Perceptions of hospital manual handling policy and impact on nursing team involvement in promoting patients' mobility.

AIMS AND OBJECTIVES: To report the findings gained from interviews with hospital nurses and care assistants, regarding the impact of hospital manual handling policies on their role in maintaining and promoting patients' mobility. BACKGROUND: Older hospitalised adults often experience deteriorations in mobility, which are often partially caused by protective or custodial care practice and environments that promote patient dependency. Hospital-induced mobility loss may be conceptualised as a problematic source of iatrogenic patient harm, worthy of attention from a patient safety standpoint. Preventative rehabilitation nursing interventions have the potential to prevent mobility loss. DESIGN: Grounded theory study. METHODS: Data were collected in three clinical settings: general rehabilitation, spinal injuries and stroke rehabilitation. Semi-structured interviews with 39 rehabilitation staff were completed. RESULTS: Perceptions of hospital manual handling policy were described via four subcategories: policy as stimulus to improved practice; policy as divorced from reality; policy as threat; and policy as hindrance to rehabilitation. CONCLUSIONS: Hospital manual handling policy was perceived negatively by some nursing team members both as a threat and as a barrier to patients' rehabilitation. Risk aversion, divided teamwork practices and overuse of patient handling equipment were matters of concern. RELEVANCE TO CLINICAL PRACTICE: Perceptions of hospital manual handling policy should be openly discussed by nursing managers and direct care providers. It is important to recognise that beliefs about and perceptions of policy will often impact later on staff practices and behaviours. Unintended consequences arising from dominant interpretations of manual handling policy must be acknowledged and risks identified. It is important that practitioners balance risk assessment and prevention of falls with patients' needs for mobilisation.

All change: the lived experience of younger women with cancer of the vulva.

AIMS AND OBJECTIVES: To generate an understanding of the women's own perspectives of their care and address a gap in knowledge in relation to the broader impact of vulval cancer. BACKGROUND: Few people go though life without experiencing events that can change their perspective on how they see themselves, their role in society and their relationship with those around them. People are multi-dimensional, so a person with has a physical illness is also affected psychologically and sociologically. DESIGN: Qualitative. METHODS: Based on the work of Heidegger and van Manen, an interpretative phenomenological research study was undertaken to explore the experiences of thirteen women under 50 years of age with vulval cancer living in the UK. RESULTS: Data were analysed using framework analysis and showed that a diagnosis of cancer of the vulva and the subsequent treatment has an effect on physical, psychological and sexual functioning. CONCLUSIONS: The concept of 'All Change' expressed the sentiment that following the diagnosis and surgery, everything has changed; life is not the same as it was before diagnosis. This included both physical and psychological changes and impacts on perceptions of body image. RELEVANCE TO CLINICAL PRACTICE: The challenge is to raise awareness of vulval cancer among health care professions and society in general and determine the most effective interventions in facilitating pre and post operative support for these women.

A survey of issues of ethnicity and culture in nursing homes in an English region: nurse managers' perspectives.

AIMS: This survey explored issues of ethnicity and culture in nursing homes in one English region. BACKGROUND: The older black and minority ethnic population in the UK is increasing, and this is the first detailed study of numbers of black and minority ethnic residents in nursing homes and of managers' perceptions of their abilities to respond to residents' needs. DESIGN: Mixed methods. METHODS: Date were collected in 2008. A postal survey was sent to all nursing homes in the region. A sub-sample of managers participated in semi-structured telephone interviews. RESULTS: A hundred and one homes responded to the survey, and 13 managers were interviewed. One-third of homes had black and minority ethnic residents, and 95% had staff from these groups. Managers' underlying philosophies of care were to treat each resident individually and not by category. It was felt that individualised care plans resulted in residents' needs being met appropriately. Culturally sensitive care delivery varied. Some homes had established systems that were responsive to residents' diversity, while others responded to the needs of black and minority ethnic residents on an 'as-required' basis. Managers' identified advantages in having staff from diverse backgrounds, although prejudice from residents towards staff emerged as a theme and managers' responses varied. Staff training in the provision of appropriate end-of-life care was identified as a need. CONCLUSION: Black and minority ethnic residents form a small but growing minority of nursing home residents. Predicted increases in this resident group mean that managers must consider the delivery of culturally sensitive services. Future research is needed to explore the perspectives of black and minority ethnic residents. RELEVANCE TO CLINICAL PRACTICE: Nursing homes in England are increasingly diverse communities, and staff training needs must be addressed to promote quality care for all residents.

The Gold Standards Framework Hospital programme: implementation and progress.

AIM: The implementation and impact of the Gold Standards Framework Hospitals (GSFH) service development programme is described. BACKGROUND: A third of hospital inpatients may be in their last year of life when admitted to hospital. Many will be repeat and unplanned admissions. National policy guidance seeks to change this pattern through implementing patient choice in end-of-life care (EOLC) planning. METHOD: GSFH training and resources help general hospital staff teams develop skills as they identify patients nearing the end of life, rapidly assess their needs and offer advance care planning (ACP). FINDINGS: Audit data shows teams that have undergone GSFH training demonstrate earlier identification of patients needing EOLC and offer ACP targeting their individual care needs. CONCLUSION: The model has been taken up by over 350 hospital wards, with a large number seeking accreditation to demonstrate sustainability of good practice in EOLC management.

Caring for families with a family history of cancer: why concerns about genetic predisposition are missing from the palliative agenda.

Care of the family is integral to palliative care, but little attention has been paid to the way nurses, or other healthcare professionals, are responding to the needs of families who are concerned about whether their family history of cancer is associated with an inherited genetic predisposition. This paper discusses how palliative care nurses perceive the care needs of patients with a family history of cancer. Data were collected through recorded, semi-structured interviews with 10 nurses who had worked in specialist palliative care. The findings show that there are cogent arguments and concerns about raising the issue of an inherited genetic predisposition at the end of life (especially when the patient is close to death and there is a lack of knowledge about genetics). Nevertheless, exemplar cases are used to illustrate the reasons why it is important that nurses working in specialist palliative care settings are aware of the needs of this patient group. The paper highlights that nurses not only need an appropriate knowledge base but also an insight of what can be achieved when supporting patients with a family history of cancer.

A literature review of the impact of a diagnosis of cancer of the vulva and surgical treatment.

AIMS AND OBJECTIVES: This paper examines the evidence available regarding the physical, psychological and sexual consequences for women following a diagnosis and treatment for cancer of the vulva. BACKGROUND: Cancer of the vulva is a rare condition affecting approximately 1000 women in the UK each year. However, little is known about the impact of the condition as there is a limited research base to inform clinical practice. DESIGN: Review. METHOD: This paper critiques the 15 studies identified in the English language literature relating to carcinoma of the vulva from 1983 to the present. Collectively these involved less than 400 women with this condition. RESULTS: The review highlighted a paucity of published studies on this patient group. There are weaknesses in the design and analytical methods of the studies and a lack of clarity in the analysis of the published data. However, the review has enabled a picture to be built up of the challenges these women face postoperatively. The lack of recent evidence to support care practices offers limited help in contemporary health care today. CONCLUSION: There is a clear need for further research to explore the issues for women facing treatment for carcinoma vulva. RELEVANCE TO CLINICAL PRACTICE: An awareness of the issues facing women following a diagnosis and subsequent treatment, usually surgery, for cancer of the vulva will allow nurses and other health care professionals to have a greater understanding of the needs of these women and thus impact on care planning.

The critical care nurse's role in end-of-life care: issues and challenges.

AIM: The purpose of this article is to discuss the challenges critical care nurses face when looking after patients needing End-of-Life (EoL) care in critical care environments. BACKGROUND: Critical care nurses frequently provide care to patients who fail to respond to treatments offered to support and prolong life. The dying phase for individuals in critical care settings, commonly after withholding/withdrawing treatment, is very short posing great demands on critical care nurses to provide physical and emotional support to both patients and their families. Despite the existence of recognized care planning frameworks that may help nurses in providing EoL care, these are not used by all units and many nurses rely on experience to inform practice. A number of aspects such as communication, patient/family-centred decision-making, continuity of care, emotional/spiritual support and support for health professionals have been indicated as contributing factors towards the provision of effective EoL care. These are considered from the perspective of critical care nursing. CONCLUSION: Skills development in key aspects of care provision may improve the provision of EoL care for critical care patients and their families. RELEVANCE TO CLINICAL PRACTICE: Critical care nurses have an essential role in the provision of effective EoL care; however, this dimension of their role needs further exploration. It is noted that educational opportunities need to be provided for critical care nurses to increase the knowledge on planning and delivering EoL care. To inform this evaluation of current EoL care provision in critical care is necessary to address a knowledge deficit of the needs of nurses who seek to support patients and their families at a critical time.

Hospice nurses and genetics: implications for end-of-life care.

AIM: The overall aim of this study is to determine hospice nurses' perception of the importance of genetics to hospice care provision and their personal level of confidence in carrying out genetics-related activities within an end-of-life care context. BACKGROUND: Hospices nurses regularly care for patients and their families affected by inherited genetic conditions (e.g. some cancers). Therefore, nurses need knowledge and awareness of the implications of genetic conditions and confidence in their abilities to provide appropriate care and support for patients and families. DESIGN: Survey. METHOD: Questionnaires were sent to a stratified sample of hospice nurses (n = 1149) in England and Wales. Using Likert scales, nurses were asked to rate the importance of and their confidence in undertaking a range of scenario-based activities that accompany caring for a patient and family affected by a genetic condition in the hospice setting. Open questions invited comments on their experiences of nursing patient/family in similar situations. Follow-up telephone interviews were carried out with hospice nurse educators to explore emerging issues. RESULTS: Response rate was 29% (n = 328). Hospice nurses felt that all aspects of genetics-related care were 'very important' to hospice care, but lacked confidence in their ability to carry out the activities. Many respondents had not considered the relevance of genetics to hospice-care prior to completing the questionnaire but now considered it essential to end-of-life care even if they were not confident to provide it. CONCLUSION: Hospice nurses' need genetics education focusing on the psychosocial implications of caring for patients and families affected by genetic conditions to enable them to provide the complex care and support in face of the difficult issues that arise in practice. RELEVANCE TO CLINICAL PRACTICE: This study highlights the genetics education needs of hospice nurses in providing end-of life care for patients and their families affected by inherited genetic conditions.

Delivering 'Gold Standards' in end-of-life care in care homes: a question of teamwork?

AIM: This paper reports findings from a study which investigated the introduction of the Gold Standards Framework for improving end-of-life care into care homes in England. BACKGROUND: The Gold Standards Framework was developed in primary care to improve the care provided for people at the end-of-life. Following its successful introduction to this setting it was adapted and implemented in care homes. DESIGN: A case study approach was appropriate for this study of a care programme into a 'real life' setting. METHOD: Fourteen managers participated in an initial telephone interview. Ten of these homes participated in the case study phase and 61 staff participated in individual or group interviews. Seven residents and three relatives participated in face to face interviews. Qualitative data were analysed in line with the template approach. Survey data were also analysed and a validated Teamworking Questionnaire was used. RESULTS: It was found that teamwork is central to the successful introduction of the Gold Standards Framework in Care Homes. Good staffing levels and management support were also perceived to be key factors in homes where the Framework became established. CONCLUSION: Effective teamwork was necessary for changes in end-of-life care to be achieved in the care homes. If end-of-life care and other improvements in practice are to continue, teamwork will need to be supported and developed. RELEVANCE TO CLINICAL PRACTICE: Effective teamwork appears to be a pre-requisite for successful implementation of new programmes of care. Organisations wishing to implement such programmes should assess the quality of teamwork and may need to address this first.

Children affected by genetic conditions in end-of-life care. Part 2: findings and discussion.

BACKGROUND: Many children cared for in hospice settings are affected by a genetic condition. Therefore, children's hospice nurses require knowledge and awareness of the issues faced by families affected. AIM: The authors carried out a study to ascertain how important children's hospice nurses perceived genetics to be within care provision generally and explore how confident they were personally in meeting these care needs. METHOD: A questionnaire survey was sent out to 277 nurses working in children's hospices across the UK. The methods used are described in detail in part 1 of the study. RESULTS: One hundred (36%) questionnaires were returned. Most children's nurses felt that an understanding of genetics was very important within children's hospice care. However, they were not confident about integrating most aspects of genetics into clinical practice. DISCUSSION: Children's hospice nurses are required to care for children and families affected by life-limiting genetic conditions and many have complex support needs, which require an insight into issues associated with genetics. This study demonstrates that more education about genetics is required by children's hospice nurses. The focus of educational courses should be on the psychosocial aspects of care, which are needed in the context of hospice care, because this is considered the most important and where nurses were slightly more confident.

An evaluation of the impact of a tracheostomy weaning protocol on extubation time.

BACKGROUND: To avoid the possible complications of prolonged intubation, it is necessary and advisable to attempt weaning from the tracheostomy tube at the earliest opportunity. However, while weaning protocols have proven successful in reducing ventilation time of critical care patients, there is little evidence of their use and impact on tracheostomy tube weaning time. AIMS: This pilot study sought to determine if the introduction of a new tracheostomy weaning protocol would reduce the time to extubation of the tracheostomy. METHOD: A quasi-experimental design used two groups of patients. A retrospective control group of patients (n = 20) who had been weaned using standard practice were identified by a search of medical records. A prospective experimental group (n = 20) had care planned using a new tracheostomy weaning protocol. Data relating to time to extubation were collected on both groups who were all patients in an eight-bedded Critical Care Unit of a District General Hospital. The same inclusion and exclusion criteria were applied to both groups. RESULTS: The results revealed a reduction of 1.35 days from commencement of weaning to extubation in the prospective (experimental) group. This was not statistically significant (P = 0.181) CONCLUSION: Although the findings from the study were not statistically significant, they can be seen as clinically significant in terms of patient comfort and reduced dependency in care by a reduction of time with a tracheostomy. It is recommended that a larger scale study be carried out to determine if a tracheostomy weaning protocol does make an impact on length of time to extubation in wider care settings.

Children affected by genetic conditions in end-of-life care. Part 1: Development of a study.

BACKGROUND: Many children receiving hospice care are affected by inherited genetic conditions. To provide appropriate care, children's hospice nurses require knowledge and awareness of the issues faced by the child and their family along with the implications of having, or being at risk from, an inherited genetic condition. Little is currently known about the competence levels of children's hospice nurses to support these children and their families. AIM: This study aims to explore how important children's hospice nurses perceived genetics to be within children's hospice care provision, and their level of confidence in meeting the care needs of children and their families with a genetic predisposition to disease. METHOD: This study involved two stages: a single-page survey to children's hospice directors of nursing designed to determine the nature of children's hospice care provision in England and Wales. Second, a postal survey using a structured, self-administered questionnaire was sent to nursing staff in a sample of children's hospices in England and Wales. A total of 277 packs were sent to the hospices for distribution to children's nurses working in their employment. Likert scales were used to rate the importance of genetic activities relevant to children's hospices, and nurses' confidence in performing them. Demographic data were also collected. The results, the discussion of the findings and implications for practice will be discussed in part 2.

The increasing use of reiki as a complementary therapy in specialist palliative care.

Palliative medicine and complementary therapies (CTs) have developed within the NHS as parallel philosophies of care. As a result, the last decade has seen an increase in the integration and usage of CTs, as adjunct therapies to conventional medical treatment. Documented benefits of relaxation, decreased perception of pain, reduced anxiety and improved sense of wellbeing have been shown to enable an enhanced quality of life, where curative treatment is no longer an option. Reiki is a more recent addition to the range of CTs available to cancer patients. As an energy-healing intervention it has gained in popularity as a non-invasive and non-pharmacological approach. Anecdotal evidence suggests that the profound relaxation effect has a positive impact on alleviating anxiety, stress, perception of pain and promotes a feeling of wellbeing particularly relating to the nature of psychospiritual wellbeing. However, there is very little evidence to support its application within clinical practice, and none within the specific field of specialist palliative care (SPC). This article will consider the position of reiki as an emerging CT within SPC. The function of the hospice movement, the role of CTs together with an understanding of energy healing will also be explored. Within this context, the rise in popularity of reiki and its potential benefits for SPC patients will be discussed. These considerations will then form the basis of the justification for further research in SPC.

What is the nursing team involvement in maintaining and promoting the mobility of older adults in hospital? A grounded theory study.

AIMS OF THE PAPER: To present a grounded theory of the nursing team involvement in the process of maintaining and promoting the mobility of hospitalised older adults. BACKGROUND: Being able to mobilise is an important determinant of quality of life in late adulthood. However, advancing age is often accompanied by worsening mobility, which may deteriorate further as a result of illness and particularly hospitalisation. Targeted in-patient rehabilitation interventions may have the capacity to maintain and promote older adults' mobility. Some authors suggest that the nursing team may have a central role in such activities. OBJECTIVES: The study set out to describe the involvement of the nursing team in the process of maintaining and promoting the mobility of hospitalised older adults. It also sought to understand how members of the nursing team viewed their work in relation to physiotherapists and in relation to hospital policy on patient handling. DESIGN: Grounded theory provided the philosophical and structural underpinning to the study. SETTINGS: Data collection centred on three clinical settings which included a general rehabilitation ward, a regional spinal injuries unit and stroke rehabilitation ward. PARTICIPANTS: Semi-structured interviews with 39 rehabilitation staff and 61h of non-participant observation comprised the data set. FINDINGS: The nursing team involvement in patients' mobility maintenance and rehabilitation was explained by the core category 'care to keep safe.' This category identified how the nursing team focused primarily on preventing patient problems rather than focusing on rehabilitation goals. A number of contextual factors in the workplace meant that the nursing team found it difficult to engage in activities to support mobility maintenance and rehabilitation. CONCLUSIONS: Significant changes in the micro and macro context for rehabilitation practice are needed to enable the nursing team to engage more fully in the processes of mobility rehabilitation. Nurse-led initiatives which allow the nursing team to take an active role in implementing intentional strategies to maintain and promote mobility should be implemented and trialled for effectiveness.

Invisibility: the lived experience of women with cancer of the vulva.

BACKGROUND: This study describes an exploration of the lived experience of 13 British women with cancer of the vulva who underwent surgical treatment. A review of the literature highlighted a paucity of knowledge as many studies were conducted during the 1980s and 1990s and investigated sexual functioning only. OBJECTIVE: An interpretive phenomenological approach based on the work of Heidegger and van Manen was used to frame the study by posing the question, "What must it be like to be diagnosed with, and have surgery for a cancer of the vulva?" METHODS: The women, younger than 50 years, were identified by purposive sampling and interviewed between 6 months and 5 years after surgery. The data were analyzed using framework analysis. RESULTS: The women's lived experience is described in its entirety by the concept of invisibility, characterized as something "no one can see," "heard of," and "talks about." CONCLUSIONS: The impact of this invisibility is discussed as the "invisibility of understanding" and "invisibility of support." IMPLICATIONS FOR PRACTICE: Although many women may expect to be cured of their vulval cancer, the invisible nature of the condition and the resulting lack of understanding and support may continue for a considerable period, as every aspect of their everyday life and in their relationships may be affected. The challenge now is to raise awareness of this condition and provide greater informational and emotional support for these women.

Educating tomorrow's clinical researchers: a review of research preparation in undergraduate education.

BACKGROUND: One large health region in England was experiencing difficulties in recruiting to clinical research posts which required registered nurse or allied health professional skills. OBJECTIVES: Pre-registration preparation may influence practitioners' career choices and the study reviewed the research content in pre-registration nurse/AHP degree level programmes in the region to i) describe key features of the modules, and ii) determine the extent to which clinical research featured. DESIGN AND SETTINGS: There are eight universities in the region. We reviewed and analysed 46 research and evidence-based practice module guides from relevant pre-registration degree level programmes. Documentary analysis was used and the findings were reviewed by the project group. RESULTS: Modules aimed to produce practitioners who were aware of the principles of evidence based practice, and who could locate and evaluate research findings. There was some exposure to clinical research, though this was largely indirect, through considering research findings. Therapy students were more likely than nursing students to conduct a small clinical study for their final year assignment. CONCLUSIONS: Pre-registration programmes focused on producing practitioners who were competent users of research evidence to inform practice, rather than clinical researchers, and this was inevitably the focus of the research modules. However, feasible opportunities for increasing students' exposure to clinical research were identified.

An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation.

BACKGROUND: In the United Kingdom approaching 20% of people aged 85 years and over live in care homes and most will die there. Improving end-of-life care is a government health priority and homes may work with primary care staff and specialist palliative practitioners to provide comprehensive end-of-life care. Consequently effective collaboration between care home and health service practitioners is vital to ensure high quality end-of-life care. OBJECTIVES: To evaluate the impact of a training programme to improve end-of-life care in nursing homes, on collaboration between nursing home staff and other health practitioners. DESIGN: Evaluation using survey methods and qualitative case studies. PARTICIPANTS AND SETTING: All 95 nursing homes in the first national 'Gold Standards Framework in Care Homes' programme in England were invited to participate in the evaluation. METHODS: A survey of homes' characteristics, the approaches to end-of-life care, and liaison with other services, was completed pre and post programme implementation. Case studies were conducted in a sub-sample of 10 homes to provide important context and depth to the evaluation. RESULTS: Pre and post surveys were returned by 49 (52%) homes. Improved collaborations as a result of the programme were anticipated by 31% of managers. Challenges to collaboration included working with large numbers of general practitioners, out-of-hours services and access to specialist practitioners. Improved collaborations between home staff and health service practitioners were identified by 33% of managers as one of the main programme outcomes. Staff reported increased knowledge of end-of-life care, and enhanced confidence, which in turn resulted in improved communication and collaboration. Post-programme, staff felt more confident initiating contact and discussing residents' end-of-life care with general practitioners and those working in specialist palliative care services. CONCLUSIONS: The Gold Standards Framework in Care Homes programme can contribute towards end-of-life care by helping to improve the quality and quantity of communication and collaboration between nursing home staff and primary care and specialist practitioners. Further research is needed to determine why this was not consistent across all homes.