From expert to tasks, expert nursing practice redefined?

Aim The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

Empowerment in nursing : paternalism or maternalism?

The aim of this article is to explore whether patient empowerment flourishes in the wake of current health reforms or if there is a power struggle between nursing and medicine as to what is in the patients' best interest. Shifting the balance of power from healthcare professionals to patients has become a key element of healthcare policy in England. The RCN's definition of nursing places patient empowerment as a central remit of nurses. However, achieving genuine patient empowerment is not easy and requires individuals and organizations to alter their beliefs, values and behaviours. To empower patients nurses must be in a position to share power and this may require a realignment of the traditional power base within health care. Although empowerment is often viewed on a one-to-one level between professionals and patients, for true patient empowerment to occur, issues of power and control must also be addressed at a national and political level.

Homophobia in nursing : a concept analysis.

It could be argued that the term homophobia may have an array of meanings, which makes it difficult to truly define. Therefore, the purpose of this article is to explore homophobia in nursing using concept analysis as described by Walker and Avant (1995). Definitions of homophobia in general terms will be identified together with a working definition of homophobia in nursing in order for the critical attributes to be explored and identified. The formation of model, borderline, and contrary cases will exemplify the key characteristics of what homophobia in nursing is and is not. The examination of the antecedents, consequences, and empirical referents allows for further refinement of the key attributes, which define homophobia in nursing.

What knowledge do ICU nurses have with regard to the effects of noise exposure in the Intensive Care Unit?

This small-scale study was undertaken to assess what knowledge nursing staff from a General Intensive Care Unit held with regard to noise exposure. To assess knowledge a self-administered multiple-choice questionnaire was used. Rigorous peer-review insured content validity. This study produced poor results in terms of the knowledge nurses held with regard to noise related issues in particular the psychophysiological effects and current legislation concerning its safe exposure. Non-parametric testing, using Kruskal–Wallis found no significant difference between nursing grades, however, descriptive analysis demonstrated that the staff nurse grade (D and E) performed better overall. Whilst the results of this study may seem self-evident in some respects, it is the problems of exposure to excessive noise levels for both patients and hospital personnel, which are clearly not understood. The effects noise exposure has on individuals for example decreased wound healing; sleep deprivation and cardiovascular stimulation must be of concern especially in terms of patient care but more so for nursing staff especially the effects noise levels can have on cognitive task performance.

Advancing Nursing Practice in Pain Management

This book showcases the development and evaluation of innovative examples of pain management initiatives by advanced practitioners. It considers each service development or community initiative both in terms of advanced practice nursing and pain management. There is a wide range of examples of innovation in pain management included - from the introduction of ketamine use in one trust, to wider issues around meeting the needs of pain management in the community. The book considers issues including use of research, education and interprofessional working in the advanced practitioner role. Each chapter looks at development of the service, challenges of implementation, evaluation of the service's success and justifying the importance of the advanced nurse in the service's achievements.

Establishing research in a palliative care clinical setting : perceived barriers and implemented strategies

There are many challenges in developing research projects in research-naïve clinical settings, especially palliative care where resistance to participate in research has been identified. These challenges to the implementation of research are common in nursing practice and are associated with attitudes towards research participation, and some lack of understanding of research as a process to improve clinical practice. This is despite the professional nursing requirement to conduct research into issues that influence palliative care practice. The purpose of this paper is to describe the process of implementing a clinical research project in collaboration with the clinicians of a palliative care community team and to reflect on the strategies implemented to overcome the challenges involved. The challenges presented here demonstrate the importance of proactively implementing engagement strategies from the inception of a research project in a clinical setting.

Circles of care : should community development redefine the practice of palliative care?

Specialist palliative care, within hospices in particular, has historically led and set the standard for caring for patients at end of life. The focus of this care has been mostly for patients with cancer. More recently, health and social care services have been developing equality of care for all patients approaching end of life. This has mostly been done in the context of a service delivery approach to care whereby services have become increasingly expert in identifying health and social care need and meeting this need with professional services. This model of patient centred care, with the impeccable assessment and treatment of physical, social, psychological and spiritual need, predominantly worked very well for the latter part of the 20th century. Over the last 13 years, however, there have been several international examples of community development approaches to end of life care. The patient centred model of care has limitations when there is a fundamental lack of integrated community policy, development and resourcing. Within this article, we propose a model of care which identifies a person with an illness at the centre of a network which includes inner and outer networks, communities and service delivery organisations. All of these are underpinned by policy development, supporting the overall structure. Adoption of this model would allow individuals, communities, service delivery organisations and policy makers to work together to provide end of life care that enhances value and meaning for people at end of life, both patients and communities alike.

Working together-apart : exploring the relationships between formal and informal care networks for people dying at home

Introduction Informal caring networks contribute significantly to end-of-life (EOL) care in the community. However, to ensure that these networks are sustainable, and unpaid carers are not exploited, primary carers need permission and practical assistance to gather networks together and negotiate the help they need. Our aim in this study was to develop an understanding of how formal and informal carers work together when care is being provided in a dying person's home. We were particularly interested in formal providers’ perceptions and knowledge of informal networks of care and in identifying barriers to the networks working together. Methods Qualitative methods, informed by an interpretive approach, were used. In February-July 2012, 10 focus groups were conducted in urban, regional, and rural Australia comprising 88 participants. Findings Our findings show that formal providers are aware, and supportive, of the vital role informal networks play in the care of the dying at home. A number of barriers to formal and informal networks working together more effectively were identified. In particular, we found that the Australian policy of health-promoting palliative is not substantially translating to practice. Conclusion Combinations of formal and informal caring networks are essential to support people and their primary carers. Formal service providers do little to establish, support, or maintain the informal networks although there is much goodwill and scope for them to do so. Further re-orientation towards a health-promoting palliative care and community capacity building approach is suggested.

End-of-life care in the intensive care unit : a systematic review of qualitative studies investigating the experiences and perceptions of the patient's family

Review question/objective The review objective is to synthesise the best available evidence on experiences and perceptions of family members of intensive care unit patients on the adequacy of end-of-life care, where life-support modalities have been withheld or withdrawn. Inclusion criteria Types of participants This review will consider studies that report on the experiences and perceptions of patients’ families on EOLC in the ICU, where life-support modalities have been withheld or withdrawn. The family is defined as “those who are closest to the patient... the family may include the biological family, family by acquisition, and the family of choice and friends”. Phenomena of interest The phenomena of interest for this review are the patients’ families experiences, perceptions or views on the adequacy of EOLC delivered in the ICU, where life-support modalities were withheld or withdrawn. These experiences may refer to the following views on domains of care considered important at the end-of-life in the ICU, which have been described already in the existing literature: timely, consistent, and compassionate communication, clinician availability, clinical decision making based on patients’ preferences, goals and values, physical care implemented to maintain patient comfort, holistic interdisciplinary care and bereavement care for families of patients who died.

Whose business is dying? Death, the home and palliative care

The process of dying at home brings the nexus between the paternalism of conventional palliative care and a social understanding of end of life care into sharp focus. Away from institutional places of care, issues of ownership, compliance and communal responsibility are heightened. At this interface, palliative care services are confronted with the irony of relinquishing their 'ownership' of dying whilst leading communities to reclaim their principal role in the business of dying. This benign – but enduring – paternalism remains a barrier to a paradigmatic shift towards a more complete understanding of the business of dying. Whilst nascent attempts to promote community engagement in end of life issues are evident in the interface between palliative care and public health, dying remains, for the most part, the remit of health care services. In this article, I contend that the business of dying is incompletely attended. This lack of attention will be partially redressed here by considering the home as a fitting death scene.

"But we’re already doing it!" Examining conceptual blurring between health promotion and palliative care

Over the past decade, an increasing number of palliative care service providers have attempted to integrate health promotion into their organisational practice. A key factor in the success of this endeavour has been the recognition by these providers of the conceptual ‘fit’ between two seemingly disparate approaches to health care. When informed of the elements of health promotion, palliative care professionals have expressed their recognition in their declaration: ‘But we’re already doing it!’ (Rosenberg 2007). Yet it appears that this association between the two suggests that health promotion in palliative care organisations is being understood in poorly defined ways. ‘Health promotion’ can be incorrectly assumed to be synonymous with ‘health education’; ‘death education’ can be understood to be synonymous with providing information about palliative care resources. Whilst these activities may be worthwhile within themselves, their presence in the activities of an organisation does not constitute the practice of health promoting palliative care (HPPC) (Kellehear 1999)...

Making context work in primary health care

Health care in the community setting is one of the more challenging contexts for evidence-based practice. Community-based care comprises more than simply transplanting hospital care into people’s homes; in addition to the provision of supportive services, it also takes a range of approaches to health care practice that promotes optimal health and builds the capacity of individuals and communities to respond to their health needs. Primary health care is comprised of the diverse activities that build sustainable community capacity to achieve health and well-being throughout all of life’s stages. The expansive nature of primary health care means that a map for practice is not feasible; however a framework which can be adapted to suit the variety of situations and practice settings can be identified. The focus of this chapter is to broadly define and explore the principles of primary health care and consider the contexts of primary health care in relation to evidence-based practice.

Palliative care provision for patients with a haematological malignancy : can we do more?

This editorial depicts the current challenges in palliative care provision for patients with a haematological malignancy and the contribution of cancer nurses. There have been significant advancements in the care of patients with a hematological malignancy over the past three or more decades1. Despite this, there still exists a significant mortality risk in curative treatment and many patients with a hematological malignancy will die from their disease1. A growing body of research indicates patients with a hematological malignancy do not receive best practice palliative and end-of-life care2. Shortfalls in care include poor referral patterns to specialist palliative care services, lack of honest discussions regarding death and dying, inadequate spiritual care for patients and families, patients frequently dying in the acute care setting and high levels of patient and family distress2. There have been a number of efforts in the United Kingdom, United States of America, Sweden, and Australia demonstrating palliative and hematology care can co-exist, exemplified through clinical case studies and innovative models of care2. However, deficits in the provision of palliative care for patients with a hematological malignancy persist as evident in the international literature2. Addressing this issue requires research exploring new aspects of a complex scenario; here we suggest priority areas of research...