A silent conspiracy: coping with dying cancer patients on an acute surgical ward

Fear of Personal Death among Physicians

Many studies have tried to explain why professionals experience difficulty when dealing with, and in treating efficiently, situations connected with death. We studied levels of fear of personal death among physicians and addressed two questions: Does exposure to death on professional and personal levels affect the level of fear of personal death which physicians experience? Is there a relationship between personality variables, represented by the repression-sensitization dimension, and level of fear of personal death? A sample of 233 physicians who specialized in oncology, internal medicine, surgery, psychiatry, and pediatrics was studied. Results revealed no differences in level of fear of personal death of physicians according to specialization, but those who had been exposed to death on the personal level feared less in relation to their own death. With respect to the personality variable, tendency to sensitization, it was found that those who were sensitized exhibited a higher level of fear of their own death compared to those who were repressive. Of the various demographic variables examined, it was found that those with many years of professional experience, who were relatively older, who were nonobservant religiously, and who were in good health had lower levels of personal fear of death.

Real-world ethics and nursing research

In this paper I argue that nursing research is losing its way. There are a number of ways in which this is happening; for example, people are spending much more time writing about methodology than getting on with the research itself and the reporting of discovery. Here, I address the extent to which we are debilitating the research enterprise through what passes as ‘ethics’ and ‘governance’.

I will refer to examples from nursing and related research to illustrate the gradual development of greater concern for the well-being of research participants and the prevention of harm. I will go on to illustrate how, in comparison to the search for knowledge in the wider world, the health professions (and in the UK nurses in particular) are making research more difficult to execute than it needs to be. In the development of defensive rules and procedures we have somehow forgotten exactly from what harms we are protecting our patients, students and staff.

For those looking for a theoretical background to my views, they are, in essence, consequential, and I hope to show that with a harms and benefits approach we could bring much common sense to the critical appraisal of previous research and the approval and conduct of nursing research now and in the future.

'It stays with me': the experiences of second- and third-year student nurses when caring for patients with cancer

Little is known about student nurses experiences of nursing patients with cancer in the UK. With the increasing survival of people with cancer and with cancer no longer seen as a terminal illness it is useful to understand student nurses clinical experience when nursing those with cancer. This study takes a phenomenological approach involving three focus group interviews with 20 student nurses from the second and third year of their course in one centre in the UK. All the students had experience of caring for patients with cancer. The key themes emerging from the study were: Communication, Impact on Self, Lack of Support and End-of-Life-Care. Students emphasised the need to have more knowledge and support in relation to cancer care. They describe how they lack communication skills and found it difficult to handle their emotions. A number of students found the whole experience of caring for patients with cancer emotionally distressing and draining and they describe avoiding contact with these patients by using distancing and avoidance strategies. Student nurses need additional support through demystifying cancer, using reflective practice and good mentoring in the clinical area to enable students to feel supported, and develop confidence in their capacity for care for people with cancer.

Measuring handwashing performance in health service audits and research studies

Handwashing is regarded as the most effective way of controlling healthcare-associated infection. A search of the literature identified 42 intervention studies seeking to increase compliance in which the data were collected by directly observing practice. The methods used to undertake observation were so poorly described in most studies that it is difficult to accept the findings as reliable or as valid indicators of health worker behaviour. Most studies were limited in scope, assessing the frequency of handwashing in critical care units. The ethical implications of watching health workers during close patient contact were not considered, especially when observation was covert or health workers were misinformed about the purpose of the study. Future studies should take place in a range of clinical settings to increase the generalizability of findings. Observation should be timed to capture a complete picture of 24h activity and should include all health workers in contact with patients because all have the potential to contribute to cross-infection. Reported details of observation should include: vantage of data collectors; inter-rater reliability when more than one individual is involved; and attempts to overcome the impact of observation on usual health worker behaviour. Ideally an additional data collection method should be used to corroborate or refute the findings of observation, but no well-validated method is presently available.

Stepping across the line: information sharing, truth telling, and the role of the personal carer in the Australian nursing home

The author draws on an Australian study using multiple qualitative methods to investigate truth telling in aged care. Thematic analysis of data from five nursing homes involving 23 personal care assistants revealed participants' role understanding as influencing their perceptions about truth telling in practice. Five themes emerged: role as the happy comfort carer, division of labor, division of disclosure, role tension and frustration, and managing the division of disclosure. Role emphasis on comfort and happiness and a dominant perception that telling the truth can cause harm mean that disclosure will be withheld, edited, or partial. Participants'role understanding divides labor and disclosure responsibility between the personal carer and registered nurse. Personal carers' strategies for managing the division of disclosure include game playing, obfuscation, lying (denial), and the use of nonverbals. These perceptions about personal carer role, information sharing, and truth telling are paramount for understanding and improving nursing home eldercare.

Nursing the clinic vs. nursing the patient: nurses' experience of a day hospital chemotherapy service

AIMS AND OBJECTIVES

This study sought to explore the nurses' experience of a day hospital chemotherapy service in an acute general hospital in Northern Ireland and how this compared with their experience of working in an inpatient setting.

BACKGROUND

Despite the many changes taking place in cancer care delivery, little research has been conducted on nurses' experience of working in more acute cancer treatment settings. Research conducted to date has tended to focus on the role of nurses in wards, hospices and palliative care settings.

DESIGN

This Heideggerian hermeneutic phenomenological study explored nurses' lived experience of day hospital chemotherapy service.

METHOD

Face-to-face focused in-depth interviews were conducted with the total population of nurses who worked in the day hospital at the time of data collection (n = 10). Data analysis involved a two-staged approach, the analysis of narratives and narrative analysis, based on the work of Polkinghorne (1995).

CONCLUSIONS

The nurses' viewed their experience of the chemotherapy day hospital as having both positive and negative dimensions. The positive dimensions included an increased sense of autonomy and the challenge of developing new skills, while the negative dimension included a perceived decrease in their caring role: (i) The individual characteristics of the nurse were seen to have a key influence on caring experience; (ii) Role changes led to a perceived dichotomy between their actual and aspired role and their caring and clinical role.

RELEVANCE TO CLINICAL PRACTICE

There is a need to achieve a balance between delivering a clinical role (administering chemotherapy) while maintaining the centrality of the nurse-patient relationship. This can be likened to achieving a balance between 'nursing the clinic' alongside 'nursing the patient'. These findings have implications for the discourse on caring within other outpatient type clinics and discourse on cancer nursing as therapy and the culture of the cancer clinic.

Autogenic training to reduce anxiety in nursing students: randomized controlled trial

AIM

This paper reports a study to determine the effectiveness of autogenic training in reducing anxiety in nursing students.

BACKGROUND

Nursing is stressful, and nursing students also have the additional pressures and uncertainties shared with all academic students. Autogenic training is a relaxation technique consisting of six mental exercises and is aimed at relieving tension, anger and stress. Meta-analysis has found large effect sizes for autogenic trainings intervention comparisons, medium effect sizes against control groups, and no effects when compared with other psychological therapies. A controlled trial with 50 nursing students found that the number of certified days off sick was reduced by autogenic training compared with no treatment, and a second trial with only 18 students reported greater improvement in Trait Anxiety, but not State Anxiety, compared with untreated controls.

METHODS

A randomized controlled trial with three parallel arms was completed in 1998 with 93 nursing students aged 19-49 years. The setting was a university college in the United Kingdom. The treatment group received eight weekly sessions of autogenic training, the attention control group received eight weekly sessions of laughter therapy, and the time control group received no intervention. The outcome measures were the State-Trait Anxiety Inventory, the Maslach Burnout Inventory, blood pressure and pulse rate completed at baseline, 2 months (end of treatment), and 5, 8, and 11 months from randomization.

RESULTS

There was a statistically significantly greater reduction of State (P<0.001) and Trait (P<0.001) Anxiety in the autogenic training group than in both other groups immediately after treatment. There were no differences between the groups for the Maslach Burnout Inventory. The autogenic training group also showed statistically significantly greater reduction immediately after treatment in systolic (P<0.01) and diastolic (P<0.05) blood pressure, and pulse rate (P<0.002), than the other two groups. CONCLUSION. Autogenic training has at least a short-term effect in alleviating stress in nursing students.

Caring for patients with cancer in non-specialist wards: the nurse experience

This study aims to describe the experiences of nurses caring for cancer patients in non-specialist wards. The study was conducted in a large (420 beds) and small (32 beds) hospital in an area health service with urban and rural populations in the west of Sydney. A qualitative descriptive approach was utilized to collect data from the nurses. Data were collected using a survey and in-depth interviews of nurses working in non-specialist cancer wards. Transcribed data were managed with Nudist Vivo software and analysed for common themes using process of constant comparison and contrast. Twenty-five surveys were returned and five nurses volunteered to be interviewed. The six major themes that emerged from analysis of data were: emotional nature of care, lack of time, lack of knowledge of cancer treatment, family support, environment not conducive to proper care and dealing with patient's non-acceptance of cancer diagnosis. The nurses in this study wished to provide quality supportive care for cancer patients and their families but the inconducive environment and inadequate relevant training hindered the nurses' efforts. This then presents further need of relevant training for nurses in cancer care and time management, to meet up with these challenges.

Drug errors, qualitative research and some reflections on ethics

AIMS AND OBJECTIVES

Observational methods as part of a qualitative approach have been specifically employed in the study of drug error and have undeniable strengths. This position paper will examine some recent research raising a number of ethical, and tangentially, methodological issues concerning the qualitative study of drug errors within United Kingdom National Health Service hospitals. Reflections on the views and ethical conduct of other qualitative researchers are provided to contextualize the discussion.

BACKGROUND

The impact of a drug error, and any resultant adverse event can be significant. The human and financial costs are considerable. Establishing an accurate estimation of the frequency of adverse event and reporting rates has been difficult; additionally, methodological weaknesses in medical error research have sometimes caused further difficulties. Unsurprisingly, observational studies and for that matter, a whole range of other methods are now being considered in the quest to establish both understanding and predictability in relation to medical error.

RELEVANCE TO CLINICAL PRACTICE

It is argued here that any participants in medical error research should be treated in a way that takes account of the prevailing culture of health care and, in the United Kingdom, the current ethos of government policy on medical error. This requires gaining informed consent, promoting transparency in method, and providing the opportunity for participants to learn. Effective error researchers can clearly increase the available knowledge in this critical area but ethical considerations and their chosen methods should show an appropriate level of respect for their participants. Carefully implemented qualitative approaches can help realize such respect.

The care encounter: Pondering caring, honest communication and control

The proposition presented in this paper is that caring, underpinned by beneficence and non-maleficence, assumes that nurses will make determinations about another's best interests and act accordingly. With some emphasis on high-level (nursing home) aged care, it is the author's contention that nurses give priority to communication that controls the care encounter rather than acting in another's best interests. This view is supported in the literature, which suggests that nurses perceive honesty and information-sharing as less important in caring than do patients, and nurses' perception that telling another the truth is harmful and, therefore, contravenes the duties of beneficence and non-maleficence.

Introducing an integrated care pathway for the last days of life

Integrated care pathways (ICPs) are multiprofessional documents designed to enable the implementation of evidence-based care and support the practical delivery of clinical governance. However, the implementation of care pathways is resource intensive and few evaluations have been conducted with respect to these areas or to the efficacy of care pathways to change practice and improve outcomes in care. This project sought to address these issues and the report outlines the approach taken by a palliative care team in South Wales, UK, to implement a care pathway for the dying throughout a district general hospital and six community hospitals. Dying can be a complex area of care and changing practice can be challenging, therefore a PRINCE Project management approach was taken and a full-time project nurse employed for the life of the project. This paper describes the strategies used to approach implementing a care pathway and provides a template for other teams who may embark on similar projects. At the end of the project, the care pathway was successfully implemented and provided demonstrable outcomes of care for those dying from cancer and nonmalignant diseases. Strikingly, a large number of patients dying from nonmalignant disease were cared for via the pathway, which was not expected.

Irish nursing students' changing levels of assertiveness during their pre-registration programme

BACKGROUND

Stress and bullying have been found to be common problems in a number of studies of Irish nursing and midwifery. Victims of bullying need high levels of assertiveness to enable them to withstand the stress of victimization. It was deemed important to measure nursing students' level of assertiveness prior to, and near completion of, their pre-registration education programme. Aim. To ascertain nursing students' perceived levels of assertiveness prior to, and nearing the completion of, their three-year pre-registration programme.

METHODS

Ethical approval was given. The students commencing general nurse education programmes in two schools in Southern Ireland agreed to take part (n=72). A questionnaire adapted from a number of assertiveness scales, and tested for validity and reliability in this population, was used to collect data.

RESULTS

In general, students' reported assertiveness levels rose as they approached completion of their three-year education programme.

DISCUSSION

The resource constrained health service of the 21st century requires nurses who are assertive to meet the needs of its users. Nursing students' assertiveness skills could be augmented through concentrated efforts from nurse educationalists and clinicians to reduce the communication theory practice gap in nurse education today. To address the multi-dimensional nature of assertiveness, strategies to increase assertiveness should operate at the individual, interface and organisational level.

CONCLUSIONS

The students in this study reported an increase in levels of assertiveness as they approached completion of their three-year education programme. To function as effective, safe practitioners registered nurses need to be assertive, therefore education in assertiveness should be an integral part of their preparation. The precise composition and mode of delivery of this education requires exploration and evaluation.

Pre-registration diploma student nurse stress and coping measures

The aim of this study is to examine the stress experiences and coping abilities of student nurses. A survey design was employed to examine the stress experiences of Diploma student nurses in a large Dublin Teaching Hospital. A questionnaire was utilized that measured and explored five specific constructs pertinent to student nurse stress. These included clinical stress, academic stress, coping, emotions and personal factors which assist students nurses during periods of stress. Findings showed that examinations, the level and intensity of academic workload, the theory-practice gap and poor relationships with clinical staff were the leading stressors identified. Emotional reactions to stress included feeling exhausted and upset under pressure. Students adopted short-term emotion focused coping strategies when attempting to deal with stress. A sense of achievement, and determination, were personal factors, which assisted students to continue in the event of stress being present. Content analysis of the open questions shed further light in relation to the stress phenomenon, particularly in relation to clinical stress. The provision of adequate support services from a clinical and academic perspective, a lecture-practitioner model of education delivery, and curriculum changes which focus on developing student self awareness skills are the suggested study recommendations.

"A small cog in a large wheel": an exploratory study into the experiences of porters, ward clerks and domestics working in an English Cancer Centre

The effect of working in an oncology environment on nurses has been widely researched but the experiences of non-clinical staff such as ancillary workers in the oncology environment have rarely been examined. This exploratory study had three aims: to explore ancillary workers' understandings of cancer, their experiences of working in a Cancer Centre and their training and support needs. Working within a naturalistic paradigm, a descriptive exploratory design was utilised employing in-depth interviews and drawing on aspects of grounded theory for data analysis. Findings indicated that these ancillary workers lacked an in-depth understanding of cancer. The experience of working in a Cancer Centre appeared to bring both costs and benefits to these ancillary workers. These ancillary workers enjoyed the level of contact they have with patients in a Cancer Centre and subsequently ascribed great value to their jobs. However, they felt that health-care professional colleagues did not always value their contribution to the care of patients. There are implications for nurses and other health-care staff working in oncology alongside these ancillary staff in terms of valuing and supporting them in the work that they do.

Nurses’ experiences of cancer

This paper provides an overview of research into nurses' experiences of working with cancer, both how nursing care is experienced by people with cancer and the effects on nurses of working in cancer treatment and care settings. The literature, although slim, suggests that the work of nurses is experienced as valuable and supportive, although this is not consistently the case. Although nurses find working with people with cancer rewarding, it is also emotionally demanding. Evidence for stress among nurses working in cancer settings is mixed and may be related to structural factors more than the difficulties of working with patients who may be dying, although this warrants further exploration. Studies of nurses' communication skills are limited by a measurement-orientated approach that measures behaviour against predetermined criteria. Observational studies provide rich insights into the complex relationship between how nurses work with people who have cancer, or who are dying, as they adjust to their predicament, how this is therapeutic, but also where it may go wrong. Little detailed or comparative work has been undertaken into the skills and experiences of nurses working in different roles, in particular those of nurse specialists. Research is needed to further elucidate themes identified, in particular to shed light on how nurses and other health professionals may be assisted to develop expert practice in working with cancer, but also to sustain health professionals in this work.

A comparative study of stress between pre‐ and post‐Project 2000 students

This paper reports upon a comparative study in an English health authority of stress experiences between 146 current Diploma in Nursing (Project 2000) Adult Branch students and a prior study of a sample of 146 students who undertook a certificate course leading to Registered General Nurse (RGN) in 1988. Both groups were administered the same questionnaire. The number of stressors common to both groups were two in education and nine in the clinical environment. Three prominent feelings of stress were expressed by both groups along with two methods of coping with stress. A constellation of 11 personality type characteristics labelled 'determination', which enabled students to sustain themselves, was identified. Three characteristics of 'determination', plus a feeling of uselessness and inability to contribute to the nursing team effort, and the intense amount of academic work were statistically significantly higher for Diploma students. Six prominent clinical stressors were experienced more intensely by third-year diploma students than first- or second-year students. Stress was found to increase with the level of training. This finding replicated the picture found among 324 students in 1988. Differences in stress experiences for different age groups were not statistically significant with the exception of physical hard work. A number of stressors experienced by students in 1988 were also experienced by students in 1997.

Health care providers and dying patients: critical issues in terminal care

Three major areas of concern can be identified in the relationship between health care providers and dying patients: a) the nature of the difficulties and stresses associated with terminal care, b) the education of providers for this kind of work, and c) the influence of organizational structure and institutionalized values on services for dying patients and their families. A review of the research literature indicates that obstacles to effective terminal care continue to exist at the personal, interpersonal, and social levels in the current American health care system. Particular attention is given to demonstrated differences among health care professionals in their sources of emotional support and to difficulties associated with innovations in terminal care. Recent developments such as the predetermined reimbursement for health care based on established diagnostic categories (DRGs) have the potential for generating further obstacles to the providers' efforts to function as one human being helping another.

Is good 'quality of life' possible at the end of life? An explorative study of the experiences of a group of cancer patients in two different care cultures

The purpose of this paper was to explore how a group of gravely ill patients, cared for in different care cultures, assessed their quality of life during their last month of life. The study material comprised quality of life assessments from 47 cancer patients, completed during their last month of life. Two quality of life questionnaires, the EORTC QLQ-C30 and a psychosocial well-being questionnaire, were used. The data were treated in accordance with instructions for the respective questionnaires, and the results are presented primarily as means, mostly at the group level. Assessments from patients in two different care cultures, care-orientated and cure-orientated, were compared. The results show that despite having an assessed lower quality of life in many dimensions than people in general, several patients experienced happiness and satisfaction during their last month of life. 'Cognitive functioning' and 'emotional functioning' were the dimensions that differed least from those of the general population, and 'physical functioning', 'role functioning' and 'global health status/quality of life' differed the most. 'Fatigue' showed the highest mean for the symptom scales/items. There was a tendency for those cared for in the cure-orientated care culture to report more symptoms than those in the care-orientated care culture. An exception to this was 'pain', which was reported more often by those in the care-orientated care culture. The implications of the results are discussed from different angles. The significance of knowledge concerning how patients experience their quality of life is also discussed with respect to the care and the planning of care for dying patients.

Nurses' attitudes to terminally ill patients

BACKGROUND

The care of terminally ill patients is a challenge for nurses that has raised special interest in recent years. Several studies have shown a stereotyped negative attitude in nurses towards terminally ill patients. However, all have used methods with several limitations.

AIM

The aim of the study presented in this paper was to identify the nurses' attitude to the terminally ill patient in Catalonia, Spain, and the relationship of this attitude to different socio-demographic data (type of centre, shift, years of experience, age and sex) by means of a new quantitative method based on the free word-association test.

METHODS

One hundred and seventy-five nurses working in 18 hospitals and hospices in Catalonia, Spain were included in the study. Data were analysed by the Associative Semantic Field Differential method by means of the computer programme CONTEXT and a quantitative evaluation of the degree of attitudes positivity was obtained.

RESULTS

The study revealed a general slight negative trend in attitudes towards the terminally ill patient. A more positive attitude was observed in older caregivers and in women. The positivity in attitude decreased from morning to night shift. No differences were observed between nurses working in hospitals and those working in hospices.

CONCLUSIONS

We conclude that nursing attitudes can be analysed by methods such as that used in this study. Attempts can be made to modify this attitude in caregivers by means of training programmes and stimulating awareness of an adequate professional approach.

Nurses' reflections on episodes occurring during their provision of care--an interview study

The aim of this study was to investigate nurses' reflections and interpretations regarding their provision of care, through interviews (N 46), using a hermeneutic method of analysis. Nurses work in a milieu that has undergone constant changes such as, in organisation, decreased number of staff, and with patients demanding more advanced care. The care provided, based on the nurses' narrated episodes were interpreted as two main aspects: interpersonal oriented aspects and task oriented aspects. The subaspects were identified as 'nurse-patient relationship', 'ability to understand the patients' suffering' and 'taking responsibility'.

Communicating with terminally ill cancer patients and their families

This qualitative study aimed to investigate whether 4th year undergraduate nursing students raise concerns about communication with terminally ill and dying cancer patients and their families. It focused on factors which could influence students' feelings of insecurity/security when communicating with this group of patients and their families, factors which could influence communication, and whether students felt adequately prepared for this kind of nursing. The research involved interviewing 12 student nurses in their 4th year of their undergraduate education at a Scottish university using content analysis for analyzing the data. Five themes and 13 sub-themes emerged from this analysis. The findings revealed that communicating with terminally ill and dying cancer patients in the acute setting is difficult for student nurses and issues about death and dying tended to be ignored. While it was found that university lectures about death and dying were helpful, lack of support and guidance within the clinical setting was a major concern.

Hardships and personal strategies of Vietnam War nurses

This study describes hardships faced in Vietnam and personal strategies used to deal with these hardships as defined by 24 female military nurses who served during the war. Purposive sampling was used, and data were generated using four core questions and in-depth interviews. The research methodology was phenomenology, incorporating data analysis procedures of Colaizzi, Lincoln and Guba, and Van Manen. Eight hardship and nine personal strategy themes were identified. This study found that caring for young, severely injured, and disfigured soldiers was a significant hardship and that nurses struggled with the moral dilemmas inherent in mass casualty situations, triage policies, and the practice of returning recovered soldiers to combat. Most nurses relied on personally proven and familiar strategies to reduce or buffer the effects of emotional hardships, whereas some discovered and used new strategies.

Being a close relative of a dying person. Development of the concepts "involvement in the light and in the dark"

The current study is based on an earlier article in which relatives' involvement in care was described as "involvement in the light" or "involvement in the dark." Involvement in the light was characterized as the relative being well informed and experiencing a meaningful involvement. The relatives involved in the dark felt uninformed, that they were "grouping around in the dark" when they tried to support the patient. The present study analyzed further the meaning of "involvement in the light" and "involvement in the dark," and investigated whether two different care cultures, the relationship with the staff, and a rapid course of illness influence the involvement of relatives. Relatives of 52 patients who died, 30 at a surgical department and 22 in a hospice ward, were interviewed after the patients' deaths. All the relatives of the patients in the hospice ward and 13 of those in the surgical department were judged to be involved in the light. Of the relatives judged to be involved in the dark, 12 either had a sick relative with a rapid course of illness or felt that the sick relative had died unexpectedly. A pattern was clearly observed: The relatives involved in the light described being met with respect, openness, sincerity, confirmation, and connection, whereas the opposite was experienced by those involved in the dark.

Collecting data in the operating department: issues in observational methodology

The UK literature contains few references to nursing in the operating department and even fewer to methods for researching nursing in what is often a complex and stressful environment. Nursing staff work under intense pressure and this presents a challenge, not only for nurses who work in the operating department, but also for researchers who choose to study nursing within its bounds. This paper focuses on some of the key issues which emerged during one study of nursing in the operating department where an observational methodology was used. The author suggests that observation, as a research method, is an important feature of contextual investigation. However, like other methods of investigation, it requires careful planning and preparation. Furthermore, the author believes that sensitivity and skill are required for the enactment of the observer role when researching nursing within this specialized environment.

Ethics and nursing research. 2: Examination of the research process

In this article, the second in a series on ethics in nursing research, the author explores the relationship between the guiding ethical principles and the steps of the research process. In the first article (Vol 8(13): 888-92) the two dominant theories of ethics, utilitarianism and deontology, along with the guiding principles of beneficence/non-maleficence and respect for human dignity, justice, informed consent and vulnerable subjects were discussed as they relate to the rights of individuals undergoing the research. In this article, the author describes the association between these principles and the elemental steps of the research process which are: the selection of the research problem; data collection; sampling; informed consent; data analysis; and research presentation. The ethical conduct of many of these research steps is guided by ethics committees but for those that are not nurses need to rely on their own integrity, honesty and committment to the current prevailing ethical principles.

Promoting a good death: an agenda for outcomes research--a review of the literature

Outcomes research is topical in discussions about health-related research. Its emphasis on effectiveness creates an important opportunity for nurse researchers to strengthen the linkages between theory, outcomes research and nursing practice but, before care can be more effective, it is logical to establish patients' desired outcomes. A thorough review of the implications of this requirement for the care of hospice patients is needed, but is lacking in the literature. Therefore, the literature on a 'good death' is reviewed as a step towards assisting hospice patients to achieve what they regard as an acceptable death. The starting point is to define more clearly what it means to die a good death. The relationship between hospice care and achieving a good death is then examined.

The last month of life: continuity, care site and place of death

A hospice ward was opened in 1991 at the Orebro Medical Centre Hospital (OMCH) in Sweden. Shortly afterwards, a research project was started, which aimed to describe different aspects of the final period of life of a group of cancer patients. This exploratory study is part of this project and aims to assess continuity in the site of care for a group of severely ill cancer patients during the final stages of their lives, and their place of death within different cultures of care. This prospective study involved 56 adults with cancer who had been admitted to six specialized departments at OMCH. Demographic and diagnostic data, documentation of when the patients changed from one care form to another, as well as place of death were obtained. The analysis of continuity in terms of care site involved care-oriented cultures (hospice ward, hospital-based home care, primary care-based home care and nursing home) and cure-oriented cultures (acute hospital wards). Considered as a group, the patients spent one-third of their time at home during their final month of life, with or without formal caregivers. For individual patients, however, there were great variations with regard to continuity of care site and care form. A pattern was found for the type of cancer the patients had and where they were during their final month. Ten patients died in their own homes, and of the 46 who died in an institution, approximately the same number died in a care-oriented culture as in a cure-oriented culture.

Involvement of relatives in the care of the dying in different care cultures: involvement in the dark or in the light?

The aim of this prospective study was to increase existing knowledge about the involvement of relatives in care of the dying and to shed light on the relatives' sense of coherence. Six relatives were followed via qualitative interviews during the patients' final period of life and after their deaths. The patients died in different forms of care: surgical department, nursing home, inpatient hospice ward, and at home. What the relatives had in common was that they had, in different ways, followed the patient from the first symptoms, through different forms of care, up until death. Some participated very actively in the care. Relatives' involvement in care can be described as involvement in the light or involvement in the dark. Involvement in the light is based on a trusting relationship between the family and the staff. Involvement in the dark is based on insufficient interplay and collaboration, in which the relatives are not seen or acknowledged by the staff, but instead must grope around in the dark when they try to support the patient. Rapid course of illness can be a risk factor for involvement in the dark. It seems that the relatives' sense of coherence was an important factor enabling them to be involved in the light. Humanistic care can constitute a buffer, thereby increasing the possibilities for relatives to be involved in the light.

The Illness Trajectory—For Patients with Cancer who Died in Two Different Cultures of Care

The aim of this study has been to retrospectively examine the illness trajectory for a consecutive group of sixty-seven patients with cancer who died at a surgical department or were referred from there to an inpatient hospice ward where they died. Relatives of fifty-two patients were interviewed after the patient's death and all sixty-seven medical records were studied. The data was analyzed with support of Glaser and Strauss' concept of a dying trajectory. A surprising result was that as many as forty-four patients had a short trajectory, and nineteen of these had one month or less between diagnosis and death. Patients at surgical wards followed a faster trajectory and were in a somewhat poorer state of health when compared to patients at the inpatient hospice ward. In the case of trajectories within three months, there is no time to lose, and it is important that caring delay are avoided.

Evaluation of the role of the health care assistant within a community mental health intensive care team

BACKGROUND

Recent changes in UK legislation concerning community care of mentally ill people have initiated comprehensive changes in the delivery of healthcare. The NHS and Community Care Act (Department of Health 1990) added impetus to the run down of residential facilities and the speed of development of community mental health services. A community mental health intensive care team was established in Essex and employed a high ratio of unqualified to qualified staff. At a time of tension within the Health Service around issues such as skill mix and unemployment among qualified nurses, it was perhaps not unreasonable that the introduction of healthcare assistants might be viewed with suspicion, as a way of diluting the workforce with a less expensive alternative. The importance of evaluating new services is self-evident.

OBJECTIVE

The growth of consumerism has led to acknowledgement that mental health service users' views have a role in shaping service provision. An attempt was made to determine the service users' evaluation of the role of the healthcare assistant within a community mental health intensive care team.

RESULTS

The use of Kelly's (1955) repertory grid technique and theoretical sampling provided rich descriptions of the role of the healthcare assistant as experienced by service users. Analysis of the healthcare assistant-client relationship demonstrated a client-centred approach was apparent with considerable emphasis placed on the personal qualities of the care provider, supporting Roger's (1961) view that 'healing' comes not so much from the therapists 'techniques', as from their personality.

CONCLUSION

It is self-evident that the clients' expressed satisfaction with the care provided by healthcare assistants argues against the professional ideology of nursing, which proposed that nursing may only be given by those with a statutory qualification. A complementary role for healthcare assistants in the provision of mental health care is proposed.

What's it all about, empathy?

This paper investigates the concept of empathy, a core element of all helping relationships. A discussion of its prevalence in the nursing literature is traced, before a discussion ensues as to whether it is a naturally acquired ability which develops with maturity, or whether it is a skill that can be taught and learnt. It is concluded that empathy remains a poorly defined, multidimensional concept which still remains not fully identified.

A comparison of the verbal interactions of qualified nurses and nursing auxiliaries in primary, team and functional nursing wards

The purpose of this study was to compare the differential contribution to patient care of qualified nurses and nursing auxiliaries in primary, team and functional nursing wards using a measurable qualitative indicator, nurse-patient verbal interaction. Twelve qualified nurses and 12 nursing auxiliaries were chosen randomly in each organizational type. Data were collected using non-participant observation and a computerized event recorder. Regardless of staff grade, nursing staff in wards practising primary nursing gave patients more choice, general explanations about their care and, in the afternoon, spent more time seeking verbal feedback from patients about their care. Implications of these findings for the employment of nursing auxiliaries in elderly care wards are discussed.

Palliative medicine and the medicalization of death

The emergence of the speciality of palliative medicine in the UK has been generally welcomed and can be seen as a continuation of the attempts to improve the care of dying people begun by the modern hospice movement. However, not everyone has welcomed the new speciality unreservedly. In part, this reflects a more general ambivalence and concern about the role of medicine in terminal care. After a brief discussion of the 'medicalization' of death and an overview of the hospital care of dying people, the paper identifies five concerns about the development of the speciality of palliative medicine in Britain. These are: the lack of clarity about its remit; a potential shift of focus away from terminal care; the inappropriate use of medical technology; the role of other health workers; the consequences for hospice care.

New directions in palliative care education

In the past, palliative care education in the United Kingdom has tended to be patchy and ad hoc, rather that systematic and comprehensive. Recently the picture has begun to change, and this paper identifies and discusses three areas where developments are occurring. Firstly, educational provision has become more comprehensive and systematic, so that the needs of staff in all care settings and at all levels of practice and experience are now being addressed. Secondly, palliative nursing curricula that draw on research into the problems of nurses working with dying patients and the dimensions of the supportive role are now being developed. Thirdly, a number of initiatives are underway to assure the quality of palliative care education. Two of those initiatives concern the preparation, support and evaluation of educational roles and the development of educational research programmes.

Purging the emotions: the lack of emotional expression in subfertility and in the care of the dying

The paper examines emotional expression by drawing on data from patients in two contrasting situations; interview data from couples attending fertility clinics, and audio-recorded conversations with terminally ill patients being cared for at home. Although the literature on subfertility and terminal illness frequently uses a bereavement model to argue for the importance of overt grieving, patients in these studies did not express a wish to discuss their feelings. This finding raises questions about how patients' needs are defined, and whether emotions may be created by discourse.

'Scripts' for dying at home--displayed in nurses', patients' and relatives' talk

Perceptions and expectations reflecting what constitutes a 'good' death that seem to exist in Western societies are explored and compared with those presented by five symptom control team nurses at their home visits to 54 terminally ill cancer patients. These perceptions and expectations are termed 'scripts' for dying and are derived from the nurses', patients' and relatives' audio-recorded conversations over a 3-month period. The elements of the 'scripts' used were identified as: (a) control of physical symptoms, (b) acceptance of cancer and its prognosis, (c) preservation of hope and 'will to live', (d) mobility and 'fighting back', (e) enjoyment of life, (f) a peaceful death at home. How these components are determined from the conversations are presented and the responses of the patients to the nurses' 'scripts' are analysed. The dilemmas created by putting the 'scripts' into action for nurses, patients and relatives are discussed.

Communication with dying patients in coronary care units

There now seems to be a much greater willingness among hospital staff to disclose a terminal prognosis to a patient. The paper starts with a review of the changing attitudes towards disclosure and then considers communication with dying patients in Coronary Care Units. After considering general factors influencing nurse communication with dying patients sources of difficulty in such communication are considered. Characteristics of patients and relatives, of nurses, and features of the work environment may all contribute to communicational difficulties. The paper closes with a brief overview of basic communicative requirements.

Empathy: a review of the literature with suggestions for an alternative research strategy

Although empathy is regarded as a necessary component of good quality nursing care, defining and measuring empathy have both been fraught with problems. A historical overview helps to explain these difficulties, as nurses have tended to accept the views of psychotherapists uncritically, and have used scales developed for clients in counselling with people who are physically ill. Methodological difficulties combined with the results of studies demonstrating low levels of empathic ability in nurses have culminated in disenchantment with this topic. A framework is used to show why nurses cannot always demonstrate empathic awareness of every patient's need and an alternative approach for exploring the nature of empathy is suggested.

Research on nurse-patient relationships: problems of theory, problems of practice

Research, theoretical and educational literature on interpersonal relations between nurses and patients has proliferated since the 1960s. This has generated a range of divergent accounts of what the nurse-patient relationship (NPR) ought to be; how this should be achieved; and how the NPR is constituted in practice. In this paper--through a selective review of the literature--the development of two contending perspectives on NPR and on nurse-patient interaction (NPI) characterized as technocratic and contextual, is discussed, and related to the increasingly problematic status of the relationship between nurses and patients in nursing theory and research.

Stressor frequency, tension, tiredness and coping: some measurement issues and a comparison across nursing groups

In nursing research a number of approaches have been adopted when measuring the relationship between stressor and stress. However, despite thorough questionnaire development, excess demand, that is the extent to which the situation actually taxes the resources of the nurse, is measured more by implications than by presence. By combining different facets of demand and by measuring them in conjunction with one another this research revealed the extent to which the demands of frequently occurring situations actually taxed the resources of the nurse; provided a procedure for more specifically investigating the relationship between stressor frequency and response and considered these findings in terms of different types of nurses (enrolled, staff, charge) and the coping strategies used. The results were discussed in terms of measurement, training, available resources, coping and interventions.

What happens in hospices: a review of research evidence

The growth of the modern hospice movement has been accompanied by some evaluative research, although this has been pursued with greater vigour in the United States than in Britain. Most studies employ the method of outcome measurement (patient or carer satisfaction for example) and only incidentally report on processes occurring within hospices or hospitals. A review of the research evidence suggests that processes of patient care may not always be very different between hospices and hospitals. This may be because hospital staff have learned from the example of hospices, but may also be due to hospice staff associated with traditional care systems compromising their ideals. Evidence from evaluative and from participant observation studies is reviewed to examine differences between hospital and hospice care in five major areas: medical therapies, psychosocial care, disclosure of prognosis, carers' involvement, in-patient care and relations between staff. The quality and scope of the research evidence in many instances needs extending. The relevance of a hospice approach to non-cancer patients is discussed and priorities for future research on the process of hospice care are outlined.