Showing papers in "Journal of Advanced Nursing in 2004"

Methodological rigour within a qualitative framework

Abstract: Aim. This paper discusses the literature on establishing rigour in research studies. It describes the methodological trinity of reliability, validity and generalization and explores some of the issues relating to establishing rigour in naturalistic inquiry. Background. Those working within the naturalistic paradigm have questioned the issue of using validity, reliability and generalizability to demonstrate robustness of qualitative research. Triangulation has been used to demonstrate confirmability and completeness and has been one means of ensuring acceptability across paradigms. Emerging criteria such as goodness and trustworthiness can be used to evaluate the robustness of naturalistic inquiry. Discussion. It is argued that the transference of terms across paradigms is inappropriate; however, if we reject the concepts of validity and reliability, we reject the concept of rigour. Rejection of rigour undermines acceptance of qualitative research as a systematic process that can contribute to the advancement of knowledge. Emerging criteria for demonstrating robustness in qualitative inquiry, such as authenticity, trustworthiness and goodness, need to be considered. Goodness, when not seen as a separate construct but as an integral and embedded component of the research process, should be useful in assuring quality of the entire study. Triangulation is a tried and tested means of offering completeness, particularly in mixed-method research. When multiple types of triangulation are used appropriately as the ‘triangulation state of mind’, they approach the concept of crystallization, which allows for infinite variety of angles of approach. Conclusion. Qualitative researchers need to be explicit about how and why they choose specific legitimizing criteria in ensuring the robustness of their inquiries. A shift from a position of fundamentalism to a more pluralistic approach as a means of legitimizing naturalistic inquiry is advocated.

Instrument translation process: a methods review

Abstract: Background. Cross-cultural and international collaborative studies are needed in nursing research. Therefore, it is necessary to translate research instruments into the language of the culture being studied. In this methods review, different processes of instrument translation and evaluation of translation adequacy in published nursing research are described and classified into a hierarchy. Methods. Studies including translation of quantitative research instruments were reviewed. Forty-seven studies were included. These were classified into six categories. Results. Studies were classified into categories as follows: forward-only translation (2), forward-only translation with testing (7), back-translation (13), back-translation with monolingual test (18), back-translation with bilingual test (3), and back-translation with both monolingual and bilingual test (4). Strengths and weaknesses are analysed. Conclusion. The studies reviewed used diverse methods of varying quality. There is need for consensus among researchers in how to achieve quality of instrument translation in cross-cultural research. Researchers should carefully attend to achieving and reporting evidence of the accuracy and validity of instrument translation. When back-translation fails to achieve semantic equivalence, the instrument development process should be replicated in the target language.

What counts as evidence in evidence-based practice?

Abstract: Background. Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. Aim. This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. Discussion. Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. Conclusion. Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.

Focus group interviews as a data collecting strategy

Abstract: Background. Focus group interviews are a method for collecting qualitative data and have enjoyed a surge in popularity in health care research over the last 20 years. However, the literature on this method is ambiguous in relation to the size, constitution, purpose and execution of focus groups. Aim. The aim of this article is to explore some of the methodological issues arising from using focus group interviews in order to stimulate debate about their efficacy. Discussion. Methodological issues are discussed in the context of a study examining attitudes towards and beliefs about older adults in hospital settings among first-level registered nurses, nursing lecturers and student nurses. Focus group interviews were used to identify everyday language and constructs used by nurses, with the intention of incorporating the findings into an instrument to measure attitudes and beliefs quantitatively. Conclusions. Experiences of conducting focus group interviews demonstrated that smaller groups were more manageable and that groups made up of strangers required more moderator intervention. However, as a data collecting strategy they are a rich source of information.

Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health

Abstract: Background. Much attention has been paid to the problem of postpartum depression in women. However, there is some indication that men also experience depression after the birth of a child, and that paternal depression is linked to maternal depression. Aims. The purpose of this integrative review was to examine current knowledge about postpartum depression in fathers. Specific aims were (1) to examine the incidence of paternal depression in the first year after the birth of a child, (2) to identify the characteristics and predictors of paternal postpartum depression, (3) to describe the relationship between maternal and paternal postpartum depression, and (4) to discuss the influence of paternal depression on the family and infant. Methods. A literature search from 1980 to 2002 was carried out using the CINAHL, PsychInfo, and Medline electronic databases. Twenty research studies were identified that included incidence rates of paternal depression during the first year postpartum. These were further examined and synthesized regarding onset, severity, duration, and predictors of paternal depressive symptoms, and for information about the relationship between maternal and paternal depression. Findings. During the first postpartum year, the incidence of paternal depression ranged from 1·2% to 25·5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period. The implications of parental depression for family health were discussed. Conclusions. Postpartum depression in men is a significant problem. The strong correlation of paternal postpartum depression with maternal postpartum depression has important implications for family health and well-being. Consideration of postpartum depression in fathers as well as mothers, and consideration of co-occurrence of depression in couples, is an important next step in research and practice involving childbearing families.

Factors related to childbirth satisfaction.

Abstract: Background. A woman's satisfaction with the childbirth experience may have immediate and long-term effects on her health and her relationship with her infant, but there is a lack of current research in this area. Aim. This paper reports a study to examine multiple factors for their association with components of childbirth satisfaction and with the total childbirth experience. Method. A correlational descriptive study was conducted with 60 low-risk postpartum women, aged 18–46 years, with uneventful vaginal deliveries of healthy full-term infants at two medical centres in the south-eastern United States. The Labor Agentry Scale, McGill Pain Questionnaire and Mackey Childbirth Satisfaction Rating Scale and a background questionnaire were completed by women. Obstetrical data were collected from the medical record. Findings. Personal control was a statistically significant predictor of total childbirth satisfaction (P = 0·0045) and with the subscale components of satisfaction (self, partner, baby, nurse, physician and overall). In addition, having expectations for labour and delivery met was a significant predictor of satisfaction with own performance during childbirth. Conclusions. Personal control during childbirth was an important factor related to the women's satisfaction with the childbirth experience. Helping women to increase their personal control during labour and birth may increase the women's childbirth satisfaction.

Psychological distress: concept analysis.

Abstract: Background. The term ‘distress’ is frequently used in nursing literature to describe patient discomfort related to signs and symptoms of acute or chronic illness, pre- or post-treatment anxiety or compromised status of fetuses or the respiratory system. ‘Psychological distress’ may more accurately describe the patient condition to which nurses respond than does the term ‘distress’. Psychological distress is seldom defined as a distinct concept and is often embedded in the context of strain, stress and distress. This creates confusion for nurses attempting to manage the care of people experiencing psychological distress. Aims. This paper is a concept analysis of psychological distress based on Walker and Avant's (1995) criteria that identifies the attributes, antecedents, and consequences of psychological distress based upon the findings of the literature review. In addition, empirical references are identified and constructed cases presented. Methods. A literature search was conducted using MEDLINE, CINAHL, Ovid, PsychINFO, and Cancer Lit databases over the last 50 years. The purposes of this concept analysis were: (1) to establish the concept of psychological distress as a clear and distinct concept, separate from strain, stress and distress, and (2) to provide nurses with a base of knowledge from which to plan effective clinical interventions. Findings. Content analysis of the literature revealed that, although used frequently in health care literature, the origin of the concept of psychological distress has not been clearly articulated and is ill-defined. Conclusions. Psychological distress is a serious problem faced by many of the people whom nurses encounter on a daily basis. An understanding of the concept of psychological distress will help nurses ameliorate this problem in patients. Nursing research related to the exploration of psychological distress is also needed.

Emotional intelligence in nursing work.

Abstract: Background Emotional labour has been widely accepted in the literature as part of nursing work, however the contribution of emotional intelligence in the nursing context requires further study. Aim This paper aims to present an analysis of the literature on emotional intelligence and emotional labour, and consider the value of emotional intelligence to nursing. Method A literature search was undertaken using the CINAHL and MEDLINE databases. Search terms used were 'emotions', 'intelligence', 'emotions and intelligence' and 'emotional labour'. A hand-search of relevant journals and significant references added to the data. Results Emotional intelligence plays an important part in forming successful human relationships. Emotional labour is important in establishing therapeutic nurse-patient relationships but carries the risk of 'burnout' if prolonged or intense. To prevent this, nurses need to adopt strategies to protect their health. The potential value of emotional intelligence in this emotional work is an issue that still needs to be explored. Conclusions Analysis of the literature suggests that the modern demands of nursing draw on the skills of emotional intelligence to meet the needs of direct patient care and co-operative negotiations with the multidisciplinary team. The significance of this needs to be recognized in nurse education. The link between emotional intelligence and emotional labour is a fruitful area for further research. The potential benefits of gaining a better understanding of how these concepts interact is largely conjecture until we have more evidence. The prospect that there may be advantages to both nurses and patients is a motivating factor for future researchers.

Advanced practice nursing roles: development, implementation and evaluation

Abstract: Aim. The aim of this paper is to discuss six issues influencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to define clearly the roles and goals, role emphasis on physician replacement/support, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation. Background. Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reflect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conflict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles. Discussion. Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for defining the specific nature and goals for introducing new APN roles. The concept of advancement further defines the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles. Advanced practice nursing refers to the whole field, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place. Conclusions. Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to predetermined goals.

Stressors, burnout and social support: nurses in acute mental health settings.

Abstract: Aims. This paper reports a study which aims (1) to investigate and compare levels of stressors and burnout of qualified and unqualified nursing staff in acute mental health settings; (2) to examine the relationships between stressors and burnout and (3) to assess the impact of social support on burnout and stressor–burnout relationships. Background. Several studies have noted that the work of mental health nurses can be highly stressful, but relatively few have focused specifically on staff working in acute inpatient settings. Although many of the pressures faced by this group are similar to those in other nursing specialities, a number of demands relate specifically to mental health settings, including the often intense nature of nurse–patient interaction and dealing with difficult and challenging patient behaviours on a regular basis. Methods. A convenience sample of 93 nursing staff from 11 acute adult mental health wards completed the Mental Health Professionals Stress Scale, Maslach Burnout Inventory and House and Wells Social Support Scale. Results. Lack of adequate staffing was the main stressor reported by qualified staff, while dealing with physically threatening, difficult or demanding patients was the most stressful aspect for unqualified staff. Qualified nurses reported significantly higher workload stress than unqualified staff. Approximately half of all nursing staff showed signs of high burnout in terms of emotional exhaustion. A variety of stressors were positively correlated with emotional exhaustion and depersonalization. Higher levels of support from co-workers were related to lower levels of emotional exhaustion. Higher stressor scores were associated with higher levels of depersonalization for staff reporting high levels of social support, but not for those reporting low levels of support (a reverse buffering effect). Conclusions. Qualified and unqualified nursing staff differed in terms of the prominence given to individual stressors in their work environment. The findings were consistent with the notion of burnout developing in response to job-related stressors. While staff support groups may be useful in alleviating feelings of burnout, the reverse buffering effect suggests that they should be structured in a way that minimizes negative communication and encourages staff to discuss their concerns in a constructive way.

Nurse competence scale: development and psychometric testing.

Abstract: Background. Self-assessment assists nurses to maintain and improve their practice by identifying their strengths and areas that may need to be further developed. Professional competence profiles encourage them to take an active part in the learning process of continuing education. Although competence recognition offers a way to motivate practising nurses to produce quality care, few measuring tools are available for this purpose. Aim. This paper describes the development and testing of the Nurse Competence Scale, an instrument with which the level of nurse competence can be assessed in different hospital work environments. Methods. The categories of the Nurse Competence Scale were derived from Benner's From Novice to Expert competency framework. A seven-step approach, including literature review and six expert groups, was used to identify and validate the indicators of nurse competence. After a pilot test, psychometric testing of the Nurse Competence Scale (content, construct and concurrent validity, and internal consistency) was undertaken with 498 nurses. The 73-item scale consists of seven categories, with responses on a visual analogy scale format. The frequency of using competencies was additionally tested with a four-point scale. Results. Self-assessed overall scores indicated a high level of competence across categories. The Nurse Competence Scale data were normally distributed. The higher the frequency of using competencies, the higher was the self-assessed level of competence. Age and length of work experience had a positive but not very strong correlation with level of competence. According to the item analysis, the categories of the Nurse Competence Scale showed good internal consistency. Conclusion. The results provide strong evidence of the reliability and validity of the Nurse Competence Scale.

Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self‐regulated learning theory

Abstract: Background Effective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skills While a number of strategies have been implemented and tested to promote these skills, educators have not been able consistently to predict their development Self-regulated learning theory suggests that this development requires concurrent attention to both the cognitive and metacognitive dimensions of reasoning in nursing care contexts Aims This paper reports on a study to explore the impact of self-regulated learning theory on reflective practice in nursing, and to advance the idea that both cognitive and metacognitive skills support the development of clinical reasoning skills Methods Integrative review of published literature in social science, educational psychology, nursing education, and professional education using the Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resource Information Center (ERIC), and American Psychological Association (PsychInfo) Databases The search included all English language articles with the key words clinical reasoning, cognition, critical thinking, metacognition, reflection, reflective practice, self-regulation and thinking Findings Reflective clinical reasoning in nursing practice depends on the development of both cognitive and metacognitive skill acquisition This skill acquisition is best accomplished through teaching–learning attention to self-regulation learning theory A critical analysis of the literature in the areas of critical thinking and reflective practice are described as a background for contemporary work with self-regulated learning theory It is apparent that single-minded attention to critical thinking, without attention to the influence of metacognition or reflection, is but one perspective on clinical reasoning development Likewise, single-minded attention to metacognition or reflection, without attention to the influence of critical thinking, is another perspective on clinical reasoning development While strategies to facilitate critical thinking and reflective practice have been used in isolation from each other, there is evidence to suggest that they are inextricably linked and come together with the use of self-regulated learning prompts Conclusions Students and practising nurses are able to improve their cognitive and metacognitive skills in clinical contexts by using self-regulated learning strategies The self-regulated learning model in nursing is offered to support teaching and learning of reflective clinical reasoning in nursing practice contexts

A framework for the introduction and evaluation of advanced practice nursing roles

Abstract: Aim. This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework). Background. Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework. Conclusions. The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.

Parenthood experiences during the child's first year: literature review.

Abstract: Parenthood experiences during the child's first year: literature review Background. Raising a child is probably the most challenging responsibility faced by a new parent. The first year is the basis of the child's development and is sig- nificant for growth and development. Knowledge and understanding of parents' experiences are especially important for child health nurses, whose role is to support parents in their parenthood. Aim. The aim of this review was to describe mothers' and fathers' experiences of parenthood during the child's first year. Method. A literature search covering 1992-2002 was carried out using the terms parenthood, parenting, first year, infancy and experience. Of the 88 articles re- trieved, 33 articles (both qualitative and quantitative) met the inclusion criteria and corresponded to the aim of this review. The data were analysed by thematic content analysis. Findings. Being a parent during the child's first year was experienced as over- whelming. The findings were described from two perspectives, namely mothers' and fathers' perspectives, since all the included studies considered mothers' and fathers' experiences separately. The following categories were identified con- cerning mothers: being satisfied and confident as a mother, being primarily responsible for the child is overwhelming and causes strain, struggling with the limited time available for oneself, and being fatigued and drained. The following categories were found for fathers: being confident as a father and as a partner, living up to the new demands causes strain, being prevented from achieving closeness to the child is hurtful, and being the protector and the provider of the family. The unifying theme for these categories was 'living in a new and over- whelming world'. Conclusion. There is a need for nurse interventions aimed at minimizing parents' experiences of strain. A suggested intervention is to find a method whereby child health nurses' support would lead to parents becoming empowered in their parenthood.

Predictors of health behaviours in college students.

Abstract: Journal of Advanced Nursing 48(5), 463–474Predictors of health behaviours in college studentsAim. This paper reports a study examining the direct effects of perceived stress,perceived availability of and satisfaction with social support, and self-efficacy, andexamines the intermediary roles of perceived threat (perceived susceptibility ·perceived severity), benefits, and barriers on alcohol behaviour, smoking behaviour,physical activity and nutrition behaviour, general safety behaviour and sun-pro-tective behaviour in college students.Background. Health behaviours formed during young adulthood may have a sus-taining impact on health across later life. Entering college can be an exciting, yetstressful event for many adolescents and young adults as they face trying to adapt tochanges in academic workloads, support networks, and their new environment.Coupled with these changes and new-found responsibilities, they have greaterfreedom and control over their lifestyles than ever before. However, researchershave shown globally that many college students engage in various risky healthbehaviours.Method. A cross-sectional sample of 161 college students enrolled in an introduc-tory psychology course completed self-report questionnaires regarding stress; socialsupport; self-efficacy; and components of the Health Belief Model including per-ceived threat, perceived benefits, perceived barriers; and common health behaviours.Step-wise multiple regression analysis was conducted and significant predictors wereretained as modifiers in the path analysis.Findings. Self-efficacy significantly predicted alcohol and smoking behaviour,physical activity and nutrition protective behaviour, general safety protectivebehaviour and sun-protective behaviour. Under high-perceived threat, self-efficacywas mediated by perceived barriers for binge drinking and moderated by perceivedbarriers for physical activity and nutrition behaviours. In addition, under

Enhancing Delphi research: methods and results.

Abstract: Background. The Delphi method provides an opportunity for experts (panelists) to communicate their opinions and knowledge anonymously about a complex problem, to see how their evaluation of the issue aligns with others, and to change their opinions, if desired, after reconsideration of the findings of the group's work. Delphi studies have the potential to provide valuable information, yet few researchers have taken further steps to support or refine their findings. Without this step there is a potential threat to the applicability, or external validity, of the results. Aims. The purpose of this article is to present an argument for further inquiry to enhance and support Delphi findings, and specific approaches to this will be considered. Methods. Methods to enhance, expand, or refine Delphi study findings are described. Mixed method design within a Delphi study on midwifery practice is described, and a follow-up narrative study to examine the findings is presented. Findings. Selected results from the follow up narrative study are presented to convey how the narrative data clarified the Delphi findings. Together, the studies provide a more robust depiction of midwifery practice, process, and outcomes. Although there were similarities to the dimensions identified previously, there was a more dynamic focus and explanation of the interaction between the midwife, the woman who had received midwifery care, and the health care system. Study limitations. Lack of diversity in the sample and the midwives’ familiarity with the author's past research represent a potential threat to the findings. Prolonged interviews and multiple narratives were gathered in an effort to control for this. Conclusion. Delphi studies are research exercises conducted by a panel of experts. Designing studies to further enhance, clarify, or refine their findings from the context of practice holds promise for their ability to influence clinical care.

Grounded theory: reflections on the emergence vs. forcing debate

Abstract: Aim. The aim of this paper is to compare Glaser's model of theory generation, where theory rises directly and rigorously out of the data, devoid of interpretivism, to Strauss's conceptually descriptive approach that encourages directive questioning and supports an interpretive stance. Background. The discovery of grounded theory (GT) was born out of a merger between Barney Glaser and Anselm Strauss, the proverbial ‘fathers’ of GT. Since the co-creation of their approach to theory development through research in 1967, these scholars have taken seemingly divergent paths in further developing and evolving the pragmatic use of GT. Discussion. Numerous researchers have used GT as a general method, applying it to both quantitative and qualitative research approaches. In this paper we discuss the stages and strategies of data sampling, collection, coding and analysing used by both Glaser and Strauss. Constant comparative analysis is identified as the primary strategy in the integrated coding and analysing stages of this theorizing method, regardless of the researcher's philosophical or research orientation. We also discuss initial or open coding, advanced coding, memoing, and theoretical sampling, with particular attention to comparing and contrasting the descriptive terms and application strategies that have been suggested by both Glaser and Strauss. Conclusion. The reported distinctions in the approach, method, and general intent of GT reflected in this paper are not easy to comprehend. The two methods reflect different basic philosophical paradigms, and therefore represent distinct approaches to GT. Researchers need to be clear about which philosophy and resulting analysis approach they are using, and the effect that approach will have on the research process and outcomes.

Altered body image: appearance-related concerns of people with visible disfigurement

Abstract: Aim. The aim of this paper is to report a study to establish the extent and type of psychosocial needs of outpatients attending for treatment of a wide range of disfiguring conditions. Background. Visible disfigurements can be associated with extensive psychosocial difficulties. The majority of research to date has been carried out with people identified by themselves or others as experiencing difficulties. Little is known about levels of distress in the broader population of patients receiving treatment for a range of disfiguring conditions. Methods. A cross-sectional survey was conducted, with a convenience sample. Participants (n = 458) drawn from 15 outpatient clinics completed standardized measures of anxiety and depression (Hospital Anxiety and Depression Scale), social anxiety and avoidance (Derriford Appearance Scale short-form) and quality of life (World Health Organization Quality of Life Brief Scale). A semi-structured interview was used to generate further quantitative and qualitative data about individual concerns, and satisfaction with the provision of care. Staff views about levels of psychosocial distress were elicited through group discussions. Results. The results revealed high levels of psychological distress in the sample, compared with normative values. The majority of difficulties related to problems experienced in social situations. Patient satisfaction with care was generally high; however, and 71% of participants expressed a moderate to strong desire for a health care professional with training to deal with their appearance-related concerns. Nursing staff felt unable to address patients' appearance-related difficulties because of time constraints, lack of an environment conducive to the discussion of patients' concerns, and lack of appropriate knowledge and training. Conclusion. A significant proportion of participants experienced psychosocial distress in relation to their visible difference. Psychosocial needs were poorly met in current outpatient care provision, and a range of options could be considered to address these more effectively.

Nurse-patient relationships in palliative care.

Abstract: Aim. The aim of this paper is to report a study exploring aspects of nurse–patient relationships in the context of palliative care. Background. Although there are numerous studies addressing nurse–patient relationships, little research has focused on these in the context of palliative are. Furthermore, no previous study has examined the relationship in the Chinese context. Methods. Qualitative data were collected from 10 hospice nurses and 10 terminally ill patients by means of open ended unstructured interviews. Respondents were asked to reflect on practices and incidents that would allow an understanding of the meaning of nurse–patient relationships in palliative care. Results. Four major categories emerged from the perspectives of patients and nurses: (1) forming a relationship of trust; (2) being part of the family; (3) refilling with fuel along the journey of living and dying; and (4) enriched experiences. Responses revealed that a relationship of trust is formed, and that nurses are not only regarded as health professionals, but also become part of the family or a good friend. Nurses who develop trusting relationships demonstrate a holistic approach to caring, show their understanding of patients’ suffering, are aware of their unvoiced needs, provide comfort without actually being asked, and are reliable, proficient, competent and dedicated in their care. Conclusion. Trust, the achievement of the goals of patients and nurses, caring and reciprocity are important elements of nurse–patient relationships in palliative care. Such relationships not only improve patients’ physical and emotional state, but also facilitate their adjustment to their illness, ease pain and can ultimately lead to a good death experience. It is nurses’ personal qualities and skills, which are embedded in these relationships, that constitute excellence in nursing care. Nurses also derive satisfaction and are enriched through the relationships.

Men nurses: a historical and feminist perspective

Abstract: Background. The history of nursing is almost exclusively a history of women's accomplishments despite the fact that, as early as the fourth and fifth centuries, men have worked as nurses. This perpetuates the notion of men nurses as anomalies. It also provides insight into the gendered nature of nursing and nurses’ work within patriarchal culture. Aim. This paper examines the history of men in nursing in Canada, Britain and the United States of America, and offer insights into the ways in which gender relations and the ideological designation of nursing as women's work have excluded, limited and, conversely, advanced the careers of men nurses. Method. A search of the literature was carried out using CINAHL, PubMed and Sociological Abstracts databases. Search words included: male nurses, history, nursing, Canada, Britain, United Kingdom and USA. Discussion. Men's participation in nursing reveals that prevailing definitions of masculinity have acted as a powerful barrier to men crossing the gender divide and entering the profession. At extraordinary times such as war and acute nursing shortages, gender boundaries are negotiable. For those men who have crossed over into nursing, a gendered division of labour is evidenced by men nurses’ long-standing association with mental health nursing and, more recently, with their disproportionate attainment of masculine-congruent leadership and specialty positions. Conclusion. Failure to recognize men's participation in nursing leaves men nurses with little information about their professional background and historical position. It also maintains the invisibility of gender relations that have shaped the experience of men and women nurses alike. Such relations, understood within their broader social context, remain poorly understood and hence uninterrupted, to the detriment of nurses and the profession of nursing.

Nurse educators’ workplace empowerment, burnout, and job satisfaction: testing Kanter's theory

Abstract: Background. Empowerment has become an increasingly important factor in determining college nurse educator burnout, work satisfaction and performance in current restructured college nursing programmes in Canada. Aim. This paper reports a study to test a theoretical model specifying relationships among structural empowerment, burnout and work satisfaction. Method. A descriptive correlational survey design was used to test the model in a sample of 89 Canadian full-time college nurse educators employed in Canadian community colleges. The instruments used were the Conditions of Work Effectiveness Questionnaire, Job Activities Scale, Organizational Relationship Scale, Maslach Burnout Inventory Educator Survey and Global Job Satisfaction Questionnaire. Results. College nurse educators reported moderate levels of empowerment in their workplaces as well as moderate levels of burnout and job satisfaction. Empowerment was significantly related to all burnout dimensions, most strongly to emotional exhaustion (r = −0·50) and depersonalization (r = −0·41). Emotional exhaustion was strongly negatively related to access to resources (r = −0·481, P = 0·0001) and support (r = −0·439, P = 0·0001). Multiple regression analysis revealed that 60% of the variance in perceptions of job satisfaction was explained by high levels of empowerment and low levels of emotional exhaustion [R2 = 0·596, F (1, 86) = 25·01, P = 0·0001]. While both were significant predictors of perceived job satisfaction, empowerment was the stronger of the two (β = 0·49). Conclusions. The results provide support for Kanter's organizational empowerment theory in the Canadian college nurse educator population. Higher levels of empowerment were associated with lower levels of burnout and greater work satisfaction. These findings have important implications for nurse education administrators.

Application of systematic review methods to qualitative research: practical issues

Abstract: Aim. This paper explores practical methodological issues which arise from the application of systematic review and meta-synthesis techniques to qualitative research studies in the context of a pragmatic health services research question. Background. The emphasis on, and volume of, qualitative research is increasing. As a result, there is a need to integrate and disseminate qualitative research findings. However, relatively little has been written about the methodology of systematically reviewing and meta-synthesizing qualitative research studies, and about the practical issues which arise in the course of these processes. Methods. A systematic review and meta-synthesis was undertaken of qualitative research studies reporting data relevant to the pragmatic health services research question: ‘What factors facilitate or impede role development and/or effective practice as a clinical nurse specialist, nurse practitioner, advanced nurse practitioner or consultant nurse based in acute hospital settings?’ Findings. The identification of relevant studies is substantially more time-consuming than the identification of relevant studies for a systematic review of randomized controlled trials. A substantially larger proportion of papers has to be retrieved for full reading. Articles with unclear titles which lack abstracts cannot be dismissed as irrelevant. Study appraisal and data analysis, being iterative processes, are also more time-consuming than the appraisal and meta-analysis of quantitative studies. It may be possible to reduce the frustrations inherent in the distance between the reviewer and the participants in the primary research by using full project reports rather than published articles. Conclusions. Conducting a systematic review and meta-synthesis of qualitative research studies is a rewarding but demanding activity, and adequate time and resources must be made available. Some recommendations are made which may facilitate those processes.

Enhancing the quality of hermeneutic research: decision trail

Abstract: Background. Researchers have ethical and professional obligations to produce research of a high standard. The constituents of quality in research appear to differ between authors, leaving readers unsure about which pathway to follow. This can reflect inadequate consideration of the theoretical framework guiding the study. Many papers fail to consider the theoretical underpinnings of the methodology chosen and the link between these and the methods employed. These need to be accessible to readers in order to assess the trustworthiness of the research. Aim. This paper discusses the development of trustworthiness in hermeneutic phenomenological research. Discussion. Referring to a study on lived experience of Chronic Fatigue Syndrome/myalgic encephalitis, I describe the decision trail and discuss the strengths and limitations of the choices made throughout the study. Conclusion. The methodology focused my approach more fully on the importance of recognizing the influences that I brought to the study and the impact of these in generating the data. It highlighted the fact that the process of setting out my horizon can never be complete, the importance of analysing the data at a macro and micro level, acknowledging the evolution of the data over time, and ensuring that analysis does not move beyond the data and out of the hermeneutic circle. In seeking to make the decision trail clear to others, researchers must distill the philosophical principles of the methodology and set these out in a way that is accessible and open to scrutiny.

Factors influencing decision to breastfeed.

Abstract: Background. The low prevalence and short duration of breastfeeding in international studies have highlighted the need for more investigations into the problems. International studies have identified certain factors that affect breastfeeding intentions. Due to insufficient published studies on the local breastfeeding situation, this study specifically investigated factors influencing the breastfeeding decision among primipara women in Hong Kong. Aim. The aim of this paper is to report a study investigating the personal, social, cultural, facilities and environmental and other factors contributing to women's decisions to breastfeed, and to exploring first-time mothers’ knowledge of breastfeeding and its influence on their breastfeeding intentions. Methods. Three private and 10 public hospitals in Hong Kong participated in the study. Both quantitative and qualitative data were collected through questionnaires and subsequently by in-depth interviews with 230 first-time mothers 24–48 hours after delivery. Results. The results indicated that personal, cultural, social, and environmental factors are common influencing factors in the decision to breastfeed. Mother's knowledge and attitudes, followed by husband's support, were identified as important in influencing infant feeding choice. Expected local cultural differences were also identified. Discussion. Acknowledgement of the influencing factors could lead to appropriate management of the promotion of breastfeeding. Further research into husband's role, recognition and support for infant feeding and the issue of ‘inadequate breast milk’ is necessary for a successful breastfeeding campaign. Some other interesting findings typical of the local culture, such as family communication and living environment relating to breastfeeding, are also discussed. Conclusions. The study has identified the influencing factors that affect women's decision to breastfeed. Recommendations are made for health care professionals and the community to create a more baby-friendly atmosphere and environment for the promotion of breastfeeding.

Technology-dependent children and their families: a review

Abstract: Background. Advances in medical technology and nursing care have enabled children who rely on long-term medical and technical support to reunite with their families and community. The impact of discharging these children into the community involves a number of unprecedented social implications that warrant policy consideration. To begin with, an effort must be made to understand the phenomenon of caring for technology-dependent children living at home. Aim. The aim of this paper is to provide a comprehensive literature review on caring for technology-dependent children living at home. Methods. The review was conducted via keyword searches using various electronic databases. These included CINAHL, MEDLINE, Social Science Index, Sociological Abstracts, Australian Family and Society Abstracts, and the Australian Bureau of Statistics. The articles and books found were examined for commonality and difference, significant themes were extracted, and the strength of the research methods and subsequent evidence were critiqued. Findings. In this paper, themes relating to home care for technology-dependent children and their families are elucidated and summarized. These are: chronic illness and children; the impact of paediatric home care on children; the uniqueness of technology-dependent children and their families; and parents’ experience of paediatric home care. Discussion. Contentious issues, relevant to the social life of these children and their families, are raised and are discussed with the intention of extending awareness and provoking further debate among key stakeholders. These issues include: the changed meaning of home; family dynamics; social isolation; saving costs for whom?; shifts in responsibility; and parent–professional relationships. Conclusion. More research is needed in the arena of paediatric home care, to facilitate relevant policy formation and implementation.

Barriers to evidence-based practice in primary care

Abstract: Background. Evidence-based practice is one of the most important underlying principles in modern health care. In the United Kingdom, successive governments have highlighted the fact that a quality health service is built upon the use of best evidence. Health professionals are becoming more accountable within clinical governance structures for the care they provide. The need to use robust research findings effectively is a critical component of their role. However, studies show that a number of barriers prevent the effective use of best available evidence. Aim. This study aimed to identify barriers to evidence-based practice in primary care. Method. A specially designed questionnaire was used to gather respondents’ perceptions of the barriers to evidence-based practice. Data were collected in 2000/2001. Findings. Findings show that general practitioners (GPs) ranked barriers differently to community nurses. GPs believed that the most significant barriers to using evidence in practice were: the limited relevance of research to practice, keeping up with all the current changes in primary care, and the ability to search for evidence-based information. In contrast, the most significant barriers to the identified by community nurses were poor computer facilities, poor patient compliance and difficulties in influencing changes within primary care. This suggests that these two groups may require different strategies for barrier removal. Conclusions. Identifying barriers is just the first step to addressing issues surrounding the use of evidence-based practice. Extra resources will be needed if these barriers are to be tackled. However, if the resultant change improves the health and wellbeing of people and communities, then the extra costs would be offset by more efficient use of services.

Chronic illness self-management: locating the 'self'

Abstract: Journal of Advanced Nursing 48(5),484–492Chronic illness self-management: locating the ‘self’Aim. In this paper, we present the findings of a recent research project in which weexplored self- management with older people who were diagnosed with asthma.Background. Asthma self-management literature has focused on the need for thepatient to ‘adhere’ to prescribed therapies, in particular the taking of medications,monitoring of respiratory function or recognizing and avoiding triggers.Method. Data were generated during a period of 9 months from three sources;in-depth interviews with 24 older participants, an open-ended questionnaire andtwo mixed-gender participatory action research groups.Findings. Based on current literature, our previous research findings which have‘unpacked’ what is ‘self’-management, and data generated in this project, we pro-pose that three asthma management models are in operation: Medical Model ofSelf-management, Collaborative Model of Self-management and Self-Agency Modelof Self-management. Locating the ‘self’ in self-management means acknowledgingthat many people living with a chronic condition are already self-determining andtheir expertise should be acknowledged as such.Conclusion. Health care professionals can best facilitate people toward self-agencyby embracing new understandings of self-management in long-term illness. Thisprocess is enhanced when the expertise a person brings to the management of theircondition is given the respect it deserves. There needs to be a focus on providingpeople with the means to grow and learn in a participative relationship that cannotbe fully realized with ‘off the shelf’ self-management solutions.Keywords: chronic illness, self-management, asthma, older people, community,nursing

Medical hegemony in decision-making – a barrier to interdisciplinary working in intensive care?

Abstract: Background. Health care policy in the United Kingdom identifies the need for health professsionals to find new ways of working to deliver patient-focussed and economic care. Much debate has followed on the nature of working relationships within the health care team. Aim. This paper reports on an ethnographic study that examined the nursing role in clinical decision-making in intensive care units. This was chosen as a case for analysis due to the close doctor–nurse relationships that are essential in this acute and complex care setting. Methods. Data were collected during two-stages of fieldwork using participant observation, in-depth ethnographic interviews and documentation across three clinical sites. Findings. The findings revealed the different types of knowledge used for, divergence of roles involved in and degree of authority in clinical decision-making. Furthermore, conflict arose between doctors and nurses due to these differences and in particular because medicine dominated the decision-making process. Conclusions. The nursing role, whilst pivotal to implementing clinical decisions, remained unacknowledged and devalued. Medical hegemony continues to render nurses unable to influence substantially the decision-making process. This has fundamental ramifications for the quality of team decision-making and the effectiveness of new ways of inter-professional working in intensive care.

Ethical practice in nursing: working the in-betweens.

Abstract: Background. While contemporary ethical theory is of tremendous value to nursing, the extent to which such theory has been informed by the concerns and practices of nurses has been limited. Purpose. With a view to complementing extant ethical theory, a study was undertaken to explore, from the perspective of nurses, the meaning of ethics and the enactment of ethical practice in nursing. Design and methods. Located in the interpretive/constructivist paradigm, using an emergent design, this inquiry employed focus groups to collect the data. Eighty-seven nurses from a wide range of practice settings were interviewed in 19 focus groups of three to nine nurses each. Findings. The nurses described ethics in their practice as both a way of being and a process of enactment. They described drawing on a wide range of sources of moral knowledge in a dynamic process of developing awareness of themselves as moral agents. Enacting moral agency involved working in a shifting moral context, and working in-between their own values and those of the organizations in which they worked, in-between their own values and those of others, and in-between competing values and interests. Conclusions. Analysis of the experiences and concerns of the nurses offered new understanding of ethics in nursing and direction for the development of ethical theory pertinent to nursing practice.

New low back pain in nurses: work activities, work stress and sedentary lifestyle.

Abstract: Background. Low back pain is common among nurses. Previous studies have shown that the risk of low back pain increases rapidly with greater amounts of physical work and psychological stress, but is inversely related to leisure activities. However, these previous studies were predominantly retrospective in design and not many took account of three factors simultaneously. Aims. This 12-month prospective study examined the relationships between work activities, work stress, sedentary lifestyle and new low back pain. Methods. A total of 144 nurses from six Hong Kong district hospitals completed a face-to-face baseline interview, which was followed-up by a telephone interview. The main study measures were demographic characteristics, work activities, work stress, physical leisure activities and the nature of new low back pain during the 12-month follow-up period. Level of work stress, quality of relationships at work, level of enjoyment experienced at work, and work satisfaction were self-reported. Results. Fifty-six (38·9%) nurses reported experiencing new low back pain. Sedentary leisure time activity was not associated with new low back pain. Being comparatively new on a ward (adjusted relative risk 2·90), working in bending postures (adjusted relative risk 2·76) and poor work relationships with colleagues (adjusted relative risk 2·52) were independent predictors of new low back pain. Conclusion. The findings of this study suggest that low back pain is a common problem in the population of nurses in Hong Kong. Being comparatively new on a ward, bending frequently during work and having poor work relationships with colleagues are independent predictors of new low back pain. Training for high-risk work activities and ergonomic assessment of awkward work postures are essential. Moreover, relaxation and team-building workshops for nurses, especially those who are less experienced in the type of work on their current ward, are recommended.