Using Social Worlds Theory to Explore Influences on Community Nurses’ Experiences of Providing Out of Hours Paediatric Palliative Care

Abstract Background: Paediatric oncology palliative care in the community is rare and nationally there is a lack of standardisation of out of hours nursing service provision. Objectives: This paper seeks to explore influences on the experiences of paediatric nurses providing out of hours palliative care within the family home to children with cancer. The study used social worlds theory to aid identification and demonstration of the findings. Methods: Twelve community-based palliative cases were purposively selected from children with cancer treated at one regional centre. Tape-recorded interviews were undertaken with 54 health professionals (general practitioners, community nurses and allied health professionals) involved in providing their palliative care and five facilitated case discussions completed. Data analysis followed a grounded theory approach; chronological comparative data analysis identifying generated themes. Social worlds theory was used as a framework to examine the data. Results: Nurses’ experiences are shaped by their social world and those of the nursing team,child and family and the inter-professional team providing the care. The lack of a formalised service, sub-optimal inter-professional working and impact of social worlds influence the experience of the nurse. Conclusions: Social worlds theory provided a new perspective in understanding these experiences based within a paediatric palliative care setting, knowledge that can be used to inform service provision.

Exploring the Experiences of Community-based Children's Nurses Providing Palliative Care

Aim: To explore the experiences of community children’s nurses (CCNs) and children’s palliative care nurses (CPCNs) who provide end-stage palliative care to children with cancer in the family home. Method: A qualitative approach was adopted. One-to-one interviews and facilitated case discussions were undertaken with 30 community nurses who had provided palliative care to a child or young person with cancer. A grounded theory approachwas used for data analysis. Findings: Because of the relative rarity of childhood cancer many CCNs and CPCNs engage infrequently in the palliative care of children or young people. This makes it difficult for them to develop and maintain knowledge and skills. There is a variation in the out-of-hours service provision available to families. Conclusion: Further funding is needed to develop teams of trained, experienced CCNs and CPCNs who can provide palliative care for children and young people 24 hours a day and 365 days a year. Keywords Community nursing, oncology, out-of-hours services, palliative care

A community nurse referral system for HMRs: Can it work?

The HMR model contains a mechanism whereby anyone who is concerned about the risk of medication misadventure can request a HMR from the patient's GP. Since nurses are widely involved in a range of triage and gatekeeping roles, utilising their primary care skills to identify patients for a HMR is a logical extension of this role. Furthermore, community nurses visit their clients in the home situation and see many difficulties the client may be experiencing at first hand. They are therefore well placed to request specialist assistance for the client. Blue Care in Brisbane, a community nursing service, approached its local Division of General practice to determine how best to request HMRs for its clients. The Division contacted The University of Queensland which initiated this study to engage the health care team to tailor the established HMR request process to the needs of community nurses and test the system developed. (non-author abstract)

Palliative care at home: general practitioners working with palliative care teams

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care-can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

How well do general practitioners deliver palliative care? A systematic review

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.

A Strategy for Nursing Midwifery and Health Visiting in NI (PDF 180KB)

This study was designed to examine critically the impact of a government-led policy document upon community nursing, midwifery and health visiting practice in Northern Ireland (Strategy for Nursing, Midwifery and Health Visiting in Northern Ireland. Action Plan for Community Nurses, Midwives and Health Visitors, Working Together: A Focus on Health and Social Well-being, DHSS, 1996). The total number of participants was (n=409) and the eleven Health and Personal Social Services Trusts in NI were represented in the sample group which consisted of 93% females and 7% males. A questionnaire containing twenty items was designed and a pilot study was carried out with twenty-five community practitioners. Following the pilot study appropriate modifications were made to the questionnaire. åÊ

La consulta de terapia antitrombótica: progresando hacia la Enfermería de Práctica Avanzada.

There is currently around one million people receiving oral anticoagulants in Spain. The drug most used is acenocoumarol, which requires coagulation monitoring to ensure that the patient is within its normal therapeutic range. Patients usually start this treatment in a hospital clinic and, when they are stabilised, they are referred to primary care, where they are followed-up by their community nurses. The usual practice is that nurses are responsible for changes in the dose when the patients are outside the range. This practice is not performed by hospital nurses, despite having sufficient experience and knowledge to adequately manage these types of patients. An Advanced Nursing Practice model has been introduced into the Haematology management unit of the Hospital Universitario Virgen de la Victoria, Málaga. This involves various aspects of attention and care of patients on anticoagulant therapy, and includes adjusting the doses of their treatment following a catalogue of therapeutic and diagnostic ranges.

Description des pratiques vaccinales d’infirmières en situation de refus parental avant et après une formation interactive

Malgré les succès spectaculaires de l’immunisation comme mesure de santé publique, certains parents continuent de refuser de vacciner leurs enfants (Diekema, 2005). C’est pourquoi qu’au cours des dernières décennies, des éclosions de maladies évitables par la vaccination comme la rougeole et la coqueluche ont été observées au Canada, surtout chez la population non vaccinée (Hinman, 2000). Au Québec, depuis l’entrée en vigueur de la loi 90 en 2003, les infirmières peuvent procéder à la vaccination sans ordonnance individuelle ou collective conformément au Protocole d’Immunisation du Québec (PIQ). Les infirmières québécoises peuvent alors influencer positivement la couverture vaccinale (Sauvageau & al, 2005). Le but de cette étude est d’évaluer les retombées de la formation VIP (Vaccination par les Infirmières/Infirmiers-Prévention) sur les pratiques vaccinales rapportées par les infirmières (N=12) de CSSS, auprès des parents d’enfants de 0-5 ans lors d’un refus parental. En premier lieu, nous avons identifié et décrit treize pratiques vaccinales en réponse à un refus parental. Par la suite, nous avons identifié des modifications dans certaines des treize pratiques rapportées tel qu’une augmentation dans la description des pratiques de correction des fausses croyances des parents, une amélioration de la justesse des pratiques d’explication et une personnalisation des pratiques décrites. En conclusion, la formation offerte aux infirmières doit permettre à celles-ci d’identifier les préoccupations parentales et d’y répondre adéquatement en utilisant une information juste et individualisée.

Género y profesión en la evolución histórica de la Enfermería Comunitaria en España

El ámbito comunitario y de salud pública es probablemente el contexto donde las enfermeras han logrado mayores cotas de autonomía profesional y donde su contribución ha sido valorada en mayor medida. No obstante, todavía persisten grandes obstáculos para el pleno desarrollo, algunos de ellos vinculados a la variable género. Por ello, resulta relevante analizar, para el caso español, los antecedentes históricos de esta situación, en la medida que puede ayudar a entender muchos de los problemas y deficiencias que sigue mostrando la Enfermería Comunitaria en la actualidad. Las enfermeras comunitarias contribuyeron al desarrollo de la salud pública en la España contemporánea, proceso que se inició en los años 1920 y que culminó durante la Segunda República, pero el periodo franquista supuso un importante freno al proceso de profesionalización. A través del ejemplo del conflicto público entre enfermeras visitadoras y practicantes, que se gestó en la Segunda República, y se prolongó durante todo el periodo franquista, se analiza cómo el discurso de género estuvo presente, entre otros condicionantes, en la evolución de la Enfermería española y cómo ha venido contribuyendo, hasta nuestros días, en la estructuración de las competencias, y la distribución de responsabilidades y poder.

COPING STRATEGIES AND PSYCHOLOGICAL WELL-BEING AMONG BHUTANESE REFUGEES RESETTLED IN OTTAWA, CANADA

Since 2008, more than 6000 Bhutanese refugees have been resettled in over 21 communities across Canada, with nearly 300 individuals residing in Ottawa. This resettling process is associated with physical and psychological stress, as individuals acclimatize to a new country. A lack of understanding of the impact of this transition exists. This study assessed the relationship between coping strategies and psychological well-being of Bhutanese refugees resettled in Ottawa. A cross sectional survey of a representative sample of Bhutanese adults (n = 110) was conducted between November and December 2015. Coping strategies and psychological well-being were measured using the Brief COPE and General Well-being (GWB) scales. The total GWB mean score of 69.04 ± 12.09 suggests that respondents were in moderate distress. GWB did not significantly differ by sex, marital status, religion, employment, part time or full time job, or length of stay in Canada. Using multiple linear regression, significant independent variables from univariate analysis with GWB (age, education, positive reframing, self-blame and venting) were modeled to determine the best predictors of general well-being (GWB, F (11, 96) = 3.61, p < .001, R² = 21.2%). Higher levels of education and positive reframing were associated with greater GWB scores while self-blame and ages 41-50 were inversely associated with general well-being. It was found that above 66% of the unemployed participants were from age groups 41 and above. This finding suggests that career guidance services and vocational training to address unemployment may benefit this community. Nurses can provide support and counselling to assist refugees to minimize the use of negative coping strategies like self-blame and venting and promote positive coping strategies. Further, collaboration between nurses, other interdisciplinary professionals and community organizations is necessary to address social determinants of health and enhance refugee psychological well-being.

Caring for Children Dying from Cancer at Home: a Qualitative Study of the Experience of Primary Care Practitioners

Background. The rarity of childhood cancers makes providing palliative care in the community an unusual event for primary care practitioners. Providing this care requires effective interprofessional collaboration with the team that forms to provide the care often working together for the first and only time. Objective. To explore the experiences of primary care practitioners following their involvement in the palliative care of a child with cancer at home. Methods. The study design was a community-based qualitative study. The study location was the West Midlands region. Purposeful sample of GPs and community nurses involved in providing palliative care to 12 children. One-to-one in-depth interviews with 47 primary care professionals (10 GPs and 37 community nurses) and 5 facilitated case discussions were undertaken. Field notes were documented and grounded theory data analysis undertaken: chronological comparative data analysis identifying generated themes. Results. GPs had minimal input into the preceding care of children undergoing treatment for cancer but sought to re-establish their role at the child’s transition to palliative care. GPs felt they had a role to play and could add value to this phase of care, highlighted their continuing role with the child’s family and acknowledged that they had gained from the experience of contributing. However, lack of specialist knowledge and uncertainty about their role within the team made this more challenging. In contrast, community nurses were routinely involved in both active treatment and palliation care phases. There was little evidence of collaboration between the specialist and primary care professionals involved. There was considerable variation in out of hours provision across cases. Conclusions. Engaging primary care practitioners needs to be more actively anticipated and negotiated at the transition to palliation. Variation in out of hours care is another cause for concern. Enhancing inter-professional collaboration and planning during both active and palliative care phases may help. Keywords. Cancer, family medicine, palliative care, paediatric.

Providing Palliative Care for the Child with Cancer: The Experience of GPs

Background Childhood cancers are rare and general practitioners (GPs) have limited experience in caring for these children and even less in providing their palliative care. Most families prefer that their child is cared for at home in the palliative phase of their illness, with professional support from those known to them (Chambers and Oakhill 1995, Vickers and Carlisle 2000, Craft and Killen 2007). A community based qualitative study examined the experiences of ten GPs following their involvement in the care of a child with cancer receiving palliative care within the family home. Methods Data collection was through 1:1 in-depth interviews and facilitated case discussion supported by field notes and grounded theory analysis (chronological comparative data analysis identifying generated themes). Social worlds theory was used as a framework to aid examination, and facilitate critical understanding, of the experiences of the GPs. Findings This presentation focuses on five of the findings relating to the experiences of the GP; the impact of minimal contact; lack of knowledge and experience, uncertain role, out of hours service provision and the emotional toll. Findings highlighted that GPs often have to re-establish their role at the child’s transition to palliative care. Factors hindering the GP in this process include a deficit of specialist knowledge and experience of paediatric palliative care and lack of role clarity. Conclusions/points of interest Strategies for enhancing the role of the Macmillan team in supporting GPs have been identified by this study, such as enhanced collaborative working. Findings have also provided further confirmation of the substantial variation in out of hours medical palliative care provision; with evidence that some GPs work beyond their remit in providing informal out of hours care. This presentation details the findings of one aspect (the experiences of GPs) of a wider study that explored the experiences of 54 community based health professionals (GPs, community nurses and allied health professionals) who had been involved in caring for a dying with cancer receiving palliative care at home (Neilson 2009).

Supervision of Community Health Agents in the Family Health Strategy: the perspective of nurses

Objective Analyzing the conceptions of supervision of nurses in the Family Health Strategy (ESF - Estratégia Saúde da Família) in relation to community health workers (ACS – Agente Comunitário de Saúde), taking for reference the work process and the power relations. Method A qualitative study, in which 18 interviews were carried out with nurses from the ESF in the countryside of the state of Goiás. Following transcription, the data were subjected to thematic content analysis and the following categories were identified: Supervision with that sees it all and Supervision is participating and working together. Results Among the findings, it is clear the character of control and monitoring that is carried out primarily through printed instruments and home visits, which constitute vertical and impositive relations, and suffer influence of the local health management. Another finding is the supervision as acting together and with the educational perspective. Conclusion The supervision carried out does not provide the changes intended by the ESF.

Attitudes of second year diploma nurses in three community colleges toward the use of computers in the nursing role /

The effectiveness of various kinds of computer programs is of concern to nurse-educators. Using a 3x3 experimental design, ninety second year diploma student nurses were randomly selected from a total population at three community colleges in Ontario. Data were collected via a 20-item valid and reliable Likert-type questionnaire developed by the nursing profession to measure perceptions of nurses about computers in the nursing role. The groups were pretested and posttested at the beginning and end of one semester. Subjects attending College A group received a computer literacy course which comprised word processing with technology awareness. College B students were exposed to computer-aided instruction primarily in nursing simulations intermittently throughout the semester. College C subjects maintained their regular curriculum with no computer involvement. The student's t-test (two-tailed) was employed to assess the attitude scores data and a one-way analysis of variance was performed on the attitude scores. Posttest analysis revealed that there was a significant difference (p<.05) between attitude scores on the use of computers in the nursing role between College A and C. No significant differences (p>.05) were seen between College B and A in posttesting. Suggestions for continued computer education of diploma student nurses are provided.