Research paradigms and the politics of nursing knowledge: A reflective discussion.

A standard view would suggest that research is a neutral apolitical activity. It neutralizes external pressures by its fidelity to robust scientific methods. However, politics is an inevitable part of human knowledge. Our knowledge of the world is always mediated by human priorities. What matters is therefore a contested and political debate rather a neutral accumulation of factual data. How researchers manage this varies. Research paradigms are one way in which research engages with knowledge. They frame knowledge within epistemological and ontological philosophies. In this paper, I will explore this view in relation to neo-positivism, qualitative research, Foucault and critical realism. I will argue that if nursing knowledge is to be effective it needs to acknowledge the political, particularly in the context of neoliberalism. Healthcare systems are having to cope with a social world increasingly dominated by market fundamentalism, extreme levels of inequality and a rise in xenophobia. These forces are undermining the provision of ethically sound health care, misdirecting research practice and contributing to a discourse of dehumanization. These forces need to be challenged politically and I will argue that epistemologically diverse approaches, alongside a realist ontology can provide a way forward for nursing research.

LIMPRINT: A Sociological Perspective on "Chronic Edema".

Background: Chronic edema is a condition that is biologically complex, distressing for patients and sociopolitically weak. Like many other complex and chronic conditions, it has a low status within health care. The result is that it has a low priority in health policy and consequently is undervalued and undertreated. While evidence-based practice promotes a hierarchy of evidence, it is also the case that clinical practice is influenced by a hierarchy of social status. These are as much political as they are scientific. Methods and Results: This article will provide an explanation for why chronic edema is a low priority. It will do this through a critical review of the literature. We examine this through the theoretical lens of Pierre Bourdieu. The sociology of Bourdieu frames an understanding of power relations through habitus, field, and capital. We will employ these theoretical tools to understand the way that chronic edema is situated within the policy arena. We identify a number of social mechanisms that affect the status of chronic edema, including diagnostic uncertainty, social capital, scientific capital, cultural capital and economic capital. Conclusion: We argue that a whole system approach to care, based on human need rather than unequal power relations, is a prerequisite for the delivery of good health care. The specialty of chronic edema is not a powerless group and we identify some of the ways that the social mechanism that acts as barriers to change, can also be employed to challenge them.

How does role transition affect the experience of trainee Advanced Clinical Practitioners: Qualitative evidence synthesis.

BACKGROUND: Advanced Clinical Practitioners have been developed to address current and future gaps in the medical workforce. Insight into problems associated with Advanced Clinical Practitioner transition may help present and future trainees adapt to their changing and demanding health environment. AIMS: To identify potential problems experienced by trainee Advanced Clinical Practitioners during transition and what the implications might be for workforce planning. DESIGN: A qualitative evidence synthesis to examine the issue of role transition for Advanced Clinical Practitioners. DATA SOURCES: The electronic databases accessed (1997-2016) were MEDLINE, EMBASE, CINAHL, BNI, AMED and PubMed and also included Researchgate, thesis publications, hand searching and NHS staffing reports. REVIEW METHODS: Eleven studies were identified between 1997 - 2016. Thematic synthesis was undertaken, creating codes, descriptive and analytical themes. Quality appraisal of individual studies was conducted using the tool of Walsh and Downe. FINDINGS: Six analytical themes were identified that addressed the key issues of transition discussed in the 11 articles and which were directly related to the proposed research project: experience of change, orientation to role, mentorship, clinical skills, clinical supervision and Masters' level education. CONCLUSIONS: Findings from all 11 articles were similar. Where these six themes were ignored, there was often either a failure to reach expected goals or resignation from the role. Future employers must ensure that they establish a comprehensive orientation and education programme to be certain that qualified Advanced Clinical Practitioners are suitably prepared for their role in health care.

Pierre Bourdieu: Expanding the scope of nursing research and practice.

Bourdieu is an important thinker within the sociological tradition and has a philosophically sophisticated approach to theoretical knowledge and research practice. In this paper, we examine the implication of his work for nursing and the health sciences more broadly. We argue that his work is best described as a reflexive realist who provides a space for a nonpositivist approach to knowledge that does not fall into the trap of idealism or relativism. We emphasize that Bourdieu was not an abstract theorist, but only utilized theories to understand and explain the social world in all its empirical complexity. Theory is emphasized over method without denying the importance of method. We then provide a brief overview of some of his key concepts: habitus, field and capital. His work is a scientifically astute practice that has an emancipatory purpose, with particular resonance to the problems of nursing as a social practice. Some have criticized Bourdieu for undermining agency and we briefly address this issue, but argue that his conceptual framework helps us to understand what endures in social practice and why change is often problematic. In short, this paper argues that Bourdieu's work is a fruitful resource for critiquing existing nursing approaches that are preoccupied with agency over structure.

Health professionals' perceptions regarding family witnessed resuscitation in adult critical care settings.

AIMS AND OBJECTIVES: To deepen our understanding of the perceptions of health professionals regarding family witnessed resuscitation in Jordanian adult critical care settings. BACKGROUND: The issue of family witnessed resuscitation has developed dramatically in the last three decades. The traditional practice of excluding family members during cardiopulmonary resuscitation had been questioned. Family witnessed resuscitation has been described as good practice by many researchers and health organisations. However, family witnessed resuscitation has been perceived by some practitioners to be unhealthy and harmful to the life-saving process. The literature showed that there are no policies or guidelines to allow or to prevent family witnessed resuscitation in Jordan. DESIGN: An exploratory qualitative design was adopted. METHODS: A purposive sample of 31 health professionals from several disciplines was recruited over a period of six months. Individual semi-structured interviews were used. These interviews were transcribed and analysed using thematic analysis. FINDINGS: It was found that most healthcare professionals were against family witnessed resuscitation. They raised several concerns related to being verbally and physically attacked if they allowed family witnessed resuscitation. Almost all of the respondents expressed their fears of patients' family members' interfering in their work. Most of the participants in this study stated that family witnessed resuscitation is traumatic for family members. This was viewed as a barrier to allowing family witnessed resuscitation in Jordanian critical care settings. CONCLUSION: The study provides a unique understanding of Jordanian health professionals' perceptions regarding family witnessed resuscitation. They raised some views that contest some arguments in the broader literature. Further research with patients, family members, health professionals and policy makers is still required. RELEVANCE TO CLINICAL PRACTICE: This is the first study about family witnessed resuscitation in Jordan. Considering multi-disciplinary healthcare professionals' views would be helpful when starting to implement this practice in Jordanian hospitals.

The development of the specialism of emergency medicine: media and cultural influences.

In this article we analyse, via a critical review of the literature, the development of a relatively new medical specialism in the United Kingdom, that of emergency medicine. Despite the high media profile of emergency care, it is a low-status specialism within UK medicine. The creation of a specialist College in 2008 means that, symbolically, recognition as a full specialism has now been achieved. In this article, we will show, using a sociology of professions approach, how emergency medicine defined itself as a specialism, and sought to carve out a distinctive jurisdiction. While, in the context of the UK National Health Service, the state was clearly an important factor in the development of this profession, we wish to develop the analysis further than is usual in the sociology of professions. We will analyse the wider cultural context for the development of this specialism, which has benefited from its high profile in the media, through both fictional and documentary sources.

An exploration of the perceptions of emergency department nursing staff towards the role of a domestic abuse nurse specialist: a qualitative study.

There is a clear body of evidence which indicates that a substantial number of people who have experienced domestic violence and abuse attend the emergency department (ED). However, many individuals do not receive effective identification or support. The present study sought to explore the perceptions of ED staff about the perceived value and utilisation of a new domestic abuse nurse specialist role that has been created in one ED in the UK. A qualitative design was used and involved sixteen in-depth interviews with a range of practitioners. The findings highlight that staff highly valued the role of the nurse specialist as one which offered support both professionally and personally. However, the study has also drawn attention to the conundrum that surrounds identification and management of abuse and of enquiry more generally. The ED is ideally suited to identify at risk individuals but is not institutionally organised in a way that prioritises the social concerns of their patients and this nursing role is one way that this issue can be addressed. In light of recent UK and global policy directives further research is needed to explore the development and implementation of identification, management and support in the future.

Nursing and the new biology: towards a realist, anti-reductionist approach to nursing knowledge.

As a system of knowledge, nursing has utilized a range of subjects and reconstituted them to reflect the thinking and practice of health care. Often drawn to a holistic model, nursing finds it difficult to resist the reductionist tendencies in biological and medical thinking. In this paper I will propose a relational approach to knowledge that is able to address this issue. The paper argues that biology is not characterized by one stable theory but is often a contentious topic and employs philosophically diverse models in its scientific research. Biology need not be seen as a reductionist science, but reductionism is nonetheless an important current within biological thinking. These reductionist currents can undermine nursing knowledge in four main ways. Firstly, that the conclusions drawn from reductionism go far beyond their data based on an approach that prioritizes biological explanations and eliminates others. Secondly, that the methods employed by biologists are sometimes weak, and the limitations are insufficiently acknowledged. Thirdly, that the assumptions that drive the research agenda are problematic, and finally that uncritical application of these ideas can be potentially disastrous for nursing practice. These issues are explored through an examination of the problems reductionism poses for the issue of gender, mental health, and altruism. I then propose an approach based on critical realism that adopts an anti-reductionist philosophy that utilizes the conceptual tools of emergence and a relational ontology.

Families' stressors and needs at time of cardio-pulmonary resuscitation: a Jordanian perspective.

BACKGROUND: During cardio-pulmonary resuscitation, family members, in some hospitals, are usually pushed to stay out of the resuscitation room. However, growing literature implies that family presence during resuscitation could be beneficial. Previous literature shows controversial belief whether or not a family member should be present during resuscitation of their relative. Some worldwide association such as the American Heart Association supports family-witnessed resuscitation and urge hospitals to develop policies to ease this process. The opinions on family-witnessed resuscitation vary widely among various cultures, and some hospitals are not applying such policies yet. This study explores family members' needs during resuscitation in adult critical care settings. METHODS: This is a part of larger study. The study was conducted in six hospitals in two major Jordanian cities. A purposive sample of seven family members, who had experience of having a resuscitated relative, was recruited over a period of six months. Semi-structured interview was utilised as the main data collection method in the study. FINDINGS: The study findings revealed three main categories: families' need for reassurance; families' need for proximity; and families' need for support. The need for information about patient's condition was the most important need. Updating family members about patient's condition would reduce their tension and improve their acceptance for the end result of resuscitation. All interviewed family members wanted the option to stay beside their loved one at end stage of their life. Distinctively, most of family members want this option for some religious and cultural reasons such as praying and supplicating to support their loved one. CONCLUSIONS: This study emphasizes the importance of considering the cultural and religious dimensions in any family-witnessed resuscitation programs. The study recommends that family members of resuscitated patients should be treated properly by professional communication and involving them in the treatment process. The implications concentrate on producing specific guidelines for allowing family-witnessed resuscitation in the Jordanian context. Finally, attaining these needs will in turn decrease stress of those witnessing resuscitation of their relative.

Audit of standards of practice in suspected hip fracture.

BACKGROUND: Hip-fracture is a common orthopaedic injury presenting to the Emergency Department, particularly within the elderly population. Standards of practice dictating the care of these patients include the early administration of analgesia and an accurate clinical assessment. Once a hip-fracture has been confirmed with diagnostic-imaging, the patient should be transferred to an orthopaedic ward as soon as possible. These standards have been identified from a range of national policies and evidence-based literature. AIM: To identify standards of best-practice for the care of patients with a suspected hip-fracture in the Emergency Department and to audit compliance with these standards. METHOD: A retrospective-audit of 185 Emergency Department Information System records for adult patients admitted with a suspected hip-fracture was conducted using a purpose-designed data-extraction spread-sheet based on discrete standards of audit. FINDINGS: It was found that the Emergency Department performed well on some audit standards, such as the medical assessment of patients. However, some problems of assessment were identified in relation to pressure-care, the timely transfer of patients to a suitable ward and the delivery of pain-relief. CONCLUSIONS AND RECOMMENDATIONS: There were examples of good practice in this audit, but also areas that require improvement. We recommend that a care bundle be implemented to focus on improvements in pain-relief, pressure-care and fast-tracking.

Reflexivity and habitus: opportunities and constraints on transformative learning.

This paper will explore the relationship between Mezirow's concept of reflexivity and Bourdieu's theory of habitus in order to develop a more robust framework within which critical reflection can take place. Nurse educators have sought to close the theory practice gap through the use of critical reflection. However, we are not convinced that this has produced the depth and quality of reflection required. Furthermore, the contexts in which critical reflection takes place is often sidelined or erased so that the whole impetus in the literature is to educate nurses in reflection rather than empower nurses to understand the complex circumstances and barriers that obstruct critical reflection. This paper argues that the reason for this position is that nurse education does not always acknowledge the role that personal and cultural values systems have on reflective practices. The literature search was undertaken using CINHAL and MEDLINE. Keywords included: values systems, habitus, and critical reflection. Inclusion criteria were determined by the theoretical approach and included seminal texts, from as far back as 1956, to identify key themes. Although critical reflection is a potentially powerful way of enhancing care it has often failed to do so. It is suggested that this is because nurse educators have frequently used models of reflection without considering the impact that student's personal values systems has on their perceptions of care and subsequently care delivery. The purpose of this paper is to promote deeper levels of reflection and is part of a programme of research aimed at developing a more robust approach to reflection in educational practice.

A critical realist approach to knowledge: implications for evidence-based practice in and beyond nursing.

This paper will identify some of the key conceptual tools of a critical realist approach to knowledge. I will then apply these principles to some of the competing epistemologies that are prevalent within nursing. There are broadly two approaches which are sometimes distinct from each other and sometimes inter-related. On one side, there is the view that all healthcare interventions should be judged on the principles of randomised controlled trials and the other is a preoccupation with language in which healthcare interventions are subjected to a discursive interrogation. These debates are configured through the idea of a hierarchy of knowledge that is accorded uncritical acceptance by some and virulent distaste by others. I will argue that the notion of hierarchy is problematic and is largely argued for in unproductive epistemological terms. What is required is a shift towards a theory that emphasises the contextual nature of the ways that knowledge is produced and disseminated. In other words, there is no single hierarchy of knowledge, but there are multiple hierarchies of knowledge.

Diversity and ethnicity in nurse education: the perspective of nurse lecturers.

This paper is a report on a qualitative study which considered the issue of how lecturers feel about teaching and managing the topic of culture and racism within their role as nurse educators. The issue of cultural diversity and the related issue of racism within nursing and society more generally means that the problem cannot be ignored since one of the central tenets of nursing is that care should be delivered in non-discriminatory ways. We interviewed a group of lecturers within a UK university to explore their views on the topic. We produced six themes: Culture; the existence of racism within nursing; challenging racism; political correctness; strategies adopted to address issues in the classroom and the presence of cultural diversity within the curriculum. We identified that the lecturers in our study were keen to address the issue but were also very concerned about their own abilities and confidence in this area.

Sedation assessment using the Ramsay scale.

Patients undergoing sedation in emergency departments (EDs) must be monitored carefully to ensure that, when they are being transferred to different departments, they are safe and that information about them is accurate. However, sedation scoring, for which several tools are available, should not be confused with assessment of consciousness, which is undertaken using the Glasgow Coma Scale. This article considers the validity and reliability of sedation scoring tools, and discusses how ED staff can choose and integrate them into patient care pathways.

Social structure and nursing research.

The concept of social structure is ill defined in the literature despite the perennial problem and ongoing discussion about the relationship between agency and structure. In this paper I will provide an outline of what the term social structure means, but my main focus will be on emphasizing the value of the concept for nursing research and demonstrate how its erasure in some research negatively effects on our understanding of the nurses' role in clinical practice. For example, qualitative research in nursing has largely focused on agency through such theories as phenomenology, hermeneutics, and symbolic interactionism. The result is that social structure may be erased or seen as epiphenomena of agency. My purpose is to provide a theoretical discussion of social structure and how such a discussion can help us to understand how nurses live and experience clinical practice. While not denying the importance of agency, I will argue that the thinned out approach to social structure places limits on our understanding of the constraints nurses experience in their working lives. The result is that nurses' attitudes and clinical failings are individualized, resulting in ever more calls for improved education, when a more thorough examination of structural issues may elucidate more fundamental problems.

Lecturers' and students' perceptions of portfolios in an English School of Nursing.

AIMS: This study was aimed at comparing perceptions of portfolios between student nurses at the early and latter stages of their training and how they compare with their lecturers' perceptions. BACKGROUND: Portfolios are used widely in nurse education. There has been research into how portfolios are perceived and understood, but there is little evidence into how student nurses and lecturers compare quantitatively in perceptions of portfolio use. DESIGN: Survey. METHOD: Forty-eight nursing lecturers and 413 nursing students, from a multi-centred School of Nursing in the UK, completed a questionnaire. Data were analysed with exploratory factor analysis, varimax rotation of the factor solution, internal consistency analysis, and analysis of variance. RESULTS: Five factors were extracted, which were labelled: (1) portfolios as a means of skills acquisition, (2) other means of teaching and learning beyond using portfolios, (3) processes of showing the portfolio to others, (4) having favourable attitudes towards portfolios and (5) lecturers' ability to share knowledge about portfolios. Scales developed from these five factors had high levels of internal consistency. Lecturers were the most positive of the three respondent groups in their views of portfolios, whereas third- and fourth-year students were the least positive. There were significant differences between student nurses and their lecturers, concerning how information on portfolios is communicated by the lecturer. CONCLUSION: There were significant discrepancies between lecturers and student nurses in their views on how portfolios are used. The value of portfolios becomes less salient to student nurses towards the end of their training. RELEVANCE TO CLINICAL PRACTICE: Lecturers and clinical mentors need to look at students' perceptions and why some nursing students' views on portfolios deteriorate. There could be regular discussions with students to see how and why the students begin to see portfolios as less useful for their education and continual professional development.

Student nurses' knowledge, skills and attitudes towards the use of portfolios in a school of nursing.

AIMS: The aims of this study are to examine the knowledge, skills and attitudes of student nurses about the value and purpose of portfolios and their relevance for professional development. BACKGROUND: Portfolios have become an integral aspect of student centred learning within nursing. The literature is generally positive about the benefits of portfolios but questions remain about their effective implementation. METHOD: A questionnaire was used to survey student nurses about the use of portfolios as a learning tool. The questionnaire was developed specifically for this study and was structured around a knowledge skills and attitude framework. RESULTS: The sample was 413 preregistration student nurses in one school of nursing in the UK across course, year of study and branch of nursing. The main findings reveal that students are unclear but positive about the purpose and use of portfolios. Specifically, academic tutors do not provide sufficient direction in the development of their portfolios. There is also evidence that students found portfolios more useful for exploring the 'art' of nursing, rather than the 'technical' skills of nursing. Students also reported that they would welcome a dedicated portfolio module. CONCLUSION: Students struggle with what is useful about portfolios and are unsure about its purpose. Nonetheless, they are positive towards portfolios as a learning tool and seem to acknowledge the usefulness of portfolios for professional development. RELEVANCE TO CLINICAL PRACTICE: The importance of portfolios for professional development is now being emphasized but how academic tutors and clinical mentors support their development remains unclear. This study provides understanding about what support students would value.

Emergency care and narrative knowledge.

BACKGROUND: Nursing knowledge is a composite of many influences. In an attempt to strengthen nursing knowledge and practice, there have been significant developments in the codification of nursing knowledge as part of the evidence-based practice movement. Using established research techniques; this has the capacity to enhance clinical practice. However, not all knowledge can be incorporated into this type of academic discourse, and there is growing interest in narrative knowledge. This paper contributes to this sometimes implicit and sometimes explicit critique of dominant paradigms. AIM: The aim of this paper is to examine the usefulness of narrative as a means of exploring the world of emergency nursing practice and its contribution to the emotional lifeworld of clinicians. METHOD: A discourse analysis of nursing narratives in their natural settings was carried out. This involved exploration of stories that were not produced for the purposes of research. FINDINGS: Narratives can open up social worlds, which escape or be deliberately erased by more formal methods. Contingent and subversive knowledge can contribute to understanding the emotional impact of emergency care. CONCLUSION: These narratives have their own 'truth', which should be incorporated into an understanding of what constitutes the lifeworld of emergency nurses.

The patient experience in emergency departments: a review of the literature.

This paper analyses the literature on the patient experience within emergency departments. We identify six themes within the literature: waiting times, communication, cultural aspects of care, pain, the environment and dilemmas in accessing the patient experience. Overall, the literature has a North American bias and is largely quantitative in approach. Although levels of patient satisfaction are high, a number of issues arise within the review, which suggest areas where quality of care could improve. We also identify the problematic nature of accessing the patient experience and suggest future areas for researchers to explore.