Professional and political reflections on the 'grand round': a critical case study.

This case study presents a critical reflective account of a change to working practices in one NHS Trust. To promote quality care and effective clinical decision making, a 'grand round' was introduced in the orthopaedic department. Implementation presented frustrations and challenges for members of the multidisciplinary team. These are explored using transformative learning and critical reflection, enabling connections to be made between micro-level interactions of clinical care and macro-level structures that frame healthcare services. It is important that nurses recognise the escalating impact of a neoliberal agenda, and new public management, that drive UK health policy and politics. The value base of nursing is threatened by a corporate culture that measures performance in terms of institutional targets rather than individual care.

Is compassion possible in a market-led NHS?

The principle of compassionate care is increasingly seen as the core element of good nursing practice. However, recent media reports have focused on the "compassion deficit". We carried out a review of national and international evidence on core professional values, which showed that caring and compassion are inherent nursing values. While the development of these values is influenced by training and role modelling, the main influence is the organisation and culture in which nurses work. This article discusses the findings of the review in relation to the national debate around compassionate care within an NHS that is being fundamentally changed. We suggest any failure in compassion is more likely to be due to government health policy and NHS organisational culture than to any shortcomings of nurses or nursing practice.

Vaccine-preventable haemophilus influenza type B disease burden and cost-effectiveness of infant vaccination in Indonesia.

BACKGROUND: Most of Asia, including Indonesia, does not use Haemophilus influenzae type b (Hib) conjugate vaccines. We estimated total vaccine-preventable disease burden and the cost-effectiveness of Hib conjugate vaccine in Indonesia. METHODS: Hib pneumonia and meningitis incidences for children with access to health care were derived from a randomized vaccine probe study on Lombok Island, Indonesia during 1998-2002. Incidences were adjusted for limited access to care. Health system and patient out-of-pocket treatment cost data were collected concurrent with the probe study. For Hib vaccine in monovalent and combined (with DTP-HepB) presentations, we used 2007 UNICEF vaccine prices of US$3.30 and $3.75 per dose. RESULTS: For the 2007 Indonesian birth cohort, Hib vaccine would prevent meningitis in 1 of every 179 children, pneumonia in 1 of every 18 children, and 4.9% of mortality among those younger than 5 years. The total incremental societal costs of introducing Hib vaccine in monovalent and pentavalent presentations were, respectively, US$11.74 and $8.93 per child vaccinated. Annual discounted treatment costs averted amounted to 20% of pentavalent vaccine costs. For the pentavalent vaccine, the incremental costs per discounted death and disability adjusted life-year averted amounted to US$3102 and $74, respectively, versus $4438 and $102 for monovalent vaccine. CONCLUSIONS: Routine infant Hib vaccination would prevent a large burden of pediatric illness and death in Indonesia. Even without external funding support, Hib vaccine will be a highly cost-effective intervention in either a monovalent or pentavalent presentation based on commonly used benchmarks.

Sex, gender and the carceral: Female staff experiences of working in forensic care with sexual offenders.

English high-secure hospitals have contained individuals deemed mentally disordered, and dangerous, since the mid-nineteenth century. With the development of gender sensitive services female patients have been moved out of these institutions into smaller secure settings. Female staff continue to work in high secure hospitals, but are often in a minority in these services. Little is known about how female staff experience the everyday world of work. This paper is based on in-depth interviews with female nurses employed in a unit caring for detained male sexual offenders with a diagnosis of personality disorder. It forms part of a much larger discourse-analytic study of nine patients, with a history of sexual offending, and eighteen mental health nurses, which focused on talk about pornography and criminality. The findings from this project have been previously reported in Mercer and Perkins (2014). This paper demonstrates how patriarchy remains an enduring cultural characteristic of caring for men detained under the Mental Health Act (1983, 2007) because of sexually violent crimes against women and children. It textures the ward environment and the relationships between people who work within it, constructing women as 'outsiders' and producing a masculine culture which leaves female staff feeling vulnerable and at risk. The analytic focus of the paper is concerned with exploring how women experience working in the male-dominated environment of a high-security Personality Disorder Unit (PDU). Three discursive repertoires are identified: the institutional space as male, the impact of working with men detained as a result of sexual offending, and the construction of therapeutic work as a 'job for the boys'. In this world, female staff, as a product of their gender, constructed themselves both as at risk and inviting risk.

Debt Counselling for Depression in Primary Care: an adaptive randomised controlled pilot trial (DeCoDer study).

BACKGROUND: Depression and debt are common in the UK. Debt Counselling for Depression in Primary Care: an adaptive randomised controlled pilot trial (DeCoDer) aimed to assess the clinical effectiveness and cost-effectiveness of the addition of a primary care debt counselling advice service to usual care for patients with depression and debt. However, the study was terminated early during the internal pilot trial phase because of recruitment delays. This report describes the rationale, methods and findings of the pilot study, and implications for future research. OBJECTIVES: The overarching aim of the internal pilot was to identify and resolve problems, thereby assessing the feasibility of the main trial. The specific objectives were to confirm methods for practice recruitment and the ability to recruit patients via the proposed approaches; to determine the acceptability of the study interventions and outcome measures; to assess contamination; to confirm the randomisation method for main trial and the level of participant attrition; and to check the robustness of data collection systems. DESIGN: An adaptive, parallel, two-group multicentre randomised controlled pilot trial with a nested mixed-methods process and economic evaluation. Both individual- and cluster (general practice)-level were was used in the pilot phase to assign participants to intervention or control groups. SETTING: General practices in England and Wales. PARTICIPANTS: Individuals were included who were aged ≥ 18 years, scored ≥ 14 on the Beck Depression Inventory II and self-identified as having debt worries. The main exclusion criteria were being actively suicidal or psychotic and/or severely depressed and unresponsive to treatment; having a severe addiction to alcohol/illicit drugs; being unable/unwilling to give written informed consent; currently participating in other research including follow-up phases; having received Citizens Advice Bureau (CAB) debt advice in the past year; and not wanting debt advice via a general practice. INTERVENTIONS: The participants in the intervention group were given debt advice provided by the CAB and shared biopsychosocial assessment, in addition to treatment as usual (TAU) and two debt advice leaflets. The participants in the control group were given advice leaflets provided by the general practitioner and TAU only. MAIN OUTCOME MEASURES: (1) Outcomes of the pilot trial - the proportion of eligible patients who consented, the number of participants recruited compared with target, assessment of contamination, and assessment of patient satisfaction with intervention and outcome measures. (2) Participant outcomes - primary - Beck Depression Inventory II; secondary - psychological well-being, health and social care utilisation, service satisfaction, substance misuse, record of priority/non-priority debts, life events and difficulties, and explanatory measures. Outcomes were assessed at baseline (pre-randomisation) and at 4 months post randomisation. Other data sources - qualitative interviews were conducted with participants, clinicians and CAB advisors. RESULTS: Of the 238 expressions of interest screened, 61 participants (26%) were recruited and randomised (32 in the intervention group and 29 in the control group). All participants provided baseline outcomes and 52 provided the primary outcome at 4 months' follow-up (14.7% dropout). Seventeen participants allocated to the intervention saw a CAB advisor. Descriptive statistics are reported for participants with complete outcomes at baseline and 4 months' follow-up. Our qualitative findings suggest that the relationship between debt and depression is complex, and the impact of each on the other is compounded by other psychological, social and contextual influences. CONCLUSIONS: As a result of low recruitment, this trial was terminated at the internal pilot phase and was too small for inferential statistical analysis. We recommend ways to reduce this risk when conducting complex trials among vulnerable populations recruited in community settings. These cover trial design, the design and delivery of interventions, recruitment strategies and support for sites. TRIAL REGISTRATION: Current Controlled Trials ISRCTN79705874. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 35. See the NIHR Journals Library website for further project information. Mark Gabbay and Adele Ring are part-funded by NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC) North West Coast and Richard Byng and Rod S Taylor, Vashti Berry and Elizabeth Shaw part-funded by NIHR CLAHRC South West Peninsula.

Imagined in Policy, Inscribed on Bodies: Defending an Ethic of Compassion in a Political Context: Comment on "Why and How Is Compassion Necessary to Provide Good Quality Healthcare?".

In response to the International Journal of Health Policy and Management (IJHPM) editorial, this commentary adds to the debate about ethical dimensions of compassionate care in UK service provision. It acknowledges the importance of the original paper, and attempts to explore some of the issues that are raised in the context of nursing practice, research and education. It is argued that each of these fields of the profession are enacted in an escalating culture of corporatism, be that National Health Service (NHS) or university campus, and global neoliberalism. Post-structuralist ideas, notably those of Foucault, are borrowed to interrogate healthcare as discursive practice and disciplinary knowledge; where an understanding of the ways in which power and language operate is prominent. Historical and contemporary evidence of institutional and ideological degradation of sections of humanity, a 'history of the present,' serve as reminders of the import, and fragility, of ethical codes.

Onward in my journey: preparing nurses for a new age of cancer care.

Cancer nursing education in the United Kingdom currently is the subject of widespread debate. The imperative to improve cancer care is driven by professional and ethical obligations for clinical excellence and an aggressive political agenda seeking to demonstrate tangible improvements through centrally administered targets and benchmarks. Attempts to provide a holistic approach to care have engendered a range of alternative approaches underpinned by an appreciation of the "cancer journey." Despite the laudable intent of national policy initiatives aimed at improving the experience of cancer treatment, they have evidenced an emerging polarization in the practice arena. Nursing interventions, priorities, and goals are at risk of becoming confused by the competing paradigms of an outcome-driven strategy and a less focused humanistic philosophy of care. This dilemma presents significant problems in the planning of appropriate and effective education preparation for cancer nurses. This article aims to address the tensions produced by a dichotomy between the pragmatics of clinical practice and a professional quest for holism. It focuses on a specialist practitioner cancer nursing program, using case examples to illustrate innovations in teaching and learning. Embracing a postmodern perspective, reflection, and critical thinking, the discussion offers a challenge to diagnostic clinical language through the discursive structures of metaphor, narrative, and story.

The influence of evil on forensic clinical practice.

As the medicalization of criminal behaviour expands through forensic psychiatric practice it is reliant upon a therapeutic ideology based on clinical assessment and effective application of treatment strategies. When such criminal offenses are particularly heinous the perpetrators are often referred to as evil by non-professional accounts. However, the extent to which the concept of evil affects the perceptions of mental health professionals working with such offenders is little understood. This paper reports on research conducted in a high-security psychiatric hospital in the North-west of England and examines the construction of care plans in relation to a number of mentally disordered offenders who are considered by a group of mental health professionals as evil. Thematic analysis of mental health professionals' discourse pertaining to the care plans revealed a complex motivational and rational structuring of evil that dictated the switch from medical ideological discourse to lay notions of badness. From this, an Airaksinen model was constructed to display the types of evil manifestations.

The vignette revisited: evil and the forensic nurse.

The vignette is a valuable and flexible research tool in behavioural sciences and health care. Joel Richman and Dave Mercer outline the variable application of this method and propose a classification in terms of the form and use of the vignette. The discussion is illustrated with an example of the way that vignettes provided access to the discursive structures of forensic mental health nurses in one maximum secure psychiatric hospital. It is suggested that this methodology, within the broader aims of the study, revealed an ordered and taxonomic discourse of evil, with significant implications for professional practice.

Video gaming and sexual violence: rethinking forensic nursing in a digital age.

This article reports findings from a qualitative study into how forensic nurses, and male personality disordered sexual offenders, talked about "pornography" in one U.K. high-security hospital. Research rationale was rooted in current professional and political debates, adopting a discourse analytic design to situate the project in a clinical context. Semistructured interviews, as co-constructed accounts, explored talk about sexual media, offending, treatment, and risk. Data were analyzed using a version of discourse analysis popular in healthcare research, identifying discursive repertoires, or collective language use, characteristic of the institutional culture. Findings revealed that masculine discourse marginalized female nurses and contradicted therapeutic goals, where men's talk about pornography, sex, and sexual crime represented discriminatory and gendered language. Nursing definitions of pornography were constructed in the context of the client group and an organizational need to manage risk. In a highly controlled environment, with a long-stay population, priority in respondent talk was given to mainstream commercial sexual media and everyday items/images perceived to have embedded sexual meaning. However, little mention was made of contemporary modes of producing/distributing pornography, where sex and sexual violence are enacted in virtual realities of cyberspace. Failure to engage with information technology, and globally mediated sex, is discussed as a growing concern for forensic health workers.

Theorising sexual media and sexual violence in a forensic setting: men's talk about pornography and offending.

This article reports findings from a discourse analytic study which critically explored the language of mental health nurses, and detained sexual offenders, in relation to pornography in one high-security hospital. It recognised previous empirical investigation, and pro-feminist theorising, into mediated representations and male sexual violence, but situated the research process in a forensic nursing context. Decision-making about access to, or restriction of, commercial sexual literature, as a component of therapeutic intervention and offender management, reveals tensions between service-user rights and treatment goals. The aim was to access nurse and patient talk in a specific culture. Semi-structured interviews with eighteen nursing staff, and nine patients, were used to co-construct accounts of pornography, sexual offending, and treatment. Analysis and data collection were undertaken concurrently. Interviews were audio-taped and transcribed. Data was coded to identify theoretical/conceptual themes and sub-themes representing discursive repertoires. Attention was given to how textual variation positioned respondents in relation to each other and the institution. Findings suggested collective male talk textured the environment, promoted gendered inequality, marginalised female nurses, and undermined rehabilitation. Shared discourse enabled male staff and patients to relate to each other as men, while maintaining distance through constructions of otherness. Discussion focuses on discriminatory discursive-practices, where men's talk about pornography and sexual violence embodied gendered knowledge/experience and contributed to a toxic culture. Consideration is given to ways of resisting institutional impediments and promoting positive therapeutic relations.

Girly mags and girly jobs: pornography and gendered inequality in forensic practice.

This article presents findings from a discourse analytic study into the constructive nature and textual variations of language in a high-security hospital. It explores how mental health nurses, and men convicted of sexual offences who also have a diagnosis of personality disorder, talked about pornography and sexual crime in the context of forensic provision. Access to sexually-explicit media, in relation to treatment environments for people convicted of sexual offences, has become a cause for professional and political concern in the UK. Data collection and analysis, undertaken concurrently, were informed by a discursive design. Semistructured interviews, as co-constructed accounts with nursing staff and detained patients, were audio-taped and transcribed. Data were coded to identify the discursive repertoires, or collective talk, of respondents. In contrast to empirical inquiry into pornography and sexual violence, methodology shifted attention from measurement to meaning, and situated research in a clinical domain. The findings focus on performative language use, where talk about pornography textured the treatment environment, contributed to an overtly masculine discourse, framed the ward as male space, and promoted gendered inequality. The discussion questions the legitimacy of the therapeutic enterprise.

Social aspects of clinical errors.

Clinical errors, whether committed by doctors, nurses or other professions allied to healthcare, remain a sensitive issue requiring open debate and policy formulation in order to reduce them. The literature suggests that the issues underpinning errors made by healthcare professionals involve concerns about patient safety, professional disclosure, apology, litigation, compensation, processes of recording and policy development to enhance quality service. Anecdotally, we are aware of narratives of minor errors, which may well have been covered up and remain officially undisclosed whilst the major errors resulting in damage and death to patients alarm both professionals and public with resultant litigation and compensation. This paper attempts to unravel some of these issues by highlighting the historical nature of clinical errors and drawing parallels to contemporary times by outlining the 'compensation culture'. We then provide an overview of what constitutes a clinical error and review the healthcare professional strategies for managing such errors.

"Modern language" or "spin"? Nursing, "newspeak" and organizational culture: new health scriptures.

A new managerial language of modernization has accompanied political restructuring of the National Health Service. Corporate goals of efficiency and audit have been integrated with the ideological manifesto of New Labour in stressing citizenship, inclusion and empowerment. Drawing on the theoretical insights of anthropology and sociology, this article critically reviews the relationship between health policy, organizational culture and nursing practise through an exploration of language in terms of "rhetoric", "jargon" and "metaphor". It is suggested that beyond the bewildering vocabulary of "buzz words" is a fundamental contradiction between the ethic of caring and the expectations of Government. Finally thought is given to the role of professional education and training where intellectual engagement with the ritual categories of "newspeak" is a subversive act.