Rehabilitation, chronic illness and disability: the missing elements in nurse education

Attitudes of nursing students toward people with disabilities

BACKGROUND

Attitudes of healthcare professionals are major factors in the rehabilitation and self-acceptance of people with disabilities. Consequently, it is important that nurses develop or maintain positive attitudes towards people with disabilities during their education. Nevertheless, more knowledge is needed about current attitudes of nursing students and factors influencing these attitudes.

OBJECTIVES

To investigate the attitude of Turkish nursing students towards people with disabilities and demographic variables mostly influence this attitude.

PARTICIPANTS

The sample of the study comprised of 587 undergraduate nursing students.

DESIGN AND SETTING

This descriptive study was conducted at two nursing schools and two health schools at undergraduate level located in three different cities in Turkey.

METHOD

Data were collected in a class composed of students from schools between January and April 2009. The questionnaire used in the study consisted of four parts: (1) a demographic data sheet; (2) background in disability (3) contact and experiences with disabled people (4) The Attitudes Toward Disabled Persons Scale (ATDP-form O).

RESULTS

All of the participants were female with a mean age of 22.25 ± 1.53. Only 2% of the participants reported having a physical disability themselves. The mean ATDP score was 64.27 ± 0.36 (range 33-96). The age, school type, prior knowledge, giving care to disabled people in the family and social life were found statistically significant factors for having positive attitudes (p<0.05).

CONCLUSIONS

The age group, type of school, prior education regarding the disabled and the condition of caregiving to disabled people are factors influencing nursing students' attitudes towards people with disabilities.

Improving neuro-oncological patients care: basic and practical concepts for nurse specialist in neuro-rehabilitation

Background

Neuro-oncological population well expresses the complexity of neurological disability due to the multiple neurological deficits that affect these patients. Moreover, due to the therapeutical opportunities survival times for patients with brain tumor have increased and more of these patients require rehabilitation care. The figure of nurse in the interdisciplinary specialty of neurorehabilitation is not clearly defined, even if their role in this setting is recognized as being critical and is expanding.

The purpose of the study is to identify the standard competencies for neurorehabilitation nurses that could be taught by means of a specialization course.

Methods

A literature review was conducted with preference given to works published between January 2000 and December 2008 in English. The search strategy identified 523 non-duplicated references of which 271 titles were considered relevant. After reviewing the abstracts, 147 papers were selected and made available to a group of healthcare professionals who were requested to classify them in few conceptual main areas defining the relative topics.

Results

The following five main areas were identified: clinical aspects of nursing; nursing techniques; nursing methodology; relational and organisational models; legal aspects of nursing. The relative topics were included within each area. As educational method a structured course based on lectures and practical sessions was designed. Also multi-choices questions were developed in order to evaluate the participants’ level of knowledge, while a semi-structured interview was prepared to investigate students’ satisfaction.

Conclusions

Literature shows that the development of rehabilitation depends on the improvement of scientific and practical knowledge of health care professionals. This structured training course could be incorporated into undergraduate nursing education programmes and also be inserted into continuing education programmes for graduate nurses. Developing expertise in neuro-rehabilitation for nurses, will be critical to improve overall care and care management of patients with highly complex disabilities as patients affected by brain tumors. The next step will be to start discussing, at the level of scientific societies linked to the field of neurorehabilitation and oncology, the development of a specialisation course in neurorehabilitation nursing.

Contemporary issues in the training of UK health and social care professionals--Looking after people with a learning disability

The health and social care of people labelled with 'learning disability' has historically been a disputed territory for those individuals working within the nursing and allied health professions. In recent times this situation has seen public debate as instances of poor care and avoidable deaths have received a high profile in the popular and professional presses. Here we report on a local initiative where students can study for a joint honours award which allows them to practise as a generic social worker and a learning disability nurse. We believe that the inter-professional perspective improves their ability to manage the increasingly complex aspects of health and social care that this client group demands. Furthermore, we suggest that if a similar model were to be applied at a foundation module level to the training of ALL health and social care professionals, then the results would be a win/win situation for all parties. This would also go some way to meeting the recommendations of Sir Jonathan Michael's report, Health Care for All (DH, 2008).

Models of disability: their influence in nursing and potential role in challenging discrimination

AIM

This paper presents a discussion of medical and social models of disability associated with experiences of disabled people as citizens and patients.

BACKGROUND

Disability is fairly universally a negative concept. Disabled people have frequent contact with health services, however much of this experience is viewed as discriminatory.

DATA SOURCES

Literature was obtained using the Psych-INFO, Medline and CINAHL databases for the years 1989-2009, using derivatives of the concept 'disability' and associated 'models', and then these terms combined with 'nursing'.

DISCUSSION

Nursing as a profession embraces the need to avoid discrimination, yet disability as an equal opportunity issue is relatively neglected in nursing. Nursing has a moral, professional and, in some countries, a legal responsibility to promote disability equality in the provision of nursing services. Insights offered by the social model of disability may be instrumental in empowering nurses to respond to this obligation. While some groups may not be well-represented in this model and there is risk in embracing the social model of exposing a policy-practice divide, it nevertheless represents a powerful tool for strengthening nurses' advocacy role. In particular, 'social advocacy' may be enhanced by a paradigm shift away from the medical model of disability.

IMPLICATIONS FOR NURSING

Nurses have an obligation to promote disability equality in relation to the provision of health care. Adoption of the social model of disability in nursing practice, education and research as a strategy to challenge discrimination should be seriously considered.

CONCLUSION

The utility value of the social model of disability in strengthening the social advocacy role of nurses should be investigated.

Rheumatology education for undergraduate nursing, physiotherapy and occupational therapy students in the UK: standards, challenges and solutions

OBJECTIVES

Rheumatological conditions are common, thus nurses (Ns) occupational therapists (OTs) and physiotherapists (PTs) require at least basic rheumatology knowledge upon qualifying. The aim of this study was to develop a core set of teaching topics and potential ways of delivering them.

METHODS

A modified Delphi technique was used for clinicians to develop preliminary core sets of teaching topics for each profession. Telephone interviews with educationalists explored their views on these, and challenges and solutions for delivering them. Inter-professional workshops enabled clinicians and educationalists to finalize the core set together, and generate methods for delivery.

RESULTS

Thirty-nine rheumatology clinicians (12N, 14OT, 13PT) completed the Delphi consensus, proposing three preliminary core sets (N71 items, OT29, PT26). Nineteen educationalists (6N, 7OT, 6PT) participated in telephone interviews, raising concerns about disease-specific vs generic teaching and proposing many methods for delivery. Three inter-professional workshops involved 34 participants (clinicians: N12, OT9, PT5; educationalists: N2, OT3, PT2; Patient 1) who reached consensus on a single core set comprising six teaching units: Anatomy and Physiology; Assessment; Management and Intervention; Psychosocial Issues; Patient Education; and the Multi-disciplinary Team, recommending some topics within the units receive greater depth for some professions. An innovative range of delivery options was generated plus two brief interventions: a Rheumatology Chat Show and a Rheumatology Road Show.

CONCLUSIONS

Working together, clinicians and educationalists proposed a realistic core set of rheumatology topics for undergraduate health professionals. They proposed innovative delivery methods, with collaboration between educationalists, clinicians and patients strongly recommended. These potential interventions need testing.

Improving the health and wellness of persons with disabilities: A call to action too important for nursing to ignore

In 2005, the US Surgeon General issued a Call to Action to Improve the Health and Wellness of Persons with Disabilities, with the goal being the improvement of the health status of men, women, and children with disabilities. Despite federal legislation to address inequities in health care for the 54-60 million people in the US with disabilities, many have reported negative experiences in their interactions with health care providers from all health professions. Collectively, the nursing profession has been silent in its response to this call. This article describes the current status of health care of individuals with disabilities in the US, and suggests appropriate responses by the nursing profession to the Surgeon General's Call to Action. Specific suggestions are identified for nursing practice, education, research, nursing leaderships, and the profession of nursing as a whole.

Attitudes towards disability in an undergraduate nursing curriculum: a literature review

In the process of introducing a new disability unit into an undergraduate nursing curriculum in a New Zealand educational setting, the opportunity arose to conduct a small study comparing the attitudes of student nurses towards people with disabilities. This paper discusses the literature reviewed, which formed the basis for the study. A range of perspectives and research was identified that explored societal and nurses' attitudes, disability studies in undergraduate nursing curricula, the impact of nurses' attitudes on patient care, and interventions for changing those attitudes. Effective nursing care can be severely compromised through negative attitudes, and concerns are expressed at the lack of attention given to this issue in nursing curricula generally. The literature showed that combining educational approaches with opportunities for student nurses to interact with disabled people provides the most effective means for student nurses to develop positive attitudes towards disabled people. The goal for nurse educators is to ensure the inclusion of disability studies as a core component in undergraduate nursing education.

Continuity of care and general wellbeing of patients with comorbidities requiring joint replacement

AIM

The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement.

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis.

METHOD

A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005.

FINDINGS

Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study.

CONCLUSION

Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.

Multidisciplinary perceptions of the role of nurses and healthcare assistants in rehabilitation of older adults in acute health care

AIM

This paper describes the perceptions of nurses, healthcare assistants, doctors and therapists of rehabilitation and the role of nurses and healthcare assistants on an acute older adults ward in a London teaching hospital.

BACKGROUND

The role perception, education and training and attitudes towards the older adults have been identified as barriers that have an impact upon the nurses' role within rehabilitation. However, little is known about the role of nurses and healthcare assistants in rehabilitation of older adults in acute health care.

DESIGN

Action research study.

METHOD

Twenty-four semi-structured interviews were conducted and audio recorded about healthcare professionals' understanding of rehabilitation, the type of skills needed and their perceptions of the role of nurses and healthcare assistants in rehabilitation. The interview transcripts were analysed using the thematic content analysis.

RESULTS

The findings suggest that the therapists relied on nurses and healthcare assistants for therapy carry-over. Healthcare assistants were perceived as the professional group who could deliver therapy carry-over. There was an evidence of role hierarchy as healthcare assistants perceived that they were not actively involved in decision-making or discharge planning.

CONCLUSION

This paper suggests that healthcare assistants and nurses are viewed as the professional group best placed to deliver therapy carry-over. However, whilst there is an acknowledgement of their role, there remains a reluctance to acknowledge healthcare assistants as a professional group and to involve them within decision-making and discharge planning.

RELEVANCE TO CLINICAL PRACTICE

Employers must be seen to advocate, support and implement education and training programs for healthcare assistants. However, whilst nurses and healthcare assistants have an integral role in rehabilitation, there needs to be more research into the how they are supported by therapy professionals.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.

Long-term conditions: making sense of the current policy agenda

This article is first of a series focusing on long-term conditions and aims to guide district nurses through the whole raft of policies that are currently emerging from the Department of Health for England and Wales. The article provides an overview of current policy by taking the reader through the initiatives, starting with population-wide prevention and concluding with policies focusing on clients with complex needs. The main triggers for government health strategies and the influence of models from the United States are discussed. The national service framework for long term conditions is explained and used as an example of the current emphasis on generic, rather than condition-specific, initiatives. The article concludes by drawing the initiatives together within the most recent model to come out of the Department of Health--the NHS and Social Care Model.

Current provision of rheumatology education for undergraduate nursing, occupational therapy and physiotherapy students in the UK

OBJECTIVES

Rheumatological conditions are common and all health professionals (HPs) therefore need sufficient knowledge and skills to manage patients safely and effectively. The aim of this study was to examine current undergraduate education in rheumatology for HPs in the UK.

METHODS

A questionnaire was sent to curriculum organizers and clinical placement officers for all undergraduate courses in adult nursing, occupational therapy (OT) and physiotherapy (PT) in the UK to ascertain the nature and amount of rheumatology theory and clinical exposure provided.

RESULTS

Of the 47 adult nursing, 26 OT and 30 PT undergraduate courses surveyed, 85-90% responded. Overall, rheumatology teaching is 5-10 h over 3 yr. Nursing students receive moderate/in-depth teaching on rheumatoid arthritis (RA) in only 52% of courses (OT 91%, PT 96%) and on osteoarthritis (OA) in 63% (OT 91%, PT 92%). Clinical experience of RA is probably/definitely available in only 56% of nursing courses (OT 72%, PT 88%), with similar results in OA. Overall, nursing students receive the least rheumatology exposure, particularly in psychosocial issues and symptom management, while PT students receive the most. OT students have limited opportunities for clinical exposure to psychosocial and joint protection issues. Use of local rheumatology clinical HP experts is variable (18-93%) and cross-disciplinary exposure is limited (0-36%). Many educators consider their rheumatology training to be insufficient (nursing 50%, PT 42%, OT 24%).

CONCLUSIONS

Rheumatology training for undergraduate HPs is limited in key areas and often fails to take advantage of local clinical expertise, with nursing students particularly restricted. Clinical HP experts should consider novel methods of addressing these shortfalls within the limited curriculum time available.

Patients with comorbidities: perceptions of acute care services

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people living with chronic illnesses. Indeed, a significant number of people will experience multiple chronic illnesses (comorbidities) and may require admission to hospital for acute care that is superimposed on their chronic illnesses.

AIM

The aim of this study was to investigate perceptions of quality of care by patients experiencing comorbidities who required an acute hospital stay.

METHOD

A qualitative descriptive design was adopted, informed by Colaizzi's phenomenological method. Single semi-structured interviews were conducted with 12 patients within 14 days of being discharged home after an acute illness episode.

FINDINGS

Data analysis revealed three themes: poor continuity of care for comorbidities, the inevitability of something going wrong during acute care and chronic conditions persisting after discharge. Combinations of chronic illnesses and treatments affected these patients' experiences of acute care and recovery postdischarge. Medicalized conceptualizations of comorbidity failed to capture the underlying health care needs of these patients. Limitations. No generalizations can be drawn because the findings and conclusions were derived from a purposive sample of patients who agreed to participate.

CONCLUSION

These findings have implications for a comprehensive and co-ordinated approach to this group of patients, and inform the body of nursing knowledge about how patients with comorbidities experience nursing care.

The International Classification of Functioning, Disability and Health (ICF) and nursing

BACKGROUND

Nursing conceptualizes disability from largely medical and individual perspectives that do not consider its social dimensions. Disabled people are critical of this paradigm and its impact on their health care.

AIM

The aims of this paper are to review the International Classification of Functioning, Disability and Health (ICF), including its history and the theoretical models upon which it is based and to discuss its relevance as a conceptual framework for nursing.

METHOD

The paper presents a critical overview of concepts of disability and their implications for nursing and argues that a broader view is necessary. It examines ICF and its relationship to changing paradigms of disability and presents some applications for nursing.

CONCLUSION

The ICF, with its acknowledgement of the interaction between people and their environments in health and disability, is a useful conceptual framework for nursing education, practice and research. It has the potential to expand nurses' thinking and practice by increasing awareness of the social, political and cultural dimensions of disability.

Rehabilitation practice: challenges to effective team working

Effective rehabilitation depends on multiple inputs from a variety of skilled multi-professional team members. This paper explores perceptions of the nurse's role within the multi-professional rehabilitation team and challenges for effective team working. It draws on findings from a 2-year qualitative study exploring the role of the nurse within rehabilitation. Substantial differences in the nurse's role were evident, depending on their and others' perceptions, especially in relation to the nurse's carry-on role. Many nurses felt their contributions were not valued and others desired greater reciprocity within the team. Blurring of role boundaries could bring benefits to clients but also led to professional tensions and rivalry.

An exploration of the contribution of the community nurse to rehabilitation

Effective hospital and community rehabilitation services are increasingly recognised as a means of meeting the changing pattern of health and social care need. While the district or community nurse has the potential to play a central part in community rehabilitation provision, this role has received relatively scant attention in the literature. This paper describes research findings on community nurses' perceptions of their role and potential contribution to rehabilitation. As part of a wider, 2-year, qualitative investigation of the role of the nurse in rehabilitation, fieldwork was undertaken with both district and community staff nurses. This comprised focus group discussions and interviews with staff recruited as a consequence of the follow-up of patients' experiencing rehabilitation. The findings indicate that community-based nurses contributed to patient rehabilitation by making assessments, referring on to other members of the multi-professional team, advocating for and liaising with other services, helping people to adapt, teaching and motivating patients and carers, supporting and involving families, and providing technical care. A number of challenges to community-based nursing roles were apparent, including feelings of exclusion, lack of recognition, a lack of time for rehabilitation and paucity of referrals for rehabilitation. Greater clarity and recognition is needed of the community-based nursing contribution to rehabilitation, and there is a need to ensure that community nursing assessments contribute to patients' rehabilitation goals and the promotion of independent living.

A framework for the role of Registered Nurses in the specialty practice of rehabilitation nursing in Australia

AIM OF THE STUDY

This study sought to explore systematically the role of Registered Nurses working in rehabilitation in Australia.

BACKGROUND

Rehabilitation has been identified as an important aspect of health care. However, evidence of a comprehensive investigation of the nurses' role in rehabilitation cannot be found. From Australia, in particular, no research has been published in this area.

METHODS

This study used a qualitative approach by engaging 13 nurses in one-to-one interviews and a further 21 in focus group discussions. Thematic analysis was conducted on the interview and focus group data.

FINDINGS

Seven domains of practice were identified and are suggested as a framework for the specialty practice of rehabilitation nursing. They capture the 'how' and 'what' of rehabilitation nursing practice. Central to this practice is a rehabilitative approach to patient care, teaching and coaching, and continual assessment. The nurses explained in detail how these aspects of rehabilitation nursing differentiate their practice from that of their acute care colleagues.

CONCLUSION

The rehabilitative approach is one of a variety of approaches to nursing care, but should not be seen as the exclusive domain of rehabilitation nurses. Rehabilitation belongs in every nurse's toolkit.

Exploring qualified nurses' perceptions of the relevance of education in preparation for their role in rehabilitation

The increasing importance of rehabilitation in the health sector and the nurses' critical role therein make it essential that nurses have the right skills and knowledge to work effectively in rehabilitation settings. Drawing from a wider qualitative investigation of the role of the nurse within the multi-professional rehabilitation team, gaps in the skills and knowledge of qualified nurses working in rehabilitation settings are presented and ways to address them are proposed. Both pre- and post-registration education were found wanting. Only one third of nurses thought, in retrospect, that their pre-registration education had provided them with adequate skills and knowledge for their role in rehabilitation. A need for greater focus on rehabilitation per se and associated clinical skills was identified. Whilst post-registration education was highly valued, substantial difficulties accessing relevant courses were noted. In-service training and ad hoc learning 'from experience' and colleagues formed additional ways to develop hands-on skills. Benefits of better education included enhancing confidence, promoting inter-professional equality and improving client care. Potential ways to address some of these concerns included: adoption of a 'thread and module' approach and dedicated rehabilitation student placements, a nationally recognized multi-professional post-registration course, and an integration of work based learning with formal educational provision.

Developing the nurse's role in patient education: rehabilitation as a case example

Over the past decade considerable emphasis has been placed on the nurse's role in patient education. Despite this numerous studies have suggested that this aspect of nursing practice is under-developed. Using rehabilitation as a case example this paper explores the nursing contribution to patient education in five conditions: multiple sclerosis; arthritis; myocardial infarction; spinal injury and stroke. Although the literature identifies considerable potential for nurses to take a lead role in patient education this is rarely achieved in practice. Analyses of printed curricula from a range of courses indicate that nurses are not adequately prepared for patient education and that a reorientation of nurse education is required.

Enabling disabled people: responsibilities of nurse education

This article examines some evidence concerning the approach nurse education takes in relation to disability issues and considers whether it is 'disabling' or 'enabling'. The role and purpose of education and training, along with an analysis of simulation as a teaching method and skills development, are explored. It is argued that nursing curricula has a key responsibility in ensuring that nursing practice is enabling rather than disabling in relation to patients with impairments who may be classed as disabled people by themselves or within society more generally.

The nursing care of stroke patients in nursing homes. Nurses' descriptions and experiences relating to cognition and mood

Registered nurses working in nursing homes often care for stroke patients with impaired cognition and mood disorders. Understanding the behaviour of these patients often puts great demands on nurses. This study illuminates registered nurses' descriptions and experiences of stroke patients and the nursing care given in nursing homes, with a focus on cognition and mood. Registered nurses responsible for the care of stroke patients in nursing homes were asked to describe the individual patient's state of health and the nursing care given. Patients' cognition and mood have been selected for this article. A qualitative content analysis was used to group the text into categories. Registered nurses' descriptions showed great complexity and variation in patients' disabilities, as well as uncertainty about understanding these patients and the appropriate nursing care. Registered nurses described the need for further education in stroke care, and adequate resources for patient activity training, as well as meeting patients' psychosocial and communicative needs.

Exploring the role of the district nurse in rehabilitation

This article reviews the available literature to examine the district nurse's contribution to rehabilitation of the older patient in the community. It is argued that policy and demographic changes indicate that there is a demand for nursing care in the home that enables individuals and their carers to live with chronic health problems and develop strategies that maintain and improve their health. The ways in which district nurses incorporate an understanding of patient rehabilitation within their work is discusses. It is suggested that although there is an expectation that district nurses can and should be involved in planning and supporting rehabilitation for their patients, the process is often poorly defined, hampered by contextual problems and dependent on the cooperation and support of others. Furthermore, in specific areas of care such as cardiac rehabilitation and services for those recovering from stroke, there would appear to be an increase in specialist nurses who either undertake or coordinate the rehabilitation process for patients. This raises questions regarding how district nurses should develop their skills in rehabilitation and what strategies could be adopted to develop patterns of work that ensure collaboration and development rather than overlap and duplication.

Disability as an equal opportunity issue within nurse education in the UK

Whilst equal opportunity policies, related research and subsequent curricula changes over recent years may have begun to have a positive impact in some areas of nursing education and practice, 'disability' struggles for recognition as an equality issue. Disabled people, making up approximately six million of the UK population, experience discrimination as part of their daily lives and this is also evident in the nursing services they receive. Far from challenging discrimination, nursing education may simply sustain the negative dominant ideological view of disability. Drawing comparisons with 'race', which has an established equal opportunity dimension, this paper explores disability equality, which is relatively neglected in nursing curricula. From this review it is argued that nursing as a profession has a role beyond patient care in influencing public perceptions concerning disabled people and should take more positive steps in promoting social justice by challenging discrimination. Stakeholders in nursing curricula and nursing practice have both legal and professional responsibilities to ensure that nursing and nurses become part of the solution to disability discrimination. Including disability in equal opportunity policies and strengthening their impact on pre and post registration nursing curricula, provides nursing with a tangible opportunity to do just that.

Gerontological nursing. 2: Refocusing the community agenda

This, the second in a series of articles considering potential developments in gerontological nursing, focuses on a community setting. It highlights current trends in policy which emphasizes the promotion of independence and outlines implications for community nurses. The authors argue that if new roles are to emerge then the educational preparation of community nurses must reflect more fully future policy initiatives.

Ways of working: CCNs and chronic illness

The study explored the role/skills used by CCNs caring for children with chronic illness. A participant inquiry paradigm was used and data were generated using semi-structured interviews supported by extensive field notes. All the CCNs described the special relationship with the children and their families which was characterised by deep understanding of current and future needs. The CCNs emphasised 'ways of working' which involved high degrees of trust, flexibility, support, reflexivity and empowerment. CCNs help families regain, maintain and develop control over their lives.