Transference in the nurse-patient relationship

The therapeutic relationship has been considered foundational to psychiatric nursing practice since at least the mid-20th century. However, this does not, in itself, guarantee either its continuity or relevance to current practice. Concepts such as the therapeutic relationship require sustained attention, both in theory and in practice, to illustrate ongoing relevance to the discipline. This paper addresses the therapeutic relationship in psychiatric nursing via aspects of psychoanalytic theory, particularly the notion of transference, as theorized by both Freud and Lacan. Two case fragments provide practice material, through which transference in the nurse–patient relationship is explored. The nurse, in the context of his/her relationship with the patient, a sick stranger, offers both a listening and the potential development of transference. This transference can be experienced, in part, as a form of attachment to the nurse, one that is not regarded pejoratively as dependency. There is the potential, within the nurse–patient relationship, for a psychical holding to develop, one from within which both the patient can speak and transference might arise. It is argued that listening to the patient has the potential to assist the patient and, with the development of transference, can provide the context for important work.

Using supervised and unsupervised techniques to determine groups of patients with different doctor-patient stability

Decision trees and self organising feature maps (SOFM) are frequently used to identify groups. This research aims to compare the similarities between any groupings found between supervised (Classification and Regression Trees - CART) and unsupervised classification (SOFM), and to identify insights into factors associated with doctor-patient stability. Although CART and SOFM uses different learning paradigms to produce groupings, both methods came up with many similar groupings. Both techniques showed that self perceived health and age are important indicators of stability. In addition, this study has indicated profiles of patients that are at risk which might be interesting to general practitioners.

"It's a tube up your bottom; it makes people nervous": the experience of anxiety in initial colonoscopy patients.

This study aimed to prospectively consider the effect of colonoscopy on patients' experiences of anxiety at 4 time points related to an initial colonoscopy, using a qualitative approach. The study involved a sample of 13 patients undergoing an initial colonoscopy at a public hospital and followed for 12 months. Four exploratory interviews were conducted with each participant: before the procedure, 1 week, 2 weeks, and 12 months after the procedure. Thematic analysis was conducted to summarize patients' responses. In these participants, colonoscopy was associated with stigma. The discussion of the procedure was perceived as stressful and embarrassing and led to anxiety. Irrational expectations regarding the procedure were also contributing to anxiety, as was a doctor-patient relationship based on unequal powers and lack of control. Before the procedure, fear of a serious diagnosis contributed to anxiety; however, postprocedure, an unclear or functional diagnosis also appeared to increase anxiety. Anticipating the preparation for the procedure was also reported as an important factor in preprocedure anxiety. A shift toward a biopsychosocial approach to healthcare, such as providing patients with a greater sense of control by participating in decision making, should be recommended as it may reduce anxiety.

Reflexivity in nursing : where is the Patient? Where is the Nurse?

Drawing upon forty years of nursing experience, in this paper we are reflexive about four issues relative to nursing clinical practices: seeking technological solutions to health and ill-health; moving from the nurse-patient relationship to the patient-healer relationship; utilising critical pathways; and, supporting evidence-based nursing. We examine current nursing practices and ask probing questions to generate debate. Most of all, we encourage nurses to engage in reflexivity and not to lose sight of their selves (knowledge, expertise and skills), and their patients' voices and subjectivity, in their contribution to health care.

Barriers to effective management of depression in general practice

Objective: The aim of this study was to investigate the effects of prior general practice training in mental health and practice location on general practitioner (GP) attitudes toward depression, self-confidence in assessing and treating depressed patients, identification of doctor, patient and practice barriers to the effective care of depressed patients in general medical practice and GP-reported current clinical practice.

Method: Fifty-two (out of 123) Divisions of General Practice that responded to an invitation to participate in the study distributed 608 anonymous surveys to a representative sample of GPs; 420 (69%) were returned. The questionnaire focused on current clinical practice, perceived barriers to care of depressed patients and doctors' self-efficacy for assessing and treating depressed patients. It also consisted of two scales, based upon previous research, designed to assess doctors' attitudes towards depression and depressed patients.

Results: General practitioners who had undertaken mental health education and training more often used non-pharmacological treatments (p = 0.00), as did female GPs (p = 0.00). Male GPs (p = 0.00) and those in rural settings (p = 0.01) more often prescribed medication for depression. Those without mental health training more often identified incomplete knowledge about depression as a barrier to its effective management (p = 0.00). Urban-based GPs (p = 0.04) and those with prior mental health training (p = 0.00) were more confident in the use of non-pharmacological treatments. Female GPs without mental health training were the least confident in the use of these methods (p = 0.01). Overall, GPs with mental health training were more positive in their attitudes toward depression and their treatment of these patients (p = 0.00). Female GPs appeared more positive in their attitudes toward depression than male GPs (p = 0.01), although the results were not entirely consistent.

Conclusions: Participation in mental health training by GPs appears to be related to their attitudes toward depressed patients and to their confidence and abilities to diagnose and manage the common mental disorders effectively.

Care : what nurses say and what nurses do

Caring is neither simply a set of attitudes or theories, nor does it comprise all that nurses do. Nursing care is determined by the way nurses use knowledge and skills to appreciate the uniqueness of the person they are caring for (changing the care noun into a caring verb). The purpose of this article is to present a range of contemporary nurse theorists' ideas on caring and to examine these ideas using the backdrop of nursing as practiced in both Australia and Canada to demonstrate a range of national and international similarities and theoretical beliefs. Caring relationships set up the conditions of trust that enable the one receiving the care to accept the help offered, underpinning the nurse-patient relationship or the therapeutic relationship. Caring is always specific and relational such as that found in the nurse-patient relationship. We believe that caring theory has much to offer nursing practice worldwide. Caring must be considered in the caring context because the nature of the caring relationship is central to most nursing interventions. Nurses need to be able to actually practice caring rather than just theorize about it-using caring theories to inform their practice.

What do general practitioners think depression is? A taxonomy of distress and depression for general practice

Objective:
To create a taxonomy of distress and depression for use in primary care, that mirrors the thinking and practice of experienced general practitioners.

Design:
Qualitative study, using an ethnomethodological approach, with observation of videotaped routine GP–patient consultations and in-depth interviews with GPs.

Setting and participants:
The study was conducted in metropolitan Melbourne in 2005. Fourteen GPs conducted 36 patient consultations where depression was a focus; nine GPs participated in in-depth interviews to elicit details of how they recognised and diagnosed depression in their patients.

Results:
GPs consider distress and depression in three steps. In the first step, a change in a group of symptoms and signs is observed (eg, facial expression, loss of drive). The second step categorises the syndrome according to whether or not there is an identifiable environmental cause (reactive or “endogenous”), with the final step categorising the reactive syndromes according to their most prominent symptoms: either anxiety and worry, or helplessness and hopelessness. The resulting taxonomy includes: endogenous depression (a chronic and perhaps characterological depression characterised by a lack of interest and motivation); anxious depressive reaction (stress or worry); and hopeless depressive reaction (demoralisation).

Conclusion:
This simple and parsimonious taxonomy has validity based on its derivation from within the primary care setting.

Ein Blick Down Under. Selbstmanagementinitiativen und Patientenschulungen in Australien

The growing burden of chronic disease and the current nature of healthcare systems which are structurally ill-equipped to cater to the complex needs of patients with chronic conditions has led to governments and healthcare providers seeking alternative ways to improve patients own capacity to actively self-manage their chronic condition. In Australia, there has been a focus on patient education and self-management programs within the healthcare system to achieve this. These programs aim to empower patients through providing information and teaching skills and techniques to improve self-care and doctor-patient interaction with the ultimate goal of improving quality of life. Patient education and self-management programs have been supported through several national government initiatives and implemented within the healthcare setting. This paper describes the current position of patient education and self-management within the Australian healthcare system. It further describes a new collaboration project between an Australian and a German research team which aims at translating an assessment questionnaire used in Australia for the evaluation of self-management programs, the “Health Education Impact Questionnaire” (“heiQ”); this instrument is expected to be of significant use in the German rehabilitative system.

Women's views and outcomes of an educational intervention designed to enhance psychosocial support for women during pregnancy

Background: Identification of psychosocial issues in pregnant women by screening is difficult because of the lack of accuracy of screening tools, women's reluctance to disclose sensitive issues, and health care practitioner's reluctance to ask. This paper evaluates if a health professional education program, a new (ANEW) approach, improves pregnant women's ratings of care and practitioner's listening skills and comfort to disclose psychosocial issues.

Methods: Midwives and doctors from Mercy Hospital for Women, Melbourne, Australia, were trained from August to December 2002. English-speaking women (< 20 wks' gestation) were recruited at their first visit and mailed a survey at 30 weeks (early 2002) before and after (2003) the ANEW educational intervention. Follow-up was by postal reminder at 2 weeks and telephone reminder 2 weeks later.

Results: Twenty-one midwives and 5 doctors were trained. Of the eligible women, 78.2 percent (584/747) participated in a pre-ANEW survey and 73.3 percent (481/657) in a post-ANEW survey. After ANEW, women were more likely to report that midwives asked questions that helped them to talk about psychosocial problems (OR 1.45, CI 1.09–1.98) and that they would feel comfortable to discuss a range of psychosocial issues if they were experiencing them (coping after birth for midwives [OR 1.51, CI 1.10–2.08] and feeling depressed [OR 1.49, 1.16–1.93]; and concerns relating to sex [OR 1.35, CI 1.03–1.77] or their relationships [OR 1.36, CI 1.00–1.85] for doctors).

Conclusions: The ANEW program evaluation suggests trends of better communication by health professionals for pregnant women and should be evaluated using rigorous methods in other settings.

Exploration of nurses' lived-experiences and understandings of the concept of healing

Explores nurses' understandings of the concept of healing, within the context of a nurse/patient relationship. Hermeneutic phenomenology is the research methodology and story-telling the means of data collection. From these descriptions, new understandings have been sought and therapeutic possibilities actively explored.

Using information and communication technologies to consult with patients in Victorian primary care : the views of general practitioners

Information and communication technologies such as email, text messaging and video messaging are commonly used by the general population. However, international research has shown that they are not used routinely by GPs to communicate or consult with patients. Investigating Victorian GPs’ perceptions of doing so is timely given Australia’s new National Broadband Network, which may facilitate web-based modes of doctor-patient interaction. This study therefore aimed to explore Victorian GPs’ experiences of, and attitudes toward, using information and communication technologies to consult with patients. Qualitative telephone interviews were carried out with a maximum variation sample of 36 GPs from across Victoria. GPs reported a range of perspectives on using new consultation technologies within their practice. Common concerns included medico-legal and remuneration issues and perceived patient information technology literacy. Policy makers should incorporate GPs’ perspectives into primary care service delivery planning to promote the effective use of information and communication technologies in improving accessibility and quality of general practice care.

Motivational interviewing techniques : facilitating behaviour change in the general practice setting

Background: One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks.

Objective: To explore current understanding regarding how and why people change, and the potential role of motivational interviewing in facilitating behaviour change in the general practice setting.

Discussion: Research into health related behaviour change highlights the importance of motivation, ambivalence and resistance. Motivational interviewing is a counselling method that involves enhancing a patient's motivation to change by means of four guiding principles, represented by the acronym RULE: Resist the righting reflex; Understand the patient's own motivations; Listen with empathy; and Empower the patient. Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management.

The caregiving role following percutaneous coronary intervention

Aim.  The aim of this study is to describe the experience of caregivers of individuals who have had a percutaneous coronary intervention (PCI). Background.  Decreased lengths of hospital stay and an increased emphasis on chronic disease self-management increase the importance of carers in assisting in recovery and lifestyle modification. Design.  Cross-sectional dual-moderated focus group design. Method.  Three focus groups using a dual facilitation approach were held in the cardiac rehabilitation setting of a tertiary referral hospital in metropolitan Sydney. All sessions were audio recorded, transcribed and thematically analysed. Results.  Four themes emerged from the data: (1) a gendered approach to health, illness and caring; (2) shock, disbelief and the process of adjustment following PCI; (3) challenges and changes of the carer–patient relationship and (4) the needs of the carer for support and information. Issues emerging from this study parallel other findings describing the experience, yet provide new insights into the issues surrounding PCI. Conclusion.  These findings highlight the need for including carers in care planning and decision-making and providing them with support and resources. Relevance to clinical practice.  • Emphasises the importance of preparing carers of the likely experience following a PCI.• Demonstrates the degree to which vigilance, deferment of carer-health needs and role conflict impact on the carer’s personal relationship.• Demonstrates the need for formal support interventions for carers of patients who have had PCI.

National indicators of health literacy: ability to understand health information and to engage actively with healthcare providers - a population-based survey among Danish adults

Health literacy is a multidimensional concept covering a range of cognitive and social skills necessary for participation in health care. Knowledge of health literacy levels in general populations and how health literacy levels impacts on social health inequity is lacking. The primary aim of this study was to perform a population-based assessment of dimensions of health literacy related to understanding health information and to engaging with healthcare providers. Secondly, the aim was to examine associations between socio-economic characteristics with these dimensions of health literacy.

The relationship between patient blood pathology values and patient falls in an acute-care setting : a retrospective analysis

Few studies have investigated the relationship between patient falls and patient blood pathology values, which can reveal objective information about the health and nutritional status of a patient. It could be that some abnormal values are associated with patients that fall. The objectives of the current study were to determine whether blood pathology values were different in patients who fell compared to patients who did not fall, and whether there was a difference in the type and number of currently documented risk factors for falls found for patients who fell compared to patients who did not fall. A retrospective audit of patient incident reports and medical records was conducted in an acute-care hospital for 220 patients who fell and who did not fall. Faller and non-faller patients were matched by casemix type and length of stay. Findings revealed a significant relationship between patients who fell and the variables of age, confusion status and alkaline phosphatase blood values.