Eleanor HOLROYD Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive 1, Singapore 117597 Email:

Abstract This discussion paper will draw on two decades of mixed methodology research on migrant women in Southern China, in particular migrant sex workers. These women are socially categorised as not adhering to behavioural norms and consequently are at risk of poor sexual health outcomes. The authors will argue that these migrant women are systematically excluded from mainstream society and healthcare services, occupying marginal positions analogous to that of a minority group. The health needs of these women are complex and include poor psychological health, risk for HIV and occupational health concerns. These migrant women have limited access to formal health care, heightened poor health vulnerability, and diminished expectations of health service protection with their host countries. In conclusion, the authors will advocate for specific strategies such as the development of an advanced postgraduate specialism in community nursing in Singapore that complements public health initiatives. There is also a need for more peer-led community based outreach services as a way of addressing and reducing sexual health risk. Key words: Sexual Health, Migration, Women, Community Nursing


countries. Some scholars have argued there was insinuation of attitudes to risk, pleasure and sexual relationship that predated migration (Zheng & Lian, 2005).

Female lower socio-economic migrant workers have specific and unique health vulnerabilities. Migration disrupts family life, and while for men it can create a demand for prostitution, often supplied by migrant women. From a public health point of view, it can potentially contribute to poor sexual health outcomes. Many migrant women leave their homebased networks to secure work, become insulated from their host society, and marginalised and stigmatised due to both their occupational and their illegal status. As a result, such temporary migrants experience little social or cultural assimilation in places of urban destination, and their temporary status contributes to poor physical, sexual and mental health outcomes (Anderson, 2007; Jacka, 2006; Pun, 2005; Solinger, 1999).

Furthermore, empirical evidence reports that migrant women who have lower levels of sexual health knowledge leads to an increased likelihood of abortions at younger ages when compared with resident populations (Liu, Xie, Yu, Song, Gao, Ma & Detels, 2004). Other research has indicated that some young migrant women perceive sexual health education received at school, if any was received at all, to be useful in reducing health risk behaviour (Wong, Leung & Lynn, 2011). Sexually experienced female migrants working in commercial sex industries are twice as likely to engage in unsafe sex when compared with migrant women working in other occupational sectors. A recent study of STI amongst female sex workers in Hong Kong found that psychological and social agencies, in particular migration status, were the most significant independent risk factors in contracting STI/HIV. The authors further concluded that we could better address the resultant health inequalities and the spread of such infections in the community by viewing these women within their personalised and unique context of migration (Wong, Holroyd, Ling & Grey, 2006a).

Against this background, a common concern associated with migration and health in both the Chinese and Western literature is an increase of sexually transmitted infections (STI), including Human Immunodeficiency Virus (HIV) infection and Acquired Immune Deficiency Syndrome (AIDS) in the Asian region. It is well known that migrant women have more exposure to sexual and reproductive health risks and low clinic attendances for preventive community health when compared to women of similar socio-economic status in their host


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Accessing healthcare services and sexual health risk

at a Non-Governmental Organisation (NGO) where outreach and research took place by the researchers (Wong, Wun, Chan, & Liu, 2008), only 35.5% of the women reported having had a cervical smear.

The combined effects of conditions in Mainland China that gave rise to migration, and the resultant legal and health polices in Hong Kong, contribute to a multiplicity of sexual health risks in particular for migrant female sex workers (FSW) (Pun, 2003). A considerable proportion of the FSW that the authors surveyed suffered from a number of non-sexual health related illnesses. However, medical consultation rate was only a third of the mean rate of the general population in Hong Kong (Wong, Grey, Ling & Holroyd, 2006b). From the same series of studies, many women professed difficulty in utilising health services in Hong Kong and only doing so for severe or acute health concerns. The women felt excluded from mainstream public health services, describing feelings of shame, stigmatisation and public blame. In addition, many women found private healthcare services unaffordable. It was common therefore for these women to self-medicate, delay seeking medical help, or travel back to China for more affordable health care. For example, of the 245 FSW screened

Heightened vulnerability and barriers to attending health services Using the World Health Organisation Quality of Life scale, a study found that migrant street FSW scored significantly lower in physical, psychological and environmental health measures when compared to non-sex workers of the same age and gender groups in Hong Kong (Wong et al., 2006a; Wong & Wun, 2003). These FSW were found to be poorly educated and had crossed the Chinese border to work in Hong Kong for economic reasons. Many women worked long hours with most of their income going back to China to support their dependents with relatively little money spared for themselves. Table 1 presents the working condition of these FSW (Holroyd, Wong, Grey & Ling, 2005).

Table 1: Working conditions of street FSW in Hong Kong (Holroyd et al., 2005) (n=89) Decision of how long to work by FSWs Self Decided by clients Employerâ&#x20AC;&#x2122;s decision Flexible(no fixed pattern) Health Maximising the income Others Experience of dangerous working conditions by FSWs* Beaten by clients Not paid by clients Raped by client Robbed by clients Verbally abused by clients ID check Pressured to sign Refused bail Photographed by police Insulted by a passer-by Chatted with a passer-by Number of dangerous working experiences 0 1 2 >2 Avoidance of being arrested by FSWs* Stop working temporary Assign someone as a watch dog No method Old clients Be careful * Respondents could check more than one option




64 6 1 11 2 1 4

72 7 1 12 2 1 5

7 18 3 14 10 47 3 1 1 11 21

8 20 3.4 16 11 53 3 1 1 12 24

28 29 13 19

31 33 15 21

74 1 12 1 1

83 1 14 1 1

Singapore Nursing Jour nal

and community nursing services for migrant populations who are at risk.

Furthermore, some migrant FSW had a negative image about themselves and felt life to be meaningless when compared to their original status in China as mother, daughters and sisters, an experience commonly felt by new migrants in Hong Kong (Pun & Wu, 2004; Zheng, 2009). Indeed, a large number of respondents in many studies had experienced violence, robbery, and verbal insults when working in Hong Kong. At the same time, they felt that they lacked protection from the police and the ability to report crimes that occurred within the workplace or in the streets without the risk of criminal charges or deportation due to their illegal working status (Kong & Zheng, 2003; Kong, 2006).

Information on the health needs of the rapidly growing migrant population in Hong Kong and South East Asia region is largely unknown. Thus gathering targeted data to establish health indicators in this area is urgently needed. Such data and the interpretation of such data will enable policymakers to make well informed decisions and to tailor appropriate interventions. There is a clear need to have greater multisectorial collaboration with formal health care services, NGO’s and advocacy groups and migrant women themselves in both service provision and research.

However, there is evidence indicating that these women were capable of exercising power and agency and acting autonomously on the job. Many women reported being free to refuse a client and to choose their work hours, including the number of days and hours they worked (Holroyd et al., 2005). Some women testified to their ability to successfully protect themselves from the dangers and hazards such as HIV and other STIs, as well as police and public harassment (Wong et al., 2006b). While highly aware of the threat of sexually transmitted diseases from unprotected sex and of potentially violent clients, they adopted personalised risk avoidance strategies (Ling, Wong, Holroyd, & Grey, 2007). These strategies included refusing a customer, networking with other street-based women from China when police were presented, insisting that a customer pay before having sex or asking a customer to shower first and thereby remove their clothes to lessen the likelihood of running away and refusing payment (Holroyd et al., 2005). The authors’ study findings suggest that to help these women, there is a need for a more nuanced and in-depth understanding of the simultaneous individual and structural constraints (e.g. gender, familial, social, economic, and legal) in which women make choices about engaging in and negotiating power in the sex industry.

Based on the present evidence about migrants’ characteristics and current health and migration policies, the authors propose to develop new community health nursing service delivery models, to increase public awareness about the positive aspects of migration, to implement interventions that tackle specific health determinants which focus on health promotion, risk prevention and health care for migrant women. Nurses play an important role in health promotion and disease prevention. To be better equipped to meet healthcare challenges, the authors recommend the development of postgraduate community nursing specialist programmes in Singapore. The curriculum of the programmes need to include components that target migrant women’s health, sexual health and the social determinates of health, as well as community based interventions. In addition to public health policies that promote free health access for migrant workers, stigma-free health service and choices such as well-women clinics, nurse-led community health initiative and outreach services and NGO-run clinics could be considered. Community based specialist nurses with sexual health knowledge as part of their postgraduate curriculum could be involved in clinical skills that include complex history taking, physical and psychosocial examination and assessment. They could conduct screening and diagnostic testing (including Pap smears) and interpret pathology results. The management of infections and hepatitis vaccination programmes, contraceptive management and counselling (sexuality in relationships, infections, contraception and men/women’s health issues) would also be a part of community nurses’ regular service in sexual health promotion. Community nurses could conduct contact tracing and coordinate drug trials. Their role could also include the management of education and health promotion programmes for health professionals and the community.

Studies reported FSW believed their work provided a source of income despite the imminent threat of HIV, STI and police arrest or intimidation. What was apparent was the women’s ability to financially and economically become self-sufficient when compared to their earning capacity and status back home (Holroyd et al., 2005; Ling et al., 2007). A study in Hong Kong (Holroyd et al., 2005) found that women reported feeling empowered at being able to manage their income, pay their bills, educate their children and provide money to parents which is in common with another study undertaken at Mainland China (Choi & Holroyd, 2007; Zheng, 2009). For health and social policy service interventions to be successful, it is crucial to draw on distinctive cultural, social, economic and demographic population characteristics of migrants that includes important social determinates perspective. Policy must be able to address the barriers of accessing to acceptable and non-stigmatising health care services. It is also necessary to understand the health and social perceptions, knowledge and beliefs of these migrant women in order to develop meaningful public health interventions

Conclusion In this paper, the authors analysed evidence on migrant Chinese women’s sexual health. Both in Hong Kong and elsewhere in Asian countries possibly including Singapore, female migrants of lower socio-economic status who engage in sex work are excluded from mainstream health services, so constituting a high risk category for both sexual and non24

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sexual health concerns. These processes further reinforce the opinion that these women come to occupy marginal positions analogous to that of a minority ethnic group. Many of the FSW in the reported studies had limited ability to self-assess their health risks, thus delayed uptake of screening services or led to late presentation of health symptoms. Based on the analysis, the authors made a number of recommendations which address sexual health for FSW that may have applicability to Singapore.

Ling, D. C., Wong, W. C. W., Holroyd, E. A., & Gray, A. (2007). An exploration of psychological health and suicidality among female street sex workers. Journal of Sex and Marital Therapy, 33, 281-299.

A service approach that develops and centralises the role of the community nurse in advocating for the rights and heath needs, as well as service provision for migrant women would serve to address their health need. The authors further contend that the development of advanced specialist community nurses would complement the bio-medical public health delivery model that exists in Singapore today.

Pun, N., & Wu, K. M. (2004). Lived citizenship and lower-class Chinese migrant women: A global city without its people. In A.S. Ku, & N. Pun (Eds.), Remaking citizenship in Hong Kong: Community, nation and the global city (pp. 139-154). Oxford: Routledge Curzon.

Liu, H., Xie, J., Yu, W., Song, W., Gao, Z., Ma, Z., & Detels, R. (2004) Liudong renkou de shengzhi jiankang fuwu’ (Migrants’ reproductive health services). Renkou Yanjiu (Population Research), 25(5), 92–96. Pun, N. (2003). Subsumption or consumption? The phantom of consumer revolution in “globalizing” China. Cultural Anthropology, 18(4), 469-92. Pun, N. (2005). Made in China: Women factory workers in a global workplace. Durham & London: Duke University Press.

Solinger, D. (1999). Citizenship issues in China’s internal migration: Comparisons with Germany and Japan. Political Science Quarterly, 114 (3), 455-478. Wong, W.C.W, Holroyd, E. (2011). Stigma and sex work: From the prospective of female sex workers in Hong Kong. Sociology of Health and Illness, 33, 50-65.

References Anderson, B. ( 2007). Exploring demand for migrant domestic workers. European Journal of Women Studies, 14, 247-264.

Wong, W. C. W., Holroyd, E., Ling, D., & Grey, A. (2006a). Patterns of health care utilization and health behaviors among street sex workers in Hong Kong. Health Policy, 77(2), 140–148.

Choi, S., & Holroyd, E. (2007).The influence of poverty, power and agency on condom negotiation among female sex workers in Mainland China. Culture, Health and Society, 9(5), 489–503.

Wong, W. C. W., Grey, A., Ling, D. C., & Holroyd, E. (2006b). Female street sex workers in Hong Kong: Moving beyond sexual health. Journal of Women’s Health, 15(4), 390-397.

Holroyd, E., Wong, W., Grey, A., & Ling, D. (2005). Working the streets across the border: The occupational health of Hong Kong’s Mainland Chinese migrant sex workers. Journal of Comparative Asian Development, 3(2), 235–248.

Wong, W. C. W., Leung, P. W. S., Lynn, H. S. Y. (2011). Sexually transmitted infections among female sex workers in Hong Kong: The role of migration status. Journal of Travel Medicine, 18, 1-7. Wong, W. C. W., Wun, Y. T. (2003). The health of female sex workers in Hong Kong: Do we care? Hong Kong Medical Journal, 9, 471-473.

Jacka, T. (2006). Rural women in urban China: Gender, migration, and social change. New York: M.E. Sharpe. Kong, T. S. K., & Zheng, T. (2003). A research report on the working experiences of Hong Kong’s female sex workers. Hong Kong: Hong Kong Polytechnic University.

Wong, W. C. W., Wun, Y. T., Chan, L., & Liu, Y. (2008). Silent killer of the night: A feasibility study of an outreach well women clinic for cervical cancer screening in sex workers in Hong Kong. International Journal of Gynecological Cancer, 18, 110- 115.

Kong, T. S. K. (2006). What it feels like for a whore: The body politics of women performing erotic labour in Hong Kong. Gender, Work and Organization, 13(5), 409-434.

Zheng, T. (2009). Red lights: The lives of sex workers in postsocialist China. Minneapolis: University of Minnesota Press. Zheng, Z. & Lian, P. (2005, July). Health vulnerability among temporary migrants in urban China. Paper presented at the XXV International Population Conference, Chinese Academy of Social Sciences, PR China.


Singapore Nursing Jour nal


Book Title: Prescription for excellence: Leadership lessons for creating a world-class customer experience from UCLA Health System Author: Joseph A. Mitchelli (2011) New York: McGraw Hill ISBN:978-0-07-177354-6


The vision statement “Healing humankind, one patient at a time, by improving health, alleviating suffering, and delivering acts of kindness” is linked inextricably to the values of integrity, compassion, respect, teamwork, excellence, and discovery. A framework is built to solicit the staff’s commitment to caring with this statement: “I will always keep my commitment to care, as I have been entrusted by patients, colleagues and society.”

This book draws on the customer experience in healthcare and offers insights for healthcare professionals to deliver the care needed by their clients, as well as hints for healthcare leader to build a caring team. It is truly worthwhile to invest some time reading and jotting down the many Diagnostic Checkup lists distributed in every chapter. The Prescriptive Summary recapping the journey through each chapter makes reading this book a joyful experience.

CICARE Specific communication behaviours were highlighted through a template called CICARE (pronounced See – I – Care). CICARE is an acronym for actions that include:

This is a book which you can choose where to start depending on your immediate area of interest. The 11 chapters address issues close to the heart of any healthcare worker who is looking for ways to enhance their standard of care, and articulate the following five principles:

• Connect with the patient of family member using Mr./Ms. or their preferred name. • Introduce yourself and your role. • Communicate what you are going to do, how it will affect the patient, and other needed information. • Ask for and anticipate patient and/or family needs, questions or concerns. • Respond to patient and /or family questions and requests with immediacy. • Exit, courteously explaining what will come next or when you will return.

Principle 1: Commit to care Principle 2: Leave no room for error Principle 3: Make the best better Principle 4: Create the future Principle 5: Service serves us The acknowledgments given by the author epitomises the following statement in the Foreword of the book: “I’ve appreciated a spirit of collegiality that enables our talented people to bring innovation to life.” A. Eugene Washington, MD, MSc, Vice Chancellor, UCLA Health Sciences, Dean, David Geffen School of Medicine at UCLA

“By appealing to our humanity and reasons we came into nursing, CICARE gave us a way to talk to one another about what we all wanted.” The CICARE approach to service excellence draws out behaviours that were already in healthcare professionals.

The CEO of UCLA Hospital System, Dr David Feinberg, MD, MBA, inserted the “face of the patient” into every business discussion at UCLA by starting every meeting with a patient story. Connecting face-to-face with patients and their families make people realise that “there are real persons in our beds who have something valuable to share with us every day.” Informal processes of listening evolved into systems that “increase the consistency of delivery and ardently solicit the voice of the patient.”

PCAT This book vividly describes how the leaders make the “management rounds” with patients using PCAT “Peer CICARE Assessment Tool”. All managers come together and visit assigned areas of the hospital, and they ask standardised questions to patients. The managers then come together and discuss the information they acquired. This exercise helps 26

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support for the client. Healthcare managers who attentively and continually seek to understand the values and drivers of their people often have the most engaged staff members, who, in turn, actively seek to “know” their customers.

managers break out of the mould of simply fixing problems and puts them in a place where they are listening to customers throughout the hospital. Patients welcome the opportunity to talk about their care experience and the audits are win/ win/win. The patients benefit, the resident benefits, and as interviewers, the managers get a lot out of this opportunity. Quality healthcare has to do with simple communication skills that can be overlooked if we do not take a disciplined approach to communication that has therapeutic value. Examples of CICARE in everyday interactions include: knocking on a door before you enter a room, introducing yourself, and asking permission before you touch or intrude on a patient. The CICARE is based on a fundamental understanding that service must come from a place that honours dignity. Leaders need to “model genuine caring that affirms the integrity of those we serve and encourage them to do the same with one another and with their patients.”

Once people feel valued, viable acts of problem resolution can be explored. Every day, we have the opportunity to strengthen our relationships with colleagues and customers by listening to them and helping them see the power that comes from “knowing”.

Being with as a form of service The ability to be presented with patients in a time of need is what distinguishes professional caregivers from those who simply transact medicine. Most service comes to your presence during an important life event and how much that means to the person served. Patients remember your being there.

George Washington Carver said: “How far you go in life depends on your being tender with the young, compassionate with the aged, sympathetic with the striving and tolerant of the weak and strong. Because someday in your life you will have been all of these.”

Read about the familiar “Doing For As A Form Of Service”; less familiar “Enabling As A Form Of Service”, timeless “Unrelenting Pursuit Of Service Excellence”; timely reminder that “Recognition Begets Recognition At All Levels” and many other engaging stories illustrating Principle 1: Commit to Care.

Since business is personal, focus on relationships Given the pace, paperwork, crises, and technology of medicine, care professionals are at risk of losing their focus on caring relationships and are vulnerable to becoming task-oriented instead. To avert these unwanted outcomes, the leadership must create opportunities and guidance for reaffirmation and a rekindled sense of hope.

“A leader is one who knows the way, goes the way, and shows the way.” John Maxwell “A life is not important except in the impact it has on other lives.” Jackie Robinson

Action by you

Maintaining a positive belief is not always about recovery from an illness, but it involves a belief in the individual or family’s ability to address life-or-death issues with comfort – positivity to find peace and meaning in the illness experience. Relationship-based care starts with a belief in the worth and dignity of others.

Convinced that the book deserves your attention? You can borrow it from the National Library of Singapore or purchase your own copy to peruse at your own leisure. After reading the book, take the time to make a written commitment. Through steadfast execution of that plan, you will elevate your service one customer at a time.

Knowing as a form of service The great end of life is not knowledge but action.

To establish helping relationship with a client, the healthcare professionals are alert of unstated needs and offer timely


Singapore Nursing Jour nal

InterGrAtIOn OF SImuLAtIOn-bASeD LeArnInG In tHe nurSInG PrOGrAmme: A reFLectIOn LIAW Sok Ying Senior Lecturer Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine National University of Singapore Correspondence address: LIAW Sok Ying Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive 1, Singapore 117597 Tel: (65) 65167451 Email:

Abstract The use of simulation as an educational tool has increasingly received much attention in nursing education. This article describes the integration of simulation-based learning at all levels in a Bachelor of Science (Nursing) programme in a local university with the aims of deepening students’ learning, integrating the clinical skills that students have learnt, facilitating the transition from classroom to clinical practice, and promoting patient safety in acute care. Key words: Simulation; Nursing Education; Learning


of the students remain in a room to observe the scene through live video streaming. The facilitator plays different roles in the scenario. At the start of a session, he/she often acts as the morning staff nurse calling the afternoon team nurses to receive their handover reports. Through the reports, students come to know the case history of the simulated patient and familiarise themselves with the patient’s documents such as clinical charts and inpatient medication records, which the students are expected to review in order to manage the case effectively. During the simulation, the facilitator may assume the doctor’s role to facilitate the simulation’s progress. By participating in the role play, the facilitator is able to control how the simulation progresses and provide cues to the team to enhance the realism of the simulation.

The emergence and expansion of computer technology has led to the development of innovative educational tools for health professionals such as simulation technology and patient simulators. A patient simulator places the learners in a realistic simulated environment that allows the students to apply their skills and knowledge to solve real life problems. Simulation-based learning has been incorporated into the undergraduate nursing programme at National University of Singapore (NUS) since 2007 to enhance students’ learning. This teaching methodology is used at several levels of the undergraduate nursing course, from simple to complex scenarios involving the development of cognitive, technical and teamwork skills. Part of the information in this paper has been published in Liaw (2011).

The use of a variety of teaching strategies can enhance learning by capitalising on the differences in learning needs and styles (Penn, 1996). Simulation technology incorporates a variety of teaching strategies to teach students about the real world of nursing. These strategies include using cases, role playing, observing the simulated role play and reviewing video clips of simulated sessions. Simulation-based learning, which employs a variety of teaching strategies, can accommodate students’ diverse learning styles (Jeffries, 2002). Visual and auditory learners can benefit from observing students’ participation in clinical situations during the role play. The kinesthetic learners, who prefer to learn through hands-on manner, will benefit from the role play that involves the demonstration of nursing skills during the simulation (Comer, 2005).

Role playing in a simulated scenario creates opportunity for the students to become immersed in a realistic environment. Assuming the role of another person through acting requires the student to participate actively (both mentally and physically) in the learning process (Nikendei et al., 2005). By immersing themselves in the role of the nursing staff, students gain valuable insights on how their skills and knowledge are relevant to their field of work. During the role play, the participants interact with one another to make decisions on appropriate nursing interventions. Although not as engaged as participants involved in the role play, the observers learn by watching the live video of the simulated role play. The real time visual experiences provide the observers with valuable clinical learning experiences. Wannan and York (2005) reported that students’ knowledge could be acquired either by watching a video or role play.

For each simulation session, four to five students from the group are asked to participate in the role play, while the rest

The students are usually involved in a simulated scenario lasting no longer than 20 minutes. This is followed by a

Deepening Students’ Learning


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Facilitating the transition from classroom to clinical Practice

debriefing session in which all students (both participants and observers) are engaged in a discussion after reviewing the video recording of the scenario. During the discussion, students learn through reflection, group interaction and questions from the facilitator. Reviewing the video provides students with the opportunity to re-visit their actions and therefore, assists them in evaluating their own performances (Rhodes & Curran, 2005). During the debriefing session with the simulator instructor, students share their experiences in the role play, critique their own or other students’ actions and discuss the appropriate actions to be taken in a real clinical situation. In addition, the facilitator engages the group in discussing the main issues by questioning and reviewing the video recording for significant events. The group discussion allows the students to re-evaluate their experiences with the facilitator and peers. The use of group discussion engages students in reflective learning as it enables the group members to consider a situation from multiple perspectives and consider other alternatives (Mezirow, 1981).

Although clinical skills laboratory are incorporated into the contemporary nursing modules to help students acquire psychomotor skills, it remains a challenge for nursing students to transfer these skills to real clinical practice. It may be possible that students lack retention of what they have learnt. Though clinical skills laboratory lessons are conducted on campus, it may be months after the session before a student nurse has a chance to apply it during his/her clinical placement. Moreover, a single skill training episode is unlikely to provide adequate preparation for skills performance (Kneebone, Scott, Darzi & Horrocks, 2004). The simulation facilitates laboratory skills practice in a ‘real’ clinical setting. The opportunity to participate in a simulation after clinical skills laboratory allows students to engage in repetitive practice. Repetitive practice is crucial for clinical skill acquisition as it makes skill demonstration effortless and automatic (Issenberg, Mcgaghie, Petrusa, Lee, & Scalese, 2005). Kneebone et al. (2004) highlighted the importance of placing simulation alongside clinical practice and the use of regular simulation to consolidate skills.

Integrating the clinical Skills that Students Have Learnt Nursing students undertake modules on contemporary nursing throughout the 3-year nursing course to develop their nursing skills and knowledge in caring for patients with various medical and surgical conditions. These modules are taught using a variety of teaching strategies such as lectures, laboratory sessions, problem-based learning (PBL) and simulation-based learning. While students can gain clinical knowledge through the lectures and PBL sessions, and acquire psychomotor skills through laboratory sessions, simulation-based learning, which is implemented at the end of the module, helps students integrate the skills and knowledge that students have learnt together, thus bridging the gap between theory and practice.

The transition from classroom to clinical practice is often associated with anxiety and uncertainty among nursing students particularly in their first clinical posting. White (2003) reported that the lack of confidence to perform a nursing skill could cause the student to be anxious about making mistakes. The implementation of simulation before a clinical practicum provides opportunities for nursing students to practice their clinical skills in a non-threatening environment. Students’ anxiety level would be reduced as the simulated ward environment removes the learners’ fear of harming a real patient. This will promote meaningful learning as the threats to self will be lower compared to the real clinical setting (Murray, Grant, Howarth & Leigh, 2008).

Through weekly laboratory sessions in the contemporary nursing module, students would have acquired a set of clinical skills. For example, after the contemporary nursing module, students are expected to have learnt a set of clinical skills related to respiratory procedures (e.g. application of pulse oximetry, administering oxygen therapy, performing lung auscultation and suctioning). The case scenario of a patient with breathlessness is used during simulation to allow the students to review and practise their clinical skills as a whole. This integration of clinical skills enables the students to perceive the relationship between various nursing skills in patient care.

Another challenge students face involves the transition from the relatively calm clinical laboratory to the fast paced clinical setting (Olesinski, Brickell, & Pray, 1998). Nurses need to know how to respond quickly to provide the patients with appropriate care in the clinical setting (Nolan, 1998). Clinical practice demands a highly complex combination of knowledge, skills and professional judgment which cannot be adequately acquired through laboratory teaching alone. The simulation, which incorporates clinical scenario, provides a complex clinical situation that helps students to develop cognitive, psychomotor and affective competencies.

Besides bringing all the clinical skills together, simulation enables the students to apply their theoretical knowledge across different nursing modules. During the simulation, students are required to apply their clinical reasoning skills in assessing a patient’s condition, and make clinical decisions to plan, implement and evaluate the nursing actions to manage his/her problem. The simulation scenario enables students to think critically, develops their decision making skills and provides them with opportunities to apply the theoretical knowledge which they have gained from various sources to patient management.

Promoting Patient Safety in Acute care An aging population and advanced medical care has made training in acute care and patient safety a priority for nursing education. Studies have shown that the majority of cardiac and respiratory arrests are preceded by observable warning signs that indicate the deterioration of the patient’s condition (Goldhill, White, & Summer, 1999; McQuillian et al., 1998). However, these warning signs and symptoms, frequently undetected, worsen morbidity and mortality (Goldhill 29

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conscious level) are used in the simulation programme. The module’s learning objectives are to help nursing students acquire assessment skills in detecting signs of deterioration, apply their knowledge to interpret the assessment findings, initiate immediate life-saving actions and communicate the patient’s situation to the doctor effectively.

& McNarry, 2004). Gibson (1997) stated that the ward nurses, often the first ones to encounter a patient’s clinical deterioration, were in the best position to provide early recognition and intervention. Thus, the emphasis should be on training the nurses to identify those who are deteriorating, and to utilise their knowledge to evaluate the assessment data and notify the doctor promptly (McArthur-Rouse, 2001). The hospitals in Singapore are implementing crisis courses such as pre-code programme and crisis team management to train ward nurses and doctors to identify and manage acutely ill patients. To enhance current efforts to improve patient safety in acute cure, such educational needs are also addressed in the pre-registration nursing curriculum.

Inter-professional collaboration is identified as an essential means of ensuring safe and effective patient care. The training of inter-professional education through simulation has shown a great deal of promise to prepare future healthcare professionals (Baker et al., 2008). A 3-hour inter-professional simulation course is implemented for the fifth year medical students and third year nursing students (Photo1). The programme is designed to introduce and improve teamwork skills among medical and nursing students on patient care during crisis. During the training, students participate in a series of simulated crisis scenarios with a high fidelity patient simulator. Debriefings are conducted after each simulation by having team members view the video recording and reflect on the team’s behaviours and skills. The Team STEPPS (Strategies and Tools to Enhance Performance and Patient Safety) evidence-based teamwork programme is incorporated into the simulation course to develop students’ teamwork, communication and leadership skills.

Although the clinical laboratory and clinical practicum in the pre-registration nursing curriculum provide invaluable learning experiences for nursing students, exposure to clinical crises cannot be guaranteed during clinical practice. The human patient simulator can capture a variety of patient conditions and create opportunities for learners to manage emergency situations in a planned and prescribed way. One of the major strengths of such high fidelity simulation is that it places the learners in a realistic situation and provides them with opportunities to apply their skills and knowledge for problem solving in a controlled environment without putting patients or others at risk (Beyea & Kobokovich, 2004; Medley & Horne, 2005). This teaching strategy enhances learning, skills and knowledge retention, and subsequently improved advanced cardiac life support outcomes (Scherer, Bruce, Graves, & Erdley, 2003).

Photo 1: Simulation-based interprofessional learning

Simulation is used to develop students’ clinical competency for providing safe, competent, timely and appropriate patient care during crises. A variety of case scenarios progressing from simple to more complex situations are used to expose the students to various clinical crises. In the first year of the nursing course, simulations are implemented using simple case scenarios such as respiratory distress and acute chest pain with the aim of consolidating students’ clinical skills relating to caring for patients with respiratory and cardiovascular disorders. In the second year, simulations are used to expose the students to common medical and surgical crises which include post-operative complications, different types of shock and metabolic conditions.

conclusion Simulation-based learning has been integrated across the undergraduate nursing course at NUS. It aims to deepen students’ learning, enable them to integrate what they have learnt and apply their knowledge to patient care. The simulator’s ability to capture a variety of patient conditions has also created opportunities for students to learn how to manage unexpected emergencies and collaborate with other healthcare teams with the ultimate goal of promoting better patient outcomes. With the development of new simulation facilities and resources in the University, we plan to incorporate more large-scale simulation activities (e.g. simulated ward programme) that involve interprofessional simulation-based learning into the undergraduate nursing curriculum. Furthermore, apart from focusing on simulation

While the simulation-based learning in the first and second years of the nursing course focuses on applying clinical nursing skills to manage acute patient care, in the final year, simulation aims to develop the students’ clinical decision making and teamwork skills in crisis management. To achieve this, we incorporate acute care simulation programme into the module on clinical decision making skills to consolidate the final-year nursing students’ critical care skills as well as to develop their clinical decision-making skills in assessing and managing patient with acute medical emergencies including cardiopulmonary arrest. A series of complex case scenario presenting common deterioration conditions (e.g. airway obstruction, breathlessness, hypotension, oliguria and altered 30

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learning, we are moving forward to developing simulationbased assessment to further enhance nursing competencybased assessment.

Liaw, S. Y. (2011). The integration of simulation into undergraduate nursing curriculum. In Centre for Development of Teaching and Learning (Eds.), Technology in higher education: the state of the art (pp. 94-104). Singapore: Grenadier Press Pte Ltd


McArthur-Rouse, F. (2001). Critical care outreach services and early warning scoring systems: A review of the literature. Journal of Advanced Nursing 36(5), 696–704.

The author would like to thank the Centre of Development of Teaching and Learning at the National University of Singapore for giving permission to the author to reprint this article in the Singapore Nursing Journal.

McQuillian, P., Pilkington, S., Allan, A., Taylor, B., Short, A., Morgan, G., . . . Smith, G. (1998). Confidential inquiry into quality of care before admission to intensive care. British Medical Journal, 316 (7148), 1853–1858. Medley, C. F., & Horne, C. (2005). Using simulation technology for undergraduate nursing education. Educational Innovations, 44(1), 31–34.

references Baker, C., Pulling, C., McGraw, R., Dagnone, J. D., Hopkins-Rosseel, D., & Medves, J. (2008). Simulation in interprofessional education for patient-centred collaborative care. Journal of Advanced Nursing, 64(4), 372–379

Mezirow, J. D. (1981). A critical theory of adult learning and education. Adult Education Quarterly, 32(1), pp. 3–24.

Beyea, S. C., & Kobokovich, L. J. (2004). Human patient simulation: A teaching strategy. AORN Journal, 80(4), 738–742.

Murray, C., Grant, M. J., Howarth, M. L., & Leigh, J. (2008). The use of simulation as a teaching and learning approach to support practice learning. Nurse Educ Pract, 8(1), 5–8.

Comer, S. (2005). Patient care simulations: Role playing to enhance clinical understanding in Nursing Education Perspective, 26(6), 357– 361.

Nikendei, C.;, Zeuch, A., Dieckmann, P., Roth, C., Schäfer, S., Völkl, M., Jünger, J. (2005). Role-playing for more realistic technical skills training. Medical Teacher, 27(2), 122–126.

Gibson, J. M. E. (1997). Focus of nursing in critical and acute care settings: prevention or cure? Intensive and Critical Care Nursing, 13, 163–166.

Nolan, C. A. (1998). Learning on clinical placement: the experience of six Australian student nurses. Nurse Education Today, 18(8), 622–629. Olesinski, R. L., Brickell, J., & Pray, M. (1998). From student laboratory to clinical environment. Clinical Laboratory Science, 11(3), 167–173.

Goldhill, D. R., & McNarry, A. F. (2004). Physiological abnormalities in early warning score are related to mortality in adult inpatients. British Journal of Anaesthesia. 92(6), 882–884.

Penn, B.K. (1996). Learning styles in staff development. In R.S. Abruzzese, Nursing Staff Development: Strategies for Success, pp. 58–70. Philadelphia: Mosby – Year Book, Inc.

Goldhill, D. R., White, S. A., & Summer, A. (1999). Physiological values and procedure in the 24h before ICU admission from the ward. Anaesthesia, 54(6), 529–534.

Rhodes, M. L., & Curran, C. (2005). Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. Computers, Informatics, Nursing, 23(5), 256–262.

Issenberg, S. B., Mcgaghie, W. C., Petrusa, E. R., Lee, G. D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10–28.

Scherer, Y., Bruce, S., Graves, B., & Erdley, W.S. (2003). Acute care nurse practitioner education: enhancing performance through the use of clinical simulation. AACN Clinical Issues, 14(3), 331–341.

Jeffries, P.R. (2002). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96–103.

Wannan, G., & York, A. (2005). Using video and role-play to introduce medical students to family therapy: is watching better than appearing? Journal of Family Therapy, 27(3), 263–271.

Kneebone, R. L, Scott, W., Darzi, A., & Horrocks, M. (2004). Simulation and clinical practice: Strengthening the relationship. Medical Education, 38(10), 1095–1102.

White, A. H. (2003). Clinical decision making among fourth-year nursing students: An interpretive study. Journal of Nursing Education, 42(3), 113–120.


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THE STATE OF NURSING SCIENCE TAN Khoon Kiat Senior Lecturer Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine National University of Singapore Correspondence address: TAN Khoon Kiat Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597 Tel: (65) 9789 8273 Email:

Abstract This paper examines the state of nursing science, by first defining science and nursing science in relation to Carper’s four patterns of knowing (1978). This is followed by a discussion of the state of nursing science, using Boyer’s framework on the discovery, teaching, application, and integration of knowledge (1990). Key words: Nursing Science; Nursing Knowledge; Carper’s Four Patterns Of Knowing; Boyer’s Framework On The Discovery, Teaching, Application, Integration Of Knowledge

What is Nursing Science?

to Daly, nursing science is ‘an identifiable, discrete body of knowledge comprising paradigms, frameworks, and theories’ (Daly et al., 1997, p10), which focuses on ‘phenomena related to human health’ (Takahashi, as cited in Daly et al., 1997, p11), and enhances our understanding of people and health (Toikkanen, as cited in Daly et al., 1997) and it is forever evolving (Barrett, as cited in Daly et al., 1997).

The root of the word ‘science’ is a Latin word ‘scientia’ meaning knowledge (Encyclo-Online Encyclopedia, 2011). The very reason why knowledge can grow and science can progress, as the philosopher Popper (1962) proposed, is because people can learn from their mistakes. In his seminal work on conjectures and refutations, Popper (1962), claimed that conjectures may be formed from observation and experience, but it is through refutation that we learn not to be conceited over our knowledge, and to understand the complexity of problems. Subsequently, we become more informed, and can then suggest better developed solutions, and thus, be nearer to what might constitute the truth. This critical and progressive nature of knowledge is the basis of the rationality of science.

Boyer (1990) categorises knowledge as developed through four separate, yet overlapping domains, namely discovery, teaching, application, and integration. Knowledge is generated through discovery, and through the processes of knowledge transfer at teaching, application in practice, and integration with other knowledge, more knowledge are gained (Smith & Crookes, 2011).

Discovery of Nursing Knowledge

In the nursing arena, Carper (1978) proposed four patterns of knowing, after exploring published articles extensively, on what nurses valued, and used at work. ‘Knowing’ refers to the ways of comprehending the self and the world (Chinn & Kramer, 2008). Carper (1978) noted that besides empirics, the science of nursing, and aesthetics, the art of nursing, there are moral and personal ways of knowing in nursing. She emphasised the importance of balance in each of these fundamental ways of knowing, and that by itself, an individual pattern is insufficient to understand the complexity of nursing.

Nursing knowledge originates from various sources. According to Boyer (1990), the discovery of knowledge adds to the pool of existing knowledge, and contributes to the intellectual culture of a discipline. The discovery of knowledge has evolved over time, for example, practices initially based on trials and errors, and astrology or religious beliefs, have more recently been based on societies’ traditions, group rituals, or intuitive knowledge (Catalano, 2009). Since then, nursing has generated nursing knowledge within the context of sound theories and models (Milton, 2005), which connect concepts relevant to nursing and health, to propose an interpretation of nursing practice (Catalano, 2009; Hickman, 2002). Models illustrating interrelated concepts in a systematic and organised way (Catalano, 2009), such as Roy’s Adaptation Model, Orem’s Self-Care Model, and Neuman’s Health-Care System Model, have four concepts in common: nursing, environment, health, and the individual or collective patient or client (Catalano, 2009).

Nursing science is nursing knowledge. Nursing knowledge is expressed as the science and art of nursing through empirics, arts, ethics, and personal knowing (Carper, 1978), and each way of knowing is shared or communicated, without one particular way of knowing being more important than the others (Chinn & Kramer, 2008). There is agreement that nursing knowledge is formulated in distinct theoretical structures. According 32

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prepares the learners to be more self-directed (Catalano, 2009), become more competent and better prepared to respond to unfamiliar situations appropriately (Watson, 2006), and thus ready for lifelong learning which assures employment and economic success, and active involvement in the society (European Commission – Education & Training, 2010). More recently, in response to the demand for high quality and cost effective healthcare, nurse preparation has evolved and proliferated into different scopes of practice at higher educational degrees, for example, Advanced Practice Nurses and Clinical Nurse Specialists (Blais et al., 2006).

Research is a scientific method of inquiry, which is an important source of nursing knowledge (Brink, 2006). The International Council of Nurses (2009, para.1) defines nursing research as a ‘systematic enquiry that seeks to add new nursing knowledge to benefit patients, families and communities ... (which) applies the scientific approach in an effort to gain knowledge, answer questions, or solve problems’. Both inductive and deductive forms of inquiry are important in the development of knowledge, and the adoption of one or both approaches, depends on the nature of the inquiry (Brink, 2006). Deductive reasoning adopts a more focused approach, reasoning from a broad generalisation to the more specific, and is concerned with testing, or verifying hypotheses (Trochim, 2006). Inductive reasoning, on the other hand, begins with specific observation, and explores the issue in a more open-ended manner, to reach generalisations or new insights (Trochim, 2006).

Since the turn of the 21st Century, the changes in nurse education worldwide, from apprenticeship to supernumerary learning models of nurse teaching and learning, have not compromised authentic learning in clinical settings. Preceptorship and nurse internship programmes for newly prepared nurses, further illustrate the advances in nurse education, In contemporary times, the use of innovative technologies, such as high fidelity patient simulators to complement experiential learning, particularly in clinical reasoning, patient safety and team behaviour, enhance the learning outcomes even more (Nehring & Lashley, 2010), emphasise the importance of transferring multiple forms of knowledge and ways of knowing nursing in practice settings.

Another source of knowledge generation is from doctoral programmes. The primary focus of these postgraduate programmes is the development of knowledge, as the learners are researchers preparing themselves for advanced roles in their respective disciplines. Regardless of whether these programmes lead to Doctor of Philosophy, Doctor of Nursing Science or Nursing Doctorate, their emphasis is primarily similar (Blais, Hayes, Kozier, & Erb, 2006), in generating new and substantially advanced disciplinary knowledge.

In the transfer process of knowledge, existing knowledge is presented and challenged, and this can give rise to new questions and knowledge. The scholarship of teaching is learner-focused, and examines how teaching can help learners gain knowledge more effectively (Allen & Field, 2005). In Boyer’s view (1990), good learning experiences activate learners to be critical and creative thinkers, who will direct their own learning beyond the boundaries of the classrooms, and subsequently, into lifelong learning. The transfer of knowledge, from the teachers to the learners, and vice versa, can occur during the teaching process (Allen & Field, 2005), and among fellow academics (Malinsky, DuBois, & Jacquest, 2010). In the classrooms as well as in the clinical setting, student nurses, newly prepared nurses, nurse educators and preceptors alike, can reflect on their learning needs and improve on the knowledge acquisition and dissemination processes. Publications and conferences can also serve as excellent platforms for the transfer of knowledge. With critical reflection and discussion, these teaching and dissemination processes can help to advance nursing knowledge.

In the practice discipline of nursing, science has progressed markedly, based on research evidence and validated theories, as nurses continue to improve the body of nursing knowledge in scope, quality, and uniqueness (Blais et al., 2006; Catalano, 2009). Research is essential in helping to identify knowledge gaps and promote an ever growing ethos of systematic inquiry.

Teaching of Nursing Knowledge The teaching of nursing knowledge has undergone tremendous changes over the years since the inception of schools of nursing, and the transfer of knowledge centres to tertiary institutions has improved nurses’ knowledge, enhanced the image of nursing, and raised the patient care standards. The nurse training attended by Florence Nightingale (1820 – 1910), for example, was three months long, but this progressed to hospital-based settings, that placed greater emphasis on academic learning (e.g. the Illinois Training School by Isabel Adams Hampton Robb, 1860 – 1910) (Catalano, 2009). By 1965, the American Nurses Association affirmed that the basic level of preparation for nurses should be at baccalaureate qualification, because there was evidence that with better educated nurses, the overall quality of care in hospitals improves (Catalano, 2009).

Application of Nursing Knowledge Knowledge application is necessary to resolve issues that arise in the society generally and disciplines specifically (Boyer, 1990). In 1854, Nightingale applied the knowledge that she had gained from the care of patients with cholera in England, to the care of soldiers in the Crimean War, and subsequently, achieved a reduction of mortality from 42% to 2% in six months (Catalano, 2009). In the last two decades, in response to the need for effective patient-centred care, the concept of practice development has been introduced (Garbett & McCormack, 2002) as a continuous process of clinical improvement (Manley, McCormack, & Wilson, 2008).

Education at higher institutions values the development of critical thinking skills. To think critically requires strong knowledge as a foundation, and the use of reflection, questioning of assumptions, analysis, inductive and deductive reasoning, and evaluation of evidence (Benner, Hughes, & Sutphen, 2008). The acquisition of these cognitive skills 33

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across different disciplines to provide a more comprehensive coverage. This is pivotal, as CPG compiles systematically a set of developed statements to advise patients and practitioners objectively for making decisions on specific clinical conditions (Field & Lohr, 1990; SIGN, 2010).

Also, evidence-based practice (EBP) as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ (Sackett, Rosenburg, Gray, Haynes, & Richardson, 1996), has been adopted as the guiding framework for the application of nursing knowledge. There is a concern that EBP may focus only on empirics, and neglect the other aspects of knowing that are essential for nursing practice, and thus, there is call to value the other forms of evidence for a more holistic practice (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001).

When a part of the system fails, it does not only affect one part, it also hampers the functioning of the whole, according to the General System Theory (Catalano, 2009). Knowledge integration through collaboration among various disciplines is crucial in the effective resolution of a problem. As early as mid 20th Century, Bode, Mosteller, Tukey, and Winsor (1949) noted: ‘Science itself shows the same growing complexity ... At all levels, decisions must be made which involve consideration of more than a single field ... We need a simpler, more unified approach to scientific problems ...’ (p.553). Early work in collaboration noted that it motivates the team to think creatively, and to take calculated risks to achieve increased productivity (Austin & Baldwin, 1992). Across disciplines collaboration can also generate more knowledge, and promote faculty development, as the teams work together to integrate their diverse interests and scientific paradigms (Thompson, Galbraith, & Pedro, 2010). Because of the role boundaries of units, disciplines, or professions, collaboration may be absent in education, clinical practice, or research fields. Without collaboration across disciplines, it is hard to achieve learner-centred education and patient-centred care (D’Amour & Oandasan, 2005). Hence, it is important to promote knowledge integration and effective collaboration across disciplines via the implementation of inter-professional education (Barr, 2001) and in the organisation of collaborative research activities and healthcare practices (Molyneux, 2001; Xyrichis & Lowton, 2008). Rolfe (2010) asserted that nursing research has been including professionals from other disciplines, but their involvement has often been limited. Rolfe (2010) suggested that a team should adopt a transdisciplinary approach to researching healthcare problems rather than solely nursing research, cross professional boundaries beyond individual disciplines, and contribute collaboratively to the creative inquiry process.

Besides the application of knowledge in nursing actions towards the actual care of patients and clients, nurses have also applied their knowledge towards the formulation of care delivery frameworks and have informed health policies. For example, with the aim of enhancing the quality of care through the improvement of patient outcomes as a driving force, Karen Zander and Kathleen Bower in the mid 1980s, translated processes used in the aviation and construction industries into case management, and subsequently, into clinical pathways (as cited in Vanhaecht et al., 2006), and these were mainly used in the acute hospital setting (Vanhaecht, Panella, van Zelm, & Sermeus, 2010). In the community care arena, in the early 21st Century, Nurse Kate Lorig, with a team of doctors, developed a self management model of care. Her contribution towards nursing knowledge in chronic disease self management programmes, has improved clients’ health, and reduced use of health services and healthcare costs (Agency for Healthcare Research and Quality, 2002; Bodenheimer, Lorig, Holman, & Grumbach, 2002; Lorig, Sobel, Ritter, & Hobbs, 2001). These care frameworks were adopted by several health ministries and have become the focus of many research projects; they have inspired the generation of more nursing knowledge towards the care and quality of life for many people.

Integration of Nursing Knowledge Boyer (1990) described knowledge integration as making sense of original research, synthesising the understandings, and bringing new insights into larger intellectual patterns within and beyond, the discipline of study. Nursing knowledge is integrated, sometimes across the healthcare disciplines, in order to care for people better. Systematic reviews and metaanalyses are excellent examples of scientific activities that integrate knowledge within a discipline to gain new insights that can inform decision-making (Mulrow, 1994). Mulrow and his peers’ work on systematic reviews has been extended into nursing, notably by The Joanna Briggs Institute since 1996 and subsequently, also by Cochrane Nursing Care Field. High healthcare expenditure and doubts over the efficient use of the limited resources spurred the interest in clinical practice guidelines (CPG) development in the USA (Field & Lohr, 1990). In 1993, the precipitating reason for the same movement in Scotland was the wide variation in practice and outcomes (Scottish Intercollegiate Guidelines Network (SIGN), 2010). Evidence-based CPG stands apart from consensus-based CPG, because it is derived from systematic reviews, rather than expert opinions (SIGN, 2010). CPG often integrates evidence

Conclusion Nursing science has made remarkable progress in its relatively short history of over 110 years. Nursing has generated a body of knowledge unique to its profession, and at the same time begun working collaboratively to integrate nursing knowledge with other disciplines, in order to achieve learnercentred education and patient-centred care. Nurses have challenged the empirical approach to EBP and proposed a more holistic practice. Nurses continue to research their discipline using both deductive and inductive stances of inquiry, initiate systematic reviews beyond the science of knowing to the other aspects of knowing, and develop, implement, and evaluate CPGs to provide holistic care. In the process, nursing science progresses exponentially, as new conjectures are generated and contested, and verified or refuted in the course of knowledge transfer, application, and integration. The constant seeking of nursing science to 34

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be nearer to representations of many forms of truth, serves to promote the health and well-being of the people for whom nurses care.

Garbett, R., & McCormack, B. (2002). Focus. A concept analysis of practice development. NT Research, 7(2), 87-100. Hickman, J. S. (2002). An introduction to nursing theory. In J. B. George (ed.), Nursing theories: The base for professional nursing practice (5th ed.) (pp. 1-20). Upper Saddle River, NJ: Prentice Hall.


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Malinsky, L., DuBois, R., & Jacquest, D. (2010). Building scholarship capacity and transforming nurse educators’ practice through institutional ethnography. International Journal of Nursing Education Scholarship, 7(1), Article 33. doi: 10.2202/1548-923X.1948.

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Manley, K., McCormack, B., & Wilson, V. (2008). Introduction. In K. Manley, B. McCormack, & V. Wilson (Eds.), International practice development in nursing and healthcare (pp1-16). Singapore: Blackwell.

Benner, P., Hughes, R. G., & Sutphen, M. (2008). Clinical reasoning, decision making, and action: Thinking critically and clinically. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from NBK2643/

Milton, C. L. (2005). Scholarship in nursing: Ethics of a practice doctorate. Nursing Science Quarterly 18(2), 113-6. Molyneux, J. (2001). Interprofessional teamworking: What makes teams work well? Journal of Interprofessional Care, 15(1), 29-35.

Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2006). Professional nursing practice: Concepts and perspectives. (5th ed.), New Jersey: Pearson Prentice Hall.

Mulrow, C. D. (1994). Systematic reviews: Rationale for systematic reviews. British Medical Journal, 309(6954), 597. Nehring, W. N., & Lashley, F. R. (Eds.). (2010). High fidelity patient education in nursing education. Sudbury, MA: Jones & Bartlett.

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Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. JAMA, 288(19), 2469-75.

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Singapore Nursing Jour nal

InforMAtIon for AuthorS Aims and Scope

(a) Reference to a journal article: Chan, S. (2010). Family caregiving in dementia: The Asian perspective of a global problem. Dementia and Geriatric Cognitive Disorders, 30, 469-478. (b) Reference to a book: Ferrell, B. R., & Coyle, N. (Eds.). (2006). Textbook of palliative nursing (2nd ed.). New York: Oxford University Press. (c) Reference to a chapter in a book: Carver, K., & Marshall, P. L. (2010). Associate degree nursing education. In W. M. Nehring, & F. R. Lashley (Eds.), High-Fidelity Patient Simulation in Nursing Education (pp. 211-232). Massachusetts: Jones & Bartlett. (d) Journal article – academic / scholarly (electronic version) with DOI: Paice, J. A., Ferrell, B. R., Virani, R., Grant, M., Malloy, P., & Rhome, A. (2006). Graduate nursing education regarding end-of-life care. Nursing Outlook, 54(1), 4652. doi:10.1016/j.outlook.2005.04.003 (e) Journal article – academic / scholarly (electronic version) with no DOI: Manley, K., Hardy, S., Titchen, A., Garbett, R., & McCormack, B. (2005). Changing patients’ worlds through nursing practice expertise: Exploring nursing practice expertise through emancipatory action research and fourth generation evaluation. (Research Report, 1998–2004). London: Royal College of Nursing. Retrieved from (f) Government Report (Corporate Author): U. S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. (2003). Managing asthma: A guide for schools (NIH Publication No. 02-2650). Retrieved from asth_sch.pdf (g) General Report (Corporate Author): American Psychological Association, Task Force on the Sexualization of Girls. (2007). Report of the APA Task Force on the Sexualization of Girls. Retrieved from (h) Conference Paper: Muellbauer, J. (2007, September). Housing, credit, and consumer expenditure. In S. C. Ludvigson (Chair), Housing and consumer behavior. Symposium conducted at the meeting of the Federal Reserve Bank of Kansas City, Jackson Hole, USA. (i) Unpublished Thesis or Dissertation: Mehta, K. (1995). The dynamics of adjustment of the very old in Singapore. (Unpublished doctoral dissertation). National University of Singapore, Singapore. (j) Reference citations in the text should give the name of the authors followed by the year of publication in parentheses. Please refer to Table 1:

The Singapore Nursing Journal (SNJ) is the official journal of Singapore Nurses Association. Published quarterly, the SNJ is a peer-reviewed journal which provides a forum for publication of professional papers in the areas of nursing practice, research and education. Our readership has a broad range of backgrounds, interest, and specialisation. Manuscripts selected for publication will therefore have some special quality that gives them relevance both to specialists and to the more general readers.

Acceptance Criteria Criteria for acceptance of manuscripts by SNJ include: the originality and timelines of the scholarly endeavour; the quality, clarity, and readability of the manuscript; and relevance of information. The revision and recommendation process may need to occur several times before a manuscript is accepted for publication.

Submission of Manuscripts We invite you to submit manuscript(s). Please send electronic submission via email to: Manuscripts should be submitted in English, typed in 12-point Arial, double space throughout with 2 centimetres margins on all sides within 8-10 pages in A4 paper and should be prepared as follows: 1. A structured abstract and keywords should be included. 2. The first page should be a title page that carry the title (in capital letters) of the manuscript, names, designation, and institutional affiliations of all authors; name, postal address, contact phone number and email address of the corresponding author; and a running head of no more than 50 characters. 3. The second page should contain the title and a structured abstract of no more than 200 words. A maximum of five key words or phrases should be included after the abstract. 4. The text should start from the third page followed by references. 5. Tables and figures should be on separate pages and their desired positions in the text should be indicated. The font of table title and table content should be in 10-point Arial, single space. 6. Graphic should be of a minimum 300 dpi resolution. 7. All pages should be numbered consecutively in the top right hand corner, beginning with the title page. 8. British English should be used. 9. Each manuscript should include not more than 40 references. They should be typed double space and in full starting on a separate page, and listing according to the alphabetical order of the last names of the authors.


Volume 38, No. 4, October - December 2011

table 1: In-text Citation Type of Citation

First citation in text

One work by two authors One work by three to five authors

Walker and Allen (2004) Walker and Allen (2004) (Walker & Allen, 2004)

One work by six or more authors Groups (no abbreviation) as authors

Edvardsson, Sandman, Nay, and Karlsson (2008) Wasserstein et al. (2005) University of Pittsburgh (2005)

Subsequent citations in text

Parenthetical format, first citation in text

Parenthetical format, subsequent citations in text (Walker & Allen, 2004)

Edvardsson et al. (2008) (Edvardsson, Sandman, (Edvardsson et al., Nay, & Karlsson, 2008) 2008) Wasserstein et al. (2005) University of Pittsburgh (2005)

(Wasserstein et al., 2005) (University of Pittsburgh, 2005)

(Wasserstein et al., 2005) (University of Pittsburgh, 2005)

review of Manuscripts

This journal draws references from the editorial style of the 2010 Publication Manual of the American Psychological Association (6th ed.). Washington, D.C.. Authors are advised to consult it in preparing their manuscripts.

Authors are responsible for checking the accuracy of material as it appears, including all references. Manuscript is reviewed with the understanding that neither the manuscript nor its content has been published or is under consideration by other journals.

10. Authors are responsible for all statements made in their work, and for obtaining permission from copyright owners if they use illustrations, or lengthy quotes that have been published elsewhere.

Decisions for publication are based on the reviews. No manuscript will be returned to the author. The Singapore Nursing Journal reserves the right to edit all manuscripts for editorial accuracy style and space requirements and to clarify the presentation.

Manuscripts requiring major English language revision will be returned to the author(s). It is not the responsibility of editors to significantly revise language. Authors for whom English is a second language may choose to have their manuscript professionally edited before submission.

Copies to the Author & reprinting Upon publication, five copies of the journal will be sent to the first author. Please supply mailing address, contact numbers and email address. Permission to reprint articles must be obtained in writing from the Singapore Nurses Association.


Dover Park Hospice (DPH) was founded in 1992 to provide palliative care to the terminally ill, including support for their distressed families. Registered as a charity in 1992, it is a member of the Health Endowment Fund. It is also a member of the National Council of Social Service and the Singapore Hospice Council. In support of our growing needs, we have the following openings:

State Registered Nurses (Inpatient & Home Care) • Minimum 3 -4 years of nursing experience in an acute care setting • Post-Basic training or relevant work experience in Palliative Care/Oncology/Geriatric Nursing is preferred

Operations Executive (Home Care) • • • •

Bachelor Degree/Post Graduate Diploma in any discipline with minimum 3 years’ experience in a health care environment Self-motivated with analytical skills Provides administrative support and responsible for smooth operation of home care service Assist with community liaison

Only Singaporean or Singapore PR need apply with resume stating current and expected salaries to : Human Resource Department Dover Park Hospice, 10 Jalan Tan Tock Seng Singapore 308436 Email:

Closing date: 10 Dec 2011 We regret that only shortlisted candidates will be notified.

Announcement :

Good News to All Members Do you find renewing your annual membership a hassle?

Here’s the good news! Starting from August 2009, you can simply renew your membership at any of our 600 AXS Stations located island-wide. This service is FREE and CONVENIENT

Website :

Hotline : 6560 2727 Subsidiary of :

Singapore Nursing Jour nal

You can make

caring extraordinary. The Institute of Technical Education’s Nursing Department prepares students for the healthcare industry with a holistic learning experience. Our passionate staff impart their knowledge and skills through an authentic learning environment consisting of a Centre for Healthcare Simulation, Paramedic Indoor and Outdoor Simulation Laboratory, and Geriatric Nursing Laboratory, while still retaining their clinical expertise. Join us and be part of the team that transforms students into future generations of healthcare professionals.

LECTURER – NURSING You should be a Registered Nurse or Nurse Educator with at least 3 years’ post-registration clinical experience, and have a Degree, Diploma or Post Graduate Qualification in Nursing. Experience in clinical teaching and a specialist qualification in any of the following nursing specialties will be an added advantage: – Psychiatry – Gerontology – Oncology – Emergency – Medical–Surgical

LECTURER – PARAMEDIC & EMERGENCY CARE You should be a Paramedic Specialist or Instructor, possess a Certificate in Paramedic IV with at least 3 years of field experience, and have a degree or diploma qualification. You should preferably have experience in teaching or coaching. Registered Nurses with a Certificate in Paramedic III may also apply. Remuneration The remuneration package will be competitive and commensurate with your qualifications and experience. ITE is committed to staff capability development and successful candidates will have various opportunities for further professional upgrading and development. Application We invite you to submit your application electronically via internet at Please visit our website at for more details on these and other positions.

CERT NO.: 2002-1-0429 ISO 9001 : 2008


Volume 38, No. 4, October - December 2011


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