Nursing and midwifery - Collected Works

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How do nurses keep children safe from abuse and neglect, and does it make a difference? A scoping review
(Elsevier, 2018-01-29) Lines, Lauren; Grant, Julian; Hutton, Alison Elly
Objectives: To explore the extent of child protection work performed by nurses and identify which interventions hold the strongest evidence for future practice. Design: This scoping review was guided by Arksey and O'Malley's framework for scoping reviews. Data Sources: Electronic databases (CINAHL, Medline, Scopus, Web of Science) and grey literature were searched in August 2017. Further studies were identified through manual literature searching. Results: Forty-one studies from seven countries met the inclusion criteria. The studies showed nurses keep children safe primarily through the prevention of abuse (n = 32), but also through detection of abuse (n = 1) and interventions to mitigate the effects of abuse (n = 8). Nurses' specific interventions most frequently involved post-natal home visiting (n = 20), parent education (n = 10) and assessment and care of children or adolescents following sexual abuse (n = 4). The main findings showed that although nurses did have positive impacts upon some measures of abuse and neglect, results were not consistent across studies. In addition, some studies used indirect measures of abuse and neglect, which may not impact children's experiences of abuse. It is difficult to extrapolate these findings to the broader nursing profession as literature did not accurately represent the range of ways that nurses keep children safe from abuse and neglect. Conclusions: This review demonstrated nurses prevent, detect and respond to abuse and neglect in many ways. However, given mixed evidence and absence of some nurse interventions in the literature, further research is needed to represent the range of ways that nurses keep children safe and determine their effectiveness.
Integrative review: Nurses' roles and experiences in keeping children safe
(Wiley, 2016-08-10) Lines, Lauren; Hutton, Alison Elly; Grant, Julian
Aim To identify nurses' role and experiences of keeping children safe. Background Approaches to preventing, identifying and responding to child abuse and neglect have moved towards a multidisciplinary approach where all professionals are expected to contribute to the goal of keeping children safe. Frequently in contact with children and families, nurses well positioned to contribute to keeping children safe from abuse and neglect. Much has been published around nurses' experiences of their role in keeping children safe, but this literature has not yet been synthesized to determine the challenges and potential scope of this role. Design Integrative review following an Integrative Review framework. Data sources Studies were identified through a search of the electronic databases CINAHL, Medline, Web of Science, Scopus and Informit to identify literature published between 2005‐2015. Review methods All the studies were critically appraised for methodological quality using the Critical Skills Appraisal Programme. Data from each study were extracted and categorized according to the review aims and the study's major findings. Results Inclusion criteria were met in 60 studies. Three main findings were identified including nurses' insufficient knowledge, need for validation and improved communication and balancing surveillance and support for vulnerable families. Conclusions Nurses have many roles and experiences in keeping children safe but often felt they did not have the knowledge, skills and support to take action in this area. Further research is needed to understand why nurses feel inadequate and disempowered to advocate and intervene on the behalf of children at risk of abuse or neglect.
Development and validation of the Australian Midwifery Standards Assessment Tool (AMSAT) to the Australian Midwife Standards for Practice 2018
(Elsevier, 2019-09-09) Sweet, Linda Phyllis; Fleet, Julie-Anne; Bull, Angela; Downer, Terri; Fox, Deborah; Bowman, Rebekah; Ebert, Lyn; Graham, Kristen; Bass, Janice; Muller, Amanda; Henderson, Amanda
Background The Australian Midwifery Standards Assessment Tool (AMSAT) was developed against the Competency Standards for the Midwife in 2017 to enable consistent assessment of midwifery student performance in practice-based settings. The AMSAT requires revision and re-validation as the competency standards have now been superseded by the Midwife Standards for Practice 2018. Objective This research revised and validated the AMSAT to assess performance of midwifery students against the Midwife Standards for Practice 2018 and assessed its sensitivity. Design A mixed-methods approach was used in a two-phase process. Phase one involved the re-wording of the AMSAT and behavioural cue statements in an iterative participatory process with midwifery academics, assessors and students. The tool was field-tested in different assessment environments in phase two. Completed assessment forms were statistically analyzed, whilst assessor surveys were analysed using descriptive statistics and qualitative content analysis. Findings Analysis of AMSAT (n = 255) indicates the tool as: internally reliable (Cronbach alpha > .9); valid (eigenvalue of 16.6 explaining 67% of variance); and sensitive (score analysis indicating increased levels of proficiency with progressive student experience). Analysis of surveys (n = 108) found acceptance of the tool for the purpose of summative and formative assessment, and in the provision of feedback to midwifery students on their performance. Conclusion This study demonstrates that the re-developed AMSAT is a valid, reliable and acceptable tool to assess midwifery students’ performance against the Australian Midwife Standards for Practice This user-friendly tool can be used to standardize midwifery student assessment in Australia and enable continued benchmarking across education programs.
Parent’s Cardiorespiratory Fitness, Body Mass, and Chronic Disease Status Is Associated with Metabolic Syndrome in Young Adults: A Preliminary Study
(MDPI, 2019-05-19) Nolan, Paul B; Carrick-Ranson, Graeme; Stinear, James W; Reading, Stacey A; Dalleck, Lance C
We sought to determine if there was an intergenerational association between parental weight, cardiorespiratory fitness (CRF), and disease status, with the prevalence of metabolic syndrome (MetSyn) in their young adult o spring. Young adults (n = 270, 21 1 years, 53.3% female) were assessed for MetSyn and self-reported parent’s CRF, body mass status, and disease status. MetSyn was present in 11.9% of participants, 27.4% had one or two components, and 58.5% had no components. A significantly higher percentage (93.9%) of young adults with MetSyn identified at least one parent as being overweight or obese, 84.8% reported low parental CRF and 87.9% reported a parent with disease (all p < 0.017). MetSyn in o spring is more likely when parents are perceived to have low CRF, increased body mass, and a diagnosis of disease. Evaluating the o spring of people with low CRF, elevated body mass, or who have a history of cardiovascular disease (CVD) or diabetes should be considered to promote early identification and treatment of young adults to reduce future premature CVD in these at-risk individuals.
Developing clinical teaching capacities of midwifery students
(Elsevier, 2016-06) Rance, Sharon; Sweet, Linda Phyllis
Background Competency Standards in Australia articulate that the midwife must be able to contribute to the professional development of themselves and others. Few undergraduate health professional curricula currently incorporate content for the development of specific knowledge and skills required for clinical teaching. This project aimed to understand and enhance midwifery students’ preparedness to assume their future clinical teaching responsibilities. Methods Design-based research was used to implement an educational intervention aimed at developing clinical teaching skills through a peer education session between 1st and 3rd year students. The perspectives of 30 undergraduate midwifery students about their preparedness for their teaching role and the intervention were obtained through 3 focus groups. A thematic analysis of the data was undertaken. Findings Three themes were identified encompassing the research aims and objectives; ‘Co-creating a culture for learning’, ‘reciprocal teaching and learning’ and ‘developing clinical teaching capacities’. The findings indicate that the midwifery students had a holistic understanding of their responsibilities in clinical teaching in the workplace. They were able to identify ways in which their teaching capacities were being developed through their clinical experiences and the curriculum, both intended and hidden. Conclusions Despite limited educational activities for clinical teaching, the midwifery students made explicit connections of the relational interdependence of workplace-based experiences and their learning. Students were clearly able to identify ways in which their own learning experiences and the culture in which this learning is embedded, assists them to develop clinical teaching skills, ready to support the next generation of midwifery students.
Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge
(Elsevier, 2017-04) James, Lucy; Sweet, Linda Phyllis; Donnellan-Fernandez, Roslyn Elizabeth
Problem Early discharge following birth has become an emerging phenomenon in many countries. It is likely early discharge has an impact on the establishment of breastfeeding. Objective To critically appraise the evidence on what women value in relation to breastfeeding initiation and support, and investigate the impact early discharge can have on these values. Method A literature search was conducted for publications since 2005 using the following databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, Scopus and PsycINFO; 21 primary articles were selected and included in the review. Findings There is no standard definition for ‘early discharge’ worldwide. Due to inconsistent definitions worldwide and minimal literature using a 24 h definition, research defining early discharge as up to 72 h postpartum is included. Seven key factors in relation to breastfeeding initiation and support following early discharge were identified, namely trust and security, consistent advice, practical breastfeeding support, breastfeeding education, comfortable environment, positive attitudes and emotional support, and individualised care. Conclusion The findings suggest individualised postnatal lengths of stay may be beneficial for the initiation of breastfeeding. Five values were not impacted by early discharge, but rather individual midwives’ practice. There is consensus in the literature that early discharge promoted a comfortable environment to support breastfeeding initiation. Wide variations in the definition of early postnatal discharge made it difficult to draw influential conclusions. Therefore, further research is required.
Validation of the Australian Midwifery Standards Assessment Tool (AMSAT): a tool to assess midwifery competence
(Elsevier, 2018-02) Sweet, Linda Phyllis; Bazargan, Maryam; McKellar, Lois; Gray, Joanne; Henderson, Amanda
Background There is no current validated clinical assessment tool to measure the attainment of midwifery student competence in the midwifery practice setting. The lack of a valid assessment tool has led to a proliferation of tools and inconsistency in assessment of, and feedback on student learning. Objective This research aimed to develop and validate a tool to assess competence of midwifery students in practice-based settings. Design A mixed-methods approach was used and the study implemented in two phases. Phase one involved the development of the AMSAT tool with qualitative feedback from midwifery academics, midwife assessors of students, and midwifery students. In phase two the newly developed AMSAT tool was piloted across a range of midwifery practice settings and ANOVA was used to compare scores across year levels, with feedback being obtained from assessors. Findings Analysis of 150 AMSAT forms indicate the AMSAT as: reliable (Cronbach alpha greater than 0.9); valid—data extraction loaded predominantly onto one factor; and sensitivity scores indicating level of proficiency increased across the three years. Feedback evaluation forms (n = 83) suggest acceptance of this tool for the purpose of both assessing and providing feedback on midwifery student’s practice performance and competence. Conclusion The AMSAT is a valid, reliable and acceptable midwifery assessment tool enables consistent assessment of midwifery student competence. This assists benchmarking across midwifery education programs.
Enhancing health professional education capacity in the Western Pacific region
(Rural and Remote Health, 2018-08-30) Sweet, Linda Phyllis; Young, Louise; Kado, Sinead
In the past 5 years there has been a rapid rise in numbers of foreign-trained medical graduates returning to their countries to work as interns across the Western Pacific. These graduates were found to have a varied and different level of clinical knowledge and skill from that previously experienced in the region. This change in workforce profile led to an urgent need for upskilling clinicians as educators and supervisors. A team of clinical education facilitators were invited to design and deliver context-specific professional education workshops to address this need. These workshops were designed to equip clinical staff with education and supervision skills to optimise teaching and learning opportunities in clinical settings for these new graduates of foreign medical programs. Embracing a collaborative approach and addressing learning needs in local contexts has enabled the team to enhance medical education capacity in the Western Pacific region. This article presents the context of the need for and development of clinical education workshops for intern supervisors in the Western Pacific.
Developing reflective capacities in midwifery students: Enhancing learning through reflective writing
(Elsevier, 2019-04) Sweet, Linda Phyllis; Bass, Janice; Sidebotham, Mary; Fenwick, Jennifer; Graham, Kristen
Practice-based or clinical placements are highly valued for linking theory to practice and enabling students to meet graduate outcomes and industry standards. Post-practicum, the period immediately following clinical experiences, is a time when students have an opportunity to share, compare and engage critically in considering how these experiences impact on their learning. Reflective practice has merit in facilitating this process. Aim This project aimed to optimise the learning potential of practice-based experiences by enhancing midwifery students’ capacity for reflective practice through writing. Methods Design-based research was used to implement an educational intervention aimed at developing reflective practice skills and enhance reflective writing. The Bass Model of Holistic Reflection was introduced to promote the development of reflective capacity in midwifery students. Academics and midwifery students were provided with guidance and resources on how to apply the model to guide reflective writing. Students’ written reflections completed before (n = 130) and after the introduction of the intervention (n = 96) were evaluated using a scoring framework designed to assess sequential development of reflective capacity. Findings The pre-intervention scores ranked poorly as evidence of reflective capacity. All scores improved post-intervention. Conclusions The introduction of a holistic structured model of reflection resulted in improved scores across all five components of reflective writing; self-awareness, sources of knowledge, reflection and critical reflection, evidence informed practice and critical thinking. While further work is required the results show that the implementation process and use of the Bass Model enables students to demonstrate their capacity to reflect-on-practice through their writing.
Maternity health care: The experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia
(Elsevier, 2017-08) Mohale, Hlengiwe; Sweet, Linda Phyllis; Graham, Kristen
Background Increasing global migration is resulting in a culturally diverse population in the receiving countries. In Australia, it is estimated that at least four thousand Sub-Saharan African women give birth each year. To respond appropriately to the needs of these women, it is important to understand their experiences of maternity care. Objective The study aimed to examine the maternity experiences of Sub-Saharan African women who had given birth in both Sub-Saharan Africa and in Australia. Design Using a qualitative approach, 14 semi-structured interviews with Sub-Saharan African women now living in Australia were conducted. Data was analysed using Braun and Clark’s approach to thematic analysis. Findings Four themes were identified; access to services including health education; birth environment and support; pain management; and perceptions of care. The participants experienced issues with access to maternity care whether they were located in Sub-Saharan Africa or Australia. The study draws on an existing conceptual framework on access to care to discuss the findings on how these women experienced maternity care. Conclusion The study provides an understanding of Sub-Saharan African women’s experiences of maternity care across countries. The findings indicate that these women have maternity health needs shaped by their sociocultural norms and beliefs related to pregnancy and childbirth. It is therefore arguable that enhancing maternity care can be achieved by improving women’s health literacy through health education, having an affordable health care system, providing respectful and high quality midwifery care, using effective communication, and showing cultural sensitivity including family support for labouring women.
Nursing students’ perceptions of the qualities of a clinical facilitator that enhance learning
(Elsevier, 2017-01) Sweet, Linda Phyllis; Broadbent, Julie
There is a wealth of research investigating the role of the clinical facilitator and the student experience of clinical education. However, there is a paucity of recent research reviewing the students' perspectives of facilitators' qualities that influence their learning. This paper explores undergraduate nursing students' perceptions of the qualities of a clinical facilitator that enhanced their learning. The study was designed as a cross-sectional survey. A total of 452 third year nursing students at one Australian University were invited to participate. A total of 43 students completed the survey and were analysed; thus, the response rate was 9.7%. Results of the study indicate that nursing students perceive availability, approachability and feedback from the clinical facilitator to be highly influential to their learning in the clinical setting. The relational interdependence of these is discussed. Clinical facilitators have an important role in student learning. The findings of this study can be used in the development of clinical facilitator models, guidelines and in continuing education.
Understanding and appraising medical students’ learning through clinical experiences: Participatory practices at work
(Routledge, 2018-12-17) Billett, Stephen; Sweet, Linda Phyllis
This chapter explores the participatory practices of some medical students’ learning through their clinical experiences. Participatory practices are those that comprise a duality between what is afforded by the social institutions in which individuals participate (e.g. educational and healthcare settings), on the one hand, and how individuals elect to engage in and learn through those practices (i.e. their processes of experiencing), on the other. Privileged here is not only the contributions to learning from these social settings and what individuals already know, can do and value, but also the relations between them. Indeed, the explanatory account of these students’ learning is founded on the concept of relational interdependence. That is, the relational nature of the interdependence between the social norms, forms and practices that individuals are afforded in these settings, and their experiencing of, and learning from what is afforded them. These concepts offer an account of the learning process associated with medical education, in which judgements about the educational worth of these programs are founded on the kinds and qualities of experiences provided for students, their relationships with the kinds of learning that arise from them, and ultimately, how students come to engage within them. This engagement includes, but is not wholly dependent upon, how students perceive the invitational qualities of these experiences.
Information sharing for the management of chronic conditions in primary health care: How does it work and what are the outcomes?
(Flinders University, 2012-02-01) Lawn, Sharon Joy; Sweet, Linda Phyllis; Skinner, Timothy; Battersby, Malcolm Wayne; Delany, Toni
The prevalence of chronic health problems is increasing across Australia. Finding ways to maximise effective use of resources in this area is particularly important given that expenditure on chronic conditions already accounts for the majority of all health care spending. Prior research indicates that chronic health problems are most effectively managed through a collaborative approach where clients and health workers from various disciplines work together to achieve defined goals. The use of care plans can assist in facilitating this collaboration and in fostering effective communication. To address the gaps in knowledge about how these processes are currently operating, our research investigated the information sharing processes that are used within the care planning process to identify how they work and to explore client and health worker experiences of them.
Medical Student ultrasounds education, a WFUMB position paper, Part 1
(Elsevier, 2019-02-01) Dietrich, Christoph F.; Hoffmann, Beatrice; Abramowicz, Jacques; Badea, Radu; Braden, Barbara; Cantisani, Vito; Chammas, Maria C.; Cui, Xinwu; Dong, Yi; Gilja, Odd Helge; Hari, Roman; Nisenbaum, Harvey; Nicholls, Delwyn; Nolsøe, Christian Pállson; Nürnberg, Dieter; Prosch, Helmut; Radzina, Maija; Recker, Florian; Sachs, Alexander; Saftoiu, Adrian; Serra, L. Andreas; Sweet, Linda Phyllis; Vinayak, Sudhir; Westaway, Susan; Chou, Yihong; Blaivas, Michael
The introduction of ultrasound into medical student education is well underway in many locations around the world, but is still in its infancy or has yet to begin in others. Proper incorporation of ultrasound education into medical training requires planning and resources, both capital and human. In this article, we discuss the state of the art of ultrasound in medical education throughout the world, as well as various methodologies utilized to improve student education and to incorporate ultrasound into every facet of training. Experiences from various educational systems and available evidence regarding the impact of ultrasound education are summarized. Representing multiple societies and specialties throughout the world, we discuss established modern as well as novel education structures and different successful approaches.
Understanding the effects of neonatal early discharge on parents: a literature review
(Wolters Kluwer, 2019-04-01) Setiawan, Jennifer; Mannix, Trudi Gaye; Sweet, Linda Phyllis
Problem: A Neonatal Early Discharge (NED) program is a supported process where preterm infants leave hospital before they have established full sucking feeds, and are gavage fed by their parents while they transition to breast and/or bottle feeds. While there is some evidence in the literature describing the outcomes of this process for preterm infants, there is even more limited evidence of the effects and outcomes of these NED programs on parents. Objective: To summarize and critically appraise the literature regarding the effects of neonatal early discharge on parents. Method: A literature search was conducted for English language publications since 2007 using Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycINFO and Google Scholar. A total of 20 primary articles met the inclusion criteria for the review. Conclusion: An integrative thematic synthesis identified four themes: establishing parenting skills/confidence, bonding with the newborn, psychological distress, and the need for support and resources. Findings suggests that parents have various concerns regarding discharge from the neonatal unit, and therefore support from health professionals and family play a crucial role during the experience. There were also various external factors such as socioeconomic status and cultural differences which impact on parents differently, and it is therefore challenging to draw definite conclusions. This warrants further research in the area.
A realist review of infant feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa: what works for whom and in what contexts
(BMC Public Health, 2019-05-14) Nyoni, Simangaliso; Sweet, Linda Phyllis; Clark, Jacinta; Ward, Paul Russell
The most recent World Health Organization (WHO) guidelines on Human Immunodeficiency Virus (HIV) and infant feeding promotes exclusive breastfeeding (EBF) in resource limited settings for the prevention of mother to child transmission (PMTCT) of HIV. Literature reveals poor uptake of WHO feeding guidelines, with mixed feeding being a regular practice. In light of the limited success in EBF promotion, a realist review was conducted, analysing the use of feeding counselling to increase exclusive breastfeeding by HIV-positive women in sub Saharan-Africa, where the majority of HIV childhood infections occur. We considered what mechanisms were at play, for whom and in what circumstances they led to exclusive breastfeeding.
Becoming a nurse preceptor, the challenges and rewards of novice registered nurses in high acuity hospital environments
(Elsevier, 2019-03-06) Smith, Janet Helena; Sweet, Linda Phyllis
Precepting is a common and expected role of nurses in clinical settings worldwide. This research explored novice nurse's experiences of precepting undergraduate nursing students in high-acuity hospital environments. An interpretive study was undertaken with 12 novice nurses (<3-years of post-registration clinical experience), who were precepting nursing students. Data was collected through focus groups and thematically analysed. The zone of proximal development theory was applied to understand the relationship of learning that occurs between students and nurses. Three themes were identified. Firstly, participants established that precepting students enhanced their own self-development, and was a rewarding role, that not only developed the student into a nurse, but provided opportunities for the novice nurse to learn. Second, precepting was both challenging and rewarding. The challenges involved the student, the context, and the preceptors' own teaching and learning skills, resulting in feelings of frustration and conflict between nursing care and preceptor roles. Third, precepting was an expectation of both the nursing role and from senior nurses. At times, the participants felt overwhelmed and drained, particularly when having students that challenged them on multiple consecutive shifts. Participants identified the need for guidance and support from more capable peers to develop confidence while precepting nursing students.
What are the components of effective chronic condition self-management education interventions for children with asthma, cystic fibrosis, and diabetes? A systematic review
(Elsevier, 2018-11-13) Saxby, Nicole; Beggs, Sean; Battersby, Malcolm Wayne; Lawn, Sharon Joy
Objective To articulate the components of educational interventions that help children learn about managing their asthma, cystic fibrosis, or diabetes, relevant to their age/developmental status. Methods A systematic review of chronic condition self-management (CCSM) educational interventions that included age/developmentally appropriate components, published before 27 January 2018, including evidence level and quality assessments. Teaching approaches were extracted and translated into practical components. Results Twenty education interventions were identified, published across 30 studies. Most studies (n = 20/30) were based on the theories of Piaget and Bandura. Similar teaching approaches were used across conditions, incorporating sequenced curriculum and a variety of active elements. Age/developmentally appropriate interventions resulted in improvements in the CCSM capabilities of children. Outcomes were improved when compared with usual care. For very young children, educational interventions were directed at parents/families. As children reached school age, interventions increasingly became child-focused, promoting autonomy. Integrated play and reinforcement were common. Adolescent interventions placed greater emphasis on communication, problem-solving, and role division. Conclusion Eight key components were identified: structured and sequenced curricula; reinforcement; active participation; collaboration; autonomy; feedback; multiple exposures; and, problem-solving. Different components are relevant to specific life stages. Practice implications Clinicians require age/developmentally appropriate practical education tools to provide effective paediatric health care.
Nursing students' perceptions of a clinical learning assessment activity: ‘Linking the puzzle pieces of theory to practice’
(Elsevier, 2019-03-13) Pront, Leeanne; McNeill, Elizabeth (Liz)
The nursing profession struggles with providing a bridge to close the theory to practice gap for students. Students are expected to graduate with competencies that promote their safe and comprehensive nursing care provision in accordance with professional standards. This paper reports on students' a simulated clinical educational intervention embedded into a second-year nursing student clinical topic offering experiential learning opportunities for a large cohort. Feedback was analysed using Braun and Clarke's (2006) thematic qualitative process to investigate student-learning experiences and present student perceptions of this experience. Three key themes were identified: support promoted learning, focus on the bigger picture and practice clarifies puzzle pieces. Students perceived the simulated clinical experience as beneficial to their confidence, learning and ability to develop their professional practice. Promotion of learning outcomes facilitated by the structured, supportive and educational approach was important for students. Nurse educators have a responsibility to develop learning experiences that enable student's ability to link theory to practice in context. Ongoing exploration and evaluation of this intervention is required however, such an approach appears to support student's knowledge development for transference across situations and within large student cohorts.
A model to teach concomitant patient communication during psychomotor skill development
(Elsevier, 2017-09-18) Nicholls, Delwyn; Sweet, Linda Phyllis; Muller, Amanda; Hyett, Jon
Many health professionals use psychomotor or task-based skills in clinical practice that require concomitant communication with a conscious patient. Verbally engaging with the patient requires highly developed verbal communication skills, enabling the delivery of patient-centred care. Historically, priority has been given to learning the psychomotor skills essential to clinical practice. However, there has been a shift towards also ensuring competent communication with the patient during skill performance. While there is literature outlining the steps to teach and learn verbal communication skills, little is known about the most appropriate instructional approach to teach how to verbally engage with the patient when also learning to perform a task. A literature review was performed and it identified that there was no model or proven approach which could be used to integrate the learning of both psychomotor and communication skills. This paper reviews the steps to teach a communication skill and provides a suggested model to guide the acquisition and development of the concomitant -communication skills required with a patient at the time a psychomotor skill is performed.

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