Lagan Briege M.
Lalor Joan G.
Lambert Veronica
Latham Linda
Lawler Jocalyn
Ledger Alison
Levine MaryAnne
Lin Mei-Chun
Long Tony
Lynch Margaret
Lyons Christina
MacGabhann Líam
Malone Anne-Marie
Corry Rita
Manning Mary
Devlin Rita
Marecki Marsha A.
Ludwig Mary Ann
Marlow Nicholas
Marteinsson Patricia
Martindale Sheelagh
McBennett Pádraig
McCallion Philip
McCarthy, Bernard
McCarthy Bridie
Murphy Siobhan
McCarthy Geraldine
Lehane Elaine
McCarthy Mary IRL
McCarthy Mary UK
McCaughan Eilis
McSorley Oonagh
McGrath Deirdre
McGrath Mary
McHugh Aine
McKeon Elizabeth
McSherry Rob
Meaney Teresa
Medd Norma
Mee Lorraine
Minnie CS (Karin)
Mitchell Elizabeth
Mitchell Khurshid
Montgomery Adrienne
Smith Siobhan
Mooney Brona
Morris Roisin
Mowatt Elaine
Muldoon Kathryn
Murphy Fiona
Murphy Joan
Murphy-Lawless Jo
Neill Freda
Huntley-Moore Sylvia
Newman Stuart
Nicholl Honor – Children’s Nursing
Nicholl Honor - Research
Nielson Guri Brit
Nolan Louise
Noone Phil
Noone Tom
O'Brien Dolores M.
O'Brien Frances
O'Driscoll Linda
O'Hare Bernadette
O'Hare Lauren E
Tooker Patricia
Olive Philippa
O'Malley Mary
O'Neill Catherine
Ronayne Sinead
O'Neill Mary
O'Regan Patricia
Ortiz Mangels Marlaine
O’Shea Joan
Gleeson Madeline
O'Tuathail Claire
Page Karen
Parlour Randal
Mullin Edith
Phelan Amanda
Philbin Mark
Philip Marilyn
Turnbull Betty
Pittam Gail
Power John J
Priest Helena
Segrott Jeremy
Quinn Griffin Mary T
Ragbir-Day Nirmala
Reagan Shelton Carol
Reid Virginia
Reynolds Heather
Rice Billiejoan
Richey Roberta
Keaney Sinead
Richmond Helen Grace
Ring Mary T.
Rogers Carol
Ronayne Sinead
Rush Thomas
Cunningham Joseph B.
Ryan Frances
Sedgewick John
Sharvin Brian
Shippee-Rice Raelene
Shipway Lyn
Pittam Gail
Smith Mary
Spence Dale
Stanmore Emma
Stewart-Moore Jill
Sutton Maire
Turner Niall
Swinburne Janet
Symon Andrew
Taguinod Fidel
Thomas Debera J.
Timmins Fiona
Tobin Gerard A - Research
Tobin Gerard A – Cancer Care
Tocher Jennifer
Traynor Marian
Turnbull Patricia
Morris David
Turnock Chris
Walsh Maura Cait
Ward Caroline
Warmington Stuart
Weeks Keith W
McWhirter George
Wellock Vanda K
Crichton Margaret A
Wells John
Whelan Jacqueline
Williams Mriga
Soper Sue
Williamson Graham R. – concurrent paper
Williamson Graham R. - poster
Wilson Karen
Wood David
Wood Maggie
Wright Kerrie
Yates Sue
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
INTERNET USE BY PREGNANT WOMEN – A LITERATURE REVIEW
Name of Authors:
Briege M Lagan PhD Student, University of Ulster
Dr Marlene Sinclair, Senior Lecturer in Midwifery, University of Ulster
Prof. George Kernohan, Professor of Health Research, University of Ulster
Room BO35, Institute of Nursing Research
University of Ulster (Coleraine Campus)
Cromore Road
Coleraine
County L’Derry
BT52 1SA
The World Wide Web is becoming a popular resource for information on a wide
range of health related issues including pregnancy and childbirth (Sinclair 2001,
Bernhardt and Felter 2004). Midwives are expected to provide relevant, up to date
information that meets the needs of women in their care. However, as women are
beginning to turn towards electronic resources for advice and support instead of
midwives the reasons for this need to be explored.
This literature review was undertaken to explore the extent and nature of published
evidence on the use of the Internet by women.
The following objectives were set:
• To provide a critical summary on the extent and nature of published and
unpublished evidence on the use of the Internet by women with particular
reference to pregnancy and childbirth
• To identify relevant papers that examine how pregnant women use the
Internet; what they use it for and if this affects their decision-making.
Searches were conducted for peer and non-peer reviewed papers. Key words such as
“internet” and “pregnancy” were used to search: the British Nursing Index, CINAHL,
MEDLINE, PsycINFO, ScienceDirect, Web of Knowledge, Pubmed, Index of Thesis
databases. This was supplemented by searching the electronic Journal of Medical
Research. Midwifery e-discussion groups were also contacted to identify any
unpublished studies. The abstracts of English language articles were read and those
satisfying the relevant criteria were critically appraised, evaluated and synthesized by
three independent reviewers. Data was categorized using the classification of evidence
framework from the Department of Health in the National Service Frameworks
(DOHNSF).
References
Bernhardt, J.M. and Felter, E.M. (2004) On line paediatric information seeking among
mothers of young children: results from a qualitative study using focus groups.
[Homepage of Journal of Medical Internet Research,] [Online]. See:
http://www.jmir.org/2004/1/e7/
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Sinclair M, Gardner J, Mackin P, Boreland Z, Hood R. (2001) Aspects of maternity
care in Down Lisburn Trust; Analyses of the Records of maternity patients deemed as
low-risk on admission and of former patients’ perceptions of maternity care.
Published by Down Lisburn Trust. See: http://www.dlt.n-i.nhs.uk/index.html.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
FETAL ABNORMALITY DETECTION IN THE SECOND TRIMESTER:
THE INFORMATION NEEDS OF WOMEN
Joan Lalor, Health Research Board Clinical Midwifery Fellow and Doctoral
Student, Prof. Cecily M. Begley, Director, School of Nursing and Midwifery,
The University of Dublin Trinity College, 24 D'Olier Street, Dublin 2.
Tel: 087 654 9012 Email: [email protected]
Background. Approximately 2% of babies with an abnormality are born to healthy,
low-risk women, and most of these abnormalities are diagnosed at the second
trimester ultrasound scan (USS). Research from the Republic of Ireland suggests that
women seek reassurance from the routine USS but have limited knowledge of its
diagnostic capability and limitations and have erroneous expectations of the
sensitivity and specificity of the test. In addition, research suggests that while women
receive little information regarding the USS, they choose to participate in routine
screening programmes.
Aim. To explore women’s information needs after the diagnosis of a fetal anomaly.
Design: A longitudinal, grounded theory study was designed for the main study. This
paper focuses on the initial phase of the process, the diagnosis of fetal abnormality.
Setting: A tertiary referral centre in Dublin was chosen as the main study site. Women
who were referred from rural areas to this centre were also included in the study.
Sample: All women with adverse ultrasound findings who had been considered low
risk for the occurrence of a fetal anomaly either booked or referred to the study site
were invited to participate. Women were offered study information by the staff in the
fetal medicine unit and indicated their readiness to participate by contacting the
researcher (JGL) by post or phone. This paper reports findings arising from the
participation of the first thirty-six women.
Ethical issues: Ethical approval was obtained from the university and study site and
the woman’s decision whether or not she took part remained confidential to her
caregivers unless she chose to disclose this to them All participating women were
offered access to counselling services and an integrated care pathway of referral to
psychiatric services was established should a participant require such support.
Data collection and analysis: Data were collected by means of an in-depth interview
in the woman’s home. Data were analysed using constant comparative analysis.
Rigour is demonstrated through recording detailed memos, which profile the
emergence of codes and categories, and through the technique of member checking
transcripts with an experienced researcher (CB).
Findings. Findings presented in this paper represent women’s views of how they
gained an understanding of the anomaly and how they accessed information from and
in addition to that available from their caregivers. A variation in informational needs
and information seeking behaviour post diagnosis was noted. The data describes the
influencing factors and provides suggestions for the ongoing provision of information
for women as they continue the pregnancy after the diagnosis.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The Experiences and Perceptions of Practice Nurses in Relation to Patients on a
Methadone Maintenance Protocol
Ms Linda Latham MSc Nursing Advanced Practice
Advanced Nurse Practitioner Primary Care
Liberties Primary Care Centre
Meath Community Unit
Dublin 8
Ireland
+ 353 87 6500775
[email protected]
This study investigated the experiences and perceptions of practice nurses in relation
to the management of patients on a Methadone Treatment Protocol in the Republic of
Ireland. Since the introduction of the Methadone Treatment Protocol in October 1998,
practice nurses have increasingly becoming involved in the care of drug misusers. In
a multidisciplinary approach to the care of these patients the Irish College of
General Practitioners have provided Level One training to General Practitioners and
a small cohort of practice nurses working in urban practices in Dublin city.
Historically, nurses have been involved in methadone maintenance in other countries
but there is no evidence of the same involvement pertinent to the Irish situation.
Negative experiences have been reported in the international literature , both from
general practitioners and nurses in hospital, community and general practice settings.
Concepts that are important in the understanding of the problems associated with the
care of drug misusers have been identified as issues of marginalisation, collaboration
and empowerment.
A qualitative methodology utilising a phenomenological approach underpinned the
design of the study. This approach assisted exploration of the meaning and
understanding of the role of the practice nurse. Insight into the perceptions and
experiences of these nurses facilitated understanding of the strengths, difficulties and
challenges of working with drug misusers within a general practice setting.
Eight practice nurses, employed by general practitioners who prescribed methadone
in Dublin, were interviewed and audio taped. The data were analysed utilising the
Colaizzi technique.
Five descriptive themes emerged from the exploration; the experience of what it is to
be a practice nurse; practice nurses’ understanding of collaborative practice; the
practice nurse as a valuable resource in relation to patients on a MTP; frustrations
associated with the MTP, and marginalisation and professional attitudes.
The findings from this study offer insight into the development of practice nursing,
the scope of nursing practice in the community and the principles required to facilitate
growth of the discipline. This study highlights the responsibilities of the nursing
profession in addressing the societal influences that may affect nursing care of
marginalized populations
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Nursing workforce and professional preparation in a global and competitive
economy: lessons to be learned from a case study of The University of Sydney,
Australia
Professor Jocalyn Lawler
Faculty of Nursing and Midwifery (M02)
The University of Sydney NSW 2006
Australia
RN, B Soc Sc, MEd (Hons), PhD, FRCNA
Phone: +61 2 93510519, Fax +61 2 9351 0506
email: [email protected]
Abstract
In 2004 The University of Sydney, Australia’s first university and one of the group of
research-intensive universities (the Go8), made a major change to the way it offered
educational programs leading to registration in nursing. It ceased undergraduate entry
and moved instead to offer only graduate entry nursing courses. This decision was
taken in the context of: (a) rapidly evolving regional and globalized competitive
environments; (b) major reform in higher education nationally; and (c) a nursing
workforce close to crisis point. The proponents were three vice-chancellors operating
in consultation with two Ministers of the Crown; and there was no prior consultation
with the profession, regulatory nursing bodies, or the University’s own nursing
faculty. The decision, when it became known, provoked an unprecedented public
debate in the media and elsewhere; and, in some quarters, there was outrage and
disbelief. A crisis ensued and stayed ‘on the boil’ for some weeks.
This paper is a case study of what happened and why. The author held a unique
position in this context; and it is from this vantage point that the analysis is made. The
faculty’s immediate and medium term response is analysed in the context of the wider
national and global issues at play. The paper is, necessarily, also a retrospective
analysis of what Michel Foucault called the ‘conditions of possibility’ that gave rise to
such a decision, and the consequences and potential effects going forward into the
21st century. In particular, the paper canvasses issues such as the nature of nursing
workforce, knowledge and research in a global economy; the relationship of nursing
labour and professional practice in a knowledge economy; and health and education
as commodities in which nursing is an essential but relatively silenced player.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Introduction
This paper is a case study of the Australian context of higher eduction for nurses and
its relationship to the nursing workforce. My primary point of reference for this
analysis is The University of Sydney’s shock decision in June 2004 to cease teaching
pre-registration Bachelor of Nursing. This was a highly successful course, in demand
from very able students, and recently accredited for the maximum period. The degree
could be taken as a stand-alone pattern of study, or in combination with the Bachelor
of Science or Bachelor of Arts. The Faculty also offered a specialty degree, the
Bachelor of Nursing (Indigenous Australian Health), which is unique. This degree
was retained until a sustainable future could be found for it.1
From 2006, the University’s Faculty of Nursing and Midwifery will be a graduateonly academic group; and this will include teaching pre-registration nursing at the
master’s level to entrants who hold a first degree in a field other than nursing. The
graduate entry Master of Nursing will take two years to complete and will also be
offered as a four year pattern in combination with selected undergraduate degrees –
Arts, Science, Health Science, and Exercise and Sports Science2. This decision
attracted considerable attention, much of which was negative, because it seemed
illogical and irresponsible for a major Australian university to make such a decision at
a time when the country – and particularly the state of New South Wales in which the
University is located – was experiencing a protracted nursing workforce crisis.
Education, Health and the Global Economy
This paper examines the University’s decision in a national context both of a health
workforce under strain and undergoing significant restructuring, while the university
sector is itself also responding to a higher education system with a different set of
strains and structural reforms. The paper analyses the motivating and strategic factors
at play in the university context and examines the wider implications for the nursing
profession arising from the differing tensions and strategic responses within health
and education. I also consider how the Faculty responded to and managed a situation
of massive, unanticipated change. This particular analysis is made from my vantage
point as Dean of the Faculty at the time; and it is a matter of some interest that I
remain the incumbent.
In an earlier paper on this issue (Lawler & Newman 2005;1) the University’s decision
to shift to a graduate entry profile was described as ‘an inevitable collision of two
policy agendas’ between the major public sector industries of health and higher
education (the former is funded by the federal government; the latter by state
governments). In that paper we traced the differing political imperatives being
pursued by health and education and explored the tensions that necessarily arise for
nursing faculties as these policy agenda gain momentum. In short:
•
In health, the policy imperative is one of structural reform to maximise
throughput and contain costs, the effects of which are the intensification of
nursing work, among other things. That, in turn, is giving rise to difficulty
maintaining a nursing workforce which is sufficient both numerically and in
relation to expertise.
•
In education, the policy imperatives focus on increasing competitiveness both
nationally and internationally by maximising opportunities for research in
growing Australia’s knowledge economy. Differentiation and rationalistion
among the universities is intended to provide the kind of environment in which
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
some universities may take on a major specialised and/or international role, while
others may concentrate on the domestic market. One vice-chancellor, Glyn Davis
of The University of Melbourne – one of the country’s leading universities – is
quoted as speculating that differentiation may result in some universities
‘surrendering undergraduate teaching across many disciplines’ (Lane 2005; p.21)
or even move to be exclusively postgraduate.
It is argued here that what happened at The University of Sydney is unlikely to be an
isolated event. Rather, it is indicative of a wave of change in the educational
preparation of nurses and health professionals generally that has the potential to grow
internationally. As a consequence, a long term impact on the nature of the nursing
workforce can be anticipated; and it is particularly likely to affect the structure of the
nursing workforce that currently relies currently on a majority of registered nurses. It
is widely anticipated, for example, in Australia that the registered nurse workforce
will shrink substantially, the gap being filled by enrolled nurses whose educational
preparation is itself moving upwards to diploma level.
It is interesting, in this context, to observe the events unfolding for the nursing group
at Sheffield in the UK where a similar move to graduate entry is occurring, albeit
from an apparently different set of circumstances.
The context of the decision-making by the University
The University of Sydney is Australia’s first university. It was founded in 1850 when
Sydney was the only significant metropolis of the then British colony of New South
Wales. It is a public, secular university having its origins in a pragmatic alliance
between the Anglican, Jewish and Catholic communities of the colony – all of whom
wanted to establish a university, but none acting alone had sufficient resources.
Together, however, they could assemble sufficient socio-political and financial
support to build a university in conjunction with the colonial government of the day.
The University of Sydney was built on prime land in a key location and, after a slow
start, grew to become a major institution symbolising the evolving economic strength
and social development of the colony. The university has progressively come to
occupy a unique place in the national psyche; and its actions and strategic moves are
observed closely by everyday Australians, politicians and social commentators, most
particularly the media. In many respects, the university is a national icon.
The Faculty of Nursing and Midwifery
The Faculty of Nursing was formally established in the University of Sydney 1991
during of a wave of amalgamations in the higher eduction system as part of a national
strategy pursued by the then Labor government. The policy imperative, at that time,
was to unify the national system of higher education, which consisted of established
universities and colleges of advanced education (where nursing was located). Nursing
had earlier moved from hospital schools to the college sector progressively from
1985; and there were a small number of ‘experimental’ nursing programs in the
colleges dating to the 1970s essentially to gather information on the effectiveness of
tertiary education for nurses and to offer courses to registered nurses (most commonly
in education, administration and community health). The Faculty of Nursing at
Sydney was the first nursing entity to be established in side the so-called Group of
Eight (G08) universities, that is, the older more established, research intensive and
prestigious universities.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The University of Sydney is the largest provider of health professional eduction and
research in the country with Faculties of Dentistry, Health Sciences (that includes all
the allied health professions except for podiatry and optometry) Medicine, Nursing &
Midwifery, and Pharmacy. These faculties taken together account for over 15,000
students and would be the same size as a small university.
In the decade following the amalgamations and the founding of faculties/schools of
nursing, the academic qualification for registered nurse courses evolved from
diplomas to degree level (initially in Applied Science, then Health Science, then
eventually in Nursing); and graduate programs were added to meet a growing demand
for specialty qualifications. Research growth in nursing has been more modest; and
unlike other countries, there is no designated funding regime for nursing and
midwifery research, despite a growing emphasis by the clinical setting on evidence
based practice. The Faculty had known for a decade, at least, that it remained
vulnerable inside a research intensive university which expected rather more interest
in, and productivity from, a growing research culture. We did not deliver on this
criterion by which one is measured as academically committed to our place in higher
education; and it remains as an active matter for the Faculty to address.
The health care system, reform and nursing workforce
During these two decades the nursing workforce was beginning to experience the
impact of economic rationalist models for health care delivery, and early signs of the
strain on the system started to emerge (see for example, Cordery 1995). During this
period there has been a series of policy changes and a major national review of
nursing education (Department of Education Science and Training, 2001). This
national review was brought about in part because of workforce shortages and also by
the persistent duck-shuffling that occurs between the states and the federal
government (and their instrumentalities) on matters of nursing education, workforce
supply and demand and regulation. Like all these reviews, it was a profoundly
political undertaking; and yet little has come of it and few of its recommendations
implemented.
It is fair to say, however, that irrespective of which government is concerned (that is,
state or federal; conservative or not) there is no national coherent policy framework
for nursing education, research or workforce. That said, the policies being pursued by
all governments have emphasised supply with little serious attempt to address the
other factors at play, particularly the effects of structural reform on nurses’ workloads
and propensity to outmigrate from the profession (Bradley 1999; Buchanan &
Considine, 2002; Buchanan, Briggs & Considine, 2004; Community Affairs
References Committee, Australian Senate, 2002).
There is, however, a national initiative to address scope of practice issues between
registered nurses and enrolled nurses across state boundaries and other sectorial
divisions e.g. acute and aged care (National Nursing & Nursing Education Taskforce,
2005). However, this is most likely to have the primary effect of tidying some messy
boundary issues, and potentially providing a basis to expand the role of the enrolled
nurse, in some instances. It is most unlikely to address core issues affecting the
nursing workforce as a whole and is not intended to address the current pressures and
frustrations being experienced by the registered nurse workforce.
Individual commentators and researchers are advocating major structural reform of
the health workforce (e.g. Duckett, 2005) and most recently the Australian
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Government Productivity Commission has recently inquired into the Australian
healthcare workforce. While it has made a number of observations about the nature of
the issues facing the health workforce, it has made no particular recommendations
(Productivity Commission, 2005). Nursing authors (see for example Kline, 2003) and
others commissioned by nursing organizations (Buchanan & Considine, 2002;
Buchanan, Briggs & Considine, 2004) are researching the underlying dynamics of the
nursing workforce crisis within Australia. These studies take a more direct approach
to understanding the macro level trends that have been studied in the global context
(Buchan, Parkin & Sochalski, 2003; Buchan & Calman 2004) and in the UK (e.g.
Dingwall & Allen 2001). Irrespective of the remedies being proposed, the researchers
all point to the same contributing factors giving rise to the global nursing workforce
situation, that is, to factors within the health system the difficulties of recruitment.
One important matter that has received scant attention, however, is the necessary
capability and practice repertoire now needed for a successful career as a registered
nurse. Even more sensitive is the issue of the minimum entry standard for nursing
and its relationship to successful practice as a registered nurse3.
The policy framework in education
The current policy framework for Australia’s university sector, pursued vigorously by
a long-serving conservative government at the national level, is one of rationalisation
and differentiation so that among its many universities, Australia will have a small
number that are internationally competitive and a smaller number which are world
class (Department of Education Science and Training 2004, 2005). The policy intent
is to ensure that Australia remains a highly competitive player in the lucrative
education and knowledge generation market so that, as a nation, we are able to
participate successfully and globally in the knowledge economy. Central to this
competitive agenda are the ranking mechanisms:
(a)
the so-called ‘league tables’ (such as those published by the British Times
newspaper and the Shanghai index), which rate universities and which affect
student choice and the prices they can be charged for courses;
(b)
the evolving research quality assessment programs (e.g. the UK’s and New
Zealand’s research assessment exercise) and the Research Quality
Framework which is to commence in Australia in 2007; and
(c)
a range of consumer-oriented publications of performance indicators such as
pass rates, student satisfaction levels, and entry scores.
The education system is becoming more commercial, market oriented and image (or
‘brand’) conscious. This raises some very interesting challenges for nursing and
midwifery groups inside universities when working conditions in the health system
may not be highly marketable; and when many nurses and midwives are studying in
other disciplines so as to outmigrate. It is instructive, therefore, to understand the
reasons why Australia’s first university made such a dramatic and unexpected move
and to anticipate where this may take us.
The Conditions of Possibility and the University’s Decision
The university made a strategic decision; and understanding this element is central to
understanding all other aspects of the change. There are several aspects to be noted.
First, the university was able to make significant changes to its overall student profile
by relinquished 250 commonwealth funded places in undergraduate nursing and
increasing intakes into disciplines where demand was high(er) and entry standards
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
where being pushed too high (that is, there was growing adverse comment about the
entry levels). Second, it achieved commonwealth funded places for nursing at the
graduate level. Third, and most importantly, it could differentiate itself nationally and
internationally by moving almost entirely to a graduate entry model for the health
professions.
What is now also known, but which was not known at the time, is that by
relinquishing undergraduate nursing, the University would significantly elevate its
ranking in the ‘league’ tables. This would, in turn, enhance the University’s goal
expressed as the 1:5:40 strategy – that is, to be ranked first in Australia; in the top 5 in
the region and the top 40 in the world.
What is now also clear, is that there may well be a more general trend, particularly by
the more research intensive universities to move professional courses to graduate
entry. Such a shift would broaden the platform for research and knowledge
generation, while also providing a more prestigious and interesting intellectual
climate, because teaching at the postgraduate level seems to be more appealing and
rewarding.
The Faculty’s Response
The Faculty’s immediate and short term response was characterised first by shock and
disbelief, followed by a soul-searching phase to come to an understanding about why
such an institutional decision would or could be made without the Faculty’s
knowledge or consultation. The inevitable happened: tense meetings were held,
industrial activity began, and public comment ensued. Generally, public comment
was negative or incredulous that such a decision would be taken when there is a
workforce crisis. The Federal parliament was sitting at this time, so parliamentary
question time was punctuated by questions to the relevant Minister, Brendan Nelson;
and Hansard makes very interesting reading.
It was not immediately clear that the Faculty could survive the impact of this
magnitude of change because more than 80% of its income would disappear within
two years, including $1M in international student fee income from international
undergraduate students. The market for graduate entry nursing was untested in
Australia, and there was no clear understanding of what graduate entry nursing would
look like.
It quickly became apparent that, such as the trajectory of this change, there was little
institutional preparedness to manage the situation after news of the decision was
communicated to the staff and the public. That is, there were no clear plans, only a
‘big-picture’ strategy; and no costings, contingency plans or analyses had been made.
This situation was remedied quickly as the Faculty sketched out how best to
reconstruct itself in a totally new environment.
As nurses do, we dealt with the immediate situation as a major emergency – a train
smash, as some called it. We did triage. We got organised, we assessed the situation
and we got down to the business of working out what the decision actually meant –
professionally, nationally, internationally, academically. Assistance and cooperation
from within the university quickly emerged; and support for us was expressed across
the profession nationally and internationally, and from the general public. Our
undergraduate students behaved with admirable maturity and passion; and they will
commence their careers with a very sharp sense of the political realities of life as a
nurse. This cohort of graduates from Sydney has been particularly radicalised in a
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
way that cannot be taught through the formal curriculum; but they have learned hard
lessons.
A year and some months later, the Faculty is significantly smaller in size, it has added
‘Midwifery’ to its name, it has fewer staff and students, it has faced a major crisis and
survived in relatively good shape. During the last year, we have had to:
•
think our way through what teaching pre-registration nursing would look like as a
graduate degree and in one third less than the usual timeframe; while also
•
farewelling many staff;
•
re-considering a wide range of apparently familiar educational processes to suit
mature students coming to us with a first degree;
•
undertaking detailed budgetary and strategic planning; and
•
submitting an unprecedented course proposal for accreditation, particularly the
combined degree patterns – first through the university, and then the Nurses and
Midwives Board. Both were bruising encounters in some respects – more so
from individual nurses and former nurses than peers from other disciplines in the
university.
Lessons to be learned from the Sydney experience: some concluding thoughts
The most profound and enduring feature of the experiences that we have been through
in the last year is that we are living through a period of major changes, in many
aspects of our professional and personal lives. In the case of those who were studying
or working at the Faculty last year, much of the comfort that was derived from the
familiar has been replaced by an underling sentiment of uncertainty, particularly as we
move into a different academic space.
For some, it has been invigorating and exciting; while for others this was simply one
re-structure too many. For those of us in our 40s and 50s, restructuring has become a
way of life and there is a sense both of restructure fatigue, and yet a philosophical
appreciation that the world is changing dramatically and rapidly; and that it is not over
yet.
Over-riding all these rather more personal responses, there is a kind of new respect for
the profession that has shown just how good it is when put under pressure. Not one
member of the Faculty wobbled during extreme pressure and an elongated period of
uncertainty (some 5 months) from the time the decision was made till agreement was
reached industrially and politically. Within the university – a most political and
robust environment – there is a palpable sense that we have earned our place in
Australia’s oldest academy. We have a way to go in building our research agenda –
as all nursing groups are finding, and we have yet to complete our transition to a
graduate academic group. These are significant ongoing challenges with a different
set of pressure points.
More widely, the signals arising from the Sydney decision are a sign of things to
come. Principal among them, in our view, is that there will necessarily be a major reshaping of the nursing workforce. It is my individual reading that the RN workforce
will shrink substantially (if only to maintain an appropriate level of supply with the
capabilities now needed to fill that role). Nurses will likely see significant
differentiated between the RNs and the second level nurse in relation to education,
scope of practice, workplace engagement (by which I mean the terms and conditions
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
of their employment), and most importantly, how they view themselves and construct
their practice world. It is from the RN population that we will derive our research
base, without which will not be able to participate in the wider debates about health
and health care.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
References
Bradley C (1999) Doing more with less in nursing work: a review of the literature,
Contemporary Nurse, 8 (3); 57-64
Buchan J & Calman L (2004) The Global Shortage of Registered Nurses: An
Overview of Issues and Actions. Geneva, International Council of Nurses
Buchan J, Parkin T & Sochalski J (2003) International Nurse Mobility: trends and
policy implications. Geneva, World Health Organization
Buchanan J & Considine G (2002) Stop Telling Us To Cope. NSW Nurses Explain
Why They Are Leaving The Profession. A Report for the NSW Nurses Association,
Australian Centre for Industrial Relations Research and Training, The University
of Sydney, Sydney
Buchanan J, Briggs C & Considine G (2004) Unions and work intensification:
Insights from the Australian Metal and Engineering and Nursing Sectors,
Proceedings of the 18th AIRAANZ Conference: New Economies, New Industrial
Relations, Noosa: Association of Industrial Relations Academics of Australia and
New Zealand (AIRAANZ); 99-106
Community Affairs References Committee, Australian Senate (2002) The Patient
Profession: Time for Action. Report on the Inquiry into Nursing. Canberra
Cordery CL (1995) Doing more with less: nursing and the politics of economic
rationalism in the 1990s. In Gray G & Pratt R (eds.) Issues in Australian Nursing
4, Melbourne: Pearson Professional
Department of Education, Science and Training (2001) National Review of Nursing
Education. Discussion Paper
Department of Education, Science and Training (2004) Rationalising Responsibility
for Higher Education in Australia. Issues Paper
Department of Education, Science and Training (2005) Building University Diversity:
Future Approval and Accreditation Processes for Australian Higher Eduction.
Issues Paper
Dingwall R & Allen D (2001) The implications of healthcare reforms for the
profession of nursing, Nursing Inquiry, 8 (2); 64-74
Duckett S J (2005) Health workforce design for the 21st century. Australian Health
Review, 29 (2); 201-210
Kline D S (2003) Push and pull factors in international nurse migration, Journal of
Nursing Scholarship, 35 (2); 107-111
Lane B (2005) The difference is experience. Weekend Australian, 10-11 September,
Postgraduate supplement, p.21
Lawler J & Newman (2005) The nursing workforce, globalisation, and the nature of
nursing work: an analysis of the underlying dynamics and institutional responses.
Proceedings of the annual conference of the Royal College of Nursing, Australia,
Adelaide, July
National Nursing & Nursing Education Taskforce (2005) Scopes of Practice
Commentary Paper, Australian Health Ministers’ Advisory Council
Productivity Commission (2005) Australia’s Health Workforce, Position Paper,
Canberra
1.
The Bachelor of Nursing (Indigenous Australian Health) is a four year degree leading to
registration as a nurse that includes a major study in Indigenous health, history and nursing. It is
the only degree in Australia that addresses specifically the health care and nursing of Indigenous
peoples. The University undertook to retain the degree because of its significance. A detailed
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
discussion of this part of the University’s decision, and the government’s approval of it, is
beyond the scope of this paper.
2.
These new courses have been approved by the Nurses and Midwives Board of NSW for 5 years
commencing in 2006.
3.
The entry abilities for a successful study program to become a registered nurse have not been
well researched and many commentators are relying on assumptions that are either obsolete or
ill-informed.
Analyses conducted on the University of Sydney nursing students, and not published widely
show, that it is possible to set a minimum benchmark for studying nursing, but this is a
politically sensitive issue while there is a workforce crisis and while the intellectual rigour of
nursing is undervalued. See, for example, Lawler J (2002) Addressing quality issues in health
sciences curricula. Synergy. Issue 17, April, 4-6
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
An evaluation of the impact of art therapy and music therapy on a continuing
care ward for people with dementia
Alison Ledger MPhil
(Music Therapy Research Associate)
Dr Jane Edwards PhD
(Course Director, MA in Music Therapy)
Irish World Music Centre, University of Limerick
Olwen Bond RgN, RPN
(Clinical Nurse Manager)
Dr Ruth Loane MB, CCST – Psychiatry & Psychiatry of Old Age
(Consultant Psychiatrist)
Jennifer Newson McMahon MA
(Art Therapist)
Simon Wale MSc
(Clinical Psychologist)
Limerick Mental Health Services for Older People, Limerick
Hazel Moore BA
Laura Moore MSc
(Trainee Clinical Psychologists)
National University of Ireland, Galway
This research project is investigating the impact of introducing art therapy and
music therapy on a continuing care ward for 23 people with dementia. While
published studies have reported significant social, emotional, and behavioural benefits
for people with dementia receiving creative arts therapies, this project is evaluating
whether these therapies help both patients and staff. Music therapy and art therapy
have been implemented five days a week by qualified therapists on a continuing care
ward, in accordance with each individual’s assessed needs and preferences. Within
sessions, patients participate in various ways, including singing, playing musical
instruments, listening to music, discussion, drawing, painting and/or collage. Two
months after commencement of the therapies, patients showed reductions in agitated
behaviours as measured by the Cohen-Mansfield Agitation Inventory (CohenMansfield, Marx & Rosenthal 1989).
The project is further investigating whether reductions in agitation have
brought about changes in nurses’ attitudes towards patients’ challenging behaviour
and job satisfaction. Nurses who volunteered to participate (N=23) completed
baseline questionnaires, including the Maslach Burnout Inventory (Maslach 1986), the
Challenging Behaviour Attributions scale (Hastings 1997), the Emotional Reactions
to Challenging Behaviours Scales (Mitchell & Hastings 1998) and the Difficult
Behaviour Self-efficacy Scale (Hastings & Brown 2002). Nurses repeated these
questionnaires between two and four months after the introduction of creative arts
therapies on the ward. Preliminary findings regarding nurses’ attitudes and levels of
job satisfaction will be presented at the 6th Annual Interdisciplinary Research
Conference. Based on these findings, recommendations for further inclusion of
creative arts therapies in the care of people with dementia will be put forward.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Cohen-Mansfield, J, Marx, MS & Rosenthal, AS 1989, ‘A description of agitation in a
nursing home’, Journal of Gerontology: Medical Sciences, vol. 44, no. 3, pp. M77M84.
Hastings, RP 1997, ‘Measuring staff perceptions of challenging behaviour: The
Challenging Behaviour Attributions Scale (CHABA)’, Journal of Intellectual
Disability Research, vol. 41, pp. 495-501.
Hastings, RP & Brown, T 2002, ‘Behavioural knowledge, causal beliefs, and selfefficacy as predictors of special educators’ emotional reactions to challenging
behaviours’, Journal of Intellectual Disability Research, vol 46, pp. 144-150.
Maslach, C & Jackson SE 1986, The Maslach Burnout Inventory, Consulting
Psychologists Press: Palo Alto, CA.
Mitchell, G & Hastings RP 1998, ‘Learning disability care staff emotional reactions to
aggressive challenging behaviours: Development of a measurement tool’, British
Journal of Clinical Psychology, vol 37, pp. 441-449.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
INTERNATIONAL IMMERSION PROGRAMMES IN BACCALAUREATE
MIDWIFERY AND OBSTETRIC NURSING EDUCATION: PROFESSOR
AND STUDENT PERSPECTIVES
Name: MaryAnne Levine
Title or Position:
Professor of Nursing/Childbearing Health
Department of Nursing
Humboldt State University, Arcata, CA
Degrees and Certifications: RN, BSN, PHN, MSN, SCM, Health Educator, PhD(c)
Correspondence Information:
MaryAnne Levine
Department of Nursing
Humboldt State University
One Harpst St.
Arcata, CA 95521
Phone: (707) 826-5137
Fax: (707) 826-5141
E-mail: [email protected]
Name: Elizabeth M. Perpetua
Title or Position:
RN
Cardiothoracic Intensive Care/Heart and Lung Transplant Unit
University of Washington Medical Center, Seattle, WA
Degrees and Certifications: RN, BSN, CCRN, HNC, PHN
Correspondence Information:
Elizabeth Perpetua
5716 20th Ave. NW
Seattle, WA 98117
Phone: (206) 940-6244
Fax: (858) 695-2208
E-mail: [email protected]
This presentation depicts the dual perspectives of professor and student,
addressing the explicit need for nursing education to implement programmes that
develop cultural competence in nursing practice, particularly in midwifery and
obstetric nursing, through self-awareness and cultural immersion. A Professor of
Nursing/Childbearing Health discusses the planning, implementation, and evolution
of the International Immersion Programme (IIP) at a Humboldt State University in
California. The student experience, integration, and evaluation of IIP and its impact
on one’s professional and personal life are described by a former baccalaureate
nursing student, currently a practicing RN, who participated in the programme in
Nakhodka, Russia.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
LAY CARERS’ EXPERIENCES OF CARING FOR INDIVIDUALS
SUFFERING FROM DEMENTIA OR WITH INTELLECTUAL DISABILITY
Mei-Chun Lin BSc MSc RN 1, Maureen Macmillan BA (Hons) PhD RGN2,
Norrie Brown3 DipCNE MEd CertEC PhD RMN RGN ILTM, Anne Rowat BSc
(Hons) PhD RGN.4Doctoral Student1, Senior Lecturer2, Senior Lecturer &
Senior Teaching Fellow3, Lecturer4, School of Acute & Continuing Care Nursing,
Faculty of Health & Life Sciences, Canaan Lane Campus, Napier University,
Edinburgh EH9 2TB
Background
The provision of UK health care has shifted policy from institutional to communitybased care including that for people with dementia and adolescents with profound
intellectual disabilities (DoH 1990). The demands placed on carers by such
impairments increases their burden (Braithwaite 1992).
Aim
The overall aim is to explore the experience changes in ‘caregiver burden’ and how
this affects the carer’s autonomy and health over time.
Method
Research design: qualitative design using a grounded theory approach. Sample: 6 lay
carers looking after dementia sufferers and 6 for adolescents with profound
intellectual disability. Data collection: 3 semi-structured interviews with each carer at
6 monthly intervals. Data analysis: interviews tape-recorded and transcribed. A
constant comparative method will be used aided by QRS NVivo.
Preliminary results
Preliminary analysis of 3 data sets shows the emergence of categories: restricted
autonomy; life and relationship changes; family support; paradox of statutory
services; responsibility-authority dilemma; health challenges; nature of being.
Preliminary conclusions
Caring is a complex phenomenon. Carers feel isolated. The support they are offered is
sometimes ‘cosmetic’ especially from relatives. Choices are restricted out of a sense
of duty. Carers’ health status is altered by the burden of caring.
References: DoH (1990) Community care in the next decade and beyond: policy
guidance London: HMSO
Braithwaite, V. (1992) Caregiver burden: making the concept scientifically useful and
policy relevant Research on Aging 14 (1), 3-27
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
DEVELOPING A FRAMEWORK FOR
LEARNING BEYOND REGISTRATION
HEALTH
PROFESSIONAL
Dr Tony Long, RN PhD, Senior Lecturer in Child Health.
Renata Eyres, MSc DCR(R) FETC SRR Professorial Fellow and Associate
Dean.
SCNMCR, Room C705 Allerton Building, University of Salford, Salford, M6
6PU, UK.
Background to the project
This project was commissioned by the English Department of Health and ran over 12
months. The purpose of the project was to develop an inter-professional framework to
support learning beyond initial registration and continuing professional development
(CPD) of healthcare professionals currently within the scope of statutory regulation in
England. Lifelong learning within the NHS has been promoted as a key feature in the
delivery of the vision of patient-centred care. Other key drivers included the
requirements for staff to work in more a collaborative manner and in new or extended
roles; concern over the link between learning and the effect on patient outcomes;
confusion caused by the lack of common terminology; a desire for common processes
for setting and monitoring standards; and difficulties with transferability of learning
between employers.
Study Design
A variety of strategies were employed to achieve the objectives. These included
• A prolonged desk-based literature review aimed particularly at establishing
existing terminology relating to CPD and identifying national outcome measures
relating to patient care.
• Widespread consultation with key informants through individual meetings and
interviews followed to ascertain existing practices, the views of professional and
regulatory bodies, and work undertaken in other initiatives.
• Two structured questionnaires were used to establish current practices in linking
CPD to patient outcomes and to further explore terminology in use: one directed at
human resource directors in 700 NHS Trusts and Primary Care Trusts, and the
second was designed for completion on-line by individual registered health
professional practitioners.
• Three open consultation “listening events” were held with varied stakeholders
following a version of the Open Space method to produce a range of key
recommendations, particularly with regard to mechanisms to link CPD more
closely to patient outcomes.
• An event was also held to elicit the view of a large Reference Group to validate
the findings from the first stage of the project.
• Presentation was made to the UK Council of Deans Retreat to elicit the match
between prescribed and actual practices in credit transfer. A brief questionnaire
was used.
• A focus group was held with representatives of other relevant initiatives to clarify
the wider picture of work into standards, quality assurance efforts, issues relating
to valuing learning in various forms, and the relative roles of various organisations
within these areas.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
•
A further structured consultation was undertaken with invited delegates from key
stakeholders, again using open space techniques, to guide the formulation of final
recommendations.
Outcomes
Confusion among employers and professionals about the content of the plethora of
DH initiatives was addressed in an interactive mapping presentation. Common
terminology was addressed through a glossary of preferred terms and a matrix of
terms which acts like a thesaurus. An adapted Business Excellence Model was
developed to link patient outcomes to CPD, supported by a Unit-Level Support Tool
to assist with implementation. A Performance Management Tool (based on the
Balanced Score Card) was adopted to support planning and monitoring of CPD. A
process and format for annual appraisal and common components for portfolios and
personal development plans was developed. These were presented in graphical format
available on-line as an interactive display at http://www.hplbr.org.uk/
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
SHADOWING-AN OPPORTUNITY TO ENHANCE INTERDISCIPLINARY
UNDERSTANDING
Margaret Lynch. Midwifery Lecturer. MSc BSc (Hons) DN (Lond) SRN RM
MTD. University of Manchester. School of Nursing, Midwifery and Social Work
Gateway House Piccadilly South. Manchester 60 7LP
Background. Shadowing has been defined as the closest one individual can get to the
role of another without actually doing the role, a ‘virtual reality’ experience NHS
Executive (1994). It provides the opportunity for observation based learning in order
to break down boundaries between different professional groups (Barr 2004). In the
development described here, shadowing was offered to midwives whose work brings
them into contact with many other healthcare professions and occupational groups.
'Alongside' may be the best way to describe these working relationships for although
roles are interdependent, evidence suggests that understanding of the roles of other
disciplines is often superficial (Thomson 1990).
Design. In order to facilitate exposure to aspects of the role of other disciplines, a
shadowing exercise was introduced in the late 1990's initially to qualified and
experienced midwives on a ‘top up’ degree programme, and then extended to
undergraduate student midwives in 2003. All those involved, with the help of a
mentor and personal tutor, are required to identify an individual about whose role they
wish to know more, and to arrange to shadow that individual for a minimum of one
working day. To date 194 midwives have undertaken shadowing. Those shadowed
include- chief executives, human resource managers, physiotherapists, social workers,
chief nurses, various laboratory staff, blood bank staff, and paramedics. One student
arranged to shadow a Parliamentary Under Secretary of State for Health.
Results. The development has been evaluated very positively. Formal evaluation
has been through a post shadowing survey questionnaire, a telephone survey of a
purposive sample of those shadowed, and seminar presentations. Themes to emerge
include, insight into, and greater understanding of the roles of other disciplines,
exposure to the culture of other disciplines, a greater understanding of the roles of
those with managerial and leadership responsibilities, some concerns over
confidentiality, and 'the grass is not always greener'. Those shadowed appreciated the
opportunity to explain their role and promote their discipline to a fellow health care
professional. There have been a few cases of 'reciprocal shadowing' which have
arisen spontaneously.
Conclusion. Shodowing offers an opportunity to health care workers to increase their
understanding of the many disciplines with whom they inter-relate and could be a
very useful, work based professional development opportunity to help to break down
interdisciplinary boundaries and enhance understanding of the roles of others in
providing the best quality care. As a result of the information gained from this
project, shadowing to enhance interprofessional understanding is to be introduced
with undergraduate social work students, audiology students and possibly paramedics.
References
Barr H (2004) NET2004 15th Annual International Participative Conference . Nurse
Education Tomorrow. London
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
NHS Executive (1994) Shadowing: management development for NHS staff.
Department of Health. London.
Thomson A (1990) Medical Confusion on Care in Childbirth and the role of the
midwife. Midwifery 5. 57-59
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
NEW ROLES, NEW WAYS OF WORKING IN MENTAL HEALTH:
INTEGRATING
WORKFORCE
DEVELOPMENT
AND
SERVICE
DELIVERY
Dr Christina Lyons PhD, MSc, RNT, SPSN, RMN, Teacher's Certificate
Senior Research Fellow
Department of Nursing
Faculty of Health
University of Central Lancashire
Preston
England
+ 44 7917 185418
[email protected]
Clare Baguley
Programme Leader
Postgraduate Certificate in Primary Care Mental Health Practice
University of Manchester
Denise Fisher
Programme Leader
Postgraduate Certificate in Primary Care Mental Health Practice
Liverpool John Moores University.
This paper presents an example of a collaborative approach that has facilitated an
integration of education and training, and organisational development to introduce an
entirely new role and new ways of working in primary care mental health services in
the northwest of England. Strengths and limitations of a collaborative methodology
are discussed.
Graduate Mental Health Workers are amongst the first wave of new roles and new
ways of working in mental health identified in the NHS Plan (DoH 2000) and are part
of the wider NHS modernisation agenda in England (DoH 1998; DoH 1999). It was
intended that Graduate Mental Health Workers help provide primary care services for
the large number of people presenting to general practitioners with mild to moderate
depression and anxiety. Graduate Mental Health Workers are part of a workforce
strategy to develop primary care mental health services, reduce pressure on specialist
secondary care mental health services, improve access to psychological interventions,
using a stepped care approach.
The introduction of the Graduate Mental Health Workers is supported by an
educational programme: post graduate certificate. Three HEIs, University of Central
Lancashire, University of Manchester and Liverpool John Moores University were
contracted to develop a programme to cover the northwest of England. The three HEIs
collaborated to develop one programme validated by each university. Because this
initiative involved the introduction of a new role and new type of service, the need for
organisational development was identified at the onset. This was achieved by the three
HEIs working collaboratively with the three northwest strategic health authorities and
the National Institute for Mental Health in England (NIMHE) northwest development
centre. This involved engaging with Primary Care Trusts (PCTs) to raise awareness,
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
develop the posts and participate in recruitment and selection of the students. It has
also involved continuing support for the PCTs to help them develop and embed the
role in their organisations.
The first wave of organisational development included road shows, networking into to
PCTs and publication of a guidance handbook. However, it has become apparent that
close monitoring of the impact of the educational programme is needed to continue to
inform both the development of the role and the programme to achieve an integrated
approach. This ensures that the university programme both supports and responds to
emerging conditions. This paper reports on three aspects of monitoring, for the first
two cohorts of students: academic achievement and progression; clinical activity; the
role of the practice based education. Reasons for the success of the collaboration,
(98% of the government target have been achieved compared with approximately
60% nationally) are discussed.
References
Department of Health (1998) Modernising Mental Health Services: Safe, Sound and
Supportive. London: Department of Health [online]
http://www.publications.doh.gov.uk/nsf/mentalh.htm
Department of Health (1999) National Service Framework for Mental Health. Modern
Standards and Service Models. London: Department of Health [online]
http://www.publications.doh.gov.uk/nsf/mentalh.htm
Department of Health (2000) The NHS Plan: A Plan for Investment; A Plan for
Reform.
London:
Department
of
Health
[online]
http://www.publications.doh.gov.uk/nsf/mentalh.htm
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE MANAGEMENT OF DUAL DIAGNOSIS (MENTAL HEALTH &
SUBSTANCE MISUSE PROBLEMS) IN IRELAND: A DUALIST DILEMMA
OR OPPORTUNITY FOR HEALTH CARE PRACTITIONERS?
Author/Presenter :
Title:
Address: Líam Mac Gabhann, RPN, BSc, MSc
Lecturer in Practice
Dublin City University, Dublin 9
Co-authors: Alexandra Scheele, Triona Dunne, Pamela Gallagher, Padraig Mac
Neela, Gerry Moore, Mark Philbin @ School of Nursing, Dublin City University
The complexities associated with treating people who have dual diagnosis are well
articulated in the literature and there are established models of best practice and
increasing knowledge of the challenges facing service providers (e.g. Department of
Health {UK), 2002). Traditional services for people with mental health problems and
substance misuse problems often evolved separately, even where provided by the
same organisations. Over the last few decades as the needs of this clinical population
were identified, healthcare providers have had to revise their understanding and
approaches to people with dual diagnosis. For example, simply treating two
diagnosed conditions does not mean that dual diagnosis is being addressed. Because
of the nuances of this condition and divergence of perceptions on best treatment
between discrete service providers, peoples needs were frequently unmet and
treatment ineffective. Improved knowledge shared wisdom and integrating practice
through innovative means have increased the effectiveness of care in some countries.
Until 2004 there was little information relating to the identification and/or
management of dual diagnosis within Irish health care provision.
Mac Gabhann et al. (2004) carried out a national study examining how dual diagnoses
was presently managed in addiction and mental health services in Ireland. .
Commissioned by the National Advisory Committee on Drugs, the study involved
three phases. Firstly a critical international literature review identifying needs of this
clinical population and models of effective service provision. With little information
available for Ireland, the second phase used an Open Forum in one geographical area
with a variety of service users, carers, voluntary bodies, primary care agencies,
statutory services and multiple professions, for data collection. The literature review
informed this open forum and the findings from both informed a national survey of
addiction and mental health services
This paper will concentrate on the global and inter service provider findings that; a)
lend to difficulties in conceptualising and identifying dual diagnosis and b)indicate
the existence of dualism in treating an intrinsically individual condition. Perhaps a
key finding is the absence of any recognition of the existence of or treatment for dual
diagnosis in pertinent national health & social policy, e.g. health & drugs strategies
(Department of Health and Children, 2001 & Department of Tourism, Sport and
Recreation, 2001). The impact of this invisibility and consequent service provision
cannot be underestimated. For example only 21% of services purport to have any
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
policy for the provision of care to this group of people, e.g. 15% – 87% of people
attending mental health and/or addiction services in other countries (Mac Gabhann et
al, 2004). Up to 58% of services operate local exclusion criteria for people who may
have a dual diagnosis, although most respondents (78%) disagreed with their own
criteria. Practitioners may assess for dual diagnosis, though frequently not treat these
people (76%), referring on or treating ‘one diagnosis’ only. Apart from lack of
service provision, only 39% of staff in services were sufficiently trained to treat dual
diagnosis. There is no systematic approach to care, with little formal communication
between specialist services, yet 75% of respondents believe an integrated service
would be the most effective. Some organisations subsume mental health and
addiction/substance misuse services under one structure. This brings about some
integration , although people still appear to be treated as two separate conditions.
There are several ambiguities emerging from this research, offering dilemmas and
opportunities for healthcare practitioners. On one hand findings suggest that our
health system by design is disenfranchising a vulnerable group of people. On the
other, presenting a dualism between services, underpinned by separate though parallel
worldviews; ethically, culturally, sociologically and professionally. This dualism is
amplified by the complexities of dual diagnosis where people do not fit in either ‘life
world’ and consequently they themselves are victims of services that are unable at
this stage to provide wholistic care.
References:
Mac Gabhann, L., Scheele, A. & Dunne, T et al (2004) Mental Health and Addiction
Services and the Management of Dual Diagnosis in Ireland. Dublin: National
Advisory Committee on Drugs.
Department of Health (2002) Mental Health Policy Implementation Guide: Dual
Diagnosis Good Practice Guide. London: Department of Health Publications
Department of Health and Children (2001) Quality & Fairness: A Health System for
You. Dublin: Stationary Office
Department of Tourism, Sport and Recreation (2001). Building on Experience:
National Drug Strategy 2001-2008. Dublin: Stationery Office.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
HEALTH-CARE ACQUIRED INFECTION AND HAND HYGIENE:
PRECISELY WHERE IS THE PROBLEM?
Anne-Marie Malone
Lecturer
R.G.N., R.C.N., R.M., Dip. Microbiology,
R.N.T.,
B.N.S., R.N.T., M.B.A.
School of Nursing and Midwifery,
Midwifery,
The University of Dublin,
Trinity College,
24, D’Olier Street,
Dublin, 2.
Rita Corry
Lecturer
R.G.N., ENB 148, B.N.S.,
MSc, PG Dip (Stats)
School of Nursing and
The University of Dublin,
Trinity College,
24, D’Olier Street,
Dublin, 2.
Health-care acquired infection (HAI) continues to be a problem with serious
ramifications for service users in terms of morbidity and mortality, as well as creating
significant challenges for health care providers and systems. Differing rates of HAI’s
are reported internationally, with estimates suggesting a rate of 10% for HAI’s in the
United Kingdom. Methacillin-resistant staphylococcus aureus (MRSA) has been
identified as having different rates of occurrence in different countries, varying from
less than 2% in Scandinavia to greater than 40% in Mediterranean countries. It has
been suggested that 15-30% of HAI’s are preventable with good infection control
practice (National Audit Office, 2000). Plowman (2001) asserts that the £1 billion
estimated cost of HAI’s per annum in the United Kingdom highlights the significant
gross economic benefits that might accrue if this problem was minimised. Many
factors have been associated with the transmission of infection in health care settings.
One of the most important preventative strategies is adherence to hand hygiene
protocols. Research has indicated that health-care workers demonstrate variable and
frequently inadequate (Vernon et al, 2003) rates of compliance to hand hygiene, and
that this is influenced by individual and organisational factors. No single strategy has
been demonstrated to improve and sustain compliance with hand hygiene protocols
(Stoor et al, 2004).
The aim of this paper is to critically review the empirical evidence on hand hygiene,
identifying issues emerging with regard to health-care workers compliance with hand
hygiene protocols. Furthermore, the paper will explore the research on organisational
factors, which impact on hand hygiene practices. Finally, the paper will endeavour to
provide a platform for valuable discussion and debate regarding this practise, and
make suggestions for further research in this area, in an Irish context.
References
National Audit Office. (2000) The Management and Control of Hospital-Acquired
Infection in Acute NHS Trusts in England. The Stationery Office: London.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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Plowman, R., Graves, N., Griffin, M., Roberts, J.A., Swan, A.V., Cookson, B. and
Taylor, L. (2001) The rate and cost of hospital acquired infections occurring in
patients admitted to selected specialities of a district hospital in England and the
national burden imposed. Journal of Hospital Infection. 47(3): 198-209.
Stoor, J. and Clayton-Kent, S. (2004) Hand hygiene. Nursing Standard. 18(40): 4551.
Vernon, M., Trick, W., Welbel, S., Peterson, B. and Weinstein, R. (2003) Adherence
With Hand Hygiene: Does Number of Sinks Matter? Infection Control and Hospital
Epidemiology. 24(3): 224-225.
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THE DEVELOPMENT OF PERSON-CENTRED PRACTICES WITH
NURSES PRACTISING IN TWO CONTINUING CARE/ REHABILITATION
SETTINGS FOR OLDER PEOPLE.
Brendan Mc Cormack, Jan Dewing, Mary Manning, Rob Garbett, Rita Devlin,
Kathleen Donnelly, Miriam Mc Guinness
Presenters:
1 Mary Manning.RGN, MSc,(Hons) Regional Practice Development Facilitator
for Gerontological Nursing, NMPDU, HSE, Midland Area.
2. Rita Devlin RGN, BSc(Hons) Nursing Science, PGC Lifelong learning
Clinical Practice Facilitator, Belfast City Hospital.
Background
Developing person-centred practices with older people is a complex activity. It is
widely recognised that the development of such practices requires continuous support
and development of staff (McCormack, 2002). This programme is an emancipatory
practice development project aimed at developing person centred practices in two
services for older people in the HSE Midland Area . The programme is collaboration
between the Nursing & Midwifery Planning & Development Unit, the University of
Ulster, St Mary's Care Centre, Mullingar and Birr Community Nursing Unit.
Aims and Objectives
The aim of the project is to establish practice and professional developments with
registered nurses and care attendants that result in the development of person-centred
practices. This is being done by; establishing a shared vision for nursing practice,
determining the existing quality of service development, developing a programme of
problem based learning that enables nurses to understand key principles of personcentredness and evaluating the impact of the programme on staff, practice and service
development.
Methodology
The development framework being used in this programme is emancipatory practice
development. The operationalisation of the methodology is through problem-based
learning and practice development. By being engaged in these activities practitioners
learn from practice and become empowered to generate new knowledge to inform the
ongoing development of practice. The methodology is facilitated by a team of internal
and external facilitators drawn from the collaborating centres.
Evaluation
The major components of a transformational culture are being evaluated in this
project. These include evidence of staff participation in the development of a learning
culture, evidence that quality is a concern across the organisation and continuous
development of self knowledge and practice development. The direct outcome of this
programme will be evidenced through systematic and rigorous practice development
activity stemming from a range of practitioner research projects, a direct focus and
impact on practice, the use of diverse but transparent sources of evidence and
evidence of matched organisational, strategic and practice level planning.
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TRANSMITTING HIV EDUCATION THROUGH IVN
Marsha Marecki, RNC, CNS-WHNP-C, Ed.D.
Associate Professor in Nursing, University at Buffalo, The State University of New
York School of Nursing; Director of the Maternal/Women’s Health Nurse Practitioner
Program
Mary Ann Ludwig, PNP, Ph.D.
Clinical Associate Professor, University at Buffalo, The State University of New York
School of Nursing; Director of Kids into Health Careers Program; Nurse Consultant
to University at Buffalo, Child Care Center
The mission of the health science schools at the University of Buffalo (UB) includes
the development of a Center for Distance Learning and Health Consultation that
brings together the distance learning (DL) technological resources of the University
and the community it serves. This proposal, funded by Bell Atlantic Foundation,
assisted in bringing this vision to reality by providing education on HIV/STDs to
students in the Schools of Nursing, Pharmacy and Medicine as well as professionals
and high school students in the Southern Tier communities of Western of New York.
A symposium was offered for ongoing, interdisciplinary professional education to UB
health professions students and professionals in rural hospitals. Experts in the field of
HIV education presented a formal continuing education symposium at UB’s Abbott
Hall DL classroom to interdisciplinary health professionals and students in Buffalo
and health professionals in rural sites. The UB students acquired valuable clinical
knowledge and experience in areas not routinely covered in the current curricula,
including: interdisciplinary and team-building skills necessary to work in today’s
health care environments; practical information about concerns related to HIV
awareness and education; working with members of the community in a nontraditional setting; working with an experienced preceptor in the community; and
learning the most effective ways of interacting with teachers, parents, and children in
a community setting.
UB health professions faculty members learned how to teach more effectively in an
interdisciplinary environment and interact more productively with their health care
colleagues at rural sites. The community-university dialogues created through our
project’s professional symposiums and community open forums will serve as models
for future informational sessions.
Also, HIV training (with CEUs) was offered through the NYS Health Department’s
AIDS Institute Education and Training Program, to UB students and community
health care providers. This training session was designed to prepare health care
providers to conduct pre-and post-test counseling for HIV.
Lastly, a community HIV outreach education forum was conducted through BOCES
schools to the Southern Tier. The open community forum consisted of sessions
specifically designed for teachers, parents, and students. Groups of UB
faculty/students presented to DL sites. These sessions were presented by trained teams
of UB students and faculty using the Project CONNECT system allowed for open
discussion with high school students, teachers, and parents at rural sites. This
educational experience relied on several evaluation formats. The formats included
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feedback on the various programs as well as reaction to DL technology by
interdisciplinary students, preceptors, rural professionals, high school students,
parents and teachers.
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A NEW PARTNERSHIP TO MEET THE CHANGING NEEDS OF THE
CARDIAC PATIENT FOLLOWING EMERGENCY STENTING IN THE
ACUTE
MYOCARDIAL
INFARCATION
–
AN
AUSTRALIAN
PERSPECTIVE
Nicholas Marlow, Director of Acute/Post Acute Care (APAC) – Northern Sydney
& Central Coast Health)
Lecturer University of Technology – Sydney Australia, Fellow of the College of
Nursing, Australia
Qualifications: Diploma of Nursing Science (Cumberland College - AUS)
Graduate Diploma of Health Studies(HIV/AIDS) (UWS – AUS)
Address: Acute/Post Acute Care (APAC)
Northern Sydney & Central Coast Health
C/- Royal North Shore Hospital
Sydney, New South Wales
Australia 2065
Cardiac Rehabilitation programs have been strongly promoted by health care bodies
such as the World Health Organisation (WHO) and local health care services across
Australia. Outcomes from traditional models of cardiac rehabilitation have shown
health improvements, cost benefits, facilitate recovery, secondary prevention and risk
factor management/reduction and 20-25% reduction in mortality (Franklin et al).
As noted in the NSW Health policy standards “the trend for shorter hospital admission
has intensified the need for patients to receive rehab services on an outpatient or
community basis”. Interventional emergency “stenting” has also seen a reduced
length of stay (a range of 1 to 3 days). This inhibits the opportunity for effective in –
hospital education.
Research studies have shown that AMI patients were
experiencing difficulty in the period between discharge and attending out-patient
cardiac rehab services (lmich 1997), and that AMI patients stated they did not receive
or had forgotten rehab advice given during their stay in hospital (Salisbury 1994).
The challenge for the Northern Sydney Area Health (NS & CCH) is to adapt and meet
the changing needs of this group of patients. It requires a multi-disciplinary,
multifaceted approach with the aim of improving the short-term recovery of patients
and encouraging long-term lifestyle changes to eliminate/reduce risk factors.
This issue has been addressed by the collaboration of two multi-disciplinary groups.
The North Shore Cardiovascular Education Centre (NSCEC) and Acute/Post Acute
Care team (APAC) have been working together since November 2003 to provide a
cost-effective solution/service by utilisation and collaboration of existing services and
resources. APAC, a NSCCH initiative offers multi-disciplinary community based
patient assessment, education and counselling with referral to other services as
required. APAC’s involvement begins as soon as the patient is discharged
incorporating home visits for assessment, monitoring, treatment and telephone
support.
The overall aim of the NSCEC/APAC partnership, involved in the ongoing care of the
emergency Stent/AMI patient is to provide a seamless continuum of care and to:
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•
•
•
•
•
•
•
Facilitate early and safe discharge of this group from the acute setting ( 344
patients Aug 2003-Sept 2005)
Reduce anxiety in the immediate post discharge period
Reduce hospital readmission currently 2.3%, this has decreased by 10% since the
APAC intervention.
Provide education, information, support and counselling
Increase and encourage return to Phase 2 of a cardiac rehab program from 21% to
71%, (Australian Av. is 20-25%)
Provide on opportunity to access a wider population group in terms of cardiac
rehab eg. Elderly patients with mobility limitations unable to attend a Phase 2
cardiac rehab program.
Reduction of Av. Hospital Length of stay by 0.8 days or $460AUD. Or 160K
To date 344 AMI Stent patients have been referred to APAC since August 2003, 80%
of total RNSH Stents appropriate to APAC criteria have been admitted and 90% of
these have gone on to phase 2 Cardiac Rehab. The feedback from patients and
stakeholders has been extremely positive.
Formal evaluation of this innovative service has recently been initiated by APAC. A
research-based analysis has started.
Acknowledgements: APAC Team in particular Helen Tsakonas Clinical Nurse
Consultant APAC/Cardiac Rehab RNSH, Gavin Brealey Occupational Therapist
APAC, Ann Kirkness (CNC) Cardiac Rehab RNSH,
Jo Orchard Cardiac Clinical Nurse Specialist APAC, Department of Cardiology @
RNSH in particular Dr Gunning.
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Title: Client's experiences of communication with nurses during health crises: a
hermeneutic phenomenological study
Presented by: Patricia Marteinsson, 144 Ballin RÍ, Collins Lane, Tullamore,
Co.Offaly, Ireland.
Qualifications: RGN, RM, MSc. H.Dip PHN, Dip. Medical Ethics, Dip. Health
Promotion, IBCLC.
Telephone No: 353 863801137
Email Address: [email protected]
INTRODUCTION
The nature of communication and interaction is well established in the literature as
important for promoting and maintaining health (Booth et al., 1999; Arthur, 1999).
The significant need for nurses to form effective relationships with clients is most
evident in the acute health crisis context as all clients are unique “beings who actively
create their own meanings”(Walters, 1995). To communicate and provide effective
care, nurses must understand the clients’ needs, their experiences of crises and the
meaning that they attach to the nurses’ professional actions. The literature on
healthcare and crisis that specifically describes the clients’ experiences of nursing
communication is scarce. The research presented here was conducted in Iceland in
2002. The research question was ´What is the client’s lived experience of nursing
communication during health-crises?’ The aim of the research was to describe and
interpret the human experience of nursing communication in medical crisis, more
specifically, to understand the client’s perspective of the significance of nursing
communication during a health crises.
LITERATURE REVIEW
The purpose of health policy is to improve patient health. Health may be viewed as an
enabling facility where:
“A person’s health is equivalent to the state of the set of
conditions, which fulfil or enable a person to work to fulfil his
or her realistic chosen and biological potentials.” (Seedhouse,
1986, p.76)
This definition assumes that health or ill health is self-induced, that people are
autonomous masters of their own destiny. Such assumptions greatly underestimate the
cultural, social and economic pressures on the individual (Townsend & Davidson
1982) and also influence healthcare policy, which at present, is cost-driven.
Recent policy recommendations of the Department of Health and Children (DOH&C
1998; 2002) in Ireland regarding first line nursing and maternity management have
the potential to facilitate better communication. Henneman (1995) suggests that
continued improvements in interpersonal care delivery would enhance patient care
outcomes by supporting the communication skills of nurses’ through increased
collaboration with clients. In Ireland and England, this collaboration is demonstrable
in the strategies of the governments that allow people at the local level to
communicate their preferences and influence the range of services provided (NHS
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Executive, 1999b; DOH&C, 2002). Active client participation in service provision
results in increased consumer satisfaction. Thus, it is important for service planning to
understand the clients’ needs during health crises due to the potential long-term
consequences for clients and their families.
Several studies have attempted to explain the effects of a crisis on the individual.
Brown and Harris’s (1978) often cited quantitative research examines the
psychological response of clients experiencing a crisis and attempts to identify the
causal relationship between the crisis and the development of depression and
schizophrenia. The researchers concluded that the link between life events and
depression appears to be causal and that “it is likely to be the meaning of the events
that is significant rather than the change as such” (p. 63). This suggests that the
personal meaning attributed to the crisis is more significant than the event itself and
concurs with Humphrey’s (2001) view that illness has meaning. Thus, it is important
to increase the understanding of the unique meaning of the crisis experience for the
individual. However, to date, research has not examined the external contextual issues
that influence the individual. It is important to note that when communication is
examined in a crisis context the complexity of the research increases.
Several phenomenological studies on the "clients’ experiences of healthcare" are
relevant to this discussion. Magnusson’s (1999) research on the experience of cardiac
crisis post-discharge indicates the importance of nursing interaction to clients. The
importance that clients in a crisis situation attach to their encounters with nurses and
the meanings that the nurse’s communications has for them as they experience being
cared for was highlighted in Burfitt et al.’s (1993) study of critically ill intensive care
patients. Thompson et al’s. (1995) study of cardiac patients and their partners, one
month post-discharge reveals that, in crisis, patients and relatives can only absorb a
limited amount of information. While the nurses tried to convey information and
advice their practical objectives were not always achieved. However, the current
research is lacking in reflective accounts of nursing communication from the
perspective of the client in health crisis.
In healthcare the nurse-client interaction is a vital relationship (Thorne, 1993;
Halldorsdóttir, 1996; Thorsteinsson, 1999; 2002). Thorne’s (1993) study of clients
with chronic illness highlights the significance of the client-nurse relationship to the
client’s trust and confidence, noting that this relationship is central to the quality of
the healthcare provided. A critical aspect of nursing communication, identified by the
clients, is that the nurse translated the doctor’s words into a form that the clients could
understand. The clients expressed the need for somebody to “hear you and
understand” (Thorne, 1993, p.83) and perceived the nurse’s role as supportive and
informative. A theme of Thorne’s (1993) was the surrendering of “control” to the
client’s family to deal with health workers, until the client felt physically able to
express their own wishes. Although the clients wanted to have input into their care,
while incapacitated, they delegated this responsibility to others. Thorne’s study is
valuable in analyzing the experience of healthcare in the clinical setting of chronic
illness and communication with clients and their relatives.
In Benner’s (1984, 1994) research, the crisis clinical setting was examined from the
perspective of the nurse rather than the client. Benner (1984) argues that the ability to
‘connect’ with the client is essential for effective client-nurse interactions. Nurses
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“cannot understand a right and good healing action without understanding what
sickness is doing to the person’s self respect, to his life plan, and to his narrative
account of his life” (Brody 1987, p.192). This understanding emerges only through
good communication and empathy. In Australia the research of Williams and Irurita’s
(1998) indicates that when there is a lack of time available for nursing care, the
healthcare relationship may be adversely affected; they recommend further research
into contextual issues.
To date, research on the client’s experiences of the nurses’ communications in the
crisis situation is lacking. The nursing studies reviewed above present a clinical
picture of the nurse-client interaction from the chronically ill person’s perspective or
more often, the nurses’ view of providing care in a crisis situation. A reflective
account of the client’s view of a previously experienced crisis event is absent in the
literature. Research is needed in order to develop an understanding of the clients’
experiences of communicating with the nurses during crises. The research presented
here was conducted with a view to exploring the implications for providing effective
nursing care, and thus, increasing the well-being of clients. Crisis is defined as an
event or episode that the client views as extremely distressing and as having a residual
impact on his or her life or health. Nursing communication is defined as all
professional inter-subjective connections between the client and the nurse including
“speaking, hearing, looking and touching” (Pierson, 1999, p.301) and fostering
understanding within the clinical, research or advisory environments (Benner &
Wrubel, 1989).
METHODOLOGY
A qualitative design was selected as the most suitable way to examine and to gain
insight into the world of the clients (Benner, 1994). The epistemological and
ontological root of phenomenology was examined in order to find an approach that
would achieve the aims of the study. This process revealed that Husserlian
phenomenology initially focuses on the epistemological question of `how may we
know the world?’ which means that a researcher should bracket out preconceptions in
order to maintain objectivity by becoming a blank slate (Walters, 1995). In contrast,
Heideggerian phenomenology concentrates on the ontological thrust of refuting the
Husserlian concept of bracketing (Koch, 1995) and accepts that complete objectivity
is not achievable when studying human phenomena as human activity involves
subjectivity (Streubert and Carpenter, 1995). Hermeneutic phenomenology, as a
methodology, focuses on the interpretation of the meaning of a phenomenon; it was
used in this study because it linked the researcher’s ontological beliefs with the
interview topic and facilitated the pursuance of an iterative research design (Rubin
and Rubin, 1995). Arguably, the hermeneutic circle is best explained by viewing the
researcher and the co-researcher as being socialised in a shared world in which they
interact with each other in dialogue; through interpretation this interaction evolves
into further understanding. Pre-understanding is important in hermeneutic
phenomenology and the researcher’s bias is accepted as positive and necessary for
understanding and interpretation. In order to interpret, one must have a situational
understanding as “lived human meanings are understood to constitute and to be
constituted by one’s experience” (Munhall and Olier-Boyd, 1993, p.122).
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DATA COLLECTION AND ANALYSIS
Written permission for the study was obtained from the Icelandic Data Protection
Board, Hospital Authority and all respondents and the ethical guidelines of The Royal
College of Nursing (1998) were followed. A convenience retrospective sample was
obtained (Halldórsdottir, 1996; Hycner, 1995; Morse, 1994) that consisted of ten
people, equally gender balanced and ranging in age from 28 to 80 years. All
participants had experienced health-crises not less than two months or more than three
years before the interviews. Eight participants had personally experienced an acute
medical or surgical life threatening health-crises as in-patients. Two participants were
relatives of in-patients:
one was the mother of a client who had died during the health-crisis and the other was
the spouse of a client who had no recollection of his/her acute illness phase.
Two pilot interviews, conducted four months before the scheduled data collection,
revealed that the clients described the health-crisis in terms of the short- and longterm impact of the event on their everyday world. Consequently, one hour interviews
were extended, as needed, to accommodate the collection of data relevant to the
client’s overall experience of nursing communication. The interviews were recorded
over a nine-month period with the facility available for a follow up interview if
required. All clients were debriefed and no further interventions were required. The
transcripts were translated from Icelandic to English with a portion of each translation
re-checked for quality (Biering 2001).
The data was analysed manually by sorting the themes using printed copies of
transcribed interviews. The key statements were grouped into sub-themes, then further
grouped into master themes. The analysis results were validated through discussion
and review with qualified researchers; two nursing colleagues analysed one interview,
which was unidentifiable, and relatively similar themes emerged.
FINDINGS
“Fear” and “presence” emerged as the two main themes of the study. The fear theme
evolved from three sub-themes: “fear of losing the stability of normal life”, “fear for
self” and “fear for other”. The presence theme emerged from two sub-themes:
personal care and non-verbal communication. Other factors affecting communication
also emerged and are presented below.
Fear
Fear was as a major theme in the clients’ experience of crisis. The participants
delayed looking for help during the crisis until they had no other option; their
experiences of fear were described as fear of losing body normality, fear for the self
and for others, especially if they were the principal care givers.
Fear of losing stability of normal life
Initially, on becoming ill, the clients tried to normalise their symptoms and delayed
seeking help. Clients were often in a quandary as to whether they were ill enough to
seek medical attention and simultaneously hoped that the illness would resolve itself
spontaneously. They felt ill-prepared to decide on the seriousness of their illness and
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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whether they could be classed as an “emergency.” This period helped them to adapt to
the possibility of a change in status or an admission to the hospital.
Fear for self
The general reaction of fear and feeling of anxiety was described by one client:
“… [as] terrible. I am not generally a person who is easily scared but - I can
tell you this fear was different’’ everyone could see that I was paralyzed
with fear and there was nothing I could do about it. I couldn’t control my
thoughts.” (C7.p12).
The clients explained that fear was reduced by a strong spiritual belief;
preconceptions or personal meaning arose when the clients were told the seriousness
of their situation. The clients who had never been in hospital had a strong faith and
trust in the healthcare system maintaining an optimistic outlook that was beneficial in
dealing with their “fear for self.”
“I did not think anything except that it would be alright. I did not allow myself
to think of any other possibility.”(C8,p.4)
While one client explained that s/he had dealt with fear by withdrawing and closing
off, others indicated they were ill-prepared to cope with the anxiety and fear.
“ there is ..the black hole of depression standing at your shoulder.”(C5, p.10)
Fear for others
The inability to foresee the effect of the illness on the family unit was described as a
fear for other individuals in the clients’ lives. The participants described experiencing
fear for their family members who were being affected by the crisis. In the hospital
environment, the fear for others was more pronounced among primary caregivers who
had a dependent partner, relative at home or were single parents. Single parents often
had no outside support system to care for their children. Fear was more pronounced
among primary care givers who had no external familial support; they felt that
healthcare professionals often had no idea of their personal situation at home. The
clients described the stress and anxiety that their families endured due to financial
worries and concern about the client’s possible temporary or permanent incapacity or
death. The clients felt that they and their families were not always equipped to deal
with this burden. Families were not aware that support from other governmental
sources was available. This important sub-theme is not detailed in the literature.
Presence
Presence was experienced as nursing communication and was related to the
experiences of trust, comfort and support. All the clients had individual
"foreknowledge" that influenced how they interpreted their present health situation
and communication. The meaning of the experience of presence for the clients was
subjective in that they did not feel alone. A key aspect of presence was how the
clients, when they connected, felt cared for and safe in the presence of the nurse. One
participant related the experience of feeling connected to the nurse.
“She made me more than a thing that was not working right. It’s hard to
explain but in going to the hospital this nurse’s communication did not make
me lose my self-respect, which was pretty low at this stage, anyway. I was as
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equally prepared for being made to feel more worthless but I didn’t care, as I
was so sick that it would not have really mattered. But it did as she could have
finished me instead she protected and cared for me.” (C2, p.1)
The clients’ experience of interacting with the nurse acted as a catalyst for readjustment. The nurse protected and maintained the client’s self-worth while
assisting the client until s/he could be self-determining. Touch was also
experienced as an important aspect of the nurses’ communication; it conveyed
a non-verbal “presence”. “Presence” was described in terms of receiving
verbal reassurance, such as:
“She told me I was going to be okay.”(C1, p.2)
The clients stated that it was not just the verbal or non-verbal interactions that nurses
used but also their actions to facilitate adjustment, as one man explained:
“My wife was moved to another room and the beds were pushed
together. I stayed with her.”(C4, p.7)
Professional interactions involving drug administration at the prescribed times
and care of intravenous sites were also viewed as a form of communication;
such routines established the nurse as trustworthy. Pain management was
viewed as an important aspect of the nurses’ verbal communications, one client
stated that the nurses asked “How one felt?” but it was your bodily pain that
they meant, they wanted you to feel good. The participants experienced the
nurses’ presence as continually monitoring, maintaining the client’s safety and
placing the client interests first. They concluded that what the nurses stated
would occur, did indeed happen.
Positive Non-Verbal Cues
Non-verbal communication was an important sub-theme of presence that the clients
experienced. The client’s were aware of the presence of the nurses looking with their
“all knowing eyes” (C2, p.4) observing and recognising fear, pain, discomfort and
sensing unease. A key statement analysed from the data included awareness of the
nurse being available in the interaction. Verbal communication was considered
unnecessary. All of the participants sensed the nurse’s non-verbal cues positively:
“There was so much fear. They (Nurses) hugged me.”(C8, p.5)
“If the individual sees the nurse is relaxed, they relax too. They know
there is nothing dangerously wrong with them if the nurse is not
rushing.”(C5, p.5)
The clients described the various non-verbal communication strategies of the nurses
as integral to the nurses’ presence and being available for communication; the
strategies viewed as necessary included smiling and the use of touch, such as,
handshaking, handholding or a kind pat on the hand. The clients expressed a need to
physically visualise the nurse on each shift:
“They should after report time go from patient to patient and talk to
them a little. Say for example, ‘and where are you from?’ ‘ How are
you feeling? Where is your family? You know it only takes 5
minutes." C5, p.7)
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The sub-themes of personalized care and contact were identified as important to the
clients:
“One has the feeling your are either zero and nothing or a person who
is being spoken to…that is respected, (pause) you feel it straight
away.” (C4, p.8)
The clients indicated that the personalized care that they received affected their
physical and emotional well-being. A client described the experience of being
cared for by a nurse, as on par with that of a family member and her presence
made the pain more tolerable. The humour used by nurses lightened the
situation; it reduced anxiety and created a positive experience for the clients.
Negative Communication
The clients also described negative communication during the acute phase of the
crisis; for example, one client received unsupported bad news:
“The nurse that was on duty did not know about this. She was in
getting another patient.”(C5, p.8)
This negative communication was viewed as due to the nurse’s lack of awareness or
oversight. The clients expressed a preference for having the nurse present when bad
news was delivered. Although the clients trusted the nurses, they often experienced
the situation in which the nurse could not tell them the truth about their condition,
they felt that the nurses should:
“Say it like it is, do not be evasive.” (C5, p.8)
The clients also referred to the fact that communication is affected by the ability of the
individual to request assistance:
“If you cannot speak or show what’s wrong you are left alone.”(C5,
p.10)
Factors Influencing Communication -Organizational and Environmental
The clients stated that, due to organizational and environmental factors, the nurses did
not always have the time to spend connecting with and fulfilling the client’s
subjective needs. They acknowledged that the nurses tried to spend time with them
and were aware that the nurses had to set priorities and help whoever had the greatest
need. However, based on their practical experience of these issues, the clients felt that
communication was inhibited. For example, staff shortages due to illness and ward
activity resulted in less time in encounters, delays and failures in processing requests.
Consequently, the physical presence of the nurse was lacking as she was busy
elsewhere. This lack of contact with the nurses led to a failure to communicate
directly with her. This highlights the impact of changes to the nursing process in the
client's care provision; sometimes a nurse did not see a change in the clients’
condition or did not ask how they were feeling. As one client explained:
“If there is more than one nurse on duty, the other one does not know
what the other one is doing…each one has their patients and no one
else may come near them, that is bad. You maybe ring the bell and
your nurse is stuck somewhere and this means that you have to wait
for a half to one hour for your painkillers even maybe longer or be
even forgotten about.” (C5, p. 6 )
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The nurses’ workload affected the client’s trust in their overall healthcare provision.
However, not all of the clients described themselves as active participants in their care
provision, some waited for the nurse to initiate change and to fulfil their needs.
Clients indicated that they were waiting for their turn with the nurse:
“Lying there I saw all the patients got the same good treatment.”
(C6, p.14)
It appears that the clients who were aware of the nurses’ workload attempted to be
good patients and did not seek care; the clients’ descriptions of care provided by the
nurses tended to be limited to physical care. The clients were aware of the factors that
were beyond the nurse’s control, several clients shared the view that:
“The nurses are good and human but they have little time. They do not
get paid to be kind and caring just to do the job.” (C8, p.15 )
The participants described nursing communication as helping them to personally selfactualise the illness experience, which allowed them to gain ownership of the situation
by describing the individual personal impact of the crisis on them. Importantly, the
clients perceived this communication process as necessary to create a modality for
recovery.
Interpretation: Existential of ‘Being’ Human in Crisis
Van Manen (1997) delineated as the existential aspects of “being” human as spatiality
(lived space), temporality (lived time), relationality (lived other) and corporeality
(lived body). A hermeneutic phenomenological interpretation of the findings is
presented below using Van Manen’s guidelines.
Spatiality
Spatiality, within a health-crisis, is identified as essential to one’s fundamental sense
of “being”. The stability of a client’s life is broken in the hospital environment;
healthcare practices and interactions with healthcare professionals may increase or
decrease the individual’s anxiety or fear, sense of loss and alienation from the normal
environment. Although the client in crisis exists physically in the hospital
environment (space), the outside factors that make the individual who s/he is, remain
excluded from this “space.” Florence Nightingale (1859) recognized that when the
“lived space” of the body is experienced as a physical weakness the individual’s
emotional ability to self-control their fear is affected. Emotions recover when the
“lived space” of the body begins to function normally. Positive interaction supports
in-patients as they adapt to the lived space of being hospitalised during a crisis and
assists them in verbalizing their feelings of anxiety and fear. In effective
communication nurses act as a catalyst to help the individual to re-adapt
psychologically to illness and begin to regain control of their “lived space”.
Temporality
Temporality is subjective time that people experience individually; previous
experiences are used to interpret the present world. The participants’ who previously
had positive experiences brought a positive outlook to the present situation and
viewed setbacks as minor, surmountable inconveniences. The validation of the illness
experience through positive communication resulted in a mutual agreement of
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
priorities that was respectful of the other’s positions and rights. Such negotiated
agreement allows joint priorities to be set while recognising the client as an expert on
him/herself and recognises that a degree of self-determination is needed to maintain
self-esteem. In contrast, negative communication reduced a client’s self-esteem, this
potentially affects one’s long-term health outcome. In the health relationship, the
client’s past negative life events influence present communication and trust allocation.
For these clients, anxiety and fear about their current situation and its outcome
increased. The clients did not verbalise these past experiences, thus, the staff was
unaware of their situation. However, they often tested the staff’s trustworthiness by
“ringing the bell” and waiting to see if somebody responded. When trust was not
maintained, some clients withdrew completely; becoming passive and not
participating in interactions that they perceived as not beneficial to them emotionally.
This resulted in nurses being in control of and responsible for their treatment. The
clients did not draw the nurses’ attention to issues that would affect their long-term
outcome; this was reflected in a failure to alert the nurses about important health
changes. This important issue has not been identified in the literature on this
population of acute in-patients.
Relationality and Corporeality
Relationality is the lived relationship that people maintain in a corporeal existence
through sharing interpersonal space. This relationship is established when nurses
introduce themselves, smile, shake hands and touch the client in a supportive fashion.
The nurses respected the clients’ rights and physical dignity while supporting them to
re-adapt to their new reality of being in-patients. The nurses’ helping role aids the
clients in reducing situational anxiety, fear and ultimately, in achieving a renegotiated degree of control and self-determination. In the crisis situation, the clients
were highly perceptive of the nurses’ availability during communication when the
wards were busy. They perceived that the nurses created a supportive environment
that allowed and encouraged the relatives to be present. This was important in helping
the clients to renegotiate their new reality.
Strengths and Limitations
A strength of the study is that it offers a broader understanding of the experiences of
clients in the overall health-crisis situation and the themes were validated by two
English speaking respondents. Although the client’s thoughts and feelings represent
data richness, it is not clear whether other clients in a different health area would have
similar experiences of nursing communication in health-crises. Although the strength
of the findings may have been increased by triangulation using a questionnaire after
the initial qualitative analysis, this was beyond the time restrictions of this study.
However, this study may function as a pilot study to form the basis for a quantitative
study.
A limitation of the study is that the sample was obtained from a small area served by
one health organization. In addition, the crisis experiences were not confined to a
specific health condition, consequently, the findings are not representative of one
group. The researcher had ethical reservations about disclosing information; the
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
decision not to disclose information on health condition, age, or, in some instances,
gender was made after data transcription.
DISCUSSION
The clients’ fear was the major theme in this study; it was examined in detail with
three types delineated: the fear of losing stability of normal life, the fear for self and
the fear for others. Although the theme of presence from the nurses’ perspective is
well documented by Benner (1984/1995), Benner & Tanner (1987) and Benner &
Wrubel (1989), the present study provides the client’s perspective of the lived
experience of nursing communication. While Benner’s exemplars reviewed ideal care
situations that practitioners strive to emulate, the present study found that clients
accept the workload of nurses as a facet of contemporary healthcare. In actual practice
nurses must often make difficult decisions on prioritising patient healthcare and this
should be examined in future research. This study adds to the existing knowledge on
the clients’ experiences of health crises (Burfitt et al., 1993, Thompson et al., 1995)
that investigated acute illness. While Magnusson (1999) described the fear associated
with the cardiac event, this study adds the clients’ unstructured retrospective
perspective of their experiences and extends the types of fear experienced. This study
increases the understanding of the contextual issues related to the meaning of illness
and its impact, initially raised in the quantitative research of Tijhuis et al. (1995),
Brown & Harris (1978), and Thoits (1995). The importance of the nurses'
communication on the client’s outcome (Riordan and Auerbach, 1999; Leininger,
1980; Benner, 1984; Halldórsdottir, 1996; Williams, 1998; Thorsteinsson 1998; 2002)
is reiterated here; as Milne & McWilliams (1996) demonstrated, all of the clients’
subjective needs are not being met. Nursing interactions have a potentially long-term
effect on the individuals’ health and well-being (Seedhouse, 1986; Foster, 1974) and
cost benefit driven health care has implications for nursing resources and availability.
CONCLUSION
This study used Van Manen’s framework of spatiality, temporality, relationality and
corporeality to interpret the phenomenon of nursing communication experienced by
clients in health crises. Fear and presence emerged as two overall communication
themes in health-crisis. The experience of health-crisis contained “personal meaning”
that clients assigned from their past experiences of “being-in-the world”. Nursing
communication is a transformational role that influences the client’s experience of
fear and assists adaptation. The nurses’ presence emerged as a catalyst that enabled
the client to readjust to illness by providing physical and subjective support. Time was
essential in developing an interactive relationship and other factors, such as
organizational issues outside of the nurses’ control appeared to have an adverse effect
on the development of the interactive relationship. Establishing a therapeutic
relationship continues to be an essential element of quality care. While interventions
in the acute crisis phase met the clients’ physical and subjective care needs, some
clients perceived that other subjective needs that emerged in the admission process
were not addressed. The literature indicates that unresolved emotional complications
in adapting to illness can affect long-term mental health and well-being. This study
found that clients viewed communication as important in reducing fear in health
crises.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
RECOMMENDATIONS
It is recommended that in:
Nurse Practice
• The admission process should help reduce the clients’ fears.
•
Clients admitted with an acute health-crisis be routinely offered support, either
spiritual or otherwise.
Organizational Management
• Local health organizations and community representatives of healthcare users
unite to produce effective community discharge healthcare plans.
Health Policy
• Public awareness of patient’s rights and entitlements is raised.
•
Discharged patients have a contact point outside the hospital for practical and
emotional support.
Future Research
• This study of the client’s lived experiences of nursing communication in healthcrises is replicated with a larger sample size and more client health detail.
• The nurse’s perceptions of the clients’ experiences of health-crises is examined in
order to identify compare and contrast the nurses’ views with those of the clients.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
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Benner, P. (1994) Embodiment, caring and ethics in healthcare and illness, Thousand
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Biering, P. (2001) ‘Explanatory Models of Youth Violence’, PhD thesis,
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Booth, K., Maguire, P. and Hillier, V. (1999) Measurement of communication skills
in cancer care: myth or reality? Journal of Advanced Nursing, 30(5), pp.1073-1079.
Brody, M. (1987) Stories of sickness, New Haven: Yale University Press
Brown, G. and Harris, T. (1978) Social origins of depression: a study of psychiatric
disorder in women, Tavistock: Taylor and Francis.
Burfitt, S., Greiner, D., Miers, L., Kinney, M. and Brayon, M. (1993) Professional
Nurse caring as perceived by critically ill patients: a phenomenologic study, American
Journal of Critical Care, 2 (6), pp.489-499.
Data Protection Authority ( 2001), Tölvunefnd, Arnarhvoli, 150 Reykjavik, Iceland.
(DOHC), Ireland, Department of Health and Children (1998) Report of the
commission on nursing, a blueprint for the future, Dublin: Department of Health
Stationery Office.
(DOHC), Ireland, Department of Health and Children (2002) Quality and fairness, a
health system for you, Dublin: Department of Health Stationery Office.
Foster, M. (1974) An adrenal measure of evaluating nursing effectiveness, Nursing
Research, 23:118.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Halldórsdóttir, S. (1996) Caring and uncaring encounters in nursing and healthcaredeveloping a theory, Linköping: LJ Fotoand Montage/Affarsstryck.
Henneman, E., Lee, J. and Cohen, J.L. (1995), Collaboration: a concept analysis,
Journal of Advanced Nursing, 21 (1), pp.103-109.
Humphreys, T. (2001) ‘Physicians, heal yourself’, in ‘Education and living’, with The
Irish Times, Tuesday, October 23, 2001, p.13.
Hycner, R. (1995) Some guidelines for the phenomenological analysis of interview
data, Human studies, 8, pp.279-303.
Irurita, V. (1999) Factors affecting the quality of nursing care: the patient’s
perspective, International Journal of Nursing Practice, 5, pp. 86-94.
Koch, T. (1995) Interpretative approaches in nursing research: the influence of
Husserl and Heidegger, Journal of Advanced Nursing, 21(5), pp.827-836.
Leininger, M. (1980) Caring: a central focus of nursing and healthcare services,
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Magnusson, C. (1999) The cardiac emergency: exploring the life worlds of clients and
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Milne, H. and Mc Williams, C. (1996) ‘Considering nursing resource as ‘Caring
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Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Polit, D. and Hungler, B. (1997) Nursing Research: methods, appraisal, and
utilization, (4th edition), Philadelphia: J.B.Lippincott.
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Seedhouse, D.F. (1986) Health: The foundation of achievement, Chichester, John
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Thorsteinsson, L. (1999) The quality of nursing care as perceived by individuals with
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Thoits, P. (1995) Identity-relevant events and psychological symptoms: a cautionary
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Contemporary Nurse, 3(3), pp.134-141.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Webster’s Dictionary (1996) Webster’s Encyclopaedic Unabridged Dictionary of the
English Language, New York: Gramercy Books.
Williams, A.M.(1998) ‘The delivery of quality nursing care: a grounded theory study
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Williams, A. and Irurita, V. (1998) Therapeutically conductive relationships between
nurses and patients: an important component of quality nursing care, Australian
Journal of Advanced Nursing, 16(2), pp. 36-44.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
EVALUATION OF AN INNOVATIVE ASSESSMENT STRATEGY IN
NURSE/MIDWIFERY EDUCATION
Dr Sheelagh Martindale PhD, MSc, RGN (Lecturer); Dave Adams MSc, RGN,
RMN (Lecturer); Dr Winifred Eboh PhD, BSc, RM, RGN (Lecturer); Neil
Johnson MSc, RGN (Lecturer); Elaine Mowatt, M Ed, RGN (Lecturer).
Address:
The Robert Gordon University
School of Nursing and Midwifery
Faculty of Health and Social Care
Garthdee Campus
Garthdee Road
ABERDEEN
AB10 7QG
A new and innovative assessment strategy has been implemented for pre-registration
nursing and midwifery students in their second year (stage two) of the course. The
assessment strategy for the ‘Research and Evidence-based Practice’ module has
changed from a 2500 word written assignment to a Computer Assisted Assessment
(CAA). The first cohort of students have undertaken the new assessment, it is
therefore paramount that an evaluation of this new form of assessment is undertaken
to ensure that this assessment strategy is improved for subsequent cohorts. The
module team want to ensure that the assessment is meeting academic standards and is
set at the correct level for students (The Quality Assurance Agency for Higher
Education, 2000). The nursing course attracts a broad spectrum of students so it is
imperative to measure CAA’s suitability and fairness for students from all these
academic backgrounds (from PhD to Standard grade school leavers) at the same time
maintaining the correct level. It’s also important to assess the students’ understanding
of the subject of research as a whole and not in part. The suitability of the actual tool
of assessment, checking internal consistency of the questions is being reviewed. The
evaluation is taking the form of a questionnaire survey for the cohort of students who
have completed the assessment as well as extracting data from the completed
assessments within the computer programme, QuestionMark Perception. The data is
to be entered and analysed in a Statistical Package for Social Sciences (SPSS)
database. This paper will report the findings of the evaluation, highlighting challenges
encountered by both students and the module team and providing an overview of
areas of change for future cohorts. The evaluation will be complete by closing the
feedback loop (Light G, Cox R., 2003).
References:
Light G, Cox R., 2003. Learning and Teaching in Higher Education. London, Sage
Publications.
The Quality Assurance Agency for Higher Education, 2000. Code of practice for the
assurance of academic quality and standards in higher education. Section 6:
Assessment of students. (Online). Available from:
http://www.qaa.ac.uk/academicinfrastructure/codeOfPractice/default.asp. (Accessed
on 21st March 2005).
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
MENTAL HEALTH NURSES’ PERCEPTIONS OF ‘REVOLVING DOOR’
ADMISSIONS TO AN ACUTE INPATIENT PSYCHIATRIC UNIT
Mr Pádraig McBennett RPN, RGN, MSc (Hons), BSc (Hons)
Lecturer
School of Nursing & Midwifery
The University of Dublin, Trinity College
24 D'Olier Street
Dublin 2
Ireland
+ 353 6088541
[email protected]
Over the past 20 years, significant progress has been made in the development of
mental health services in Ireland. Despite this progress however, there remains an
over reliance on hospital beds as the core of psychiatric care, with readmissions
accounting for 70% of all inpatient episodes. This is often referred to as the ‘revolving
door’ phenomenon and is a topical issue in psychiatry.
The purpose of the study was to explore mental health nurses’ perceptions of
rehospitalisation to an acute inpatient psychiatric unit. The data-gathering process was
guided by the following questions:
1. How do registered mental health nurses perceive ‘revolving door’ psychiatric
admissions to an acute psychiatric unit?
2. What individual/organisational strategies that can be brought to bear on the
‘revolving door’ phenomenon?
A qualitative, Husserlian phenomenological research design was used. Data
collection was by means of semi-structured interviews of a purposive sample (n=9) of
experienced registered mental health nurses across a range of work settings. Data
analysis was undertaken using Colaizzi’s (1978) framework procedures. Five
categories, each comprising a number of themes emerged. These were:
inappropriateness of inpatient model of care, attitudinal response of mental health
nurses providing care, psychosocial treatment interventions, service development and
role perception.
Key findings suggest that mental health nurses view the rehospitalisation phenomenon
in a negative way, with feelings of demoralisation and despondency evident, resulting
from a perceived sense of failure to achieve positive outcomes with some patients
who have a ‘revolving door’ pattern of admissions. The attitudinal response of mental
health nurses providing care is influenced by the treatment setting, with a more
collaborative therapeutic relationship developing between nurses and clients outside
the inpatient environment.
The findings suggest that mental health nurses are in an ideal position to provide
valuable information regarding service developments which may help inform the
body of knowledge in relation to future mental health policy direction.
References
Colaizzi P. (1978) Psychological research as a phenomenologist sees it. In Existential
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Phenomenological Alternatives for Psychology (Valle R. & King M.) (eds.)
Oxford University Press, New York, 48-71.
Daly A. Walsh D. (2003) Activities of Irish Psychiatric Services. Health Research
Board, Dublin.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
MENTAL HEALTH NURSES’ PERCEPTIONS OF ‘REVOLVING DOOR’
ADMISSIONS TO AN ACUTE INPATIENT PSYCHIATRIC UNIT
Mr Pádraig McBennett RPN, RGN, MSc (Hons), BSc (Hons)
Lecturer
School of Nursing & Midwifery
The University of Dublin, Trinity College
24 D'Olier Street
Dublin 2
Ireland
+ 353 6088541
[email protected]
Over the past 20 years, significant progress has been made in the development of
mental health services in Ireland. Despite this progress however, there remains an
over reliance on hospital beds as the core of psychiatric care, with readmissions
accounting for 70% of all inpatient episodes. This is often referred to as the ‘revolving
door’ phenomenon and is a topical issue in psychiatry.
The purpose of the study was to explore mental health nurses’ perceptions of
rehospitalisation to an acute inpatient psychiatric unit. The data-gathering process was
guided by the following questions:
1. How do registered mental health nurses perceive ‘revolving door’ psychiatric
admissions to an acute psychiatric unit?
2. What individual/organisational strategies that can be brought to bear on the
‘revolving door’ phenomenon?
A qualitative, Husserlian phenomenological research design was used. Data
collection was by means of semi-structured interviews of a purposive sample (n=9) of
experienced registered mental health nurses across a range of work settings. Data
analysis was undertaken using Colaizzi’s (1978) framework procedures. Five
categories, each comprising a number of themes emerged. These were:
inappropriateness of inpatient model of care, attitudinal response of mental health
nurses providing care, psychosocial treatment interventions, service development and
role perception.
Key findings suggest that mental health nurses view the rehospitalisation phenomenon
in a negative way, with feelings of demoralisation and despondency evident, resulting
from a perceived sense of failure to achieve positive outcomes with some patients
who have a ‘revolving door’ pattern of admissions. The attitudinal response of mental
health nurses providing care is influenced by the treatment setting, with a more
collaborative therapeutic relationship developing between nurses and clients outside
the inpatient environment.
The findings suggest that mental health nurses are in an ideal position to provide
valuable information regarding service developments which may help inform the
body of knowledge in relation to future mental health policy direction.
References
Colaizzi P. (1978) Psychological research as a phenomenologist sees it. In Existential
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Phenomenological Alternatives for Psychology (Valle R. & King M.) (eds.)
Oxford University Press, New York, 48-71.
Daly A. Walsh D. (2003) Activities of Irish Psychiatric Services. Health Research
Board, Dublin.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Intervention effectiveness findings on quality of life for nursing home residents
with dementia: Results of a systematic literature review and meta-analysis.
Philip McCallion, Ph.D.
Professor and Director
Center for Excellence in Aging Services
RI 207
University at Albany
Albany, NY 12222. USA
Dayna Maniccia, MPH
Research Associate
Center for Excellence in Aging Services
RI 209
University at Albany
Albany, NY 12222. USA
Mary McCarron, Ph.D.
Acting Director of Research & lecturer
School of Nursing and Midwifery studies
Trinity College Dublin
Background: Given trends of increasing numbers of individuals with dementia in
nursing homes interventions to improve/support the quality of life for these
individuals have become a critical concern, one on which resources are increasingly
expended. There are many anecdotal reports of intervention effectiveness but not
sufficient systematic attention that an evidence base for interventions appears
established.
Strategy: A systematic review of the literature was undertaken. Sixteen electronic
databases were searched using the key works dementia, Alzheimer’s, and nursing
home. Search strategy terms were expanded to include possible variations of the root
whenever possible. Articles published between January 1, 1980 and March 31, 2004
that addressed interventions to improve QoL in nursing home residents with dementia
were included. Any articles dealing with the biology or pharmacology of the disease
were excluded. After review of titles and/or abstracts, 1016 potential articles emerged.
Meta-analytical techniques will then applied using Cochrane Collaboration
recommendations More than 700 full articles were then acquired and reviewed. Two
percent of the works were in a language other than English. Effect sizes were
calculated where possible and analyses performed to establish which interventions
reached a threshold of evidence based, which worthy of further systematic
consideration, and which appeared ineffective.
Findings: The majority of the references discussed case or descriptive studies (19%
and 18% respectively). Thirty-nine percent were either quasi-experimental or
experimental designs. The majority of the references dealt with interventions directed
at an individual (residents, staff, or family) and included such topics as music,
training, physical activity, behavioral interventions, light therapy, and family
involvement. Of the works published about facility level interventions, the majority
discussed special care units. A third category, administrative interventions, included
staffing, tracking, and management styles.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Conclusions: The majority of interventions did not reach a threshold of evidencebased but there were many for which beginning data on effectiveness is present. More
systematic approaches supported by this and other meta-analyses hold the potential to
advance knowledge on which interventions will support quality of life for persons
with dementia.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Title of Paper: PERFORMANCE APPRAISAL PERCEPTIONS AND
ATTITUDES OF STAFF NURSES TO ITS INTRODUCTION.
Author: Bernard McCarthy, (RNMH, RGN, BSc., MSc.), Lecturer, Centre for
Nursing, NUI Galway.
email [email protected]
Tel 091-493817
Background to study: The people in an organisation are its most valuable resource; it
is therefore wise to develop these individuals to their optimum potential. There are
many ways of developing staff yet the most important and basic element involved is
knowing what your staff need in relation to their role within the organisation and
tailoring your development plans to meet their needs. The Performance Appraisal
Process is a means of bridging this gap between the current needs of staff and the
long-term requirements of the organisation. A negative view have prevented
performance appraisal from being taken on board within the Irish Healthcare System.
Performance appraisal now needs to become a reality for Irish Healthcare as
highlighted in the Dixon & Baker Report (1996) and in the more recent pay
agreements. Prior to the successful introduction of an appraisal system it is necessary
to examine how those who will be utilising it feel about it. Since Langen-Fox et al
(1996) believe that it is reasonable to expect that individuals reactions to appraisal
systems would have just as much impact on it’s success and effectiveness as would
the technical aspects of the system. Therefore In this study the author explored the
perceptions of nurses to the introduction of a formal staff appraisal system.
Design of the study: A qualitative research methodology was utilised in two acute
clinical settings in the West of Ireland. A combination of research methods was
utilised. The staff nurses who participated were interviewed using a focus group of 8
and 10 members, where as the ward sisters were, interviewed individually using a
semi-structured interview.
Sample Selection: The sample consisted of 18 staff nurses and 7 ward managers. A
representative Staff nurse was randomly selected from each of the ward areas in both
participant hospitals. 13 participants were confirmed to attend the initial focus group
and 10 for the second focus group. Attendance on the day for each of the focus groups
was 8 and 12 respectively. Ward managers were also randomly selected from
available personnel.
Data Analysis: Thematic analysed of the data was undertaken utilising the software
package Ethno4 to identify categorised. The emerging categories were checked
participants to ensure accuracy and prevent misinterpretation of the data. The results
presented in the form of a discussion on the issues highlighted.
Results: The data that emerged highlighted several important issues which required
close consideration if management decide to introduce and execute an appraisal
system effectively into nursing in this region. Management support, dignity and
respect, along with staff involvement in the process were the main issues highlighted.
Participants felt that the purpose of appraisal in theory appears straight forward but in
practice the variety of expectations between management and the workforce are too
vast for a simple solutions. It is for this reason that several participants specified the
need for the purpose of appraisal to be clearly defined from the onset. Participants had
mixed opinions as to who would benefit from the process. The majority of
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
participants kept in line with the general thinking reported in the literature, that it
improved:
• The profession
• The “standard of care” appeared to be the most agreed upon.
• The patient was seen by most as the end benefactor, usually as a consequence of
the effects appraisal had on other
• The global view of appraisal being beneficial to all, indicated by a number of
participants.
The main areas of benefit identified by participants of the appraisal process were it
role as a forum for communication and as a gateway for feedback
Dixon, M. & Baker, A. (1996) A Management Development Strategy for the Health and
Personal Social Service in Ireland. Dublin, Department of Health.
Langan-Fox, J., Bell, R., McDonald, L., Morizzi, M. (1996) The dimensional grating of
performance appraisal systems. Australian Psychologist, Nov. 31,3,194-203.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
ASSESSMENT OF CLINICAL PRACTICE:
A GUIDE FOR STUDENTS AND PRECEPTOR NURSES
Bridie McCarthy, RGN, RM, BNS, RNT, BA Counsel. MSc.
College Lecturer, School of Nursing & Midwifery, Brookfield Health Sciences
Complex, University College Cork.
Telephone Number; (021)4901497 ( [email protected])
Siobhan Murphy, RGN, BSc, RNT, MSc
College Lecturer, School of Nursing & Midwifery, Brookfield Health Sciences
Complex, University College Cork.
Telephone Number; (021)4901492 ([email protected])
The BSc undergraduate nursing programme was introduced in Ireland in 2002.This
programme heralded many challenges for nurse practitioners and nurse educationalists
alike. An Bord Altranais (2003), whilst acknowledging the tremendous change that
has occurred in nursing, commend the nursing profession for embracing these
challenges.
Assessment of students during clinical placements is one area that has presented such
a change. Prior to 2002, student nurses were assessed by Clinical Nurse Managers
using the Proficiency Assessment Format. In contrast, the new programme requires
nurse practitioners (preceptors) to assess student nurses levels of learning as they
progress from year one to year four of the programme. An Bord Altranais, (2002) did
suggest the use of the Steinaker and Bell Experiential Taxonomy (1979) for assessing
students during clinical practice. This taxonomy was originally developed by
Steinaker and Bell in 1979 to make explicit degrees of human experiences as one
learns and specifies five separate and distinct levels of learning from experiences
(exposure, participation, identification, internalisation and dissemination). Whilst this
taxonomy has a sound theoretical underpinning however, An Bord Altranais gave no
specific detail as to the operationalisation of this taxonomy as a strategy for assessing
levels of learning within clinical practice. Therefore, a need existed to adapt this
complex taxonomy to the specific needs of undergraduate students and their assessors
(preceptor nurses). Thus a modified version of the original taxonomy titled the
‘Adapted Steinaker and Bell Experiential Taxonomy’ (ASBET), was developed by the
current researchers as a means of supporting students and preceptor nurses in this
onerous and challenging task.
This paper will outline how this complex taxonomy was adapted to facilitate:
ƒ students to recognise that levels of learning exist and how progression is
possible along the continuum of the taxonomy in clinical practice
ƒ preceptor nurses to engage in assessing students levels of learning through the
four years of the programme.
This Adapted Steinaker and Bell Experiential Taxonomy (ASBET) was implemented
in September 2004. Still in it’s infancy this taxonomy has not been evaluated as yet.
However, it’s usefulness in facilitating assessing students levels of clinical learning
may be valuable to other third level nursing institutions and indeed other healthcare
programmes.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
References
An Bord Altranais (2002) www.nursingboard.ie/elearning/competency 02/03/2005
Steinaker, N. and Bell, M (1979) The Experiential Taxonomy: A New Approach to
Teaching and Learning, London: Academic Press
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Authors
Professor Geraldine McCarthy PhD
Head of the School of Nursing & Midwifery
Brookfield Health Sciences Complex
University College Cork
Dr. Eileen Savage PhD
Senior Lecturer,
School of Nursing & Midwifery
Brookfield Health Sciences Complex
University College Cork
Ms. Elaine Lehane RGN, BSc.
Lecturer
School of Nursing & Midwifery
Brookfield Health Sciences Complex
University College Cork
TITLE: NURSING & MIDWIFERY RESEARCH PRIORITIES IN THE
SOUTHERN HEALTH BOARD REGION
Abstract
Aim: To identify research priorities for nursing and midwifery in the Southern Health
Board area in Ireland for the immediate and long term. Method: Ten focus groups
were conducted over a two-month period with 70 nurses and midwives working in
clinical, managerial and educational roles participating. Based on focus group
findings and a literature review a multi-item Likert type questionnaire was constructed
and administered to 520 nurses and midwives (response rate 95% n=494). Results:
Research priorities were identified as: impact of staff shortages on retention of
RNs/RM’s (80%); quality of life of chronically ill patients (76%); stress and bullying
in the workplace (76%); assessment and management of pain (75%); skill mix and
staff burnout (73%); cardio-pulmonary resuscitation decision making (72%); coordination of care between hospital and primary care settings (69%); medication
errors (67%); and promoting healthy lifestyles (64%). Respondents also indicated that
these priorities warranted immediate attention. Implications for practice include the
need for: emphasis on quality pain control; recognition and exploration of the ethical
issues relating to resuscitation; management of the context within which clinical care
is given.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
A CONCEPTUAL DESCRIPTION OF THE ROLE OF NURSING
PRACTICE DEVELOPMENT CO-ORDINATORS’ IN IRISH
GENERAL HOSPITALS
Mary McCarthy, 22 Ballypark, Flaxmill Lane, Drogheda, Co. Louth.
RGN, RM, RNT, BNS, MSc., PGDCHSE
A/Director, Nursing & Midwifery Planning & Development Unit, HSE North
East Area, Ardee, St. Brigid’s Complex, Co. Louth
Abstract
The position of Nursing Practice Development Co-ordinator constitutes a relatively
new occupational in Irish healthcare and was introduced in tandem with the transfer of
undergraduate nurse education to the higher education sector. Established since 1996,
there is an absence of empirical research on this occupational role, the scope of which
extends to practice, management, education, and research.
Situated in all major teaching hospitals and set at assistant director of nursing level,
these are significant posts. Those occupying these positions have a central role in
influencing the clinical learning and practice environment. It could be reasonable
argued that they are central to determining the approaches, priorities, focus,
methodologies, and momentum of clinical practice development in their respective
organisations.
The aim of this study was to gain a conceptual description of the role of Nursing
Practice Development Co-ordinators as perceived by those who occupy these
positions. A qualitative approach using a grounded theory design was used. Data
were collected through in-depth interviews from a sample of ten Nursing Practice
Development Co-ordinators from general hospitals throughout Ireland.
From the analysis, three major conceptual categories emerged to describe the role.
These were: an unseen unknown quantity, against the tide, and building structures. A
tentative care category, creating the dynamic for culture change through leadership
and empowerment was thought to describe the psychological social process of being a
Nursing Practice Development Co-ordinator.
The findings of this study provide an overview of the evolution of Irish nursing, an
understanding of nursing culture, and the influence of nursing culture on the
endeavours of those who are striving to develop nursing practice. Recommendations
were made for policy, practice and management, education and research.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Midwives’ Personal Accounts of Stillbirth
Ms Mary McCarthy MSc, BA (Hons) Psychology, FETC, DPSM, PGDipE, RGN,
RM.
Senior Lecturer in Midwifery
Middlesex University
Archway Campus
Furnival Building
10 Highgate Hill
London N19 5LW
England
+ 44 208 411 6739
[email protected]
Aims
To investigate the needs of midwives who have encountered stillbirth within the
clinical setting of a hospital maternity unit, and to ascertain whether there is a need for
counselling and education in such situations.
Background and Rationale
A review of the literature revealed that this area is poorly articulated, searching for
literature on the culture of nursing revealed some findings but again this is an areas
under researched. The lack of research suggests very little attention is paid to the
National Health Service professional in relation to nursing and midwifery. Bowden
(1988) in looking at what nurses and midwives actually do refers to the taken-forgranted assumptions inherent in the present culture.
Whilst recognising the needs of the parents who have encountered stillbirth, The
Kohner Report, (1984) raised awareness with regard to the neglected needs of
midwives in relation to stillbirth.
Design
A qualitative approach using semi-structured interviews, piloted initially using two
samples. The sample study consisted of eight midwives of varying experience and
age. The midwives had attended a stillbirth in a delivery suite of a maternity hospital
(UK) within a period of over thirty years. This period of time was selected to identify
possible changes with regard to stillbirth and support systems offered to midwives.
Date Collection and Analysis
Data were collected through in-depth open-ended interviews and transcribed. During
the transcription phase certain steps were taken to facilitate this task of analysis,
according to Brooks and Warren (1967). Data analysis was guided by constant
comparative analytical approach research methodology. Identified themes that
emerged from the data were
Interpreted and categorised.
Findings
Three major categories were identified, Personal, Professional and Institutional
Variables. These categories were consistent throughout indicating that midwives felt
unsupported personally, emotionally, professionally when having
to attend a stillbirth.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Limitations
This study has its limitations in that it need further research on a wider scale and
depth, doctoral level to examine what kind of support systems are available to
midwives in the present time. Recommendations need to be addressed and developed
within National and Local Policy and developed within the midwifery curriculum.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
BREAST CANCER REVIEW CLINICS: PERCEPTIONS OF NEED BY:
PATIENTS, NURSES AND DOCTORS
Eilis McCaughan, RGN, BSc (Hons), Dip Oncology Nur, PGDHE, PhD.
Lecturer in Cancer Nursing, School of Nursing, University of Ulster
Oonagh McSorley, RGN, BSc (Hons), PGDSP, RSN. Research Assistant, Belvoir
Park Hospital, Belfast
Background: The value of routine medical follow-up both in terms of detection of
recurrence and patient satisfaction has been questioned. The NICE (2002) guidelines
recommend women are fully discharged, after three years post-treatment. However,
there appears to be a general reluctance to carry this out. The literature also shows that
while medical staff’s time is stretched, there is an underuse of nurses as a potential
manpower to meet the needs of these patients in an effective way (Koinberg et al
2004).
Aims: The overall aim of the study was to explore the healthcare needs of women
attending breast cancer review clinics from their own perspectives. It also explored
how these needs were being met, as well as healthcare professionals’ perceptions of
ways in which the service could be delivered more efficiently and effectively.
Methods: The study used a qualitative approach including observations and
interviews. Observations were carried out during seven outpatient oncology/surgical
breast review sessions. Twenty-one women, who were attending the breast cancer
review clinic, were interviewed in their own homes. Interviews were also carried out
with outpatient nursing staff, breast care nurses, oncologists, surgeons and a social
worker. Purposive sample were selected from each of these groups. Data analysis is
still in progress.
Findings: Although these women saw themselves as having returned to a pre-cancer
state, they still had a deep-seated fear of recurrence and a need for reassurance that
they were disease free. This reassurance was generally met through the review clinic.
However many psychosocial needs were left un-addressed. Medical and nursing staff
perceived that women needed to be reviewed but acknowledged that appropriately
prepared nurses could deliver a more effective and efficient service.
Source of Funding: Research & Development Office, Northern Ireland
References
National Institute for Clinical Excellence (2002) Guidance on cancer services:
improving outcomes in breast cancer.
Koinberg I-L, Fridlund B, Engholm G-B & Holmberg (2004). Nurse-led follow-up on
demand or by physician after breast cancer surgery: a randomised study. European
Journal of Oncology Nursing 8, 109 –117.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
ANALYSIS OF FATIGUE IN WOMEN CANCER SURVIVORS
Ms Deirdre McGrath RN, RNT, BSc Health Studies, PGDip CHSE, MSc
Advanced Nursing
Lecturer in Nursing
The School of Nursing and Midwifery
Queen's University Belfast
Medical Biology Centre
97 Lisburn Road
Belfast BT9 7BL
Northern Ireland
+ 44 2890 975835
[email protected]
Fatigue may be characterised as a multi-dimensional phenomenon that develops over
time, diminishing energy and mental capacity of cancer patients. Survivors of
women’s cancer frequently suffer from chronic fatigue. Although most cancer patients
experience fatigue as a major obstacle to maintaining normal daily activities and
quality of life, little is known about what factors underlie it and indeed how common
this condition is. Consequently, it is seldom assessed and treated in clinical practice
(Cella et al., 1998).
Aim
To provide insight into the aetiology and clinical course of cancer-related fatigue.
Objectives
1. Determine the incidence of fatigue, and its impact on quality of life, in women
cancer survivors versus the control population by using the Piper fatigue scale
(Piper 1998).
2. Evaluate cytokines in the pathogenesis of fatigue.
3. Establish whether cancer and cancer treatment can alter quantitative measures of
cellular immunity and subsequently lead to side effects such as fatigue.
4. Examine the interrelationship among biological processes, medical variables and
cancer-related fatigue.
Results
The current study indicates this patient population is significantly fatigued when
compared with the control group. The quality of life was significantly impaired in
participants who demonstrated severe fatigue. There was some variation in cytokine
levels between fatigued and non-fatigued participants.
Implications for patient care
The results of this study are currently being used in the development of protocols
pertaining to the assessment and management of patient care. It is also anticipated that
this study will lead to a greater understanding of the fundamental processes, which
underlie cancer-related fatigue and may direct the development of clinical
interventions for maintaining health in women who have suffered and survived
cancer.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The technological environment an ‘alien environment’: The experienced critical
care nurse’s experience
Author’ Name:
Mary McGrath
Address:
5 Maple Grove, Castleknock, Dublin 15.
Job Title:
Lecturer in Nursing
Qualifications:
Certificates: Registered Gen. Nurse (Mater
Hospital, D.) Registered Midwife (Coombe
Hospital, Dublin)
Post Grad Critical Care Nurse (Mater Hospital,
Dublin)
Diplomas: First Line Management (College of
Industrial Relations, Ranelagh).
Degree: Bachelor of Nursing Studies (UCD)
Masters: MSc Nursing (Royal College of Nursing)
Abstract
Purpose: The paper presents one of the three themes (‘alien environment) that
emerged from a phenomenological study of ‘the lived experiences of experienced
critical care nurses caring within a technological environment’.
Background: Although nursing practice in inextricably interwoven with technology,
due to the sparse and speculative nature of the available literature, the relationship is
not well understood (Barnard and Gerber, 1999). Literature that does exist reflects a
dichotomy between the positive and negative; this orientation is referred to as the
optimism and pessimism debate (Sandelowski, 1997; Barnard, 2000). Theorists such
as Leininger (1988) urge nurses to study technology in nursing. She hypothesized that
the greater the signs of technological care giving, the less the signs of interpersonal
care manifestations. On a more personal level, having spent thirteen years caring in
the critical care area I believe that it is possible to be patient centered in the critical car
area.
Method: Following ethical approval, ten experienced nurses from two cardio thoracic
critical care units in Ireland participated in the study. The methodology used was a
Heideggerian phenomenological approach.
Results: The theme ‘alien environment’ is presented under three sub-themes ‘existing
in an alien environment’, embracing technology’ and ‘creating a home’ It illuminates
how experienced critical care nurses can transcend the obtrusive nature of technology
as they care and create a home for their patients/families.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
References
Barnard, A. (2000) Alteration to will as an experience of technology and nursing,
Journal of Advanced Nursing, 31(5), pp.1136-1144.
Barnard, A. and Gerber, R. (1999) Understanding technology in contemporary
surgical nursing: a phenomenographic examination, Nursing Inquiry, 6, pp.157-166.
Leininger, M. (1988b) The phenomenon of caring: importance, research questions and
theoretical considerations, in Leininger, M. (editor), Qualitative research methods in
nursing, Orlando: Grune and Stratton.
Sandelowski, M. (1997) Ir/reconcilable differences? The debate concerning nursing
and technology, Image Journal of Nursing Science, 29(2), pp.167-174.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
A Pilot Evaluation of Clinical Supervision as Implemented upon an Acute
Psychiatric Admission Unit.
Name of Authors:
*Declan Patton, RPN, RNT, BNS(Hons), PGDipEd, MSc Lecturer School of Nursing
and Midwifery, University College Dublin [email protected] +353 1 7166417.
*Aine McHugh, RGN, RPN, RNT,BNS (hons), MSc.Lecturer School of Nursing and
Midwifery, University College Dublin [email protected] +353 1 7166433 .
*Damien O Dowd, Director of Nursing, St. John of God Hospital, Stillorgan, Dublin.
*Cathy Shelley, Clinical Nurse Manager 2, St. John of God Hospital, Stillorgan,
Dublin.
*Stephen Boss, Clinical Nurse Manager 1, St. John of God Hospital, Stillorgan,
Dublin.
*Geraldine Kerrigan, Clinical Nurse Manager 1, St. John of God Hospital, Stillorgan,
Dublin.
This paper sets out the process, which was used to implement and evaluate a Clinical
Supervision programme, which was facilitated over a twelve-month period in an acute
psychiatric admission unit (acute unit) in a Dublin Psychiatric Hospital. This project
was initiated on foot of a staff request for a programme of continuous professional
development. Subsequent to this a clinical supervision implementation committee was
developed. This committee comprised members from nursing management, nursing
practice and lecturers from a third level institution. The goal of this committee was to
implement a programme of clinical supervision upon an acute unit, and to evaluate the
effectiveness of this supervision. The focus of evaluating this clinical supervision
programme was on ascertaining supervisor and supervisee perceptions of the
effectiveness of the clinical supervision employed. Evaluation of such perceptions
occurred post the implementation of the clinical supervision programme. Data was
collected via a questionnaires and focus group interview. The questionnaire was
administered to those who had received supervision whilst those who facilitated
supervision engaged in a focus group interview. The questionnaire was formed after
an extensive review of literature relevant to clinical supervision in nursing.
Questionnaire data was analysed using descriptive statistics whilst focus group data
was analysed using qualitative content analysis. Findings indicate that engaging in
supervision has the potential to increase a supervisees confidence in themselves as a
practitioner and as a member of the multi disciplinary team. Subsequently, this may
lead to an improved level of nursing care. The only impediment to the supervision
process in this study was that of supervision not taking place at its allocated time. This
was due to the unpredictable nature of practice on the acute unit. In relation to the
preparation of supervisors it was found that in order for clinical supervision to be
implemented successfully, greater consideration must be given to supervisor and
supervisee preparation. This could happen through the facilitation of information and
educational workshops. In conclusion, the presentation related to this paper will
highlight how a clinical supervision programme was implemented within an acute
psychiatric admission unit. It will then detail how data was collected in the evaluation
of the supervision programme. Questionnaire and focus group findings will be
detailed, after which the presenters will suggest ways in which this pilot study can
help with the implementation of clinical supervision within any clinical area.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
HSE-Eastern Region
Nursing & Midwifery Planning & Development Unit
TITLE:
Presenter:
Nurse Practice Development Initiative 2004/2005
Elizabeth Mc Keon, RNID, Dip. Mgt., BNS,
Msc in Education & Training
Nursing & Midwifery Planning & Development Unit
HSE – Eastern Region
Mill Lane,
Palmerstown,
Dublin 20.
One of the priorities for the Nursing & Midwifery Planning & Development Unit
(N.M.P.D.U.) HSE-eastern region is to promote, support and enable the further
growth of nurse practice development activity within the region. In support of this a
practice development initiative supported by the National Council for the Professional
Development of Nurses and Midwives and The Nursing & Midwifery Planning &
Development unit was set up. The initiative was inclusive of all care groups across
primary, secondary and tertiary services aimed primarily at services that do not have
access to practice development resources in their service and was developed in
partnership with health care service providers, Royal College of Surgeons Ireland,
Irish Nursing Practice Development Association and in liaison with Professor
Brendan Mc Cormack, University of Ulster.
Objectives:
• To identify an area of practice that required consideration and change
management to improve patient / client outcomes.
• To negotiate with management teams for organisational and multidisciplinary
support to facilitate this change process.
• To introduce the concept of practice development into health care services that
do not have access to practice development resources, by providing education
and training to address the driving and restraining forces that the participants
may encounter when introducing practice development into their own services.
• To facilitate change management and development of practice at local level,
and to monitor and evaluate the progress.
Method: A regional steering group was set up. A Selection of 28 service providers
representing all care groups from voluntary and statutory services. A tailor made
five-day training programme was developed to address relevant topics that would
support the participants in their practice. The programme was held in November 2004.
This programme was evaluated utilising focus groups, questionnaires and feedback
sessions.
Progress: The programme was held in November with 100% attendance and
participation. Evaluation suggests that the programme was successful in achieving its
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
objectives and outcomes in promoting the concept of practice development and
provided the participant with valuable resources to embark in the introduction of
practice development in their services. Further evaluation on the progress of
implementing practice development into the services occurred in May 2005 when the
participants came together to share their experiences of their projects and identify
driving and restraining forces that they have encountered.
This poster presentation will outline
• Purpose of the initiative
• The process involved
• Outcomes of the initiative
• Synergyo Developed networks and support locally
o Links developed with Irish Nursing Practice Development Association,
and services from other care groups
o Higher Education Institutes input
•
The next step
For further information please contact :
Liz Mc Keon at 01-7006582
e-mail: [email protected]
Or
Ms. Eithne Cusack
NMPDU _ Eastern Region
Mill Lane
Palmerstown
Dublin 20
01-6201701
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE NURSE CONSULTANT: AN EVALUATION STUDY USING A THREE
HUNDRED AND SIXTY DEGREE INTERVIEW FRAMEWORK.
Rob McSherry RGN, DipN (Lon), B.Sc. (Hon’s), MSc, PGCE, RT
Principal Lecturer Practice Development,
and
David Mudd RGN, RMN, RCNT, BA, RNT
Senior Lecturer Practice Development
School of Health and Social Care
University of Teesside
Teesside
Middlesbrough
England
United Kingdom.
Background
Ambiguities exist about the nature, function and value of the Nurse Consultant (NC)
role to the individual, nursing and the National Health Service (NHS). Yet, to date
minimal research studies have evaluated the lived experience of staff to demonstrate
the perceived impact of the NC in practice McSherry & Johnson (2005).
Aims and objectives
This study aimed to evaluate the perceived impact of the NC through the lived
experience of staff.
Design/method
A qualitative research design was developed to evaluate the perceived impact of the
nurse consultant through the lived experience of staff by the utilization of a threehundred and sixty degree semi structured interview framework. Interviews were
undertaken with executive, senior managers, medical, nursing and allied healthcare
professional colleagues. The study was based on three nurse consultants working at a
University Hospital in the North East of England. A collaborative purposive
sampling technique was used involving ten participants in order to provide detailed,
objective and relevant information associated with the NC role.
Findings
A total of thirty semi-structured interviews were undertaken. A thematic analysis
using Bowling (1997) approach to deciphering interview data revealed nine primary
categories. With the exception of the personal qualities the NC brings to the role. A
series of generalist themes emerged associated with how the role can be enhanced in
the future by involving, informing and engaging staff and by developing a phased
approach to implementing and evaluating the role.
Conclusions and recommendations
The findings indicate that the continued success of the NC role is associated with
developing a more structured approach to implementation and evaluation within the
employing organizations. The recommnedations broadly catergorise into two areas.
Educationally it is about raising awareness of the NC through communication,
clarification of expectations by engaging and supporting staff in the acceptance of
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
the role. Organizationally there should be a more phased approach to establishing,
implementing and evaluating the NC.
Key words Nurse consultant, evaluation, qualitative research, semi-structured
interviews.
References
Bowling A (1997) Research Methods in Health. Open University Press.
Buckingham.
McSherry, R, Johnson, J (2005) Demystifying the Nurse/Therapy Consultant: A
Foundation Text, Nelson Thornes, Cheltenham.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE NEEDS OF THE BREASTFEEDING MOTHER AS IDENTIFIED BY
MIDWIVES IN CLINICAL PRACTICE.
AUTHOR
Teresa Meaney
College Lecturer (Nursing)
ADDRESS
Centre For Nursing Studies,
National University Of Ireland Galway,
IDA Buisness Park,
Lower Dangan,
Galway.
QUALIFICATIONS
Msc (Nursing), BNS, DNS ,RGN, RM,RNT, RMT
ABSTRACT
The aim of this study was to explore the experience of midwives caring for the
breastfeeding mother. A review of the literature indicates a dearth of material relating
to this issue, despite the fact that the midwife has been identified as the key person
responsible for this aspect of maternity care (Department of Health ,1994). It appears
that the issues relating to the personal experience of breastfeeding have been lost in
the accounts of the health advantages of breastfeeding. Health professionals have
tended to focus on the biomedical model of breastfeeding exposing its benefits for
mother and baby (Cunningham et al .;1991;Schmiedet al.2001).
A purposive sample of ten registered Midwives was chosen for this study. The
midwives worked in a large teaching hospital in the Republic of Ireland. A qualitative
research approach,using Heideggerian phenomenology was chosen for this study.
Data was collected using unstructured interviews. The interpretation of the text for
this study was guided by a phenomenological hermeneutic analysis method .Analysis
of the interview data revealed the following needs of the breastfeeding mother as
identified by midwives in clinical practice. Mothers need to personally want to
breastfeed.,”Mothers need to engage in the intimacy/psychosocial aspects of
breastfeeding,”Mothers need to be prepared for a realistic expectation of what
breastfeeding involves, Mothers need to understand that breastfeeding involve a
process,
Mothers
need“Consistent
advice/support/time”,
Mothers
need
Commitment/determination.
The study findings suggested that midwives need to address the psychosocial aspects
of breastfeeding in order to facilitate the breastfeeding mother. Breastfeeding is not
simply the physical process of feeding a baby ,but rather successful breastfeeding
involves an emotional and intimate engagement between mother and baby that is
mutually satisfying. The findings from this study challenge the focus of maternity care
to shift and include the psychosocial aspects of breastfeeding for mother and baby.
Health professionals cannot afford to ignore the deep psychological intimacy shared
between mother and baby in successful breastfeeding.
Recommendations arising from this study are made in an attempt to acknowledge the
importance of the psychosocial and intimate aspects of breastfeeding and its
contribution to successful breastfeeding.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Cunningham,A.S.,Jelliffe,D.and Jelliffe,P. (1991)Breastfeeding and health in the
1980s;a globalepidemiologic review,Journal of Paediatrics,118 (5),pp.659-665.
Department of Health (1994) A National Breastfeeding Policy For Ireland
Dublin:Department of Health.
Schmied,V.,Sheehan,A and Barclay,L.(2001)Contemporary breastfeeding policy and
practice: implications for midwives,Midwifery,17(1),pp.44-54.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
AN EVALUATION OF THE EARLY EXPERIENCES AND PERCEPTIONS
OF THE SURGICAL CARE PRACTITIONER ROLE
AUTHOR: Norma Medd MA BSc (Hons) PgC RN, Senior Lecturer, University
of Teesside, School of Health and Social Care, Centuria Building.
Middlesbrough. TS1 3BA
ABSTRACT:
Research Purpose:The purpose of the study is to undertake a research evaluation to
establish the early perceptions and experiences of members of the multidisciplinary
team and the Surgical Care Practitioner (SCP) of the introduction SCP role in cardiac
surgery. The study is being carried out for three reasons. Firstly, this is the
introduction of a new role professional in the health service. Secondly, there is a
deficit in the literature on this particular role. Finally it is being carried out as a part of
the SCP programme evaluation.
Background:The concept of the SCP role is new and unique although it has some
attributes that are similar to roles previously undertaken by the First Assistant (FA),
the Surgeon’s Assistant (SA) and the Nurse Practitioner (NP). The role is different
when compared to the FA, SA and NP as its focus is on providing holistic care for the
surgical patient throughout their stay in the hospital setting and follow up care in the
outpatients’ clinic. The evaluation is also linked to new Degree Programme set up to
facilitate and support the introduction of this new professional role in clinical practice
.
Research Design:A qualitative approach is used, utilising semi- structured interviews
as a data collection tool. Each individual interview lasted 20 to 50 minutes. The data
was collected by the researcher using individual audiotape recordings. A list of theme
questions was used to obtain focus for the interviews and to also provide consistency
with questions across the sample group. The questions were specifically based around
issues relating to the introduction and development of the SCP role.
Sample:15 participants was interviewed (n=15). All 15 participants are involved in
the development of the SCP role. These were three SCPs, four cardiothoracic
consultant surgeons who were mentors to the students, three clinical managers
supporting the SCP Trainees and the development of the programme, two theatre
scrub nurses working in the cardiothoracic theatres, one senior specialist
cardiothoracic surgical registrar, one surgical cardiac nurse practitioner and one
cardiac consultant anaesthetist.
Setting:The study was carried out in a large cardiothoracic centre in the United
Kingdom
(UK) covering a population of 1.5 million people.
Data Analysis:The data was analysed using Burnard’s (1991) method of thematic
content analysis.
Results and conclusions: Many benefits were identified. These were related to
improvement in the quality of patient care, job satisfaction, better management of
theatre time and consultant time and reduction in doctors working hours. There were
issues with regards to communication, teamworking, understanding, acceptance and
development of the role by both medical and nursing staff.
References:
Burnard P (1991) A method of analysing interview transcripts in qualitative research.
Nurse Education Today .11, 461- 466.
Department of Health (2005) The Curriculum Framework for the Surgical Care
Practitioner- A consultation document. London: HMSO.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE PHENOMENON OF CARING AS PERCIEVED BY REGISTERED
NURSES WORING IN CLINICAL PRACTICE IN A UNIVERSITY
COLLEGE HOSPITAL.
Lorraine Mee M.Sc. (Nurs.), B. Health Studies (Hons), RNT, RM, RGN.
Lecturer
Centre for Nursing Studies
Aras Moyola
NUI Galway
Ireland
The aim of this study was to describe the phenomenon of caring in nursing as
perceived by registered nurses from their experiences in clinical practice in a
University College Hospital. A qualitative approach, using a descriptive
phenomenological methodology was chosen for the study to encapsulate the lived
experiences of the participants. Seven registered nurses shared their experiences of
caring during tape recorded unstructured interviews. Data was transcribed and
analysed according to Colaizzi’s procedure. Three main tentative themes emerged
from the data. These were “professional nursing care”, “communicative relationships”
and “compassionate humanity”. A description of the structure of caring for this group
of nurses was developed. The structure of caring in nursing for these nurses was the
union of a compassionate nurse – patient relationship with their professional
competence and responsibilities.
It is suggested that gaining an enhanced understanding of the meaning of caring in
nursing will provide nurses with an opportunity to articulate the knowledge hidden
within their practice, evidence for nurse managers to support nurses in their caring
and guidance for nurse educators designing educational programmes to prepare
student nurses in their development of caring practice.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE CHOICE OF BABY-FEEDING MODE WITHIN THE REALITY OF
THE HIV/AIDS EPIDEMIC: HEALTH EDUCATION IMPLICATIONS
Authors:
Mrs CS Minnie, Prof M Greeff
Job title:
Senior Lecturer (Midwifery)
Qualification:
B Art et Scien (Nursing Science)
B A Honns (Psychology)
M Cur (Midwifery and Neonatal Nursing Science)
Adress:
School of Nursing Science
North-West University (Potchefstroom Campus)
Private Bag X 6001
Potchefstroom 2520
Republic of South Africa
Approximately one third of the women who visit the antenatal clinics in the North
West Province of South Africa are HIV positive. These women need to decide on the
most appropriate method of feeding for their babies. As early as 1985 it was proven
that HIV transmission through breast milk could take place. Although total avoidance
of breast-feeding entirely rules out the risk of HIV-transmission, it is not necessarily
the best choice for all women. Other factors that make it dangerous for some women
and their babies to avoid breast-feeding must also be taken into consideration. These
factors include unhygienic circumstances, fear of identification of being HIV-positive
when bottle-feeding, the expense of milk formula etc. Because the risk of HIV
transmission through breast milk depends on factors such as the virus load in the
mother's blood and milk, and whether the mother's and baby's skin and mucus
membrane are intact or not, a HIV positive mother who breast feeds, can make
adjustments to limit the risk of HIV transmission. In order to be able to make an
informed decision on the most appropriate baby-feeding method, pregnant women
must be empowered. Effective health education about HIV-transmission and baby
feeding should therefore be done during pregnancy.
The aim of the study was to explore and describe the factors that should be taken into
consideration by midwives in their health education of pregnant women on HIV and
baby-feeding, the perceptions of midwives and pregnant women pertaining to these
factors, as well as the level of knowledge of the midwives and pregnant women
regarding HIV-transmission and baby-feeding.
A quantitative survey design was used. Two structured questionnaires were used to
collect data. An all-inclusive sample of midwives who work in the antenatal clinics in
the Potchefstroom district of the North West Province and an availability sample of
pregnant women who visit these clinics were used. A total of 17 midwives and 93
pregnant women took part in the study after having giving their consent. Data analysis
was done by means of frequency analysis and cross-references.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
On the basis of the findings the conclusion was made that, although the midwives
have a basic knowledge of HIV and baby-feeding, specific knowledge-gaps and
confusion regarding distinct themes do exist. The aspects that the midwives do not
have sufficient knowledge of are those of recent tendencies and discoveries. On the
aspects final clearance has not yet been reached in the literature and through research,
confusion still exists. Furthermore it has been found that the knowledge the midwives
do indeed have is not efficiently conveyed to the pregnant women. According to the
perceptions of the midwives and the pregnant women, they aren't sufficiently
empowered by the health education to be able to make an informed decision.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
TITLE:
REHABILITATION
CARE:
PROFESSIONAL
ROLES,
CONTINUITY OF CARE AND DECISION-MAKING AS PERCEIVED BY
OLDER PEOPLE IN HOSPITAL
Mitchell, E. A. (, BSc (Hons) Specialist Practice in Stroke Care, RGN, Postgrad
Dip Ed.
Lecturer in Nursing University of Ulster at Magee Campus
Northland Road
Londonderry
Northern Ireland
BT48 7JL
McCormack, B. (Professor of Nursing Research Royal Hospitals
Trust/University of Ulster, Nursing Development Centre, Royal Victoria
Hospital, Belfast),
Reed, J. (Professor of Health Care of Older People, Centre for Care of Older
People, Northumbria University),
Glenda Cook (Lecturer of Nursing, Community and Education Studies,
Northumbria University),
Susan Childs (Research Associate, Northumbria University) and Amanda Hall
(Research Associate, Northumbria University).
ABSTRACT
Older people may have long-term and complex health needs, and for them continuity
is a key aspect of care. Gaps in and between systems of care cause a variety of
problems for service users (RCP/RCN/BGS, 2000). The National Beds Inquiry
(2000) recommended a ‘whole systems’ approach to service planning, commissioning
and delivery. The aims of this research were to conduct a detailed systematic
literature review and to investigate one whole service system, with particular
emphasis on hearing the voices of older service users. The whole system descriptive
study sought to illuminate the services that promoted and achieved maximum
independence, and the experiences of older patients as they moved through hospital
systems. Interviews were conducted with patients aged 65 years of over (n=50), who
were encouraged through the use of opening prompts and reflective listening to
provide narrative accounts. This approach enabled the researchers to glean rich data
on the perceptions of older patients in hospital. Taped interviews were transcribed
verbatim and analysed. ‘Real time’ tracking of older people (n=18) as they journeyed
through the health care system and analysis of records and documentation, provided
information on the interfaces between and within services and professions.
Themes emerged pertaining to ‘access to services’, ‘service fragmentation’,
‘continuity of care’ and ‘routinised care’. The impact of disempowering relationships
can be seen to transcend all of the data and impacts greatly on actual continuity of
service delivery and perceptions of quality among service users and providers.
Participants were acutely aware of the importance of rehabilitation to their overall
care plan. When helpful relationships with key rehabilitation personnel were
established, patients were able to actively work towards rehabilitation goals. The
roles of carers and family were particularly significant in sustaining the hopes and
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
aspirations of the patient. Frequently they acted as advocates in communicating on
the patient’s behalf with the multidisciplinary team.
The recommendations from this study support the need for more effective
communication with older patients and liaison between rehabilitation staff from the
point of entry to the system, as decisions made and actions taken then have a
significant impact on the subsequent patient journey. For whole systems working to
be effective much more emphasis needs to be placed on lessening the demarcations
between and among professional groups.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
CHILDBIRTH: A MOMENTOUS OCCASION-MUSLIM WOMEN’S
CHILDBIRTH EXPERIENCES
KHURSHID MITCHELL
RN, RM, M Arts Appl. (Nursing),
Western Institute of Technology at Taranaki,
PO Box 2030,
New Plymouth,
New Zealand.
0064 6 757 3100
[email protected]
CHILDBIRTH: A MOMENTOUS OCCASIONMUSLIM WOMEN’S CHILDBIRTH EXPERIENCES
The childbirth experience has been described as a deeply felt, multifaceted, and
significant event in a woman’s life. Not only is it a physiological process, it is also an
emotional, cognitive and spiritual event. It is a time of major life changes and one of
the most moving times in a woman’s life and the culmination of nine months of
learning, planning and social influence (Callister, Semenic & Foster, 1999; Callister,
Vehvilainen-Julkunen & Laurie, 1996; Nichols, 1996; Simkin, 1996; Callister, 1995;
Sherr 1995). This is also a time when she feels vulnerable, exposed, and alone
because of what she is experiencing (Simkin, 1996; Dawson, 1983).
While the birth process itself has not changed in all of human history, what has
changed is the context in which birth takes place (Simkin, 1996). Economic patterns,
cultural attitudes, migration, and the amount of support a woman has, all have an
impact on how a woman perceives her birth experience (Simkin, 1996; Sharts-Hopko,
1995).
For women who move from country to country, they cross cultures no matter where
they live. They live in two cultures and try to live by balancing the values of their
cultural heritage with those of their host country. Within the health care system they
are expected to conform to the mainstream values (Meleis, 1991).
Similarly, those who work within the health field also cross cultures. They cross the
cultures of their work environment, and those of their clients, who may come from a
range of ethnic, cultural, and socio-economic backgrounds. Midwives and nurses are
similarly challenged in how to create care that is considered safe by the clients and to
keep themselves safe.
The aim of this study was to enable Muslim women to tell the stories of their
childbirth experiences in New Zealand. There are now some 23,000 Muslims living in
New Zealand from 40 nationalities (Statistics New Zealand, 2002; Al Mujaddid,
2000, March, p.11). While some are immigrants by choice, there are others who have
come as refugees. This population also consists of a small number of Westerners who
have adopted Islam (Shepard, 1996; Shepard, n.d. cited in Tiwari, 1980). The majority
of Muslims are married couples ranging from 20-40 years with young children, with
some teenagers and elderly making up the rest of this population. The transient
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
population consists of overseas students, embassy staff, and some immigrants who
move on after a few years.
Muslims follow Islam, a monotheistic faith embracing Allah as the one God who is
the creator of the universe. Allah is the Arabic word which stands for the one and only
God, the Merciful and the Compassionate. “Islam means submission to the Will of
God and obedience to His Law” (ABDALATI, n.d. p.7). The Qur’an is the sacred
book -the Word of God revealed to Prophet Mohammed (Peace be upon him) through
the angel Gabriel. It is the main source of Islamic law. Hadith traditions are the
practices of the Prophet Mohammed (PBUH) showing in practical terms what he did.
These two sources serve as a guide to Muslims all over the world as to what is halal
[lawful] and what is haram [unlawful]; what they are supposed to do and what they
are not allowed to do (Chand, 1998; ‘Abd al ‘Ati, 1977; Abdal-Ati, 1974;
ABDALATI, n.d.).
Caring for Muslim Childbearing families
With reference to the childbearing family, modesty (Hijaab) and diet (halal) are
considerations to be taken into account when caring for a Muslim women as these are
Islamic laws (Hutchingson & Baqi-Aziz, 1994). Some women may wear the clothes
that reflect the customs of their countries of origin or where they are living, but they
usually adjust their clothing to be modest. Women in Islam prefer to be attended by
female health professionals, as it involves the matter of modesty and privacy and this
is more so in issues related to private parts of the body. There are some exemptions
for women from worship rituals like performing prayers, fasting, and reading the
Qur’an during specific periods like menstruation and childbirth.
The birth of a child is considered be a welcome event regardless of it being a boy or a
girl and one should be grateful to Allah (Subanaho Wa Ta’ala). There are certain
religious and traditional practices that are performed following the birth of a baby.
The religious ceremony includes the reciting of ‘Adhan,’ (call to prayer) Praise to
Allah into the baby’s ear soon after it is born. The Adhan is performed either by the
father, or an elder male from the community. It is preferable to bath the baby before
the Adhan is performed but not necessary as the baby is ‘Tayyab’ (good). It is more
for aesthetic reasons and for the Maudin [one who calls the Adhan], so that he is not
repelled by the sight of any birth products on the baby (Members of Muslim
community, Personal communication, 1, August, 2001). Most Muslim women will
breastfeed their babies (Hutchinson & Baqi-Aziz, 1994; Zaidi, 1994).
Naming the child is usually done within seven days of birth in accordance with
Sunnah practice. The meaning of Sunnah must include the idea of following what the
Prophet did or said, (Rahman, 1987). Most people prefer to name a child at birth just
in case the unforeseen happens and the baby dies. There are some traditional events
that take place on the seventh day, and these include two main events, the shaving of
the baby’s head with the recommendation that silver equivalent to the weight of
baby’s hair be given as alms to the poor and needy, and the slaughtering of an animal
as a thanksgiving to Allah, asking for His protection for the newborn child. The meat
is distributed to family, relatives, neighbours and the needy. This whole ceremony is
called ‘Aqiqah’ (Al-Kaysi, 1986).
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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Literature Review
Cultural and spiritual meanings women attribute to their childbirth experience and
importance has been discussed from the perspective of women from a number of
cultures (Semenic, Callister, & Feldman, 2004; Callister & Kartchner, 2003; Callister,
2002; Callister, Vehvilainen-Julkunen, & Laurie, 2001; Callister, Semenic, & Foster,
1999; Callister & Vega, 1998; Callister, Vehvilainen-Julkunen & Laurie, 1996;
Callister, 1995; Callister, 1992).
The importance of the context within which a birth occurs and the amount of support
a woman receives has also been emphasised in the literature as the latter is seen to
enhance a woman positive feelings in her coping abilities thus leading to satisfaction
with her birth experiences (Oweis, 2004; Martell, 2003; Holroyd, Yin-king, Wong
Pui-yuk, Yau Kwok-hong & Leung-Lin 1996; Simkin, 1996; Tarka & Paunonen,
1996; Moon Park & Dimigen, 1994).
The experiences of women giving birth in a country other their own has shown that
childbearing in a cross-cultural context is a stressful experience as they are deprived
of role models, affirmation, cultural support and feel isolated (De Souza, 2003; King
and Farley, 2000; Small, Liamputtong, Yelland, & Lumley, 1999; Sharts-Hopko,
1995; Rubin, 1984).
Other authors have highlighted many of the needs and practices of Muslim women
(Kitzinger, 2005, Al-Oballi Kridli, 2002; Bradshaw, 2000; Khalaf and Callister, 1997;
Gatrad, 1994; Hutchinson & Baqi-Aziz, 1994; Zaidi, 1994; Homebirth Australia
Newsletter, 1990; Luna, 1989; McDonald, 1985). These include the avoidance of
physical contact, i.e. touches and hugs between non family members of the opposite
sex, the importance of family support, availability of female carers in keeping with
Islamic teachings of segregation of the sexes, Nahas (1997), the issue of informed
consent, as generally the husband, father, or elder brother would give consent for the
care of a female relative (McKennis, 1999; Sheets & El-Azhary, 1998) and the
avoidance of alcohol-based medications (Robertson, 1993).
In New Zealand, Dawson’s (1993), book on ‘Customs of Childbirth’ gave an insight
into aspects of Islamic culture and ethnic culture through the story of Azra, a Muslim
woman from India who had a child in New Zealand. In 1994, an article by Marina Isa
outlining the needs of Muslim women appeared in the New Zealand College of
Midwives Journal.
Design of the study
A Storytelling/Narrative approach, which is situated within the qualitative research
paradigm was utilised for this study. The study aimed to explore women’s childbirth
experiences. The appeal of Storytelling/Narrative was the freedom to use everyday
ordinary language that would give the possibility of revealing the richness of the
Muslim women’s stories. It was also considered to be culturally appropriate as in
some cultural contexts and in certain population groups, some situations are better
described through storytelling than through specific statements (Veseau, 1994;
Melies, 1991).
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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Method
Following ethical approval from the Regional Ethics Committee and a letter of
support from the two Muslim community leaders, four Muslim women were invited to
share their childbirth experiences. They were reassured their participation was
voluntary. They were under no obligation to participate and had the right to withdraw
at anytime.
Background of the women
The three women who agreed to participate came from different ethnic backgrounds
and their ages ranged from 31 years to 42 years. Two of the women were immigrants
of South Asian descent and had lived in New Zealand for a number of years, while the
third woman was of European descent born in New Zealand and identified herself as a
‘Kiwi Muslim’. Two of the women were professionals in the education field and the
third woman was a tertiary student. Their birth experiences which took place in a
hospital environment ranged from a normal delivery, to a premature labour and
delivery of a baby at thirty-two weeks, with the baby remaining in the neonatal unit
for a number of weeks, and the third woman having a story of births through
Caesarean sections.
The data was collected by two semi-structured interviews lasting one hour each in
settings which the women chose to be appropriate. The interviews were conducted in
English as they could all express themselves clearly in English, and some of the
language used by the immigrant women reflected their knowledge of local speech
patterns. The stories which became the narratives were audiotaped with the women’s
permission and transcribed verbatim into text for content analysis.
Results
The following themes emerged from the data
Essence of each story
Relationship with staff (Khadija)
Khadija had to work really hard at building relationships with the staff, when as she
put it, she should have been recovering from the operation and spending time with her
child. She graphically described her situation using the following powerful words.
“I remember counting the rosters, and working out who was going to be on
and waiting for an hour when the next person was on who would be all right,
and actually some of the old timers were real dragons. One of them got on all
right with me but I really had to suck up to her and be so perky that’s not quite
the right word, be so cheerful, and I wasn’t feeling well, I had to really act,
and then I got the results from her. Like I had to milk the kindness out of her.
That’s awful”. (Khadija)
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Loneliness (Ayesha)
Ayesha described her loneliness, the lack of nurturing, and a sense of regret over her
childbearing experiences. While she had a good network of friends, her extended
family lived overseas. She went into premature labour and had the baby while on a
visit to another city. The following excerpts reveal the extent of her loneliness and the
feeling of not being nurtured.
“I remember feeling quite lonely anyway, being so far away from family… I
didn’t feel nurtured at all. I mean I had to seek for some nurturing, to be
nurtured. The closest to be nurtured is going to a friend’s place where there is
food, where I didn’t have to cook, and just sit there and then just eat what was
there”. (Ayesha)
Parental obligations compromised (Amina)
Amina’s story was that her parental duties were compromised, as her request to bath
her babies had been overridden by the hospital rules and regulations. It was important
for her to have her babies bathed as that was what happened in her family culture
prior to the religious duties being performed, and also because of her own discomfort
of others handling the babies before they had been bathed. Her husband was overseas
at the time of the birth of her first baby, therefore another family member would have
had to perform the Adhan.
“Even though I asked for both my children to bath the baby, they said “no”,
according to our health this and that, it is good for the baby to not be washed
for seven hours so that they have the good skin, and I didn’t think much of
that, but if it was in my hands I would have bathed the baby instantly”.
(Amina)
Common Themes across stories
Supportive actions
The theme “supportive actions” encompassed a number of actions that were taken by
health professionals in recognition of the specific needs of the women. The women
certainly remembered these special actions with genuine appreciation as the following
excerpts reveal.
There was one midwife that was just wonderful. She was wonderful. ( . . . ) She
helped me a lot with the breastfeeding. She was a lovely person and there was
no …(long pause) it was all goodness coming out of her”. (Khadija)
“But I remember ( . . . ) what was nice was, even at home, the Plunket Nurse
that came showed me how to bath the baby, you know, came and checked on
me every other day or something. I actually looked forward to that visitor. I
remember looking forward to that person coming, so that I can just natter”.
(Ayesha)
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
“There was a midwife the ( . . . ) who became very close to me since I was
staying in the hospital. ( . . . ) I could talk openly to her, so even though she
was supposed to go home, but I think she knew that I was going to have my
baby soon so she stayed with me, so it was a very good thing that even though
I didn’t have my family around I knew somebody was going to be with me, and
I was free to talk to her”. (Amina)
Vulnerability
Vulnerability is a common theme with all the women in this project. The women were
able to recall a number of events from which it can be inferred that they felt
particularly vulnerable for a number of reasons. The following sub themes reflect this
issue of vulnerability - feelings of anxiety, dignity being compromised, postnatal being left on her own, having to deal with male health professionals, inappropriate
diet, assumptions and unclear explanations, relationship with staff, parental duties
compromised and feeling lonely. The following is an example of one of the issues.
Dignity compromised (Khadija)
Khadija experienced situations where her dignity and privacy were compromised (Re
The situation which seemed to be the worst, was the operating theatre experience, for
not only were there a number of people but there also happened to be a male Muslim
doctor, as she pointed out.
I was wheeled into the room and there were a couple of people, a
Paediatrician and the Paediatric nurse and they each seemed to have students,
and there was the Anaesthetist ( . . . ). He had an assistant and they seemed to
have a couple of students as well, and then there was a House Surgeon who
was actually a Muslim guy, of Indian background I think, and my Obstetrician,
and all these students. And what was really horrible, this one, was that
everybody was standing around leaning against the wall, all around this huge
room, I mean the room was like a big hall, it wasn’t very warm, and I had to
sit up on the side of the trolley thing and bend forward while they put the
epidural in, which isn’t a fast operation, and I had to bend forward, and I had
one of those hospital gowns and the back was all open so I had no clothes on
except this horrible gown, and there I was bending forward exposing the crack
in my backside to all these people leaning against the wall. And that was just
awful, but again I was in this state of being, you know, not in a position of
being assertive, things were being done to me and I was just having to accept
them ( . . . ) I felt really vulnerable because I don’t expose my body to people, I
just go around showing my hands, feet and face, and then to have all my back
and the top of my backside all exposed, and the gowns are short, so it would
have been from my knees down and everything, and I was sitting up with
everybody standing there, the spectators, that was just awful”. (Khadija)
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Discussion
The women in sharing their stories, shared ‘secrets’ which are in fact stories that have
not had a safe place to be vented previously. The descriptions of their experiences
were vivid and graphic even after all these years. This seems to resonate with
Simkin’s (1991) findings that women remember their birth experiences and their
caregivers for a number of years. It became apparent from the women’s stories that
the negative experiences overshadowed the positive ones.
Two of the women said, telling their stories helped them make sense of what had
happened. The advantages of storytelling as a tool for healing is well documented
(Bacon, 1933 cited in Banks-Wallace, 1999; Bowles, 1995; Heiney, 1995; Sedney,
Baker & Gross, 1994; Krysl, 1991). While acknowledging the positive practices
demonstrated by midwives and some nurses, the negative issues raised by the Muslim
women in this study have been mirrored in other studies which included Muslim
women participants (Sivignanam 2004; Katbamna, 2000; Vose, 1996;Woollett and
Dosanijh-Matwala, 1990).
Clinical Implication
In this age of constant global migration midwives and nurses are providing care for
women from diverse cultures and it is increasingly becoming a challenge in how to
provide care that is culturally safe. In New Zealand, the recognition and
implementation of the concept of ‘Cultural Safety’ in midwifery and nursing practice
is the guide to delivering culturally safe care, and this is defined by those who receive
care (Nursing Council of New Zealand, 1996). The global migration trend has
prompted authors such as Callister, (2001), Ottani, (2001), St Clair and McKenry
(1999) and Downs, Bernstein and Marchese, (1997) to provide frameworks from
which culturally competent nursing care can be implemented.
Finally, this study adds to the richly descriptive literature of the existing body of
knowledge on Muslim childbearing women by providing insights into their religious
social and cultural needs.
Thankyou
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
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School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
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School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
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School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
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School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE CHALLENGE AND AWAKENING OF CULTURAL DIVERSITY AND
UNIVERSALITY IN NURSING PRACTICE
Adrienne Montgomery (Lecturer) RGN, RM, RCNT, Dip.N.(Hon) MSc Nursing
(Wales)
Centre for Nursing Studies
National University of Ireland
Galway
Siobhan Smyth (Lecturer) RPN,Dip.CPN; RNT; PG.Dip CHSE; BNS (Hons); MSc.
Centre for Nursing Studies
National University of Ireland
Galway
Abstract
The purpose/aim of this poster is to present how cultural care preservation,
accommodation and re-patterning can be embedded more in nursing practice. If we
are to develop nurses who are competent in today’s multicultural milieux it is
essential that we address a number of key elements. Care and culture are said to be
inextricably linked and therefore cannot be separated from care actions and decisions.
The changing cultural diversity of Ireland requires nurses to examine their beliefs,
values and moral so as to provide culturally sensitive care within a framework of a
public care ethic. The nursing system explicated by Leininger (1988) provides the
framework to evolve nurses beliefs further than diversity and for this to become
reality in nursing practice. It is this culturally appropriate care ethic that needs to be
born and nurtured and to be adopted communally in nursing and nursing education.
The challenge is can Irish nurses bring this ethic to birth?
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Information Needs of Family Members of ICU Patients
Ms. Bróna Mooney
Lecturer in Nursing Studies
MSc. Nursing (Education), B.N.S. (Hons.) R.G.N., R.N.T.
Certificate in Critical Care Nursing.
School of Nursing and Midwifery,
Trinity College Dublin,
24 D’Olier St,
Dublin 2.
The communication of clear and accurate information assists family members to cope
with the admission of a loved one to the Intensive Care Unit. The need for
information is compounded with difficulty in processing information. Information
enables family members to create coping mechanisms that allow them to anticipate
what may occur in the following stages of their loved one’s illness.
Seven participants were invited to discuss their experience of visiting a loved one in
the intensive care unit with particular regard to their informational needs during this
time. Interviews were tape-recorded and transcribed with permission from
participants. A synthesis approach to grounded theory analysis interpreted by Eaves
(2001) was be utilised to form categories from the interview transcriptions.
The findings suggest that family members report receiving fragmented, inconsistent
information regarding their loved one. Issues such as waiting for information,
searching for information, receiving inadequate information are highlighted. Family
members describe needing to receive information regularly from doctors and nurse,
however, the amount and type of information received varied and seemed to be
largely dependent upon the primary nurse at the patient’s bedside. Information was
acquired through formal and informal meetings with staff. Difficult accessing medical
staff for patient information was raised and some families commented on the quality
of information they received from medical staff. Family members respected
practitioners that spoke frankly about the patient, but this information was not always
clearly understood by some participants and required further clarification.
Finally, recommendations are made to promote the development of therapeutic and
supportive interventions in the delivery of family focused care in the intensive care
unit.
Reference
Eaves Y.D. (2001) A synthesis technique for grounded theory data analysis. Journal
of Advanced Nursing 35(5), 654-663.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
USING DELPHI METHODOLOGY TO INVESTIGATE WHAT IRISH
MENTAL HEALTH NURSES CONSIDER TO BE THE CORE ELEMENTS
OF THEIR NURSING PRACTICE
AUTHORS:
Ms Roisin Morris, MSc, Research Fellow, School of Nursing, Dublin City
University
Dr Padraig MacNeela, Psychology Lecturer, National University of Ireland, Galway
Professor Anne Scott, Principal Investigator, Head of the School of Nursing, Dublin
City University
Professor Pearl Treacy, School of Nursing and Midwifery, University College Dublin
Dr Abbey Hyde, Senior Lecturer, School of Nursing and Midwifery, University
College Dublin
Mr Jonathan Drennan, MSc, RPN, Lecturer, School of Nursing and Midwifery,
University College Dublin.
Ms Anne Byrne, MSC, RGN, Research Fellow, School of Nursing and Midwifery,
University College Dublin.
Mr Gerard Clinton, MSc, RGN, Lecturer, Research Assistant, School of Nursing,
Dublin City University.
Dr Michelle Butler, Lecturer, School of Nursing and Midwifery, University College
Dublin.
Ms Melissa Corbally, MSc, RGN, Lecturer, School of Nursing, Dublin City
University.
Ms Pamela Henry, MSc, RGN, Lecturer, School of Nursing, Dublin City University.
Presenter
Ms Roisin Morris, Research Fellow, School of Nursing, Dublin City
University, Glasnevin, Dublin 9.
In Ireland the idea of ‘making nursing visible’ has become an important issue in
recent times. Clark (1999) notes that nursing is poorly understood and as a result, it is
undervalued. Without full knowledge and understanding of what nurses do and how
nursing activities and interventions impact on patient/client outcomes it is extremely
difficult to evaluate the impact of nursing care on health care delivery as a whole.
This study describes the use of a three round Delphi study to gain consensus
agreement on the core elements of mental health nursing care in Ireland. The Delphi
study consists of three rounds to enable consensus to be achieved from a sample of
community and acute mental health nurses on the patient problems, nursing
interventions, coordination of care activity and nursing outcomes that nurses agree to
be core to their nursing work. Data was analysed using both quantitative and
qualitative research techniques. Overall, the results of this study identified a number
of items that are emerging as the core elements of mental health nursing in Ireland.
This research was conducted as part of a larger research programme to develop an
Irish Nursing Minimum Data Set and to investigate the nature of clinical judgement
and decision-making among nurses in Ireland.
References
Clark J., (1999), A language for nursing, Nursing Standard 13(31) pp 42-47
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
INNOVATIVE USE OF COMPUTER ASSISSTED ASSESSMENT (CAA) IN
NURSE/MIDWIFERY EDUCATION
Elaine Mowatt, M Ed, RGN (Lecturer); Dave Adams MSc, RGN, RMN
(Lecturer); Dr Winifred Eboh PhD, BSc, RM, RGN (Lecturer); Neil Johnson
MSc, RGN (Lecturer); Dr Sheelagh Martindale PhD, MSc, RGN (Lecturer).
Address:
The Robert Gordon University
School of Nursing and Midwifery
Faculty of Health and Social Care
Garthdee Campus
Garthdee Road
ABERDEEN
AB10 7QG
A new module assessment strategy for second year (stage two) pre-registration
nursing and midwifery students has been developed. It is related to the ‘Research and
Evidence-based Practice’ module. Previously students were assessed on a 2500 word
written semi-structured essay. During the redevelopment of the pre-registration
nursing course, the research module was scheduled to run at the same time as two
other modules. Looking at the assessment strategies of these other two modules, it
was agreed that in fairness to the students, another written assessment was not an
option. It was also highlighted that with a module team of five lecturers and up to 300
students, the marking of written assessments was unfair to the students as the quality
of the marking could vary within and between lecturers due to tiredness and fatigue.
The module team decided to provide the students with an innovative assessment
strategy using Computer Assisted Assessment (CAA) to offer variety for the students
during their theoretical semester. It was also considered that the type of subject matter
within the module was theoretical and lent itself to this form of assessment. CAA can
offer more to the student than purely multiple-choice questions suitable for assessing
lower cognitive domain (Bull J, 2004). Stage two students are expected to
demonstrate knowledge and understanding of the subject, but should also be showing
insights into higher cognitive learning skills such as analysis, synthesis, evaluation,
problem solving according to Blooms Taxonomy (Krathwohl D, 1971). This paper
will introduce the CAA format, the pragmatics of questionnaire development and
transfer of this data into the computer programme. This was particularly challenging
to the module team who had never used this assessment strategy before posing a steep
learning curve. The module team’s presentation will hopefully act as a catalyst for
more innovative assessment of nursing students within select areas of higher
education.
References:
Bull J, 2004. Blueprint for computer-assisted assessment. London; Routledge Falmer.
Krathwohl D, 1971. Taxonomy of educational objectives: the classification of
educational goals. Handbook 2 – Affective Domain.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
FIRST TIME MOTHERS EXPERIENCES OF CARING FOR THEIR NEW
BABY
Author: Kathryn Muldoon
Midwifery Tutor - RGN, RM, BNS, RNT, MSc PHC
School of Midwifery
Coombe Women’s Hospital
Dolphins Barn, Dublin 8
Abstract
Aims: The overall aim of this study was to explore first time mothers’ experiences of
caring for their new baby. and to identify areas for improvement that could enhance
their experience.
Background: The study was undertaken because there is limited information on
mothers’ experiences of caring for their baby within an Irish context. Due to the
current change in family structure many women expecting their first baby have never
cared for a newborn infant. This results in fewer mothers benefiting from an
apprenticeship for motherhood. Therefore it was thought necessary to explore the
experiences of these women.
Methodology: A descriptive phenomenological approach was used to conduct the
study. Data was analysed using Colaizzi’s framework. Eight first time mothers were
interviewed in their own homes six weeks after the delivery of their baby.
Findings: The transition to motherhood is challenging and difficult and the women
had the most difficulty in the early days after leaving hospital. It was also evident that
it is difficult to prepare for the reality of caring for a new baby. Infant feeding posed
many challenges for the women, with mothers who artificially fed their babies
experiencing the greatest difficulties. The importance of support from a variety of
sources was also a significant finding in this study.
Conclusion: It is important that midwives provide accurate, adequate, factual and
realistic information to women about the postpartum period. Women may need more
than one visit from the public health nurse during the early transition period. Mothers
who are bottle feeding their babies must be provided with the necessary knowledge
and skills in order to feed their babies safely.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
SEXUALITY AND RENAL DISEASE: NEVER THE TWAIN SHALL MEET
Fiona Murphy
Lecturer in Nursing
RGN, RNT, Dip Research, Dip Prof Stud, BSc (Hons) Health Stud,
BSc (Hons) Renal Nurs, P.G.Dip Adv. Nurs. Scie, P.G.Dip C.H.Scie.Ed, MSc.
School of Nursing & Midwifery Studies
The University of Dublin, Trinity College
24 D’Olier Street
Dublin 2.
Phone: + 00353 1 608 3108
Email: [email protected]
Abstract
Sexuality can be particularly difficult to address within nursing. Everyday nursing
practice involves intimate contact with patients’ bodies, emotions, relationships and
lives in general. It brings together the professional and the personal in a delicate
interface (White, 2002). Sexuality is not entirely about sexual function but includes
the way one feels about oneself, it includes self-esteem, sexual self-esteem, body
image and how one is perceived by others (Sheils, 2003). Yet the majority of the
literature pertaining to renal patients’ sexuality addresses this area from a purely
sexual dysfunction perspective. There is a paucity of literature concerning how renal
patients feel about issues surrounding their sexuality whilst living with this chronic
illness. Sexual problems can exist for patients during the pre-dialysis stage through
dialysis and even after transplantation. However Mahon (2003) identifies that
sexuality is one such area that many staff will avoid discussing wherever possible.
Patients prefer health care professionals to initiate a discussion about sexual concerns,
but many nurses expect patients to do this. When no one introduces the topic of
sexuality, patients are often left to resolve sexual concerns alone (Waterhouse &
Metcalfe, 1991). Nurses must be educationally and emotionally prepared and feel
secure in their own sexuality in order to facilitate open communications with patients
(Kralik, Koch & Telford, 2001).This paper aims to explore the literature surrounding
sexuality within renal disease and to identify areas whereby renal nurses can assist
patients and their partners to cope with this important issue.
References
Kralik, D., Koch, T., Telford, K. (2001) Constructions of sexuality for midlife women
living with chronic illness. Journal of Advanced Nursing. 35 (2): 180-187.
Mahon, A. (2003) Sexuality and erectile dysfunction. In: Digwall, R. R. (ed) Towards
a closer understanding. Lucerne: EDTNA/ERCA.
Sheils, P. (2003) Sexuality and the older person. The World of Irish Nursing.
September, 31-32.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Waterhouse, J., Metcalfe, M. (1991) Attitudes toward nurses discussing sexual
concerns with patients. Journal of Advanced Nursing. 16 (1): 1048-1054.
White, I. (2002) Facilitating sexual expression: challenges for contemporary practice.
In: Heath, H., White, I (eds) The Challenge of Sexuality in Health Care. Oxford:
Blackwell Science.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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GROWTH, BODY COMPOSITION AND PUBERTAL DEVELOPMENT IN
CHILDREN AND ADOLESCENTS WITH DOWN SYNDROME & NEW DS
SPECIFIC GROWTH CHARTS UK AND IRELAND
Joan Murphy1, Lewis J1, Philip M1, S Macken, Roche EF1, Hoey HMCV1
1
Department of Paediatrics, University of Dublin, Trinity College, The National
Children’s Hospital, AMNCH, Tallaght, Dublin 24.
2
The Children’s University Hospital, Temple Street, Dublin 1.
ABSTRACT
Short stature is well recognised in Down syndrome (DS) (Cronk 1988, McCoy 1992).
The pattern of growth and puberty in those with DS is poorly understood. In some,
associated conditions, such as hypothyroidism (Karlsson 1998, Sharav 1988), sleep
related upper airway obstruction (Stebbens 1991) or coeliac disease (George 1996,
Jansson 1995) may contribute to short stature and must be promptly excluded to
optimise their already compromised growth potential. Those with DS have an
increased incidence of overweight and obesity (Chumlea 1981, Prasher 1995).
Obesity is associated with significant adverse health outcomes.
Aims: To assess growth and pubertal development in children and adolescents with
DS in Ireland; compare with the general population and similar groups
internationally; and assess the effect of cardiac disease.
Methods: A cross-sectional study of 394 children with DS was undertaken in the
Eastern Health Board Region. Height, weight and head circumference measurements
were performed and clinical assessments of pubertal development were recorded.
Results: Height and head circumference were 2 standard deviations (SD) below the
mean of the general population but median weight was similar. Body mass index was
greater than the 97th percentile in 31% of those over 10 years of age. Mean age of
menarche was earlier than the general population. Associated cardiac disease had no
effect on height.
Conclusion: Children with DS are shorter, have a smaller head circumference but
similar weight to the general Irish population indicating a significantly greater body
mass index (BMI). Monitoring growth requires DS specific growth charts and
targeted weight management programmes. Puberty requires early anticipation, child
and parental education and support.
References
1. Cronk C, Crocker A, Pueschel S, Shea A, Zackai E, Pickens G, Reed RB (1988).
Growth Charts for Children with Down Syndrome: 1 Month to 18 Years of Age.
Pediatrics, 81: 102-110.
2. George EK, Mearin ML, Bouquet J, von Blomberg BME, et al (1996). High
frequency of celiac disease in Down syndrome. J. Pediatr, 128: 555-57.
3. Jansson J, Johansson C (1995). Down syndrome and celiac disease. J Ped
Gastroenterology and Nutrition. 21: 443-445.
4. Karlsson B, Gustafsson J, Hedov G, et al (1998). Thyroid dysfunction in Down's
syndrome: relation to age and thyroid autoimmunity. Arch Dis Child, 79: 242-5.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
5. McCoy EE (1992). Growth Patterns in Down’s Syndrome. In: Down Syndrome:
Advances in Medical Care, Ed. Lott IT, McCoy EE, Wiley-Liss, Inc. New York
ISBN 0471561843:78-82.
6. Sharav T, Collins RM, Baab PJ (1988). Growth studies in infants and children with
Down’s Syndrome and elevated levels of thyrotropin. AJDC, 142.
7. Stebbens VA, Dennis J, Samuels MP, Croft CB, Southall DP (1991). Sleep related
upper airway obstruction in a cohort with Down’s syndrome. Arch Dis Child, 66:
1333-1338.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
WOMEN’S EXPERIENCES OF MATERNITY CARE IN IRELAND: AN
OPPORTUNITY FOR MIDWIFERY-LED CARE?
Jo Murphy-Lawless BA, MA, PhD
Lecturer in Sociology
Cecily M. Begley RGN, RM, RNT, FFNRCSI, MA, MSc, PhD, FTCD
Professor of Nursing and Midwifery/Director
Declan Devane RM, RGN, RNT, DipHE, BSc(Hons), PgDip(Stats), MSc
Doctoral Student/Lecturer in Midwifery
School of Nursing and Midwifery
The University of Dublin, Trinity College
24, D’Olier St.
Dublin 2, Ireland.
Tel: 353 1 6083979, Fax: 353 1 6083001
Literature review
Women’s experiences of childbirth and the structures of support that surround them
receive relatively little attention in the Irish media and press. Childbirth appears to be
seen as a ‘women’s issue’, and becomes of concern usually only when there are
perceived problems of securing ‘safety’ and ‘choice.’ These issues of safety and
choice are themselves embedded in the medicalisation of birth and the rising rates of
intervention that have accompanied it (Devane and Begley 2004, Devane et al., in
press).
Over the past twenty-five years, numerous studies have shown that women are apt to
accept the maternity services provided to them (Oakley 1979, 1980, Macintyre 1984,
Porter 1990, Kirkham and Stapleton 2004). Although some may quietly criticise
aspects of care, they do not, in general, voice these criticisms with the health
professionals caring for them at the time (Kirkham and Stapleton 2004, Edwards
2005).
In 2000, two local maternity units in Monaghan and Dundalk, in the North-Eastern
region of the Health Services Executive (Republic of Ireland), were closed following
a report on maternity services in that area (Condon 2000). Women in these localities
now had to travel much further to attend for antenatal and intrapartum care at one or
other of the two remaining units in the region, in Cavan and Drogheda. The adverse
public reaction to the closure of the units was so great that a new expert group was
established, which recommended the introduction of pilot midwifery-led units in the
area (Kinder 2001). As these units, and the models of care therein, represent a
considerable deviation from the standard consultant-led maternity services, an
exploratory study was conducted to determine the views held by women of the current
organisation of maternity care.
Aim
To ascertain women’s views of maternity care in the then North Eastern Health Board
region of the Republic of Ireland prior to the implementation of pilot midwifery-led
units.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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Methods
As there was no previous work carried out on women’s views in this area, a
qualitative design was chosen to explore women’s and midwives’ views of maternity
care in their region. To explore women’s views, twenty-seven women were
interviewed. The majority of women were accessed either through the maternity
services managers in the two maternity units in Cavan and Drogheda, who also gave
permission for the study to be conducted, or through local groups who were
campaigning to retain maternity services in Monaghan and Dundalk. One woman was
contacted through the input of an independent midwife.
A brief outline of the proposed research was given to all women, who could then ask
questions of the researcher, following which their consent was requested. Participants
were informed that they could withdraw their participation at any time and that their
involvement in the study would be kept confidential. All interviews were held
between March 2002 and June 2002. Seven unstructured individual interviews were
held, one with a woman who had given birth in hospital and at home. The remaining
twenty women were interviewed in four audio-taped focus groups. Two of these
group interviews were with women in Monaghan and Dundalk who were involved in
the campaign to maintain consultant-led maternity services in those areas. All data
were kept strictly confidential, using identifying letters for participants.
Data analysis
The transcriptions of the taped interviews were combined with detailed field notes
from the individual interviews and data were analysed, using ‘grounded theorizing’
(Glaser and Strauss 1967) and ‘progressive focussing’ (Hammersley and Atkinson
1983: 175). Three main themes emerged, entitled: “Midwifery support,” “Left all
alone, nobody called” and “Midwifery-led care”.
Findings and Discussion
“Midwifery support”
The data showed that women accepted and were uncritical of many features of
existing maternity care and there was very little critique of the routines and
interventions of the medical model. It was clear that when women felt both cared for
and listened to they reported these instances as positive experiences, and midwives
were very often mentioned in this context:
Fine, good, I had the same midwife more or less, and there was a student
midwife with me all the time, and the midwife would come and go, but I was
happy with that…
I could not speak more highly of the midwives that were there. I would place
my full trust in them.
However, a lack of continuity of care was obvious in many other statements from
women who attended the larger maternity hospitals in the area. Continuity of care is
promoted as a basic principle of good maternity care and is suggested to result in
improved outcomes and greater maternal satisfaction (Wagner 1994). The women
who had attended the smaller maternity units, now closed, spoke with pleasure of how
the midwives knew them from successive births:
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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I had been in about six weeks ago, with a kidney infection, and well I knew all
the nurses from before, and they’d all come and say “I know your face” and that
makes you feel “God out of everybody, she remembers me” you know…
Here you would have a core group week in and week out and they deliver your
baby. It’s great because you know them intimately, as they know you! It is
lovely and it adds to the security and the comfort and the general well being,
everything. You can’t replace that.
Eventually when I did get into the labour ward the obstetrician came into me and
said ‘You are only 3cm’ or whatever it was, and said I would have a while to go
yet. The nurse said “No, no she won’t, I know this girl from before and she’s
going to have the baby very, very quick”. And only that she stood there and
made the point very clear, he wouldn’t have believed how quickly she’d be born
and in 10 min she was born. Had they not been there I don’t know what would
have happened.
When complications arose during pregnancy or labour, midwives were described as
having been of tremendous support to the women:
To me, if you’ve somebody running round you and making you excited and
saying “Come on, you have to do this, you have to do that” I’ll tell you, you
wouldn’t be thinking about coming back or even having another kid, for that
matter. If they bring you along nicely…..there’s a right and a wrong way of
doing it, so personally speaking, I think a lot of credit has to go to the girls on
the team here. I loved the lassies here, they were all brilliant.
With my first baby, I was lucky the hospital was here at the time because they
thought it was an ectopic pregnancy I had. I was haemorrhaging and I was very
sick and only for them I wouldn’t have got through what I got through. Nine
months in and out of hospital……They are more than just nurses, they are
friends.
These are incomplete and sometimes conflicting opinions; the women saw midwives
as doing superb work in terms of supporting them, but, in general, they spoke of them
as “nurses” and they did not see how the present structures governing maternity care
hindered midwives from more effective working. For example, there was little
appreciation or understanding by the women that support from midwives could assist
them to have less painful and more effectual labours. In describing their labours and
the pain involved, most of these women thought first of drugs that over-ride the
body’s natural functions in labour, rather than using midwifery and lay support to
work with their contractions:
I’d like the epidural to be there, if it’s a slow procedure, you know, just to have
it there.
With me I found the back, now, when I came into hospital nearing labour, the
back was really troubling me, so I had use of the TENS machine. And I found
that was great when I got down to the delivery room and I had the gas,
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
and…..when I asked about the epidural, just not knowing what’s ahead of you
and keeping your options open, it was refused because of the possibility of me
having an infection perhaps, and not starting to interfere with the spine or
whatever, you know. But thankfully I didn’t need it and everything went okay.
But this time round I would like to have my options available to me.
There appeared to be a lack of awareness on women’s parts about the role that support
during labour plays (Hodnett et al 2003), along with aspects such as adopting a
vertical position (Gupta & Hofmeyr 2003) or the use of water (Cluett et al 2004), in
helping women to have shorter, less painful and more confident labours.
“Left all alone, nobody called”
In comparison to the positive statements made regarding the care they received in
labour and during the antenatal period, some women voiced concern about the
perceived lack of support they experienced in the immediate postnatal period:
We need somebody to talk to us. You don’t like interrupting a nurse, you know,
they’re up to their eyes.
After I had the twins I was very down, I don’t know, maybe it was going to be
different than the first child, anyway, I was saying to myself “was this normal?”
And I had nobody to talk to and nobody was coming into the room. Nobody
came in.
In particular, help with breast-feeding was thought to be insufficient, even in the
immediate postnatal days spent in the hospital:
The aftercare that is happening in the centralised hospitals at the minute,
breastfeeding etc., what numbers are breastfeeding there? Are they getting the
attention they should? That would be one of my thoughts, a first time mother
coming into hospital, it is traumatic, and being left to leave in a day or two- with
breastfeeding you do need help with it.
…..are they really getting anything? And then, you know, you’re tempted
anyway to use the bottle.
The midwives were described as “too busy” to assist women to breastfeed their
babies:
…that woman stopped trying to breastfeed and gave the baby a bottle to
suck…..it wasn’t the nurses’ fault, they just can’t cater for it. Now if that
woman had had help for another 24 hours, maybe she wouldn’t have given up.
Difficulty with learning the particular skills related to breast-feeding in the immediate
post-natal period (Colin & Scott 2002) and the importance of appropriate support to
minimise the cessation of breastfeeding (Kronborg & Vaeth 2004) are important
considerations in the provision of effective postnatal care. Close follow-up and
support in the first few days at home could help increase breastfeeding initiation and
continuation rates, but such dedicated expenditure of professional’s time is not
feasible in Ireland, where public health nurses have increasing numbers of newly-
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
discharged patients and elderly people to care for in addition to visiting new mothers
and babies (Begley et al 2004). This gap in professional services is filled for some
women by La Leche League, a lay support group who provide advice on
breastfeeding to women in the community.
Hospitals in Ireland are not, at present, funded to provide a national, dedicated
midwifery service in the community. This deficiency was noted 14 years ago (Carroll
1991), and little appears to have changed:
A lot of our issues are not really in-hospital care, it’s pre- or after-, reassurance.
Organised lay support has been used in Ireland to great effect by means of the
‘Community Mothers’ system. In this scheme experienced mothers, who undergo a
short education progr, provide advice and support to first time mothers in their area;
however, this service is only available in some areas.
Midwifery-led units
The women from Monaghan and Dundalk, in particular, spoke about midwifery-led
units and their potential role in local maternity services in the future. There was great
concern about declining levels of care following the closure of the two small
maternity units as women now had to travel greater distances and perceived
themselves as having received less individualised care:
When I was in hospital last time in (a small maternity unit, now closed) and
there was a woman in the bed beside me who was trying and trying [to
breastfeed] but the baby just kept crying. Now the midwives were able to come
in and sit with her and help her and that woman went home and was able to
continue breastfeeding. Then when I was in (a large maternity unit) just now
the same situation happened with a woman in the bed beside me. The baby was
roaring the place down but the nurses did not physically have the time to sit
down with her….
Following the closure of the two small units in the area, the two larger maternity units
naturally had increased pressure on space and staff, and this had been noted by the
women:
The other angle on it is that you go to (one of the large maternity units), you
have your baby and it’s “Bye, see ya” Shipped out straight away, and what
about their re-admission rate?
The only thing is that, do they have the time to spend with you? You’re always
thinking, “They’ve somebody else to see”, because they will tell you that they
are overdone as well, they’re being dragged everywhere, you know.
Some women spoke of their concern regarding safety in a midwifery-led unit where
obstetricians would not be involved routinely. These concerns are similar to those
expressed by some midwives in the area also (Begley et al 2005). It will take an
enormous effort of careful education for women to understand the concept of
midwifery-led care and the evidence base that supports it as a legitimate and
important model of maternity care. Women need to be enabled to develop confidence
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
in the belief that midwifery-led care can be a safe option for the majority of women,
particularly as they are used to the Irish system of maternity care, which is one of the
most medicalised in the world (Wagner 2001, Kitzinger 2005). Johanson et al (2002)
propose introducing a philosophy of care that cherishes expertise in supporting normal
vaginal birth, midwifery skills, emotional support, continuity of care and care in the
community, as a means of counteracting many of the concerns that now pervade
childbirth systems. Some excellent leaflets have been produced that present evidencebased care with the purpose of encouraging informed choice (MIDIRS 1999a, 1999b),
but despite distribution by midwifery staff with help given to women on how to use
them, there were ineffective in promoting women’s informed choice (O’Cathain et al
2002).
Conclusion
It is clear from this study that these women appreciated the midwives’ care and
attention, while not perhaps fully comprehending their role. They appreciated
continuity of care, but noted that it very often did not happen within the context of the
present system of care. They derived tremendous support from midwives, particularly
during labour and birth; however, such support was not as obvious during the
postnatal period, particularly in relation to breastfeeding and advice on baby issues. In
relation to midwifery-led care it was apparent that these women did not fully
comprehend the complexities of the midwife’s role or the opportunities made
available by the setting up of midwife-led units. The apprehension concerning safety
issues in childbirth was apparent and the dependence upon obstetricians as the main
care providers appeared to be strong.
The data presented here bears out once again Oakley’s most critical observation from
more than two decades ago: women’s engagement with pregnancy and birth does not
end at the moment of birth, but is a life-long undertaking (Oakley 1980). As Kennedy
has consistently argued (Kennedy 1997, 1998, in press), we need coherent long-term
maternal policies dealing with health and social support that reflect the complexity of
the many tasks women carry out as mothers. With those in place, the change in Irish
maternity services required to respond to the findings of this study will happen if
midwives develop a belief in themselves and their profession, feel confident in their
practice and are willing and facilitated to practise autonomously. The phased
introduction of midwifery-led units will provide an option of care that a proportion of
women are requesting, and will provide enhanced opportunities for midwives to fulfil
their role.
Acknowledgements
We are grateful to the women in the Health Services Executive-North Eastern Area
(HSE-NE) who gave so generously of their time in discussing their perceptions of
current maternity service provision, and everyone who assisted with access for
interviews. We are grateful for the support of staff in the region and the HSE-NE
Area, who are funding Professor Cecily Begley and Declan Devane to evaluate the
pilot midwifery-led units.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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References
Begley C. M. et al (2004) A Study of the Role and Workload of the Public Health
Nurse in the Galway Community Care Area Unpublished report. Dublin: School of
Nursing and Midwifery Studies, Trinity College, Dublin.
Begley C.M., Lawless J., & Devane D. (2005, 25th-28th July) Meeting the needs of
childbearing women in Ireland? Midwives' views of maternity care. Paper presented
at the 27th Congress of the International Confederation of Midwives, Brisbane.
Carroll M. (1991) The mother at home during the early post-natal period. Is the
midwife's care in the home of benefit? An experimental study. Unpublished BNS
dissertation, Dublin: University College Dublin.
Colin W.B., Scott J.A. (2002) Breastfeeding: reasons for starting, reasons for stopping
and problems along the way. Breastfeed Rev, 10(2): p. 13-9.
Cluett E R, Nikodem VC, McCandlish RE, Burns EE. (2004) Immersion in water in
pregnancy, labour and birth. The Cochrane Database of Systematic Reviews, Issue 1.
Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub2.
Condon, D. (2000) Report of the Review Group on Maternity Services in the North
Eastern Health Board. Kells: North Eastern Health Board.
Devane D., Begley C. M. (2004) Childbirth: how safe is safe enough? British Journal
of Midwifery, 12(7), 416-417.
Devane D., Murphy-Lawless J., Begley C. M. Childbirth Policies and Practices in
Ireland and the Journey towards Midwifery-led Care Midwifery (in press).
Edwards N. (2005) Birthing Autonomy: women’s experiences of planning home
births. Routledge, London.
Glaser B. and Strauss A. (1967) The Discovery of Grounded Theory. Chicago, Ill.:
Aldine. Hammersley M. and Atkinson P. (1983) Ethnography: Principles and
Practice London: Routledge.
Gupta JK, Hofmeyr GJ. (2003) Position in the second stage of labour for women
without epidural anaesthesia. The Cochrane Database of Systematic Reviews, Issue 3.
Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2.
Hodnett ED, Gates S, Hofmeyr G J, Sakala C. (2003) Continuous support for women
during childbirth. The Cochrane Database of Systematic Reviews, Issue 3. Art. No.:
CD003766. DOI: 10.1002/14651858.CD003766.
Johanson R., Newburn M., & Macfarlane A. (2002) Has the medicalisation of
childbirth gone too far? British Medical Journal 324, 892-895
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Kennedy P. (1997) A Comparative Study of Maternity Entitlements in Ireland and
Northern Ireland. In A. Byrne and M. Leonard, M. (eds.) Women and Irish Society: a
Sociological Reader. Belfast: Beyond the Pale.
Kennedy P. (1998) Between the Lines: Mother and Infant Care in Ireland. In
Returning Birth to Women: Challenging Policies and Practices. Dublin: Centre for
Women’s Studies/Women’s Education Research and Resource Centre.
Kennedy P. (in press) Maternity in Ireland: Health, Welfare, and Labour Market
Policies. Dublin: The Liffey Press.
Kinder P. (2001) Report of the Maternity Services Review Group. Kells: North
Eastern Health Board.
Kirkham M. and Stapleton H. (2004) The culture of the maternity services in Wales
and England as a barrier to informed choice. In M. Kirkham (ed.) Informed Choice in
Maternity Care. London: Palgrave, pp. 117-145.
Kitzinger S. (2005) The Politics of Birth. Edinburgh: Elsevier.
Kronborg H., Vaeth M. (2004) The influence of psychosocial factors on the duration
of breastfeeding. Scand J Public Health, 32(3): p. 210-6.
Macintyre S. (1984) Consumer reactions to antenatal services. In L. Zander and G.
Chamberlain (eds.) Pregnancy Care for the 80s. London: Macmillan.
MIDIRS and NHS Centre for Reviews and Dissemination (1999a) Place of Birth.
Informed Choice for Professionals: National Electronic Library.
MIDIRS and NHS Centre for Reviews and Dissemination (1999b) Epidurals.
Informed Choice for Professionals: National Electronic Library.
Oakley, A.
Oakley, A.
Blackwell.
(1979) Becoming a Mother. London: Martin Robertson.
(1980) Women Confined: towards a Sociology of Childbirth. Oxford:
O'Cathain A., Walters S.J., Nicholl J.P., Thomas K.J., & Kirkham M. (2002) Use of
evidence based leaflets to promote informed choice in maternity care: randomised
controlled trial in everyday practice. British Medical Journal 324, 643.
Porter, M. (1990) Professional-client relationships and women’s reproductive health
care. In S. Cunningham-Burley and N. McKegany (eds.) Readings in Medical
Sociology. London: Routledge.
Wagner M. (1994) Pursuing the birth machine: the search for appropriate birth
technology. ACE Graphics, Sevenoaks, Kent.
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Journal of Gynecology & Obstetrics 75: S25-S37.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
An Evaluation of Nurse Lecturer’s Perceptions of their Effectiveness in the
Practice Setting: Some Preliminary Findings.
Ms Freda Neill
Clinical Skills Manager
School of Nursing and Midwifery
Trinity College Dublin
24 D’Olier St.,
Dublin 2.
Ireland
+353 1 6083704
[email protected]
Ms Sylvia Huntley-Moore
Director of Staff Education and Development
School of Nursing and Midwifery
Trinity College Dublin
24 D’Olier St.,
Dublin 2.
Ireland
+353 1 6083704
[email protected]
Background
The increasingly complex role of today’s nursing practitioners has been accompanied
by demands on nurse educators to look at new ways to facilitate learning in the
clinical area (Camiah 1996). Over the past decade nurse education internationally has
undergone a period of major change. In the Irish arena the need for change was
recognised by the Report of the Commission of Nursing (1998) which recommended
that pre-registration nurse education should be fully integrated in the third level
education sector and based on a four year degree programme, incorporating one year
of employment, with structured clinical placement in the health service. The
recommendation was fulfilled in 2002 with the commencement of undergraduate
nurse education in universities and institutes of technology across the Republic.
The profession of nursing is a combination of the academic and the practical, and
needs to maintain effective integration of theory with practice. Where a gap exists
between theory and practice, efforts should be taken for its reduction (Raferty 1996).
In nurse education, clinical placements provide the student with opportunities to
achieve learning outcomes which bridge this gap (An bord Altranais 2000). The
richness of learning from clinical placements is widely recognised (Fretwell 1982,
Ogier 1989). With this in mind clinical placements were introduced from year one of
the TCD undergraduate Nurse education programme.
The nurse lecturer occupies an important role in the clinical setting both in respect of
students and clinical staff (Gerrish,1992). Thirty nurse lecturers from the TCD School
of Nursing and Midwifery committed to this role from the commencement of the
2004-2005 academic year.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The purpose of this study was to evaluate the perceived effectiveness of the nurse
lecturers in the practice setting in relation to three key roles adapted from Gerrish
(1992):
1. Providing educational support for practice-based staff
2. Teaching students
3. Facilitating evidence-based practice
Aim: To evaluate Nurse Lecturers’ perceptions of their effectiveness in the practice
setting.
Objectives:
1. To explore the effectiveness of the support and training provided for nurse lecturers
before they commenced teaching in the practice setting
2. To explore the extent of the educational support for practice-based staff provided
by nurse lecturers.
3. To identify the scope of nurse lecturers’ teaching in the practice setting
4. To explore the extent to which nurse lecturers perceive they were able to promote
research mindedness and facilitate evidence-based practice in the practice setting.
5. To identify key factors which are of particular relevance to the future development
of the School’s role in teaching in the practice setting
Research Method
This evaluative study included both qualitative and quantitative components. A
questionnaire comprised of mainly Likert -scale items with a small number of short
answer questions was distributed to the sample group. The data was collected by the
researchers and the software statistical package EXCEL was used to derive
descriptive statistics. The qualitative data was analysed using a structured thematic
approach.
Some Preliminary Findings:
•
The importance of briefings and skills updating for Nurse lecturers prior to
practice teaching
•
•
•
Opportunities to share research knowledge with practice-based staff were
limited
Nurse Lecturers appreciated the opportunity to get to know nursing
students in the clinical setting
Opportunities to facilitate evidence-based research with practice staff were
limited
References:
An bord Altranais (2000) Requirements and Standards for Nurse Registration
Education Programmes 2nd edition, Dublin, An bord Altranais.
Camiah, S. (1996) The changing role and work of British tutors: a study within two
demonstration Project 2000 districts. Journal of Advanced Nursing 23, 396 407.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Fretwell, J. (1982) Ward Teaching and Learning. London RCN
Gerrish, K. (1992) The nurse teacher’s role in the practice setting. Nurse Education
Today 12, 227-232
Government of Ireland (1998) Report of the Commission on Nursing. Dublin:
Stationery Office.
Ogier, M (1898) Working and Learning Creating a Learning Environment in the
Clinical Nursing Area. London, Scutari Press.
Rafferty, A.M., Allock, N., Lathean, J. (1996) The theory/practice gap: taking issue
with the issue. Journal of Advanced Nursing 23, 685 691.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
THE IMPACT OF HEALTH REFORM ON NURSE MANAGERS AND
THEIR MANAGEMENT OF NURSING SERVICES: A STUDY OF THE
AUSTRALIAN CONTEXT
Stuart Newman
RN, Int. Care Cert., BEd (Nursing), MHA
Lecturer in Health Services Management and
Director: International and Professional Relations
Faculty of Nursing and Midwifery
The University of Sydney
Sydney 2006 Australia
Telephone: +61 2 9351 0614
Fax: +61 2 9351 0679
Email: [email protected]
ABSTRACT
Several international studies have outlined the impact of health reforms on nursing as an
occupation and nurses as individuals, however, the effects of these reforms on nurses who are
responsible for managing nursing services has not been previously researched.
This study was principally concerned with the impact of New South Wales (NSW) public
sector health reforms on nurse managers and their management of nursing services. This
research project was descriptive (statistically) and qualitative in design and sought to explore
nurse managers’ experiences of the means by which they are expected to manage the delivery
of health care services directly to patients as well as provide professional and clinical
leadership in nursing, the issues that confront them and how or if they could resolve these in
the current policy context.
Participants were recruited from the membership of a professional organisation and two
instruments were utilised for data collection. All participants had the opportunity to
anonymously complete a 40-item questionnaire. Subsequently, 10 interviews were conducted
with respondents who had more management experience and who volunteered to be
interviewed. Data analysis included summary statistics to provide a demographic profile of
the participants and interview data was analysed using standard qualitative techniques of
identifying common themes (to the extent that these are consistent with the themes/sections of
the questionnaire). These data were analysed with a focus on the narrative accounts, reflecting
the interviewees’ experiences in nursing management and which were contextualised as life
histories as managers.
The preliminary findings show the health reform agenda has severely and negatively affected
the ability of nurse managers to manage nursing services and as a result, their job satisfaction
and commitment to the nursing profession are also affected.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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INTRODUCTION
Health care systems are arguably one of the most significant public sector enterprises in
developed countries (along with education) and have been specifically targeted for reform due
to the increasing demand for health services based on, among others: (i) greater consumer
knowledge and expectations; (ii) increasing problems surrounding equity and accessibility,
particularly for disadvantaged/minority groups; (iii) the rapid expansion of health related
technology and the associated costs; and, increasing life expectancy. These factors have lead
economists to predict the level of health care consumed in developed countries will become
financially unsustainable in the near future (Mooney & Scotton 1999:32). Within this context,
governments are concerned with the increasing costs associated with sustaining public sector
enterprises in the tradition of the welfare state, while at the same time face increasing public
and political pressure to ensure the quality and safety of these public sector entities. As a
result, the concept of reform has become a common feature of the political and economic
landscape in developed countries and reflects fundamental concern for the increasing costs of
health services and the limits on the amount of finance governments are prepared to or are
able to allocate to health care (Bloom 2000:4).
Critics and supporters of health sector reform have published extensively and the bulk of this
literature has addressed the advantages, disadvantages and overall impact of technical and
allocative (supply-side) reforms from social justice and economic perspectives (Cordery
1995, James 1997, Chen & Miroslav 1998, Marmor 1998 & Lumby 2001). Over the last
decade, research and commentary on the impact of health reform on nurses and nursing as an
occupation has also emerged. However the primary focus of this research has been the impact
1
on clinicians and clinical practice, in particular, debate surrounding the need for
redefinition/restructuring of professional roles given the debate surrounding issues in relation
to the international nursing recruitment and retention crisis (Shindul-Rothschild 1994, Dixon
1996, Solecki 1998, Corey-Lisle, Tarzian, Cohen & Trinkoff 1999, Hewison 1999, Bullock
2001, Fletcher 2001, Chan & Morrison 2002, Newman 2003 and Newman & Lawler 2005).
Various authors have also reported on the experience of nurse managers in the changing
health care systems in New Zealand, Canada, the United States of America and Hong Kong
(Wong 1998a, Wong 1998b, Proenca 1999, McNeese-Smith 2001, Newhouse & Dang 2001
and Franco, Bennett & Kanfer 2002). However, the greatest volume of research in and around
this area has focused on reforms within the British National Health Service (Currie 1997,
Willmott 1997, Gould, Kelly & Maidwell 2001, Bolton 2003, Ewens 2003 and Merali 2003).
The underlying theme(s) of this research has been the impact of reform on the role of nurse
managers, mainly regarding the transition of the nurse manager role (from charge nurse-tonurse manager), and the accompanying increased financial and managerial accountabilities
characteristic of the managerial wisdom. In this sense, the literature has focused on the need
for realignment of the role of nurse managers and recommendations and strategies to achieve
this realignment are prescribed from the perspective of facilitating, enabling and empowering
nurse managers to meet the demands placed on them by contemporary health care
organisational activity. However, these recommendations and strategies also represent the
covert nature of managerialist campaigns to realign the role of nurse managers to better fit
with the reform agenda and subsequently the requirements of organisations in the NPM
context. There is a lack of focus within the literature on the quality of patient care and human
resource responsibilities, which characterised the pre-reform charge nurse role.
1
.
The terms clinician refers to a range of nursing position descriptors or titles, depending on the
structure of the nursing workforce in various countries. For example, nursing structures and hence
position titles differ between the United States, Great Britain, Canada, New Zealand and Australia. In
the Australian context, and in the context of this study, the term clinician refers to registered nurses. In
NSW, registered nurses are required to have completed a recognised education program leading to
registration with the Nurses and Midwives Board of NSW.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
In this sense, the literature is typical of the historically prescriptive nature of management
research and literature, which has attracted mounting criticism because of inhered
functionalism. Darmer (2000) argues the foremost problem with management literature is that
it regards management as a contingency-variable or situational factor in the effectiveness of
organisations because the management skills of managers are considered the single most
important factor in whether or not organisations are successful. Consequently, the principal
focus of management research and theory, and more recently NPM theory, has been to
identify what constitutes effective management. The inherent functionalism in this framework
epitomises the neo-positivistic paradigm through its assumptions about the rationality of the
world and people and its attempts to identify truths about management practice and “what
managers ought to do to make organisations [and people] effective” (Darmer 2000:341).
Therefore, the current management constructs in and around managing nursing services are
written about as if they are self-evident.
The dominance of the neo-positivist paradigm in management research and theory is
problematic for gaining an understanding of the experiences of managers and how they
construct their management practice. From the perspective of health reform and the impact on
nurse managers, the neo-positivist paradigm is problematic for gaining understanding about
the experiences of nurse managers in the context of reform and how reforms have affected
and changed their role requirements and current activities in the management of nursing
services.
Darmer argues for a more “constructivistic” approach to management research (2000:347).
Constructivistic management research is epistemologically subjective and in direct contrast to
the functionalistic approach. It is not concerned with the identification of truths but with
human reality and how it is constantly being constructed and developed in response to
experience. The constructivistic approach is premised on the concept that managers do not act
rationally but rather, their actions (and inactions) are subjective and in accordance with their
reality (Darmer 2000:347). In this sense, it is the manager’s experience and hence perception
of reality that determines their decisions and actions based on “highly filtered, personalized,
idiosyncratic understandings of the their situations” or the environments and policy contexts
in which they are expected to manage (Finkelstein & Hambrick 1996:75).
The design for this study emerged from concern over the complex set of relationships that has
developed between the Australian health reform agenda, nurse managers and management
practice as it is conceptualised and theorised in the new public management (NPM)
framework. Nurse managers are fundamental to the professional and political presence of
nursing in health care organisations and central to the operational activities of health services
in the Australian health care system. However, there is a lack of consideration of how this
group of highly skilled and knowledgeable professionals has experienced health reforms and
how health reforms have impacted on their management of nursing services and what this
means to and for them. Equally there is a lack of understanding of nurse managers’
experiences of the means by which they are expected to manage the delivery of health care
services directly to patients as well as provide professional and clinical leadership in nursing,
the issues that confront them and how or if they can resolve these in the current policy context
driving the reform agenda. Additionally, this project addresses an underlying if not central
dynamic in the current workforce crisis in western nursing.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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THE STUDY
Research Purpose and Questions
The purpose of the study was to achieve three things: (i) gather in-depth information about
nurse managers’ experiences of health reform and the means by which they are now expected
to manage the delivery of safe health care services directly to patients as well as provide
professional and clinical leadership in nursing; (ii) compose a detailed information base about
the professional and management issues that confront nurse managers and how or if they can
resolve these issues in the context of current health policy under the reform agenda; and, (iii)
to obtain a detailed demographic and occupational profile of the nurse manager workforce in
NSW.
Data Collection
Data collection for this study utilised a reflective questionnaire and structured interviews.
A 40-item questionnaire was developed to obtain data in five key areas: (i) participants’
biographical data and relevant professional history; (ii) participants’ current management
practice(s); (iii) the key elements of managing nursing services; (iv) the participants’
understanding of health care reform; and (v) the impact of reform on the participants’
management of nursing services.
The use of a questionnaire provided the opportunity to profile the participants in much the
same way as Duffield profiled nursing unit managers in NSW in 1989 (see Duffield 1992)
and in 1999 (see Duffield, Moran, Beutel, Bunt, Thornton, Wills, Cahill & Franks 2001).
These are the only studies to date profiling nursing unit managers in NSW and there has been
no similar study of nurse managers. However, Rawson (1988) provided a profile a Directors
of Nursing as part of a larger study of the executive triumvirate (Chief Executive Officer
[CEO], the Director of Medical Services [DMS] and the Director of Nursing [DON]) of
Australian hospitals. Rawson’s study is of limited value to this study because it only provided
a comparative skills profile of the executive triumvirate and only targeted Directors of
Nursing in hospitals of 200 beds or more. Given the lack of studies profiling nurse managers,
some of the questions in the questionnaire in this study were used in the same or similar
format to those used by Duffield (1992) and Duffield et al. (2001) to provide a foundational
profile of nurse managers.
The questionnaire consisted of a series of questions requiring a rated response (using a Likert
scale of 1-5) and open-ended questions. The design and specific sequencing of the
questionnaire aimed to move participants through their accounts of their relevant professional
background, management experience and practices, and ultimately their experiences of health
reforms in the same way as one would move through or contextualise a life history. This
process was ultimately to support analysis of questionnaire and interview data, focusing on
these narrative accounts, reflecting the interviewees’ experiences in nursing management and
contextualising these experiences as life histories as nurse managers.
The second stage of data collection for this study utilised structured interviews from a small
subset of participants (N = 10) who completed the questionnaire and who subsequently
volunteered to be interviewed. The interview was used to explore in more detail individual
participant’s answers to the questionnaire as well as exploring more open narratives about
their experiences as nurse managers. This provided a method of gaining more narrative or
deeper data, particularly in relation to their experiences of health reforms and the impact on
their management of nursing services.
Because the interviews were designed to seek more narrative or deeper data and expand on
their answers to the questionnaire, each participant was asked a series of pre-established
questions. While the themes of the questions followed the section structure of the
questionnaire, the precise questions for each participant varied according to their
questionnaire responses and to a certain extent, their responses to questions during the
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
interview. In this way the interviews were structured, however, the intention was not to limit
the variation in response, as one would do in the purest sense of a structured interview
(Fontana & Fey 2000:649) but rather have a scope for gathering wider experiential data.
Recruitment of Participants
Participants for this study were recruited using the membership database of The Institute of
2
Nursing Executives Incorporated (INE) . The decision to use the membership of the INE
offered significant advantages to the recruitment of participants for this study because of the
comprehensive nature of the membership. These advantages included: (i) representation from
diverse management positions; (ii) a group with a wide range of nursing and nursing
management experience; and, (iii) representation from the multiple genres of nursing
management, including acute care, aged care, community and mental health.
216 questionnaires were mailed and subsequent to mailing the questionnaire, 10 nurse
managers who were not members of the INE contacted the researcher requesting to participate
in the study and questionnaires were mailed to them.
Following the return of completed questionnaires, five criteria were used to exclude
participants’ from inclusion in the study. These criteria were: (i) employees of private sector
(for profit) organisations; (ii) employees of church and charitable organisations (with the
3
exception of schedule 3 organisations under the Health Services Act 1997) ; (iii) honorary
4
members and fellows of the INE , (iv) INE members or fellows not currently working in a
management position; and, (iv) INE members or fellows not working in NSW.
Thirty-five questionnaires were returned, representing a 15.5% response rate. Five
respondents were excluded based on the exclusion criteria.
Ten participants were selected from the total participants who volunteered to be interviewed
(N = 17). Three criteria for selection for interview were developed in keeping with the
purposes of the study and these were: (i) five or more years of management experience; (ii)
that the interviewees should be representative of the multiple genres of nursing management,
for example, acute care, aged care, community and mental health; and (iii) that interviewees
should represent where possible the range of nurse manager positions as defined by the NSW
Nurses (State) Award.
Data Analysis
2
.
The INE is a professional organisation for nurse managers. It provides a forum for all levels of
nursing managers and senior clinicians to discuss and comment on matters relating to the profession of
nursing, particularly nursing management issues. Current membership (or fellowship) of the INE was
the single criterion for inclusion in the initial recruitment of participants for this study. Membership of
the INE requires certain qualifications and experiences including: (i) current registration as a nurse; (ii)
a tenured management position in nursing/health; and, (iii) a degree or diploma in management (or
equivalent). In special circumstances, candidates who do not meet the membership criteria may be
admitted to membership with Council approval because of their outstanding contribution to the nursing
profession. Fellowship of the INE is conferred on members who, according to the Council, have made
significant contribution to nursing management and the nursing profession.
3
.
Schedule 3 organisations are classified as affiliated health organisations under the Health
Services Act 1997 section 62 and replace the system of separate institutions and associated
organisations recognised under Part 5AA and section 29B (1) of the Public Hospitals Act 1929. This
schedule recognises not-for-profit, religious, charitable and non-government organisations that control
hospitals, health organisations/services and health support services and contribute to the overall health
system. Schedule 3 organisations / institutions are therefore treated as part of the NSW public health
system.
4
.
The Council of the INE confers honorary membership and fellowship of the INE on nurses,
nurse managers and non-nurses who, according to the Council, have made significant contribution to
nursing management and/or the nursing profession. Honorary members and fellows are not required to
meet the same admission criteria as members and fellows.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
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The demographics of the participants were analysed using summary statistics. Interview data
were analysed using standard qualitative techniques of identifying common themes (to the
extent that these were consistent with the themes/sections of the questionnaire), central
concepts, differences, unique experiences and common experiences. These data were
analysed with a focus on the narrative accounts, reflecting the interviewees’ experiences in
nursing management and were contextualised as life histories as managers (Connelly &
Clandinin 1990).
FINDINGS
Demographics
From the demographic data the participants can be identified as a highly experienced and
qualified group of nurse managers. The gender characteristics of the group reflect the broad
gender division in nursing with 90% or participants female and 10% male, however, it is
likely that while males are acknowledged as overrepresented in nursing management
generally (in relation to the percentage of men in nursing) they are underrepresented in this
group.
All participants were in the age groups 40 and above and 96.7% of participants had greater
than 15 years experience in nursing with 93.4% gaining their initial nursing qualification in a
hospital-based training program. Additional clinical qualifications are held by 96.7% of the
group, with the majority (33.3%) at degree level. However, 26.7% have additional clinical
qualifications at post-basic certificate level and 23.3% at master’s level. Management
qualifications are held by 83.3% of the participants: 60% at master’s level, 32% at degree
level and 4% respectively at graduate certificate, diploma and graduate diploma level.
All participants were currently working in management and the majority (86.7%) of
participants have worked in management for longer than 6 years with 46.7% for longer than
15 years. The length of time in their current position ranged from 2-5 years (50%), 6-9 years
(16.7%) to 10-15 years (13.3%) (16.7% did not respond to this item). No participant had
worked in their current job longer than 15 years with only 1 (3.3%) had worked in their
current position less than 2 years.
The positions held by participants range from Nursing Unit Manager (Level 2) to Nurse
5
Manager (Grade 9) under the NSW Nurses (State) Award , with 53.3% at Nurse Manager
(Level 5) and above. The majority of participants (70%) work in hospitals, with 6.7%
respectively in rural health facilities/multipurpose centres and community health while only
one participant worked in aged care. Four participants (13.3%) responded as ‘other’ and
identified their positions as area-wide or area-sector positions. Of these four participants,
three hold positions outside the NSW Nurses (State) Award structure: two under the Health
Services Award and one under the Health Executive Service (previously the State Executive
Service). In regard to their current position, 90% of the participants indicated budget
responsibility ranging from less than AUD $1M (7.4%) to greater than AUD $20M (14.8%).
Interview Data
Themes emerging from the interview data included, among others: the concept of health
reform and politics; change; the marginalisation of nurse managers; micromanagement; and,
visibility and leadership.
Health Reform and Politics
5
.
Under the NSW Nurses (State) Award, nursing unit managers are classified in levels 1-3 and
nurse managers in grades 1-9. The level to which a nursing unit manager is appointed or the grade to
which a nurse manager is appointed is determined by the complexity of the position. The factors
determining the level of appointment include (among others): bed numbers, adjusted daily average,
staffing responsibility, budget responsibility and scope of the position (e.g. organisation or area wide).
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Participants considered the general concept of health care reform positively with regard to
managing health services ‘better’, in particular, managing services to meet the needs of the
ageing population and redressing the imbalance between institutional and community
services. In principle, participants considered the concept of reform to be “well intentioned”
and based on the identified need to improve the quality of the health care system. In this
sense, the public representation of reform was not challenged. However, participants were
critical of the rhetoric surrounding health reform and the implementation of reform activities
at “grass roots level” or “at the frontline” (terms used by many participants to distinguish
between the decision-making arena and where the ‘business’ of the health care system takes
place – that is, the provision of care).
Finance and politics were identified as the principal drivers of the health reform agenda.
Finance was considered foremost to the extent that “dollars are more important than the
needs of the patient/client/family” and the “economic focus [is] overriding safety and
quality”.
Participants also expressed concerns over the speed with which financial decisions were made
and implemented and this was attributed to the politics underpinning the reform agenda and
subsequently political imperative surrounding reform initiatives – considered the other major
principal force driving reform. The covert nature of political point scoring surrounding health
care was a source of discomfort for participants, because changes are “implemented due to
political influence” rather than on a “needs basis”. On the topic of politics and health reform,
one participant recounted:
[It] is about satisfying someone’s latest whims. That’s how I see a lot of the
health reform that’s come through … often a whim of the Minister [for Health] …
picks up on a report … his aid … picks up on something and insists on running
with it … that’s where they go. I mean maybe if we listened to our clinicians
more health reform would be much more proactive … and I know as a DON
[Director of Nursing] you talk to your team … and they just say ‘look … you
know what we should be doing … not this … we should be doing this’. And they
make sense you know … practical, reality-based stuff from their experience.
Change
A second emergent theme was change, and while change was deemed necessary as part of
meaningful reform activities, change in the current environment was considered by various
participants to be “unpredictable and ad hoc” with no significant gains – “the more we
change the more we stay the same”. To this degree, many of the changes surrounding reform
were associated with “just moving the deckchairs”.
Having said that, changes generally were viewed as underpinned by political point scoring or
political imperative and basically seen to be the result of a “whim of the latest manager” or
indeed the politicians themselves. As one participant stated: “the Minister [for Health] gets a
major complaint about something and ‘we’re going to do this … or ‘we’re going to do that’!”
To this end, participants’ regarded the concept of significant and meaningful change, as
articulated by the reform discourse, to be an illusion.
You know, if we keep going the way we’re going and just tinkering at the edges,
which is really what we’re doing … I’m talking about tinkering at the edges but
in fact we’ve probably made significant inroads into things like 23 hour wards,
day of surgery admissions, tracking through the emergency departments,
psychiatric emergency care centres, all of those sorts of things …[but they] are
making us able to tread water at the moment. They’re not making us able to
make enormous leaps and bounds as far as reform is concerned.
Marginalisation of Nurse Managers
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Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The third theme to emerge from the questionnaire and interview data was the marginalisation
of nurse managers from decision-making and subsequently disempowerment within
organisations and the health reform agenda generally.
Marginalisation and disempowerment was seen to be due to a lack of professional
consultation in regard to reform activities and a lack of understanding of how decisions were
likely to impact on nurse managers and nursing services. The disquiet over the
marginalisation of nurse managers was expressed in relation to the centrality of nurse
managers to the operational activities of the health care system and while “nurse managers
often highlight issues that need to be addressed, they [the issues] fall into the ‘too hard
basket’ or the ‘too expensive options bracket”. According to one participant:
nurse managers are very much marginalised; they’re not respected for their
contribution. Whilst we might be respected from those below us I think as you
move up the echelon I don’t think there’s that respect at all and I certainly don’t
think from the very top that nurse managers are seen to make a contribution at
all.
The concept of marginalisation was reported as a consequence of the principal drivers of the
reform agenda and participants expressed extreme concern over the “lack of nursing voice”
and, to a certain extent a lack of respect for the nurse management positions. One participant
observed that “we [nurses] are not wanted in setting agenda or guiding health care” which
was particularly evidenced by the comment regarding “the infiltration of non-nurses into what
were traditionally nursing management positions”, and subsequently the exclusion of nurse
managers from decision-making processes. Another participant similarly described the
situation, stating that: “nurse managers are being pretty well ignored if not run over in the
whole process of reform”.
Micromanagement
Subsequent to the restructuring of the area health services in NSW, various participants
expressed a high degree of apprehension over the ensuing level of micromanagement, or the
extent to which they are being over-managed unnecessarily. While employee empowerment is
a catch cry of the NPM framework, the level of micromanagement was perceived by
participants as a response to economic pressures and a lack of trust in managers – “a huge
lack of trust. They’re all out … and this seems very extreme but people are looking after their
own backsides”.
While participants acknowledged the high degree of micromanagement was, in some way, an
attempt to improve performance across the area health services, there was also
6
acknowledgement that it was aimed at preventing mistakes made previously . One participant
commented that “they’re not going to let that happen anywhere else or they’re going to put
everything into place to try keep that from happening”.
However, while such action was considered reasonable given the circumstances, the level of
micromanagement was also considered a significant de-motivator, creating resentment and
frustration because of its impact on what was perceived as their principle management
functions – primarily the quality of nursing services and professional leadership. Participants
reported micromanagement as evidenced by the proliferation of communication, both paperbased and electronic, which usually required a response either in the form of information or a
statistical report. One participant highlighted the level micromanagement and its impact on
managers saying:
I think people are agitated about it … nobody likes to be managed like this …
nobody likes to feel that they aren’t trusted or that their decisions aren’t trusted
that you have to run them by everyone. I mean, we getting paid a good salary to
6
.
This comment refers to incidents in the operating theatres at Canterbury Hospital and deaths at
or following admission to Camden, Campbelltown and Liverpool hospitals.
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
make decisions and to wear the fallout but they aren’t going to allow us to fall.
They’re going to make sure everything is run by them and that no decisions are
made at facility level anymore.
Visibility & Leadership
The concept of leadership emerged as a key theme in the questionnaire and interview data and
there was a range of responses regarding the importance of their visibility and leadership
within their organisations. For example, one participant commented that visibility and
leadership is:
crucial, absolutely crucial. You’ve got to walk the talk and I know that’s a
hackneyed phrase but I still I believe in it. You’ve got to get out there and you
have to be visible, as much as you possibly can and that means going to ward
meetings, having night duty meetings, just walking around.
Leadership was also emphasised as central to the success of clinical care activities and
according to one participant we should not.
underestimate the absolute importance of the nurse unit manager or the nurse
manager because where you see the sheer pockets of brilliance and where staff
and patients have a great time and they have great outcomes … then you can
almost guarantee that it’s because of the leader.
The majority of participants emphasised the increasing difficulty in maintaining their
leadership function given the escalating requirements of their role. Essentially, participants
attributed these increased requirements to political imperatives and the micromanagement
activities which are increasingly characteristic of the administration of health services.
The Department [of Health] has imposed a tremendous amount of reporting on
the area who has in turn imposed that upon the facilities, so I have to report on a
daily basis on the number of beds that I have opened and who’s occupying those
beds. [The] same thing with nursing staffing, vacancies, weekly reports [and]
waiting lists. Reporting has become a tremendous and onerous sort of job. There
are for example 16 audits associated with the waiting lists that are done every
month. There’s a weekly report where this clerk has to count the number of
people in each specialty on each waiting list and it just goes on and on and on.
So probably, 50% of my time is suddenly spent doing reports and justifying our
business.
In a similar comment, another participant explained increased requirements as:
responding to Ministerials, responding to complaints, responding to urgent crap
that comes from the system [health system] … having to deal with crises …
usually bed management crises. You [expect those sorts of things] but sometimes
they can consume your whole day and your whole week and your weekend and
your after hours because you’re on call.
Given the increasing pressures and difficulties, participants also commented on the type of
visibility they are able to maintain and in these instances, it was the ‘wrong’ type. With
reference to dealing with crises, visibility was often related to “fixing problems” or dealing
with difficult staff. As a result, participants acknowledge their visibility was perceived
negatively as opposed to the positive aspects of visibility, for example, “doing the rounds and
saying ‘how’s the day going, what’s happening’?”
Intention to Remain in Nursing
One of the final questions on the questionnaire asked participants to indicate whether the
pressures of managing nursing services had: increased; decreased; stayed the same; or, varied.
Overall, 93.3% of participants indicated the pressures had increased. Participants were also
asked if their intention was to remain in nursing. 50% responded ‘yes’, while 20% responded
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
‘no’ and 30% ‘don’t know’. The reasons provided for ‘no’ and ‘don’t know’ responses
included: “too stressful and a feeling of lack of achievement because [the] goal posts move to
often”; “constantly required to save money by asking staff to do the same or more with less or
the same resources”; “increased workload and pressure with no extra resources”; and, “not
sure I can keep up the hard work required”.
DISCUSSION
The preliminary findings of this research project reflect nurse managers’ perceptions and
criticisms of the health care reform agenda. Participants described how the changes resulting
from the reform agenda have impacted on them personally and professionally because their
roles have come under increasing pressure as the complexity of managing nursing services
has escalated.
Financial and political imperatives were identified as the key drivers of the reform agenda to
the extent that improving the effectiveness, quality and safety of health services is seen as a
secondary consideration. This type of environment threatens the ability of nurse managers to
provide the appropriate number of nursing staff with the appropriate skillmix to ensure the
provision of safe and effective patient care.
As the reform agenda unfolds, nurse managers are being increasingly marginalised.
Organisational restructuring as part of the reform activities has meant management work
previously done by others has become the domain of nurse managers, while at the same time
there has been increasing erosion of the nurse manager’s professional and occupational
territories. This is consistent with the work of Baumann and Silverman (1998) who concluded
that restructuring reduced professional autonomy and replacing professionals with less costly
nonprofessionals masked professional identity. As a result, professional discourse within the
organisation becomes further silenced subsequently further disempowering the professional
group.
Comments from various participants replicate research findings in the motivation/satisfaction
and occupational stress literature. For example, excessive workload, lack of support and
micromanagement are having a severe and negative effect on nurse managers’ morale,
commitment and job satisfaction. At the same time, increasing levels of nursing staff
dissatisfaction and low morale challenge nurse manages because they recognise the need for
greater attention to motivation strategies and professional leadership, but are unable to
provide the level of leadership and support they see as crucial.
In general, the impact of health reforms on nurse managers and their management of nursing
services reflect what Appelbaum et al. (1999) described as corporate survivors’ syndrome.
Nurse managers are expressing greater levels of anger and frustration as well as decreased
commitment and morale. They essentially fear for their professional role in the future of the
health care system and have an increasing cynicism for the health reform agenda and the
politics underpinning it, which to them are inconsistent with the public health system’s raison
d’être. As Currie (1997:132) suggested, there is undoubtedly “contested terrain” between the
health reform agenda and the management and professional ideologies of nurse managers.
REFERENCES
Appelbaum SH, Livigne-Schmidt S, Peytchev M & Shapiro B (1999) Downsizing: Measuring
the costs of failure, Journal of Management Development, 18(5):436–463
Baumann A & Silverman B (1998) Flattening the hierarchy: Deprofessionalization in health
care, in Groake L (ed.) The Ethics of the New Economy, Wilfred Laurier University Press,
Canada
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
Bloom AL (ed.) (2001) Health Reform in Australian and New Zealand, Oxford University
Press, Melbourne
Bolton SC (2003) Multiple roles? Nurses as managers in the NHS, The International Journal
of Public Sector Management, 16(2):122–130
Bullock C (2001) Background Briefing: Nurses: Double Shifts, Double Danger, Australian
Broadcasting Corporation, Radio National, July 8th
Chan E & Morrison P (2002) Factors influencing the retention and turnover intentions of
registered nurses in a Singapore Hospital, Nursing and Health Sciences, 2:113–121
Chen M-S & Miroslav M (1998) Health care reform in Croatia: For better or for worse?
American Public Health Association, 88(8):1156–1160
Connelly FM & Clandinin DJ (1990) Stories of experience and narrative enquiry, Educational
Researcher, 19(5):2–14
Cordery CL (1995) Managing (in)differently: The management and delivery of Australian
health care under the economic rationalists, Health Care Analysis, 3:339–344
Corey-Lisle P, Tarzian AJ, Coehn MZ & Trinkoff AM (1999) Healthcare reform: Its effects
on nurses, Journal of Nursing Administration, 29(3):30–37
Currie G (1997) Contested terrain: The incomplete closure of managerialism in health service,
Health Manpower Management, 23(4):123–132
Darmer P (2000) The subject(ivity) of management, Journal of Organizational Change
Management, 13(4):334–351
Dixon A (1996) New Zealand: The effects of New Zealand health reforms on nurses and
nursing, International Journal of Nursing Practice, 2(4):243
Duffield C (1992) Future responsibility and requirements for first-line nurse managers in New
South Wales, Image: Journal of Nursing Scholarship, 24:39–43
Duffield C, Moran P, Beutel J, Bunt S, Thornton A, Wills J, Cahill P & Franks H (2001)
profile of first-line nurse managers in New South Wales, Australia in the 1990s, Journal of
Advanced Nursing, 36(6):785–793
Ewens A (2003) Changes in nursing identities: Supporting a successful transition, Journal of
Nursing Management, 11:224–228
Finkelstein S & Hambrick DC (1996) Strategic Leadership: Top Executives and Their Effects
on Organizations, West Publishing Company, St. Paul, Minneapolis
Fletcher CE (2001) Hospital RNs job satisfactions and dissatisfactions, Journal of Nursing
Administration, 31(6):324–331
Franco LM, Bennett S & Kanfer R (2002) Health sector reform and public sector health
worker motivation: A conceptual framework, Social Science and Medicine, 54:1225–1266
Gould D, Kelly D & Maidwell A (2001) Clinical nurse managers’ perceptions of factors
affecting role performance, Nursing Standard, 15(16):33–37
Hewison A (1999) The new public management and the new nursing: related by rhetoric?
Some reflections on the policy process and nursing, Journal of Advanced Nursing,
29(6):1377–1384
James A (1997) Beyond the market in public service, Journal of Management in Medicine,
11(1):43–50
Lumby J (2001) Who Cares? The Changing Health Care System, Allen & Unwin, Sydney
Marmor TR (1998) Hope and Hyperbole: The rhetoric and reality of managerial reform in
health care, Journal of Health Services Research Policy, 3(1):62–64
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
McNeese-Smith DK (2001) Staff nurse views of their productivity and non-productivity,
Health Care Management Review, 26(2):7–19
Merali F (2003) NHS managers’ views of their culture and their public image: The
implications for NHS reforms, The International Journal of Public Sector Management,
16(7):549–563
Newhouse R & Dang D (2001) Measuring roles changes for nurses, Journal of Nursing
Administration, 31(4):173–175
Newman S (2003) New South Wales health care reforms and nursing services: A story of
rationalism, conflicting ideologies and scapegoating, Proceedings of the 4th International
Research Conference, Faculty of Health Sciences University of Dublin Trinity College,
November
Newman S & Lawler J (2005) The dark side of reform, Proceedings of the Royal College of
Nursing Australia Conference, Adelaide, July
Proenca EJ (1999) Employee reactions to managed care, Health Care Management Review,
24(2):57–70
Rawson G (1988) Directors of Nursing in Australia: A profile, Nursing Outlook, 36(4):198–
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Shindul-Rothschild J (1994) Restructuring, redesign, rationing, and nurses’ morale: A
qualitative study on the impact of competitive financing, Journal of Emergency Medicine,
20:497–504
Solecki SM (1998) From the caring value to the bottom line: The impact of health care reform
on nursing, Nursing and Health Care Perspectives, 19(2):60
Wong FKY(1998) The nurse manager as a professional-managerial class: A case study,
Journal of Nursing Management, 6(6):343–350
School of Nursing & Midwifery, Trinity College Dublin: 6th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: November 2nd – 4th November 2005 – Conference Proceedings L-Z
The use of language in nursing practice- an exploration of the terms that nurses
in Ireland use when caring for “life-limited” children.
Ms Honor Nicholl RGN, RSCN, RCNT, RNT. BSc., MEd.
Lecturer
School of Nursing and Midwifery Studies,
University of Dublin Trinity College,
24 D'Olier Street,Dublin 2.
Ph: 6083702
Email: [email protected]
Abstract
Increasing numbers of children are surviving with a range of complex medical health
problems and there are major shifts occurring in the provision of community services
care for these children. This group of children with chronic, life- limiting and
sometimes, progressive disorders is also not a homogenous one. Literature, experience
and discussion with colleagues in Ireland, undertaken as part of a larger research
study, indicate that there is a multiplicity of terms used for these children. These terms
also differ depending on who is using them. Professionals for example, identify
children with life threatening illnesses, life limiting disorders, “technologically
dependent children” (Campbell 1998), complex health care needs, “disabled” (Roberts
and Lawton 2000), “medically complex” or a “child requiring palliative care”. Parents
conversely refer to their child by name and not necessarily by their needs or disability.
This plethora of terminology also pervades the care services for such children and
includes learning disability, early intervention and children’s hospice or respite
services. Sutherland et al (1994) suggests that the development of these services may
also be hampered by the lack of an agreed set of working definitions.
In this presentation the researcher will identify and discuss the results of a telephone
survey and present terms used by children’s nurses in Ireland who have experience in
caring for children with life limiting conditions. New, emerging and culturally
specific terms will also be identified. The practical implications of this complexity in
language for parents and those involved in health care delivery with children will be
discussed.
REFERENCES
Campbell T. (1998) Caring for the technology dependent child-a case study. Nursing
Praxis in New Zealand. 13, 2, 5-10.
Roberts K.& Lawton D. (2000) Acknowledging the extra care parents give their
disabled children. Child: Care, Health and Development.27, 4, 307-319.
Sutherland R.., Hearn J. & Baum D.& Elston S. (1993) Definitions in paediatric
palliative care. Health Trends. 25,4,148-50.
INTERVIEWING: SOME METHODOLOGICAL ISSUES IN QUALITATIVE
RESEARCH
Ms Honor Nicholl RGN, RSCN, RCNT, RNT. BSc., MEd.
Lecturer
School of Nursing and Midwifery Studies,
University of Dublin Trinity College,
24 D'Olier Street,
Dublin 2.
Ph: + 353 1 6083702
Email: [email protected]
Dr Catherine Tracey Ph.D., MBA., MSc., RGN., RPN.
Lecturer
School of Nursing and Midwifery Studies,
University of Dublin Trinity College,
24 D'Olier Street,
Dublin 2.
Ph: 6083901
Email: [email protected]
Abstract
In qualitative research interviewing is one of the most widely used approaches of data
generation (Gubrium & Holstein 2002). Interviewing is“…not a research method but
a family of research approaches that have only one thing in common-conversation
between people in which one person has the role of researcher” (Arskey and Knight
1999:2).
In exploring through qualitative interviewing sensitive health-related issues which
may be considered highly confidential, personal and/ or threatening Brannen (1988),
amongst other writers proposes a range of contingencies sets. These sets include
approaching the topic, dealing with the complexities in the interview situation, the
operation of power and control and fourthly the conditions under which interviewing
takes place.
In this paper the speakers will draw on their experiences of completed and on going
studies using interviewing as a data generation approach with two different groups mothers and top level nurses using two different approaches – unstructured and elite
semi-structured interviews. Discussion will include the theoretical and pragmatic
issues and their implications that may require consideration in planning and
undertaking interviews to explore health-related sensitive research issues.
REFERENCES
Arskey H. and Knight P. (1999) Inteviewing for Social Scientists An Introductory
Resource with Examples. Sage Publications:London.
Brannen J. (1988) The study of sensitive subjects. Sociological Review.36:552-63.
Gubrium J. and Holstein J.(Eds)(2002) Handbook of Interview Research. Thousand
Oaks: Calfornia
INTERVIEWING: SOME METHODOLOGICAL ISSUES IN QUALITATIVE
RESEARCH
Ms Honor Nicholl RGN, RSCN, RCNT, RNT. BSc., MEd.
Lecturer
School of Nursing and Midwifery Studies,
University of Dublin Trinity College,
24 D'Olier Street,
Dublin 2.
Ph: + 353 1 6083702
Email: [email protected]
Dr Catherine Tracey Ph.D., MBA., MSc., RGN., RPN.
Lecturer
School of Nursing and Midwifery Studies,
University of Dublin Trinity College,
24 D'Olier Street,
Dublin 2.
Ph: 6083901
Email: [email protected]
Abstract
In qualitative research interviewing is one of the most widely used approaches of data
generation (Gubrium & Holstein 2002). Interviewing is“…not a research method but
a family of research approaches that have only one thing in common-conversation
between people in which one person has the role of researcher” (Arskey and Knight
1999:2).
In exploring through qualitative interviewing sensitive health-related issues which
may be considered highly confidential, personal and/ or threatening Brannen (1988),
amongst other writers proposes a range of contingencies sets. These sets include
approaching the topic, dealing with the complexities in the interview situation, the
operation of power and control and fourthly the conditions under which interviewing
takes place.
In this paper the speakers will draw on their experiences of completed and on going
studies using interviewing as a data generation approach with two different groups mothers and top level nurses using two different approaches – unstructured and elite
semi-structured interviews. Discussion will include the theoretical and pragmatic
issues and their implications that may require consideration in planning and
undertaking interviews to explore health-related sensitive research issues.
REFERENCES
Arskey H. and Knight P. (1999) Inteviewing for Social Scientists An Introductory
Resource with Examples. Sage Publications:London.
Brannen J. (1988) The study of sensitive subjects. Sociological Review.36:552-63.
Gubrium J. and Holstein J.(Eds)(2002) Handbook of Interview Research. Thousand
Oaks: Calfornia
METAPHORS AS KNOWLEDGE REPRESENTATION
EDUCATION
THE CASE OF CLINICAL SUPERVISION
IN
NURSING
Guri Brit Nielsen, RGN, Psychiatric nurse. B.Sc. (social sciences), M.Sc.
(pedagogy), p.t. PhD student (caring science)
Akershus University College, P.O. Box 423, 2001 Lillestrøm, Norway
Tel. +47 64849201, Fax +47 64849001
[email protected]
Abstract:
Background
A condition for good nursing is good nursing education. A problem however referred
to as the theory-practice gap is still a challenge demanding new solutions. The paper
is about clinical supervision in nursing education. Clinical supervision is seen as the
crux in the education intending to bridge the gap between theory and practice. The
paper deals with parts of my PhD work which is still in progress.
Aim, research paradigm and research questions
The aim of the study is to develop a tentative theoretical model of clinical supervision
in a caring science and a socio-cultural learning perspective. The research paradigm is
qualitative seeing caring science as humanistic science and using discourse analysis as
methodological approach. The main research question is: How is nursing constructed
in clinical supervision as a situated learning activity? The focus is on discourses as
social interaction and metaphors as representations of knowledge as revealed by
participants in clinical supervision. Metaphors are basic concepts in the construction
of world views (ontology) and knowledge about the world (epistemology). Metaphors
are historically and culturally embedded and function to reduce a complex world to
meaningful entities. Metaphors signify a transfer of meaning from one domain to
another. Metaphors in western vocabularies are dominated by nouns indicating a
‘things-ontology’.
Sampling, data collection and analysis
Sampling is purposive and includes 27 participants (9 students, 9 clinical supervisors
(preceptors) and 9 college teachers) selected from one nursing college of a 3-year
basic nursing education. The participants represent different educational levels and
clinical fields in the program and they participate on a voluntary and informed consent
basis. The data collection methods are individual interviews, triad and dyad
supervisory talks, focus group interviews, ‘critical incident’ narratives and
documentary analysis. In this paper data from documentary analysis (curriculum
plan), triad talks and focus group interviews will be presented and discussed. The data
analysis method is discourse analysis. Discourse analysis is a social constructionist
approach where theory and method are tied together and grounded in philosophical
premises about the meaning of language in the social construction of reality. The
approach is interdisciplinary with emphasis on anti-realism, constructivism and
multiple versions of the world. The approach in this study is based upon discourse
psychology and critical discourse analysis.
Indication of results
Findings in the study, limited to the research question and data material in this paper,
indicate a ‘thing’ bias in conceptions of the clinical field and the learning process.
Two main discourses are framing the findings, one about learning and one about
caring. The learning discourse, dominated by the teacher, is represented by metaphors
such as ‘formalism’ and ‘acquisition’ and the caring discourse, dominated by the
supervisor, is represented by metaphors such as ‘context’ and ‘participation’. The
student is in an intermediate position between ‘acquisition’ and ‘participation’ trying
to compromise. Overall the learning metaphors are dominant. It seems to be a
migration of metaphors from theory to practice indicating a reification of the clinical
world. Although counteracting metaphors support a ‘metaphorical plurality’ in the
clinical world the tension between theory and practice seems to persist.
CARING FOR PERSONS WITH DEMENTIA IN AN ACUTE HOSPITAL –
THE NURSE’S PERSPECTIVE
Ms Louise Nolan RGN, RNT, BNS,MSc
Lecturer
School of Nursing & Midwifery
The University of Dublin, Trinity College
24 D'Olier Street
Dublin 2
Ireland
+ 353 1 6083931
[email protected]
Abstract:
Effective person centred quality care for persons’ with dementia is a challenge to
health professionals. Specifically in the acute context, where resource and
environmental considerations may affect the outcome of care, there is limited
knowledge available to inform nursing care, which meets the needs of the person with
dementia and their relatives/carers. Therefore the purpose of this study was to
illuminate nurses’ perceptions of the experience of caring for persons with dementia
in an acute hospital setting. The researcher utilised a hermeneutic approach informed
by Gadamerian philosophy to facilitate the interpretive process. A purposive sample
of seven nurses was interviewed regarding their perceptions of the research
phenomenon. Thematic content analysis consistent with the description outlined by
Cohen et al (2000) facilitated the data analysis process and multiple data sources were
used to expand the researcher’s horizon of understanding. The research phenomenon
was interpreted through the five themes which emerged. This poster will present the
findings relating to two of the themes ‘Working together – the importance of the
nursing team’ and ‘Living this experience – coping’.
A QUALITATIVE STUDY OF NEWLY QUALIFIED DIPLOMA NURSES’
PERCEPTION OF PREPARADENESS FOR PRACTICE
Phil Noone MA, MSc, RNT, RM, RGN.
Programme Director and Nurse Lecturer, Centre for Nursing Studies, National
University of Ireland, Galway.
The present study was conducted in the light of major reforms to nurse education
which have taken place in Ireland since 1994. The aim of this study was to explore the
experiences of the newly qualified diploma nurses’ preparedness for practice.
Previous studies have indicated that the transition period from student to staff nurse is
fraught with difficulty (Gerrish 2000; Grey 1998; Jasper 1996; Kramer 1974). A
qualitative grounded theory approach was utilised. Data collection using a semistructured interview with a purposeful sample of five newly qualified nurses was
employed. Influenced by the strategy of Glaser & Strauss (1967), data was analysed
using the method of constant comparative analysis. From the analysis, five conceptual
categories emerged to describe the experiences of the newly qualified nurses’
preparedness for practice: being responsible, differences between being a student
delivering care and a staff nurse; turning point – a sense of identify; needing support
and being different. The findings indicate that newly qualified nurses’ feel ill prepared
for their new role, especially in the areas of management and communication.
However, findings also suggest that the diploma course is creating nurses who are
questioning and more assertive, better equipped intellectually and professionally. This
study will contribute to and develop the debate regarding the support structures in
place for newly qualified nurses.
References:
Gerrish K. (2000) Still fumbling along? A comparative study of the newly qualified
nurse’s perception of the transition from student to qualified nurse. Journal of
Advanced Nursing 32, 473-480.
Grey M (1998) A Longitudinal investigation into the first year experiences of being a
staff nurse: The transition from diploma to staff nurse. Final Report, Napier
University Faculty of Health Studies.
Jasper (1996) The first year as a staff nurse: the experiences of a first cohort of Project
2000 nurses in a demonstration district. Journal of Advanced Nursing 24, 779-790.
Kramer M (1974) Reality Shock. St Louis: Mosby.
Quality Enhancement : Issues for improvement through insights and
experience in managing a course in nurse education.
Mr Tom Noone. RGN(Hons) RPN(Hons) BNS-RNT(Hons)
M.Med.Sc.Nurs(Hons)
Lecturer in Nursing
School of Nursing & Midwifery Studies
24 D’Olier St.
Dublin 2
Managing a course in nurse education presents many demands and challenges for the
course leader. The main demands are the administrative workload and the
coordination of activities on a daily basis. The challenges for the course leader are
administrative, managerial and educational and also include the need for quality. To
meet the administrative demands requires coordination and planning of activities on a
daily basis as well as for the long term. The challenge of day to day managing a
course requires managerial skills such as communication, decision making, leadership
and teamwork (Daft 2000). The educational challenges also provide a challenge for
continuous improvement to meet the demands of a changing health care environment.
Quality is imperative in the business world and strives to improve the product or
service for the customer or consumer. Over the decades the recognition of quality and
its achievement is marked by various awards and one such as the ISO9000 series is
quite familiar. According to Sallis ( 2000:p2 ) “the new consciousness of quality has
now reached education”. The recognition of the need for quality in education is
reflected in the establishment of quality offices or centres for quality in higher
education institutions. While higher education institutions require to respond to the
challenges and need for quality course leaders also need to be conscious of the need to
enhance the quality of the courses they lead. The enhancement of quality in leading a
course in nurse education may be addressed from the administrative, managerial and
educational perspectives. Quality enhancement is not a panacea for all course issues
be they administrative, managerial or educational. According to Sallis (2000) quality
provides a philosophy and a methodology for management in educational institutions.
Acknowledgement of quality as a philosophy and methodology in nurse education
not just a concept to be taught to students will provide a focus the enhancement of
quality in course delivery in nurse education.
This paper will address the concept of quality from the perspective of leading a course
in nurse education. The need for quality is addressed as well as course issues which
provide a focus for quality enhancement. Administrative, managerial, and educational
issues provide the main focus for attention in terms of quality enhancement. The
authors experience of leading a course in nurse education also provide insights into
aspect of course delivery which may assist in enhancing quality in leading a course in
nurse education. The presentation will provide an opportunity to reflect upon and
consider quality enhancement in nurse education.
References
Daft, R. L. (2000) Management (5thEdn). Forth Worth : The Dryden Press.
Harper, H. (1997) Management in Further Education : Theory and Practice. London :
David Fulton Publishers.
Sallis, E. (2000) Total Quality Management in Education (3rd edn). London: Kogan
Page.
Mc Ghee, P. (2003) The Academic Quality Handbook : Enhancing Higher Education
in Universities and Further Education Colleges. London : Kogan Page.
TITLE: AN INVESTIGATION INTO THE PERCEPTIONS OF A GRADUATE
COHORT TOWARDS THE IMPACT OF THE BACHELOR OF NURSING
STUDIES PROGRAMME ON THEIR CLINICAL PRACTICE.
Author: Dolores M. O' Brien, Lecturer, RGN, BA, RNT, M.Ed. School of
Nursing and Midwifery, University College Dublin, Belfield, Dublin 4.
Aim: The research study aims to determine whether the BNS programme has had a
positive impact on clinical practice and to suggest related areas for further research.
Background: The knowledge and skills of nurses and midwives need to be constantly
updated if nurses and midwives are to cope effectively with their professional
demands. As the scope of practice changes to include the evolution of the advancedbased practice professional development has never been greater.
Method: The illuminative model of curriculum evaluation was applied to the research
question. A quantitative section entailed the use of a questionnaire, which was
specifically designed to extract information on how the BNS programme impacted in
clinical practice. A qualitative section of the study consisted of individual interviews
and was developed from the findings of the questionnaire. The fact that only two
interviews were undertaken, is a recognized limitation of the study. The population
was a BNS graduate cohort from a School of Nursing and Midwifery on the east coast
of Ireland. Data collection for the quantitative part of the study was by means of a
postal questionnaire. This provided maximum anonymity for each respondent. The
qualitative data collection tool employed the use of semi-structured interviews, using
an interview schedule. Five broad questions were asked. These questions had potential
for expansion.
Data analysis: Analysis of the quantitative section was obtained using SPSS version
8 statistical package. The qualitative section used a content analysis approach,
identifying emerging themes. From 160 questionnaires distributed by post, a total of
49% were returned.
Results: The results were presented in and supported by appropriate tables and charts.
The main findings are that the BNS programme positively impacted on clinical
practice. Other salient findings are analyzed and discussed in the findings. The
findings are not generalizable to other groups. The study concludes with a number of
recommendations concerning clinical practice recognizing the need for further
research in this field.
THE EXPERIENCES OF MATURE STUDENTS IN NURSE EDUCATION
Frances O’Brien RGN, DNS, BNS, RNT, MA (Adult and Community
Education)
Lecturer, School of Nursing and Midwifery, Trinity College, 24 D’Olier Street,
Dublin 2.
In recent years mature students have been encouraged into nurse education for the
valuable qualities they are known to possess, along with their ability to assist in
providing a sustainable solution to the current health care crisis. Mature students
currently account for approximately twenty five per cent of the total number of preregistration nursing students in the Republic of Ireland (An Bord Altranais, 2005).
Despite the widening of access of educational provision, little is known about mature
students experiences on pre-registration nurse education programmes in Ireland.
Research on mature students on other higher education programmes has shown that
while the majority of full time mature students have a positive experience of higher
education (Fleming and Murphy, 1997) mature students often experience greater
problems academically, psychologically, socially and financially than traditional
students (Leonard, 1999), which can contribute to a high attrition rate for this group of
students.
This study explored the experiences of mature students on a full time pre-registration
nurse education programme in the Republic of Ireland. A qualitative research design
was employed using semi-structured interviews as a means of gathering data from
five mature students. Data was analysed using thematic content analysis.
Findings revealed that mature students face many challenges on their return to fulltime education from a personal, academic and financial perspective. Support from
spouse, family or friends was identified as crucial to their survival and the reaction of
a spouse to their partners return to education was found to be influential to the
education experience. Mature students with children seemed to experience the most
difficulty with the course as finding time to study was a key factor. Findings also
revealed that the overall learning needs of mature students are not catered for
adequately. Essay writing and not knowing the standard that is required to pass was
the dominant problem that emerged in this theme. While all students identified
finance as a problem, those most at risk were lone parents.
References
An Bord Altranais, (2005) Nursing: A Career for You, Dublin: An Bord Altranais
Fleming, T., and Murphy, M. (1997) College Knowledge: Power, Policy and the
Mature Student Experience at University, Maynooth: MACE.
Leonard, M. (1999) “Educating real-life Ritas: Mature female students in higher
education in Belfast”, In Connolly, B., and Ryan, A.B. (Eds) Women and Education
in Ireland Volume 1, Maynooth: MACE.
Prison officers’ knowledge of and attitudes to Harm Reduction, particularly
Needle Exchange Programmes, within the Mountjoy Prison Complex
Linda O’Driscoll
Nurse
The Mews
224, NCR
Dublin 7
Ireland
Tel (01) 8383852
Fax (01) 8384830
[email protected]
RGN, RSCN, M.Sc. Nursing (Addiction and Substance Related Difficulties)
Abstract
Background
Health care in prison is an area of increasing international concern, with the ideal
situation being a health care service that ensures equivalence of care between the
prison population and the general population. Notwithstanding the fact that there
have been significant improvements with regard to treatment options available to
substance misusers in prisons, the Irish prison system lags considerably behind
current best practice especially with regard to prevention of the spread of blood
borne viruses, such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus
(HBV) and Hepatitis C Virus (HCV). There is no comprehensive harm reduction
programme in place in Irish Prisons. The aim of this research study was to
determine the views of all grades of prison staff towards the provision of Harm
Reduction, including Needle Exchange Programmes (NEPs) in prison, available to
those prisoners who continue to use illicit drugs intravenously while in prison.
Methodology
A cross sectional study was undertaken using self administered questionnaires on a
sample of the total population of officers in Mountjoy male prison and Dochas
female prison. The questionnaire was developed from the literature review and was
peer reviewed. Respondents were asked to answer questions on socio-demographic
details, equivalence of health care, drug use in prison and risk behaviour, NEPs and
personal safety concerns. They were then asked to estimate the number of NEPs in
European prisons, the prevalence rates of blood borne viruses in Irish prisons, and
to add any additional comments they may have about harm reduction, including
needle exchange in prison. An overall response rate of 39% was achieved.
Results
The majority of respondents were male prison officers with an average of 12.04
years service. While most agreed that prisoners are entitled to equivalence of health
care, this agreement did not extend to include the provision of NEPs. High levels of
concern were expressed that needle exchange would pose a security risk, and the
majority were concerned about the risk of a sharps injury. Respondents agreed
strongly that prisoners were involved in risk behaviour that included sharing
injecting equipment despite knowing they had blood borne viruses. Officers
supported mandatory urine screening and additional and effective security measures
to try and prevent drugs entering the prison. Although the majority correctly
estimated the high levels of both HIV and Hepatitis C that are present in Irish
prisons, they did not agree that needle exchange was the way forward. They
overwhelmingly agreed that there should never be needle exchange introduced into
their workplace, and that a NEP would never be accepted. Themes emerged from
the final questionnaire item that emphasised the concerns officers had about safety
and security risks and the response of prison management to illicit drug use.
Conclusion
While prison officers acknowledge the extent of drug use and the risk behaviour
that prisoners participate in, they are more supportive of measures to try and curtail
drugs entering the prison than the implementation of a NEP. Many are of the
opinion that providing a NEP implies tolerance of illicit drug use, and that
ultimately it will increase heroin use. Concerns are centred on the perceived
security risks involved in NEPs and the majority are of the opinion that NEPs will
never be accepted in the Mountjoy complex.
Recommendations made include education and support for staff, broader harm
reduction options for prisoners, including a pilot NEP, and further research in this
field in Ireland.
NURSING STAFF’S ATTITUDES TOWARDS MENTALLY DISORDERED
OFFENDERS IN A LOW SECURE MENTAL HEALTH CARE SETTING
Bernadette O’Hare – Consultant Nurse: Forensic Mental Health
R.M.N.; BSc (HONS) Nursing (Forensic); Specialist Practitioner (Forensic
Psychiatric Nursing); MSc Advanced Clinical Practice.
Dorset Healthcare NHS Trust, St. Ann’s Hospital, 69 Haven Road, Poole, BH13
7LN, Dorset.
There is growing National debate and media attention on the care, treatment and
management of Mentally Disordered Offenders. This interpretive study explores the
attitudes held by nursing staff towards Mentally Disordered Offenders in a low secure
mental health care setting. Previous studies have focussed on the attitudes held by
staff in other mental health care settings and on nursing staff’s attitudes towards
specific patient groups or aspects of certain patient groups.
A phenomenological approach was applied in order to allow the exploration of the
attitudes held by nursing staff from their own experiential point of view. Six nursing
staff participated in an unstructured audio taped interview and transcriptions were
analysed using the four steps suggested by Giorgi (1987).
Participants viewed the patient group as Unpredictable, Criminal, Challenging,
Controlling, Different, Controlled, Dependent, Disadvantaged and Rewarding. These
findings suggest that nursing staff experience a range of situations involving the
Mentally Disordered Offender patient group generating the attitudes which impact on
their care, treatment and management. Compared with previous studies and aided by
the design and methodology used in the study, this study provided a more in-depth
view, from the participants’ own experience, of the attitudes held specifically by
nursing staff towards Mentally Disordered Offenders in a low secure mental health
care unit. In a fast growing speciality within the mental health care arena, these
findings can be taken forward to inform future training, education, research and
service development programmes in Forensic Mental Health Care.
REFERENCES
Bryman A and Burgess R G (Eds) (1994); Analysing Qualitative Data; Routledge;
London.
Department of Health (2002a); National Policy Implementation Guidelines –
Minimum Standards for Low secure and Psychiatric Intensive Care Units; London;
The Stationery Office.
Department of Health (2003) Personality Disorder – No Longer a Diagnosis of
Exclusion; London; The Stationery Office.
Doyle J (1999); A Qualitative Study of Factors Influencing Psychiatric Nursing
Practice in Australian Prisons; in Perspectives in Psychiatric Care; Volume 35; Issue
1; Nursecom Inc; Philadelphia.
INSTITUTING COMMUNITY-BASED NURSING
COMMUNITY SERVICE LEARNING EXPERIENCE
EDUCATION:
A
Dr. Lauren E. O’Hare Ed.D., R.N. Associate Professor and Chair, and
Patricia Tooker M.S., R.N. Assistant Professor of Nursing
Specializations: Adult and Community Health, Leadership and Research
Nursing.
Wagner College, Department of Nursing, One Campus Road, Staten Island, New
York, 10301
Historically, nursing curriculum has always had its roots in the community setting. In
healthcare today, not only are there more patients in critical need of care, but the care
is most often rendered outside of the hospital setting and in the community. The
number of patients seen in their own homes or at free-standing community medical
centers has greatly increased, thereby necessitating a renewed interest in the care of
the patient outside of the hospital setting.
Nursing faculty members at a small, private, liberal arts college decided to institute a
community-based nursing curriculum, which focused on community service learning
as the building blocks of its educational change. Beginning with the first fundamental
nursing course and throughout the following two years, students in this upperdivision program were assigned a community to serve and learn through. Teaching
and learning activities focused on the family and its needs. All courses incorporated
the assigned community in its curriculum plan and both theory and clinical involved
contact with community members.
Through the close contact with the community, students were able to diagnose and
treat various problems identified in the initial fundamental course and monitor the
changes that were made as a result of the community research. Both students and
community members took great pride in their accomplishments together.
A pilot study of practice in the care of emergency department patients who
experience domestic violence.
Philippa Olive RN RSCN MSc. BSc. PGCE
Senior lecturer – Emergency nursing, Department of Nursing
University of Central Lancashire, Preston PR1 2HE
01772 893626 [email protected]
Background:
Domestic violence is associated with adverse health outcomes, resulting from
significant physical and psychological sequalae. The extent of domestic violence in
the general population in England has placed tackling domestic violence high in
health and social policy priorities. The Department of Health (2000) has placed a duty
of care on all health care professionals to identify and provide interventions for people
who are experiencing domestic violence. This has particular relevance for emergency
department staff as there is evidence of greater prevalence of domestic violence
amongst emergency department patients than in the general population. A literature
review found that the evidence base of care for emergency department patients who
have experienced domestic violence is limited. This along with areas of ambiguity in
practice guidelines is likely to result in practice variance.
Aims:
To conduct a pilot study to test the research design and validate research methods to:
1. Identify current practices in the care of emergency department patients who
experience domestic violence.
2. Measure services for emergency department patients who experience domestic
violence against the current practice guidelines and evidence base
3. Compare practices in the care for emergency department patients who experience
domestic violence by region and hospital type.
Design and Methods:
A pilot postal cross-sectional survey was carried out. A self administered
questionnaire asking about practices in domestic violence care was mailed to the
senior nurse from a 10% sample of emergency departments in England. Prior to
piloting, the questionnaire underwent critique by an expert review panel and pretesting by senior emergency nurses. Data from the pilot postal self-administered
questionnaire was managed and analysed using the Statistical Package for the Social
Sciences
Sample:
Pilot survey: Lead nurses from 22 emergency departments.
Findings, Discussion and Conclusion:
Preliminary findings of the pilot survey demonstrate the success of the design and
methods to measure services for emergency department patients who experience
domestic violence. The results suggest wide levels of practice variance and
inequitable health care for minority groups. There are areas of low congruence
between reported practices and the current evidence base. The preliminary findings
have identified that analysis for relatedness is not feasible amongst regional groups,
however relationships between department volume and practices will be feasible in
the main survey. Discussion will focus on methodological successes and problems. It
is concluded that the main survey is undertaken with the implementation of
recommendations to improve the study’s design and methods.
RECRUITING GENERAL PRACTITIONERS AND PRACTICE NURSES TO
PARTICIPATE IN RESEARCH: EXPERIENCES FROM THE SPHERE
STUDY.
Mary O’Malley 1, Mary Byrne2 , Ailish Houlihan2 , Claire Leathem3 , Susan
Smith1 ,
Molly Byrne2, Margaret Cupples3 , Andrew Murphy2
1
Department of Public Health and Primary Care, Trinity College Centre for
Health Sciences, Tallaght Hospital, Dublin 24.
2
National University of Ireland, Galway (Department of General Practice).
3
Queen’s University Belfast (Department of General Practice).
The SPHERE study is a randomised controlled trial of a two-year intervention to
improve secondary prevention of coronary heart disease in general practice. The
intervention includes training of Practice Nurses in facilitating behaviour change.
Following development and piloting work, the main trial is now underway and fortyeight practices have been recruited to participate – sixteen in each of three study
centres (Dublin, Belfast and Galway).
Reasons for practice participation and non-participation in the study were solicited
and recorded by the SPHERE research nurse. The recruitment process involved five
distinct stages, allowing all practice staff the opportunity to carefully consider the
study before agreeing to participate. Eligible practices received a phonecall from a
research nurse, followed by an information leaflet and a second phonecall. An on-site
meeting with the research nurse was then arranged for interested practices and all
practice staff signed their agreement to becoming involved in the study.
Participating practices are offered an honorarium of €1000 or the Sterling equivalent.
As an additional incentive, GP attendance at SPHERE training sessions is accredited
by the Irish College of General Practitioners and the Northern Ireland Medical and
Dental Training Agency. Unfortunately as yet there are no such incentives for Practice
Nurses.
Cited reasons for participation included (in descending order of frequency)
opportunity to establish a practice register of patients with CHD, potential to improve
patient care, particular interest in CHD, development of a structured recall system,
and desire to be involved in research generally. Cited reasons for non-participation
included heavy workload, staff shortages, time of year, involvement in other
initiatives, and low remuneration.
There have been relatively few randomised controlled trials in general practice in the
Irish context to date. The lower-than-expected uptake rate is a cause for concern, both
in terms of generalisability for the present study as well as the outlook for future
research studies. Feedback from practitioners indicates that a number of steps can be
taken to make participation in research more attractive to them, including minimising
extra workload arising from study involvement; framing research in a way that makes
it relevant to practitioners and their patients; awareness amongst researchers of the
everyday environment of practices; and the development at national level of a culture
that is supportive of Practice Nurse involvement in research.
CLINICAL
LEARNING
ENVIRONMENT
AUDIT
TOOL
POSTGRADUATE
CLINICAL
PLACEMENTS:
REPORT
DEVELOPMENT AND PILOT STUDY
FOR
ON
Authors and Presenters: Aileesh Corcoran, Dr. Paula Lane, Catherine O’Neill,
Ceire Rochford and Sinead Ronayne.
Job Title: A. Corcoran, Link Facilitator (Accident and Emergency Programme);
Dr. P. Lane, Course Leader/Project Officer, Graduate Diploma in Nursing
(Specialist Strands); C.O’Neill, Clinical Facilitator, (Critical Care Programme);
C. Rochford, Clinical Facilitator, (Peri-operative Programme); S. Ronayne,
Nurse Tutor, Graduate Diploma in Nursing (Specialist Strands).
Qualifications: A. Corcoran, RGN, Dip. in Nursing, BSc.; Dr. P. Lane, PhD,
RGN, RM, HDipN (Dist), BNS(Hons), FNRCSI; C.O’Neill, RGN, BSc.; C.
Rochford, RGN, H. Dip Peri-anesthesia Nursing, S. Ronayne RGN, Dip. HEPD
in Nursing, HDip in Cardiovascular Nursing, MSc. in Nursing (Clinical
Practice).
Address: Postgraduate Nursing Office, Unit 2, Waterford Regional Hospital,
Dunmore Road, Waterford.
Email: [email protected] (Course
Secretary)
The clinical learning environment significantly impacts upon student learning and
continuing professional development (An Bord Altranais, 2003). Since their
inception, the Graduate Diploma in Nursing Programmes, in the Health Service
Executive South Eastern area (HSE/SE) have evolved in tandem with changes in
service requirements, patient profiles and resultant practice development initiatives.
Following the expansion of clinical learning sites from 4 to 17, direct implications for
the role of the Clinical Facilitator emerged. Opportunity for clinical facilitation of,
and support for students, staff and preceptors posed significant challenges.
Consequently, a more rigorous approach to auditing clinical learning environments
was warranted.
The clinical learning environment audit tool from The University of Dublin Trinity
College was adapted for local use, with written authorisation. The purpose of this
modified audit tool is to ascertain activity and acuity levels, commitment to
continuing professional development and appropriateness and suitability of specialist
clinical areas. A pilot study was conducted over a period of one month in three
clinical sites, representing the course specialties and within the geographic catchment
area of HSE/SE. Reliability and validity of the tool was assured for the purpose of this
audit. Data were analysed using the Quasar2 package for statistical analysis, allowing
numeric, aggregate representation of the audit findings.
The audit highlighted learning opportunities for the student in the clinical area
regarding clinical exposure relevant to the attainment of required competence and the
clinical support structures available to them, both personally and professionally. The
audit also facilitated the identification of staffs’ and preceptors’ educational needs and
support required. Furthermore, it was a means of establishing the effectiveness of the
clinical learning environment in terms of enabling students to understand the
integrated nature of theory and practice and to acquire the skills, attitudes, knowledge
and competencies critical to the delivery of specialist nursing care, as recommended
by An Bord Altranais (2003).
References
An Bord Altranais (2003) Guidelines on the Key Points that may be Considered when
Developing Quality Clinical Learning Environment, (1st Edition). Dublin: An Bord
Altranais.
PARTNERS IN CARE - INVESTIGATING COMMUNITY NURSES’
UNDERSTANDING OF AN INTERDISCIPLINARY TEAM-BASED
APPROACH TO PRIMARY CARE
Ms Mary O'Neill
RGN, RM, PHN, BSc Nursing (Hons), MSc Primary Health Care (Hons)
Faculty of Nursing & Midwifery
Royal College of Surgeons in Ireland
123 St Stephen's Green
Dublin 2
Ireland
Abstract
Current health policy in Ireland identifies the development of primary care teams as
central to meet the health and social needs of the population. This paper presents the
key findings of a research study of community nurses’ understanding of an
interdisciplinary team-based approach to primary care to meet the current and future
needs of the population. The outcome of this study will contribute to a high quality,
patient-centred, seamless service by informing strategies for effective team working in
primary care.
A qualitative research design using focus group interviews with community nurses
working in the areas of public health nursing, general nursing and practice nursing
was used to explore this issue. Non-probability sampling was used to recruit
participants to form three homogeneous focus groups of twelve each. The systematic
data collection process was guided by a sequenced-questioning framework, which
provided a rich source of data. Data analysis followed an inductive approach and the
thematic content analysis framework provided a comprehensive recording of the
group discussions. Key themes were identified, compared and contrasted to find
patterns within and across the group discussions.
The findings provided valuable insights into community nurses’ understanding of an
interdisciplinary team-based approach to primary care. The key findings in this study
highlighted the need to further develop primary care and community services. It also
emerged that primary care teams require the full complement of team members to
function effectively, and that collective team efforts enhance patient care. Nurses
clearly articulated their contribution to primary care, but recognised that there are
many challenges to overcome. Nurses have a significant contribution to make to the
further development and re-orientation of primary care services. An enhanced
primary care team will allow the public access to both the individual and collective
skills and knowledge of an interdisciplinary team.
References
Krueger R. A. (1998) Developing questions for focus group interviews: focus group
kit 3. Sage, London.
Morse J. M. and Field P.A. (1996) Nursing research; the application of qualitative
approaches. 2nd edition. Nelson Thornes, UK.
Ritchie J., Lewis J., and Elam G. (2001) Designing and selecting samples. In Ritchie
J. and Lewis J. (Eds.) Qualitative research practice: a guide for social science
students and researchers. Sage Publications, London, 77-108.
Sim J. (1998) Collecting and analysing qualitative data: issues raised by the focus
group.
Journal
of
Advanced
Nursing
28(2),
345-352.
A Comparative Study of the Sources of Stress that Diploma Student Nurses
Encounter
Patricia O Regan, MSC, BNS, RNT, RGN, ENB 237, ENB 998.
College Lecturer
School of Nursing and Midwifery
Brookfield Health Centre
College Rd
Cork
Stress is considered to occur in many aspects of occupational endeavour, and can have
serious consequences for the health of the individual, as well as posing problems for
the organisations (Sutherland and Cooper 1990). The climate of continuous change
that health professionals including student nurses work in has become a potential
health hazard in terms of stress related diseases. Health professionals including nurses
are an occupational group frequently studied because of exposure to events or
incidents that are generally considered to be stressful (Cavanagh and Snape, 1997).
Regardless of the desired outcome, the learning environment of student nurses can be
a very stressful experience. Whether in the clinical or education environment, stress
can adversely affect their lives incredibly. Recently levels of distress in trained and
student nurses was shown to exceed female community norms, with 41% of trained
nurses and 67% of student nurses showing significant levels of distress (Jones and
Johnson, 1997).
The aims of the study are to identify the sources of stress that second and third year
student nurses encounter and to compare findings from both cohort of students using
quantitative methodology. The instrument used was the Student Nurse Stress
Experience Questionnaire (50 item scale) specifically designed for the study. The
sample frame consisted of second year n = 48 and third year n=43 at one large health
care institution. Questionnaires were distributed and data was collected when both
cohorts where in the theoretical environment. Data was analysed using Statistical
Packages for the social Sciences.
Findings revealed that both cohorts of students indicated degrees of stress. From the
key concepts analysed the theoretical environment was shown to have lower degrees
of stress than the other two categories of clinical environment and personal /
interpersonal environment, with the personal / interpersonal environment by far rating
the highest category of stressor scores in the study. The highest stress score in the
whole study was in relation to financial concerns and anxiety in attempting to stretch
the grant allowance. Comparative analysis of the study indicated levels of significance
in relation to clinical tasks with third year students scoring higher stress levels. The
personal / interpersonal environment stressors indicated levels of significance in
relation to family and work commitments and lack of integration into the university
with second year students rating significantly higher levels with these variables.
Limitations of the study included the relatively small sample size.
References
Cavanagh, S. J,and Snape, J.( 1993). Nurses under stress. Senior Nurse 13(2): 40-42.
Jones, M.C. and Johnston D.E. (1997). Distress, stress and coping in first-year student
nurses. Journal of Advanced Nursing .26, 475-482.
Sutherland, V. J., Cooper, C. L .(1990). Understanding stress: a psychological
perspective for health professionals. London: Chapman and Hall.
AN INITIAL VALIDATION OF AN INSTRUMENT TO
MEASURE SEXUAL READINESS
Author: Marlaine Ortiz Mangels, EdD, R.N., CNA,BC
Visiting Assistant Professor in Nursing
State University of New York at Brockport
350 New Campus Drive
Brockport, New York 14420-2914
As the nation progresses into the 21st century, many problems face the teenagers of
this country. One of the most serious is premature sexual intercourse and the
consequences associated with early sexual activity. A national objective for the year
2010 is to increase to 95% the proportion of adolescents who abstain from sexual
intercourse or use condoms if currently active. Adolescents face many challenges and
decisions related to sexual behaviors, but when teenagers are prematurely involved in
sexual relationships, there are many dangers and unfortunate outcomes such as
pregnancy, sexually transmitted diseases and HIV.
The purpose of this study was to test an instrument created by Kirschenbaum (1998)
entitled “Are You Ready for Sex? A Personal Inventory”, for content and construct
validity. This inventory includes five major categories and several questions related to
each category regarding sexual readiness. The readiness categories are: psychological;
relationship; choice of a partner; knowledge about sex, risks and protection; and the
ability to handle consequences. A personal questionnaire was also administered that
included demographic data and outcome measures of health and relationship
outcomes and health risk behaviors. The hypothesis of this study was that higher
levels of sexual readiness at the onset of sex will lead to more positive health
outcomes.
To validate the content of this inventory, content experts in the sexuality field,
researchers, educators, physicians and nurses who work with and teach adolescents
were asked to review this inventory for use as a research instrument. These data were
collected and analyzed and this instrument was changed to reflect this input.
In order to validate the inventory, a total of 268 students from two local colleges were
asked to complete this questionnaire. These students were asked to think back to the
first time that they had sexual intercourse and answer the questions based on that time
in their lives.
These data were analyzed using descriptive statistics, internal consistency estimates,
factor analysis and hypothesis testing. Each measure had significant findings and the
hypothesis of this study was supported.
This instrument begins to provide insight into outcomes related to sexual readiness
and health and risk behaviors. This study also has implications for future education.
New Perspectives in Nursing Communication- Reflecting on Communication
Across the Nursing Disciplines
Colin Griffiths
Lecturer
School of Nursing and Midwifery
The University of Dublin, Trinity College
24 D’Olier Street
Dublin 2
Catherine McCabe
PhD student, Research Fellow
School of Nursing and Midwifery
The University of Dublin, Trinity College
24 D’Olier Street
Dublin 2
Madeline Gleeson RGN RPN BNS
Lecturer
School of Nursing and Midwifery
The University of Dublin, Trinity College
24 D’Olier Street
Dublin 2
Joan O’Shea BNS MSC CNM 1
Neonatal Intensive Care
Coombe Women's Hospital
Dublin 8
Fiona Timmins MSC NFESC FFNRCSI BNS BSc RNT RGN
Director, BSc (Cur)
School of Nursing and Midwifery
The University of Dublin, Trinity College
24 D’Olier Street
Dublin 2
This paper presents in brief, the combined results of four empirical studies that
examined communication across different nursing settings (neonates, mental health,
intellectual disability and general nursing). It represents four different client/family
groups (parents, nurses, clients with profound intellectual disability and patients in a
general hospital). It also presents a variety of methodologies used within the
qualitative and quantitative paradigms. From the experiences of how nurses
communicate issues such as ‘lack of communication’, ‘attending’, ‘empathy’, and
‘friendly nurses’ are explored. People with severe and profound intellectual
disabilities who find great difficulty communicating with others illuminate the
importance of non-verbal communication. Some views of mental health nurses’
perceptions of touch further enhance the discussion as does parental experiences of
having a child in Neonatal Intensive Care. Overall the mixed variety of views and
methods explored and reported in brief represents a new paradigm in our
understanding of communication. Rather than an over reliance on traditional models
of communication, these authors argue that far more subtlety is required in day-to-day
interactions. Every word every gesture has meaning and importance for both sender
and receiver. Although operating from a skilled knowledge base in practice, nurses
can increase their impact upon the client/family relationships through reflection upon
their own communication skills. Genuineness, empathy and attending is the way
forward for nursing to truly embrace client centred communication.
TOWARDS INTERPROFESSIONAL ASSESSMENT OF OLDER
PEOPLE: ANALYSIS OF THE CHANGE PROCESS
Claire O’Tuathail RGN, MSc, Dip. Gerontology, PGCert.Ed
Lecturer, Centre for Nursing Studies, National University of Ireland, Galway,
Ireland
Fiona Ross BSc, PhD, RGN, DN
Director, Nursing Research Unit, King’s College London, James Clerk Maxwell
Building, 57 Waterloo Road, London SE1 8WA
ABSTRACT
This paper discusses the process of change that took place in an intervention study of
standardised multidisciplinary assessment guidelines implemented in a ward for older
people in a South London hospital (O’Tuathail and Ross 2005). The relationship
between research and healthcare practice is often uneasy and challenging particularily
around the practicalities of implementing findings. The importance of understanding
complexity is well documented in the change literature and this issue informed our
approach and analysis (Pettigrew et al 1992, Van de Ven 1999). A multifaceted
approach to change that comprised evidence-based guidelines, leadership and change
management was evaluated before and after the implementation by telephone
interviews with patients, a postal survey of community staff and interviews with ward
staff. The change process was informed by a diagnostic analysis of current assessment
practice.
This paper draws on descriptive and qualitative data and addresses the links between
contextual issues and the processes and pathways of change, informed by theoretical
ideas from the change literature. Key themes emerged: working through others and
across boundaries, managing uncertainty and unanticipated challenges. Adherence by
ward staff to using the guidelines was high and the change sustained over a number of
years after the project finished.
The analysis contributes to understanding about the nursing leadership of change
within an interprofessional arena of practice. It highlights the importance of
understanding the context in relation to conducting a diagnostic analysis in the early
stages of implementation. This has implications for implementing change in nursing
and interprofessional practice in other settings as change agents are required that have
the support from the organization, have the skills to implement research evidence,
manage uncertainty and build trust with a range of other professionals.
References:
Ross F., O’Tuathail C. and Stubberfield D. (2005) Towards multidisciplinary
assessment of older people: Exploring the change process. Journal of Clinical
Nursing. 14, 518-529.
Pettigrew A, Ferlie E & McKee L (1992) Shaping Strategic Change. Sage, London.
Van de Ven AH, Polley DE, Garud R & Venkataraman S (1999) The Innovation
Journey. Oxford University Press, New York.
REDUCING MEDICATION RELATED RISK – A WORKSHOP FOR
UNDERGRADUATE NURSING STUDENTS
Karen Page Teaching Fellow RGN RCNT PGCE B Sc Health Studies
B Sc Specialist Practice(Stroke Care)
Queen’s University Belfast
Medical Biology Centre
97 Lisburn Road
Belfast BT7 7BL
[email protected]
Nurses play an important part in the administration of medicines and consequently
require a sound knowledge base in order to fulfil their responsibility in this role. It is
therefore of concern that a literature review highlights that there is a limited amount
of information available focusing specifically on the educational needs of nurses with
regard to pharmacology and in fact suggests that nurses may not have adequate
preparation to fulfil their potential in this situation.
Studies by Manias and Bullock (2002a) and King (2004) highlighted that students
experienced difficulties relating pharmacology to practice, as it was perceived that
their education was inadequate for dealing with medication issues that arose in
clinical practice. Considering the high number of medication incidents that are being
experienced by patients it seems that the cost of ignoring this situation is extremely
high. It is estimated that drug related incidents result in an annual expenditure for the
NHS of up to £2 billion pounds and it is suggested that medication incidents account
for between 10-20% of all adverse events in the NHS (DoH 2001).
In view of these findings our aim was to address this problem within the nursing
curriculum and endeavour to increase the knowledge and awareness of undergraduate
nursing students particularly with regard to their role in the prevention of medication
incidents. In collaboration with pharmacists from the Northern Ireland Medicines
Governance Team we developed a Medication Safety study day which has been
included as part of the final year programme for undergraduate nursing students in
Queens University Belfast. This consists of a lecture and series of workshops
designed to increase the students’ awareness of a number of specific risks, which are
closely associated with medication administration incidents. To date this has been
evaluated very positively by both staff and students and has increased awareness
amongst nursing students as to how they can more effectively help to reduce the
number of medication incidents in practice.
References
Department of Health (2001) Building a safer NHS for patients-implementing an
organisation with a memory Department of Health London
King, R.L. (2004) Nurses’ Perception of their pharmacology educational needs
Journal Of Advanced Nursing 45 (4) 392-400.
Manias, E. and Bullock, S. (2002a) The educational preparation of undergraduate
nursing students in pharmacology: perceptions and experiences of lecturers and
students International Journal of Nursing Studies 39 757-769.
Transforming the culture and context of care for
older people through the Essence of Care framework
Randal Parlour, MSc, BSc (Hons), RMN, RGN
Regional Practice Development Co-ordinator
HSE-North West
Tel. 0719822106 E-mail: [email protected]
Edith Mullin, MSc, Dip. Health Care Man., Cert. Health Econs., RMN, RGN
Service Manager (Older Person Services)
HSE-North West
Tel. 0749189000 E-mail: [email protected]
Abstract
In recent years there has been growing emphasis within healthcare services on
redefining standards of care, implementing evidence based practice and encouraging
innovation within organisations and clinical teams. Within the National Health
Service (NHS) this has seen expression through the development of national service
frameworks, the creation of the National Institute for Clinical Excellence (NICE) and
the Commission for Health Improvement. Similarly, within the Irish Health Services
Executive (HSE) we have witnessed the formation of bodies such as the Health
Information Quality Authority (HIQA), Irish Health Services Accreditation Board
(IHSAB) and an emphasis within the national health strategy ‘Quality and Fairness’
(2001) on the provision of evidence based, person centred care for all service users.
Mounting pressure is being exerted to ensure that the delivery of care is evidence
based and clinically effective (Rycroft-Malone, 2004).
In addition we have witnessed a significant increase in the level of resources and
number of publications which strive to bring better quality, research-based
information to the nursing workforce. However, what remains unclear is what, if any,
impact these methods of presenting information are having on clinical decisionmakers (Thompson et al 2002). In fact, many recent initiatives which set out to
develop and improve standards have failed to achieve the required level of change and
innovation in practice settings (Page et al, 1998; Clarke and Proctor, 1999; Ferlie et al,
2000).
Kitson et al (1998) argue that getting evidence into practice is not a simple process
and propose a conceptual framework: Promoting Action on Research Implementation
in Health Services (PARIHS). This framework represents the interplay among three
core elements – the nature and strength of the evidence, the context or environment
into which the evidence is placed, and the method through which the process is
facilitated. Kitson et al suggest that the most successful adoption occurs when there is
a convergence of ‘high’ levels of evidence, sympathetic context, and effective
facilitation.
This study considers practice development and in particular the role of facilitation in
enabling clinical teams and practitioners to deliver innovative and person centred
care. The Essence of Care is considered central to this process and provides a
framework for bringing together all local actions for improving and assessing clinical
activity into a single coherent programme which all stakeholders within healthcare
can be part of and work towards. Particularly, within the context of this study, it is
about changing the culture of care in a systematic and demonstrable way, moving
towards a learning culture so that quality infuses all aspects of our work. Essence of
Care offers practitioners a framework, with patients, clients and their carers'
experiences at the heart of the process - a qualitative approach to identifying,
measuring and reflecting on the quality of services provided (Chambers, 2002). The
PARIHS framework is used to assist the description of the processes and outcomes of
this implementation programme.
The research will be guided by the principles of ‘realistic evaluation’ outlined by
Pawson and Tilley (1997). Realistic evaluation, conducted within a partnership of
research and practice, offers a strategic solution (Pawson & Tilley, 1997) to achieving
evaluated practice innovations. In particular, it seeks to place the evaluation in a clear
organizational and policy context so that the extent to which any outcomes are
influenced by this context can be analysed. In short, stage one will address what might
work for whom and in which circumstances, whilst stage two of the study will focus
on what does (or does not) work?
References
Chambers, N (2002) Essence of Care: making a difference. Nursing Standard; 17: 11,
40-44
Clarke, C. Proctor, S. (1999) Practice development: ambiguity in research and
practice. Journal of Advanced Nursing; 30: 4, 975-982
Department of Health (2001) Essence of Care. Patient-focused Benchmarking for
Health Care Practitioners. London, The Stationery Office
Department of Health and Children(2001) Quality and Fairness-A Health System for
you. Dublin: Stationery Office
Ferlie, E. et al (2000) Getting evidence into clinical practice: an organizational
behaviour perspective. Journal of Health Services Research & Policy; 5: 2, 96-102
Kitson A, Harvey G, McCormack B. (1998) Enabling the implementation of evidence
based practice: a conceptual framework. Qual Health Care; 7: 3, 149– 158.
Page, S. et al (1998) The Practice Development Unit: An Experiment in Multidisciplinary Innovation. London: Whurr
Pawson R, Tilley N. (1997) Realistic Evaluation. London: Sage.
Rycroft-Malone, J. (2004) The PARIHS Framework-A framework for guiding the
implementation of evidence based practice. Journal of Nursing Care Quality; 19: 4,
297-304
Thompson, C: McCaughan, D; Cullum, N; Sheldon TR. (2002) Nursing, The value of
research in clinical decision making. Nursing Times; 98:42, 30-34
Older People and Elder Abuse: A Concept Analysis
Amanda Phelan RGN, RM, PHN. BSc (Hons), MSc, RTN, PhD candidate.
Lecturer, School of Nursing, Midwifery and Health Systems
College of Life Sciences, University College Dublin
01 716 6482, Fax: 01 716
[email protected]
Abstract
Ireland’s present and projected demographics indicate a rise in the percentage of the
population over 65 years of age. Currently, older people represent 11.5% of the
population. Projections for the future depend upon varying foundations based on
general population trends. These projections propose that by 2050, Ireland could have
24% of its population over 65 years of age (CSO 2005). It is also expected that the
current trend of a rapid increase in the ‘older old’ subset would continue. One of the
pivotal issues pertaining to older people is that of elder abuse and its understanding,
interpretation, and interventions by healthcare staff.
Elder abuse is a phenomenon which has been overtly acknowledged in global society
since 1975 (Baker 1975). Although, it was initially presented in the domain of
medicine in the United Kingdom, the United States has undertaken the predominant
advances in terms of legislation, research and policy. Ireland’s policy on elder abuse
was published in (DOHC) 2002, but the implementation of recommendations has
been sporadic.
Theories of elder abuse have been developed since its ‘discovery’ but as Geller (1997)
argues, theory development in this area has been hampered by myths and
controversies that hinder understanding. A primary problem, which is also present in
other areas of family violence, is the issue of definition. Without a globally standard
consensus and comprehension of the phenomenon, comparison and interpretation of
research results has been severely hampered and therefore theories have been
developed inductively with supporting evidence lacking any decisive support.
This paper presents a literature review focusing on the current theoretical frameworks
based within the areas of sociology, social psychology and psychology considering
their philosophical bases, their ‘truth claims’ and current research which supports or
refutes each of the dominant stances.
Baker, AA (1975). Granny battering. Modern Geriatrics, 8, 20-24.
Central Statistics Office (2005) Population Estimates. Available from:
http://www.cso.ie/px/pxeirestat/database/eirestat/Population.asp [Accessed 4th April
2005].
Department of Health & Children (2002) Protecting our Future. Stationery Office,
Dublin.
Gelles R.J. (1997) Intimate Violence in Families. 3rd edn, Sage Publications,
Thousand Oaks.
THE EFFECTIVENESS OF A PROFESSIONAL DEVELOPMENT MODULE
IN SOLUTION-FOCUSED THERAPY FOR MENTAL HEALTH NURSES: A
QUALITATIVE EVALUATION
Mark Philbin RPN, DipN (Lond), BSc (Hons), MA
Lecturer in Nursing
School of Nursing
Dublin City University
Collins Avenue
Dublin 9
In this study, qualitative interviews were used to explore the views of mental health
nurses that have undertaken a professional development module in solution-focused
therapy. The module was initially funded by the National Council for Professional
Development in Nursing and Midwifery and two cohorts of students were supported
by this funding. A total of thirty eight nurses completed the module during the funded
period and a sample of twelve were purposefully selected to reflect a variety of mental
healthcare settings. Interviewees were asked about whether and how the module had
impacted upon their everyday nursing practice. In response, they described greater
confidence in relating to patients or clients, a wider repertoire of responses to clients
and a sense of having something more positive to offer to clients. Of particular
interest was the way in which interviewees were able to give detailed accounts and
examples of how the module had made a difference to their work with clients. For this
conference presentation, these findings are examined and some implications are
drawn for continuing professional development.
‘A Qualitative Study into the Effectiveness of GP Assistant Education &
Training’
Marilyn Philip RGN, RNT, MBA, MSc. Senior Lecturer, School of Acute and
Continuing Care Nursing
Betty Turnbull RGN, RCNT with Dip CNE, RNT, MSc, BSc, Dip in Asthma
Care, ENB 100, Lecturer, School of Acute and Continuing Care Nursing
HE Institution/address – Napier University, Canaan Lane Campus, 74 Canaan Lane,
Edinburgh EH9 2TB
This paper will explain the background to module development for “GP Assistant”
education and training, consider module compilation, and review the findings from a
qualitative study of six participants. A grounded theory approach was used to glean
new theory. Analyses of research findings will be offered, and future developments
identified.
Background: To achieve the 2004 NHS Plan within the Directive 93/104/EC
concerning the organisation of working time, General Practitioners (GPs) will need to
make the most efficient and effective use of the skills of all their staff. With this in
mind GP’s from health care practices within the Borders region were approached for
their views on education and training requirements for untrained general practice
assistants. Negotiation with the School of Acute and Continuing Care Nursing
resulted in the development of new and innovative 15 week modules to educate
‘general practice assistants’ in theory and practice of clinical skills to meet GP
requirements and address local population needs. Theory was delivered over 5 days,
and encompassed a range of topics, including, medico-legal aspects of the role, health
and safety, communication and informed consent, principles and practice of infection
control, the cardio-vascular system, venepuncture, ECG recording, BP recording,
BMI analysis, and urine testing.
Learning outcomes were set for theory and practice. Assessment strategies included a
formative MCQ, a summative MCQ, supervised clinical assessments, and completion
of a work-based clinical portfolio to provide evidence of competence and successful
learning.
On completion of this module a qualitative research approach was used to glean data
from the participants. Face- to- face interviews, using an interview guide provided
data. Theory was generated from the data gathered which, following systematic
analysis, will provide the basis for future developments of general practice assistant
education and training.
References/Bibliography:
Bowling A. (1997) Research Methods in Health: Investigating Health and Health
Services Buckingham Open University Press
Scottish Executive (2004) Executive welcome for new GP contracts.
http://www.scotland.gov.uk accessed 3 August 2004
THE CHARACTERISTICS THAT INFLUENCE THE IMPLEMENTATION
OF INQUIRY-BASED LEARNING IN CLINICAL PRACTICE
Gail Pittam, MSc, BSc: PhD Candidate / Research Assistant, Institute of Health
and Social Care
Dawn Hillier, PhD: Researcher and Principal Consultant, Strategic Change
Partnership
Dankay Cleverly, MA, BA, Cert ED, RCNT, RGN: Project Director, Curriculum
Development, Institute of Health and Social Care
N103, Anglia Polytechnic University, Victoria Road South,
Chelmsford, CM1 1SQ
[email protected]
A new generation of nursing students is being educated by means of student-centred
learning philosophies such as inquiry based learning (IBL) (Cleverly, 2003). The
skills that IBL promotes include shared learning, self-directed learning and the ability
and motivation for lifelong learning and evidence-based change. These skills are also
increasingly encouraged for all qualified health care professionals. However nursing
is a well-established profession that encompasses individuals with a variety of beliefs
about the nature of nursing and of learning, many of whom have seen several changes
to the delivery of nursing education over the years.
The sample included facilitators who have direct personal experience in the
application of IBL in both clinical and university settings (n=15). 8 individuals (53%)
agreed to take part and were interviewed using a personal construct theory format
(Kelly, 1955) in which a repertory grid was constructed comparing various people and
places who do or do not demonstrate the characteristics promoted by IBL. Cluster
analyses were performed on the individual repertory grids using the REP IV software
(2005) and emerging themes from the interview transcripts were assessed through
content analysis.
This paper will build a picture of the realities of using IBL in clinical practice settings
and will identify the major factors that are associated with whether IBL is or is not
supported by a particular person or practice area. The key differences between people
and places who do or do not support the characteristics promoted by IBL include:
their ability to cope with uncertainty, in their knowledge and in their daily practice;
their ability and willingness to engage in team work with colleagues and students; the
behaviour and learning beliefs of the placement manager; and their workload and
access to learning resources. Student-centred learning methods have been adopted
with considerable enthusiasm across many fields of education and this study into the
reality of using these methods in clinical settings will be of considerable interest and
value to policy makers, curriculum developers and practitioners from a wide range of
disciplines.
References
• Cleverly, D. (2003) Implementing Inquiry-Based Learning in Nursing (Routledge,
London)
• Kelly, G. (1955) The Psychology of Personal Constructs, volumes 1-2 (Norton,
New York)
• Rep IV (2005) Accessible at: http://repgrid.com/RepIV/
Health and Healing Practice
John J. Power , Teaching Fellow BA(Hons);Msc ;Cert Mang. ;Cert Ed; RGN
The School of Nursing and Midwifery ,
Queen’s University, Belfast
1. Introduction
Before the rise of scientific medicine, healing was practiced across a broad cosmology
involving body, mind and spirit (Grell and Cunningham, 1996). Practices included the
laying on of hands (HP). The professional medical world is skeptical of HP and
remains fixed within a limited medical model (Davies, 2004).
HP practitioners believe that HP helps to stimulate, focus or re-balance ‘energies’ and
thereby contribute to a restoration of health (Benor, 2002, Davies, 2004).To help
understand HP it is necessary to understand the models and cosmology within which
it is understood to operate and their apparent differences from the medical model.
This study examines; the interface of understanding between individual professional
nurses and nurse educators and those engaged in healing practice; models of HP
involving Therapeutic Touch; Reiki practice and Judeo Christian forms of HP and the
potential for the inclusion of HP within the practice and art of nursing
2. Literature Review
The literature examines; HP and the concepts of ‘energy medicine’; concepts of
‘spirit’ and spirituality; the role of placebo.; the dominance, legitimacy and defining
role of medical science ; the history and development of HP ; a critique of HP and the
potential for a greater synthesis in the understanding of spirituality, healing and HP.
3. Theoretical Framework
The research examines the theories of energy medicine; spirituality and placebo.
4. Research Methodologies and Methods.
Within a predominantly qualitative framework, the research examines both the
practices of HP and practitioners and professional nurses understanding of HP.
Qualitatively the Subjects comprise 30 practitioners and 30 professional nurses.
The professional nurses are also predominantly engaged in nurse education. The study
employs observation, interview and coded thematic analysis. The study also employs
a quantitative questionnaire. The study adopts a critical perspective in examining the
dominant role of ‘medical science’.
Ethical approval has been obtained. Some observational and interview fieldwork has
been undertaken.
Davies, E. (2000) My journey into the literature of Therapeutic touch and healing
Touch: Part 1. The Australian Journal of Holistic Nursing 7 (2) 20-8
Benor, D. (2000)
What is Spiritual Healing -@
www.incognito.com.au/~healing/docs/whatis.html
Benor, D. (2003)
Spiritual Healing and Psychotherapy @
www.athealth.com/Consumer/farticles/Benor.html
Grell, P.,Cunningham, A. (1996) Religio Medici.- England ;Scholar Press
DEVELOPING RESEARCH CAPACITY THROUGH RESEARCHING
RESEARCH CAPACITY
Barbara Green, Professor in Healthcare and Nursing Education BA MA EdD
RGN, HV Cert., Cert. Ed. University of Wales Swansea, Singleton Park,
Swansea SA2 8PP
Helena Priest, Senior Lecturer BA MSc PhD RMN Dip. N Dip. N Ed Keele
University, Staffordshire, England
Jeremy Segrott, Research Officer BA MA PhD University of Wales Swansea,
Singleton Park, Swansea SA2 8PP
Abstract
Researchers at the University of Wales Swansea and Keele University undertook a
collaborative research project to compare the research capacity strategies and
development of nursing lecturers at the two institutions. The research project
highlighted the development of neophyte researchers and the difficulties experienced
by both these and more experienced researchers in accessing expertise to enable them
to progress their knowledge, skills and experience to equip them to undertake
research.
This paper illustrates and evaluates how the two departments provided opportunities
for their neophyte research staff to engage with the project and thus progress their
research capability to enable them to add to the research capacity of their respective
Schools. An approach reported by Nchinda (2002).
The project utilised Case Study Methodology. The methods comprised a literature
search, interviews, focus groups, documentary analysis and secondary analysis of
statistical data. The research was managed using the principles of project management
through which the research design and the research tools devised by the researchers at
the University of Wales Swansea were agreed, developed, implemented and evaluated
for both sites.
Nurse lecturers from both institutions were invited to participate in this project. Ten
lecturers mostly with limited experience of undertaking research opted to do so and
were provided with the opportunity of learning about managing research. They were
able to choose within the parameters of the research project which particular aspect of
engaging with the research they were most interested in. These comprised observation
of focus groups and/or interviews; participating in the literature searching and review;
undertaking interviews; participating in the documentary search and analysis and
involvement in the analysis of the interviews. A publications strategy was devised to
enable all of the staff involved to participate in the writing up process.
Utilising this approach was not without its challenges. Pressure was exerted on the
‘expert’ researchers and the participants had high expectations, which had to be
realised. Also the lead researchers were anxious about the outputs due to the pressure
of other work on the people involved. However, this approach is regarded by some as
a desirable way of accomplishing the goals of research as arguably the research can
proceed faster and tedious jobs can be less onerous (Hanson 1988).
The success of the project was accomplished through the management process and the
training strategy. An interesting feature was the symmetry between the findings and
the process. All of the novice researchers were encouraged to read widely and were
given training and supervision both on an individual and group basis. Teams of
researchers had both face to face and video conferences.
Both novice researchers and experienced researchers learned a great deal from this
facet of the wider research project. Research knowledge and skills of both were
enhanced as were the interpersonal and communication skills. It might be argued that
undertaking research utilising so many researchers and the division of labour involved
could have been a recipe for disaster. This was not the case. To be successful research
projects need to be carefully managed and capably executed. There was a high level
of commitment and accountability which will be reflected in the robustness and the
outcomes of the research collaboration between Swansea and Keele. The value added
dimension is in the enhanced capability and capacity of the two Schools.
References
Hansom SM, 1988. Collaborative research and authorship credit; beginning
guidelines. Nurse Researcher 37 (1) 49-52.
Nchinda T., 2002. Researching capacity strengthening in the South. Social Science
and Medicine 54 (11)1699-1712.
TRANSFORMING
HEALTH
IMPLICATIONS FOR NURSES
CARE
WITH
GENOMICS
-
Mary T. Quinn Griffin PhD., MSN., MEd., RN., Assistant Professor,
Case Western Reserve University, 10900 Euclid Avenue, Cleveland,
Ohio 44106-4904, USA.
The Human Genome Project, completed in 2003, had the following goals: to
map the human DNA sequence; to determine the Human Genome sequence
variation; to develop technology for functional genomes; and to investigate
ethical, legal, and social issues. The benefits of this research include
improvements in medicine, and more accurate risk assessment. There is
tremendous exciting but also frightening implications of research on the Human
Genome. It is now possible to find genes associated with specific and diseases
and disorders, and this has led to new approaches to biological research. These
approaches such as the use of microarray techniques and gene chip technology
will be discussed. Examples of sequences for non-disease and disease will be
demonstrated.
What is important to nursing from the sequencing of the Human Genome?
Pedigree construction as part of the routine history that is taken from the patient
is very important when trying to identify genes associated with disease. Three
generation pedigrees will be discussed. Overviews of both autosomal dominant
and recessive inheritance such as Huntington disease and cystic fibrosis with the
latest genomic information will be detailed. A brief overview of the genetics of
specific complex diseases such as cancer, breast cancer cardiovascular disease,
diabetes and obesity will be given.
Pharmacogenomics are important and exciting consequences of the genome
project. There is no longer “one drug for all”. Customized drugs will be
prescribed for patients based on their genetic code. Examples of specific drugs
will be given. Gene therapy is another cutting edge intervention that is available
for some diseases,
The ethical, legal, and social implications of genomic research will be discussed.
These issues will include fairness in the use of genetic information; privacy and
confidentiality; psychological impact and stigmatization; genetic testing;
reproductive issues; implications for families, commercialization, and
enhancement genetics.
Genomics have implications for nurse education, practice and research.
Competencies for genomics in nursing are being developed and are being
integrated in curricula. Nurses must be involved in policy-making and in
developing research guidelines. New paradigms for understanding health and
disease are needed along with new technologies and procedures for diagnosis,
treatment, and prevention of disease. The post genomic era is the age of
predictive care and customized treatments based on the individual’s genetic map.
This is changing the way nurses provide care as we move from a paradigm of
curing and caring to one of prevention.
IS A VALUES-BASED APPROACH TO HEALTHCARE COST-EFFECTIVE?
Nirmala Ragbir-Day
Public Health Manager
BSc Economics; MSc Health Economics, PhD Health Economics
North and East Yorkshire & Northern Lincolnshire Strategic Health Authority,
St John's House, Innovation Way, Heslington, York YO10 5NY
Background
In the United Kingdom, recent reports have consistently shown that between one
quarter and one half of National Health Service (NHS) staff report significant
personal distress 7. Large scale research suggests levels of occupational stress to be
higher in the NHS than in otherwise comparable professions.
Notwithstanding the human cost of these levels of stress, there exists a
significant monetary cost for NHS Organisations, comprised of factors such as lack of
productivity due to staff conflicts, recruitment and retention problems, burnout,
absenteeism, litigation and rapid staff turnover 8. The Nuffield study: ‘Improving the
health of the NHS workforce’ 9 suggests that sickness rates of 5% or more are
currently costing the NHS some £700 million each year. If the NHS could cut
sickness by only one per cent, that is about two and a half days per staff member per
year, over £140 million could be saved (the equivalent of one per cent of total pay). In
2001/02 33 million working days were lost due to work related ill health 10. Sick leave
cost the economy £11.6 billion in 2002, an average of £476 per worker and
approximately 40% of absence costs were from the long term sick 11.
The UK government has set out a 10-yr modernisation strategy for the NHS to
bring about major and continuing improvements in the quality of clinical care
delivered to patients across the NHS. An integral part of this drive for quality is
improved patient care. However, for this to happen, high morale, positive attitudes
and enthusiasm among healthcare workers ought to be present. ‘Values in
Healthcare: a spiritual approach’ is a training manual recently developed which aims
to tackle issues of low morale and stress among healthcare workers on a personal
level, and their consequences at an organisational level. By focusing on selfdevelopment and self-care, the Values in Healthcare programme aims to build selfesteem and a renewed sense of purpose amongst health care professionals, and
consequently to improve patient care.
The area of development for this research involves assessing the economic impact
of Values in Healthcare focusing on:
• Improved performance among health professionals (reduction in stress).
7
Weinberg, A. & Creed, F. Stress and Psychiatric Disorder in Healthcare Professionals and Hospital Staff. The
Lancet, 355 February 12th, 2000.
8
Foxall, M.J., Zimmerman, L., Standley, R. & Bene-Captain, B. (1990). A comparison of frequency and sources
of nursing job stress perceived by intensive care, hospice and medical surgical nurses. Journal of Advanced
Nursing 15, 577-584.
9
Williams, S., Mitchie, S. & Pattini, S. (1998) Improving the health of the NHS workforce. London, Nuffield
Trust
10
Self-reported work-related illness in 2001/02: Results from a household survey, National Statistics HSE col
06/03 and stated in ‘Choosing Health? A consultation on action to improve people’s health’, Spring 2004.
11
See A Safer Place to Work, NAO 2003; Absence and Labour Turnover Survey, CBI, 2003; Business and Health
Care for the 21st Century, CBI, 2001.)
•
The cost savings in terms of productivity gains (reduction of sick leave which
could be positively correlated to stress on the job) and the cost per QALY.
The outcome would be an efficient delivery of health services thereby improving,
in the long term, the quality of care to the patient. In this paper the focus is on
evaluating the Values in Healthcare programme implemented in two pilots, one in the
public sector and one in the private sector. The evaluation aims to show whether
there is any impact of the programme on the ability of the participants to cope with
stress particularly in the workplace, their productivity level and job satisfaction.
A values-based approach
Early in 2000 a UK charity called The Janki Foundation for Global Healthcare,
which is committed to promoting holistic healthcare, brought their experience from
working and teaching in their own specialties (general practice, psychiatry, nursing,
medical education, surgery, complementary therapy, occupational therapy, and
organisational consulting) and drew on a wide variety of other sources for information
and inspiration to come up with the Values in Healthcare programme. The group
considered that the issues of low morale and burnout are essentially a ‘spiritual’
problem, in that healthcare professionals need to find meaning and purpose in their
work, and reconnect with their personal values. It is by doing this that they will be
able to create an environment of healing and co-operation, and build a positive vision
of healthcare for the future 12.
Re-emphasising the importance of values is one of the keys to raising morale in
healthcare today (in guiding practice and at all levels). Values in Healthcare offers a
unique blend of experiential group exercises and opportunities for reflection and selfenquiry to help healthcare professionals and teams to do this. With its emphasis on
self-care and support, the programme aims to help participants to identify their own
values and discover how their insights can enhance their personal lives and revitalise
their work 13. Given the current challenges faced by people working in the healthcare
field today, the Values in Healthcare programme sets out to redress the balance by
adopting three key principles in teaching values:
1. The professional caregiver is placed at the centre of healthcare delivery and gives
life to the ideal of ‘physician heal thyself’. Support of and personal development
in such workers would most likely help to raise morale and restore the sense of
purpose and altruism with which they set out in their careers.
2. Values in healthcare are best understood and explored through direct experience,
with experiential learning, time for silence and reflection, and sharing in a
supportive environment.
3. The learning experience should be relevant to participants’ work and lives, with an
emphasis on reflection, action planning and evaluation, and a commitment to
ongoing learning 14.
The core values explored and developed are: Peace, Positivity, Compassion, Cooperation, Self-care, Healing and Caring. The main premise of Values in Healthcare
is that in developing a conscious, values-based approach, participants can rediscover
their own peacefulness, think more positively, and act with compassion and cooperation, while putting their own self-care at the centre of their efforts.
12
Values in Healthcare: A Spiritual Approach, Janki Foundation for Global Healthcare, 2003
op. cit. pp. 4.
14
op. cit. pp. 4-5.
13
The Values in Healthcare programme comprises seven modules, each of which is
designed to help groups of healthcare professionals to explore values in depth, as they
relate to their personal lives and professional practice. The modules are:
• Module 1: Values Core values and Values at work
• Module 2: Peace Being peaceful and Peace at work
• Module 3: Positivity Being positive and Positive inter-action at work
• Module 4: Compassion Finding compassion and Compassion in practice
• Module 5: Co-operation Co-operation and Working in teams
• Module 6: Valuing yourself Self-care and Self-esteem
• Module 7: Spirituality in healthcare Healing and Caring.
The programme has a distinctive style of training and approach. The materials are
not designed to be taught, but rather to guide both participants and facilitator to
experience core values. The following ‘tools’ are used throughout the training
programme and include: Meditation, Visualisation, Reflection, Listening,
Appreciation, Creativity and Playfulness. The exercises prompt an internal experience
which can be surfaced, identified and subsequently expressed more consciously in
personal and work situations. This provides the foundation for addressing how to
provide better spiritual care for patients.
Clinical side of Values in Healthcare
Stress is an inevitable part of life: the car breaks down, a family argument erupts,
and a job deadline looms ahead. Stress is an ambiguous word that is used on different
occasions to denote positive or negative strain in a physical or emotional context. For
the purposes of this paper, stress is defined 15 as the "physical, emotional and mental
strain resulting from the mismatch between an individual and his/her environment"
which results from a "three way relationship between demands on a person, that
person's feelings about those demands and their ability to cope with those demands" 16.
Scientists have long known that emotional stress can also bring on physical
symptoms such as headache, upset stomach, or insomnia 17. The mind really does
seem to be connected to the body and stress does more harm than causing irritability,
anxiety, and even depression.
The most important point to remember about stress is that it is literally a nervous
reaction and it occurs within the Autonomic Nervous System (ANS). The ANS is a
vast network of nerves branching out from the spinal cord, reaching and directly
affecting every organ in the body. It is responsible for maintaining the equilibrium of
our internal environment - anything and everything that we experience automatically.
The ANS divides into two distinct systems: the 'Sympathetic' Nervous System and the
'Parasympathetic' Nervous System. The Sympathetic Nervous System allows us to
deal with stressful situations and the 'Parasympathetic' Nervous System allows us to
be 'chilled-out'. Whenever we perceive danger the former will tense our musculature,
constrict our blood vessels and speed up our thinking process, amongst numerous
other activities. Then, after the danger has passed, the Parasympathetic Nervous
System will take over, decreasing heartbeat, relaxing blood vessels and clearing away
metabolic waste products such as adrenaline and lactic acid. This is how it should
15
Richards C. The health of doctors. King’s Fund, London. 1989
Bynoe G. Stress in women doctors. Br J Hosp Med 1994; 51(6): 267-8
17
The Mayo Clinic Family Health Book. New York: William Morrow & Co., 1996.
16
happen: action followed by relaxation; the tide of life ebbing and flowing, expanding
and contracting within the ANS. 18
There are armies of professional people out there whose purpose is to awaken this
all-too-often dormant part of us - the Parasympathetic. As a culture we have
systematically trained ourselves to override the ANS, our instinctual life, in favour of
a faster, more "convenient" lifestyle. Our conscious mind, or head, should be able to
overrule the ANS, or heart, because it is not always wise to do exactly what we feel
like doing. And this process works fine, so long as the control exerted is relaxed after
the stressful situation has passed. The problem comes when this does not occur. When
we continue to hold on and to disallow the ANS its natural functioning, stress is the
not-so-natural result. It is a gift to have the ability to control the life that is flowing
through us. Stress is the abuse of this gift 19.
Values in Healthcare focuses on the Parasympathetic, with the aim to develop
one’s ability to be in control of the situation rather than let the situation be in control.
The notion is that the individual operates from an internal/individual perspective
towards external factors and react in a positive and controlled manner. It provides the
parameters for a voyage of inner discovery. Figure 1a describes the pathway of the
Values in Healthcare programme as a clinical intervention in coping with stress. The
basis of the programme is to allow the person to re-discover core values that are
within the self such as Peace, Positivity, Compassion, Co-operation, Self-care,
Healing and caring. Figure 1b takes Co-operation as an example of a value and shows
how the process would operate within the Values in Healthcare programme.
Objectives of the Research into Values in Healthcare
The research into the Values in Healthcare programme aims to test the hypothesis
that values instilled in oneself would lead to high morale, positive attitudes and
enthusiasm amongst healthcare workers which would then lead to increases in
productivity due to reduction in stress and sick leave, thereby improving the effective
and efficient delivery of quality healthcare to the patient. The empirical nature of the
investigation involves testing the cost-effectiveness of the Values in Healthcare
programme to show whether the programme works in terms of improved work
performance and job satisfaction from the employee and increases in productivity and
cost savings to the employer.
Following the evaluation from two pilot sites in the public and private sectors
within the UK where the full Values in healthcare programme was carried out, the
preliminary analysis of the pilots paves the way for further rigorous evaluation of the
programme. The study question asks: Is the Values in Healthcare programme costeffective – in terms of quality of life years (QoL) and in terms of the National Institute
for Clinical Excellence (NICE) guidelines? Using decision analysis, the study
compares the cost-effectiveness of the programme to a ‘do nothing’ alternative in both
the public and private sector. The comparative experimental study in the public and
private sectors in the UK involves ‘before’ and ‘after’ analysis together with costeffectiveness analysis where cost per QoL would be monitored over a period of 6
months after participants attended the Values in Health programme. The results of this
research would then be compared in regional and international settings where the
Values in Healthcare programme is being implemented.
18
19
Sands, R The Power of the Parasympathetic Nervous System, Stress News October 2002 Vol.14 No.4
op. cit.
Methods
Dates and Setting
Two ‘before’ and ‘after’ pilots were carried out over a 7-month period from
November 2003 to May 2004 which examined the level of stress, productivity and job
satisfaction among health care professionals in two hospital settings within the UK.
The first site was in the public sector at the Royal National Orthopaedic Hospital
(RNOH), Stanmore, UK and the other site was in the private sector at the Highclear
Group which has nursing care homes throughout the UK. The method of
implementing the training was via seminars and focus groups with evaluation forms
for feedback from each of the 7 seminars.
Perspective
A multiple perspective was adopted for the study with focus on the employee and
the employer within the organisations. For the employer perspective the focus is on
the effects on productivity and on cost savings, due to reduction in sick leave and
absenteeism. For the employee perspective the focus is on improved work
performance due to fewer stressors and job satisfaction.
Instrument
The instrument used was an evaluation questionnaire to test the reliability of the
seminars and to gather information on performance and costs. Based on self-reported
‘before’ and ‘after’ questionnaire feedback, the Values in Healthcare programme was
evaluated to show whether there was any impact in work satisfaction and ability to
cope with occupational stressors at the workplace and one’s life. Together with using
the EuroQol questionnaire, additional questions (on productive level, satisfaction and
fulfilment, motivation at work, sense of well being and inter-personal relations) were
structured using Appreciative Inquiry (AI) where the focus is on a positive way of
asking questions. This is in keeping with the positive intension of the Values in
Healthcare programme. However, a few questions were structured in a negative way
so that the respondent does not follow a pattern of giving the same responses.
All participants were given a ‘before’ questionnaire at the start of each training
session to complete and were then either given an ‘after’ questionnaire if they
attended the second seminar or via post if not. The same questions (together with
additional questions asking about the impact of the seminar) were asked on average
one month after the training. The time lag was given for contemplating and putting
into practice aspects of the training session(s). At the Royal National Orthopaedic
Hospital and the Highclear Group training sessions were offered to all staff at the
hospital/nursing home and participants who attended the seminars, chose to attend.
The approach adopted recognises that persons interested in attending the seminar do
not form a homogenous group but a heterogeneous group.
Results
At the Royal National Orthopaedic Hospital the evaluation of the Values in
healthcare programme started from the second seminar (the evaluation mechanism
was not yet in place). The participants at the RNOH varied per seminar as did the
facilitators with a small number of participants attending more than one seminar. At
the Highclear Group, the pilot was carried out with the same participants and same
facilitators for all 7 seminars and staff from two of their nursing homes participated.
Table 1 summarises the demographic data from the participants from both the
public and private sectors. In the public sector pilot (RNOH), 38 ‘before’
questionnaires were sent off and 32 ‘after’, with response rates of 82% and 59%,
respectively. For the private sector pilot (Highclear), 13 ‘before’ questionnaires were
given out at the first seminar only and a 100% response rate was achieved. Although
the participants were the same for the remaining seminars in the private sector,
responses from participants for each seminar were aggregated. Of a total of 67 ‘after’
questionnaires sent out, 53 were completed, a response rate of 79%. The average time
taken to complete both a ‘before’ and ‘after’ questionnaire at the RNOH was 12
minutes, with 73% and 94%, respectively saying it was ‘fairly easy’ to fill in. The
Highclear group took less time on average to fill in the questionnaire with 9 minutes
for the ‘before’ and 6 minutes for the ‘after’. The consensus in both pilot sites of
filling in both questionnaires was either ‘fairly easy’ or very easy’.
The majority of the participants at the RNOH were female (87%) but there was
more of a mix at the Highclear sessions (54% males, 46% females). At both sites the
majority of the participants (30%) were each in the 31-40 age groups. The majority of
the participants at RNOH and Highclear had permanent work contracts (93% vs. 85%)
and the ethnicity of the participants in both settings was mainly British White (67%
and 85%, respectively). Over 70% of the participants in both setting had an education
continuing after the minimum school leaving age and had a degree or equivalent
professional qualification. Participants in the public sector had on average, worked
more years than those in the private sector with 23% working more than 15 years in
the former.
Table 2 summarises selected results from the ‘before’ and ‘after’ questionnaires
for both pilots. After attending the Values in Healthcare programme there was a
marked decline in the participants experiencing severe anxiety or stress within
themselves and in others that they care for. For participants at the RNOH the
reduction was from 97% and 64% to 50% and 22%, respectively. A similar trend
followed at the Highclear group but with lower levels of reduction (see Figure 2).
This could be an indication that more participants in the public sector were stressed at
the start of the seminar as confirmed by the results that 74% of participants at RNOH
suffered from at least one stress-related disease compared to 69% at the Highclear
group. The number of hours worked on average was less in the public sector than in
the private sector. However, more participants worked an additional 1 to 5 hours more
in the former (53% vs. 38%) but with a larger number (38%) working more hours (6
to 10) in the latter. This could be an indication that over-worked and long hours
contribute to additional stress.
The results suggest that the participants benefited positively from having attending
the seminars of the Values in healthcare programme. The benefits are much greater in
the public sector with 95% the participants at RNOH stating that they learned new
coping mechanisms to deal with stress in the workplace at the seminar (this compares
to 51% in the Highclear group). When asked whether the participants were able to
put into practice in their workplace any of the mechanisms learnt, 95% vs. 51%
(RNOH vs. Highclear) agreed. In both sites, the participants claimed they received
positive results from using methods from the seminar to deal with stress in the
workplace (68% vs. 60%). When asked whether work performance, self worth and
job satisfaction had improved as a direct result of having attended the seminar, the
benefit was greater in the RNOH group in all three instances. The highest impact was
in self worth with 95% vs. 55% in the RNOH and Highclear groups respectively (See
Figure 3).
More interesting were the results given for sick leave and errors (see Figure 4).
Before participating in the seminars, 74% of RNOH staff on average took no sick
leave from work in the last month and 47% of the staff contributed to no errors at
work. Of those participants who responded, 19% took 1 to 2 sick days and 53%
contributed to 1 to 2 errors in the last month. After participating in the Values in
Healthcare seminars the former reduced to 16% and there was a reduction in errors
made (participants making 1-2 errors in the last month declined from 53% to 50%).
With the Highclear group the number of staff taking 1 to 2 days off sick increased to
23%. This corresponds to a reduction of 15% of staff taking 3 to 5 days off being
reduced to 2% after attending the seminars. There is an indication that the number of
sick days off work declined after attending the seminars. With regards to errors
contributed in the last month, there was no change in staff making no errors, but there
was a slight increase from 54% (before) to 57% of staff making 1to2 errors and a
reduction of 2% of staff making 3 to 5 errors after attending the seminars.
In both settings participants worked in a team, found it easy to work together, and
the team had clear objectives and met regularly. The impact of having attended the
Values in Healthcare seminars was positive in both workplaces and in the interaction
with other co-workers. Using a score on an incremental scale between 1 and 5 where
1 is strongly disagree and 5 strongly agree, participants were asked their responses
before seminars and then after the seminar on their de-stress level, wellbeing, job
satisfaction, motivation and communication levels at work (see Table 2). On average,
a response greater than 3 signifies participants agree and a score less than 3 indicates
their disagreement. The RNOH participants on average recorded a 3 score and there
were indications of overall improvement in de-stress, well-being, satisfaction and
communication and some aspects of motivation (set realistic goals) but mixed results
with the Highclear group. Although the majority of the Highclear participants on
average responded with a 3 (‘agree’) score for the above responses, there was a
reduction in satisfaction and communication levels at work. With these participants
the scores reported indicated little improvement listening attentively and relating
effectively.
Another interesting result was the effect bad weather had on work performance
and whether the time of year, contributed to low work performance. These variables
were introduced as confounders. The questions were introduced in the ‘after’
questionnaire and the results from both sites (RNOH vs. Highclear) were positive with
over half of the participants from the public and private sectors agreeing that bad
weather (82% vs. 60%) and the months of January and December (93% vs. 51%)
contributed to low work performance.
Discussion
The effects of stress on health professionals may be seen as being increased errors
such as in prescribing, disloyalty, increased staff turnover, limited team working,
increased numbers of patients’ complaints, poor time- keeping and sickness absence,
resistance to change or the adoption of new technology or systems, and disruption in
the practice organisation even resulting in a practice partnership split. Staff may be
less motivated or effective. GPs may have little energy or capacity to listen or
empathise with patients, and communication between doctors and patients may be
poor. Experience of stress does not necessarily result in pathological changes or
damage but prolonged stress does. Recognising the symptoms and causes of job
stress is an important first step towards finding solutions which can then lead to
preventive measures.
The findings in this study of the Values in Healthcare: a spiritual approach
programme in the public and private sectors indicate that on a personal level, one’s
attitude and perception of situations at the workplace can influence the outcomes
when faced with stressful or trying circumstances. The ultimate result is a change in
behaviour and lifestyle which could result in a change in one’s perception of stressful
external situations and circumstances, which are constantly changing and are all
around us. Whether spirituality helps improve mental and physical health is a topic
that interests researchers. 20 Spiritual practice may even change lifestyles and lead to
more healthy habits by helping people avoid smoking, excessive drinking, and drug
abuse. These findings are supported in other studies 21 22 which examined the effects
of stress management training and modified lifestyles through exercise, group
therapy, meditation, and yoga. The results suggest that there may be clinical and
economic benefit to offering preventive stress management.
Several limitations exist in this study. Because this study is currently a work in
progress only six of the seven seminars were evaluated in both public and private
sector sites, and an overall evaluation of the results from Values in Healthcare
programme was not possible at the time of writing the paper. Also the small sample
sizes make it difficult to interpret whether the feedback was a clear indication of
change. Change in behaviour, thinking and lifestyle require a considerable time
period to materialise. Six seminars over a 6-month period in the case of the Royal
National Orthopaedic Hospital and Highclear group did show improvement in the
participants’ attitude to their work, job and employer but a prolonged effect would
give a better indication of the impact of the training sessions on the participants. A
six-month follow-up on both sites is planned. The Values in Healthcare programme
will undergo a second implementation at the RNOH at their request. This is an ideal
opportunity to increase the sample size from the pilot, to improve the response rate
and to gather more data on the prolonged effects of the programme.
The EuroQol questionnaire 23 was included in the questionnaires used in the two
pilots with the aim to establish whether there were improvements in the health states
20
Brody, Jane and Denise Grady, The New York Times Guide to Alternative Health. New York: New York Times
Co., 2001. 203-244.
21
Ornish, D., Scherwitz, L.W., et al. "Intensive Lifestyle Changes for Reversal of Coronary Heart Disease."
Journal of the American Medical Association (JAMA), 1998, Vol. 280. 2001-2007
22
Blumenthal JA, Babyak M, Wei J, O'Connor C, Waugh R, Eisenstein E, Mark D, Sherwood A, Woodley PS,
Irwin RJ, Reed G. Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men, Am
J Cardiol. 2002 Jan 15;89(2):164-8.
23
The EuroQol health states range from 0 to 100 with the best health state marked at 100 and the worst health state
at 0. Participants were asked to indicate on this scale how good or bad their own health was at the time of filling in
the questionnaire.
that participants were in before participating in the seminars compared to those after,
having put into practice aspects of the seminar in their lives and in the workplace.
Because the ‘after’ questionnaires from the Highclear group with the health states
were not received at the time of writing, the quality adjusted life years (QALY) could
not be calculated and compared to the RNOH. However, this can be done and cost
per QALY calculated when the information is received.
An interesting outcome from the evaluation of the Values in Healthcare
programme is the effect of the employer on the work lives of the employees. The
results from the pilots indicate that in both pilots there was an improvement at the
individual level. However, there were less improvement on the participants’ scores
when asked about recognition for good work, support from line manager, freedom to
choose own method of working, opportunities to use one’s abilities and being valued
by the employer (see Table 2 question 6). This can be interpreted to mean that
although the employees could benefit from the Values in Healthcare programme the
employer should redefine the way employees are treated and valued in the workplace.
These positive shifts would add to the overall performance of the workforce and
produce benefits in terms of increase in productivity, cost savings due to reduction in
sick leave and a much happier and appreciated workforce.
Although the impact of the Values in Healthcare programme on the employer is
an important aspect to consider and test, it was not the focus in the pilots. However,
focus groups are planned in the near future with managers at both pilot sites to
evaluate the programme from their perspective in terms of cost savings and improved
outcomes. A second phase of the research is currently planned which involves
implementing and evaluating the Values in Healthcare programme in a more rigorous
manner within both the public and private sectors. A comparative analysis of the
programme would be done together with a cost-effectiveness analysis of introducing
the Values in Healthcare programme into the public and private sectors within the
UK. The methodology to be used is decision analysis, comparing the costeffectiveness of the Values in Healthcare programme to a ‘do nothing’ alternative in
both the public and private sector and observing the trend on certain variables
(workload, stress reduction, reduction in sick leave, satisfaction and fulfilment).
As part of an effort of the National Health Service (NHS) Improving Working
Lives (IWL) in the UK 24, achieving Stage Three Practice Plus of IWL (where
evidence of organisational and cultural change has occurred and is perceived by the
staff), the Values in Healthcare programme could be a way forward to create the
forum for this to be implemented and possibly achieved.
In summary, the Values in Healthcare programme implemented and evaluated at
the two pilot sites shows positive results is terms of coping with stress, reduction in
sick leave and job satisfaction from the employee perspective. The results from the
pilots do show some indication of positive change amongst the participants of the
study at both pilot sites but the evidence is only partially conclusive. This however
can be improved by a follow-up over a period of time to track the behavioural change
24
The Improving Working Lives (IWL) programme is an important element in the drive towards ensuring that
enough well-qualified, motivated people are in place to deliver the quality of healthcare envisaged in the NHS
Plan. It is in three stages:
Stage One: Pledge - All NHS organisations to make a public commitment, by having the policies, practices and
people in place to achieve IWL accreditation by April 2001.
Stage Two: Practice - organisations to provide a portfolio of evidence over a wide range of policies and procedures
that improve the working lives of staff.
Stage Three: Practice Plus - achievement in all staff groups across the whole organisation and is awarded once all
the gaps have been remedied.
of the participants and to test the empirical impact of the Values in Healthcare
programme over time. Clearly for the Values in Healthcare programme to be
accepted as a cost-effective clinical intervention it needs to be proved in more
rigorous settings to show that it generates cost savings and enhances work
performance; but for this more research is needed.
Acknowledgements: Many thanks to the Janki Foundation for Global Healthcare for
allowing me to carry out research into the Values in Healthcare programme; the Royal
National Orthopaedic Hospital and Highclear Group for agreeing to run the two pilots
at their sites; North and East Yorkshire & Northern Lincolnshire Strategic Health
Authority for personal development time given towards the research; Department of
Economics and Related Studies at the University of York for financial assistance to
attend this conference; and to Robert Day for his continued support into this research
and his invaluable technical assistance with the data analysis and graphics.
Table 1 Participants Demographics from Pilots
DESCRIPTION
RNOH
(Public sector)
Before
After
38
32
Questionnaires sent out
31
19
Completed (n = )
82%
59%
Response rate
12
12
Average time taken for
minutes
minutes
questionnaire
Ease of filling questionnaire
- very difficult
3%
0%
- fairly difficult
1%
0%
- fairly easy
73%
94%
- very easy
10%
6%
Gender
Before
- male
13%
- female
87%
Age
- 16 to 20
0%
- 21 to 30
13%
- 31 to 40
30%
- 41 to 50
30%
- 51 to 65
27%
- 66 +
0%
Education
- Educated after min leaver age
70%
- Degree
71%
Ethnic Group
- White
67%
- Asian
20%
- British mixed
0%
- Black
13%
- Chinese
0%
- Other
0%
Employment
93%
- Permanent
7%
- contract (inc. seconded & locum)
27%
Manager
Years worked in organisation
- less than 1
3%
- 1 to 2
13%
- 3 to 5
37%
- 6 to 10
10%
- 11 to 15
17%
- more than 15
23%
(Source: Author)
HIGHCLEAR
(Private sector)
Before
After
13
67
13
53
100%
79%
9
6
minutes
minutes
8%
0%
54%
38%
0%
17%
46%
37%
Before
54%
46%
8%
23%
31%
15%
23%
0%
92%
83%
85%
15%
0%
0%
0%
0%
85%
15%
77%
8%
15%
54%
15%
8%
0%
Table 2 Selected Results from Before & After Pilot Questionnaires (Source: Author)
SELECTED QUESTIONS
Q1. Severe Stress within
- Yourself (% Yes)
- Others that you care for (% Yes)
Q2. Stress Diseases (At Least One)
RNOH (Public Sector)
BEFORE
AFTER
97%
64%
74%
Q2n. New Coping Mechanism (% Yes)
Q3n. Put Into Practice
Q4n. Positive Results
Q5n. Direct Result Of Seminar
- Work Performance (% Yes)
- Self Worth (% Yes)
- Job Satisfaction (% Yes)
Q3. Hours Worked (Average)
Q4. Additional Hours Per Week (%)
- 1 To 5
- 6 To 10
Q5. Teamwork (% Yes)
- Work in a Team
- Clear Objectives
- Working Closely is Difficult
- Regular Team Meetings
Q6. Satisfaction (Average)
- Recognition For Good Work
- Support From Manager
- Freedom In Work Method
- Support From Colleagues
- Amount Of Responsibility
- Opportunities To Use Abilities
- Valued By Employer
Q8. Sick Leave & Errors (% Yes)
- Days Off Sick In Last Month
- Errors Contributed In Last Month
Q11a. De-Stress (Average)
- Cope With Stress Easily
- Comfortable With Workload
- Emotionally Drained By Work
- Easily Relax With Work People
Q11b. Wellbeing (Average)
- Look Forward To Going To Work
- Aim To Keep Staff Turnover Low
- Peaceful Most Of The Time
Q11c. Satisfaction (Average)
- Satisfied With My Job
- Clear And Happy With Tasks
- Empowered To Achieve Goals
- Fulfilled With Contribution To Work
Q11d. Motivation (Average)
- Keep Staff Morale High
- Self Motivated
- Set Realistic Goals
Q11e. Communication (Average)
- Communicate Clearly
- Listen Attentively
- Relate Effectively
Q12Nb. Bad Weather Contributes
Q13Nb. Dec/Jan Contributes
50%
22%
HIGHCLEAR (Private Sector)
BEFORE
AFTER
69%
54%
69%
46%
28%
95%
95%
68%
51%
51%
60%
50%
95%
44%
38%
55%
15%
32.7
40.2
53%
10%
38%
38%
94%
86%
30%
86%
92%
75%
33%
58%
3.5
3.4
3.9
3.7
3.5
3.5
3.3
3.6
3.5
3.9
4.2
3.8
3.6
3.2
3.0
3.2
3.5
3.5
3.7
3.8
3.4
3.1
3.1
3.5
3.6
3.7
3.5
3.0
none
1 to 2
none
1 to 2
none
1 to 2
none
1 to 2
74%
47%
19%
53%
74%
50%
16%
50%
77%
38%
0%
54%
75%
38%
23%
57%
3.06
2.93
2.77
3.27
3.22
2.94
2.83
3.61
3.38
2.69
2.85
3.46
3.38
2.90
2.81
3.51
3.20
3.65
3.29
3.44
3.60
3.54
3.38
3.77
3.00
3.32
3.85
3.49
3.30
3.43
3.55
3.57
3.28
3.33
3.89
3.44
3.23
3.54
3.85
3.15
3.11
3.47
3.66
3.21
3.54
4.03
3.68
3.35
3.94
3.72
3.54
4.08
3.46
3.62
3.87
3.58
3.87
3.97
3.90
3.94
4.06
4.11
82%
93%
3.69
4.23
3.92
3.81
3.77
3.79
60%
51%
Introduce
Values
Acceleration
of Change
in Values
Positive
Outlook
Positive
Feelings
Clinical Pathway of
Change in
Attitude
Perception
of Stress
Shifts: External
Values in Healthcare
to Internal
Change of
Lifestyle
Outcomes:
+health
+productivity
Stressrelated
Diseases
Reduce
Impact on
Body &
Mind
Many Hands
Make Light
Work
Worthiness
Acceptance
Harmony
Things done
effectively &
efficiently
Values in Healthcare
Cooperation
More Values
taken on as
benefits
gain
Cooperation
becomes a
way of life
Clinical Pathway of
Co-operation
Goals/tasks
Achieved
Efficiently
Eliminate
Headaches
/Anxiety
Stress
Declines
where
Values
More
Energy and
Lightness
Cooperation
Source: Author
Figure 1 Clinical Pathways
Figure 2 Stress
Levels at
RNOH and
HIGHCLEAR
Severe Stress Levels - RNOH
100%
90%
Percentage Yes
80%
70%
60%
50%
40%
30%
20%
10%
0%
- yourself
Before
- others you care for
After
Severe Stress Levels - HIGHCLEAR
80%
70%
Percentage Yes
60%
50%
40%
30%
20%
10%
0%
- yourself
Before
- others you care for
After
Source: Author
Impact of Seminars
100%
90%
Percentage Yes
80%
70%
60%
50%
40%
30%
20%
Figure 3 Impact of Seminars at RNOH and HIGHCLEAR
io
n
Jo
b
sa
tis
f
ac
t
el
fw
or
th
S
ce
rf
pe
or
k
W
P
os
i
ti v
e
or
m
re
pr
ac
nt
o
ut
i
P
an
tic
e
m
ni
s
ha
ec
m
pi
ng
N
ew
co
su
l ts
10%
0%
RNOH
HIGHCLEAR
Source: Author
Figure 4 Sick
Leave and
Errors at
RNOH and
HIGHCLEAR
Sick Leave & Errors - RNOH
100%
90%
Sick Leave
Percentage Yes
80%
Errors
70%
60%
50%
40%
30%
20%
10%
0%
none
1 to 2
3 to 5
none
1 to 2
3 to 5
Before
Number of Incidents
After
Sick Leave & Errors - HIGHCLEAR
100%
90%
Sick Leave
80%
Errors
Percentage Yes
70%
60%
50%
40%
30%
20%
10%
0%
none
1 to 2
3 to 5
none
Number of Incidents
1 to 2
3 to 5
Before
After
Source: Author
Childbirth Transformation and Technology: A Critical Analysis
Carol Reagan Shelton, R.N., Ph.D.
Professor of Nursing and Women’s Studies
Rhode Island College
600 Mount Pleasant Avenue
Providence
Rhode Island 02908
USA
The historical record provides us with enormous differences in the way in which
childbirth is transformed from one period of history to another and from one culture to
another. The transformation is a result of many factors: the home/hospital
environment, the caregivers at birth, the utilization of technological and medical
devices, the availability of childbirth education, among other social, cultural, medical
and historical factors.
Although there are differences in the culture of childbirth from one country to
another, contemporary, advanced industrial societies have been at the forefront of
developing and using technology almost universally in the obstetrical units of our
hospitals. The United States is perhaps in the lead in this trend, and that has led to
increasing numbers of births by Caesarean Section. In recent years the percentage of
women giving birth surgically has risen to 25-30% of all births.
There is no doubt that not every woman can birth a baby vaginally or that every baby
exits the uterus healthy and well. However one can be permitted a healthy skepticism
in questioning the notion that one out of four babies needs to be removed surgically or
that labor in itself is a pathological condition. In some segments of American society
(and perhaps in Brazilian and other societies as well), women are now given the
option of a caesarean birth. What are the consequences of this trend of surgically
managing the birth process and /or offering it as a non-consequential choice? Is there
evidence that caesarean births are low-risk interventions for both mother and child?
What has led to the cultural acceptance of surgery as an appropriate intervention in
childbirth?
This presentation aims to examine these questions and to critique contemporary
cultural trends in light of the evidence that exists. Childbirth cannot be examined in
isolation from the cultural expectations and constraints that exist in the environment
in which it takes place. Sociologists such as Barbara Katz Rothman have proposed a
frame of reference to understand these matters. Recognizing the powerful ideologies
that affect motherhood, Rothman examines patriarchy, technology and capitalism.
This frame of reference can be helpful in examining the trends occurring not only in
childbirth but in parenting approaches as well.
25
The aim of this presentation is to provide:
25
Rothman, Barbara Katz. The Ideology of Motherhood. Rutgers University Press. New Brunswick,
NJ 2000
•
•
•
•
an historical analysis of trends that have developed in childbearing in recent
years
a compilation of recent data regarding Caesarean sections
an analysis of popular culture regarding the proliferation of surgical births
a critique of contemporary trends using the Rothman model
Title: Alcohol Detoxification from Primary Care in the North West of
Ireland
Short Title: Alcohol Detoxification from Primary Care in the NWHB
Total Word count: 1976 (excluding abstract)
Authors:
Ms. Virginia Reid*
Ms. Moira Mills
Dr. Tony Sharkey
Dr. Paul Stewart
*Department of Public Health Medicine,
HSE North West,
The Old Church,
Drumany,
Letterkenny,
Co. Donegal,
Ireland.
[email protected]
Conflict of Interest: None
Alcohol Detoxification from Primary Care in the North West of Ireland
Abstract:
General Practitioners (GPs) have an important role to play in treating
problem drinkers although no study in Ireland has attempted to document
their opinion or use of detoxification for patients at home. A questionnaire
was mailed to all GPs in the North Western Health Board (n=119) to
ascertain current practice in this area and identify demographics of patients
availing of this treatment. A total of 45 responses were obtained representing
67% of group practices and 42% of single-handed practices. The majority
(80%) of GPs who responded offer home alcohol detoxification. Within a
year, the mean number of patients detoxified per GP was 4. The majority of
patients detoxified (73%) were male. The average duration of alcohol
problems was 15 years (SD 7.69). Librium was the most common
pharmacological drug prescribed (63%). Training on home detoxification
was requested by 34% of GPs and 87% of GPs requested information on this
treatment.
Introduction:
Alcohol-related harm is a public health issue. The spiralling harm due to excessive
alcohol consumption is well documented and the Irish are the second highest
consumers in the EU at 14.2 litres of pure alcohol per capita1.Alcohol disorders
accounted for 17% of all admissions to Irish psychiatric hospitals in 20022. The
management of alcohol disorders often includes detoxification from alcohol.
Stockwell3 describes detoxification as “a treatment designed to control both medical
and psychological complications which may occur temporarily after a period of heavy
and sustained alcohol use”.
Many people with mild to moderate withdrawal symptoms can be detoxified safely,
successfully and much more cost effectively in the community under medical
supervision4. Furthermore, there is evidence that many patients prefer home alcohol
detoxification5.
Recent years have seen increased movement of patient care away from in-patient
hospital treatment to more localised care in the community. It is widely recognised
that GPs have a pivotal role to play in the successful management of alcohol related
disorders yet the management of alcohol detoxification at home has been an area slow
to develop.
Aims:
The aim of this research was to ascertain GP attitudes and practice in relation to home
alcohol detoxification and provide demographics of patients currently availing of this
treatment.
Method:
A postal questionnaire with prepaid envelopes was sent to all GPs in the NWHB area.
A second questionnaire was similarly distributed 2 months later to non-respondents.
The questionnaire comprised sections dealing with home detoxification offered from
the practice, attitudes towards protocols and demographics and details of patients
detoxified from primary care.
Results:
In total, 46 questionnaires were returned representing 39% of all GP’s. At
least one response was received from 67% of primary care group practices
and 42% of single-handed practices. Of these, 65% (30 / 46) were from the
Donegal area and 35% (16 / 46) were from the Sligo/Leitrim area. The
response rate for individual items among returned questionnaires ranged
from 72% to 100%. The mean length of time in practice was 19.4 years (S.D.
8.03; range 4 – 33 years).
• Home detoxification offered, numbers of patients and screening:
Some 80% of GPs in the NWHB who replied to the questionnaire offer home alcohol
detoxification whilst the remaining 20% of respondents did not offer this type of
treatment. Within a year, the mean number of patients detoxified per GP was 3.7
(SEM 0.61). 3 GPs stated that they did not know how many patients they would have
detoxified within a 12-month period. Interestingly, 2 GPs had over 20 patients within
a 12 month period although these GPs has a specialist role in alcohol detoxification
and an unusually high number of patients and were therefore excluded from analysis
pertaining to number of patients treated.
Overall, 97% of GPs used clinical experience and judgement in assessing a patient’s
suitability for home detoxification and in addition, another 32% use a screening
instrument for assessing patient suitability.
With regard to patients with general alcohol problems, almost a third (32%) of GPs
routinely use a screening tool to assess patients. The CAGE questionnaire was the
instrument exclusively cited as employed for this task.
• Attitudes towards protocols, information, research and training:
In the NWHB, 24% of practices have a policy on home detoxification in place
although the majority (64%) of GPs were in favour of an NWHB standard
home/community policy. Some 25% of GPs thought that a standard policy was not
needed and 11% replied that they didn’t know. Over half (54%) of those that currently
did offer detoxification stated that a standard Health Board protocol was needed and
all respondents that did not currently offer the treatment had stated that one was
required.
When asked whether training or information on home detoxification was required,
34% of GPs stated that would like training and 87% would like information on this
subject. Equally as many GPs currently providing this treatment as not providing this
treatment requested information. Almost half, (48%) of GPs would be willing to
participate in a pilot programme on home alcohol detoxification in the community.
• Demographics and details of patients detoxified from primary care:
GPs returning this questionnaire provided unidentifiable demographic information on
54 patients. The vast majority (73%) of the patients availing of this service were
male. The average age of patients was 46.7 years (SD 13.26). Overall, the average
duration of alcohol problems was 17 years (SD 8.2) for men and 12 years (SD 4.0) for
women.
When asked: “which of the following words best describes this home detoxification,”
responses were obtained on 47 of the 54 patients. Overall, 38% of home
detoxifications were regarded by the GP as “successful”, 28% were of “equivocal”
outcome and 34% were deemed to have “failed”. There was no difference between
genders in abstinence rates with 58% of both groups abstinent to the GPs knowledge
at the time of completing the questionnaire. One-third of men (33%) and fifty percent
(50%) of women undergoing home alcohol detoxification had at some time been
admitted to in-patient care for alcohol treatment. 68% of patients had been referred to
addiction services following the detoxification and 51% of patients had used other
treatment agencies such as Alcoholics Anonymous.
With regard to medications prescribed to patients, Librium was the most popular
medication prescribed to over 50% of patients, followed by Xanax at 22%. Thiamine
was prescribed to 7% of patients.
The questionnaire asked whether or not the patient had other co-morbid conditions
ranging from depressive disorders to schizophrenia. GPs ticked the box for any that
applied. Overall, 35% of patients had no other co-morbid conditions as listed in the
questionnaire. 19 patients (35%) had one condition listed and 15 patients (28%) had at
least 2 conditions. Table 1 outlines the distribution of commonly cited co-morbid
conditions.
An attempt was made to ascertain whether or not the GP believed that the
detoxification was a success for the particular patient. In 50% of female
detoxifications, the GP had viewed the detoxification as a success although a smaller
number, (33%) of male detoxifications were deemed successful. The same
proportions of men to women (58%) were abstinent at the time of the GP completing
the questionnaire.
Discussion:
Alcohol detoxification in Ireland is not a standardised procedure and is usually
determined by local policies. This survey was an attempt to identify current practice
in the area and provide a basis for further work particularly, future developments
around standardising procedures and the development of protocols in the management
of patients availing of home alcohol detoxification. This would thereby support the
initiation of community and home detoxification in the North West and reduce
ambiguity regarding this treatment.
Home alcohol detoxification can safely and effectively be carried out in the patients
own home where they have access to daily supervision to allow early detection of
complications such as delirium tremens, continuous vomiting, or deterioration in
mental state and are administered drugs and thiamine to prevent Wernicke’s
encephalopathy and withdrawal syndrome 6. In-patient treatment is necessary for the
small proportion of dependant drinkers who are at risk of experiencing severe
withdrawal symptoms and for those who do not live in supportive environment i.e. the
homeless, those living alone or those living with other heavy drinkers 4.
A large proportion of GPs in the NWHB currently offer home alcohol detoxification
to patients. A higher proportion of GPs in the North West undertake this treatment
than that reported by Kaner et al, 7 in a UK population at 80% and 66% respectively.
In fact, an estimated 4 patients are detoxified safely by each GP offering this
treatment from primary care each year yet home alcohol detoxification is an area
neglected in terms of guidelines for GPs. The reason for GPs not responding to this
questionnaire is unknown although it is possible that non-responses could be due to
not offering this treatment.
The majority (80%) of GPs had 5 or less patients requiring home detoxification within
a 12-month period. However, difficulty in remembering accurately and non-recorded
detoxifications may be responsible for a lower than actual level of reporting.
Almost two-thirds (64%) of GPs stated that a standard policy on home detoxification
was needed in the NWHB. Interestingly, all of the GPs that currently did not offer
home alcohol detoxification requested a standardised policy for this treatment.
Therefore, it could be assumed that ambiguity around the correct management of
patients and lack of training and information are reasons for the GP not undertaking
this treatment at present.
Almost half of GPs that returned the questionnaire would be willing to participate in a
pilot project around home detoxification, which could be interpreted as indicative of
the level of interest in this treatment and indeed the increasing burden that alcohol is
placing in primary care generally.
• Patients
The number of patients detoxified from primary care in relation to the population is
similar to that reported by Stockwell et al, 9. The proportion of male to female patients
and the average age of patients undertaking home detoxification in the North West is
comparable to other studies in area 10. With an average duration of alcohol problems
in this group of patients of 15 years and an average age of 46.7 years it is likely that
this group of people could benefit from intensive support and are well known to
health professionals in the NWHB.
A large proportion of patients had been referred to addiction services although there
remained over 30% that had not been referred to this service. It is likely that at least
some of these patients could benefit from referral. Similarly, of those that had been
detoxified from primary care; over half had attended other treatment agencies such as
Alcoholics Anonymous.
The preferred medication for reducing withdrawal symptoms is a tapering regimen of
long acting benzodiazepines either alone or with other medications 11. In line with
this, this survey identified that chlordiazepoxide (Librium) followed by alprazolam
(Xanax) were the most common drugs administered. Although it remains a subject of
debate as to the correct dosage of thiamine to be administered to patients, it ought to
be routinely prescribed in preventing Wernicke’s encephalopathy and other serious
complications 12. Furthermore, vitamin B deficiencies are prevalent in alcohol
dependant individuals 13. In this study, only 7% of patients were prescribed Thiamine
although the demographics of patients indicate a client group with serious alcohol
problems of lengthy duration. It could be argued that GPs felt that merely immediate
pharmacological regimens were required in response to this question. Nevertheless,
the value in administering thiamine in conjunction with other medications must be
highlighted for this patient group.
By virtue of the numbers of patients likely to require home alcohol detoxification in
the North West, the value in providing a standardised NWHB protocol for the
management of these patients requiring detoxification cannot be underestimated. By
using a systematic standardised assessment such as the CIWA-r and combining
monitoring, medication and nursing care, individuals should be able to undergo
alcohol detoxification in their own home safely and without complications.
Furthermore, all GPs in the North West should be provided with training and
information on this treatment thereby aiding in the patient availing of this service
throughout the North West.
Conclusion:
GPs in the North West are detoxifying patients from alcohol at home much more
often than had been anticipated. It is apparent that these professionals require
adequate information and training on this treatment in order to provide a standard of
best practice in the area for all patients.
The profile of patients undergoing home detoxification provides an indication of the
type of patients accessing treatment and indeed the need for improved patient care
with regard to referral procedures and medications prescribed. Furthermore, this
group of people, many of whom have other co-morbid conditions may need
specialised support in altering their drinking habits.
The NWHB has initiated the development of detoxification services locally. This has
been realised through recent strategies and interest in the area of alcohol, particularly
since the formation of the North West Alcohol Forum. These developments and
association with primary care are crucial to successful community and home based
detoxification.
References:
1. Ramstedt M., & Hope, A. The Irish Drinking Culture: Drinking and DrinkingRelated Harm, A European Comparative perspective. (In press) Journal of
Substance Use.
2. Daly, A. & Walsh, D. Activities of Irish Psychiatric Services 2002, Mental Heath
Research Division, Health Research Board, (2003). Dublin.
3. Stockwell, T., The Exeter home detoxification project, In: Helping the Problem
Drinker: A New Initiative in Community Care, (eds Stockwell T. & Clement S.).
Groom Helm, London, (1987) pp. 191.
4. Williams, S., Introducing an in-patient treatment for alcohol detoxification into a
community setting, Journal of Clinical Nursing, (2001), 10 (5): 635-42.
5. Stockwell T., Bolt L., Milner I., Pugh P., Young I., Home detoxification for
problem drinkers: acceptability to clients, relatives, general practitioners and
outcome after 60 days. British Journal of Addiction, (1990), 85 (1): 61-70.
6. Ashworth M., Gerada, C., ABC of mental health: Addiction and dependence – II:
Alcohol, Clinical review, British Medical Journal; (1997), 315:358-360.
7. Kaner, E.F.S., Masterson, B., The Role of general practitioners treating alcohol
dependent patients in the community, Journal of Substance Misuse for Nursing,
Health and Social Care, (1996), 1 (3): 132-6
8. Shaw, J.M., Kolesar, G.S., Sellers, E.M., Kaplan H.L. & Sandor, P., Development
of optimal treatment tactics for alcohol withdrawal, Assessment of effectiveness
of supportive care. Journal of Clinical Psychopharmacology, (1981), 1 (6), 382388.
9. Stockwell, T., Bolt, E., Hooper, J., Detoxification from alcohol managed at home by
general practitioners, British Medical Journal, (1986), 292, 733-736.
10. Allan, C., Smith, I. And Mellin, M., Detoxification form alcohol: A comparison of
home detoxification and hospital based day patient care, Alcohol & Alcoholism,
(2000) 35, (1) 66-69
11. New South Wales Health Department, Detoxification clinical practice guideline,
(New South Wales Health Department), (1999), ISBN: 0 7347 3034 9.
12. Day, E., Bentham P., Callaghan, R., Kuruvilla, T., George S. Thiamine for
Wernicke-Korsakoff Syndrome in people at risk from alcohol abuse (Cochrane
Review). (2004), In: The Cochrane Library, Issue 1.
13. Naik, P.C., Lawton, J., Brownell, L.W., Comparing general practitioners and
specialist alcohol services in the management of alcohol withdrawal, Psychiatric
Bulletin, (2000), 24, 214-215.
Acknowledgement:
The authors thank the participating general practitioners of the NWHB who kindly
completed the questionnaire.
Table 1:
Co-morbid conditions of patients detoxified from primary care
Condition
No other co-morbid condition
Depressive Disorders
Anxiety
Personality Disorders
Affective Disorders
Drug Dependency
Other
Number of Patients
19
16
14
6
5
6
5
% of patients
35.18
29.62
25.92
11.11
9.26
11.11
9.26
Note: More than 1 condition was noted for 28% of patients therefore total figures are higher than one hundred
percent.
IMPROVING PERINATAL OUTCOMES : EFFICACY OF
CENTERINGPREGNANCY®: A GROUP PRENATAL CARE MODEL
Ms Heather Reynolds CNM, MSN, FACNM
Associate Professor
Yale University School of Nursing
100 Church Street
South Box 9740
New Haven
Connecticut
USA 06519
+ 1 203 737 2370
[email protected]
CenteringPregnancy® is a model of group prenatal care developed in 1993-94 by
Sharon Rising, CNM, MSN, a nurse-midwife and educator in Connecticut. Eight to
twelve women grouped by gestational age receive their prenatal care together in 10
two-hour sessions that reflect the schedule of routine prenatal care. The women are
taught to do self-care activities and each has a brief time for individual prenatal exam
with the health provider within the group space. There are specific curricular content
included in each session, although a facilitative leadership style allows for flexibility
in the discussion. Opportunity is provided for women to socialize and form
community.
Evaluative data on patient satisfaction consistently demonstrates at least a 96%
preference of patients for receiving their care in this way. The need for formalized
research on perinatal outcomes led to the large studies which began at our institution
in 1999. Prior to the institution of a randomized clinical trial of Centering, we
undertook a prospective, matched cohort study of pregnant women (N = 458) who
entered prenatal care at a gestational age of 24 or less weeks. Half of the subjects
received group prenatal care with women of the same gestational age, while the
remainder received usual individual prenatal care. The women, who were
predominantly black and Hispanic, were matched by clinic, age, race, parity, and
infant birth date. The subjects received their care from public clinics in Atlanta,
Georgia or New Haven, Connecticut.
The results from this cohort study provided beginning evidence of the importance of
this model in influencing some clinical perinatal outcomes. The infant birth weights
were greater for infants of women in group in comparison to infants of women who
received individual prenatal care (P < .01). Even in those infants born preterm, infants
of group patients were significantly larger than infants of individual-care patients
(mean, 2398 versus 1990 g, P < .05). A trend was found for infants of group patients,
who were less likely than those of individual-care patients to be low birth weight (less
than 2500 g; 16 versus 23 infants); very low birth weight (less than 1500 g; three
versus six infants); early preterm (less than 33 weeks; two versus seven infants); or
whom experienced neonatal loss (none versus three infants). This latter trend was not
statistically significant. Both groups were similar relative to the number of prenatal
visits or other risk characteristics, including woman’s age, race or prior preterm
delivery (Ickovics, J. et al, 2003). Currently a large randomized trial is on-going at
these same institutions.
Group prenatal care results in higher birth weight, especially for infants delivered
preterm and provides a structural innovation, permitting more time for provider–
patient interaction and therefore the opportunity to address clinical as well as
psychological, social, and behavioral factors to promote healthy pregnancy. Results
have implications for design of sustainable prenatal services that might contribute to
reduction of racial disparities in adverse perinatal outcomes.
References:
Ickovics, K., Kershaw, TTS., Westdahl, C., Rising, SS., Klima, C., Reynolds, H., &
Magriples, U., 2003. Group prenatalcare and preterm birth weight: Results from a
matched cohort study at public clinics. Obstetrics & Gynecology, 102(5,part1), 10511057. [email protected]
SHOULD FAMILY MEMBERS WITNESS RESUSCITATION OFTHEIR
LOVED ONE? A CRITICAL AND SYSTEMATIC REVIEW OF THE
LITERATURE AND GUIDELINES FOR CLINICAL PRACTICE
Billiejoan Rice BSc, RGN, PGDIP Education, MSc.
Teaching Fellow
School of Nursing & Midwifery
Medical Biology Centre
Queen’s University
Lisburn Road
Belfast BT9 7BL
N Ireland
[email protected]
Abstract
The overall aim of this review is to critically appraise the literature to date concerning
opinion, consensus and research in the field of witnessed resuscitation. The literature
is presented with specific emphasis on relatives’, patients’ and health care
professionals’ experiences and opinions and the ethical and legal issues surrounding
the area of witnessed resuscitation. Evidence both for and against witnessed
resuscitation is presented outlining the gaps in theoretical knowledge and the
methodological limitations of the studies.
The literature highlighted 17 articles, primarily composed of survey research. The
literature suggests that families wish to be given the option of remaining with their
loved one during resuscitation. When given the option families often choose to remain
in the resuscitation room (Barratt and Wallis, 1998, Doyle et al, 1987, Eichorn et al.
1996, Robinson et al, 1998). These relatives report favourable experiences and feel it
is beneficial to the patient and themselves. Conversely, findings from a recent study
revealed that only 29% of patients stated they would want their next of kin present
during their resuscitation with 71% stating they did not want their resuscitation to be
witnessed by the next of kin. Distress was cited as the main reason why the patient did
not wish any relative to be present (Grice et al, 2004). If the witnessed resuscitation
process were explained, with emphasis on the role of the chaperone, then acceptance
may improve (Robinson et al, 1998).
Health care professionals have mixed opinions regarding family presence during
resuscitation. Nurses have more favourable views than physicians (Chalk, 1995). One
small pilot randomised controlled trial of relatives allocated to a witnessed group or
non-witnessed group, found little evidence to support the exclusion of relatives who
wish to be present from the resuscitation room (Robinson et al, 1998).
There still appears to be conflicting opinion related to the practice of witnessed
resuscitation for family members. Perhaps the over-riding concern should be to offer
the relative and patient choice regarding this issue, ensuring support by a chaperone or
designated nurse.
ave more favourable views than physicians (Chalk, 1995). One small pilot randomised
controlled trial of relatives allocated to a witnessed group or non-witnessed group,
found little evidence to support the exclusion of relatives who wish to be present from
the resuscitation room (Robinson et al, 1998).
There still appears to be conflicting opinion related to the practice of witnessed
resuscitation for family members. Perhaps the over-riding concern should be to offer
the relative and patient choice regarding this issue, ensuring support by a chaperone or
designated nurse.
REFERENCES
Barratt F., Wallis D.N. (1998) Relatives in the resuscitation room: their point of view.
Journal of Accident and Emergency Medicine 15, 109-111.
Chalk a. (1995) Should relatives be present in the resuscitation room? Accidnet and
emergency Nursing 3 (3), 58-61.
Doyle C.J., Post H., Burney R.E., Maino J., Keefe M., Rhee K.J. (1987) Family
participation during resuscitation: an option. Annals of Emergency Medicine 16 (6),
673-675.
Eichorn D.J., Meyers T.A., Mitchell T.G., Guzzetta C.E. (1996) Opening the doors:
family presence during resuscitation. Journal of Cardiovascular Nursing 10 (4), 5970.
Grice A.S., Picton P., Deakin C.D. (2003) Study examining attitudes of staff, patients
and relatives to witnessed resuscitation in adult intensive care units. British Journal of
Anaesthesia 91 (6), 820-824.
Robinson S.M., Mackenzie-Ross S., Campbell-Hewson G.l., Egleston C.V., Prevost
A.T. (1998) Psychological effect of witnessed resuscitation on bereaved relatives. The
Lancet 352, 614-617.
AN EXPLORATION OF INNOVATIVE NURSING AND MIDWIFERY
ROLES IN NORTHERN IRELAND
Roberta Richey RGN Bsc (Hons) MRes, Research Associate, Institute of Nursing
Research, School of Nursing, University of Ulster
Hugh McKenna RGN RMN DipN(Lond) BSc(Hons) Adv Dip Ed RNT DPhil FRCSI,
Dean of the Faculty of Life and Health Sciences, University of Ulster
Sinead Keeney BA (Hons) MRes, Senior Research Fellow, Institute of Nursing
Research, School of Nursing, University of Ulster
Felicity Hasson BA (Hons) MSc, Research Fellow, Institute of Nursing Research,
School of Nursing, University of Ulster
Brenda Poulton School of Nursing, RGN RHV RHVT BA(Hons) MSc PhD Professor
of Community Nursing, Institute of Nursing Research, University of Ulster
Marlene Sinclair RN RM RNT BSc(Hons) DASE Med PhD Senior Lecturer, Institute
of Nursing Research, School of Nursing, University of Ulster
INTRODUCTION
Over the past decade there has been a proliferation of new nursing and midwifery
roles. These roles have escalated as a result of national and regional policy (RobertsDavis & Read 2001), the effects of changes to medical working practices (Cameron &
Masterson, 2000) and the on-going practice and professional development in nursing
(Read et al., 2001). Buchan and Daz Pol (2002) noted that there was a dearth of
research into how these roles were introduced, their prevalence and their
effectiveness. Studies have shown the importance of proper planning for new roles
within the employing organisations (Cameron & Masterson, 2000) and ensuring that
adequate resources were available to the post holder (Collins et al., 2000). WilsonBarnett et al. (2000) considered the provision of support from nurse managers and
senior clinicians vital for role development.
Confusion can exist regarding the ‘scope of practice’ of new roles (Jamieson &
Williams, 2002). This lack of clarity about the scope of the innovative role may have
contributed to the concern that the introduction of specialists into an area has the
potential to de-skill generic staff (Jack et al., 2004; McGee & Castledine, 1999). The
confusion is not relieved by the variety of job titles that post holders possess (Read et
al., 2001; Barnes 2004;). Concern remains that nurses and midwives in new roles
have simply taken on duties that were previously the remit of other professions and
this has diluted nursing and midwifery care (Rose et al 1997).
The Northern Ireland Practice and Education Council (NIPEC) commissioned the
University of Ulster to explore the innovative nursing and midwifery roles that existed
within Northern Ireland.
AIM OF THE STUDY
The aim of this study was to conduct an exploration of innovative nursing and
midwifery roles and associated levels of practice, across the eighteen Health and
Social Services (HSS) Trusts and four Health and Social Services Boards in Northern
Ireland.
DEFINITION OF INNOVATIVE NURSING AND MIDWIFERY ROLES
At the outset of the project NIPEC provided the researchers with the following
definition of innovative roles:
"Roles occupied by registered nurses or midwives that function outside the traditional
hospital and community nursing and midwifery clinical structures, for example, Staff
Nurse/Midwife, Ward Sister/Charge Nurse or other Ward Manager titles, District
Nurse, Health Visitor, School Nurse, Community Psychiatric Nurse and also
excluding Nurse Consultant positions."
This definition not only encompassed innovative clinical roles but also those roles
where the emphasis is on Practice Development, Audit, Research, Quality
Improvement and Education Facilitation.
ENRiP PROJECT
The Exploring New Roles in Practice (ENRiP) project was undertaken in the UK
between 1996 and 1998. Its recommendations focused on: setting up new roles;
management issues; professional issues; resource issues; education, training and
professional development; effectiveness and outcome measurement; the future; and
strategic issues.
METHODOLOGY
Stage One - Semi-structured interviews were completed with the eighteen Trust
Executive Directors of Nursing, the four Board Chief Nurses and the four Board
Directors of Primary Care.
Stage Two - The second stage comprised a postal survey with innovative post holders
in nursing and midwifery throughout Northern Ireland, 614 postal questionnaires were
distributed with a response rate of 74% (n=454).
Stage Three - The third stage involved six case studies with innovative post holders.
The case studies focused on roles in midwifery, community nursing, primary care,
mental health, acute care and a non-clinical post.
FINDINGS
Stage 1 Findings: Interviews with Directors of Nursing, Chief Nurses and
Directors of Primary Care
Stimuli and support for innovative roles
Participants were supportive of the development of innovative nursing and midwifery
roles and acknowledged the importance of managerial support and a carefully devised
infrastructure to assist the post holders to fulfil their role effectively. Drivers
identified as underpinning the development of new roles included; national and
regional policy, the emphasis on professional development in nursing and midwifery,
the changing healthcare service and altering patient needs, and the influence of
individual nurses and midwifes who had recognised a service need.
Impact of innovative roles
Patient/client care was noted to have been positively influenced by new role
development. Innovative roles had developed practice and post holders were being
used as a resource for knowledge, skills, training and education by other staff. There
was some concern that the introduction of new roles could lead to the de-skilling of
more generic staff. The importance of the innovative post holder being recognisable
as a member of the nursing/midwifery profession was also stressed. This anxiety
emerged from the view that nurses and midwives could be used to fill the gaps in the
workforce plans of other disciplines, notably medicine.
Evaluation and value for money
Furthermore, most posts were funded on a fixed term temporary basis due to
difficulties in obtaining long term funding for a new post at its inception. While the
participants described the innovative roles as being value for money, it was accepted
that this was difficult to assess. There was an acknowledgement of the need for
evaluation and audit.
Stage 2 Findings: Postal survey of innovative post holders in nursing and
midwifery
Demographic findings
The majority of innovative roles had been established since 2000. Many respondents
had contracts that required them to work part of the time in an innovative role and part
of the time as a generic nurse. The difficulty caused by such a job division is
illustrated by the fact that 66.7% (n=300) regularly worked more than their contracted
hours in their innovative role.
Innovative role job titles
The overabundance of job titles is reflected in the finding that 449 respondents
(65.8%), were identified with 296 different job titles and of these 227 (76.7%) had the
word nurse, sister, health visitor or midwife in their designation.
Education, Training and Research
Education levels of respondents were high with 81.8% (n=36) possessing a diploma,
advanced diploma, first degree, masters degree or PhD. However, over half (59.1%,
n=264) did note barriers, such as time and an inability to get their post covered, to
obtaining further education and training. Over a third (37.1%, n=167) had undertaken
research in their current role, though of these only 51 (11.3%) had had the research
published.
Job description and role assessment
Most respondents (92.4%, n=416) had a current job description, these were
considered to reflect the post holder’s current role either reasonably well (52.4%, n=
236) or very well (19.3%, n=87). IPR/appraisal was the most common method used
to assess the post holder’s performance, though for 10% (n=45) their performance was
not assessed at all.
Factors that aid and hinder effective working
The main factors identified by participants, which ensured that they could work
effectively in their innovative role were: support for the role (notably from
management level); personal skills and knowledge; clinical supervision; and
teamwork. The main barriers to working effectively included: lack of time for the
role; lack of facilities/resources/space; lack of secretarial support; and lack of support
from management.
Stage 3 Findings: Case studies with innovative post holders
Six case studies were undertaken with roles in community nursing, acute care, mental
health, midwifery, primary care and a non-clinical role. The case studies confirmed
the findings from the previous two stages. Effectively fulfilling the scope of their
innovative role was influenced strongly by the skills of the individual, not only on a
professional level but also on a personal one; these posts had evolved as they gained
experience in the role. This was related to their ability to build good relationships
with patients/clients and other colleagues, both within and outwith the post holder’s
profession. The impact of the roles on patient/client care and on the development of
nursing/midwifery practice was also evident.
DISCUSSION
Nursing and midwifery roles have developed rapidly in response to ongoing changes
in healthcare provision both nationally and internationally. Previous research has
considered the impact of policy decisions (Roberts-Davis & Read, 2001), changes in
medical working practices (Cameron & Masterson, 2000) and the drive for
professional development and changes in service need (Read et al., 2001). These
were also identified in this study as stimuli for the rapid increase in the number of
innovative roles in nursing and midwifery. Findings also indicated that managers
recognised the individual impact that practitioners had on the development of
innovative roles.
The importance of providing a supportive infrastructure for the innovative post holder
was emphasised throughout the study. Wilson-Barnett et al. (2000) had noted that
support from nurse managers and senior clinicians were vital for new role
development. Clinical supervision, appropriate training/education for the role and
appraisal of the role were seen as necessary to ensure safety for patients and
maintenance of high standards of care.
The lack of consistency in how innovative post holders are titled, found in this study,
has been an ongoing topic throughout the literature on role development, noted
previously by Barnes (2004) and in the ENRiP project (Read et al., 2001).
The positive aspect of these roles encroaching on the remit of other health and social
care professionals was the opportunities for professional development and improved
continuity of care for patients. In contrast the negative aspect concerned the fear that
the basics of nursing care could be eroded. These concerns concur with those from
previous studies that highlighted the unacceptability of nurses undertaking medical
work at the expense of nursing work (Rose et al. 1997). The possible de-skilling of
generic staff through the employment of specialists was also a concern, this reflected
a concern noted in previous studies (Jack et al., 2004; McGee & Castledine, 1999).
The significance of planning and resources for innovative roles emerged as a
recommendation from the ENRiP project (Cameron & Masterson, 2000; Collins et al.,
2000). In this study participants noted that while basic equipment and resources had
been available to them on commencing their role, there were ongoing deficits in the
provision of secretarial support, appropriate software and specialist equipment. Both
ENRiP and this study also noted that a perceived lack of time impacted negatively on
the ability of post holders to undertake their role (Collins et al., 2000).
The post holders in the case study phase were identified as exemplars and therefore
can be considered to be experts in their field. Conway (1998) acknowledged the
difficulty in defining what an expert nurse is. Her criteria for specialist nurses of:
extended knowledge bases; acting as consultants to other nurses; autonomy; distinct
roles; innovative in terms of practice and agreements and protocols to enable them to
expand their role, are reflected in the key aspects of good practice and the autonomy
and decision-making capabilities found within the six case studies.
CONCLUSIONS
The findings from this study illustrate that there is substantial activity with regard to
innovative nursing and midwifery role development in Northern Ireland’s HPSS,
particularly since 2000. This activity has been influenced by a number of factors that
have combined to encourage role development. The planning and development of
these innovative roles needs careful consideration with an infrastructure developed
which will both provide support for the role and a means of evaluating the impact of
the role on the service. This study has provided verification that ongoing professional
development in nursing and midwifery has been influenced positively by the
establishment of innovative roles. This study also evidenced the positive impact on
patient care resulting from role development.
REFERENCES
Barnes P. (2004) The nurse clinician: a time to reflect qualification. Paper presented
at NMC Post Registration Nursing Framework Consultation Conference, February
Buchan J. & Seccombe I. (2003) More nurses working differently? A review of the
UK nursing labour market 2002 to 2003. RCN, London
Buchan J. & Daz Pol M. (2002) Skill mix in the health care workforce: reviewing the
evidence. Bulletin of the World Health Organisation. 80 (7) 575-580
Cameron A. & Masterson A. (2000) Managing the unmanageable? Nurse Executive
directors and the new role in nursing. Journal of Advanced Nursing. 31 (5) 10811088
Collins K., Jones M.L., McDonnell A., Read S., Jones R. & Cameron A. (2000) Do
new roles contribute to job satisfaction and retention of staff in nursing and
professions allied to medicine. Journal of Nursing Management 8 3-12
Conway J.E. (1998) Evolution of the species ‘expert nurse’. An examination of the
practical knowledge held by expert nurses. Journal of Clinical Nursing 7, 75-82
Jack B., Hendry C. & Topping A. (2004) Third year student nurses perceptions of the
role and impact of Clinical Nurse Specialists: a multi-centred descriptive study.
Clinical Effectiveness in Nursing. : 39-46
Jamieson L. & Williams L.M. (2002) Confusion prevails in defining advanced
nursing practice. Collegian 9 (4) 29-33
Jenkins-Clarke S. & Carr-Hill R. (2003) Workforce and Workload: Are nursing
resources used effectively? NT Research. 8 (4) 238-248
Levenson B. & Vaughan B. (1999) Developing new roles in practice: an evidence
based guide. University of Sheffield
McGee P. & Castledine G. (1999) A survey of specialist and advanced nursing
practice in the UK. British Journal of Nursing 8 (16) 1074-1078
Northern Ireland Practice and Education Council for Nursing and Midwifery (2004)
Development Framework for Nurses and Midwives: Consultation Document NIPEC,
Belfast
Read S., Lloyd Jones M., Collins K., McDonnell A., Jones R., Doyle L., Cameron A.,
Masterson A., Dowling S., Vaughan B., Furlong S. & Scholes J. (2001) Exploring
new roles in practice: implications of developments within the clinical team (ENRiP).
School of Health and Related Research (ScHARR), University of Sheffield, Sheffield
www.shef.ac.uk/content/1/c6/33/98/enrip.pdf - accessed June 2004
Roberts-Davies M. & Read S. (2001) Clinical role clarification: using the Delphi
method to establish similarities and differences between Nurse Practitioners and
Clinical Nurse Specialists. Journal of Clinical Nursing 10, 33-43
Rose K., Waterman H. & Tullo A. (1997) The extended role of the nurse: reviewing
the implications for practice. Clinical Effectiveness in Nursing 1, 31-37
Royal College of Midwives (2005) Annual Staffing Survey 2004. RCM, London
Scholes J., Furlong S. & Vaughan B. (1999) New roles in practice: charting three
typologies of role innovation. Nursing in Critical Care. 4 (6) 268-275
Wilson-Barnett J., Barriball K.L., Reynolds H., Jowett S. & Ryrie I. (2000)
Recognising advancing nursing practice: evidence from two observational studies.
International Journal of Nursing Studies 37, 389-400
Mentorship in Midwifery in the New Millennium
By Helen Richmond
Senior Lecturer in Midwifery
MA, PGDipE, MSc, DPSM, RM, SRN
Anglia Polytechnic University
Bishops Hall Lane
Chelmsford
Essex
CM1 1SQ
Aims:
To understand midwives perception of their role as mentors.
To explore the experience of midwifery mentors in two contemporary NHS Trusts
attached to a University in the South East of England.
Background/rationale:
Little data had been collected on the subject of the experience of midwives in their
mentoring role in recent years but mentoring in the clinical area is now a pre-requisite
of most clinically based courses. Where research has been done, it mainly centred on
nurses (Pulsford, et al 2002, Chow and Suen, 2001, Smith and Gray 2001, Gray and
Smith, 2000,). There is a need to examine the experiences of midwives separately
from nurses as their working pattern is different from nurses creating different
pressures. It was this fact in mind that this research was designed.
Design:
A questionnaire was designed based on the work of Darling 1985, and Davies et al
1997, and the results of a pilot study, which contained quantitative and qualitative
questions. It was re-piloted before use and adjusted appropriately. 270 midwives
were surveyed in relation to their views and experience about mentorship in the new
millennium. 109 responded, making it one of the largest surveys on this subject.
Data analysis was done by using an SPSS 11 package. Ethical limitations meant that
the participants could not be pursued beyond the first mailing, and could not be
followed up with interviewing.
Results/Findings:
The midwives in the sample ranged from newly qualified midwives to very
experienced. Most midwives did not have any difficulties mentoring students (48%)
and indicated that they found some job satisfaction in it. However where difficulties
were identified four themes emerged. The four themes were: Not enough time to
mentor students (21%), too much paperwork (15%), student problems (12%), and
mentor confidence problems (9%). Mentors viewed themselves as role models for
best practice wanted enthusiastic students who were well mannered and had good
personal hygiene. Mentors indicated they did not feel well supported by the university
or their managers in their role as mentors.
Implications for practice:
The amount of time that midwives have in their working day to teach student
midwives needs to be discussed at management level and a more suitable plan
designed to accommodate the role of mentorship. The amount of paper work that
midwives have to complete during a student midwives training needs to be reviewed
by universities. More support needs to be given to midwives, from the university in
the practice area, when they encounter problems, with their students. Opportunities
for this should be identified and utilised, by universities and managers. There should
be careful preparation of midwives before they commence their mentoring role;
otherwise they tend to become distressed in their role as mentors.
A collaborative approach between universities and trusts needs to be pursued to
prepare students for the clinical area.
References:
Chow, F.L.W., Suen, L.K.P. (2001) Clinical staff as mentors in pre-registration
undergraduate nursing education: student’s perceptions of the mentors roles and
responsibilities. Nurse Education Today. 21(5), 350-8
Darling, L. 1985 Mentor matching: The Ideal Mentor. Nurse Educator 10(4),
17-18
Davis, C., Davis, B.D., Burnard, P. 1997 Use of the QSR.NUD.IST computer
program to identify how clinical midwife mentors view their work Journal of
Advanced Nursing 26(4), 833-839
Gray, M., A., Smith, L.N. 2000 The qualities of an effective mentor from the student
nurse’s perspective: findings from a longitudinal qualitative study. Journal of
Advanced Nursing 32(6),1542-49
Pulsford, D., Boit, K., Owen,S. 2002 Are mentors ready to make a difference? A
survey of mentors’ attitudes towards nurse education Nurse Education Today Vol 22
p 439 - 446
Smith, P., Gray, B. (2001) Reassessing the concept of emotional labour in student
nurses education: the role of the link lecturers and mentors in a time of change. Nurse
Education Today. 21(3), 230-7
SOURCES OF OCCUPATIONAL STRESS AS PERCEIVED BY
REGISTERED NURSES WORKING IN MEDICAL AND SURGICAL WARDS
IN A MAJOR UNIVERSITY TEACHING HOSPITAL IN THE REPUBLIC OF
IRELAND.
Author: Mary T. Ring, RGN, RNT, BNS, ENB 100, MSc. Nursing,
Nurse Tutor/specialist co-ordinator,
Centre of Nurse Education,
Cork University Hospital.
[email protected]
021 4922142
Fax 021 4922821
Background
Stress has become one of the most significant occupational health issues of recent
years (Lu, Shiau and Cooper, 1997). A wealth of international literature reveals that
nurses experience numerous occupational stressors (Kirkcaldy and Martin, 2000).
Although these stressors are well recognised, there has been little attempt to rank
them in terms of significance. In addition, there appears to be a paucity of published
studies related to the stressors experienced by Irish nurses working in acute medical
and surgical wards.
Design of study
The modified Delphi technique was utilised in order to identify, prioritise and rank the
most significant occupational stressors for this group of nurses.
Sample selection method
A non-probability convenience sample of seventy-one nurses commenced the study.
Fifty-six nurses completed the study. This represented an overall response rate of
seventy-two per cent.
Data collection and analysis
Three rounds of questionnaires were utilised. Data was analysed using the Statistical
Package for Social Sciences (SPSS). In round one the informed participants were
asked to rate a series of series of sixty-two occupational stressors identified from the
literature. Participants were given the opportunity to identify other stressors they
considered significant. Forty-four stressors received a median score of three or greater
and progressed for rating in round two. Seventeen stressors which received a median
score of four and interquartile range of <1.2 proceeded to round three. In round three
participants identified and ranked the ten most significant stressors.
Results
Staff shortages were identified as being the most significant stressor. Lack of time to
perform care to ones satisfaction, constant interruptions, fear of making a mistake and
incompatible demands on ones time were the most significant workload related issues.
Dealing with aggressive relatives was ranked sixth overall. The findings suggest that
this group of nurses identify issues related to staffing levels and workload as the most
significant occupational stressors.
Kirkcaldy, B.D. Martin, T. (2000) Job stress and satisfaction among nurses individual
differences, Stress Medicine, 16 (2), pp.77-89.
Lu, L. Shiau, C. Cooper, C. (1997) Occupational stress in clinical nurses, Counselling
Psychology, Quarterly, 10(1), pp. 30-50.
SILENT NO LONGER – WOMEN’S STORIES ABOUT LOSS OF BOWEL
CONTROL FOLLOWING CHILDBIRTH
Carol Rogers, RN MHSc, Associate Professor, Faculty of Nursing, University of
Calgary, 2500 University Dr. NW., Calgary, Alberta, T2N 1N4, Canada
Phone: 1-403-220-4629; Fax: 1-403-284-4803; email – [email protected]
Loss of bowel control or fecal incontinence is not a complication of childbirth that
women expect to experience. The literature identifies possible causes of this - use of
episiotomy and instrumental delivery, particularly with forceps (Sultan et al, 1993).
ButI could find no literature to tell me how women live with this complication.
As a postpartum nurse and a nursing teacher, I was concerned about this gap in
information and in understanding. As a nurse, I cannot provide relevant nursing care
unless I know what care is important to my patients. But to do this, I needed to know
what it is like for women to live with this loss of bowel control.
I conducted a descriptive qualitative study using narrative inquiry to hear and
understand the stories of women who have experienced the loss of bowel control
following childbirth. A purposive sample of women who had had this complication
surgically repaired was accessed through a colon and rectal surgeon’s practice. Sixty
to ninety minute interviews were done, then transcribed, read for general meaning
then re-read for recurring ideas that can be interpreted for their meaning. The
interpretation became the narrative account. This account of her interview was sent to
each woman so she could add, delete as necessary. Commonalities across interview
data sets were noted.
Nine women in their 30’s and 40’s chose to participate. All but one experienced loss
of bowel control after her first delivery. The length of time from delivery to meeting a
colon rectal surgeon ranged from 5 days to 12 years. The length of time from delivery
to surgery ranged from 5 months to 19 years. Four women had more than one rectal
surgery.
Each woman’s story was unique but there were common themes. These were “I knew
I wasn’t right”; what it was like to lose control; the loss of freedom; the
embarrassment; the need for support; and finally, what doctors and nurses could do.
None of these women had difficulty in telling their stories. They were silent no
longer.
Sultan, A.H., Kamm, M.A., Bartram, C.I. and Hudson, C.N. (1993). Anal
sphincter trauma during instrumental delivery. International Journal of Gynecology
and Obstetrics. 43: 263-270.
DIPLOMA IN NURSING STUDENTS’ EXPERIENCES OF POTENTIAL
STRESSORS
IN THE CLINICAL LEARNING ENVIRONMENT
Author and Presenter: Sinead E. Ronayne
Job Title: Nurse Tutor, Graduate Diploma in Nursing (Specialist Strands),
Waterford Institute of Technology/Health Service Executive – South East
Qualifications: RGN, Dip. in Higher Education in Professional Development in
Nursing, H. Dip. Cardiovascular Nursing Studies, M. Sc. in Nursing (Clinical
Practice)
Address: Postgraduate Nursing Office, Unit 2, Waterford Regional Hospital,
Dunmore Road, Waterford. Email: [email protected]
Abstract
Clinical education is an important component of pre-registration nursing curricula,
accounting for approximately 65% of nursing education (Simons et al. 1998). For
students, clinical experiences are integral to the development of practical skills, the
integration of theory and practice (Nolan 1998) and their socialisation into nursing
(Campbell et al. 1994). A plethora of international literature suggests that many
stressors exist for nursing students in clinical settings. However, there is a dearth of
Irish literature addressing potential clinical stressors for nursing students. Considering
the changes that have occurred and those currently underway within nurse education
in Ireland, investigating nursing students’ clinical experiences may enhance
understanding among all those involved in nurse education, of students’ needs on
clinical placements.
The aim of this study was to explore the experiences of a group of first and third year
nursing students on the pre-registration, Diploma in Nursing programme, regarding
potential stressors in the clinical learning environment. The conceptual framework
underpinning this study was the transactional model of stress, by Lazarus (1966). This
study used a quantitative, non-experimental, cross-sectional, descriptive survey
design. The Clinical Stress Perception Scale (CSPS), developed by the researcher,
was a self-administered, structured, standardised questionnaire. The convenience
sample consisted of 56 first year and 29 third year nursing students, undertaking a
Diploma in Nursing Studies in General Nursing in one large teaching hospital in
Ireland. Data were analysed using descriptive and inferential statistical procedures,
using the Statistical Package for Social Sciences (SPSS).
This study was significant in identifying students’ experiences regarding potential
stressors that may create stress and compromise learning for nursing students.
Students experienced moderate stress in clinical areas. Overall, third year students
experienced a higher degree of stress than did first year students. Experiences
regarding dealing with emergency situations, critically ill patients, death and terminal
illness, feelings of personal inadequacy, fear of harming patients and integration with
the ward team were identified as the most stressful. Interpersonal relationships and
procedural care were considered the least stressful clinical experiences. This study’s
findings may facilitate therapeutic discussions between clinicians, educationalists and
students in attempting to anticipate, minimise or eliminate sources of stress for
nursing students in clinical areas and raise awareness of students’ need for sustained
support throughout their nursing education programme. A framework was developed
from the current study’s research, which may assist in future explorations of students’
experiences in clinical areas.
References
Campbell, J. E., Larrivee, L., Field, P. A. and Reutter, L. (1994) Learning to nurse in
the clinical setting. Journal of Advanced Nursing. 20(3), 1125-1131.
Nolan, C.A. (1998) Learning on clinical placement: the experiences of six Australian
student nurses. Nurse Education Today. 18(8), 622-629.
Lazarus, R. S. (1966) Psychological Stress and the Coping Process. McGraw Hill,
New York.
Simons, H., Clark, J.B., Gobbi, M. and Long, G. (1998) Nurse Education and
Training Evaluation in Ireland: Final Report. An Bord Altranais, Dublin.
Standards of essential nursing care: nurses’ perceptions and management issues
Mr. Thomas Rush RGN, RMN, B.A., MSc
Lecturer
&
Mr. Joseph B Cunningham RGN, RMN, RLDN, Dip Nursing (London), BSc
(Hons), MSc (Applied Social Research)
Lecturer
Room 12L12
Faculty of Life and Health Sciences
The University of Ulster at Jordanstown
Shore Road
Newtownabbbey
Co Antrim
Northern Ireland BT 37 0QB
+ 44 28 9068225
[email protected]
[email protected]
Abstract:
Aim: To examine the attitudes of nurses towards the standards of delivery of essential
care and how they perceive managements’ interest in its delivery.
Background: The nursing profession in the UK has been the subject of continuing and
growing criticism over standards of essential care in recent years. These criticisms
raise important issues not just for nurses but for the corporate management of hospital
trusts; the most important issues are, what should nurses’ manage and what attention
is paid to care which is basis of comfort?
Design and Methods: A survey of 277 nurses in Northern Ireland using Likert scales.
Results: Eighty-six percent of nurses believe they don’t have time for essential or
basic care. Fifty-eight percent of nurses blame management for deficits in standards of
care and only 44 % believe they get support from management for the day-to- day
aspects of care. Eighty-six percent believe that nurses who meet the real needs of
patients seldom get recognition.
Conclusion: Nurses are concerned about the quality of care and with the lack of
management involvement in basic care.
Empowerment in nurse education
Ms Frances Ryan RGN, RCN, DNS (Hons), BNS (Hons), RNT, MA (Hons)
Lecturer
School of Nursing & Midwifery
The University of Dublin, Trinity College
24 D'Olier Street
Dublin 2
Ireland
+ 353 1 6083925
[email protected]
Abstract
Adult education within the context of lifelong learning embraces the notion of
enabling people to realise their full potential throughout the lifecycle. Its underlying
philosophy is based on a participatory, egalitarian and empowering type of learning
that is concerned with self-development and social awareness. Inherent in the
philosophy are the principles of transformative and empowering learning. This study
examined a nurse education initiative through the lens of adult education and
empowerment. While it focused on the experiences of registered nurses returning to
learning, the findings have significance for nurse education in general. The Return to
Nursing Practice Course was designed to facilitate nurses to return to practice. These
courses are hospital-based and devised primarily to recruit nurses back into the
workforce. Nurses who are returning to learning and practice after an absence have
been found to be a special needs group in terms of the emotional and practical support
they require. It is significant to question therefore, whether or not the principles of
adult education and empowerment are a reality for participants on such courses. The
data from the study consisted of the texts of six semi-structured, audio-taped
interviews that were transcribed verbatim. The data were analysed using hermeneutic
phenomenological analysis, and the constant comparative method of grounded theory.
The findings of the study indicated that the course was family-friendly and flexible. It
was found to be an empowering experience only in terms of the increased selfconfidence felt by all participants after completing it. The lack of employment after
the course was found to have a negative effect on participants. Participants stated that
very little of their own life experiences were included in the learning process, and all
found the course too short to meet their learning needs adequately. None of the
participants stated that the course transformed or changed their personal meaning
systems in any way. None of the findings indicated that the participants reached a
level of critical reflection. The results indicated that both the curriculum content and
duration of the course required alteration in order to allow for a more participatory,
empowering and critically reflexive type of learning to occur. Future research in the
area of nurse education within the context of adult education is desirable if nurses are
to negotiate the challenges of a rapidly changing profession and truly partake in
learning for life.
Title: TRANSFORMING PRE-DIALYSIS EDUCATION USING CONJOINT
ANALYSIS – PREFERENCES OF PATIENTS & CARERS
Name of Authors
*John M Sedgewick
**Dr. Carl Thompson
Job Title
*Programmes Director & Principal Lecturer (Nephrology)
University of Teesside, Tees Valley, Cleveland
& Post Graduate Student University of York
**Dr.Carl Thompson
Senior Research Fellow
Department of Health Sciences
University of York
York
Primary Contact Details
John Sedgewick, MSc, BSc (Hons) RN, RMHN, DipNurs, Renal Cert, CertEd/RNT
School of Health and Social Care
University of Teesside
Tees Valley
Cleveland
England
Tel
+441 642 384996
Fax
+441 642 384105
Email [email protected]
TRANSFORMING PRE-DIALYSIS EDUCATION USING CONJOINT
ANALYSIS – PREFERENCES OF PATIENTS & CARERS
*John Sedgewick & **Dr Carl Thompson
*University of Teesside, UK & **Department of Health Sciences, University of York,
UK
Abstract
Background: This study examines preferences for pre-dialysis education in a group
of dialysis patients using conjoint analysis (Ryan 1998). Conjoint analysis helps
understand the trade off’s individuals make when choosing between various products
or services. The National Service Frameworks for Renal Services (DoH 2004)
emphasise strengthening patient choice and addressing service design in collaboration
with service users.
Design of Study: A mixed methods approach (triangulation) was adopted in the
collection of qualitative data during stage one (focus group) and quantitative data
collected during stage 2 (conjoint survey).
Sample: Ten participants purposely sampled from across three renal units participated
in stage one. Fifty participants undergoing dialysis for between 3-12 months were
invited to participate in the completion of the self administered conjoint survey during
stage two.
Method: Focus group data identified key attributes and levels of attributes seen as
important to pre-dialysis education. A full factorial design for the numbers of
scenarios used in the conjoint survey was not feasible and so a fractional factorial
design was used, allowing estimation of the main effects between attributes and
levels.
Data Collection & Analysis: Focus group data was analysed using content analysis
with the development of cognitive mapping. SPSS Orthoplan procedure was used to
ensure orthogonality between scenarios in the survey. Conjoint linear regression
analysis was used, with the expressed preference as the dependent variable and the
attributes at various levels as the independent variables.
Results: Importance was most strongly associated with the content of education
session (17.78%), staff grade providing education (17.36%) and the need for review
sessions to occur at three monthly intervals (17.11%). Least importance was
associated with type of educational resource used within pre-dialysis teaching
(10.27%), venue for pre-dialysis education sessions (10.09%) and the format of
delivery of pre-dialysis education (9.36%). Analysis was relative to individual utility
scores (strength of preference). The development of an ‘ideal package ‘of pre-dialysis
education emerged taking into account both individual and group preferences. The
difference between the ideal package of pre-dialysis education (80% respondent
satisfaction) and the least preferred package (30% satisfaction) suggested an overall
reduction in satisfaction of 27%. Conjoint analysis provides the opportunity to
identify the critical attributes and levels associated with a particular service as well as
help understand what ‘trade-offs’ are made in choosing between various aspects of
pre-dialysis education provided.
References:
Department of Health (2004) The National Service Framework for Renal Services:
Part One: Dialysis and Transplantation. . London. DOH
Ryan M, McIntosh E & Shackley P (1998) Using conjoint analysis to elicit the views
of health service users: an application to the patient health card. Health expectations
1: 117 – 129
A Descriptive Survey Investigating The Nature And Effects Of Paid Part-Time
Employment On Academic Performance Among General Student Nurses.
Mr Brian Sharvin MSc; BSc (Hons); RGN; RNT.
Lecturer in Nursing
Department of Nursing
College Street Campus
Waterford Institute of Technology
Abstract
Introduction
The aim of this study was to investigate the nature of paid part-time employment and
its effects on academic performance as perceived by a group of student nurses in a
regional school of nursing in Ireland.
The evidence from the literature consistently suggests that the majority of students
engage in part-time work and that the key motivational factor for doing so is related to
financial hardship (Lindsay and Paton-Saltzberg, 1993; Ford et al., 1995; Leonard,
1995; Ferguson and Cerinus, 1996; Mckechnie et al 1998; Taylor and Newman,
1998; Lee at al, 1999; Flanagan et al, 2000; USI, 2001). However there is less
concurrence in the literature as to whether or not part-time employment has a negative
impact on academic performance. Subsequent to the literature review three research
questions were developed:
1. What is the nature of paid part-time employment amongst student nurses?
2. What are the reasons for student nurses undertaking paid part-time employment?
3. What effects do student nurses perceive paid part-time employment has on their
academic performance?
Methodology
A descriptive survey approach was employed utilising a self-administered
questionnaire. There were two main reasons why this data collection approach was
chosen. The first of these was the sensitive nature of the data under investigation.
The second reason was that impression based data has been found to be a valid
indicator of the objective performance of working students (Lindsay and PatonSaltzberg ,1993) .
The questionnaire was specifically designed for the purposes of this study and was
administered to all students undertaking a Diploma in General Nursing in the study
hospital (n=136) in May 2002. A total of 133 questionnaires were returned,
representing a 97.8% response rate.
Data was collected on the nature of paid part-time employment and the effects of paid
part-time employment. Questions relating to these key areas were derived from the
literature. Those relating to the effects of part-time work had previously been found
to be reliable indicators of the actual effect of part-time work on academic
performance (Lindsay and Saltzberg, 1993). Biographical information was also
collected to assist with the classification of responses at the analytical stage.
The data was analysed using the Statistical Product and Service Solution computer
package, version 10.1 for Windows. A combination of descriptive and inferential
statistics was used to describe and explore relationships between the variables. The
Chi-square test was used to calculate significance (p<0.05).
Results
The results show that 53.4% of student nurses surveyed were undertaking paid parttime work and 75% indicated that they had undertaken part-time work at some stage
during their Diploma course. The predominant reason given for undertaking part-time
work was related to financial hardship. These findings are consistent to those from
other studies (Lindsay and Paton-Saltzberg, 1993; McKechnie et al, 1998 and Taylor
and Newman, 1998).
Closer examination revealed that students in the second year of study were
significantly more likely to be working than those in any other year. Furthermore, it
was found that third year students were significantly more likely to have previously
had a part-time job than those in any other year. More specifically, 75% of third year
students had at some point undertaken paid part-time work while undertaking the
Diploma in nursing yet only 30.4% of third year students were currently working parttime. The significant drop in employment among the third year students in this study
would seem to lend credence to the suggestion that third year students give up work to
concentrate on the academic demands of their final year such as assignments and
examinations (Leonard, 1995; McKechnie et al, 1998; Taylor, 1998).
A key finding from this study was the significant relationship between the number of
part-time hours worked and the pre-determined effects of part-time work on academic
performance. The results clearly show that as the number of part-time working hours
increased so did the probability that a student would be ‘late for a class’, ‘miss a
class’, ‘be late for a shift’ or ‘miss a shift’. Furthermore, tests showed no statistical
significance between the pre-determined effects of paid part-time work and the other
key variables related to biographical data and the nature of part-time work. This
suggests that if the variables of ‘age’, ‘sex’, ‘marital status’, ‘number of dependants’,
‘reasons for undertaking part-time work’, ‘type of job’, ‘rate of pay’ and whether or
not the part-time work was during ‘weekdays’ or at ‘weekends’, have any influence on
these predetermined effects, it is probably by chance. The number of part-time
working hours undertaken by a student appears to be the key variable that influences
the probability of these pre-determined effects occurring.
A further key finding was that 76.8% of those who responded believed that
undertaking part-time work impaired their academic performance to ‘some extent’.
The negative effects identified included ‘tiredness/poor concentration in class’,
‘reduced study time’, and ‘reduced time to complete assignments’.
Conclusion
The findings from the study have increased our understanding of the nature and
effects of part-time work on academic performance among student nurses and have
provided a sound pilot study for future investigation. Furthermore the study findings
raise a number of challenges for those involved in the planning and development of
nursing curricula.
The implications for nursing are far reaching. If as suggested, students are missing
important components of their theoretical and clinical curricula, then, one has to
consider the ultimate implications of this for post qualification patient care.
Transforming nursing practice at Alexandrovska Hospital, Bulgaria: The role of
continuing education in supporting vision, courage, and determination.
Raelene V. Shippee-Rice, PhD, RN, University of New Hampshire, Durham, NH,
USA
Telephone: 01-603-370-0239
FAX:
01-603-942-8765
Email:
[email protected]
Magdalena Ninova, MS, Chief Nurse, Alexandrovska Hospital, Sofia, Bulgaria
Email:
[email protected]
Vihra Milanova, MD, PhD, Medical University of Sofia, Sofia, Bulgaria
Telephone: 359-923 05 12
Email:
[email protected]
Bulgaria is a small country with a population of approximately 7.5 million. The
country is a recent nation state embedded in an ancient history. As a former Soviet
block country, Bulgaria is emerging economically and politically with plans to join
the European Union in 2007. At the present time many of the country’s resources
target economic development and business expansion. The health and human services
infrastructure is poorly funded and not well developed.
The Alexandrovska Hospital, historically the largest hospital in the Balkans, was
established in 1879. The hospital is associated with the Medical University of Sofia
and provides care to patients from throughout Bulgaria. Nursing practice is limited in
its independent function and traditionally serves under the direction and power of
physicians. However, nurses at the hospital are determined to create a new vision for
nursing based on a more autonomous model of nursing practice.
The chief nurse and one of the hospital psychiatrists at Alexandrovska Hospital
collaborated with the Bulgarian-American Fulbright Commission to invite a nurse
educator who had received a United States Fulbright Award to conduct continuing
education seminars at the hospital. The purpose of the seminars was to assist in
helping 1) psychiatric nurses apply nursing process and therapeutic communication
into their nursing practice and 2) senior nurse leaders create a strategic plan for
implementing nursing process, patient education, and therapeutic communication
across hospital units. Using a continuing education model, two seminar series were
developed and presented to two groups of nurses: 11 psychiatric-mental health nurses
and 30 senior nurse leaders. The American Nurses’ Association standards of nursing
practice (American Nurses’ Association, 2005), patient centered care (Felgen,2003),
and Lewin’s change theory (Lewin, 1951) provided a conceptual framework for
organizing the seminars.
The seminars were offered in 3-hour sessions for up to 12 weeks. The seminars for
the senior nurse leaders focused on strategic planning and nursing process with an
emphasis on interpersonal communication, patient education, and models of nursing
practice. Senior nurses identified change strategies based on identified barriers and
facilitators. Models of nursing care, nursing process, patient education, and
therapeutic communication were major areas for changing nursing practice. The
senior nurses also were asked to develop a strategic plan for each of their units that
included goals, outcomes, action plan and time line.
The psychiatric-mental health seminars focused on nursing process, therapeutic
communication and caring. The psychiatric nurses were asked to describe how they
spent their time on a typical shift. Based on that information, they were asked to
determine which of the tasks and functions they performed required the expertise of a
nurse and which, if any, of the tasks and functions could be conducted by someone
who was not a nurse. Using this information, the nurses considered the possibility of
a model of patient care that could include the use of non-nursing personnel.
Initial evaluation at the completion of the seminar series indicated that the psychiatric
nurses were applying concepts discussed in the seminar. Seminar evaluation
indicated that the nurses in both groups found the overall program very helpful and
useful. Using a scale of 1-5 with 5 as very helpful and 1as not at all helpful. The
overall program evaluation score for the senior nurses was 4.87 and 4.89 for the
psychiatric-mental health nurses. Both groups indicated that case studies, discussions,
and role-plays were much more useful than power point presentations.
At the completion of the program, all participants were able to apply the nursing
process to a patient care situation and utilize therapeutic communication in role-play
activities. Observation of psychiatric-mental health nurses indicated that they were
spending more time with patients, using basic therapeutic communication skills, and
engaging with other members of the health care team in more active, positive ways.
They also expressed interest in conducting patient assessments, and developing a plan
of care based on the nursing process.
Approximately 31 senior nurses participated in the senior nurse seminar series. The
age of senior nurses ranged from 34-55 years with a mean of 44 years. The number of
years in clinical practice ranged from 2-34 with a mean of 21.5. Almost 60% of the
senior nurses had at least a bachelor’s degree with approximately 20% of these
holding a master’s degree. Approximately 40% identified a nursing diploma as the
highest educational credential. Some of these may have held a post diploma certificate
but as this information was not included in the demographic questionnaire, the data
are limited in regards to post diploma education.
Evaluation results indicated that the senior nurses across all educational levels found
identifying patient goals/outcomes, monitoring/evaluating patient progress,
therapeutic communication, and patient education as areas of greatest learning. The
master’s prepared nurses identified nursing standards and organizational change as
important areas of learning. Several senior nurses developed a strategic plan for their
individual units including goals, outcomes, action plans, and timelines.
Senior nurse leaders recommended that follow up seminars should address the
following topics: included identifying and solving problems, how nurses in other
countries cope with the problems, and more role play about working in a team and
means of solving problems between nurse-nurse, nurse/physician, nurse/patient.
Future steps planned by the organization include offering ‘continuing education’
seminars to nurses on all units throughout the institution. The primary focus of the
seminars will be therapeutic communication, nursing process, patient education, and
organizational change.
In conclusion, the continuing education format was successful in helping nurses at
Alexandrovska Hospital create a vision for nursing practice and identify strategies for
bringing about change at the organizational and individual unit levels.
REFERENCES
American Nurses Association (2004) Nursing: Scope and standards of practice.
Washington, DC: American Nurses Association.
Felgen, JA (2003). Caring core value, currency and commodity – Is it time to get
tough about “soft”? Nursing Administration Quarterly, 27, 208-212.
Lewin, K. (1951) Field theory in social science. New York: Harper & Row.
HIGH PREVALENCE OF DOMESTIC VIOLENCE IN A SPECIFIC
GEOGRAPHICAL LOCATION AND THE ROLE OF THE LOCAL HEALTH
PROFESSIONALS
Lyn Shipway, Learning and Teaching Advisor, Institute of Health and Social
Care
Gail Pittam, MSc, BSc: Research Assistant, Institute of Health and Social Care
Demountable Building, Anglia Polytechnic University, Victoria Road South,
Chelmsford, CM1 1SQ. [email protected]
The numbers of women who report domestic violence/abuse to the police are
generally low nationally. This contrasts with high levels detected in community
surveys, which have up to ¼ of women experiencing violence within intimate
relationships during a lifetime (BMA 1998). Health research has revealed that up to
50% of women accessing mental health services are, or have been victims of domestic
abuse. Additionally the health and social functioning of other families involved in
domestic abuse is undermined by a history of living with violence.
This study explored the possible reasons why, in one particular housing estate in SE
England there appeared to be a significant increase in the number of women reporting
incidents of domestic violence to the local police. Data was collected through one-toone interviews and two focus group sessions involving professionals with
responsibility for dealing with individuals who have specific needs because of living
within abusive relationships, including representatives from the police, health,
housing, social services and local statutory and voluntary organisations. This was
supplemented by the critical analysis of data and information already in the public
domain.
This study concluded that the health service interventions do not appear to have the
benefit of a comprehensive strategy for assessing, recording and dealing with abused
and injured clients. We found little evidence to show that the multi-agency
organisations, specifically healthcare, ‘tagged’ domestic violence cases in a way that
enabled ‘tracking’ of each incident/ family, or that this information was shared across
professional boundaries in any meaningful way. Nor could we find any evidence of
‘official’ strategies for co-ordinating the needs of individuals with or without children,
except where the professional or organisation had in place specific policies related to
child protection. Whilst the various individuals and agencies knew of the work
undertaken by the others, and attended an established multi-agency forum, like many
similar partnerships across the UK, the actual incidents of domestic violence could not
be collated. In addition, although generally the staff co-operated at the level of an
individual, it was apparent that there is no authoritative agreement or policies on
information sharing. These deficits are reflected in the national literature and this
study concludes that a comprehensive multi-agency approach to domestic violence is
the way forward, otherwise the energy of individuals and groups will be dissipated.
References
• British Medical Association (1998) Domestic Violence: A Health Care Issue?
London: BMA
Shipway, L. (2004) Domestic Violence: A Handbook for Health Professionals
London: Routledge
NATIONAL SURVEY OF ICU STAFF REGARDING ISSUES RELATING TO
CADAVERIC ORGAN DONATION IN IRELAND
Authors: Mary Smith SRN SCM MSc, Research Officer; Professor Hannah
McGee, Director Health Services Research Centre,
Department of Psychology
Royal College of Surgeons in Ireland
Mercer Street
Dublin 2
[email protected]
Background: Impediments to optimum cadeveric organ donation (OD) constrain the
supply of transplantable organs and transplant services. This study aimed to describe
attitudes and behaviours among ICU staff that might act as barriers or facilitators to
optimum organ donation (OD).
Study design: Mixed methods were used to gather data from staff at all ICU units
nationwide likely to ever engage with cadaveric organ procurement. An anonymous
postal questionnaire was used to gather quantitative data. The findings were
supplemented by qualitative data obtained from a purposive sample of volunteers
from among the survey respondents, using focus groups and one-to-one interviews.
Methods: Ethical approval for the study and the cooperation of N=37 ICUs was
obtained. All nursing staff (N=1,233) and a sample of medical staff most strategic to
organ donation (N= 261) were invited to return the anonymous questionnaire by
freepost. Respondents returned separately a postcard indicating their decision to
participate in the survey and providing contact details if they wished to participate in
further qualitative inquiry. A purposive sample was selected from among those
volunteering. The sample represented diversity across a range of characteristics that
included years experience in ICU, professional seniority and location of workplace.
Interviews and meetings were audiotape recorded, data obtained was transcribed,
categorised .and analysed for themes and issues. Quantitative data were analysed
using Data Desk © soft-wear.
Results: All 37 ICUs participating in the national organ retrieval programme
participated in the survey. An overall response rate of 68% was achieved; 72%
(N=875) of nursing staff responded; 51% (N=132) of doctors; 27 staff participated in
subsequent qualitative inquiry.
Findings: Stated support for OD in the survey was high (90%) but related behaviours
were reported by fewer doctors and nurses; these included having discussed one’s
own wish for personal OD with own family (reported by 59% and 71% respectively)
and carrying a donor card (35% and 57% respectively). Doctors were significantly
less likely than nurses (p<0.0001) to report carrying donor cards. Nurses perceived
doctors as being less ‘pro-donation’ than doctors considered themselves to be; all staff
believed the public support for OD is less than evidenced. Confidence among all staff
in performing OD related tasks was negatively affected by organ retention
‘controversies’ and perceived diminished public support for OD; 25% were
uncomfortable with the criteria for brain stem death; 27% with medico-legal issues
surrounding OD; and 25% believe staff shortages affect opportunities for donation.
Professional seniority and greater number years ICU experience were associated with
more positive attitudes and behaviours in relation to OD
Conclusions: Perceived public and collegiate support for OD are among the issues
requiring attention if OD rates are to be increased. Educational interventions are
required, particularly by junior by staff. Increased staff and bed numbers are needed
for ICU.
INTRAUTERINE GROWTH RESTRICTION AND QUALITY OF LIFE IN
ADULTHOOD
D Spence, PhD MSc BSc RGN RM1, FA Alderdice, BSSc PhD1, MC Stewart, MD
FRCPCH FRCP DCH2, HL Halliday, MD FRCP FRCPE2, AH Bell FRCP (Ed)
FRCPCH3.
School of Nursing & Midwifery
Queen’s University Belfast
21 Stranmillis Road
Belfast BT9 5AF
Email: [email protected]
Tel: 02890 9765601,
Dept Child Health, Queen’s University Belfast2,
Ulster Hospital, Belfast3.
Background: Intrauterine growth restriction (IUGR) remains a major clinical
problem in obstetrics. Over the past few decades advances in neonatal intensive care
have resulted in an increased survival rate of a heterogeneous group of babies,
including those born with IUGR. It is important to assess if associated problems
impact on health related quality of life, which is now considered an important
outcome measure for healthcare interventions in adults and are key determinants of
health service use. There is a dearth of literature on the relationship between IUGR
and quality of life, particularly in later life.
Methods: A retrospective cohort design was used. The cohort consisted of babies
born in Royal Maternity Hospital, Belfast between 1954 and 1956, who were traced
and assessed in adulthood, after a period of almost 50 years. The cohort was
assembled from historical birth records on exposure status. The exposure in this
defined population group was IUGR. The study group comprised singleton babies
born at term (>37 weeks’ gestation), who were growth restricted (<10th centile). The
comparison group was singleton babies born at term (>37 weeks’ gestation) and not
growth restricted (>10th centile). A gender-specific validated questionnaire which
included the Short Form 36 Health Survey (SF-36) was used. The primary question
addressed in this study was “do infants born growth restricted achieve the same
quality of life in adulthood as infants born with normal birth weights?” Study
objectives were to compare health related quality of life, general health, health service
use and socio-economic status in adulthood between these groups. The data collected
included physical, biological, psychological and socio-economic aspects over the
lifecourse.
Analysis: Univariate and multivariate analyses was undertaken. A score for each
participant was calculated for each dimension of the SF-36, with 0 indicating the
worst possible health state and 100 the best possible health state. Analysis was
carried out on each of the dimensions to compare mean scores between the study and
comparison groups. Adjustments were made for potential confounding variables.
Results: Overall, both groups reported similar quality of life on each dimension of the
SF-36, although the IUGR group had higher scores on the physical dimensions and
lower scores on the psychological dimensions, than those born with normal birth
weight. However, these differences between groups were statistically non-significant.
The IUGR group also tended to use health services more but this difference between
groups was not statistically significant.
Title: Crossing professional and organisational boundaries - The implementation
of generic Rehabilitation Assistants within 3 organisations in the northwest of
England.
Authors: Emma Stanmore* MRes, BNurs (Hons), DN, RN
Susan Ormrod** PhD
Heather Waterman*** PhD, BSc, RGN, OND
Affiliation: *Lecturer in Nursing, School of Nursing, Midwifery and Social Work,
University of Manchester, UK
**Research Fellow, National Primary Care Research and Development Centre,
University of Manchester, UK
***Professor of Nursing, School of Nursing, Midwifery and Health Visiting,
University of Manchester, UK
Correspondence: E Stanmore, School of Nursing, Midwifery and Social Work,
University of Manchester, Gateway House, Piccadilly South, Manchester. M60 7LP.
UK. Tel: 0161 237 2317 Fax: 0161 237 2958 Email: [email protected]
Keywords: Rehabilitation, Rehabilitation Assistants, New roles, Older People,
Generic, Support Workers, Therapists, Nursing
Abstract
Purpose: New generic support worker roles are being developed within rehabilitation
and intermediate care services throughout the UK, as a consequence of staff shortages
and the policy drive to look at new ways of working to meet the needs of older
people. This paper describes a joint project between a Primary Care Trust, an Acute
Trust and Social Services in one region in the northwest of England. It aims to
describe the process of introducing new roles within rehabilitation and evaluates the
acceptability and integration within different settings.
Methods: Thirty support worker staff from an Acute Trust, Primary Care Trust and
Social Services were trained over a period of 18 months to become generic
Rehabilitation Assistants (RAs). A total of 55 semi-structured interviews of patients,
associated professionals and RAs were conducted to examine the acceptability and
integration of the new role. This data was inductively analysed and categorised into
themes.
Results and conclusions: Several factors appeared to influence the acceptance and
integration of the new role, namely: prior experience and the degree of role change,
familiarity and inter-staff relationships, role distinction and contribution and resources
and management. Patients and professionals reported huge appreciation of the new
role. The evaluation demonstrates how an innovative, inter-organisational approach
can deliver new solutions to address workforce issues. Further research is
recommended nationally, to track the development and evaluate the effectiveness of
similar roles.
Transforming Inter-professional Education – Boundaries between Midwives and
Doctors
Dr Anne Lazenbatt BSc, PhD
Reader in Health Sciences
School of Nursing and Midwifery, Queen’s University Belfast, 50 Elmwood Avenue,
Lisburn Road, Belfast, BT7 1NN
Ms Frances McMurray MA, RM
Associate Head of School
School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology
Centre, Lisburn Road, Belfast, BT 7 1NN
Ms Jill Stewart-Moore MSc PGCEA,RM,RM
Midwifery Teaching Fellow
School of Nursing and Midwifery, Queen’s University Belfast, 50 Elmwood
Avenue, Belfast, BT7 1NN
Tel 02890975837 Fax 02890975871
e mail:[email protected]
Inter-professional education has been identified as a means of achieving the
collaborative working required for effective health care delivery (Cable 2002). A
formative evaluation was conducted of an inter-professional education programme for
midwives and doctors engaged in maternity care within the Royal Jubilee Maternity
Service in Northern Ireland, reporting on the processes involved and the impact of the
pilot intervention. The study was funded by the Northern Ireland Practice and
Education Council for Nursing and Midwifery (McMurray, Lazenbatt and
McElearney 2004).
The project involved the development of a Postgraduate Certificate for Registered
midwives and doctors, to develop expertise in women centred care by extending their
collaborative knowledge, skill and practice working towards an academic
qualification. The development of advanced practice and work-based learning is a
central focus for the Postgraduate Certificate.
Aim
To conduct a formative evaluation of an inter-professional education programme for
midwives and doctors engaged in the delivery of maternity care within the Royal
Jubilee Maternity Service in Northern Ireland, reporting both on the processes
involved and the impact of the intervention.
Objectives
1. To assess the effects of inter-professional education on the collaborative learning of
midwives and doctors, knowledge, attitudes and skills
2. To document and describe the context and process of delivery of the interprofessional curriculum.
3. To identify process and contextual, factors which influence the effectiveness of the
inter-professional curriculum.
Design
A prospective design was employed, spanning the 14 month period between October
2002 and December 2003. A four month inter-professional education programme was
delivered where participants undertook the postgraduate certificate in women- centres
care and three phases of data collection.
Time schedule
October 02-March 03
April-July 03
August- September 03
Nov/December 03
January 2004
Design
Pre-programme phase of data collection
Postgraduate Certificate in Womancentred Care
Post-programme data collection
Follow up data collection
Final report
A qualitative methodology was employed to facilitate an in-depth exploration of the
process of implementing the programme and an exploration of the experience and
perspective of the various stakeholders (Denzin and Lincoln 2000).
Pre programme data collection involved individual interviews with programme
participants and uni- professional focus groups. Data was generated from six
individual interviews with programme participants and two uni-professional focus
groups with doctors and midwives working within the setting.
A purposive sampling strategy was used to recruit the total sample of the three
midwives and three doctors participating in the programme to take part in the
individual interviews (Mays and Pope 1995; Curtis et al 2000). The busy nature of
maternity work determined that a convenience strategy be used in sampling and
recruiting focus group participants, namely co- workers, five doctors and five
midwives to take part in focus groups.
Post programme data collection involved individual interviews with the programme
participants. Five of the six programme participants took part in individual interviews
aimed at exploring their experience of taking part in the programme and the impact of
the programme. In addition a number of key people within RJMS setting including the
Midwife managers and Specialist Registrar Tutor were recruited using a purposive
sampling strategy to participate in interviews aimed at exploring the contextual and
organisational factors that have contributed to the development of the programme.
Follow up data collection involved recruiting the total sample of course participants in
individual telephone interviews three months after course completion.
Data analysis
The transcripts of the interviews were checked for accuracy and then imported into
NUD*IST qualitative data management package which facilitated the conduct of a
thematic analysis of the data.
Thematic analysis of the data identified a central theme of ‘tackling boundaries’. The
emergence of many themes confirms the complexity surrounding inter-professional
education and working within the clinical practice environment (Cable 2002).
Emerging themes were:
1. Project management.
2. Scheduling of a certificate programme.
3. Content, delivery & accreditation of certificate programme.
4. Recruitment of programme participants and environmental factors.
Recommendations:
1. To move models of postgraduate inter-professional certificate education from
pilot projects to core inter-professional postgraduate Diploma and Masters
Programmes.
2. Build a consensus amongst stakeholders around the importance of interprofessional education.
3. Include more clinical placements in NI for participants to learn together.
4. Commence programme in September rather than April to overcome difficulties
with advertising, staff rotas, library opening times and avoiding holiday periods.
5. Clear advertising and promotion of the programme.
6. Provide a balanced mix of participants in the course in relation to clinical
experience. In the pilot project midwives were very experienced whereas the
doctors had less obstetric experience.
7. Build a mentorship scheme into the course, with protected time for staff to
undertake the course.
Cable, S. (2002) The context- why the current interest? [pp1-20]. In Glen, S. and
Leiba, T. (2002) (Eds) Multi-professional learning for nurses: breaking the
boundaries. Palgrave: Hampshire.
Curtis S, Gesler W, Smith G and Washburn S (2000) Approaches to sampling and
case selection in qualitative research: examples in the geography of health Social
Science and Medicine 50 1001-1014.
Denzin, N. and Lincoln, Y. (2000) The discipline and practice of qualitative research
[pp1-29]. In Denzin, N. and Lincoln, Y. (eds) (2000) Handbook of qualitative
research [2nd ed], Sage Publications: California.
Mays, N. and Pope, C. (1995) Rigor and qualitative research. British Medical Journal,
311, 109-112.
McMurray F, Lazenbatt A and McElearney A (2004) Prospective evaluation of an
Inter-professional education programme for midwives and doctors: learning together
to provide woman-centred care Queen’s University of Belfast : Belfast.
Can a community education project reduce the duration of untreated psychosis?
Dr Deirdre Jackson
Research Registrar
Professor Eadhard O’Callaghan
Ms Laoise Renwick
Community Psychiatric Nurse
Ms Maire Sutton
Clinical Nurse Specialist
Mr Niall Turner
Programme Co-ordinator
DELTA PROJECT
1 Marine Terrace
Dun Laoghaire
Co Dublin
Ireland
Aims
The project aims to answer the question posed; can a community education project
reduce the duration of untreated psychosis (DUP)? .
Background
In Ireland public education campaigns and early detection strategies have been
developed to combat diseases such as breast cancer and heart disease. In Ireland over
65,000 individuals suffer from psychosis and each year over 1,000 mostly young
people develop psychosis for the first time. The personal, familial, social and
economic consequences of psychosis to the individual, their family, the health service
and tax payer are vast (Tennakon et al, 2000),(Andrews et al, 1985, McGorry et al,
1998, Clarke and O’Callaghan 2003) yet no strategy for the early detection of serious
mental health disorders has been piloted in Ireland until this project.
Many studies have highlighted an alarming delay in detecting psychosis (Larsen et al,
1996). The time period between the onset of frank psychotic symptoms and receiving
effective treatment is known as the duration of untreated psychosis (DUP). Our own
work in Ireland demonstrates that DUP is one to two years (Clarke et al, 1998). Many
who present with psychosis will have had several contacts with key referral sources in
the year prior to referral (Lincoln et al, 1998). Projects elsewhere have reduced DUP
(Johannssen et al, 2001) and furthermore, research here (Clarke et al,2002; Clarke et
al, in preparation; Clarke & O’Callaghan, 2003) and elsewhere (Melle et al 2004)
indicates that DUP predicts the short and medium outcome for these young people.
Method
The project has both educative and assessment components. The education
component targets the general public and key referrers including GP’s, A&E Depts,
teachers, counsellors, probation services and community nurses. The assessment
component will use standardised instruments to gather information about the
antecedents and clinical course of psychosis of all those from the catchment area who
present with signs of psychosis. We will research the effect of DUP on clinical
presentation including quality of life, symptomatology, family burden of care,
activities of daily living etc. Follow up assessments will be carried out at intervals
during the project. This is a service/research initiative that has been funded for 5 years
commencing in 2004 and finishing in 2008.
PROMOTING NUTRITION HEALTH: A REPONSE TO THE GROWING
TRENDS OF OVERWEIGHT AND OBESITY AMONG PEOPLE WITH
INTELLECTUAL DISABILITIES
Name: Janet Swinburne, Policy Development Co-Ordinator, MSc, BSc, RNLD
Address: National Federation of Voluntary Bodies, Oranmore Business Park,
Oranmore, Galway
Overweight and obesity has over the last decade become an increasingly prevalent
condition among people with intellectual disabilities and it has been found to be
significantly higher in comparison to that of the general population. However,
numerous studies have indicated that General Practitioners more often that not
provide a reactive service to this population group. The aim of this study was to
therefore investigate the current attitudes, knowledge and beliefs of General
Practitioners in the North Eastern Health Board to the growing trends of overweight
and obesity among people with intellectual disabilities.
The study involved a census sample (probability sampling method) of 169 General
Practitioners in the North Eastern Health Board registered with the Irish Medical
Directory 2003-2004 (Gueret, 2003). The study employed a quantitative research
approach to guide this research enquiry. A postal questionnaire was developed to
collate the information required and a pilot study was carried out to test the reliability
and validity of the questionnaire. A 49% response rate was obtained. The Statistical
Package for Social Sciences (SPSS) Version 11.0’ was used to analysis the closed
questions and statements, and ‘content analysis’ was used to analysis the open-ended
statements within the questionnaire.
The results of the study indicated that although most of the General Practitioners had
considerable knowledge of the increased risk, prevalence and prevention of
overweight and obesity among people with intellectual disabilities, they felt
inexperienced and that they lacked the knowledge and expertise required in this area
of practice. In addition, the majority of the General Practitioners did not perceive
weight management to be a responsibility of the person with intellectual disabilities,
nor was there a consensus on whether weight management is a responsibility of
General Practitioners.
In summary, the findings strongly support the need for a fundamental change in the
development of public health policy to include and address the specific health needs
of people with intellectual disabilities. The findings also suggest that a fundamental
change is required in the provision of training, information and education to General
Practitioners, to enable them to provide effective support and recognise their role and
responsibilities to people with intellectual disabilities within general practice.
Encouragingly, the majority of the General Practitioners welcomed the support of
other professionals, organisations and the provision of further training and the
development of clinical guidelines to manage the increasing trends of overweight and
obesity among people with intellectual disabilities in Ireland.
Gueret, M. (2003) Irish Medical Directory: Directory of Irish Medical Healthcare.
Dublin: IMD.
CLINICAL NEAR MISSES IN MATERNITY CARE
Andrew Symon RGN, RM, MA (Hons), CTHE, PhD.
Senior Lecturer,
School of Nursing & Midwifery,
University of Dundee,
Ninewells Hospital,
Dundee DD1 9SY
Bernadette McStea RGN, RM, BSc.
Midwifery Sister,
Ninewells Hospital,
NHS Tayside
Tricia Murphy-Black RM, RCNT, MSc, PhD.
Professor of Midwifery,
University of Stirling
Background Although adverse health care incidents are documented and routinely
analysed, there is little focus on clinical ‘near misses’, which may reveal just as much
useful information. In theory near misses share a common aetiology with adverse
outcomes (Reason 2000); they are events that could have adverse consequences but do
not and are “indistinguishable from fully fledged adverse events in all but outcome”
(Barach & Small 2000). Following on from a postal survey, group interviews in four
maternity units were used to explore midwives’ understanding and experiences of this
subject.
Methods / Sample
Ethical approval was obtained. Four group interviews with 26
clinical midwives, some of whom had completed the earlier postal survey, explored
how they perceived the circumstances and consequences of near misses and poor
outcomes (Bailey & Tilley 2002). Sampling was both purposive and opportunistic.
The interviews were transcribed verbatim. A process of narrative inquiry was used; a
sequential analysis of emergent themes was carried out.
Results
Although there were diverse understandings of ‘near misses’,
midwives across the units had shared insight into the circumstances that give rise to
poor outcomes and near misses. Five principal themes emerged: ‘Unit culture’
referred to the general working atmosphere, and included supervision and peer
support; this was generally believed to have improved in recent years. ‘Causes’: errors
and near misses were commonly perceived to arise from pressure of work, and
equipment misuse. ‘Helping to prevent mistakes’ covered protocol use, support and
intervention by colleagues, and learning from previous errors. ‘The consequences of
near misses’ were varied, and could be as bad as those relating to adverse outcomes in
terms of staff coping with stressful situations. ‘Staff confiding in one another’ is a
support mechanism used by practitioners to cope with distressing circumstances.
Professional relevance
These data bear out the belief that adverse events and
near misses share common sequential patterns, reflecting contemporary systems-based
analyses. The systematic analysis of clinical near misses may provide a significant
educational benefit, resulting in improved clinical management and better clinical
outcomes. As there are many more near misses than poor outcomes, this is a large
potential educational resource.
References
Bailey P, Tilley S 2002 Storytelling and the interpretation of meaning in qualitative
research. Journal of Advanced Nursing 38(6): 574-583
Barach P, Small SD 2000 Reporting and preventing medical mishaps: lessons from
non-medical near miss reporting systems. British Medical Journal 320: 759-763
Reason J 2000 Human error: models and management. British Medical Journal 320:
768-70
EXPERIENCES OF OVERSEAS NURSES RECRUITED IN THE IRISH
HEALTH SERVICE
Fidel Taguinod, RGN BSN MSc.
Staff Nurse, Saint James’s Hospital
Tel: 041 9886448
E-mail: [email protected]
BACKGROUND
Many countries are experiencing a shortage of nurses. Health care systems around the
world are facing significant challenges in an attempt to solve this nursing crisis. As a
consequence, more developed countries, including Ireland, have turned to
international recruitment as an alternative approach to traditional workforce planning.
Since the year 2000, Irish nursing managers and healthcare employers have been
actively involved in the recruitment of nurses from abroad, particularly from
developing countries like Philippines, India and South Africa.
Registration figures had shown that the recruitment from abroad in recent years had
been extremely high. In the last four years (2000- 2003), there have been 6,819 nurses
(46.5%), whose qualifications were gained overseas, registered with An Bord
Altranais, compared to 7,861 nurses (53.5%) from Ireland (ABA 2003). The
increasing reliance of the Irish health service to overseas staff has started to raise
concerns regarding the sustainability and ethical implications of this initiative. Due to
competition among developed countries to recruit from developing nations (Buchan
2000), the Irish Nurses Organisation (2002) argued that the government and health
service employers should start developing retention initiatives for overseas nurses and
ensuring that they have more positive experiences in living and working in Ireland.
AIM
The study aimed to explore the experiences of overseas nurses in the Irish health
service from the recruitment process to the orientation/ adaptation period, settling in
and integration.
METHODS
The study used a qualitative grounded theory method. Data were collected using three
focus group interviews, composed of fourteen overseas nurses in total. The data were
transcribed and analysed using constant comparative analysis as described by Glaser
(1992). Issues of methodological rigour were addressed and ethical dimensions were
ensured to protect the participants of the study.
FINDINGS
The findings of the study indicated that the experiences of overseas nurses were
shaped by their motivations and expectations. The stages of recruitment and induction
were crucial in their successful adaptation. Although they experienced initial
difficulties, participants recognised the support provided to them by their colleagues,
employers and by the Irish Nurses Organisation (INO). These nurses were motivated
to come to Ireland because of economic, professional, and personal reasons. These
motivations were intertwined and influenced their expectations regarding the Irish
health service in general, and Irish nursing in particular. Participants described their
experiences in the workplace according to the way they were treated by their
colleagues, other professionals and by their patients. While they were mostly treated
with understanding and acceptance, experiences of indifference, resentment and
bullying, and discrimination were not unusual.
As migrant workers, overseas nurses continued to adjust in the community where they
live in and within the wider context of Irish society. Family reunification was a major
issue among the participants and would mainly influence their decision to stay longer
in Ireland. Experiences of racial abuse and discrimination were also reported and
perceived to be more directed towards nurses of Black ethnic background. The
findings in this study brought out issues that would have implications in nursing
practice and social policy particularly in areas of ethical recruitment, cultural
diversity, migration and integration.
CONCLUSIONS
This study offers an overview of the experiences of overseas nurses recruited to work
in the different sectors of the Irish health service. It suggests that awareness and
understanding of their expectations, motivations and experiences in the workplace
would significantly improve the relationship between them and other members of the
multi- disciplinary team. The findings would also provide a basis for the formulation
and/ or revision of integration strategies and other social policies affecting overseas
nurses and other migrant workers.
REFERENCES
An Bord Altranais (2003) Registration of Nurses By Nationality (Unpublished Data).
An Bord Altranais, Dublin.
Buchan, J. (2000) Nursing brain drain. Nursing Standard 15(4), 22-23.
Glaser, B. (1992) Basics of Grounded Theory Analysis. Sociology Press, CA.
Irish Nurses Organisation (2002) A Discussion Document: Towards a National Action
Plan Against Racism in Ireland. Irish Nurses Organisation, Dublin.
WOMEN’S EXPERIENCE OF MENOPAUSE FROM THE LATE 1930s
THROUGH THE EARLY 1960s
Debera Jane Thomas, DNS
Associate Professor
Florida Atlantic University
Christine E. Lynn College of Nursing
777 Glades Rd.
Boca Raton, FL 33431
USA
The purpose of this study was to compare women’s actual experience of
menopause with what was written about the subject in the medical, nursing, and
popular literature during the time that each woman experienced menopause. This was
done in an effort to document the evolution of the experience, as well as determine if
there was dissonance between what was actually experienced and what women were
being told about the experience of menopause.
A triangulated method of phenomenology and historical research was used to
answer the research question: “What are women’s perceptions of their menopausal
experience and how do they compare with what was written in the medical, nursing,
and popular literature at the time of their menopause?” A purposive sample of
twenty-six women ranging in age from 63-100 years old were interviewed about their
menopausal experience. Journal and magazine articles about menopause were
collected from 1935-1965. Medical and nursing textbooks, as well as popular books,
were surveyed for content related to menopause. Data analysis included comparison
of themes from the interviews with the literature, both lay and professional, during the
each of the decades from the 1930s through the 1960s. The results indicated that, in
general, the women found menopause to be a relief, natural transition, and an
unimportant life event. This contrasted sharply with the themes from the medical
literature where menopause was seen as an endocrinopathy.
Developing a framework to guide nurses providing information to patients with
Acute Coronary Heart Disease
Fiona Timmins MSC NFESC FFNRCSI BNS BSc RNT RGN
Director, BSc (Cur), School of Nursing and Midwifery, Trinity College Dublin.
Nurses caring for clients with Acute Coronary Heart Disease are aware of the need to
inform patients about recovery from illness, symptom management, and lifestyle that
affects health and the importance of taking prescribed medication correctly. This work
aims to equip nurses, for the first time, with a comprehensive understanding of their
role as educators in this area. Using Knowles (1989) theory of Andragogy as a
theoretical framework, it is suggested that information needs of clients are
individualized, dependent upon readiness to learn, previous experience and selfconcept. In response to these findings educational programs and information provision
are recommended to be nurse/client negotiated and tailored to individual needs.
Building upon this notion, a strategy is proposed for individualizing patient teaching
that is grounded in Knowles (1989) theory of Andragogy and developed using
behavioral/nursing theories and research in the area. This represents a new paradigm
of acute cardiac patient education that draws on a number of well-defined theories as
well as research on the topic. The presentation will provide nurses the with an
overview of suggested tools for assessing patients learning needs, readiness to learn
and an explanation of the education process required.
Title of Paper CLEAN ETHICS AND MESSY PROCESS: AN EXPLORATION OF THE
DYNAMIC NATURE OF REAL WORLD RESEARCH – A REFLECTIVE JOURNEY OF
ETHICAL DISCOVERY WITHIN A PHENOMENOLOGICAL STUDY.
Presenter Gerard A. Tobin
Lecturer/ Acting Director for Academic & Professional Affairs
School of Nursing & Midwifery
University College Dublin Trinity College
24 D’Olier Street
Dublin 2
Contact Email: [email protected]
Phone: 086 8335197
Abstract
The aim of this paper is to describe the experience of undertaking a qualitative study
within an area which was sensitive for the participants to explore and which forced
the researcher to question the ‘I’ of their research and their own mortality.
The primary findings are part of a wider study, which explored the experiences of
health care professionals in giving bad news and the impact on recipients and
significant others when the news is broken. The phenomenological study utilised
unstructured interviews, as the main data collection tool.
Healthcare professionals and recipients of bad news were invited to participate in the
study. For the purpose of this presentation, the focus will be on the reflexive
experience of the researcher in dealing with a concept of a linear ethical process and
the ‘messy’ ethical realities of qualitative research..
Ones ethical stance not only reflects moral, political, social and cultural location, but
within the endeavour of research it also reflects ones epistemological and ontological
beliefs. This paper will offer these issues as the ‘canvas’ on which the research
narrative was exposed. Some would refer to this as part of an audit trail, in reality it
was the essence of what happened (intentionally and serendipitously). Truth and
goodness became the bedrock of purpose and action through the research endeavour.
Whilst ethical guidelines and principles informed and offered direction and a sense of
boundaries, they were seen as a parallel trajectory within the research trajectory. The
reality of qualitative research may seem ‘messy’ and unpredictable to those from a
positivist paradigm, and indeed the reality is that this is often the case. Hence, the
argument for a recognition of the embeddings of ‘ethics as a way of being’ rather than
fixed point within a study.
This paper presents a very ‘real’ account of the messy, cyclical nature of qualitative
enquiry. It offers emerging criteria within qualitative research as a means of offering
ethical process and research ‘goodness’ to ensure robustness within a qualitative
paradigm.
ENCOUNTERS WITH CANCER - NARRATIVES OF CANCER SURVIVORS WITHIN THE
DIAGNOSIS TRAJECTORY.
Presenter Gerard A. Tobin
Lecturer/ Acting Director for Academic & Professional Affairs
School of Nursing & Midwifery
University College Dublin Trinity College
24 D’Olier Street
Dublin 2
Contact Email: [email protected]
Phone: 086 8335197
Abstract
The aim of this paper is to offer the meanings and experience of a group of people
who were given a cancer diagnosis. The power of their stories and the insightfulness
of their narrative provided a rich tapestry from which we as nurses can gain insight.
The discussion will focus on the meanings attributed to their experience of what will
be refereed to as the diagnosis trajectory.
The primary findings are part of a wider study, which explored the experiences of
health care professionals in giving bad news and the impact on recipients and
significant others when the news is broken. The phenomenological study utilised
unstructured interviews, as the main data collection tool.
Recipients (people who received a cancer diagnosis) and significant others (identified
by recipient) were invited to participate. For the purpose of this presentation, the
focus will be on the narrative of the recipient and the meanings which they attributed
to their story.
A number of core themes which emerged were: The Waiting game – ‘knowing and yet
not knowing’; Being seen – ‘more than a breast’; Pretty is important – ‘I need to be
me’; Dismissive – ‘Don’t worry mantra’; .Living the diagnosis – ‘Second wave and
hope for the future’.
Truth and openness were seen as critical to enabling the person to cope. The need to
have ones suspicions acknowledged and not dismissed and the overwhelming cry for
recognition as a person, a mother, a lover and not just a lump or blockage was a heart
cry of many as they shared from the depth of their experience and the reality of the
everyday celebration of surviving.
The study highlights the use of narrative to inform and challenge practice as a
powerful tool and recognises the strength of voice and clarity of experience as
offering methodological and ethical challenges for the nurse and the researcher.
Do Abdominal Aortic Aneurysm Repair Patients Report High Levels of
Satisfaction with Post Operative Pain?
Jennifer Tocher BSc (Hons), PhD
Lecturer
Nursing Studies
University of Edinburgh
Medical School
Teviot Place
Edinburgh
EH8 9AG
Background
Over 3500 patients undergo elective repair of an abdominal aortic aneurysm (AAA)
each year in the United Kingdom (Mercer et al 2004). This is an operation of
moderate to high risk. It has long been established that high levels of satisfaction with
pain management are very often reported in patients despite suffering from severe to
moderate levels of pain (Calvin et al, 1999. Donovan 1983).
Aims
The aim of this study was to establish whether high satisfaction levels and moderate
to high pain levels were reported in patients who had undergone repair of AAA.
A review of the relevant literature highlighted the fact that there had been no such
studies conducted within a similar such homogenous group.
Design
The study set out to establish that there was a link between moderate to severe pain
levels and high satisfaction ratings within the chosen AAA subject group. A three
staged approach to data collection was employed.
Method
In order to give as full an understanding of the phenomena of patient satisfaction and
post operative pain levels a mixed method approach was applied. This involved
quantitative data analysis of pain scores and qualitative interviews with subjects to get
a feel of their lived experience of the operation.
Results
The study demonstrated that patients recorded moderate to high levels of satisfaction
and yet experienced critical levels of pain.
Summary
This study demonstrated that there is indeed an anomaly between satisfaction and post
operative pain experience.
References
Donovan, B. (1983) Patient Attitudes to Postoperative Pain Relief. Anaesthetic
Intensive Care. vol.11. pp.125-129.
Calvin A., Becker H., Biering P. & Grobe S. (1999) Measuring Patient opinion of
Pain Management. Journal of pain and Symptom Management. vol.18(1)
pp. 17-26.
Mercer K G, Spark J I, Berridge D C et al (2004).Randomised clinical trial of
intraoperative autotransfusion in surgery for abdominal aortic aneurysm.
British Journal of Surgery vol. 91: pp.1443-1448.
THE USE OF SIMULATED TECHNOLOGY TO ENHANCE LEARNING
AND TEACHING IN AN UNDERGRADUATE NURSING SCIENCES
PROGRAMME.
Authors:
(1) Marian Traynor EdD, MEd, BSc, RGN
Head of Division
Undergraduate Nursing Sciences
School of Nursing and Midwifery,
Queen’s University Belfast
Medical Biology Centre,
97, Lisburn Road,
Belfast
[email protected]
Telephone 02890975819
(2) Anne Gallagher Msc, BSc, RGN
School of Nursing and Midwifery,
Queen’s University Belfast
Medical Biology Centre,
97, Lisburn Road,
Belfast
[email protected]
(3) Lorna Martin MPhil, BSc, RGN
School of Nursing and Midwifery,
Queen’s University Belfast
Medical Biology Centre,
97, Lisburn Road,
Belfast
[email protected]
(4) Susie Barnes BSc, RGN
School of Nursing and Midwifery,
Queen’s University Belfast
Medical Biology Centre,
97, Lisburn Road,
Belfast
[email protected]
(5)
Billiejoan Rice
MSc, BSc, RGN
School of Nursing and Midwifery,
Queen’s University Belfast
Medical Biology Centre,
97, Lisburn Road,
Belfast
[email protected]
Background
The purpose of this study was to pilot an advanced “Human patient Simulator” (HPS)
as a learning and teaching tool for third year undergraduate nursing students. Clinical
case scenarios were developed to provide nursing students using the HPS with an
opportunity to acquire and refine their nursing skills and to integrate theory with
practice.
Aim and objectives of the study
The aim of this study was to develop and evaluate the use of clinical case scenarios
for third year nursing students using the HPS. The objectives were to promote an
integrated approach to student learning through the use of case scenarios and to
promote the development of a practitioner with the ability to think critically and
analytically.
Design of the study
Third year Adult Branch nursing students (n= 112) were invited to take part in the
study. The study was designed over a nine-day period: ten students per day, five in the
morning and five in the afternoon. Students were randomly assigned to the study and
were asked to access the web for details of the date and time of their session.
The simulated sessions occurred in an area similar to a side ward in the clinical
environment. Students had access to nursing and medical notes and to a telephone to
help them to communicate with other members of the clinical team. A two-way
mirror and a microphone allowed the teaching team to supervise and interact with the
students during the scenarios.
Students were given the scenario and informed that they had fifteen minutes in which
to carry out the appropriate nursing interventions. The nurse teachers monitored the
interventions via the two-way mirror and responded appropriately via the simulator.
Each session was concluded by a fifteen minute debriefing facilitated by the nurse
teachers. This provided the students with the opportunity to reflect on their role, both
as an individual and as a team member.
Data Collection and Analysis
Each participant completed a 21-item questionnaire. Participants could choose one of
five options, from “strongly agree” to “strongly disagree” when responding to each
item. The responses were scored 1 to 5 with a score of 3 being assigned to the
“undecided” group.
Results:
The questionnaires were analysed using SPSS. Results indicate that students strongly
support the use of a HPS as a learning and teaching tool.
References:
Alinier, G Hunt, B and Gordon, R (2004) Determining the value of simulation in
nurse education: study design and initial results. Nurse Education in Practice pp 200207
Devitt, J.H. Kurrek, M.M. Cohen and Cleave-Hogg,D (2001) The validity of
performance assessments using simulation. Anaesthesiology 95, pp 36-42
Cioffi,J (2001) Clinical Simulations: development and valiation, Nurse Education
Today, 21, p. 477-486
THE IMPACT OF DYSLEXIA ON THE CAREER DEVELOPMENT OF
REGISTERED NURSES IN THE UK
Patricia Turnbull Senior Lecturer RGN, BN, MSc, RNT
David Morris Senior Lecturer RGN, MSc, RNT
Both at: Room N212, North Building, Anglia Polytechnic University
Park Road, Chelmsford, Essex. CM1 1LL
Background: The issue of disability in the workplace has been brought sharply into
focus recently (SENDA 2001, Looking Beyond Labels 2000). Historically, people
with disabilities have been discriminated against within the workplace through lack of
recruitment, career progression and working conditions. For dyslexia as a disability,
most literature focuses on difficulties associated with literacy, memory and hand-eye
co-ordination. Yet there is ample work available to suggest positive characteristics of
lateral thinking, enhanced empathic and problem-solving skills, and creativity are
equally prevalent. Dyslexia, then, has the potential to impact on the practice and
progression of the Registered Nurse. The aim of this study is to explore the influence
of dyslexia on the careers of Registered Nurses in the UK.
Design of Study: Questionnaire-based exploratory survey utilising both quantitative
and qualitative data
Sample Selection Methods: Self-selecting participants in response to a national
nursing journal advertising campaign and a web-based information portal.
Data Collection and Analysis: Data were collected through postal and electronic
questionnaire. These are currently being processed using content analysis.
Results: Preliminary results indicate dyslexia has an influence on career
development. Participants considered career progression to be slower than for nondyslexic colleagues. For some, fear of exams and academic work influenced choice of
post-basic education programme. Participants were selective in their decision to
disclose their dyslexia. Support in the workplace was largely informal with little
evidence of structured assistance.
DOH (2000) Looking Beyond Labels: Widening the Employment Opportunities for
Disabled People in the New NHS. Department of Health, London.
HMSO (2001) Special Educational Needs and Disability Act 2001 (amendment)
Chapter 10. HMSO, London.
MAKING PRACTICE BASED LEARNING WORK – Crossing the Rubicon
Chris Turnock, M.Phil., M.Sc., DANS, DPSN, RN
Principal Lecturer,
Academic Registry,
Northumbria University,
Newcastle-upon-Tyne
England
The FDTL Phase 4 project, Making Practice Based Learning Work, aims to make
practitioners more effective at supporting & supervising students in the workplace
across a range of healthcare disciplines. So far the project has:
•
Identified and documented good practice on preparing health care practitioners for
their educational role.
• Developed learning materials for practitioners.
• Evaluated learning materials for practitioners.
• Commenced dissemination of learning materials.
The workshop includes an overview of the project’s current processes and outcomes
before focussing on a participatory exploration of:
•
•
Effective ways to disseminate information about developed learning materials.
Strategies to embed developed learning materials into work based learning
contexts.
The workshop will utilise participants’ experiences in enhancing student learning
within work-based environments to inform the discussion.
Further Reading
Blackwell A, Bowes L, Harvey L, Hesketh A J, Knight P T (2001) Transforming
work experience in higher education. British Educational Review Journal. 27(3):
269-285.
Burgess R, Phillips R & Skinner K (1998) Practice placements that go wrong. Journal
of Practice Teaching. 1(2): 48-64.
Damodaran L, Gordon G, Runcie A (2002) Studying the Effects of Mentoring in
Higher Education. HESDA Briefing Paper 104.
Dick E, Headrick D & Scott M (2002) Practice Learning for Professional Skills: A
review of literature. Scottish Executive. Edinburgh.
Dutton C (2003) Mentoring: the contextualisation of learning – mentor, protégé and
organisational gain in higher education. Education and Training. 45(1): 22-29.
Evans D (1999) Practice Learning in the Caring Professions. Ashgate. Aldershot.
Jowett V & Stead R (1994) Mentoring students in higher education. Education and
Training. 36(5): 20-27.
LECTURERS’ UNDERSTANDING AND EXPEREINCES OF SELFDIRECTED LEARNING AND ITS RELEVANE TO UNDERGRADUATE
NURSE EDUCATION
Name of Author: Maura Cait Walsh
Job Title: Clinical Skills Co-ordinator
Qualifications: R.G.N, R.M, RNT, BNS, MSc (Educ)
Address: Trinity College Dublin 2
Abstract
This qualitative study, using a grounded theory methodology, explored lecturers’
understanding and experiences of self-directed learning (SDL) and its relevance to
undergraduate nurse education. The decision to conduct this study was based on the
need to generate research in this previously unexplored area and to make the
necessary recommendations for change. This research is central to the development of
an overall body of knowledge for the future and is significant, as all nurse educators
today need to clearly understand SDL in order to facilitate the students of the future.
Data were collected through in-depth interviews with five purposively chosen
participants. The transcription of the data and analysis were performed manually.
Maintenance of rigour was achieved by using member checks and peer assessment.
Ethical approval was obtained and the researcher has made every effort to ensure that
the study was ethically and morally sound.
The findings of the study suggest that participants’ understanding of SDL vary and as
a result their experiences of the concept differ considerably. In implementing SDL,
lecturers in nursing become facilitators of learning and require ongoing staff
development in order to facilitate students effectively through the SDL process. The
lack of a consensus definition of SDL and a common preparatory course for lecturers
influences their role as facilitators. Data saturation was not achieved but a type of
saturation was apparent, the sample size was insufficient to establish this suggestion.
Further research is required into this important area of Nurse Education.
A study to investigate the learning needs of nurses working on medical and
surgical wards regarding the care of highly dependent patients.
Authors: Caroline Ward RGN, Dip.N, BSc.N., PG Dip.N (ICU/CCU), MSc student.
Staff Nurse, ICU, Adelaide and Meath Hospital, Tallaght, Dublin 24.
Address: 10 the Park, Athlumney Abbey, Navan, Co. Meath.
Tel: 046 9020549, Email: [email protected]
Gobnait Byrne RGN, BNS (Hons), RNT, MPH, PG Dip Stats
Lecturer, School of Nursing and Midwifery Studies, Faculty of Health
Sciences, Trinity College Dublin.
Abstract:
Literature Review
In Ireland, there is a shortage of critical care beds. The Intensive Care Society (ICSI,
2001) audited critically ill patients’ access to intensive care units (ICUs) in Ireland
and found that 30% of all ICU emergency admissions were refused admission due to
lack of an ICU bed or an ICU nurse. As a result these critically ill patients were cared
for on general wards. A recent unpublished report by the Eastern Region Health
Authority (ERHA, 2004) reviewed critical care services in the Eastern region and
highlighted a severe shortage of High Dependency Unit (HDU) beds. They
recommend that the current complement of HDU beds needs to be increased to eleven
times the existing capacity. Almost half of the acute hospitals in the Eastern region
lack any HDU beds, which provide an intermediate/ step-down level of care between
ICU and the general wards. Therefore, one may infer that in these hospitals, many
highly dependent patients are being cared for on general wards. An audit carried out
in the UK showed that in hospitals without HDUs, 7% of patients on general wards
actually required HDU care (Audit Commission, 1999).
Much of the medical and nursing literature has acknowledged that ward patients are
more highly dependent than they were in the past (Abner, 2000; O Riordain, 2003;
Gibson and Douglas, 2000; Viner, 2002 and Thorne and Hackwood, 2002). A
combination of improved surgical and anaesthetic techniques means that patients who
would have previously been deemed unfit for surgery are now being operated on.
Many procedures that were traditionally only done in ICU are now being carried out
on general wards, such as non-invasive ventilation, epidural analgesia (Abner, 2000
and Audit Commission, 1999).
However, many of the skills needed to care effectively for these highly dependent
patients are not part of undergraduate nurse education in Ireland. The ERHA (2004)
maintains that in order to care for high dependency patients on wards, ward-based
nurses require formal training on aspects of high dependency care. However, the
ERHA does not provide any details as to what the content or format of any such
training should be. As many of the skills necessary to care for this patient group are
not covered in undergraduate nurse training, there is a need for Continuing
Professional Education (CPE), as nurses must adapt their practice to meet the
changing needs of their patients (Storey, 2001). An Bord Altranais (1994) maintains
that continuing education and professional updating is necessary in order to maintain
standards in a health service that is continually changing. Nurses in Ireland have a
professional responsibility to be competent in order to act within their scope of
practice (An Bord Altranais, 2000).
In the UK, many hospitals have set up high dependency skills courses for their wardbased nurses in order to help them care effectively for this patient group. Indeed, one
hospital in the eastern region of Ireland has also set up a similar programme.
However, from the literature, it appears that ICU nurses and nurse educators have
largely determined the content and structure of these courses without any input from
the ward-based nurses (Viner, 2002; Thorne and Hackwood, 2002 and O Riordain,
2003). No published literature has asked the nurses working on general wards what
their learning needs are in relation to the care of highly dependent patients. A learning
needs assessment of ward-based nurses is necessary in order to aid with the planning
of any CPE relating to this patient group. A learning needs assessment is necessary in
order to ensure the relevance, efficiency and effectiveness of any in-service education
(Office for Health Management, 2002).
Learning needs are gaps in knowledge that exists between a desired level of
performance and the actual performance, in other words the gap between what
someone knows and what someone needs to know (Kitchie, 1999). Kiger (1995)
maintains that different people perceive these needs differently and that learning
needs may change over time. The literature outlines many methods of carrying out
learning needs assessments. The staff survey method is the most common method
used and involves surveying an entire target group or a sample of a specific group
(Williams, 1998).
In the UK Coad and Haines (1999) audited requests for education from ward-based
nurses caring for highly dependent patients and found that respiratory and
cardiovascular themes dominated. Nurses requested education on tracheostomies,
Continuous Positive Airway Pressure (CPAP), arterial blood gases. They also
requested education on haemodynamic assessment, fluid and electrolyte balance,
central lines and drug therapies. Coombs and Dillon (2002) audited one UK trust’s
critical care outreach team service. Similar to Coad and Haines (1999) they found that
respiratory and cardiovascular themes dominated the requests for advice sought from
the outreach team by ward-based nurses.
Methodology
This study defines a highly dependent patient as “one who has recently been
transferred from an ICU/HDU, ones who requires close observation due to a potential
or actual deterioration in one or more organ systems, or a postoperative patient who
requires close observation for more than 12 hours “ (Adapted from UK Department of
Health, 1996). The aims of the study were to identify the learning needs of nurses
working on medical and surgical wards regarding the care of highly dependent
patients and to explore whether there was a relationship between length of experience
as an RGN and amount of learning needs identified. A further aim was to determine
what type of educational input ward-based nurses preferred with respect to their
identified learning needs.
This study is a descriptive exploratory quantitative study and took place in a major
academic teaching hospital in the eastern region. A census sample of all RGNs who
were working as staff nurses on the medical and surgical wards of the study hospital
was used in the study. Access to the sample group was obtained by seeking the
approval of the hospital’s ethics committee as well as the Director of nursing.
Data collection was by means of self-report using a questionnaire designed by the
researcher. Questionnaires were distributed to all medical and surgical wards in the
hospital accompanied by a participant information sheet. Anonymity and
confidentiality were assured. The participants returned the completed questionnaires
to a sealed box left on each ward. Data collection occurred over a five-week period.
The reliability and validity of the questionnaire was established prior to the start of the
study. A pilot study was carried out on one ward and minor adjustments made to the
questionnaire following this.
The sample size for this study was 237 nurses and a response rate of 38% (n=89) was
achieved. The questionnaires were coded and analysed using the Statistical Package
for Social Sciences (SPSS) Version 12. Combinations of descriptive and inferential
statistics were used. Tests of normality on the data indicated a non-normal distribution
so non-parametric inferential statistics were used.
Findings
The majority of the sample was female and 75% were aged 29 years or less. 16.9% of
the sample had less than one years’ experience as an RGN while 36% had between 1
and 5 years experience. There was no statistically significant difference between the
learning needs of those nurses who were less than 1 year qualified and those who
were longer qualified.
21.3% of the participants were working for less than 1 year in the study hospital.
75.3% had a diploma or degree in nursing. 37.1% of the participants had done their
undergraduate nurse training outside the Republic of Ireland.
The number of learning needs identified by participants varied according to the ward
they worked on. Nurses who worked on wards that received highly dependent patients
infrequently had a greater number of learning needs than those nurses that worked on
wards that received these patients regularly. The respiratory ward had the most
number of highly dependent patients but their staff nurses had the least amount of
educational needs.
All except two participants reported caring for highly dependent patients in the
previous twelve months. 40.4% of participants reported caring for more than 20
highly dependent patients in the previous year.
The top ten learning needs identified by the participants were: CPAP, non-invasive
ventilation, analysis of arterial blood gases, nursing management of severe sepsis,
care of chest drains, shock types and management, tracheostomy care, care of patient
with epidural, cardiac monitoring and cardiovascular assessment.
Care of central line was the highest ranked learning need followed by non-invasive
ventilation, cardiovascular assessment and tracheostomy care. Participants favoured
supervised practice or competence assessment for respiratory topics primarily and
preferred theory sessions on most other topics.
This study highlighted a lack of in-service in the study hospital regarding high
dependency topics. The numbers of nurses who received any education on any of the
topics in the past year ranged from just 9% to 42%. Some newly qualified nurses
commented that they had not received any education since finishing college.
Interactive e-learning improves examination performance for 1st Year Nursing
students in the biosciences.
Warmington, S1; Breakwell, N2. & McKee, G3.
Department of Physiology, Trinity College Dublin1;
Revfacto Limited, Ranelagh, Dublin 62 and
School of Nursing and Midwifery, Trinity College Dublin3.
Entry level nursing students find the biosciences especially challenging. There are a
number of contributing factors to this difficulty including poor pre-existing
knowledge and level of class attendance (McKee, 2000). Increasing retained
knowledge of core anatomy and physiology is important since it forms the foundation
for subsequent courses and, ultimately, can impact patient outcomes (Aiken et al,
2003).
1st year Nursing and Midwifery students at Trinity College Dublin are provided with a
series of interactive revision tools designed to complement existing teaching resources
and to improve examination performance in end of year Biological Science exams.
These inter-linked revision tools included revision lectures in the form of animated
movies, tutorial style exercises, practice multiple choice exams with tutorial feedback
and examination preparation in the form of interactive model short question and essay
style examination answers.
For ethical reasons all 233 students were given access to the revision tools. Two
samples were selected based on the amount of usage of the revision tools. “NonUsers” did not use the revision tools at all or logged in to the system on 5 or less
occasions (n = 177). “Users” logged in to the system on 7 or more occasions, with a
range of 7 to 376 login occasions (n = 56).
Login data was compared with academic performance throughout the year including
continuous assessment, MCQ exam, Short Answer Question (SAQ) Exams and final
total examination score. The results were analysed with the students’ t-test. In all
comparisons Users scored significantly higher grades than Non-Users. For the overall
year grade, Users scored an average of 64.59 ± 1.49 compared to 57.74 ± 1.06 for
Non-Users (p = < 0.01). Of importance is the fact that while Users performed better
than Non-Users, this difference was only significant when the examination questions
related directly to content contained within the revision packs. For example, on an
SAQ relating to the cardiovascular system, for which interactive revision content was
available, Users (mean = 8.51 ± 0.31) performed significantly better than Non-Users
(mean = 7.25 ± 0.26, p = <0.01), whereas on an SAQ relating to the nervous system,
for which no revision content was available, Users (mean = 7.60 ± 0.31) performed
better than Non-Users (mean = 7.03 ± 0.22, but this difference was not significant (p
= 0.15).
It can be concluded from these data that the examination performance of entry level
nursing students in the biological sciences is significantly improved when engaging
resources that allow flexible, self-directed and on-demand learning are used to
complement existing teaching.
McKee, G. Why is biological science difficult for first-year nursing students? Nurse
Educ Today. 2002 Apr;22(3):251-7
Linda H. Aiken, Sean P. Clarke, Robyn B. Cheung, Douglas M. Sloane, Jeffrey H.
Silber, "Educational Levels of Hospital Nurses and Surgical Patient Mortality,"
Journal of the American Medical Association (JAMA), Vol. 290, September 24, 2003,
1617-1623.
BRIDGING THE THEORY-PRACTICE DIVIDE IN THE ACQUISITION OF
MEDICATION DOSAGE CALCULATION SKILLS. E-LEARNING SOLUTIONS
THROUGH THE DESIGN AND DEVELOPMENT OF AUTHENTIC WORLD
LEARNING ENVIRONMENTS.
Dr Keith W. Weeks (Principal Lecturer, University of Glamorgan, Pontypridd, Wales)
Norman Woolley (Principal Lecturer, University of Glamorgan, Pontypridd, Wales)
George McWhirter (Lecturer, Cardiff University, Cardiff, Wales)
Nurses were first reported as having difficulty with math calculation 65 years ago (Faddis,
1939). Evidence from international nursing literature and the DOH (2004) indicates that
medication dosage calculation errors continue to be widely committed by health care
professionals in clinical practice. This paper summarizes the background to the problem and
the classification of three key dosage calculation error types identified during previous
research (Weeks et al 2000, Weeks et al 2001a, Weeks et al 2001b).
Evidence is provided of the relationship between these errors and curricula which divorce
theory from authentic dosage calculation problem-solving activities. The paper will describe
how ‘proceduralisation’ of dosage calculation in clinical practice commonly obscures expert
problem-solving techniques from the student. We contend that these education and clinical
practices manifest a distinct theory-practice divide.
We describe and illustrate how: constructivist theories of learning underpin an e-learning
solution through the design and development of an Authentic World learning environment;
and how learning occurs through:
•
Modeling of authentic features of medication dosage problems.
•
Promoting understanding of expert problem-solving processes via computer modeling
of the relationship between dosage problems and relevant formulae and equations.
•
Promoting development of essential computation skills via interactive tutorials.
•
Authentic diagnostic assessment of student understanding of dosage and computation
problems.
Following a call for a national strategy to address the problem of poor calculation skills in
clinical practice (Sabin, 2001), we propose that the e-learning program provides the
infrastructure for an international learning, teaching and assessment programme within this
domain.
References
Department of Health (2004) A scoping study to describe interventions used to reduce errors
in calculation of drug doses:
http://www.publichealth.bham.ac.uk/psrp/pdf/Paediatric%20medication%20errors.doc
accessed on Feb 2nd 2004
Faddis, M. (1939). Eliminating errors in medication. American Journal of Nursing, 39,
1217.
Sabin (2001) Competence in Practice Based Calculation: Issues for Nursing Education:
A critical review of the literature. London LTSN
Weeks K.W. (2001) Setting a foundation for the development of medication dosage
calculation problem solving skills among novice nursing students. The role of constructivist
learning approaches and a computer based ’Authentic World’ learning environment.
Unpublished Ph.D. thesis. May 2001. University of Glamorgan.
Weeks K.W., Lyne P. & Torrance C. (2000) Written drug dosage errors made by students:
the threat to clinical effectiveness and the need for a new approach Clinical Effectiveness in
Nursing 4, 20-29
Weeks K.W., Lyne P., Mosely L. & Torrance C. (2001) The strive for clinical effectiveness
in medication dosage calculation problem solving skills: the role of constructivist theory in
the design of a computer-based ‘authentic world’ learning environment. Clinical
Effectiveness in Nursing 5, 1-8
Exploration of the Interaction between Pregnant Women with Symphysis Pubis
Dysfunction (SPD) and Health Care Professionals
Vanda K Wellock (Public Health Midwife, Sure Start Programme, Manchester);
Margaret A Crichton (Lecturer in Midwifery, The University of Manchester);
Linda McGowan (Lecturer in Women’s Health The University of Manchester).
Background: The condition of Symphysis Pubis Dysfunction (SPD) may be defined as an
abnormal stretching of the pubic joint during childbirth (Wellock 2002). The physiological
non-pregnant pelvic gap is thought to measure 4-5 mm. Any further separation of 5-9 mm
may be confirmed by X-ray or ultrasound (Lindsay et al 1988).
Possible theories for regarding the causation of this condition are numerous but one of the
most frequently discussed concepts is relaxin. However, whilst some researchers argue that
relaxin is responsible for the enhanced separation of the symphysis pubis, there is little
evidence to support this concept (Kristiansson 1996); yet some authorities still quote this
hormone as a probable cause for the symptoms suffered.
It would appear that SPD is on the increase in several areas of the United Kingdom. A study
in Leeds (UK) found an incidence of 1:36 (Mason et al 2000) while in a smaller study in
Manchester (UK) the incidence was found to be 1:27 (Wellock 2002).
Past research has focussed on understanding causality and extent of this condition; hence the
research has been primarily medical and/or epidemiological in nature. There has been a
paucity of research concerning the women’s own experience of living with, and managing,
SPD.
Aims of the Study: The aim of this study was to explore pregnant women’s perceptions of
SPD and the effect on their quality of life during pregnancy and their experiences with health
care professionals.
Methods:
Design:
A qualitative approach was chosen with emphasises on the Hermeneutic approach, utilising
the phenomenological method. This particular philosophical tradition was chosen in order to
capture the “lived in” or “essence” of the experience for each woman. Hermeneutics ensures
that the researcher can reach “the nature of understanding” and make a difficult issue into a
more comprehensive whole and thereby make it more easily understood. It goes further than
describing a phenomenon and aims to explore a deeper understanding of the human
experience. The authors also favoured the Heideggerian approach to phenomenology, since
he did not feel that “bracketing” was a hindrance but that any preconceptions would aid
understanding and add to the richness of the research.
Procedure:
Ethical approval was obtained prior to conducting this study. Women were interviewed using
a semi structured interview schedule. The interviews took place at three time points at initial
diagnosis, thirty-six weeks gestation and six weeks post delivery during between March 2003
and March 2005. It should be noted that the time of diagnosis was variable, this ranged from
18 weeks to 38 weeks gestation. Twenty-seven women recruited to the study and there were
no refusals or withdrawls, this resulted in a total of fifty-one completed interviews. Women,
who were referred to the Physiotherapy Department with probable SPD, were assigned to one
of the four categories of SPD mild, moderate, severe or other, by the physiotherapist. In order
to access a wide range of experiences all of these of women were invited to participate in the
study. The women were given a specific information sheet which outlined the study. This
was followed-up by a phone call to the woman from the two researchers who were
conducting the interviews (first and second authors), to answer any outstanding questions and
queries. Women were interviewed in a place of their choosing usually home, and informed
consent was obtained prior to each interview. The women were interviewed on two or three
occasions, depending on their gestation at the time of recruitment to the study. There were
three women interviewed on three occasions, seventeen interviewed twice and eight
interviewed once only.
Analysis:
All interview tapes were transcribed verbatim. Analysis was informed by the
phenomenological tradition, the specific method of analysis chosen was that of who
recommends an analysis framework of ‘seven steps’, these include: 1) collection of data from
participants 2) detailed examination of interview transcripts 3) extraction of phrases directly
related to the phenomenon 4) consideration of the meanings of these phrases 5) extraction of
themes from interpretation of the phrases 6) themes then become a description of
phenomenon and finally 7) return to participants to check for trustworthiness. Emergent
themes and sub themes were identified and explored.
Findings:
There were four main themes and several sub-themes that emerged from the study. One of the
main themes was ‘Interaction with Health Care Professionals’ and that is what we will
present today.
The main health care professionals identified in the study by the women were midwives,
general practitioners/doctors and physiotherapists. There were a range of positive and
negative comments about each of the professionals from the women. The majority of women
were satisfied with their care but felt that there was room for improvement
“…Whatever happened in that hospital has been brilliant…they were up to the fact that I had
symphysis pubis dysfunction…” VM13
Interaction with Midwives
On a positive note,
“…They all seemed very concerned…there wasn’t anything like, ‘don’t worry about it, it’s
just general aches and pains’…I didn’t want to be a nuisance…” VM45
On a more negative note,
“…I saw the midwife at the surgery and she was trying to feel the baby and I was crying
because it was hurting…she was feeling low down and it was really …really sore on
symphysis pubis…” VM43
Interaction with Doctors
The women appeared to have some difficulty in explaining the severity of pain to the doctors:
“…I went to the GP (general practitioner) and explained about the pain and she said ’…if
you’re in that much pain why don’t you go to casualty?’…I was stuck inside all day…and I
couldn’t move…and she said…’are you getting depressed?’…and I said, well, I am depressed
that you have dragged me all the way here…the doctor was no good at all…” VM44
Some of the women sought out female doctors in the hope that they would be more
sympathetic however, as is evidenced by the above statement, this was not always the case.
The attitude of the health care professional seemed to be more important than the gender or
qualification.
“…a particular doctor was good, better than the midwives…” VM12
On some occasions a more negative view was expressed by doctors, this was largely because
the pain the women felt was so severe and debilitating it was difficult to explain. When the
women present to some doctors they receive a negative response.
“…this doctor said’ other than SPD, are you coping?’…and something went inside me at the
word coping and I screamed at him...’ if sitting on the kitchen floor at 3am with a knife in my
hand thinking…if I put a cut in here, they will have to finish the job…and if that’s coping then
I’m coping’…he had to go away and find someone to calm me down…”VM11
There appeared to be more emphasis placed on conditions by health care professionals that
are known and are related or impacting on delivery:
“…it’s more on the lines of…ehm…the rhesus antibodies side and it’s how you’re getting on
with that…but it’s not affecting me and my symphysis pubis dysfunction was…”VM32
Interaction with Physiotherapists
On a very positive note:
“…think the world of (name of physiotherapist)…she gave me advice…referred me to a pain
clinic…and continues to be supportive…” VM19
However, the long wait for an appointment to the department proved to be very distressing
for many women:
“…she said she could put me down for it (an appointment) but there would be no point…by
the time it came through…there is a long wait for appointments…” VM30
On a negative note:
“… the physio was probably testing my physical limits, well I was in agony for two weeks…”
VM44
“…what annoys me more than anything really…is physio’s. You think they’ll do something
but they can’t...” VM40
Key Findings
•
•
•
Women with symphysis pubis dysfunction appear to have a range of unmet needs
The most profound finding was the way women’s rich narrative described their pain
and the detrimental effects on quality of life
It appeared that women became dissatisfied with health care professionals when
accounts of their ‘reality’ of pain was rejected and they felt negatively labelled.
Implications for practice
Health care professionals, particularly midwives must raise awareness of the effects of
symphysis pubis dysfunction. Researchers must disseminate the findings of studies using a
multi-disciplinary approach.
Guidelines need to be produced and updated in order to help manage the condition.
Training packages must include the social and psychological effects of symphysis pubis
dysfunction so that midwives are empathic and supportive of women.
Last Sentiment
“…everybody associates the aches and pains with pregnancy…it’s far worse…and the
consultant…she explained to me with her fists, about your pubic bone, made it sound like I
was lucky because when I was giving birth it would open up my pelvis that little bit more…I
don’t have to have a caesarean…thought, what am I here for? I need help…I was talking to
her…ladies stories on the internet…she said ‘you know more about it than I do’ and
laughed…how does nobody know? Hasn’t anyone spoken up for these women…how isn’t
someone waving a banner and saying, why should we have to put up with this...?”VM44
References
Colaizzi,P.F (1978) Psycholoical Research as the Phenomenologist Views it. In: Valle,R &
King,M (ed) Existential phenomenological alternatives for psychology. Pgs 48 – 71. Oxford
University Press. Oxford.
Kristiansson,P. Svardsudd,K& Schoultz,B (1996) Serum relaxin, symphyseal pain and back
pain during pregnancy. American Journal of Obstetrics & Gynaecology. No 175. Pgs 1342 –
1347.
Lindsey,R.W.Leggon,R.E.Wright,D.G.Nolasco,M.D(1988)Separation of the symphysis pubis
in association with childbearing. Journal of Bone Joint Surgery. No70A (2). Pgs 289-292.
Mason,G&Pearson,A(2000) Symphysis Pubis Dysfunction. Journal of the Association of
Chartered Physiotherapists in women’s Health. No 87. Pgs 3-4.
Wellock, V.K (2002) The ever widening gap- symphysis pubis dysfunction. British Journal
of Midwifery. Vol 10. No 6. Pgs 348 – 353.
COMMUNITY MENTAL HEALTH POLICY – A CASE STUDY IN
CORPORATE AND ‘STREET LEVEL’ IMPLEMENTATION
Dr John Wells PhD, MSc, BA (Hons), PGDip (Ed), RNT, RPN
Head of Department
Department of Nursing
Waterford Institute of Technology
Waterford
Ireland
+ 353 51 845539
[email protected]
The degree to which inter- and intra-personal feelings and conflicts influence health
care delivery by clinicians is increasingly recognised as a central concern of policy
implementation (Fitzgerald et al., 2003). This paper reports upon a study that explored
the influence on implementation of views on policy held by individual clinicians
within two Community Mental Health Teams (CMHT) and their relationships with
local managers in one mental health trust in London. Drawing upon Sabatier’s (1999)
analytical recommendations, the theoretical work of a number of policy analysts was
utilised. However, Lipsky’s (1980) theory of ‘street level bureaucracy’ and Fisher’s
work (1998) on decision heuristics were particularly utilised.
A qualitative case study design was employed. National and local policy documents
were examined to identify contextual information. A sample of managers (N= 8),
local commissioners (N=3) and a number of clinicians from two CMHTs (N= 17)
were interviewed and observed in their operationalisation of mental health policy.
Four group interviews were held (N=14) to provide further perspectives on the issues
of interest. Interview and observational data was transcribed, entered into a qualitative
data analysis computer package and analysed utilising the Frameworks Approach
(Ritchie and Spencer, 1994).
It was found that a number of managers and clinicians exhibited similar
implementation perspectives on policy issues. A number of respondents seemed to
employ a set of heuristics that could be organised into an interacting ‘economic’ and
‘risk’ schemata. Managers utilised this schemata within a corporate perspective whilst
a number of clinicians utilised it within a context of personal gain and loss. It is
argued that the employment of these schemata affected the response of each group in
terms of prioritisation of policy. This prioritisation was influenced by the nature of the
‘audience’ that needed to be satisfied that policy was implemented. The result was
that policy was implemented with regard to what was ‘sufficient’ rather than absolute
in terms of ‘audience’ needs.
REFERENCES
Lipsky, M (1980) Street Level Bureaucracy Plenum Press New York
FitzGerald, L., Ferlie, E., Wood, M. and C. Hawkins (2002) 'Interlocking Interactions:
the Diffusion of Innovations in Health Care', Human Relations, 55(12): 1429-1450
Fisher, C.M. (1998) Resource Allocation in the Public Sector – Values, priorities and
markets in the management of public services London Routledge
Ritchie, J.; Spencer, L. (1994) Qualitative data analysis for applied policy research In
Bryman, A.; Burgess, R. (eds.) Analysing Qualitative Data London Kegan Paul Ch.9,
pp. 173-194
Sabatier, P. (1999) The Need for Better Theories In Sabatier, P. (ed.) Theories of the
Policy Process Oxford, Westview Press, Ch.1, pp5-16
THE CARING DIMENSION IN NURSE EDUCATION: A HERMENEUTIC
ENQUIRY OF STUDENTS NURSES MEANING AND EXPERIENCE OF
CARING
Jacqueline Whelan
Lecturer in Professional Nursing Studies R.G.N., R.C.N., B.N.S. (HONS.), R.N.T,
MSc. (Nursing) London
Faculty of Health Sciences,
School of Nursing and Midwifery Studies,
University of Dublin,
Trinity College,
24, D’Olier St,
Dublin, 2.
The primacy of caring in nursing has been acknowledged with universal acceptance as
an important concept in understanding and substantiating the discipline of nursing
(Roach, 1984; Leninger, 1989; Kirby and Slevin, 1992; Watson, 1999). Although
caring is accepted as an inherent core value that is characteristic of nursing practice
and nursing education (Kahn and Steeves, 1988; Grigsby and Megel, 1995), caring
remains elusive and is largely unexplored from an educational perspective (Cohen,
1993; Paterson and Crawford, 1994). This paper reveals the nature and meaning of
caring from the perspective of General Nursing Students enrolled in a higher Diploma
Programme. The lived experiences of a combination of 10 students (male and female)
as they learned to care is the focus of this phenomenological research study with a
view to unraveling the meaning and experiences of caring in both academic and
clinical environments during students educational experiences.
It is incumbent upon all nurse educators to recognize and acknowledge the
significance and meaning of caring in nursing as a serious academic concern and to
concern themselves with effective ways of preparing students to become caring
practitioners of nursing (Appleton, 1990). Leninger (1988b) asserts that concepts,
practices and principles related to human care have not been established as a normal
expectation of nursing. There is limited knowledge on how students come to know
caring and perceive how caring occurs (Hanson and Smith, 1996, p.105). There is a
paucity of research which relates to the meaning and experience of caring as it is
interpreted and understood from the perspective of the nursing student in academic
environments (Hughes, 1992; Nelms et al, 1993; Hanson and Smith, 1996; Redmond
and Sorrell,1996; Van der Wal, 1999).
A qualitative phenomenological research design was adopted for the purposes of
conducting this study, to illuminate student perspectives of the meaning and
experience of caring in nursing education. The main research questions explored the
phenomenon of caring by asking, ‘As a student what is caring for you?’ (‘What does
caring mean to you and what does it represent for you? ’) followed by ‘What is your
experience of caring as you experience it in your student life?’. A list of probing
questions concerning how students learn to care, how caring is communicated,
knowledge and teaching of caring, and personal and clinical caring experiences
uncovered meanings attributed to the phenomenon in question.
Purposive sampling was utilised for selecting participants for the study. Semistructured interviews were conducted for the purposes of data collection. Transcripts
of the tape recorded interviews were analyzed using Van Manen’s framework to
uncover thematic aspects.
One central theme ‘ meaning and experience of caring ’ and three related themes of
‘learning to care’, ‘teaching of caring’ and ‘building confidence’ were drawn from
data using Van Manens (1990b) method. All students expressed difficulty in
articulating what caring meant to them as well as the process of caring contained
within the participants’ experiences. Caring was viewed as an innate characteristic
and something that primarily stems from family and life experiences. Meaning is
limitedly identified through educational experiences. There was mixed views
regarding whether caring can be taught or learned. However it is the nature of family
and clinical experiences to which students are exposed where greatest meaning is
found. Implications for nursing education, practice, management and research are
described.
References
Appleton, C. (1990) ‘The meaning of human care and the experience of caring in a
university school of nursing’, in Leninger, M.M. and Watson, J. (editors) The caring
imperative in nurse education, New York: National League for Nursing, pp.77-94.
Cohen, J. (1993) Caring perspectives in nursing education: liberation, transformation
and meaning, Journal of Advanced Nursing, 18 (4): 621-626.
Grigsby, K.A. & Megel, M.E. (1995) Caring experiences of nurse educators, Journal
of Nursing Education, 34 (9): 411-418.
Hanson, L. & Smith, M. (1996) Nursing students’ perspectives: experiences of caring
and not so caring interactions with faculty, Journal of Nursing Education, 35 (3): 105112.
Hughes, L. (1992) Faculty-student interactions and the student perceived climate for
caring, Advances in Nursing Science, 14 (3): 60-71.
Kahn, D.L. & Steeves, R.H. (1988) Caring and practice: construction of a nurse’s
world, Scholarly Inquiry for Nursing Practice, 2 (3), 210- 216.
Kirby, C. & Slevin, O. (1992) ‘A new curriculum for care’ in Slevin, O. and
Buckenham, M. (editors) Project 2000 Innovations in the nursing curriculum: the
teachers speak, Edinburgh: Campion Press Ltd, pp.57-88.
Leninger, M.M. (1988b) ‘The phenomenon of caring: importance, research questions
and theoretical considerations’, in Leninger, M. M. (editor) Caring : an essential
human need , Detroit : Wayne State University Press, pp.3-15.
Leninger, M.M. (1989) ‘Historic and epistemologic dimensions of care and caring
with future directions’, in Stevenson, J.S., and Tripp- Reimer, T. (editors) Knowledge
about care and caring: state of the art and future developments, Missouri: American
Academy of Nursing, pp.5-17.
Nelms, T.P., Jones, J.M. & Gray, D.P.(1993) Role modeling: a method of teaching
caring in nursing education, Journal of Nursing Education, 31(1):18-23.
Paterson, B. & Crawford, M. (1994) Caring in nursing education: an analysis, Journal
of Advanced Nursing, 19 (1): 164-173.
Redmond, G.M. & Sorrell, J.M. (1996) Creating a caring learning environment,
Nursing Forum, 31 (4), 21-27.
Roach, M.S (1984) Caring: the human mode of being, implications for nursing,
Toronto: Faculty of Nursing, University of Toronto.
Van Manen, M. (1990b) ‘Investigating experiences as we live them’ in Van Manen,
M. Researching lived experience, SUNY series, USA: State University of New York
Press, pp.52-76.
Van Manen, M. (1990c) ‘Hermeneutic phenomenological reflection’ in Van Manen,
M. Researching lived experience, SUNY series, USA: State University of New York
Press, pp.77-109.
Van der Wal, D. (1999) Furthering caring through nursing education, Curationis, 22
(2), 62-71.
IMPROVING PRACTICE THROUGH INDIVIDUALISED PROGRAMMES
Ms Mriga Williams MSc in Practice of Education, Cert. Ed, BSc (Nursing),
RNT, RGN
Senior Lecturer
Institute of Health and Social Care
APU
Bishops Hall Lane
Chelmsford
Essex CM1 1SQ
England
+ 44 1245 493131 extn 4135
[email protected]
Ms Sue Soper BSc(Hons) Professional Studies in Nurse Education, Cert Ed.
RNT, RCNT, RGN
Principal Lecturer
Institute of Health and Social Care
APU
Bishops Hall Lane
Chelmsford
Essex CM1 1SQ
England
+ 44 1245 493131 extn 4160
[email protected]
This abstract sets out to describe an innovative individualised open learning pathway.
The award is a step on – step off pathway leading ultimately to an Honours degree or
any stage between; certificate, diploma, or straightforward degree. Existing wellestablished University processes, such as open, distance and e-learning, negotiated
awards and admission with credit have underpinned the development of the pathway.
An individual’s professional requirement to engage in continuing professional
development is often met with resource constraints. Recognising these issues and in
order to meet the Government targets of widening access and participation (HEFCE
1996, Dearing 1997, Clarke 2003) and promotion of multidisciplinary learning (DoH
2000), the BSc (Hons) Health Care Practices Pathway was developed.
The pathway does not hold professional recognition and is therefore accessible to any
candidate with current or recent health care experience. Flexibility lies in the length of
time over which a part time award can be undertaken and the nature of the modules
available, which allow students to link theory to practice effectively. Action research
incorporating a team approach and ongoing evaluation ensures the provision of
quality education. Student support is provided by library access at a distance, use of
WebCT, face to face, e-mail and telephone tutorials.
Quality care delivery is sought by continuing professional development (Fryer 1997,
UKCC 1997) as a vital component of Clinical Governance within the National Health
Service (NHS Executive 1998). Whilst in the wider educational field, the Government
agenda to promote inter-professional and life long learning (DoH 2001), aims to
improve working lives and the economy through increased productivity. In the current
political and economic climate, this pathway can provide for both NHS and
educational trends, which are driving forces in the health care arena.
REFERENCES
Clarke C 2003 The Future of Higher Education. Department for Education and
Skills, London
Dearing R 1997 Higher Education in the Learning Society. HMSO London
Department of Health (DOH). 2000 The NHS Plan: A Plan for investment, a plan for
reform. The Stationery Office, London:
Department of Health (DOH). 2001 Working Together, Learning Together. A
framework for lifelong learning in the NHS. Available:
http://www.doh.gov.uk/lifelonglearning
Fryer R 1997 Learning for the Twenty –first Century. HMSO, London
Higher Education Funding Council for England 1996 Widening Access to Higher
Education. A Report by the HEFCE’s Advisory group on Access and Participation.
HEFCE, Bristol,
NHS Executive 1998 A First Class Service, Quality in the new NHS, NHS Exec.
London
United Kingdom Central Council for Nursing, Midwifery and Health Visiting. 1997
Post Registration Education and Practice. UKCC London
ISSUES AND CONCERNS OF NEOPHYTE ADVANCED HEALTH CARE
PRACTITIONERS
Dr Graham R. Williamson BA (Hons), MA, PhD, RGN
Senior Lecturer, Adult Nursing
Faculty of Health and Social Work
University of Plymouth
Exeter Centre
Earl Richards Road North
Exeter
Devon EX2 6AS
England
+ 44 1392 457150
[email protected]
Background
Health care professionals’ roles are currently being transformed in the UK as a result
of government policy aimed at reducing the traditional demarcations between the
skills and tasks of medicine and other professions (DoH, 2000). For many health care
professionals, this is likely to mean that they come to occupy innovative roles, are
involved in developing aspects of service delivery and in commissioning new patientfocused services (Marsden et al, 2003). There is thus currently a policy commitment
to equip non-medical professionals with a range of skills previously associated with
medicine, as a central concept in the drive to reduce junior doctors’ hours, increase
the responsiveness of services and of practitioners’ autonomy, and as part of NHS
Lifelong Learning strategy. This will benefit both employers, because it will
encourage recruitment and retention, and existing staff, who will be able to develop
new skills in order to develop new roles (DoH 2003). It is possible that undertaking
such advanced roles might have an impact on the occupational stress of health care
practitioners, and that there may be some impact on this as a result of undertaking
master's level preparation.
Study Design
In order to explore these issues and concerns amongst multi-disciplinary health care
staff working in the UK NHS, intent on developing careers in advanced practice roles,
we undertook focus groups in a qualitative study with students beginning a Masters’
level programme of educational preparation.
Sample selection methods
All students from two cohorts (n=50) enrolled on the MSc Advanced Health Care
Practice at the University of Plymouth were invited to attend two focus groups. A
total of 16 students attended the focus groups, eight in each group.
Data collection and analysis
Data were collected in two focus groups, moderated by an experienced qualitative
researcher. These focus groups were audio-recorded and the tapes subsequently
transcribed, analysed and key themes will be discussed and agreed within the team,
adding to the trustworthiness and credibility of the findings.
Brief results
Data analysis is currently ongoing, but preliminary analysis indicates that students
were concerned with
•
Service development opportunities
•
Personal and professional development opportunities (particularly improving
knowledge and skills)
•
Time pressures (work/study/home) and related stress
•
Conflicts with work colleagues
STIMULATING RESEARCH AND DISSEMINATION IN NURSING
Dr Graham R. Williamson BA (Hons), MA, PhD, RGN
Senior Lecturer, Adult Nursing
Faculty of Health and Social Work
University of Plymouth
Exeter Centre
Earl Richards Road North
Exeter
Devon EX2 6AS
England
+ 44 1392 457150
[email protected]
A key issue in evidence-based practice is overcoming barriers to successful
implementation of research findings. Also important are uncovering and
disseminating innovative clinical research and service development.
At the Royal Devon and Exeter NHS Foundation Trust, we established the
Respiratory Service Development Group in 2004 with the intention of facilitating
•
dissemination of innovative service developments
•
dissemination of research outcomes
•
planning future clinical research activities.
A wealth of activities are currently being undertaken, including
•
Running innovative nurse led services
•
Access to services project (IDEA) and resulting service developments
•
Inhaler compliance audit project
•
Long Term Oxygen Therapy project
•
Arterial blood gas training competencies project
•
Issues in bovine TB screening
•
Home IV therapy project for cystic fibrosis patients
This presentation will review the literature on barriers to successful dissemination and
implementation of innovative research and development activities, and will also
briefly outline findings from the Ideal Design of Emergency Access (IDEA) project.
This used Continuous Quality Improvement methodology to redesign and improve
services for respiratory patients at this NHS Foundation Trust, illustrating that key to
successful service development in health care is local support and facilitation
(Kajermo et al 2000, 2001; Parahoo, 2000)
REFERENCES
Kajermo, et al (2000): Perceptions of research utilization: comparisons between health
care professionals, nursing students and a reference groups of nurse clinicians.
Journal of Advanced Nursing 31(1): 99-109
Kajermo et al (2001): Nurses’ experiences of research utilization within the
framework of an educational programme. Journal of Advanced Nursing 10(671-681).
Parahoo, K (2000): Barriers to and facilitators of research utilization among nurses in Northern Ireland.
Journal of Advanced Nursing. 31(1): 89-98
Practice Education Facilitators
Ms Carol Dickie RGN
Practice Education Facilitator
Lister Street
Crosshouse Hospital
Kilmarnock
Ayrshire
Scotland
Ms Karen Wilson RGN
Practice Education Facilitator
Heathfield House
Heathfield Road
Prestwick
Ayrshire KA6 9DX
Scotland
[email protected]
As part of the ‘Facing the Future’ (D.O.H. 2001) agenda and the commitment to
recruiting and retaining more student nurses, the Scottish Executive Health
Department, NHS Education for Scotland, Higher Education Institutions and NHS
Boards have invested in the introduction of new roles to support practice education.
Practice Education Facilitator’s (P.E.F’s) are a new initiative introduced as a result of
the recognised gap between theory and practice in student nurse education. This
recognition highlights the need to support and develop practice-based learning.
P.E.F’s are practitioners who are committed to the ongoing education and continual
professional development of all mentors, newly qualified nurses, and nursing students.
In partnership with our clinical and educational colleagues this is achievable through
the process of facilitation, co-ordination, and support. Therefore the P.E.F.`s aim in
NHS Ayrshire and Arran is to identify opportunities for learning and continuous
development in the clinical environment.
The role of the P.E.F. within NHS Ayrshire and Arran is “to equip mentors in the
provision of appropriate guidance and support to students in preparation for, during
and after their placement” (NHS Education for Scotland. 2001)
The role is continually evolving to meet the demands of the clinical staff, students and
the higher educational institutions. Following evaluation of a group of Newly
Qualified Nurses the P.E.F.`s identified, in collaboration with the Director of Nursing,
the need for an ongoing support mechanism for the Newly Qualified Nurse.
The Professional Development Competency Programme for Newly Qualified Nurses.
In accordance with guidelines set out by the Nursing and Midwifery Council (NMC
2004).
As P.E.F.`s we are proactive and supportive of ongoing education and continual
professional development. Thus ensuring that the confidence and competence of the
mentors, newly qualified nurses, and nursing students, is of the standard expected by
the stakeholders in the delivery of patient care.
References
NHS Education for Scotland. 2001. `Quality Standards for Practice Placements`.
Edinburgh.
Scottish Executive Department of Health. 2001. `Facing the Future’. Edinburgh.
Nursing and Midwifery Council. 2004. `Consultation on a standard to support
learning and assessment in practice`. NMC Press. London.
RISK BEHAVIOUR AND HARM MINIMISATION POLICIES IN PRISON
David Wood (M.Sc., B.A. (hons), R.N.)
Lecturer
Faculty of Health and Social Care
Nidd Building
University of Hull
Cottingham Road
Hull
HU6 7RX
01482 (46)3417
Greenway (1994) argued that prisons contain a disproportionately high number of
individuals who have placed themselves at risk from HIV infection through their
behaviour both inside and outside prison. It appears that a sizeable proportion of
prisoners engage in unprotected sexual activity and the sharing of intravenous (IV)
needles for drug use (Decker and Rosenfeld, 1992). These factors coupled with little
or no access to the resources and information required to prevent infection have made
inmates a vulnerable population. Indeed the activities in prisons that spread HIV are
usually illegal within the prison environment and so meet with disciplinary measures
not health measures.
HIV and AIDS in prisons is one area which has not been tackled sufficiently at a
policy level in England and Wales. Furthermore the policies that do exist have not
always been effectively implemented. Findings from European research studies
indicate that it is possible to implement innovative and effective policies to minimise
the risk of HIV transmission in prison (Van Doorninck and De Jong, 1998; Dolan,
1997; Shaw, 1994). Godin et al. (2001) argued that it is often the attitude of prison
officers that is crucial in the implementation of harm minimisation policies.
This qualitative research study gathered information to examine the extent to which
high risk behaviour, that is likely to lead to HIV infection, occurs in prison. It then
investigated by means of semi-structured interviews the extent to which existing harm
minimisation policies are implemented in English and Welsh prisons and how
custodial institutions could utilise information and ideas from some European
initiatives.
The extent to which planned health promotion interventions affect health beliefs,
attitudes and behaviours of pre-registration nursing students.
Maggie Wood DNSc, MSc in Nursing, Dip Nurse Ed, RGN, RSCN,
Department of Nursing and Health Sciences, Galway Mayo Institute of
Technology,
Castlebar,
Co.
Mayo,
Tel
+353
(0)94
9025700;
[email protected]
The literature suggests that health professionals who are healthy role models are more
effective health promoters, that nursing students and qualified nurses do not always
practice healthy behaviours, and that nursing education does not prepare students
adequately for their role as health promoters. Models of health behaviour change can
provide useful frameworks for interventions in promoting health. Poor nutrition,
smoking, alcohol consumption above safe recommended limits, and lack of physical
activity are key contributors to increased morbidity and mortality rates. The literature
does not indicate the most effective methods of preparing nursing students as healthy
role models and there is a lack of research investigating planned interventions using
models of health behaviour change in this area.
The effect of planned intervention in the health promotion curriculum on the health
beliefs, attitudes and behaviours in these four areas was therefore measured in one
cohort of nursing students (N=44) in a Health Board School of General Nursing over
the three-year period of their National Diploma in Nursing pre-registration course.
Two models of health behaviour change were used as frameworks for the
intervention: The Health Belief Model (Becker, 1974 and Rosenstock, Strecher and
Becker, 1988) and the Transtheoretical Model (Prochaska and DiClemente, 1984 and
Prochaska, DiClemente and Norcorss, 1992). Data were collected via a purposely
designed self-report questionnaire. A comparison group (N=75) was formed from
nursing students from two similar schools of nursing, where no such intervention took
place. A pilot study tested both the intervention and the data collection tool. The
intervention used a planned and progressive approach to teaching health promotion,
using a variety of teaching methods and framed in models of health behaviour change.
Students were encouraged to improve their own health behaviours, and then those of
peers and finally patients, using the health behaviour change theories identified above.
Students in the intervention group tended to demonstrate more favourable outcomes
than those in the comparison group. Statistically significant differences were
demonstrated in relation to drinking behaviour (p=.01), beliefs and attitudes in
relation to smoking (p=.03), and exercise behaviour (p<.001). Two-way analysis of
variance (pairwise comparisons of group with stage) demonstrated that most of the
change occurred either by the commencement of the third year or during the third year
of the course. This was a small scale intervention study, using a self-report
questionnaire, which limits the generalisability of the findings. This study is also
limited by the researcher’s dual role as researcher and teacher. However, the study
suggests that planned and progressive education within the pre-registration curriculum
can have positive effects on nursing students’ health beliefs attitudes and behaviours,
which may increase their effectiveness as health promoters. Models of health
behaviour change have been shown to be useful in planning such interventions, but
themselves need further testing and clarification in operationalising variables.
FROM PATIENT TO PARTICIPANT: CHRONIC BACK PAIN PATIENT’S
EXPERIENCES OF BEING ON A CLINICAL TRIAL
Kerrie Louise Wright, Nursing Lecturer, MSc, BSc (Hons), RGN, RNT
74 Lidgett Park Court, Roundhay, LS8 1ED
Study background Chronic (non-malignant) back pain is a complex health problem
affecting a substantial portion of the population. There is however limited evidence of
sustained drug efficacy amongst this patient group (Schnitzer et al. 2004). Despite this
there continues to be pharmaceutical investment utilising chronic back pain sufferers
as research participants in randomised controlled trials. In comparison the experience
of being a participant and the impact upon patient’s lives appears to be poorly
investigated. Learning from participant experiences is an important safeguard and an
essential component of good research practice (Department of Health 2001).
Study design The study was a phenomenological investigation of the patient’s lived
experience of being a trial participant.
Sampling The study used a purposive sample of 8 chronic back pain patients who had
completed 13 months as a participant on an international randomised controlled trial
investigating the efficacy of oral versus transdermal opiates.
Data collection Semi-structured interviews were undertaken.
Analysis Using Colaizzi’s methods of data analysis (1978) specific statements were
extracted from individual descriptions, from which meanings were formulated. In turn
these were clustered into themes in order to provide an exhaustive description of the
lived experience. The themes were returned to the participants in order to validate
their accuracy.
Results Patients acknowledged that their pain journey had resulted in a lack of faith in
the medical establishment however the reasons they gave for trial participation was to
please (primarily) their consultant or their loved ones. Therapeutic relationships with
the researchers and accessibility of the nurse-led clinics were of the utmost
importance to patients. However they experienced embarrassment because they
perceived the treatment they received to be preferential to that of their acquaintances
attending other clinics, which evoked feelings of guilt. Although patients felt well
informed about the trial, once randomised the drugs they were taking often resulted in
side effects which made them feel as though they had traded one medical problem for
another. Alternatively others received immense relief, although they were unable to
isolate whether this was physical or psychological in nature, but feared that a battle
may ensue if they were unable to continue to have access to the drugs in the long
term. The trial coming to end signified a great loss to these patients, it had become
their norm. To some the outcome resulted in a loss of hope, to others the outcome was
irrelevant; the trial gave their pain recognition and promoted a level of social
acceptance in the outside world.
Colaizzi P cited in Valle R and King M (1978) Existential phenomenological
alternative for psychology, New York, Oxford University Press
Department of Health (2001) Research Governance Framework for Health and Social
Care, London, The Stationary Office
Schnitzer TJ, Ferraro A, Hunsche E and Kong SX (2004) A comprehensive review of
clinical trials on the efficacy and safety of drugs for the treatment of low back pain,
Journal of Pain and Symptom Management, 28, 1, 72-95
UNDERSTANDING THE LIVED EXPERIENCE OF WOMEN CANCER
CARERS.
Ms Sue Yates MA, BSc, PGCE, RN
Senior Lecturer
Department of Nursing
Greenbank Building
University of Central Lancs
Preston PR1 2HE
England
+ 44 1772 893640
[email protected]
Background: Carers have become part of the health care agenda and there has been a
fundamental recasting of community care policy and a recognition in cancer services of
the importance of informal carers, both as supporters of cancer patients and as people
who have cancer-related psychological needs of their own (DOH 1995, 2000).There
has also been a recent shift in rhetoric from the focus of care in the community to care
by the community and a recognition that home is the preferred place of death. This
shift has obvious implications for cancer carers and women in particular. Carers are
predominantly women aged over 50, with women carers providing more ‘hands on’
care (DOH, 2000, 1999).
Aims
At a basic level, the study aims to understand the experiences of women living with a
partner with cancer (in any site) who is not expected to survive. A number of related
questions were formulated:
What are the changing needs of women throughout their partner’s illness?
How do women make sense of ‘who’ they are and what they have experienced
throughout their partner’s illness?
In what ways do women experience their relationships with health care professionals?
Method.
A hermeneutic phenomenological approach was adopted.
Sample: Twenty women were recruited to the study.
Data collection was carried out over a two and a half year period, involving two
recorded, unstructured interviews with each participant. Participants were also asked
to keep a journal between the first and second interview. Data was analysed
thematically
Preliminary Findings: Despite recent government recognition of the importance of
informal carers the women in this study continue to report a lack of information and
support. Services offered were sporadic and often offered too late, in some cases in
the last days of life. Feelings of helplessness and isolation increased as the illness
progressed. Many women felt overwhelmed by the physical and emotional demands
of caring for a partner at home; with over half expressing a preference for a hospital
or hospice death for their partner.
References
Department of Health (1995) A policy framework for commissioning cancer services,
The Stationery Office, London.
Department of Health (1999) Caring about carers; A national strategy for
carers.http://www.dog.gov.uk/carers.htm
Department of Health (2000) The NHS Cancer Plan: A plan for investment. A plan for
reform, The Stationery Office, London.