Advance care planning for people with dementia: Ordinary everyday conversations

Advance care planning for people with dementia has become a focus of dementia care policies in developed countries. In New Zealand, the framework for dementia care relies on the person with dementia having a level of competence to enable them to participate in the planning process. For people with dementia, it may be too late to initiate these discussions in terms of decision-making capacity. Consequently, decisions about end-of-life care for people with dementia are typically made by a family member who acts as a surrogate decision maker on behalf of the person with dementia. An exploratory qualitative study of 23 people who had been carers or provided support for a family member with dementia who had died within five years of the interview was undertaken. The overarching theme, ‘ordinary everyday conversations’, describes how informal conversations and discussions within the family relating to preferences at the end of life had been embedded in interactions within the families over years. Sub-themes revealed three important components enabling adherence to the prior wishes of the person with dementia through these conversations: knowing the person and belief in ‘doing the right thing’; the importance of Wills and Enduring Power of Attorney; and negotiating unexpected encounters. There is potential for families to be well prepared for the time when they may need to make decisions for the person with dementia based on ordinary everyday conversation that take place within families and throughout life. This study also suggests that more innovative approaches to making a Will may provide an important vehicle for expressing advanced care wishes.

Ethical and methodological issues in palliative care studies

This paper reports on the experiences of a nursing-led research group, ‘The Palliative and End of Life Care Research Group’, within the School of Nursing and Midwifery at the University of Sheffield. There is a long tradition of research in palliative care in which nurses have played an important role and currently opportunities to conduct research in palliative care are expanding. Nurses face a number of ethical and methodological challenges in conducting palliative care research, many of which extend beyond individual research conduct. Drawing on practical examples in each case, this paper explores the following themes: issues involved in raising participation and recruitment to studies of palliative care; how the topics of palliative and end-of-life care are introduced and explored with participants; what ‘special’ needs participants have in palliative care research; interpersonal issues in conducting palliative care research; and providing support and supervision to researchers.

Using the Canadian Code Of Ethics for Registered Nurses to Explore Ethics in Palliative Care Research

Nursing research in palliative care raises specific and challenging ethical issues. Questions have arisen about whether such research is morally justified, given the low likelihood of direct benefit to dying patients as research participants. The Canadian Code of ethics for registered nurses outlines eight primary values intended to guide nursing practice. We use these values to explore the moral dimensions of research with the palliative care population. Our conclusion is that palliative care research is needed to foster excellent care for these patients and their families, but that nurses must remain constantly vigilant to ensure that participants are protected from resultant harms. Through this exploration we highlight particular considerations that nurse researchers must contemplate when accessing a vulnerable population.

Working together with persons with early stage dementia and their family members to design a user-friendly technology-based support service

This article describes how researchers, practitioners and technicians in West Sweden worked together with older people with early stage dementia and their family members to develop a user-friendly technology-based information, education and support service, based on the generic ACTION participatory design model. Ways of working in partnership with older people with early stage dementia and their family members are explored, and key lessons learned are highlighted. The overriding message is that elders with early stage dementia can be actively involved throughout the entire research and development process. Essential prerequisites are time and ongoing support by skilled practitioners and family members. Preliminary findings reveal that older people with early stage dementia can learn and benefit from user-friendly technology, especially when used together with others in a similar situation.

Ethical conduct of palliative care research: enhancing communication between investigators and institutional review boards

Palliative care has faced moral and ethical challenges when conducting research involving human subjects. There are currently no resources to guide institutional review boards (IRBs) in applying standard ethical principles and terms-in a specific way-to palliative care research. Using as a case study a recently completed multisite palliative care clinical trial, this article provides guidance and recommendations for both IRBs and palliative care investigators to facilitate communication and attain the goal of conducting ethical palliative care research and protecting study participants while advancing the science. Beyond identifying current challenges faced by palliative care researchers and IRBs reviewing palliative care research, this article suggests steps that the palliative care research community can take to establish a scientifically sound, stable, productive, and well-functioning relationship between palliative care investigators and the ethical bodies that oversee their work.

Lung cancer diagnosed following emergency admission: a mixed methods study protocol to improve understanding of patients' characteristics, needs, experiences and outcomes

BACKGROUND

Lung cancer is the leading cause of death from cancer in England. About 40% of patients with lung cancer are diagnosed following an emergency admission (DFEA) to hospital. DFEA is more common in women, and more likely with increasing age and deprivation. Most have advanced disease and survival is poor, but little else is known about this group. The aim of this study is to obtain a detailed understanding of the characteristics, needs, experiences and outcomes of this group.

METHODS/DESIGN

This is a single centre study with quantitative and qualitative work packages (WP). WP1 gathers basic details about all patients diagnosed with lung cancer during a 12 month period, focusing on demographics, diagnostic and treatment pathways and selected outcomes. WP2 obtains information from those patients DFEA or, when unable, their carers, about their holistic needs and experiences, using the Sheffield Profile for Assessment and Referral to Care questionnaire and selected questions from the National Cancer Patient Experience Survey. WP3 uses in-depth qualitative interviews with patients and carers to obtain detailed accounts of their symptoms, help-seeking behaviours prior to admission and subsequent experiences of care.

DISCUSSION

Relatively little is known about the experiences of lung cancer patients DFEA and this study will provide detailed information about their needs, characteristics, experiences and outcomes. It should identify areas in the diagnostic and treatment pathway where there is scope to improve the care provided to this group of patients and their carers. The findings will also inform the need for further focused research.

Awareness contexts revisited: indeterminacy in initiating discussions at the end-of-life

AIMS

To explore if and how information about a transition to a palliative care approach was communicated to patients recently discharged from hospital and who fulfilled standardized criteria for palliative care need.

BACKGROUND

Palliative care philosophy and, more recently, UK palliative care policy, endorse a context of 'open' awareness, where all parties openly acknowledge that the patient's death is approaching. The perceived benefits of making the patient aware of their prognosis encompass a variety of planning activities, which mean that death, when it occurs, is arguably more in keeping with the wishes of the patient.

DESIGN

A qualitative inductive interview study conducted in 2010-2011.

METHODS

Fifteen semi-structured interviews were conducted with 15 patients and 3 family carers. All patients were identified as having palliative care needs according to standardized criteria, 3-6 months after discharge from hospital. A thematic analysis was undertaken.

FINDINGS

Contrary to the professed ideal of 'open' awareness, some participants were only partially aware and others wholly unaware that they were likely to be approaching the end-of-life. Those identified as unaware were over 85. Participants displayed a reluctance to acquire knowledge which would require them to face the imminence of death.

CONCLUSION

Philosophy and policy aside, people do not always conform to the autonomy paradigm of a self-directed life followed by a self-directed death.

Compassion and vigilance: investigators' strategies to manage ethical concerns in palliative and end-of-life research

BACKGROUND

Ethical concerns were identified as a potential barrier to advancing palliative and end-of-life science at the 2004 National Institutes of Health State of the Science Meeting. However, data are lacking about the nature of ethical concerns and strategies for balancing the need to advance science with human subjects protections.

METHODS

A qualitative case-study design was used to follow 43 end-of-life studies from proposal development through the review process and implementation. Investigators participated in semi-structured telephone interviews and provided document data regarding their experiences with grant and IRB reviews. Using constant comparative analysis within and across cases, the investigators identified commonly encountered and unique concerns and strategies for managing these concerns.

FINDINGS

Investigator strategies fell into two broad categories: 1) Recruitment and consent strategies related to subject identification and enrollment; and 2) Protocol-related strategies related to the process of data collection. These strategies shared the overarching meta-themes of compassion, as evidenced by a heightened sensitivity to the needs of the population, coupled with vigilance, as evidenced by close attention to the possible effects of study participation on the participants' well-being, clinical care, and the needs of research staff.

CONCLUSIONS

Ethical concerns have led to the development of compassionate and vigilant strategies designed to balance the potential for risk of harm with the need to advance the science of palliative and end-of-life care. These strategies can be used by investigators to address ethical concerns and minimize barriers to the development of palliative and end-of-life care science.

Recruiting and retaining older persons within a home-based pilot study using movement sensors

In this paper, we report on key aspects of recruiting and retaining a small group of community dwelling older adults in to a study, piloting motion sensors in their homes for 8 weeks. This was to further understanding of older adults' falls at home. We consider our recruitment strategy in terms of informed consent and non-exploitation; planning and explaining, and our retention strategy in terms of communicating and recording and pacing and sharing data. Offering reflective analyses of our challenges and strategies may help develop skills that maximise the involvement of older adults in research, particularly technologies related research, whilst at the same time ensuring inclusive and non-exploitative research relationships.

Review: a narrative review of the published ethical debates in palliative care research and an assessment of their adequacy to inform research governance

The quality of research, and the resulting quality of evidence available to guide palliative care, is dependent on the ethical decisions underpinning its design, conduct and report. Whilst much has been published debating the ethics of palliative care research, an assessment of the quality and synthesis of the central debates is not available. Such a review is timely to inform research governance. The methodology of this study is based on the principles of systematic reviews. Fifty-seven papers were reviewed following a thorough search, and were critically appraised for their literary quality, the knowledge on which they drew and the research standards they addressed. The debates identified address vulnerability, moral appropriateness, consent, gate-keeping and inclusion and research culture. The quality of debate and the sources of knowledge varied. The debate was rich in quality and knowledge with respect to the protection of the dignity, rights and safety of research participants, but less developed in relation to those of researchers and other staff. There is also little debate about the ethics of reporting of research and the ethics underpinning research leadership. A framework is offered that reconciles the ethical issues raised with potential methodological strategies identified from the review.

An investigation into the role of spirituality in nursing

This article examines spirituality in nursing in terms of a critical literature review. The literature suggests that there is an increasing demand for holistic care within the NHS. Holistic care is based on the idea that there should be a balance between body, mind and spirit, however, clinical experience suggests that the spiritual dimension of nursing is rarely considered as there is a focus on what is perceived as scientific professionalism. The aim of this article is to explore the nature of spiritual care, discuss whether there is a need for it in nursing and explore ways in which nurses can provide it. This article is based on a critical review of the literature and empirical data on spirituality in nursing and identifies contrasting opinions around the definition of spiritual nursing care. Nurses can provide spiritual care by being conscious of their own spirituality as well as that of patients.

Ethical Issues in the Use of In-Depth Interviews: Literature Review and Discussion

This paper reports a literature review on the topic of ethical issues in in-depth interviews. The review returned three types of article: general discussion, issues in particular studies, and studies of interview-based research ethics. Whilst many of the issues discussed in these articles are generic to research ethics, such as confidentiality, they often had particular manifestations in this type of research. For example, privacy was a significant problem as interviews sometimes probe unexpected areas. For similar reasons, it is difficult to give full information of the nature of a particular interview at the outset, hence informed consent is problematic. Where a pair is interviewed (such as carer and cared-for) there are major difficulties in maintaining confidentiality and protecting privacy. The potential for interviews to harm participants emotionally is noted in some papers, although this is often set against potential therapeutic benefit. As well as these generic issues, there are some ethical issues fairly specific to in-depth interviews. The problem of dual role is noted in many papers. It can take many forms: an interviewer might be nurse and researcher, scientist and counsellor, or reporter and evangelist. There are other specific issues such as taking sides in an interview, and protecting vulnerable groups. Little specific study of the ethics of in-depth interviews has taken place. However, that which has shows some important findings. For example, one study shows participants are not averse to discussing painful issues provided they feel the study is worthwhile. Some papers make recommendations for researchers. One such is that they should consider using a model of continuous (or process) consent rather than viewing consent as occurring once, at signature, prior to the interview. However, there is a need for further study of this area, both philosophical and empirical.

Understanding patients' lived experience following photodynamic therapy for the treatment of advanced cancer

AIM

To gain an understanding of patients' lived experience following photodynamic therapy (PDT) for the treatment of advanced cancer.

BACKGROUND

Existing literature on PDT tends to be predominantly grounded in basic science and mainly associated with the effect of PDT on the cancer rather than the individual's experience. An appreciation of the impact on patients' day-to-day life may enhance the support and advice offered to patients undergoing this treatment.

METHOD

A Heideggerian hermeneutic phenomenological approach was used as the philosophical framework. Semi-structured interviews were conducted with a purposive sample of six participants. Thematic content analysis was adopted to analyse the data, which yielded six themes.

FINDINGS

Analysis of the data yielded six themes: the impact on day-to-day life; existential meaning; the physical effects of treatment; kaleidoscope of emotions; information gap; and family burden.

CONCLUSION

PDT offers palliation of symptoms for some participants while offering hope of enhanced quality of life. Patients and their families have to be willing and well-informed of the need to comply with the guidance provided by healthcare professionals and information leaflets to avoid any photosensitive reaction. There is a need for education for healthcare professionals as PDT is not well recognized or understood as a treatment for advanced cancer.

The relevance of time in palliative care nursing practice

This article describes time as a contextual factor in palliative caring practices and contributes to an understanding of the connections between time and the quality of palliative care. The article is based on an explorative and qualitative research study inspired by grounded theory. The empirical data of the study were obtained through field studies and interview. The interpretation is indebted to a philosophical interpretation that assumes time to be consciously organised into two categories: an objective clock time and a subjective personal time. Two scenarios are presented: one in which clock time is insufficient and another in which clock time is sufficient. Each scenario outlines how nurses relate to time in different ways according to whether clock time is insufficient or sufficient, respectively. It is found that the two scenarios have different implications for palliative care, nurses' personal time, and nurses' opportunities for reflection and professional development.

Getting it right under pressure: action research and reflection in palliative nursing

This article describes a qualitative research project using a combination of reflection and action research. Eight experienced registered nurses identified their need to 'get it right under pressure' in their work in palliative care. Participants collaborated in generating and evaluating an action plan to enhance the likelihood of getting palliative nursing care right, under pressure, more often.

Exploring painful experiences: impact of emotional narratives on members of a qualitative research team

AIM

This paper reports a study of the impact of emotional narratives on the well-being of members of a qualitative research team during the conduct of sensitive research.

BACKGROUND

Qualitative data are frequently collected from participants using repeated in-depth interviews when exploring sensitive issues such as loss and grief. The research process can evoke highly emotional responses in the participant and others involved in the study. While consideration has been given to the impact of the research process on participants when a highly affective component is involved, relatively little attention has been given to research team members' experiences.

METHOD

Through analysis of fieldwork records from a grounded theory study of the experiences of women who were carrying a baby with a foetal abnormality, we discuss the affective issues arising in conducting sensitive research. Data sources included two reflexive journals, written comments from two transcribers and the transcript of an interview with the research supervisor.

FINDINGS

The core category of 'Connecting with the data' emerged, to which each substantive category relates. Three substantive categories -'bearing to watch,''bearing to listen' and 'bearing to support'- emerged as independent but inter-related aspects of the research process as experienced by the researcher, transcribers and supervisor. Methods of protecting the research team and the integrity of the study when the substantive issue is highly emotive are discussed.

CONCLUSION

The emotional impact of research on participants is normally considered prior to the conduct of any sensitive research, and efforts are made to protect them. The potential for researchers, transcribers and supervisors to be harmed should also be carefully considered when planning a project with significant affective elements.

The needs of children and their families at end of life: an analysis of community nursing practice

BACKGROUND

there are few studies in the literature describing or evaluating the workload of children's community nurses prior to and following the death of a child with a non-oncological life-limiting disorder.

METHOD

a documentary analysis of nursing records of all children under the care of the Lifetime Service who died during a 5-year period was carried out.

RESULTS

the number of visits and telephone calls involving children's community nurses in the end of life and bereavement periods was analysed and the level of the input to families found to vary widely. In total, the number of visits range from 0 to 50 (median 8). The total number of telephone calls made or received for each child ranged from 0 to 127 (median 20). Calls and visits were with a wide range of people relating to diverse subject areas and continued even when children were in hospital.

CONCLUSION

community children's nurses liase with a wide range of professionals and organisations and the nature of their workload at the end of life is often hidden.

Exploring the ethical issues of the research interview in the cancer context

This paper sets out to reflect on ethical issues in the context of a study exploring cancer patients', relatives' and nurses' experience of a day hospital chemotherapy service. Interviewing can be considered as a well-used approach within qualitative methodology, yet little attention has been paid to a many of the ethical deliberations that are inherent when adopting this approach, particularly in the context of cancer. It is the intention of the authors that this paper might raise awareness of these issues, contribute to the ongoing debate about conducting research interviews on sensitive topics and provide a 'real-world' application of these principles. It is considered that the article potentially raises more questions that answers and illustrates that there are not always quick-fix solutions for the 'real-world' problems qualitative researchers' experience.

Loss of appetite: a poetic exploration of cancer patients’ and their carers’ experiences

AIM

To explore the experience of loss of appetite among palliative care cancer patients and their carers supported by a specialist palliative care team in the community.

METHOD

Semistructured interviews were conducted with seven palliative care cancer patients and their carers in the community. A poetic transcription of participants' words was made to capture and communicate the essence of each person's experience before the thematic analysis was undertaken.

FINDINGS

Six common themes emerged from the data: a fickle phenomenon; the cost of caring; facing uncertainty and death; adaptations; accepting limitations; and what patients want: 'listen to me'. These were illustrated by the poetic transcriptions.

CONCLUSION

Meeting the differing needs of palliative care patients with loss of appetite and their carers is challenging. It demands a thorough assessment of symptoms, an understanding of the underlying pathophysiology and of the role food plays in society. An understanding of the experience of loss of appetite is essential to the provision of appropriate care and support to those affected by it. The study demonstrated that, although unusual, poetic transcriptions can be an effective method of presenting data in terms of acceptability to participants and communicating their experience to others.

Is the Palliative Care Outcome Scale useful to staff in a day hospice unit?

AIM

this study was undertaken to elicit a day hospice team's experience of using the Palliative Care Outcome Scale (POS), with the intention of determining its usefulness to staff. An adapted version of POS was used for the purpose of the study.

SAMPLE

a multiprofessional team of eight day hospice staff took part in the study. All had used POS on a weekly basis for a minimum period of 3 months.

DESIGN

a focus group was conducted at the hospice. It was tape-recorded and transcribed verbatim. The data were analysed using an interpretive phenomenological approach.

RESULTS

staff felt POS had limited value as an outcome measure for use in this day hospice. Other simultaneous organizational changes at the hospice may also have influenced staff negatively. Further research is needed to explore similar implementation issues in more depth, as practice developments may be abandoned for potentially the wrong reasons.

Nurses' views of longitudinal genetic screening of and research on children

There is a lack of empirical data exploring ethical issues of genetic screening and longitudinal research involving children. Therefore, this pilot interview study explored the perceptions of nurses and midwives in relation to their involvement in an ongoing genetic preventive screening process involving children - the All Babies in South-east Sweden (ABIS) study (n=17,005). Data were collected through semistructured interviews with 10 nurses involved in all information and sampling procedures. While providing the preliminary nature of this study, it supports the idea of the importance of further research, both from a nursing professional perspective and from other parties involved in clinical research. The findings made in this study suggest that for such studies it is vital that nurses and midwives are fully informed about aims, methods, and potential intervention/prevention since in many cases they have a central role in several areas of screening and clinical longitudinal research involving children, e.g. information to potential research participants, obtaining informed consent, and data collection. With a thorough understanding of the research, including both basic aims and methods as well as potential future prevention aims, the nursing staff involved will be better placed to help participants make an informed choice and to provide additional information to the participants. Further research may be needed that aims to develop effective methods in preparing data collectors. It is also suggested that the design of the information process, and especially in longitudinal research involving young children, is of utmost importance before such studies are commenced.

Enhancing hospital nurses' knowledge of palliative care: a network nurse programme

The palliative care network nurse programme was developed to educate and skill generalist nurses in the care of the dying patient within the acute hospital setting. It developed at the request of nurses who had been involved in the piloting of the Liverpool Care of the Dying Pathway. The programme consists of a monthly meeting that encompasses an educative component and networking opportunities. In a preliminary evaluation of the programme, a questionnaire was sent to the network nurses (response rate 80%, n = 33). The nurses reported the programme to be beneficial in providing them with increased palliative care knowledge. Support and networking opportunities were also identified. This article discusses the programme, the evaluation findings and makes suggestions for further research.

Patients' views of using an outcome measure in palliative day care: a focus group study

Outcome measures are being increasingly used in palliative care. Palliative day care is significantly different to other specialist palliative care settings, as patients may attend for much longer periods of time. The aim of this study was to elicit patients' views on using an adapted version of the Palliative Care Outcome Scale (POS) and to determine its value in identifying their individual needs. This qualitative study involved a focus group of nine patients who had used POS weekly for a minimum of 3 months. The focus group discussion was tape recorded and transcribed verbatim. Data were analysed using an interpretive phenomenological approach. Participants found POS to be a useful communication tool, which helped them to identify their individual needs.

Ethical issues arising from a research, technology and development project to support frail older people and their family carers at home

The present paper provides an overview of the application of the key ethical issues which arose in an EU-funded research, technology and development project, Assisting Carers using Telematics Interventions to meet Older Persons' Needs (ACTION). The primary aim of the ACTION project was to support frail older people and their family carers in their own homes across England, Northern Ireland, the Republic of Ireland, Sweden and Portugal via the use of user-friendly information and communication technology. Ethical guidelines were developed in the project and used as a tool to enable the multidisciplinary project team to increase their awareness of ethical issues in their everyday work, and to act as a useful ethical framework for regular team discussions at international and local meetings across the partner countries. A range of ethical issues arose during the field-study phases of the project when the ACTION services were introduced into a number of families' own homes. It can be argued that these ethical issues reflect factors relating both to the application of research into practice, as well as those relating more directly to the use of new technology by families and care professionals. Key issues centre upon the ethical concepts of autonomy, independence, quality of life, beneficence, non-maleficence and justice, and more specifically, on ethical issues of security, privacy and confidentiality, increased expectations, and withdrawal of the service. This paper is intended to facilitate dialogue and debate in the area of enabling (assistive) technology in home care for older people and their families.

The experience of dysphagia and its effect on the quality of life of patients with oesophageal cancer

This qualitative study was designed to explore the experience of dysphagia in oesophageal cancer and how this impacts on quality of life. The aim of the study was to add to the knowledge and comprehension of this poorly understood symptom. Data was collected through in-depth interview and administration of the EORTC QLQ-C30 and EORTC QLQ-OES24 quality of life tools with six people with incurable oesophageal cancer who had dysphagia. The interviews were tape-recorded and then transcribed verbatim for each participant. Through a thematic analysis of the interview data and a descriptive analysis of the questionnaires a detailed description of the experience of dysphagia and its impact on quality of life was obtained. Five basic themes emerged from the participant's accounts and these were recognizing dysphagia, the physical experience, the emotions evoked, the impact on social life and dysphagia and treatment. In conclusion dysphagia is a troublesome symptom which affects all aspects of quality of life.

Qualitative research in palliative care 1990-1999: a descriptive review

A collaborative, evaluative review of qualitative research in palliative care published between 1990 and 1999 has been conducted. Nearly 30,000 articles in 48 journals from specialist palliative care, oncology, death studies, medicine, nursing, gerontology, health and the social sciences were examined. From these journals, 138 articles (0.5%) reporting qualitative research with a focus on palliative care in the context of death, dying or bereavement were identified. These articles were reviewed using a proforma designed by the group. This article describes the review process, and the following findings: the distribution of different forms of qualitative research in palliative care; the location of such papers; the focus of the research; and the research methodology and methods adopted.

Human research ethics committees: issues in palliative care research

Palliative care research is fraught with many difficulties. There are challenges associated with conducting research with vulnerable patients and families, difficulties with obtaining informed consent, and methodological complexities. Thoughtful construction of research protocols may overcome many of these problems. However, researchers may be powerless to overcome the discomfort of members of human research ethics committees (HRECs) who disallow access to palliative care patients and families. The notion of conducting research with this group is often perceived as abhorrent by those who do not practise in palliative care. This is because of a persistent idea that dying people and their families are so burdened by the dying process and so vulnerable to exploitation that they should not be approached to be involved in research. This over-protectiveness regarding palliative care research often distorts the proper gate-keeping role of HRECs and health-care professionals. This article draws on the authors' experiences of presenting applications to HRECs over the last 20 years. It explores the responsibilities of HRECs, the responsibilities of palliative care researchers and the rights of patients and families. HRECs and health professionals who endeavour to undertake palliative care research are encouraged to reflect and re-examine the role of ethics committees.

Ethical considerations in researching user views

Researching user views has become a central plank of UK cancer and palliative care policy, not least because it is recognized that current systems for treatment reflect inadequately the experiences and concerns of cancer patients. This paper examines the process of accessing user views about cancer and palliative care from an ethical perspective, drawing by way of example on a study of outcomes associated with Macmillan nursing. A moral theory framework is used to discuss some of the issues involved in trying to achieve ethically sound practice and some essentially political issues that frame the process of accessing users' views are highlighted. The paper recommends that models of research be developed for accessing user views that are congruent with the values and philosophies of supportive and palliative care. This requires striking a fine balance between the ethical duties of providing care and support, nurturing independence and autonomy, and achieving research outcomes that are rigorous while also being accessible and meaningful to users. It also requires developing an understanding of the social, political and economic context of research enquiry with users.

Leveling the playing field? Exploring the merits of the ethics-as-process approach for judging qualitative research proposals

There has been a recent growth in claims that qualitative research proposals are not treated equitably by ethics committees. In response, recent arguments centered on establishing the ethics of qualitative research, in the eyes of ethics committees, have indicated the need for an "ethics-as-process" approach. Accordingly, in this article, the authors illustrate the merits of this approach and provide three examples from the field: the outcomes of participating in qualitative interviews, sensitive handling of ending in qualitative research relationships, and the ongoing establishment of informed consent. The authors hope to increase awareness of the potential benefits of this approach and contribute to the ensuing debate.

A service users' research advisory group from the perspectives of both service users and researchers

Much has been written about the importance of involving service users in the research process. Far less is available about the experience of involvement from the perspective of service users themselves. The present paper is a joint account by service users and researchers of a service users' advisory group set up to support and advise a project to evaluate diabetes services in Bradford, UK. The establishment of a separate advisory group for service users is, to our knowledge, an innovative approach to lay involvement within mainstream National Health Service (NHS)-based research. Factors that contributed to the group's success included personal contact, continuity of membership and integration into the management structure of the project. Also valued were the confidence in numbers which membership of the group gave, and the opportunity to meet and discuss issues away from the formal and somewhat intimidating atmosphere of the project's steering group. Aside from the personal value to participants and any impact on the quality of research outcomes, wider benefits included the ability to share knowledge with others and gain greater intercultural understanding.

Being in a lived retreat--embodied meaning of alleviated suffering

Meanings of alleviated suffering in persons living with life-threatening cancer are explored in this life-world phenomenologic study. In repeated conversations, 16 patients with cancer who were receiving palliative care shared their embodied experiences in personal narratives. When interpreting the narratives, the following meanings of experiencing alleviation of suffering were disclosed: an endurable body being independent and feeling at home, feelings of connectedness, taking a long view of the suffering, being lifted out of the suffering, and an inner peace. Movements that were found in alleviation were dampening the suffering, arousing a zest for life, and focusing on both the present and the patient's dignity. As an interpreted whole, alleviation of suffering was found to be an embodied experience of "being in a lived retreat." This is a symbolic place owned by the person and is experienced in either the company of others or solitude. This lived retreat can provide a feeling of being at home, creating peace, rest, confidence, and breathing space in the person's suffering. It means coping with the altered lived body and feeling dignified. This is a personal experience that is both intersubjectively created and dependent. The importance of openness and responsibility in palliative care is emphasized in the findings and the notion of control of suffering in palliative care is accordingly rejected.

A practice-based evaluation of a liquid barrier film

In palliative care it is often the little things such as being comfortable that help to improve a patient's quality of life. When the opportunity arose in our hospice to take part in a practice-based evaluation of a product that promised to make patients more comfortable, we were pleased to take part. Our small-scale evaluation was part of a wider study of SuperSkin, a liquid barrier film designed to protect skin at risk of damage. Information was collected from the patient, patient's medical notes and the nursing staff - a patient daily diary record was used in addition to normal information recordings. We evaluated the efficacy of the product and found this liquid barrier film to have a positive effect in several ways. It appeared to assist in the healing of skin damaged by friction and shearing forces, and from excoriation from wound exudates, urine and faeces. In addition, it appeared to protect healthy, 'at risk' skin from the same problems.

Evaluation of a hospice based reflexology service: a qualitative audit of patient perceptions

Complementary therapies are being increasingly used in palliative care in the drive to improve patients' emotional, psychological and spiritual health, and enhance the quality of their lives. The importance of seeking the 'user' perspective when evaluating such services is becoming increasingly acknowledged. However, it is also extremely important that we elicit such perspectives in an ethically sensitive manner. This study used a simple semi-structured questionnaire to elicit the views of a convenience sample of 34 patients receiving palliative care at a specialist palliative core unit in the north of England who had completed a course of 4-6 sessions of reflexology. Patients' comments about the therapy and the service as a whole were overwhelmingly positive. They identified relaxation, relief from tension and anxiety, feelings of comfort and improved well-being as beneficial effects of their course of reflexology. Patients also spontaneously evaluated the experience holistically in terms of the wider therapeutic environment--the centre, the staff and the therapist as well as the therapy itself. The increasing demand for evidence based practice now challenges researchers to provide a relevant holistic assessment of complementary therapies using approaches that are both ethical and sensitive to the needs of this vulnerable patient population.

Judging the ethics of qualitative research: considering the "ethics as process" model

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.

Involving patients in research: setting up a service users' advisory group

Looks at some of the issues raised by patients' involvment in the research process. Uses the example of a service users' advisory group established as part of a diabetes service evaluation in the north of England. Key conclusions were: a precise role for the group should be specified at the outset; genuine user involvement is needed; wide and accurate representation of all relevant groups in society is essential; and, researchers must approach users with open minds with a view to shared decision making rather than control.

Constructions of sexuality for midlife women living with chronic illness

AIM

In this paper, we reveal constructions of sexuality that were articulated by women who participated in an inquiry which aimed to understand the experiences of midlife women who live with chronic illness. The aim of this paper is to illuminate sexuality as an important health issue for women living with chronic illness and to offer ways that nurses may acknowledge and facilitate sexuality issues for women.

BACKGROUND

The first author, as part of her doctoral study, corresponded with 81 women living with chronic illness. The participatory inquiry was framed by feminist principles and enabled women to anonymously share their experiences and collaborate in the direction of the research. During the analysis phase of the research, it became evident that illness had altered the way in which women conceptualized sexuality.

DESIGN

The three authors performed secondary analysis of the original data set in order to re-examine the impact that chronic illness had on the sexuality of midlife women who live with chronic illness. Whilst we acknowledge that sexuality has multiple meanings, in this paper we describe the way in which women themselves have constructed and articulated their sexuality.

FINDINGS

We found that sexuality incorporated women's desires, appearance, sexual feelings and expression and imposed on aspects of their lives that they had not needed to acknowledge before illness intruded. Three concerns are discussed; the changing body, meeting the needs of others and communicating sexuality.

CONCLUSIONS

This paper reveals that issues of sexuality are an important health concern for women who live with long-term illness and should be acknowledged in sensitive and responsive health practices. The paper concludes that it is important for nurses to provide women opportunity for open and genuine communications about sexuality. In this way, a foundation of acceptance for the whole person is established which provides women permission to ask questions and seek assistance with sexuality issues.

Analysing qualitative data: examples from two studies of end-of-life care

This article examines the analysis of qualitative data, identifying and explaining some key approaches which researchers may wish to use to contribute to the developing knowledge base of palliative nursing. Drawing on the work of Grbich (1999), practical examples from the authors' own studies of end-of-life care are used to illustrate some of the possibilities for analysing interview and observational data. The article concludes with an examination of the concept of 'rigour' in qualitative inquiry and suggests some practical ways of helping nurses who are new to palliative care research.

A randomized trial of winged Vialon cannulae and metal butterfly needles

The purpose of this parallel randomized study was to evaluate whether subcutaneous infusion sites initiated with winged vialon cannulae would have fewer skin reactions and longer site duration than metal butterfly needles and reduce needlestick injuries to staff. Data were collected on 42 hospice inpatients from the time of insertion of the first needle or cannula to the time of the first replacement of that device. A non-parametric survival plot for time (Kaplan-Meier method) was conducted and the survival time to replacement of the Vialon cannula was found to be longer than the metal butterfly needle. During the study period there were a total of four needlestick injuries to staff from metal butterfly needles. The authors conclude that Vialon cannulae reduce the frequency of site changes and are safer for staff to use because of the reduced risk of needlestick injuries.