Findings from a Delphi exercise regarding conflicts of interests, general practitioners and safeguarding children: 'Listen carefully, judge slowly'.

General practitioners (GPs) have to negotiate a range of challenges when they suspect child abuse or neglect. This article details findings from a Delphi exercise that was part of a larger study exploring the conflicts of interest that arise for UK GPs in safeguarding children. The specific objectives of the Delphi exercise were to understand how these conflicts of interest are seen from the perspectives of an expert panel, and to identify best practice for GPs. The Delphi exercise involved four iterative rounds with questionnaires completed by an expert panel. Results from each round were distilled and findings sent to panel members until consensus was reached. Panel members shared insights regarding their understanding of conflicts of interest in relation to GPs and safeguarding children and responses when conflicts of interests arise. Findings suggested a broader understanding of conflicts of interest (intrapersonal, interpersonal, interprofessional and interagency), the importance of professional judgement in uncertain situations when both action and inaction have potentially negative consequences and the importance of trust. The Delphi exercise was an effective means to bring together a wide range of professional and disciplinary perspectives on a complex topic. Findings caution against the oversimplification of the conceptual and practical issues, emphasise the importance of professional judgement, and support the development of open and trusting relationships with families and among professionals in health and social care agencies.

Eleven themes of patient-centred professionalism in community pharmacy: innovative approaches to consulting.

OBJECTIVES: The study aimed to clarify patient-centred professionalism within and across community pharmacy settings; position that knowledge in a modern-day environment, accessing the opinions and experiences of patients and professionals; inform the literature on the value of consultation workshops within this context; and develop a template of positive and challenging exemplars of patient-centred professionalism within these contexts. METHODS: Thirty-nine study participants contributed to extended consultation workshops. Sessions were supported by bio-photographic data of healthcare practices across a range of different settings, and a final forum event. KEY FINDINGS: Thematic analysis of qualitative data, supported by the Nominal Group Work technique, led to a template containing 11 themes of positive and challenging aspects of patient-centred professionalism: safety, professional characteristics, relationships with patients, confidentiality and privacy, accessibility, training, professional pressures, services, environment, changing professional roles and patient characteristics. Themes, while descriptive and rich, highlight difficulties in defining this notion, which is both nuanced and ambiguous. While study participants were interested in the everyday examples of practice and interaction, they were strongly influenced by their different agendas and experiences. Patients, for example, wanted a quick and efficient dispensing service, where their needs and expectations came first. Pharmacists, on the other hand, found that pressing patient demands and overarching company policies led to professional anxiety that distracted them from what they perceived to be the defining aspect of their professionalism, dispensary work. CONCLUSIONS: The study outcomes indicate, in line with international literature, that while proud of supporting patients, many pharmacists feel demoralised, torn between pressing public and professional demands and the expectations of advice-giving in unfamiliar, formal situations within nondescript, corporate workspaces.

The use of vignettes within a Delphi exercise: a useful approach in empirical ethics?

There has been an increase in recent years in the use of empirical methods in healthcare ethics. Appeals to empirical data cannot answer moral questions, but insights into the knowledge, attitudes, experience, preferences and practice of interested parties can play an important part in the development of healthcare ethics. In particular, while we may establish a general ethical principle to provide explanatory and normative guidance for healthcare professionals, the interpretation and application of such general principles to actual practice still requires interpretation and judgement. And many situations in healthcare practice are complex and may involve a variety of principles, each of which may conflict with the others. Simple surveys or interview studies may not be sufficient if we wish to develop a nuanced approach to ethical practice that can be set out in guidelines, codes or directives. We do not resolve moral questions by plebiscite. In this paper, the authors argue for the use of consensus methods to develop shared understanding of ethical practice, and they argue further for the combination of the Delphi method with the use of vignettes to illustrate the kind of situations that may occur in practice. They develop their argument in part by reference to their experience of using this approach in their recent research.

Obtaining consensus regarding patient-centred professionalism in community pharmacy: nominal group work activity with professionals, stakeholders and members of the public.

OBJECTIVES: The aim of this study was to develop a ranked thematic list encompassing the positive and negative exemplars of patient-centred professionalism in community pharmacy. METHODS: An adapted Nominal Group Work (NGW) method was used in six individual consultation workshops (two with established pharmacists, one with newly qualified pharmacists, one with pharmacy staff, one with stakeholders and one with members of the public) followed by a mixed-group forum event. KEY FINDINGS: Each of the six workshops resulted in the production of approximately 10 positive and 10 negative exemplars of patient-centred professionalism. The thematization of these exemplars allowed the development of 11 broad themes. The mixed-group forum event then provided a mechanism for ranking the importance of these themes. Safety, professional characteristics and relationships with patients were ranked as the most important themes by our study participants. CONCLUSIONS: The adapted NGW was a useful method to allow the development of a ranked thematic list that illustrated the important positive and negative exemplars of patient-centred professionalism in community pharmacy.

Understanding general practitioners' conflicts of interests and the paramountcy principle in safeguarding children.

As family physicians, general practitioners play a key role in safeguarding children. Should they suspect child abuse or neglect they may experience a conflict between responding to the needs and interests of the child and those of an adult patient. English law insists on the paramountcy of the interests of the child, but in family practice many other interests may be at stake. The authors argue that uncritical adoption of the paramountcy principle is too simplistic and can lead, paradoxically, to greater harm. They argue for a more subtle and nuanced view of interests and of conflicts of interest in safeguarding children.

Is the 2008 NMC Code ethical?

In 2008 the United Kingdom Nursing and Midwifery Council (NMC) published the latest version of its code of conduct (The code: standards of conduct, performance and ethics for nurses and midwives). The new version marked a significant change of style in the Code compared with previous versions. There has been considerable controversy and the accrual of an extensive body of literature over the years in the UK and Europe criticizing nursing codes of ethics and questioning their ethical standing and their usefulness. In this article we review the current NMC Code. We argue that the NMC has been misguided in labelling the Code as a code of ethics, and suggest that the new document falls short in many respects.

Understanding student nurse attrition: learning from the literature.

Student attrition in nursing causes concern, but is not a new phenomenon. Challenges in defining and understanding attrition, changes in the commissioning of nurse education and developments within the United Kingdom National Health Service (UKNHS) and the profession contribute more generally to making this a complex topic for managers and for research. In this paper we discuss findings from an integrative review of the UK literature and discuss three levels of possible contributory factors identified from the literature (micro/individual; meso/institutional; and macro/political and professional). In conclusion, we argue that a concern with attrition is legitimate and that strategies should be put in place to respond to each level of contributory factors. Factors contributing to attrition are complex and interact. We argue that some degree of attrition is inevitable if we are to maintain standards within the profession. There is, therefore, an ethical and professional imperative for attrition in some circumstances. We suggest that Tinto's model relating to social integration might inform further research.

Nurses' views on dignity in care.

AIM: The aim of the RCN dignity survey was to gain the perspectives of nurses, healthcare assistants and nursing students regarding the maintenance and promotion of dignity in everyday practice. This article presents survey respondents' experiences of providing dignified care for older people. METHOD: A survey questionnaire was developed including fixed response and free text questions. A survey link was emailed to RCN members. Of the 2,048 respondents, 1,110 (54 per cent) worked with older people. These responses were analysed using an Excel spreadsheet for the quantitative data and the free text data were analysed thematically. RESULTS: The respondents perceived that the physical environment and organisation influenced the provision of dignified care. Respondents described how they endeavoured to promote dignity during care activities which might threaten dignity through thoughtful planning, sensitive communication, preserving privacy and promoting choice. CONCLUSION: A conducive physical care environment, a supportive organisation and individual nurses' actions can do much to promote the dignity of older people while they are undergoing health care.

The RCN dignity survey: implications for leaders.

In response to concerns about a lack of dignity in care raised in the media and several studies, the RCN launched last year its dignity campaign, Dignity: At the heart of everything we do. A major part of this campaign was a dignity survey of more than 2000 nurses, nursing students and healthcare assistants, making it the largest dignity survey of the U.K. nursing workforce ever undertaken. This article outlines what some of the survey findings mean for nurse managers and leaders, and discusses the relationship between dignity and nursing.

Dignified care for children and young people: nurses' perspectives.

AIM: To explore the perspectives of nurses working with children and young people on dignified care and the challenges of providing such care. METHODS: A questionnaire was developed including fixed response and free text questions. A survey link was emailed to RCN members. Of the 2,048 respondents, 149 worked mainly with children and young people. From their responses, quantitative data were analysed using a spreadsheet and free text data were analysed thematically according to the question topics. RESULTS: Only 34 per cent of respondents reported having enough time to devote to the dignity of patients and clients. Many respondents (74 per cent: sometimes; 8 per cent always) felt distressed or upset that they were unable to give the kind of dignified care they aspired to. The physical care environment and organisation influenced the provision of dignified care but respondents described how they endeavoured to promote dignity during care activities through thoughtful planning, communication and preserving privacy. CONCLUSION: Nurses can do much to promote the dignity of children and young people in their care.

Demonstrating dignity.

The concept of dignity is commonly used by nurses, but not widely understood. Here the concept is unravelled and its importance to good nursing care is explained.

Dignity in the care of older people - a review of the theoretical and empirical literature.

BACKGROUND: Dignity has become a central concern in UK health policy in relation to older and vulnerable people. The empirical and theoretical literature relating to dignity is extensive and as likely to confound and confuse as to clarify the meaning of dignity for nurses in practice. The aim of this paper is critically to examine the literature and to address the following questions: What does dignity mean? What promotes and diminishes dignity? And how might dignity be operationalised in the care of older people?This paper critically reviews the theoretical and empirical literature relating to dignity and clarifies the meaning and implications of dignity in relation to the care of older people. If nurses are to provide dignified care clarification is an essential first step. METHODS: This is a review article, critically examining papers reporting theoretical perspectives and empirical studies relating to dignity. The following databases were searched: Assia, BHI, CINAHL, Social Services Abstracts, IBSS, Web of Knowledge Social Sciences Citation Index and Arts & Humanities Citation Index and location of books a chapters in philosophy literature. An analytical approach was adopted to the publications reviewed, focusing on the objectives of the review. RESULTS AND DISCUSSION: We review a range of theoretical and empirical accounts of dignity and identify key dignity promoting factors evident in the literature, including staff attitudes and behaviour; environment; culture of care; and the performance of specific care activities. Although there is scope to learn more about cultural aspects of dignity we know a good deal about dignity in care in general terms. CONCLUSION: We argue that what is required is to provide sufficient support and education to help nurses understand dignity and adequate resources to operationalise dignity in their everyday practice. Using the themes identified from our review we offer proposals for the direction of future research.

Real nursing? The development of telenursing.

AIM: This paper is a report of a study to understand the impact of telenursing from the perspective of nurses involved in its provision, and in more traditional roles. BACKGROUND: Nurse-led telephone helplines have recently been introduced across the United Kingdom, a major step in the development of nursing practice. METHOD: A structured questionnaire was sent to all nurses working in the NHS Direct (National Health Service Direct) Wales telephone service (n = 111). Ninety-two completed questionnaires were returned (response rate 83 per cent). Two focus groups were conducted: one with telephone service nurses (n = 8) and one with other nurses (n = 5). The data were collected in 2002. FINDINGS: Respondents represented a highly educated workforce from a range of healthcare specialties. They reported that they joined the telephone service for improved salary and flexible working. Two-thirds reported improved job satisfaction. All focus group participants reported that the development of nursing skills was affected by the use of decision support software and the remote nature of the consultation. Participants reported opportunities for skill development, although the role could be stressful. All agreed that the service was popular with callers, but the nurses from outside raised concerns about whether telenursing was 'real' nursing and about the evidence base for the service and access by disadvantaged groups. CONCLUSION: Differences between the groups reflect policy tensions between the need to develop new nursing skills, including the use of technology, to improve efficiency and recognition of the worth of hands-on nursing. These tensions must be addressed for the telephone service to function as part of an integrated healthcare system.

On different types of dignity in nursing care: a critique of Nordenfelt.

Dignity appears to be an important concept in nursing philosophy and more widely in health care policy and provision. Recent events in the UK have generated much interest in the subject. However, there appears to be some confusion about the precise meaning and application of the concept. An influential contribution to the debate has come from Nordenfelt, who, as part of a European project investigating dignity and the care of older people, has proposed a four-part typology of dignity. In this article, we will explore some of the background to the dignity debate in UK nursing and health care, give a brief overview of Nordenfelt's position, offer some criticisms of his work and propose some modifications to his view.

Ethical aspects of withdrawing and withholding treatment.

Decisions about withdrawing and withholding treatment are common in health care. During almost every encounter between health professionals and patients a decision needs to be made about treatment options. In most cases these choices do not pose any difficulty, for example, starting antibiotics when a patient has an infection. However, decisions not to treat, or to stop treating, raise fundamental questions about the nature and purpose of nursing and the ethics of end-of-life care. This article argues that nurses need to be proactive in deciding what is nursing care and what is treatment. An ethical distinction is drawn between acts and omissions. How this distinction relates to withdrawing and withholding treatment will be considered. Further ethical issues discussed relate to judgements about the futility of treatment, patient autonomy and nurses' duty of care to patients at the end of life.