Showing papers in "Journal of Advanced Nursing in 2005"

The integrative review: updated methodology

Abstract: Aim. The aim of this paper is to distinguish the integrative review method from other review methods and to propose methodological strategies specific to the integrative review method to enhance the rigour of the process. Background. Recent evidence-based practice initiatives have increased the need for and the production of all types of reviews of the literature (integrative reviews, systematic reviews, meta-analyses, and qualitative reviews). The integrative review method is the only approach that allows for the combination of diverse methodologies (for example, experimental and non-experimental research), and has the potential to play a greater role in evidence-based practice for nursing. With respect to the integrative review method, strategies to enhance data collection and extraction have been developed; however, methods of analysis, synthesis, and conclusion drawing remain poorly formulated. Discussion. A modified framework for research reviews is presented to address issues specific to the integrative review method. Issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analysing data, and presenting the results are discussed. Data analysis methods of qualitative research are proposed as strategies that enhance the rigour of combining diverse methodologies as well as empirical and theoretical sources in an integrative review. Conclusion. An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives.

Men and health help-seeking behaviour: literature review.

Abstract: Aim. This paper reviews the key research literature regarding men's health-related help seeking behaviour. Background. There is a growing body of research in the United States to suggest that men are less likely than women to seek help from health professionals for problems as diverse as depression, substance abuse, physical disabilities and stressful life events. Previous research has revealed that the principle health related issue facing men in the UK is their reluctance to seek access to health services. Method. The investigation of men's health-related help seeking behaviour has great potential for improving both men and women's lives and reducing national health costs through the development of responsive and effective interventions. A search of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsychINFO and the Cochrane Library databases. Results. Studies comparing men and women are inadequate in explaining the processes involved in men's help seeking behaviour. However, the growing body of gender-specific studies highlights a trend of delayed help seeking when they become ill. A prominent theme among white middle class men implicates ‘traditional masculine behaviour’ as an explanation for delays in seeking help among men who experience illness. The reasons and processes behind this issue, however, have received limited attention. Conclusions. Principally, the role of masculine beliefs and the similarities and differences between men of differing background requires further attention, particularly given the health inequalities that exist between men of differing socio-economic status and ethnicity. Further research using heterogeneous samples is required in order to gain a greater understanding of the triggers and barriers associated with the decision making process of help seeking behaviour in men who experience illness.

Establishing rigour in qualitative research : the decision trail. Commentaries

Abstract: The aim of this paper is to show the way in which the decision trail of a qualitative research process can be maintained It is argued that the trustworthiness (rigour) of a study may be established if the reader is able to audit the events, influences and actions of the researcher The actual study containing the recording of this decision trail aimed to express the concerns of older patients who were admitted to the acute care sector The study took place in two care of the elderly wards in a 1000-bed National Health Service hospital in the UK, in 1991 Eventually, 14 patients were interviewed, each on several occasions, and their concerns are expressed in themes, namely: routine geriatric style of care, depersonalization, care deprivation and geriatric segregation I describe the preparations that were undertaken before patient interviews could commence The literature recording the process of the interviewer's experience as data in qualitative research is scarce I show the researcher's participation in making the data as part of an existential phenomenological research process Existential phenomenology relies on recording influences while generating data such as significant literature, media reports, my value position and journal data

Meta-synthesis method for qualitative research: a literature review

Abstract: Aim. This paper discusses the purpose and stages of meta-synthesis and the epistemological status of knowledge generated from the technique. Particular attention is paid to exploring the contested areas of the method that remain. Background. There is a growing interest in meta-synthesis as a technique for generating new insights and understanding from qualitative health care research. An increasing number of meta-synthesis papers are appearing in the nursing and midwifery literature. Methods. Literature on the technique of meta-synthesis and examples of meta-synthesis papers were searched and reviewed. A meta-synthesis exercise was undertaken, and this informed reflection and critique of the method. Findings. Meta-synthesis attempts to integrate results from a number of different but inter-related qualitative studies. The technique has an interpretive, rather than aggregating, intent, in contrast to meta-analysis of quantitative studies. Examples from the literature indicate that some aspects of the technique are not yet fully established. Conclusion. Despite the contingent nature of evidence gleaned from meta-synthesis and current lack of consensus about some of its aspects, meta-synthesis is an important technique for qualitative researchers and can deepen understanding of the contextual dimensions of health care.

Reflexivity: A Practical Guide for Researchers in Health and Social Sciences

Abstract: Reflexivity is a popular tool used to analyse personal, intersubjective and social processes which shape research projects. It enables researchers, particularly within the qualitative tradition, to acknowledge their role and the situated nature of their research. In the current climate, which sees the popularity of qualitative methods coupled with increased public and professional scrutiny of research, reflexivity provides a means of bolstering greater transparency and quality in research.

Burnout contagion among intensive care nurses.

Abstract: Aim. This paper reports a study investigating whether burnout is contagious. Background. Burnout has been recognized as a problem in intensive care units for a long time. Previous research has focused primarily on its organizational antecedents, such as excessive workload or high patient care demands, time pressure and intensive use of sophisticated technology. The present study took a totally different perspective by hypothesizing that – in intensive care units – burnout is communicated from one nurse to another. Methods. A questionnaire on work and well-being was completed by 1849 intensive care unit nurses working in one of 80 intensive care units in 12 different European countries in 1994. The results are being reported now because they formed part of a larger study that was only finally analysed recently. The questionnaire was translated from English to the language of each of these countries, and then back-translated to English. Respondents indicated the prevalence of burnout among their colleagues, and completed scales to assess working conditions and job burnout. Results. Analysis of variance indicated that the between-unit variance on a measure of perceived burnout complaints among colleagues was statistically significant and substantially larger than the within-unit variance. This implies that there is considerable agreement (consensus) within intensive care units regarding the prevalence of burnout. In addition, the results of multilevel analyses showed that burnout complaints among colleagues in intensive care units made a statistically significant and unique contribution to explaining variance in individual nurses’ and whole units’ experiences of burnout, i.e. emotional exhaustion, depersonalization and reduced personal accomplishment. Moreover, for both emotional exhaustion and depersonalization, perceived burnout complaints among colleagues was the most important predictor of burnout at the individual and unit levels, even after controlling for the impact of well-known organizational stressors as conceptualized in the demand-control model. Conclusion. Burnout is contagious: it may cross over from one nurse to another.

Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature.

Abstract: Aim. This paper reports a literature review examining factors that enhance retention of knowledge and skills during and after resuscitation training, in order to identify educational strategies that will optimize survival for victims of cardiopulmonary arrest. Background. Poor knowledge and skill retention following cardiopulmonary resuscitation training for nursing and medical staff has been documented over the past 20 years. Cardiopulmonary resuscitation training is mandatory for nursing staff and is important as nurses often discover the victims of in-hospital cardiac arrest. Many different methods of improving this retention have been devised and evaluated. However, the content and style of this training lack standardization. Method. A literature review was undertaken using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and British Nursing Index databases and the keywords ‘cardiopulmonary resuscitation’, ‘basic life support’, ‘advanced life support’ and ‘training’. Papers published between 1992 and 2002 were obtained and their reference lists scrutinized to identify secondary references, of these the ones published within the same 10-year period were also included. Those published in the English language that identified strategies to enhance the acquisition or retention of Cardiopulmonary resuscitation skills and knowledge were included in the review. Results. One hundred and five primary and 157 secondary references were identified. Of these, 24 met the criteria and were included in the final literature sample. Four studies were found pertaining to cardiac arrest simulation, three to peer tuition, four to video self-instruction, three to the use of different resuscitation guidelines, three to computer-based learning programmes, two to voice-activated manikins, two to automated external defibrillators, one to self-instruction, one to gaming and the one to the use of action cards. Conclusions. Resuscitation training should be based on in-hospital scenarios and current evidence-based guidelines, including recognition of sick patients, and should be taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the training reflects the potential situations that nurses may face in practice. Nurses in clinical areas, who rarely see cardiac arrests, should receive automated external defibrillation training and have access to defibrillators to prevent delays in resuscitation. Staff should be formally assessed using a manikin with a feedback mechanism or an expert instructor to ensure that chest compressions and ventilations are adequate at the time of training. Remedial training must be provided as often as required. Resuscitation training equipment should be made available at ward/unit level to allow self-study and practice to prevent deterioration between updates. Video self-instruction has been shown to improve competence in resuscitation. An in-hospital scenario-based video should be devised and tested to assess the efficacy of this medium in resuscitation training for nurses.

Causes and management of patient aggression and violence: staff and patient perspectives

Abstract: Aim. This paper reports a study of staff and patient perspectives on the causes of patient aggression and the way it is managed. Background. The incidence of aggression in healthcare is reportedly on the increase, and concerns about the management of this problem are growing. Method. A convenience sample of 80 patients and 82 nurses from three inpatient mental healthcare wards were surveyed using The Management of Aggression and Violence Attitude Scale. A further five patients and five nurses from the same sample participated in a number of follow-up interviews. Results. Patients perceived environmental conditions and poor communication to be a significant precursor of aggressive behaviour. Nurses, in comparison, viewed the patients’ mental illnesses to be the main reason for aggression, although the negative impact of the inpatient environment was recognized. From interview responses, it was evident that both sets of respondents were dissatisfied with a restrictive and under-resourced provision that leads to interpersonal tensions. Conclusion. There are differences between the views of staff and patients about reasons for aggression and its management. Future approaches therefore need to be developed that address these opposing views. For example, training in the use of fundamental therapeutic communication skills was advocated by patients, whilst the need for greater attention to organizational deficits was advocated by nurses. A move away from reliance on the use of medication was also felt to be necessary. Evaluation of local needs and practices must be an integral part of this process.

Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis.

Abstract: Aims. This paper reports a study whose aim was to identify and synthesize qualitative research studies reporting barriers or facilitators to role development and/or effective practice in specialist and advanced nursing roles in acute hospital settings. Background. The number of clinical nurse specialist, nurse practitioner, advanced nurse practitioner and consultant nurse roles has grown substantially in recent years. Research has shown that nurses working in innovative roles encounter a range of barriers and facilitators to effective practice. Methods. Systematic literature searches were undertaken, and relevant studies identified using specific inclusion and exclusion criteria. The selected studies were appraised, and their findings synthesized using Ritchie and Spencer's ‘Framework’ approach. Results. Fourteen relevant studies were identified, mostly from the UK. They described a range of barriers and facilitators affecting specialist and advanced nursing practice. These related to the practitioner's personal characteristics and previous experience, professional and educational issues, managerial and organizational issues, relationships with other health care professionals, and resources. The factors most widely identified as important were relationships with other key personnel, and role definitions and expectations. Conclusions. Relationships with other staff groups and role ambiguity are the most important factors which hinder or facilitate the implementation of specialist and advanced nursing roles. These factors seem interlinked, and the associated problems do not appear to resolve spontaneously when staff become familiar with the new roles. In order to reduce role ambiguity and the consequent likelihood of negative responses we recommend that, when specialist and advanced nursing roles are introduced, clear role definitions and objectives are developed and communicated to relevant staff groups; these definitions and objectives should be updated as necessary.

Health literacy: concept analysis.

Abstract: Aim. This paper reports an analysis of the concept of health literacy in order to clarify its meaning, reduce ambiguities associated with references to it, and promote consistency in using the concept in nursing dialogue and research. Background. Health literacy is a relatively new concept in health promotion research. Only within the last decade have researchers identified the problems associated with health literacy, the role it plays in an individual's ability to comprehend health and self-care information, and its relationship to health outcomes. Clarifying the concept is essential so that nurses develop an awareness of the phenomenon and its relationship to the outcomes of their communication and health education efforts. Method. The method used for this concept analysis was that of Walker and Avant (1995). Findings. Health literacy empowers people to act appropriately in new and changing health-related circumstances through the use of advanced cognitive and social skills. The defining attributes of health literacy are reading and numeracy skills, comprehension, the capacity to use information in health care decision-making, and successful functioning as a healthcare consumer. Antecedents of health literacy are literacy and a health-related experience. Consequences of health literacy include improved self-reported health status, lower health care costs, increased health knowledge, shorter hospitalizations, and less frequent use of health care services. Empirical referents of the concept are the Test of Functional Health Literacy in Adults and the health literacy component of the National Assessment of Adult Literacy. Conclusions. An analysis of the concept of health literacy enhances nurses’ ability to assess more accurately their clients’ levels of health literacy, thus identifying those at risk for misunderstanding health care instructions, shame associated with inadequate reading skills, and inability to adhere to health care recommendations.

Initiation and continuation of breastfeeding: theory of planned behaviour

Abstract: JournalofAdvancedNursing50(3),272–282Initiation and continuation of breastfeeding: theory of planned behaviourAims. This paper reports a study investigating new mothers’ subjective norms inrelationtobothbreast-andbottle-feeding.Theinfluenceofnormsonwomen’sinfantfeeding decisions and the relative influence of social referents at varying degrees ofsocial distance were assessed.Background. Increasing breastfeeding initiation and continuation rates is a keychallenge for health educators. The perceived influence of other people’s views(subjective norms), including the views of women’s partners and health care profes-sionals, is an important predictor of infant feeding behaviour.Methods. Semi-structured questionnaires were administered to 203 new mothers incentral and northern Scotland and followed-up by postal questionnaire at 6 weeks.Infant feeding intentions, feeding behaviour at birth and follow-up, behaviouralbeliefs and subjective norms for both breastfeeding and bottle-feeding were assessed.The data were collected in 1998–1999.Results. Subjective norms were important determinants of initiation and continu-ation of breastfeeding for breast- and bottlefeeders. Breastfeeders rated close socialreferentsasmoreinfavourofbottle-feedingandmoreagainstbreastfeedingatfollow-up, whereas bottlefeeders’ ratings did not change. Partner’s and nurses’/midwives’views were an important influence at baseline and follow-up. Breastfeeding ‘contin-uers’ perceived their partners as more pro-breastfeeding at 6 weeks. Discontinuersperceived more overall social pressure to bottle-feed. However, sampling limitationsmay have led to over-representation of the views of breastfeeders at baseline andfollow-up.Conclusions. Nurses and midwives have a crucial role in communicating positiveviewsonbreastfeedingtonewmothersatdifferenttimepoints.Futureinterventionstopromote breastfeeding could adopt a broad social approach, encouraging positivenorms for existing and potential mothers and fathers, families and people in general.Keywords: subjective norms, Theory of Planned Behaviour, midwifery,bottle-feeding, breastfeeding

Measuring neonatal intensive care unit-related parental stress

Abstract: Aims. This paper reports a study: (1) to determine the validity and reliability of the Parent Stressor Scale:Neonatal Intensive Care Unit (PSS:NICU) for use with United Kingdom (UK) parents; (2) compare UK scores with those from a contemporary reference sample from the United States (US), (3) to identify the sources of greatest NICU-related stressors for parents and (4) to identify demographic or situational factors influencing NICU-related parental stress. Background. Evaluation of the adequacy of nursing care and psychosocial support services for parents of ill infants in the NICU requires valid and reliable measures of parental stress. The PSS:NICU is a well-validated scale developed in the US to measure NICU-related parental stress. However, it has not been tested in the UK. Methods. Consecutive samples of parents (n = 257) of infants in nine UK NICUs and two reference US units completed the PSS:NICU and the Spielberger State-Trait Anxiety Scale approximately 1 week after admission. Psychometric properties of the PSS:NICU, including internal consistency reliability and construct, concurrent and predictive validity, were evaluated. Results. PSS:NICU scores were similar in the UK and US samples and high internal consistency reliability was found for all metrics (e.g. Overall Stress: 0·94 for both samples). A three-factor principal components solution accounted for 66% of the variance in the scores, with the items grouped into the three a priori scales specified in the PSS:NICU (Infant Behaviour and Appearance, Parental Role Alterations, and Sights and Sounds). Stress Occurrence and Overall Stress were moderately correlated with State Anxiety in both samples (r = 0·46–0·61, P < 0·001). Thirty-one per cent of the variance in Stress Occurrence in the UK sample was explained by State Anxiety, infant severity of illness score, parent gender, and less frequent visitation. Conclusions. The PSS:NICU demonstrated appropriate psychometrics in a large sample of parents from diverse NICUs in the UK. These findings support its wider use in research and clinical practice to identify parental distress and evaluate the effectiveness of nursing care and psychosocial support services for parents.

Perceived parental efficacy: concept analysis.

Abstract: Aims. This paper describes a concept analysis carried out to remove some of the ambiguity surrounding the conceptual meaning of perceived parental efficacy and to distinguish it from related concepts such as parental confidence and parental competence. Background. Constructing parental efficacy is a crucial step for family members after the birth of their first child. For some authors, perceived parental efficacy is a motor for adequate parental practices. Confusion about the definition and measurement of this concept has hindered both psychology and nursing practice and research. Concept delineation and concept clarification are required in order to further the development of the concept of perceived parental efficacy. Methods. A literature search using a variety of online databases yielded 113 articles between the years 1980 and 2000. The final sample (n = 60) consisted of 30 articles from two disciplines: nursing and psychology. A content analysis of the literature was done using Rodger's evolutionary concept analysis method. Findings. Content analysis of the literature yielded four contributors to perceived parental efficacy: positive enactive mastery experiences, vicarious experiences, verbal persuasion and an appropriate physiological and affective state. Perceived parental efficacy can thus be defined as ‘beliefs or judgements a parent holds of their capabilities to organize and execute a set of tasks related to parenting a child’. Conclusion. This conceptual analysis has allowed perceived parental efficacy to be distinguished from parental confidence and parental competence. Both nursing and psychology research, practice and education will benefit from a more precise and delineated concept.

Non-somatic effects of patient aggression on nurses: a systematic review.

Abstract: Aim. This paper describes a systematic review of the predominant non-somatic effects of patient assault on nurses. Background. Patient aggression towards nurses is a longstanding problem in most nursing domains. Although reports on the consequences of physical aggression are more numerous, the non-physical effects create much suffering. Method. A systematic review of literature from 1983 to May 2003 was conducted using the Medline, CINAHL, PsychINFO and PSYINDEX databases. Articles from international journals in English or German and reporting at least three non-somatic responses to patient aggression were included. Findings. The electronic search produced 6616 articles. After application of the inclusion and exclusion criteria, 25 texts from eight countries and four domains of nursing remained. Twenty-eight main effects were found, and these were categorized using a system suggested by Lanza and including bio-physiological, emotional, cognitive, and social dimensions. The predominant responses were anger, fear or anxiety, post-traumatic stress disorder symptoms, guilt, self-blame, and shame. These main effects occurred across most countries and nursing domains. Conclusion. Despite differing countries, cultures, research designs and settings, nurses’ responses to patient aggression are similar. Standardized questionnaires could help improve estimations of the real prevalence of non-somatic effects. Given the suffering caused by non-somatic effects, research should be aimed at preventing patient aggression and at developing better ways to prepare nurses to cope with this problem.

Mindfulness-Based Stress Reduction as supportive therapy in cancer care: systematic review

Abstract: Aim: This paper reports a systematic review and critical appraisal of the evidence on the effectiveness of Mindfulness-Based Stress Reduction for cancer supportive care. Background: The experience of cancer can have a negative impact on both psychological and physical health and on quality of life. Mindfulness-Based Stress Reduction is a therapy package that has been used with patients with a variety of conditions. In order to draw conclusions on its effectiveness for cancer patients, the evidence requires systematic assessment. Methods: A comprehensive search of major biomedical and specialist complementary medicine databases was conducted. Additionally, efforts were made to identify unpublished and ongoing research. Relevant research was categorized by study type and appraised according to study design. Clinical commentaries were obtained for each study and included in the review. Results: Three randomized controlled clinical trials and seven uncontrolled clinical trials were found. A lack of relevant qualitative research studies was identified. Studies report positive results, including improvements in mood, sleep quality and reductions in stress. A dose-response effect has been observed between practice of Mindfulness-Based Stress Reduction and improved outcome. A number of methodological limitations were identified. Modifications to the traditional Mindfulness-Based Stress Reduction programme make comparison between studies difficult and a lack of controlled studies precludes any firm conclusion on efficacy. Conclusion: Mindfulness-Based Stress Reduction has potential as a clinically valuable self-administered intervention for cancer patients. Further research into its efficacy, feasibility and safety for cancer patients in the nursing context is recommended.

Music improves sleep quality in older adults

Abstract: Aim. The aim of this paper is to report an investigation of the effects of soft music on sleep quality in older community-dwelling men and women in Taiwan. Background. Sleep is a complex rhythmic state that may be affected by the ageing process. Few studies have focused on the effects of music, a non-pharmacological method of improving the quality of sleep in older adults. Method. A randomized controlled trial was used with a two-group repeated measures design. Sixty people aged 60–83 years with difficulty in sleeping were recruited through community leaders and screened using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale. Those reporting depression, cognitive impairment, medical or environmental problems that might interfere with sleep; and those who used sleeping medications, meditation, or caffeine at bedtime were excluded. Participants listened to their choice among six 45-minute sedative music tapes at bedtime for 3 weeks. There were five types of Western and one of Chinese music. Sleep quality was measured with the PSQI before the study and at three weekly post-tests. Groups were comparable on demographic variables, anxiety, depressive symptoms, physical activity, bedtime routine, herbal tea use, napping, pain, and pretest overall sleep quality. Results. Music resulted in significantly better sleep quality in the experimental group, as well as significantly better components of sleep quality: better perceived sleep quality, longer sleep duration, greater sleep efficiency, shorter sleep latency, less sleep disturbance and less daytime dysfunction (P = 0·04–0·001). Sleep improved weekly, indicating a cumulative dose effect. Conclusion. The findings provide evidence for the use of soothing music as an empirically-based intervention for sleep in older people.

Healthcare workers' hand decontamination practices: compliance with recommended guidelines

Abstract: Aim. This paper reports a study of healthcare workers' handwashing/hand hygiene practices from a behavioural perspective. Background. Hospital acquired infection poses a very real and serious threat to all who are admitted to hospital. Pathogens are readily transmitted on healthcare workers’ hands, and hand hygiene substantially reduces this transmission. Evidence-based guidelines for healthcare workers’ hand hygiene practices exist, but compliance with these is internationally low. Methods. A quasi-experimental design with a convenient sample was used. The Predisposing, Reinforcing, Enabling Constructs in Educational Diagnosis and Evaluation Health Education Theory was used as the theoretical framework, and the data were collected in 2001. Healthcare workers’ handwashing practices (observation of behaviour, n = 314) and their predisposition (attitudes, beliefs and knowledge) towards compliance with hand hygiene guidelines (questionnaire, n = 62) were studied. Nurses, doctors, physiotherapists and care assistants involved in direct patient care in the study unit participated in the study. The interventional hand hygiene programme aimed to predispose healthcare workers to adopt hand hygiene behaviour (poster campaign and educational handout), reinforce (feedback on pretest results) and enable the behaviour (provision of an alcohol hand rub beside each patients bedside). Results. Implementation of the multifaceted interventional behavioural hand hygiene programme resulted in an overall improvement in compliance with hand hygiene guidelines (51–83%, P < 0·001). Furthermore, healthcare workers believed that their skin condition improved (P < 0·001). An increase in knowledge about handwashing guidelines was also found. Conclusions. In order to be effective, efforts to improve compliance with handwashing guidelines must be multifaceted. Alcohol hand rubs (with emollients) need to be provided at each patient's bedside. Issues surrounding healthcare workers’ skin irritation need to be addressed urgently.

Adapt or adopt: developing and transgressing the methodological boundaries of grounded theory.

Abstract: Aims. While acknowledging that there is an existing debate regarding the nature of grounded theory, the aim of this paper is to highlight a number of common and key areas/issues where adaptation/adoption of Glaserian grounded theory in nursing-related studies often occurs. These issues are: the differences between conceptual description and conceptual theory; beginning the study with a ‘general wonderment’ or a more defined research question; establishing the credibility of the theory; identifying a basic psycho-social process and emerging vs. forcing. Background. Since the development and introduction of grounded theory in 1967, the number of studies, in a wide range of disciplines including nursing, that purport to be using a grounded theory method has grown enormously. While Glaser and Strauss acknowledged then that it was entirely appropriate for the methodology to evolve and develop, some of the studies that claim to be based on grounded theory methodology share little methodological similarity, and at times, bear only a passing resemblance to Glaserian grounded theory. Discussion. Some methodological transgressions in papers that purport to be grounded theory studies are such that it would be inaccurate to term the resulting method grounded theory at all. Instead such studies are more accurately thought of as a form of qualitative data analysis. Such transgressions include a study that has no evidence of conceptualization; one that does not identify a basic psycho-social process; and one that moves from ‘emerging’ to ‘forcing’. Other methodological adaptations of grounded theory, such as beginning the study with more than a general wonderment and broadening the approach to establishing the credibility of the theory, are more in keeping with Glaser and Strauss’ position on the evolution of the method. In such cases, it is necessary to distinguish such methods from ‘pure’ Glaserian grounded theory, and it would be prudent and methodologically accurate to describe the resulting method as ‘modified’ grounded theory.

First-time mothers: social support and confidence in infant care.

Abstract: Aim. This paper reports a study whose primary aim was to explore the relationship between social support for first-time mothers and their confidence in infant care practices. A secondary aim was to identify their sources of support in the postnatal period. Background. Policy documents emphasize the importance of support for new mothers in the postnatal period in caring for their infants. Nurses/midwives require a working knowledge of how social support influences maternal confidence in infant care practices, specifically during the first 6 weeks postdelivery. Methods. A descriptive, correlational design was used. A 28 item questionnaire was designed to measure social support in the specific context of first-time motherhood and confidence in infant care practices. Content validity was sought and the instrument demonstrated reliability using Cronbach's alpha. A convenience sample of 135 first-time mothers was recruited and 74% completed questionnaires at 6 weeks after birth. Data were collected in 2000. Results. Appraisal support had a statistically significant moderate relationship with confidence in infant care practices (r = 0·4, P < 0·01). Informational support had a weaker but statistically significant relationship (r = 0·2, P < 0·05). Respondents’ primary sources of appraisal support were husbands/partners and their own mothers. Public health nurses and mothers were primary sources of informational support. Conclusions. First-time mothers’ husbands/partners need to become active participants in antenatal and postnatal care. Interdisciplinary educational programmes need to be developed so that public health nurses and midwives work collaboratively in facilitating social support for first-time mothers in caring for their infants. Curricula for public health nurses and midwives need to be evidenced-based with respect to social support.

Effects of rotating night shifts: literature review

Abstract: Aim. This paper reports a review examining the concept of sleep and its antithesis of fatigue, and considers the evidence on nurses’ ability to cope with the demands of continually changing hours of work, their safety, and the impact any manifestations of sleep disruption may have on the care of their patients. While many aspects of this paper may apply to nursing in general, special consideration is given to nurses in the critical care environment. Background. Night duty rotations are common practice in nursing, and particularly in specialist units. It is essential that nurses working in these environments are able to maintain careful and astute observation of their vulnerable patients, and concern arises when they may be unable to do so. Research suggests that fatigue can negatively affect nurses’ health, quality of performance, safety and thus patient care, and that the effects of fatigue may be exacerbated for nurses over 40 years of age. Method. The literature was examined for the 10-year period up to December 2003. The databases searched were Ovid, Proquest, Blackwell Science, EBSCO Online, Australian Health Review and WebSPIRS, using the keywords of, shiftwork, rosters, intensive care, fatigue, sleep deprivation and sleep studies. Findings. There is consensus amongst researchers on the adverse psychological and physiological effects of night rotations on nurses when compared with their permanent night duty peers, particularly for those over 40 years of age. Evidence also suggests that the effects of fatigue on nurse performance may negatively affect the quality of patient care. Conclusions. The literature reinforces concerns about the adverse relationship between fatigue and performance in the workplace. Optimal standards for patient care may be difficult to achieve for more mature nurses, who may suffer from sleep deprivation and health problems associated with rotational night work and disrupted physiological rhythms.

Preoperative education for orthopaedic patients: systematic review.

Abstract: Aims. This paper presents a systematic review whose aim was to describe the scope and methods of the current literature on preoperative patient education and to identify the effects of this education. Background. Preoperative patient education is a common and important intervention in surgical nursing, yet there is very limited systematic evidence on its precise role. Methods. The Medline, CINAHL, Eric, Psycinfo and Social Sciences Index databases and the Cochrane Library were searched, covering the period from the beginning of each database to April 2003. Studies were included if they concerned adult orthopaedic patients, preoperative nursing patient education and were based on randomized controlled or clinical trials. Meta-analysis was carried out where appropriate. Results. We identified 11 articles involving 1044 participants. Most studies included one experimental and one control group; only two had more than one experimental and control group. The educational interventions varied widely, but the majority were based on written materials alone, or written materials in combination with other teaching methods. The most common outcome measures related to pain, knowledge, anxiety, exercises and length of stay, and the least common to self-efficacy and empowerment. The methodological quality of the studies varied. Almost all reported one or more statistically significant effects. Based on the findings of the meta-analysis, preoperative education appears to have some impacts on patients’ anxiety and knowledge levels. Conclusions. The review clearly highlights the need for well-designed, methodologically sound research into the outcomes of patient education. It also points to the need to study patient education from the point of view of empowerment.

Parent or nurse? The experience of being the parent of a technology-dependent child

Abstract: Aims. This paper reports a study exploring parents’ experiences of caring for a child who is dependent on medical technology, and in particular of performing clinical procedures on their own children. Background. A group of children with a continuing need for the support of medical technology have emerged in community settings as a result of medical advances and government policies. Caring for these children has a significant social and emotional impact on parents, because of their specialized and intensive care needs. Obtaining appropriate and coordinated home support services is problematic. Methods. Grounded theory techniques were used, and in-depth interviews were conducted with the parents of 24 children. Findings. Parents’ accounts revealed that their constructions of parenting were shaped by the nature of their role in caring for their child and by the transformation of their homes by medical equipment and personnel. They described themselves as having a role that had both parenting and nursing dimensions. Parents managed this tension and defined their role and relationship to their child to be primarily one of parenting by differentiating parental care-giving and its underpinning knowledge from that of professionals, particularly nurses. Conclusions. Parenting a technology-dependent child alters the meaning of parenting. Professionals need to recognize that providing care has a substantial emotional dimension for parents, and that they need opportunities to discuss their feelings about caregiving and what it means for their parenting identity and their relationship with their child. A key professional nursing role will be giving emotional support and supporting parents’ coping strategies. Parents’ perceptions of nurses raise questions about whether nurses’ caregiving is individualized to the needs of the child and family, and whether parental expertise is recognized.

Motivational interviewing to promote physical activity for people with chronic heart failure.

Abstract: Aim. This paper reports a study comparing, over a 5-month period, two different methods of increasing physical activity: a traditional exercise programme and one based on motivational interviewing. Background. Chronic heart failure is associated with poor quality of life that can be improved by increased physical activity. Patients who are directed to engage in physical activity have a record of low compliance. Method. Sixty older aged heart failure patients were randomly assigned to standard care, motivational interviewing or both treatments. The primary outcome was physical activity (kcal/kg/day), with the 6-minute walk test as a secondary outcome. Findings. At entry, no significant differences were observed between the three groups. Following treatment, the ‘motivational interviewing’ and ‘both treatments’ groups reported an increase in their level and type of activities, whereas the ‘standard care’ group did not. All groups significantly increased their 6-minute walk distance. Conclusions. Motivational interviewing, which incorporates established behaviour change principles and a flexible approach to promotion of activity, increases reported physical activity in older patients with heart failure over a short period. In terms of level and type of activity, this approach gives a better outcome than standard care, and nurses should explore alternative strategies to promote health in this population.

Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review

Abstract: Aim. The aim of this systematic review was to determine the characteristics and efficacy of various multicomponent intervention strategies for delirium in hospitalized older people. Background. Delirium is a common accompaniment to acute illness in hospitalized older people and has greater costs of care concurrent as well as greater morbidity and mortality. Methods. A comprehensive search was undertaken involving all major databases (including the Cochrane Library, Medline, Cumulative Index for Nursing and Allied Health Literature and Invert) and reference lists of all relevant papers. Selection criteria were: evaluation of a multicomponent intervention for delirium, inclusion of an operational definition for delirium consistent with the Diagnostic and Statistical Manual of Mental Disorders-criteria, randomized controlled trials, studies with a quasi-experimental design and reporting on primary data. To generate a description of the characteristics of these multicomponent strategies, the components of these programmes were identified and categorized. Effects on incidence of delirium, cognitive functioning, duration and severity of delirium, functional status, hospital length of stay, and mortality were analysed. Findings. Three randomized controlled trials, three controlled studies and one before–after study were identified. Intervention strategies to prevent delirium proved to be the most efficacious in reducing its incidence, both with surgical and medical patients. Some additional positive effects of preventive strategies were found on the duration and severity of delirium, and functional status. Conversely, strategies to treat delirium were rather ineffective in older people admitted to medical services. In a population of older people admitted for surgery, however, a shorter duration and a diminished severity of delirium were demonstrated. None of intervention strategies produced beneficial effects on length of stay or mortality. Conclusion. Multicomponent interventions to prevent delirium are the most effective and should be implemented through synergistic cooperation between the various healthcare disciplines. Nurses should play a pivotal role in prevention, early recognition and treatment.

Improving uptake and adherence in cardiac rehabilitation: literature review

Abstract: Aims. This paper presents a comprehensive systematic review of literature carried out to identify studies of interventions to improve uptake, adherence and professional compliance in cardiac rehabilitation. Background. Guidelines recommend that cardiac rehabilitation should be offered to patients following acute myocardial infarction and revascularization. Uptake and adherence are low, particularly in women, older people, and socially deprived and ethnic minority patients. Although patient, service and professional barriers to rehabilitation uptake have been described, no attempt has been made to evaluate systematically interventions aimed at improving uptake and adherence in cardiac rehabilitation. Methods. A comprehensive search strategy identified studies of cardiac rehabilitation, using the terms uptake, adherence and compliance. The search included grey literature, hand searching of specialist journals and conference abstracts. No language restriction was applied. Studies were summarized in three qualitative overviews and assessed by quality of evidence. Results. From 3261 publications identified, 957 were acquired on the basis of title or abstract. Few studies were of sufficient quality to make specific recommendations. Six, 12 and five studies, respectively, provided adequate information on methods to improve uptake, adherence or professional compliance. A minority of studies were randomized controlled trials. Studies of motivational and self-management strategies and use of lay volunteers showed some promise in improving rehabilitation uptake or lifestyle change. Nurse-led coordination of care after hospital discharge may have a role in improving rehabilitation uptake. Limited information was provided on resource implications, and there was a lack of studies with under-represented groups. The literature contained numerous suggested interventions which merit evaluation in appropriately designed studies. Conclusions. Little research has been reported evaluating interventions to improve uptake, adherence and professional compliance in cardiac rehabilitation. A wide range of possible interventions was identified and further evaluations of methods are indicated.

Packaging: a grounded theory of how to report physiological deterioration effectively

Abstract: Aim. The aim of this paper is to present a study of how ward-based staff use vital signs and the Early Warning Score to package physiological deterioration effectively to ensure successful referral to doctors. Background. The literature tends to emphasize the identification of premonitory signs in predicting physiological deterioration. However, these signs lack sensitivity and specificity, and there is evidence that nurses rely on subjective and subtle indicators. The Early Warning Score was developed for the early detection of deterioration and has been widely implemented, with various modifications. Method. The data reported here form part of a larger study investigating the practical problems faced by general ward staff in detecting physiological deterioration. During 2002, interviews and observations were carried out using a grounded theory approach, and a total of 44 participants were interviewed (30 nurses, 7 doctors and 7 healthcare support workers). Findings. Participants reported that quantifiable evidence is the most effective means of referring patients to doctors, and the Early Warning Score achieves this by improving communication between professionals. Rather than reporting changes in individual vital signs, the Early Warning Score effectively packages them together, resulting in a much more convincing referral. It gives nurses a precise, concise and unambiguous means of communicating deterioration, and confidence in using medical language. Thus, nurses are empowered and doctors can focus quickly on identified problems. Conclusion. The Early Warning Score leads to successful referral of patients by providing an agreed framework for assessment, increasing confidence in the use of medical language and empowering nurses. It is essential that nurses and nursing students are supported in its use and in developing confidence in using medical language by continued emphasis on physiology and pathophysiology in the nursing curriculum.