The essence of 'community' within community nursing: a district nursing perspective

Community nurses' perspectives on a novel blended training approach: a qualitative study

Background

Transiting into the community setting often presents novel difficulties for nurses because the role demands skills that might not have been obtained through usual clinical experience or training. The Ageing-in-Place Community Care Team (AIP-CCT) Community Nurse Basic Training programme was developed to address this learning gap. This training programme prepares nurses to lead in a multi-disciplinary team in delivering patient-centred care to patients with progressive or life-limiting conditions in the community setting. This study evaluated the inaugural training programme provided to a group of nurses from an acute hospital in Singapore.

Methods

Qualitative in-depth interviews were carried out with 13 participants from the training programme three-months after completion of the AIP-CCT Community Nurse Basic Training programme provided by an acute hospital to understand the programme’s impact on their knowledge, skills and clinical practice, as well as barriers and facilitators to learning.

Results

Overall, perception towards the training course was mixed. Course content was found to be relevant, and participants reported that training led to improvement in their practice. However, experienced nurses felt that the content of some modules were lacking in depth. This could have explained why only junior nurses tended to hold favourable attitudes and felt that the training led to increase in their confidence level. Although medical content was assessed favourably, the course was not able to address some of the constraints faced by community nurses such as managing expectations and handling difficult patients in the home care setting. For some modules, face-to-face training was preferred and e-learning components can be improved to increase communication and interaction.

Conclusion

This study provided insights into how a community nurse training programme could be developed to meet the needs of community nurses. The training was able to reinforce skills and knowledge, address knowledge gaps and provide new clinical care approaches and communication strategies. These incremental effects on experienced community nurses could be extrapolated to have greater benefits for inexperienced community nurses. Based on findings of the study, potential changes to the training programme were discussed to improve training outcomes.

Relationship between emotional labor and sense of career success among community nurses in China, Beijing: A cross-sectional study based on latent class analysis

Background

This study investigated different patterns of emotional labor among community nurses in China and analyzed the relationships between the sense of career success and emotional labor.

Methods

A total of 385 community nurses from Beijing participated in this investigation. Latent class analysis was used to identify meaningful subgroups of participants, and analysis of variance was used to analyze relationships between emotional labor classes and the sense of career success.

Results

Emotional labor among community nursing staff in China was divided into three latent classes: active (n = 90, 25.6%), apathetic (n = 65, 18.5%), and moderate (n = 197, 55.9%). The active emotional labor classes had significantly higher career success (p<0.05). The “gaining recognition” dimension showed significant differences across the three classes.

Conclusion

Our findings suggested managers to implement a variety of measures to strengthen interventions for employees’ emotional labor that are targeted to incentive mechanisms, which will improve nurses’ sense of career success.

'I think we're getting a bit clinical here': A qualitative study of professionals' experiences of providing mental healthcare to young people within an Australian rural service

This paper contributes to scholarship on the medicalisation of mental health support for young people through a case study of a multidisciplinary mental health service in rural Australia. All staff (n = 13) working at the service participated in semi-structured, individual interviews. Transcripts of interview data were read and selectively coded and interpreted in relation to the overarching question of how participants view and experience mental health care provision to a diverse range of young people. Following analytical reflection, codes pertaining to engagement, accessibility and care provision were re-examined using the concept of medicalisation to understand the biomedical underpinning of mental healthcare and how this plays out in the experiences and perceived challenges participants talked about in responding to the mental health concerns of diverse young people. The resulting analysis is presented under five theme headings: (a) privileging clinical expertise and priorities within service provision, which was an important source of conflict for some participants; (b) 'multidisciplinary' teams-a 'difficult kind of culture at times'; (c) articulations of where cultural barriers lie; (d) the tracks along which young people are directed to 'engage' with 'mental health'; and (e) a clinical 'feel' to space. We suggest that service and system investment needs to be given to alternative ways of thinking about and approaching mental health and care provision that are cognisant of, and engage with, the inherent connections between individual circumstance and social, place, cultural, economic and political contexts. This is particularly relevant to the provision of care in rural contexts because of limited service options and the complexities of access and providing care to a diverse range of young people living in isolated environments. Interdisciplinary frameworks need to be enacted and services must acknowledge their own cultural positions for alternative ways of working to become possibilities.

Nurses' experiences of encounters in home care: a phenomenological hermeneutic study

PURPOSE

nurses working in home care often encounter patients with multiple diagnoses in unpredictable environments. This may cause ethical and emotional challenges and influence nurses' daily work. The aim of this study was to illuminate the meaning of nurses' lived experiences of encountering patients in home care.

METHODS

narrative interviews were conducted with 11 nurses. These interviews were audiotaped and transcribed verbatim and analysed using a phenomenological hermeneutic approach.

FINDINGS

the findings are presented under three main themes: (1)"Being receptive to the other" (with subthemes "Caring about the encounter," and "Establishing trusting relationships"). (2) "Need to handle Handling the unpredictable" (with subthemes "Being alone in the encounter" and "Being experienced and competent"). (3) "Managing frustration" (with subthemes "Feeling insufficient" and "Feeling restricted". Having overall nursing responsibility challenged the nurse's self-confidence in providing care trustfully.

CONCLUSIONS

encountering patients in home care means relating to the other unconditionally, which aim to highlight patients' needs. Being a nurse in home care is both emotionally demanding and rewarding. Having the courage to face their own and the patients' vulnerabilities will entail the promotion of natural receptivity and responsiveness to patients' needs.

Negotiating Relational Practice Patterns in Palliative Home Care

Providing palliative care in the home presents a variety of challenges for nurses and other care providers. As part of a focused ethnographic study examining client/caregiver/care-provider relationships within the socio-cultural context of home-based palliative care, this paper describes the provision of palliative care to Canadian seniors with advanced cancer from the perspective of nurses. Data were collected through in-depth interviews (n=19) with three palliative care nurses and participant observations in four households over a six-to-eight-month period. Home-based palliative care nursing was depicted in this study as a dialectical experience, revealing three relational practice patterns: making time-forfeiting time, connecting-withdrawing, and enabling-disabling. Nurses attempted to negotiate the tensions between these opposing approaches to palliative care. Study findings suggest that the socio-cultural context of palliative care is not conducive to high-quality palliative care and provide several insights related to future directions for practice, policy, and research.

The right place? Users and professionals' constructions of the place's influence on personal recovery in community mental health services

Background

Current mental health policy emphasizes the importance of community-based service delivery for people with mental health problems to encompass personal recovery. The aim of this study is to explore how users and professionals construct the place’s influence on personal recovery in community mental health services.

Methods

This is a qualitative, interpretive study based on ten individual, semi-structured interviews with users and professionals, respectively. A discourse analysis inspired by the work of Foucault was used to analyze the interviews.

Results

The findings show how place can be constructed as a potential for and as a barrier against recovery. Constructions of the aim of the services matter when choosing a place for the services. Further, constructions of user–professional relationships and flexibility are important in the constructions of an appropriate place for the services.

Conclusions

The aim of the service, the user–professional relationship, and flexibility in choosing place were essential in the participants’ constructions. To find “the right place” for mental health services was constructed as context-sensitive and complex processes of assessment and co-determination.

Trial registration The study is approved by the Regional Committee for Medical Research Ethics, Norway (REK-Midt 2011/2057)

Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer

Objectives

Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care.

Methods

This is a qualitative study of 19 National Health Service (NHS) organisations, 7 of which had community service provision. We conducted ethnographic observations of practice and interviews with front-line nursing and senior staff. Analysis was based on the constant comparison method.

Results

Measurement in community settings presents distinct challenges, calling into question the extent to which measures can be easily transferred. The NHS-ST was seen as more appropriate for acute care, not least because community nurses did not have the same access to information. Data collection requirements were in tension with maintaining a relationship of trust with patients. The aim to collect data across care settings acted to undermine perceptions of the representativeness of community data. Although the tool was designed to measure preventable harms, care providers questioned their preventability within a community setting. Different harms were seen as priorities for measurement and improvement within community settings.

Conclusions

Measurement tools are experienced by healthcare staff as socially situated. In the community setting, there are distinct challenges to improving care quality not experienced in the acute sector. Strategies to measure harms, and use of any resulting data for improvement work, need to be cognisant of the complexity of an environment where healthcare staff often have little opportunity to monitor and influence patients.

Evangelical Protestants and the ACA: An Opening for Community-Based Primary Care?

Evangelical Protestants make up the largest religious subgroup in the United States, and previous research has shown that Evangelical churches are disproportionately active in community engagement and efforts toward social change. Although Evangelical Protestant perspectives have been considered with regard to persistent socioeconomic stratification and racial discrimination, less focus has been given to how churches interpret poor health outcomes within the United States. In particular, this research addresses how enduring health disparities are understood within the larger discussion of healthcare reform. Due to the similarity of approaches favored by participants in this study and community-based philosophy, a suggestion is made for future health policy dialogue. Although Evangelical Protestants have been most likely to reject all aspects of the Affordable Care Act, in many ways the findings of this study suggest the potential for successful future health policy collaboration. In particular, community-based primary care might appeal to Evangelicals and health professionals in the ongoing effort to improve population health and the quality of healthcare in the United States.

Factors influencing community nursing roles and health service provision in rural areas: a review of literature

AIMS

This review sought to better understand the issues and challenges experienced by community nurses working in rural areas and how these factors shape their role.

METHODS

Databases were searched to identify relevant studies, published between 1990 and 2015, that focussed on issues and challenges experienced by rural community nurses. Generic and grey literature relating to the subject was also searched. The search was systematically conducted multiple times to assure accuracy.

RESULTS

A total of 14 articles met the inclusion criteria. This critical review identified common issues impacting community nursing and included role definition, organisational change, human resource, workplace and geographic challenges.

CONCLUSION

Community nurses are flexible, autonomous, able to adapt care to the service delivery setting, and have a diversity of knowledge and skills. Considerably more research is essential to identify factors that impact rural community nursing practice. In addition, greater advocacy is required to develop the role.

A poststructural rethinking of the ethics of technology in relation to the provision of palliative home care by district nurses

Technology and its interfaces with nursing care, patients and carers, and the home are many and varied. To date, healthcare services research has generally focussed on pragmatic issues such access to and the optimization of technology, while philosophical inquiry has tended to focus on the ethics of how technology makes the home more hospital like. However, the ethical implications of the ways in which technology shapes the subjectivities of patients and carers have not been explored. In order to explore this, poststructural theory, in particular the work of Butler, Foucault, and Deleuze, is used to theorize the relationship between subjectivity and materiality as ethically mandated on producing rather than precluding the development of subjectivities in novel ways. This theoretical understanding is then utilized through a process of 'plugged in' as described by Jackson and Massie that aims to link empirical data, research, and philosophical inquiry. Through this process, it is suggested that power, which the empirical data demonstrate, is frequently exercised through medical discourses and restricts patients' and carers' ability to shape the material environment of the home as a place to live and be cared for in palliative stages of illness. Alternative discourses are suggested both from the empirical data as well as other research, which may offer patients and carers the possibility of reclaiming power over the home and their subjectivities. Finally, the dichotomy between the home and hospital, mediated via technology, is posited as being problematic. It is argued the dichotomy is false and should be moved away from in order to allow an ethical embrace of technology in palliative care.

District nurse advocacy for choice to live and die at home in rural Australia: a scoping study

BACKGROUND

Choice to live and die at home is supported by palliative care policy; however, health resources and access disparity impact on this choice in rural Australia. Rural end-of-life home care is provided by district nurses, but little is known about their role in advocacy for choice in care.

OBJECTIVES

The study was conducted to review the scope of the empirical literature available to answer the research question: What circumstances influence district nurse advocacy for rural client choice to live and die at home?, and identify gaps in the knowledge.

METHOD

Interpretive scoping methodology was used to search online databases, identify suitable studies and select, chart, analyse and describe the findings.

RESULTS

34 international studies revealed themes of 'the nursing relationship', 'environment', 'communication', 'support' and 'the holistic client centred district nursing role.

DISCUSSION

Under-resourcing, medicalisation and emotional relational burden could affect advocacy in rural areas.

CONCLUSION

It is not known how district nurses overcome these circumstances to advocate for choice in end-of-life care. Research designed to increase understanding of how rural district nurses advocate successfully for client goals will enable improvements to be made in the quality of end-of-life care offered.

In search of legitimacy--registered nurses' experience of providing palliative care in a municipal context

BACKGROUND

The palliative care approach was originally developed for hospice care and for persons with cancer diseases, but has gradually expanded to embrace other contexts and people of all ages, with various life-threatening diseases. The palliative care concept thus also applies to older people and the context of municipal care, where Registered Nurses (RNs) hold key care provision positions. The municipal context is not, however, focused primarily on advanced nursing care, and it is important to highlight RNs' prerequisites for care provision.

AIM

The study's aim was to describe RNs' experience of providing palliative care for older people in a municipal context. Data were collected through focus group discussions with 20 RNs from four different municipalities in southern Sweden and were analysed using conventional content analysis.

FINDINGS

The results showed that the nurses experienced that it was they who cushioned the effects of unclear responsibilities between different organizations, but had limited legitimacy in the municipal context and in relation to other care providers. The results also showed that nurses lacked proper support and prerequisites for providing high-quality palliative care to older dying patients.

CONCLUSION

The results pinpoint the importance of increased acknowledgement of nurses' knowledge and skills and a critical view on the effects of moving towards an organization composed of different consultants, which can lead to even more unclear responsibility for nursing care provision.

Relationships between nurses and older people within the home: exploring the boundaries of care

AIM

To explore the nature of relationships between nurses and older people within the home and to illuminate the nature and quality of caring boundaries within this setting.

BACKGROUND

Older people are increasingly receiving nursing care in the home. There has been little exploration of the nature of the nurse-older patient relationship within this setting.

METHODS

An ethnographic approach using semi-structured interviews with 16 community nurses and 13 older patients (aged 65 years and over), were undertaken to explore the nature of care relationships within the home setting.

FINDINGS

The study has highlighted the centrality of the location of care and the concept of 'the home' in terms of geographical and metaphorical meanings. Moreover, the study has clearly illuminated the complex nature of relationships and boundary construction from a number of perspectives.

CONCLUSION

As the location of care for older people continues to move closer to home it is crucial that the implicit qualities that are valued within nurse-patient relationships within this context of care, and which contribute to the quality of care, are recognized and made more explicit at the organizational and policy level.

PRACTICE IMPLICATIONS

For nurses working within the home there is a clear impetus to clearly define and articulate the full breadth of their role, the nature of relationships and issues surrounding professional boundary construction within this environment. There is also a need for the core qualities that underpin the receipt of care within the home and the facets of the nurse-patient relationship valued by older people to be fully recognized and accounted for.

The role of health care assistants in supporting district nurses and family carers to deliver palliative care at home: findings from an evaluation project

AIMS AND OBJECTIVES

To examine the role of trained health and personal care assistants in supporting district nurses and family carers in providing palliative and end of life care in the community.

BACKGROUND

In the UK, there is a policy directive to improve end of life care and to enable greater numbers of people to die at home. This places considerable demands on community nursing services and family carers. In response to this, the Complex and Palliative Continuing Care Service employing generic health and personal care assistants was developed as part of the Marie Curie Delivering Choice Programme in one city in the UK. This paper draws on findings from an independent evaluation of the scheme.

DESIGN

The wider evaluation used a formative evaluation methodology.

METHOD

This paper draws on in-depth interviews with a range of stakeholders (n = 17), in-depth interviews with bereaved carers (n = 6) and an analysis of documentation.

RESULTS

Stakeholders and bereaved carers perceived that the health and personal care assistants made a vital contribution to community palliative care. Careful recruitment, specific training, case management by district nursing with allocation of specific tasks and close ongoing communication were key features which stakeholders indentified. Family carers welcomed the way assistants developed relationships and became familiar and able to meet the care needs of patients. There were some problems reported which related to capacity, work flow and the need for extensive written care plans.

CONCLUSION

Employing health care assistants under the supervision of district nurses appears to support patients and family at home during end of life care and contribute to good quality nursing care.

RELEVANCE TO CLINICAL PRACTICE

The needs for community-based palliative and end of life care will increase rapidly over the course of the next 20 years, placing pressure on community nursing services and family carers.

Swedish District Nurses' experiences on the use of information and communication technology for supporting people with serious chronic illness living at home--a case study

The aim of this case study was to describe two District Nurses' (DN) experiences of using information and communication technology (ICT) to communicate with chronically ill people in their homes. An electronic messaging program via computers and mobile phones with an Internet connection was used, enabling DNs and the ill people to exchange messages to and from anywhere. The program comprised different virtual rooms, and communication was via text messages. The DNs in this study used the program two to four times each week from November 2003 to March 2004. Semi-structured interviews were performed before, during and after the implementation of the new technology and were analysed using thematic content analysis. The results showed that the DNs felt that the technology increased accessibility to nursing care through a more direct communication with the ill person meaning that a more trusting relationship could be created. The DNs also experienced that the use of ICT saved working time. This study indicates that the use of ICT for communication allowed the DN to better support a chronically ill person at home leading to improved home nursing care. This method of communication cannot replace physical presence, but can be seen as a complement to nursing care at home.

Patients as `Safeguard' and Nurses as `Substitute' in Home Health Care

One aim of this study was to explore the role, or subject position, patients take in the care they receive from nurses in their own home. Another was to examine the subject position that patients say the nurses take when giving care to them in their own home. Ten interviews were analysed and interpreted according to a discourse analytical method. The findings show that patients constructed their subject position as `safeguard', and the nurses' subject position as `substitute' for themselves. These subject positions provided the opportunities, and the obstacles, for the patients' possibilities to receive care in their home. The subject positions described have ethical repercussions and illuminate that the patients put great demands on tailored care.

Defining roles, relationships, boundaries and participation between elderly people and nurses within the home: an ethnographic study

Recently there has been a marked shift in the location of nursing care in the UK from the hospital setting to the community and more particularly the home, with elderly people identified as key recipients of care in this setting. A number of commentators have highlighted the particular situation of elderly people with regard to care provision, illuminating the often disempowering nature of care interactions between nurses and elderly people. However, although there is clear evidence from a number of settings that care for elderly people has been less than optimal, to date there is little comparable evidence available regarding elderly people's experiences of nursing care within the home environment. Utilising an ethnographic approach, incorporating participant observation and semistructured interviews with nurses and elderly people (aged 65 years and over), the aim of this study was to explore the nature of the care relationship within the home setting. Thirteen elderly people who were receiving nursing care within the home and 16 community nurses within one Primary Care Trust in the UK took part in the study and data were collected over a period of 1 year. Three themes emerged from the data: the location of care; the nature of nurse-patient relationships; and the meaning of health and illness. These offer an account of the ways in which roles and relationships are constructed, negotiated and experienced by nurses and elderly people in the home, illuminating the centrality of relationships between nurses and elderly people in defining the experiences and perceptions of both groups of the quality of care overall. As the location of care continues to move closer to home, it is crucial that the implicit qualities that are valued within nurse-patient relationships in this context are recognised and made more explicit at both the organisational and policy level.

District nurses' involvement in pain care: a theoretical model

AIM

To explore district nurses care of chronic pain sufferers and to create a theoretical model that can explain the variation in district nurses experiences when caring for these patients.

BACKGROUND

Many people suffer from chronic pain, which greatly affects their wellbeing and causes physical suffering and psychosocial limitations. District nurses frequently meet patients who suffer from chronic pain and consequent problems. District nurses often feel powerless and ill-equipped, and they experience difficulties during interactions with these patients.

METHOD

This is a qualitative study with a theory-generating approach. Data were collected from interviews with 20 district nurses in five focus groups. Interviews were taped, transcribed and then analysed as per the grounded theory method.

RESULTS

The result is a theoretical model of district nurses' involvement in pain care. The model: (1) illustrates three main conditions in the care situation that influence district nurses' involvement in pain care and (2) explains the connection between how district nurses actively or passively detect and actively or passively respond to patients with pain problems.

CONCLUSIONS

The model explains why district nurses sometimes feel powerless or ill-equipped in dealing with chronic pain problems. Insufficient conditions make it difficult for district nurses to become involved with pain problems and thus result in passive detection of and passive response to pain problems. Supporting patients to communicate their pain, collaboration with and involvement from other professionals regarding pain care, the organisation's guidelines and support for pain care and training in pain care are interventions that will contribute to district nurses' involvement in pain care.

RELEVANCE TO CLINICAL PRACTICE

Through the model, chronic pain care can be better explained and understood; consequently chronic pain care can be improved. The model can be used in each, unique, case-study analysis. Nursing staff and students can also use the model as a basis for discussions about chronic pain sufferers.

A third place in the everyday lives of people living with cancer: functions of Gilda's Club of Greater Toronto

The purpose of this paper was to examine the therapeutic functions of Gilda's Club of Greater Toronto in the everyday lives of people living with cancer. Gilda's Club is a non-institutional setting, where people living with cancer join together to build physical, social, and emotional support as a supplement to medical care. Findings reveal members regarded Gilda's Club as an escape from the stressors of home and hospital, a place where they could meet others living with cancer, and a social environment in which they could confront or distance themselves from their health problems. The paper demonstrates the significance of "third places" for health and calls on researchers to afford such places greater attention.

Client-nurse relationships in home-based palliative care: a critical analysis of power relations

AIM

To elicit an in-depth understanding of the sources of power and how power is exercised within client-nurse relationships in home-based palliative care.

BACKGROUND

As in all social relations, power is present within client-nurse relationships. Although much research has focused on interpersonal relationships in nursing, the concept of power within the client-nurse relationship in palliative care settings has not been extensively investigated.

METHODS

Applying a critical lens, secondary qualitative data analysis was conducted. Seventeen nurse and 16 client transcripts from a primary study were selected for secondary data analysis. These 33 transcripts afforded theme saturation, which allowed for both commonalities and differences to be identified. Data analysis involved analytic coding.

RESULTS

Study findings help make explicit the underlying power present in the context of home-based palliative care and how this power is used and potentially abused. In analysing the sources and exercise of power, the linkage between macro and micro levels of power is made explicit, as nurses functioned within a hierarchy of power. The findings suggest that educational/occupational status continues to be a source of power for nurses within the relationship. However, nurses also experience powerlessness within the home care context. For clients, being able to control one's own life is a source of power, but this power is over-shadowed by the powerlessness experienced in relationships with nurses. The exercise of power by clients and nurses creates experiences of both liberation and domination.

CONCLUSIONS

Nurses who are willing to reflect on and change those disempowering aspects of the client-nurse relationship, including a harmful hierarchy, will ultimately be successful in the health promotion of clients in home-based palliative care. Additionally, it should be recognized that nurses work within a specific health system context and, therefore, their practice is influenced by policies and funding models implemented at various levels of the health care system.

RELEVANCE TO CLINICAL PRACTICE

The insights gained through this investigation may assist nurses and other health professionals in reflecting on and improving practices and policies within home-based palliative care and within home care in general.

Nurses and palliation in the community: the current discourse

A core component of community nursing practice in Australia is the provision of palliative care, however this area of practice has been minimally researched. We, therefore, undertook a broader review of the contemporary literature in community nursing; palliative nursing; and community nursing palliative care. Literature was searched electronically in OVID, CINAHL and nursing databases and manually in relevant journals. Findings revealed community and palliative care nursing to be both complex and challenging. Community and palliative nurses ideals for care are compromised by competing practice demands. Changing health systems and philosophical views, limited resources and the perceived 'visibility/invisibility' polarity are identified as major job stressors. Therapeutic use of 'self' and interpersonal communication are recognized as contributing to job satisfaction. Community nurses providing palliative care is as an under researched area yet it is a role that arguably requires critical understanding and recognition. Further research is needed into the relationship between emotional well-being and professional satisfaction for community and palliative care nurses providing palliation.

Referral criteria: making the district nursing service visible

The development of referral criteria has been seen as one of the keys to the proactive enhancement of the district nursing service to ensure equity and efficiency of service provision (Audit Commission, 1999). Referral criteria specify what constitutes an appropriate district nursing referral and who is the best person or service to undertake the care if it is not. With the continued focus of shifting the balance of care away from the hospital and into the community and a historically reactive rather than proactive work force, district nurses in Lothian, Scotland developed referral criteria for the service. This article discusses the drivers for the development of these criteria, how they were developed, and the anticipated difference implementation of the criteria would make to district nursing.

Place, policy and practitioners: On rehabilitation, independence and the therapeutic landscape in the changing geography of care provision to older people in the UK

A growing body of literature in geography and other social sciences considers the role of place in the provision of healthcare with particular interests emerging around the role of the psychological, social and cultural aspects of place in care provision. As healthcare stretches increasingly beyond the traditional four walls of the hospital, so questions of the role of place in practices of care become ever more pertinent. In this paper, we examine the relationship between place and practice in the care and rehabilitation of older people across a range of settings, using qualitative material obtained from interviews and focus groups with nursing, care and rehabilitation staff working in hospitals, clients' homes and other sites in England. By analysing their testimony on the characteristics of different settings, the aspects of place which facilitate or inhibit rehabilitation and the ways in which place mediates and is mediated by social interaction, we consider how various dimensions of place relate to the power-inscribed relationships between service users, informal carers and professionals as they negotiate the goals of the rehabilitation process. We seek to demonstrate how the physical, psychological and social meanings of place and the social processes engendered by the rehabilitation encounter interact to produce landscapes that are more or less therapeutic, considering in particular the structuring role of state policy and formal healthcare provision in this dynamic.

Health protection: communicable disease, public health and infection control educational programmes—a case study from the UK

The health protection (HP) landscape is changing. Issues related to infectious diseases in the context of global health are receiving the attention of world leaders and policy makers. In the UK, the national health policies resonate with such transformations, presenting a range of opportunities and challenges. The opportunities include the formation of a new national organisation dedicated to protecting the people's health and reducing the impact of infectious disease, the Health Protection Agency. The opportunities also include the opening of non-medical specialists's pathways in public health. The challenges represent the limited number of centres offering infection control education; the hospital focus and bias of the courses; new, resurgent and emerging infections; globalisation and travel; bacterial resistance; vaccine safety and coverage; bioterrorism; global response capacity; and visa restrictions. Within this context, this paper presents a case study of a HP educational programme at a British university in the south of England. It outlines the course design and philosophy, participants, recruitment, aims, descriptions and learning outcomes. A range of teething problems associated with the initiation and running of such programmes is considered. These include aspects related to the university, features associated with the modules, characteristics of the students, and other interconnected larger scale international issues. Some suggestions for the way forward are presented. Collectively, attention to the suggested measures can ensure that the processes that teaching programmes embrace to refine their content and delivery will equip tomorrow's professionals with the requisite HP knowledge and skills.

Patients' perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies

BACKGROUND

The delivery of technology-enhanced home care is growing in most industrialized countries. The objective of our study was to document, from the patient's perspective, how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. Understanding what makes a technology user-friendly should help improve the design of home care services.

METHODS

Four home care interventions that are frequently used and vary in their technical and clinical features were selected: Antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. Our qualitative study relied on the triangulation of three sources of data: 1) interviews with patients (n = 16); 2) interviews with carers (n = 6); and 3) direct observation of nursing visits of a different set of patients (n = 16). Participants of varying socioeconomic status were recruited through primary care organizations and hospitals that deliver home care within 100 km of Montreal, the largest urban area in the province of Quebec, Canada.

RESULTS

The four interventions have both a negative and positive effect on patients' lives. These technologies were rarely perceived as user-friendly, and user-acceptance was closely linked to user-competence. Compared with acute I.V. patients, who tended to be passive, chronic patients seemed keener to master technical aspects. While some of the technical and human barriers were managed well in the home setting, engaging in the social world was more problematic. Most patients found it difficult to maintain a regular job because of the high frequency of treatment, while some carers found their autonomy and social lives restricted. Patients also tended to withdraw from social activities because of social stigmatization and technical barriers.

CONCLUSIONS

While technology contributes to improving the patients' health, it also imposes significant constraints on their lives. Policies aimed at developing home care must clearly integrate principles and resources supporting the appropriate use of technology. Close monitoring of patients should be part of all technology-enhanced home care programs.

Families in home care--a resource or a burden? District nurses' beliefs

BACKGROUND

Caring for families in home care is a growing part of Swedish district nurses' professional work. District nurses' facilitative and constraining beliefs about families guide the extent to which families are acknowledged and engaged in the care.

AIMS AND OBJECTIVES

The aim of the study was to explore district nurses' beliefs about families in home care.

DESIGN

Explorative, descriptive.

METHODS

Five district nurses participated in focus group interviews on three separate occasions. Each interview lasted approximately 90 minutes, was audio taped and transcribed verbatim. A thematic content analysis was used for analyses of the data.

RESULTS

The result revealed two underpinning beliefs held by the district nurses towards families in home care: families are a resource and Families are a burden. Families could be a resource for the patient, for the other family members as well as for the district nurses themselves. Families could be a resource for the patient both practically and emotionally by e.g. being present and listening. Being open in communication with other family members and district nurses was also considered as a resource. The district nurses considered families as a burden when they were experienced as demanding in various ways, for example, when family members did not act in a way that pleased the district nurses or when family members showed their suffering.

CONCLUSIONS

This study highlight some facilitating and constraining beliefs held by district nurses: families can be both a resource and a burden.

RELEVANCE TO CLINICAL PRACTICE

It is important that district nurses are aware of what beliefs they hold as their beliefs guide their actions towards the families.

Exploring the significance of place in community nursing

There has been a dramatic shift in emphasis in health care in the UK in recent years towards the community setting. Care for someone in his or her own home takes place in a different context from caring for them in hospital, and requires a different approach. This article highlights a number of issues raised by this change, and suggests that there needs to be a focused effort to understand the impact of these issues on practice.