Experiencing transformation: the case of Jordanian nurse immigrating to the UK.

AIMS AND OBJECTIVES: This study explored how Jordanian nurses experienced the transition from home to host country to illuminate the elements of transformation. BACKGROUND: Much research has been conducted on topics such as the current international nursing shortage and the recruitment of nurses from various countries. International nurses have unique needs with regard to adapting to new host cultures and workplaces; furthermore, the literature has revealed little evidence of nurses' professional and personal experiences related to migration. DESIGN: A qualitative study was conducted, collecting data via individual interviews. METHODS: Twenty-five face-to-face and telephone interviews with Jordanian migrant nurses. RESULT: This study showed that living and working in a host country changes the personal, social and professional attributes of migrant nurses. When nurses migrate, they encounter opportunities and significant challenges in their professional and personal lives. Although Jordanian nurses contributed their knowledge and skills to the UK healthcare system, they encountered enormous professional adaptation demands. Work setting discrepancies between source and host country are likely a major element behind the required nursing profession alteration. nurses' lives are transformed in terms of their personal and social networks in the host country. CONCLUSIONS: Social transformation is an integral and inseparable part of engagement with professional organisation(s) in the host community. Professional integration likely has far-reaching effects and consequences involving not only the individual but also their home and host country families and their professional networks. RELEVANCE TO CLINICAL PRACTICE: To provide high-quality nursing care, we must learn about the transformation experience, expand our sense of who we are and gain a degree of control over how we perform our nursing roles when we move away from our home.

How do nurse prescribers integrate prescribing in practice: case studies in primary and secondary care.

AIMS AND OBJECTIVES: To report a study investigating how nurse prescribers integrate prescribing in clinical practice. Factors that influence integration are explored and how nurses approach integration is defined. BACKGROUND: There are expectations that nurse prescribers will prescribe for patients. Nurse prescribers share jurisdiction of prescribing with doctors in the workplace and new divisions of labour must be agreed to enable the nurse to begin prescribing. Little is known about how nurses integrate prescribing in practice but these agreements are potentially important to the organisation of professional work and the delivery of healthcare. DESIGN: Case study. METHODS: Twenty six nurse prescribers were interviewed in case studies of primary and secondary care prescribing. Case data were collected by semi-structured interview and combined with field notes and socio-demographic data in case summaries. Data were organised in vivo (QSR International Pty Ltd, Doncaster, Victoria, Australia) and subject to manual analysis at single and cross-case level. RESULTS: Twenty-one of the 26 cases were prescribing. Trust between doctor and nurse and nurse and employer was shown to be necessary for effective integration. There were differences in how prescribing agreements were reached in primary and secondary care. Restrictions were imposed in secondary care. In primary care, nurses made decisions themselves about the medicines they prescribe but frequently asked doctors to check their decisions. Nurses described three approaches to prescribing: as opportunity presents, for specific conditions and for individuals. CONCLUSIONS: Nurse prescribers described three approaches to prescribing and in two approaches the nurse self-restricted prescribing activity. Secondary care prescribers had more employer restrictions than their primary care counterparts. Trust between doctor nurse and nurse employer was shown to be necessary for integration; without trust, the nurse will not prescribe. RELEVANCE TO PRACTICE: Trust in prescribing relationships is necessary for effective integration of nurse prescribing in practice.

The role of primary care professionals in women's experiences of cervical cancer screening: a qualitative study.

BACKGROUND: The UK Cervical Screening Programme, delivered mostly through primary care, commands impressive levels of public support. However, considerable evidence suggests that women find the experience of screening problematic. OBJECTIVE: To investigate this tension using women's accounts of cervical screening, with a view to informing practice to better meet their needs. METHODS: A qualitative interview study with 34 participants focussed on their experiences and understandings of cervical cancer screening in the UK. Analysis was based on the constant comparative method. RESULTS: The highly intimate and personal nature of the test is challenging, and many women report unsatisfactory experiences. Problematic issues include: embarrassment and discomfort (sometimes severe) in exposing an intimate and personal part of their body; surrendering control and finding the test painful, uncomfortable and personally threatening. Though there is an important role for primary health care professionals in easing discomfort and facilitating positive experiences, women often report feeling disappointed with how the procedure is conducted. Women suggest that practitioners' attempts to normalize the interaction and maintain a degree of detachment could have the perverse effect of making them feel more uncomfortable and that more personalization would be welcome. CONCLUSIONS: This work identifies the ways in which women may find personal engagement with cervical screening difficult and demonstrates the important role of primary care practitioners in contributing to women's experiences of the encounter. We draw on Erving Goffman's work on the 'interaction order' to explain some of the problems reported by women and to help inform good practice in primary care.

Challenges faced by nurses in managing pain in a critical care setting.

AIM: To explore nurses' challenges in managing pain among ill patients in critical care. BACKGROUND: Pain can lead to many adverse medical consequences and providing pain relief is central to caring for ill patients. Effective pain management is vital since studies show patients admitted to critical care units still suffer from significant levels of acute pain. The effective delivery of care in clinical areas remains a challenge for nurses involved with care which is dynamic and constantly changing in critically ill. DESIGN: Qualitative prospective exploratory design. METHODS: This study employed semi structured interviews with nurses, using critical incident technique. Twenty-one nurses were selected from critical care settings from a large acute teaching health care trust in the UK. A critical incident interview guide was constructed from the literature and used to elicit responses. RESULTS: Framework analysis showed that nurses perceived four main challenges in managing pain namely lack of clinical guidelines, lack of structured pain assessment tool, limited autonomy in decision making and the patient's condition itself. CONCLUSIONS: Nurses' decision making and pain management can influence the quality of care given to critically ill patients. It is important to overcome the clinical problems that are faced when dealing with pain experience. RELEVANCE TO CLINICAL PRACTICE: There is a need for nursing education on pain management. Providing up to date and practical strategies may help to reduce nurses' challenges in managing pain among critically ill patients. Broader autonomy and effective decision making can be seen as beneficial for the nurses besides having a clearer and structured pain management guidelines.

Investigating the safety of medication administration in adult critical care settings.

BACKGROUND: Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings. PURPOSE: This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant. CONCLUSION: The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.

Fiber diffraction of skin and nails provides an accurate diagnosis of malignancies.

An early diagnosis of malignancies correlates directly with a better prognosis. Yet for many malignancies there are no readily available, noninvasive, cost-effective diagnostic tests with patients often presenting too late for effective treatment. This article describes for the first time the use of fiber diffraction patterns of skin or fingernails, using X-ray sources, as a biometric diagnostic method for detecting neoplastic disorders including but not limited to melanoma, breast, colon and prostate cancers. With suitable further development, an early low-cost, totally noninvasive yet reliable diagnostic test could be conducted on a regular basis in local radiology facilities, as a confirmatory test for other diagnostic procedures or as a mass screening test using suitable small angle X-ray beam-lines at synchrotrons.

Nurse and pharmacist supplementary prescribing in the UK--a thematic review of the literature.

OBJECTIVES: Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically, the literature on nurse and pharmacist SP, to inform further research, policy and education. METHODS: A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic databases, grey literature and journal hand searches. RESULTS: Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses and under-evaluation of safety, economic analysis and patients' experiences were identified in empirical studies. There was a perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing. CONCLUSIONS: There is a need for additional research regarding SP and despite nurses' and pharmacists' enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.

The traps and pitfalls inherent in the correlation of changes in the fibre diffraction pattern of hair with breast cancer.

After a correlation between breast cancer and changes in the fibre x-ray diffraction of hair was first published, a number of groups reported their failure to reproduce this phenomenon. There is evidence that these failures resulted from either diffraction images of insufficient quality or analysis techniques unable to distinguish features resulting from the presence of breast cancer from those resulting from mechanical damage. Using an independent analysis of the same dataset reported by one of these unsuccessful groups, the author demonstrates some of the critical flaws inherent in this type of intensity-based analysis.

Professional attitudes to Changing Childbirth in Nottingham, UK.

Changing Childbirth has been a central focus of maternity care policy in England. The objective of this study was to determine whether different professional groups involved in maternity care-hospital and community midwives, general practitioners and obstetricians-had different professional attitudes to a local implementation scheme. Data were obtained using a postal questionnaire, based on an agenda developed from focus groups. Whilst general practitioners appeared to be somewhat less optimistic than were midwives, there existed clear differences of opinion within the midwifery profession itself, depending upon whether the midwife worked in the community or in hospital. All professionals appeared conscious of the gap between the service ideals and the limited resources available to achieve them, and expressed uncertainty over future directions and ways of working.

Further challenges to medical dominance? The case of nurse and pharmacist supplementary prescribing.

Doctors have traditionally been viewed as the dominant healthcare profession, with the authority to prescribe medicines, but recent non-medical prescribing initiatives have been viewed as possible challenges to such dominance. Using the example of the introduction of supplementary prescribing in the UK, this study sought to explore whether such initiatives represent a challenge to medical authority. Ten case study sites in England involving primary and secondary care and a range of clinical areas were used to undertake a total of 77 observations of supplementary prescribing consultations and interviews with 28 patients, 11 doctors and nurse and pharmacist prescribers at each site. Supplementary prescribing was viewed positively by all participants but several doctors and patients appeared to lack awareness and understanding of supplementary prescribing. Continued medical authority was supported empirically in five areas: patients' and supplementary prescribers' perception of doctors as being hierarchically superior; doctors legitimation of nurses' and pharmacists' prescribing initially; doctors' belief that they could control (particularly nurses') access to prescribing training; supplementary prescribers' frequent recourse to use doctors' advice, coupled with doctors' encouragement of such 'knock on door' prescribing advice policies; doctors' denigration of most routine prescribing but claims that diagnosis was more skilled and key to medicine. Supplementary prescribing appeared to be successfully accomplished in practice in a range of clinical settings and was acceptable to all involved but did not ultimately challenge medical dominance. However, more recent nurse and pharmacist independent prescribing (involving diagnosis) may represent a more significant threat.

The Molecular Architecture for the Intermediate Filaments of Hard α-Keratin Based on the Superlattice Data Obtained from a Study of Mammals Using Synchrotron Fibre Diffraction.

High- and low-angle X-ray diffraction studies of hard α-keratin have been studied, and various models have been proposed over the last 70 years. Most of these studies have been confined to one or two forms of alpha keratin. This high- and low-angle synchrotron fibre diffraction study extends the study to cover all available data for all known forms of hard α-keratin including hairs, fingernails, hooves, horn, and quills from mammals, marsupials, and a monotreme, and it confirms that the model proposed is universally acceptable for all mammals. A complete Bragg analysis of the meridional diffraction patterns, including multiple-time exposures to verify any weak reflections, verified the existence of a superlattice consisting of two infinite lattices and three finite lattices. An analysis of the equatorial patterns establishes the radii of the oligomeric levels of dimers, tetramers, and intermediate filaments (IFs) together with the centre to centre distance for the IFs, thus confirming the proposed helices within helices molecular architecture for hard α-keratin. The results verify that the structure proposed by Feughelman and James meets the criteria for a valid α-keratin structure.

Extremely Early Diagnostic Test for Prostate Cancer.

PURPOSE: This article reports the results of a blinded fibre diffraction study of skin samples taken from TRAMP mice and age-matched controls to determine whether changes noted in fibre diffraction studies of human skin were present in these TRAMP mice studies. These mice are bred to progress to Gleeson Type 3 to Type 5 prostate cancer. METHODS: Small strips, 1mm×5mm, cut from the mouse skin samples were loaded into cells in the same way as human samples and slightly stretched to remove the crimp. They remained completely hydrated throughout exposure to the synchrotron beam. RESULTS: The added change that was reported for prostate cancer in 2009 was obtained for all TRAMP mice samples, indicating that this change can be read as High Grade Cancer in human diagnostic tests. DISCUSSION: These changes were evident for all 3 and 7 week old TRAMP mice samples but not for any of the control samples. This indicates that the changes in the fibre diffraction patterns appear much earlier than in any other available prostate cancer diagnostic test which cannot verify the presence of prostate cancer before 10 weeks of age. The fibre diffraction test is therefore the most accurate and earliest test for high grade prostate cancer.

The Connection between the Presence of Melanoma and Changes in Fibre Diffraction Patterns.

An accurate diagnosis of melanomas at an early stage correlates directly with a better prognosis. However the incidence of melanoma is still increasing along with the number of related deaths. Melanoma cells grow extremely fast, with the result that many patients present after metastasis has occurred, too late for effective treatment. This paper describes the changes in the fibre diffraction patterns of skin that indicate the presence of a melanoma. Identification of these changes would provide an alternative early low-cost, totally reliable diagnostic test which could be conducted on a regular basis in local radiology facilities using rotating anode x-ray generators or as a mass screening test using suitable small angle x-ray beam-lines at synchrotrons.

Beliefs about personal control and self-management in 30-40 year olds living with Inflammatory Bowel Disease: a qualitative study.

BACKGROUND: Inflammatory Bowel Disease is a collective term for two distinct long term conditions: Ulcerative Colitis and Crohn's disease. There is increasing emphasis on patients taking greater personal control and self-management of this condition, reflecting earlier research into the management of chronic illness. Nurses play a pivotal role in this process, yet how optimal personal control is self-assessed and self-managed in Inflammatory Bowel Disease is poorly understood. OBJECTIVES: This study set out to explore beliefs about personal control and self-management of Inflammatory Bowel Disease. It focused on the role of physical, psychological and socio-economic factors within the individual's life experience. DESIGN: A qualitative approach was used comprising 24, one-to-one, semi-structured interviews with participants aged 30-40 years. Participants with a histological diagnosis of Inflammatory Bowel Disease for at least 12 months were eligible and recruited by gastrointestinal specialist staff from outpatient clinics at a large National Health Service Trust in the United Kingdom. Interviews were transcribed verbatim. Data analysis was informed by existing theories of personal control and used the 'systematic framework analysis' approach. RESULTS: In addition to existing theories of personal control, self-discrepancy theory helped to explain how people viewed the control and self-management of Inflammatory Bowel Disease. One main theme emerged from the findings: 'Reconciliation of the self in IBD', this was supported by three sub-themes and eight basic themes. Some participants found that being unable to control and predict the course of their condition was distressing, however for others this limited control was not viewed as a negative outcome. Being able to share control of IBD with specialist health care staff was beneficial, and participants stated that other priorities in life were as equally important to manage and control. A key barrier to ensuring greater personal control and self-management was a lack of knowledge and awareness by non-specialist health care staff, employers and the wider society. CONCLUSIONS: Nurses involved in the care of individuals with Inflammatory Bowel Disease should support and prepare patients for the discrepancies and uncertainties of living with the condition. Greater training about Inflammatory Bowel Disease is recommended, specifically for non-specialist health care staff and employers.

A self-harm training needs assessment of school nurses.

Self-harm is acknowledged to be increasing and is especially prevalent in young people. School nurses are central to adolescent mental health, delivering initial and sustained intervention. However, few studies have considered their experiences and training needs in fulfilling this role. This training needs assessment explored the self-harm training needs of school nurses within one UK primary care trust by utilizing questionnaires and interviews developed specifically for the study. School nurses felt frustrated and inadequate when working with young people who self-harm. The majority had attended self-harm training, yet felt that it only helped a little. Nurses desired training, particularly in practical approaches when working with young people who self-harm, however, analysis suggested that they also needed underpinning theoretical knowledge. Therefore, this study highlights the need for self-harm training for school nurses, incorporating both practical approaches and theoretical knowledge, to ensure that young people who self-harm receive an effective, high-standard service.

The Perception of Nurses and Doctors on a Care Bundle Guideline for Management of Pain in Critical Care / Percepción de enfermeras y médicos sobre el uso de un paquete de atención como una guía para el manejo del dolor en cuidados críticos / A percepção das enfermeiras e dos médicos sobre o uso de um pacote de atendimento como guia para lidar com a dor em cuidados críticos

Objective: The aim of this study was to explore nurses' and doctors' perception on using a care bundle as a guideline for the management of pain in critical care. Despite the development of evidence-based guidelines and protocols on the management of pain in critical care, pain is still a major problem. The introduction of care bundles in critical care has improved the management of ventilated patients. A care bundle in pain management aims to reduce variations in practice. Method: This study employed a qualitative prospective design using a semi-structured, in-depth interview of 23 nurses and doctors in a critical care unit. Result: Four main themes emerged: 1) suitability to the critical care setting; 2) applicability to the critical care setting; 3) ownership of the Pain Care Bundle; and 4) necessity for current practice. The results showed a poor uptake by the healthcare professionals in managing acute pain among critically ill patients. Conclusion: The study found that nurses and doctors did not perceive the pain care bundle as a useful tool for improving pain managment, with evidence pointing to a gap between pain management practice, as described by the care bundle, and actual practice.

Objetivo: el objetivo de este estudio fue explorar la percepción de las enfermeras y los médicos sobre el uso de un paquete de atención como una guía para el manejo del dolor en cuidados críticos. A pesar del desarrollo de guías y protocolos para el manejo del dolor en cuidados críticos, basados en la evidencia, el dolor sigue siendo un problema importante. La introducción de un paquete de atención para cuidados críticos ha mejorado el manejo de los pacientes ventilados. Un paquete de atención en el manejo del dolor tiene como objetivo reducir las variaciones en la práctica. Método: el estudio tiene un diseño prospectivo cualitativo desarrollado mediante una entrevista en profundidad y semi-estructurada de 23 enfermeros y médicos en una unidad de cuidado crítico. Resultado: cuatro temas principales surgieron: 1) la adecuación al escenario de cuidado crítico, 2) la aplicabilidad al escenario de cuidado crítico, 3) la propiedad del Paquete de Atención al Dolor, y 4) la necesidad en la práctica actual. Los resultados mostraron una pobre aceptación del paquete por parte de los profesionales de la salud en el manejo de dolor agudo en los enfermos críticos. Conclusión: el estudio encontró que las enfermeras y los médicos no percibieron el paquete de atención al dolor como una herramienta útil para mejorar el manejo del dolor, con pruebas que apuntan a una brecha entre la práctica del manejo del dolor, tal como se describe por el paquete de atención, y la práctica real.

Objetivo: o objetivo deste estudo foi explorar a percepção das enfermeiras e dos médicos sobre o uso de um pacote de atendimento como guia para lidar com a dor em cuidados críticos. Apesar do desenvolvimento de guias e protocolos para lidar com a dor em cuidados críticos, baseados na evidência, a dor continua sendo um problema importante. A introdução de um pacote de atendimento para cuidados críticos vem melhorando o tratamento dado a pacientes ventilados. Um pacote de atendimento no tratamento da dor tem como objetivo reduzir as variações na prática. Método: o estudo tem um desenho prospectivo qualitativo desenvolvido mediante uma entrevista em profundidade e semiestruturada de 23 enfermeiros e médicos em uma unidade de cuidado crítico. Resultado: quatro temas principais surgiram: 1) a adequação ao cenário de cuidado crítico; 2) a aplicabilidade ao cenário de cuidado crítico; 3) a propriedade do Pacote de Atendimento à Dor, e 4) a necessidade na prática atual. Os resultados mostraram uma baixa aceitação do pacote por parte dos profissionais em saúde no tratamento da dor aguda nos doentes críticos. Conclusão: o estudo constatou que as enfermeiras e os médicos não perceberam o pacote de atendimento à dor como uma ferramenta útil para melhorar o tratamento da dor, com provas que apontam a uma brecha entre a prática do tratamento da dor, tal como se descreve pelo pacote de atendimento, e a prática real.

An evaluation of a specialist multiagency home support service for older people with dementia using qualitative methods.

BACKGROUND: Standard home care support for people with dementia has been criticised in statutory inspection reports, and may lead to unnecessary crises, hospital or care home admissions. OBJECTIVE: To establish whether a specialist multiagency home care service for older people with dementia delivered better quality care than standard services, and how any improvements were achieved. DESIGN: Qualitative study, using semi-structured interviews, focus groups and small group interviews. SETTING: Two demographically similar areas in Nottingham, one served by a specialist home care team, the other by standard services. PARTICIPANTS: Twenty-seven service users, 18 family carers, 17 home care workers, 20 health/social care professionals, across both services. RESULTS: The specialist service demonstrated greater flexibility and responsiveness to the particular needs and circumstances of service users and family carers, who were encouraged to participate in routine decision-making and activities. By sharing responsibilities, the specialist service helped reduce carer stress and prevent crises. These outcomes depended on the configuration of the service, including multidisciplinary health and social services input, careworker autonomy and independence, continuous reassessment of clients' circumstances and preferences and the capacity to develop long-term relationships, through careworker continuity. The standard service, which used a task-orientated approach, lacked these characteristics. CONCLUSIONS: This study provides evidence of the benefits of a specialist multiagency home support service over standard home care, in the opinion of service users, carers and careworkers, and defines the operational model that achieves this. Findings confirm best practice recommendations, based on models of dementia care which emphasise respect for 'personhood'.

A place for fiber diffraction in the detection of breast cancer?

AIMS: To review the potential relevance and the place that a particular change in the fiber diffraction of hair might have in the future management of breast cancer and other pathologies. METHOD: A comprehensive overview was obtained using a complete search of the Australian National University Library (data range) and Medline (data range) using the search terms "review breast cancer screening/diagnosis/detection" and "X-ray diffraction of hair". Publications in the past 5 years were selected but older reports that were commonly referenced were not excluded. RESULTS: To date, our results have demonstrated that a specific change occurs in the diffraction pattern of hair for persons with breast cancer. Further research has shown that this change is present in the hair at an earlier stage of the cancer growth than is detectable by mammography. In addition, the change has been found to disappear when the cancer has been successfully removed. DISCUSSION/CONCLUSION: This technology uses only a few hairs, is totally user-friendly, non-invasive and does not require the patient to be exposed to any radiation. As a low-risk procedure, it could potentially provide a much needed, cost-effective early screening test for the presence of breast cancer in women of any age. As the patients are not required to be present during the test, it could also provide a testing service for women in remote areas. In this review, the origin of the diffraction pattern and the diagnostic information that can be gleaned from it are outlined.