Perceptions of the Nurse Practitioner Role in Facilitating the Implementation of an Onsite Pain Management Team in Long Term Care

Background: One strategy to improve pain management in long term care (LTC) is to optimize the emerging role of the nurse practitioner (NP) in LTC. The purpose of this sub study was to learn about the NP role in implementing an onsite, interdisciplinary Pain Team in the LTC home setting.

Methods: We used a case study design that included two NPs who worked at separate LTC homes. Each of the NPs completed a weekly questionnaire of pain-related activities that they engaged in over a one-year implementation period; and a diary, using critical reflection, about their experiences and strategies used to implement the Pain Team. Descriptive statistics and thematic content analysis were used to analyze the case study data.

Findings: NPs tended to be most engaged in pain assessment and collaborated more with licensed nurses and personal support workers; less with pharmacists. NPs were more involved in organizational level activities, such as participating in committee work or assisting with the development of policies and procedures about pain. NPs created palliative care and pain service protocols; engaged in policy development, in-servicing, quality assurance and advocacy; and encouraged best practices. NPs were challenged with time constraints for pain management and balancing other role priorities and felt that increased scope of practice for them was needed.

Conclusions: The results of this study highlight how NPs implemented a Pain Team in LTC which may be helpful to others interested in implementing a similar strategy to reduce residents’ pain.

Nurses' experiences providing palliative care to individuals living in rural communities aspects of the physical residential setting

Introduction: Efforts are needed to improve palliative care in rural communities, given the unique characteristics and inherent challenges with respect to working within the physical aspects of residential settings. Nurses who work in rural communities play a key role in the delivery of palliative care services. Hence, the purpose of this study was to explore nurses’ experiences of providing palliative care in rural communities, with a particular focus on the impact of the physical residential setting.

Methods: This study was grounded in a qualitative approach utilizing an exploratory descriptive design. Individual telephone interviews were conducted with 21 community nurses. Data were analyzed by thematic content analysis.

Results: Nurses described the characteristics of working in a rural community and how it influences their perception of their role, highlighting the strong sense of community that exists but how system changes over the past decade have changed the way they provide care. They also described the key role that they play, which was often termed a ‘jack of all trades’, but focused on providing emotional, physical, and spiritual care while trying to manage many challenges related to transitioning and working with other healthcare providers. Finally, nurses described how the challenges of working within the physical constraints of a rural residential setting impeded their care provision to clients who are dying in the community, specifically related to the long distances that they travel while dealing with bad weather.

Learning fluid prescription skills: why is it so challenging?

IIt is well recognised that medical students and junior doctors find fluid prescription a challenging topic. This study was designed to gain a greater understanding of the experiences that medical students face related to learning about fluid prescribing. Methods: A qualitative approach, using focus groups, was employed in this research. Final-year medical students in academic year 2011-12 at Queen's University Belfast were invited to participate during their 'Assistantship' placement in March 2012. Discussions in focus groups, consisting of between six and eight students, were recorded and transcribed verbatim. The research team, consisting of three separate investigators, conducted thematic analysis independently. A final consensus regarding emerging themes was reached by discussion within the whole research team. Medical students and junior doctors find fluid prescription a challenging topic Results: Five prominent themes emerged: 'Teaching experience: a disruptive variation'; 'Curricular disconnections'; 'The driving test: Theory-practice transformation'; 'Role modelling: which standard to aspire to?'; and finally 'Reconciling the perceived risk'. Discussion: This re search provided insights into medical students' opinions of the teaching practices and learning experiences related to fluid prescribing. The learning of prescribing skills is complex andcontextual. In the development of such skills, medical students are often exposed to conflicting educational experiences that challenge the novicelearner in making judgements on best prescribing practice. This study adds to the body of evidence that fluid prescription is a difficult topic, and has generated a number of multifaceted and strategic recommendations to potentially improve fluid prescription teaching.

Reconstructing apology: David Cameron's Bloody Sunday apology in the press

While there is an acknowledgement in apology research that political apologies are highly mediated, the process of mediation itself has lacked scrutiny. This article suggests that the idea of reconstruction helps to understand how apologies are mediated and evaluated. David Cameron's apology for Bloody Sunday is examined to see how he constructs four aspects of apology: social actors, consequences, categorization, and reasons. The reconstruction of those aspects by British, Unionist, and Nationalist press along with reconstructions made by soldiers in an online forum are considered. Data analysis was informed by thematic analysis and discourse analysis which helped to explore key aspects of reconstruction and how elements of Cameron's apology are altered in subsequent mediated forms of the apology. These mediated reconstructions of the apology allowed their authors to evaluate the apology in different ways. Thus, in this article, it is suggested that the evaluation of the apology by different groups is preceded by a reconstruction of it in accordance with rhetorical goals. This illuminates the process of mediation and helps to understand divergent responses to political apologies.

Spectres of Shakespeare:Ong Keng Sen’s Search: Hamlet and the Intercultural Myth

Arguably, the myth of Shakespeare is a myth of universality. Much has been written about the dramatic, thematic and ‘humanistic’ transference of Shakespeare’s works: their permeability, transcendence of cultures and histories, geographies and temporalities. Located within this debate is a belief that this universality, among other dominating factors, is founded upon the power and poeticism of Shakespeare’s language. Subsequently, if we acknowledge Frank Kermode’s assertion that “the life of the plays is the language” and “the secret (of Shakespeare’s works) is in the detail,” what then becomes of this myth of universality, and how is Shakespeare’s language ‘transferred’ across cultures? In Asian intercultural adaptations, language becomes the primary site of confrontation as issues of semantic accuracy and poetic affiliation abound. Often, the language of the text is replaced with a cultural equivalent or reconceived with other languages of the stage – song and dance, movement and music; metaphor and imagery consequently find new voices. Yet if myth is, as Roland Barthes propounds, a second-order semiotic system that is predicated upon the already constituted sign, here being language, and myth is parasitical on language, what happens to the myth of Shakespeare in these cultural re-articulations? Wherein lies the ‘universality’? Or is ‘universality’ all that it is – an insubstantial (mythical) pageant? Using Ong Keng Sen’s Search Hamlet (2002), this paper would examine the transference of myth and / as language in intercultural Shakespeares. If, as Barthes argues, myths are to be understood as metalanguages that adumbrate social hegemonies, intercultural imaginings of Shakespeare can be said to expose the hollow myth of universality yet in a paradoxical double-bind reify and reinstate this self-same myth.

Building capacity in palliative care for personal support workers in long-term care through experiential learning

Background

Providing palliative care in long-term care (LTC) homes is an area of growing importance. As a result, attention is being given to exploring effective palliative care learning strategies for personal support workers (PSWs) who provide the most hands-on care to LTC residents.

The purpose of this intervention was to explore hospice visits as an experiential learning strategy to increase the capacity of PSWs in palliative care, specifically related to their new learning, and how they anticipated this experience changed their practices in LTC.

This study utilised a qualitative descriptive design.

Eleven PSWs from four Ontario LTC homes were sent to their local hospice to shadow staff for one to two days. After the visit, PSWs completed a questionnaire with open-ended questions based on critical reflection. Data were analysed using thematic content analysis.

PSWs commented on the extent of resident-focused care at the hospice and how palliative care interventions were tailored to meet the needs of residents. PSWs were surprised with the lack of routine at the hospice but felt that hospice staff prioritised their time effectively in order to meet family and client care needs. Some PSWs were pleased to see how well integrated the PSW role is on the community hospice team without any hierarchical relationships. Finally, PSWs felt that other LTC staff would benefit from palliative care education and becoming more comfortable with talking about death and dying with other staff, residents and family members.

This study highlighted the benefits of PSWs attending a hospice as an experiential learning strategy. Future work is needed to evaluate this strategy using more rigorous designs as a way to build capacity within PSWs to provide optimal palliative care for LTC residents and their family members.

PSWs need to be recognised as important members within the interdisciplinary team. PSWs who shadow staff at hospices view this experience as a positive strategy to meet their learning needs related to palliative care.

Let's talk about health: shoppers' discourse regarding health while food shopping

Objective: The present study aimed to examine the role of health in consumers’ food purchasing decisions through investigating the nature of people’s discourse regarding health while conducting their food shopping.

Design: The study employed the think-aloud technique as part of an accompanied shop. All mentions of health and terms relating to health were identified from the data set. Inductive thematic analysis was conducted to examine how health was talked about in relation to people’s food choice decisions.

Setting: Supermarkets in Dublin, Republic of Ireland and Belfast, Northern Ireland.

Subjects Participants: (n 50) were aged over 18 years and represented the main household shopper.

Results: Responsibility for others and the perceived need to illicit strict control to avoid ‘unhealthy’ food selections played a dominant role in how health was talked about during the accompanied shop. Consequently healthy shopping was viewed as difficult and effort was required to make the healthy choice, with shoppers relating to product-based inferences to support their decisions.

Conclusions: This qualitative exploration has provided evidence of a number of factors influencing the consideration of health during consumers’ food shopping. These results highlight opportunities for stakeholders such as public health bodies and the food industry to explore further ways to help enable consumers make healthy food choices.

The Development of the Contextual Analysis of Human Remains in Ireland

The colonial experience has been a dominant factor in the production of culture in Ireland, including narratives of the past. In the context of nineteenth century British imperialism, physical anthropology and archaeology were just two of a number of scientific discourses recruited to rationalise and justify colonialist policies. Legitimation was in part provided by racialised and sectarian conceptualisations of local populations in both past and present. After the partition of the island in the early twentieth century, racialised notions of the Irish population were embraced by both nationalist movements (green and orange) on the island. Changes came with the impact of processual archaeology and the appearance of bioarchaeology in the early 1980s, the latter directly influenced by the North American tradition. The last two decades have seen considerable achievements in bioarchaeology in Ireland. The profile of the discipline has been raised, and despite the impact of the recent economic downturn, the number of archaeologists gaining the necessary specialist skills has finally reached critical mass. The focus in Irish bioarchaeology is now on synthetic and thematic projects, and a number of initiatives are currently underway which will go some way towards furthering understanding of the past populations of Ireland.

Étude des impacts écologiques du dynamisme spatio-temporel des habitats naturels sur la faune menacée du Complexe Zones Humides Mahavavy-Kinkony, Madagascar.

This study of the Mahavavy-Kinkony Wetland Complex (MKWC) assesses the impacts of habitat change on the resident globally threatened fauna. Located in Boeny Region, northwest Madagascar, the Complex encompasses a range of habitats including freshwater lakes, rivers, marshes, mangrove forests, and deciduous forest. Spatial modelling and analysis tools were used to (i) identify the important habitats for selected, threatened fauna, (ii) assess their change from 1950 to 2005, (iii) detect the causes of change, (iv) simulate changes to 2050 and (v) evaluate the impacts of change. The approach for prioritising potential habitats for threatened species used ecological science techniques assisted by the decision support software Marxan. Nineteen species were analysed: nine birds, three primates, three fish, three bats and one reptile. Based on knowledge of local land use, supervised classification of Landsat images from 2005 was used to classify the land use of the Complex. Simulations of land use change to 2050 were carried out based on the Land Change Modeler module in Idrisi Andes with the neural network algorithm. Changes in land use at site level have occurred over time but they are not significant. However, reductions in the extent of reed marshes at Lake Kinkony and forests at Tsiombikibo and Marofandroboka directly threaten the species that depend on these habitats. Long term change monitoring is recommended for the Mahavavy Delta, in order to evaluate the predictions through time. The future change of Andohaomby forest is of great concern and conservation actions are recommended as a high priority. Abnormal physicochemical properties were detected in lake Kinkony due to erosion of the four watersheds to the south, therefore an anti-erosion management plan is required for these watersheds. Among the species of global conservation concern, Sakalava rail (Amaurornis olivieri), Crowned sifaka (Propithecus coronatus) and dambabe (Paretroplus dambabe) are estimated the most affected, but at the site level Decken’s sifaka (Propithecus deckeni), kotsovato (Paretroplus kieneri) and Madagascan big-headed turtle (Erymnochelys madagascariensis) are also threatened. Local enforcement of national legislation on hunting means that MKWC is among the sites where the flying fox (Pteropus rufus) and Madagascan rousette (Rousettus madagascariensis) are well protected. Ecological restoration, ecological research and actions to reduce anthropogenic pressures are recommended.

Positioning Clinical Nurse Specialists and Nurse Practitioners as Change Champions to Implement a Pain Protocol in Long-Term Care

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

A critical ethnography of communication processes involving the management of oral chemotherapeutic agents by patients with a primary diagnosis of colorectal cancer: study protocol

Aim
To describe the protocol used to examine the processes of communication between health professionals, patients and informal carers during the management of oral chemotherapeutic medicines to identify factors that promote or inhibit medicine concordance.

Background
Ideally communication practices about oral medicines should incorporate shared decision-making, two-way dialogue and an equality of role between practitioner and patient. While there is evidence that healthcare professionals are adopting these concordant elements in general practice there are still some patients who have a passive role during consultations. Considering oral chemotherapeutic medications, there is a paucity of research about communication practices which is surprising given the high risk of toxicity associated with chemotherapy.

Design
A critical ethnographic design will be used, incorporating non-participant observations, individual semi-structured and focus-group interviews as several collecting methods.

Methods
Observations will be carried out on the interactions between healthcare professionals (physicians, nurses and pharmacists) and patients in the outpatient departments where prescriptions are explained and supplied and on follow-up consultations where treatment regimens are monitored. Interviews will be conducted with patients and their informal carers. Focus-groups will be carried out with healthcare professionals at the conclusion of the study. These several will be analysed using thematic analysis. This research is funded by the Department for Employment and Learning in Northern Ireland (Awarded February 2012).

Discussion
Dissemination of these findings will contribute to the understanding of issues involved when communicating with people about oral chemotherapy. It is anticipated that findings will inform education, practice and policy.

Up close and personal: A qualitative study exploring the lived experience of older carers. Mental Health and Learning Disabilities Research. 8 (1). Pp.15-29.

This study explored the experiences of informal carers who were aged 65 years and over. It has been estimated that 15 per cent of those aged 65 or over provide some form of informal care in England. Despite a growing literature on the involvement of older people in research, there is a paucity of literature on the involvement of older carers. In this study, older carers were identified via a General Practice (GP) register in one urban medical practice. Data was collected through a series of focus groups, which were transcribed and analysed using
thematic analysis. Every carer aged 55 or over and registered with the medical practice was invited to take part in the study. Four female carers and one male carer took part in the study (age range 65-83). Themes that emerged during data analysis included, 1) managing things in an emergency, 2) feeling valued because they took part in the research and 3) the day-to-day reality of living with social exclusion. GP registers provide a valuable tool for identifying older
carers who may otherwise be difficult to engage in research. However, persuading GPs to engage with qualitative research may be a challenge.