Special not different: general practitioners' accounts of their care of dying people

In modern Britain the majority of terminal care occurs in people's own homes and many dying people and their carers would prefer the death itself to occur in the home. The quality of terminal care in the home and the possibility of a home death depend to a great extent upon the care provided by GPs and community nurses. This paper reports on GPs' experiences of caring for dying people and their attitudes towards such work. It is based on unstructured interviews with 25 GPs who graduated from the 1979 entry cohort to the University of Leicester medical school. The respondents were recruited via a questionnaire following up previous research with this cohort on 'fear of death'. Although self-selecting, interviewees were not significantly different from those who did not volunteer for interview in any of the statistical analyses of the questionnaire data. There were a number of similarities in their accounts of their care of dying people. Common themes were that the care of dying people was important, rewarding and satisfying; that the GPs saw themselves as part of a team of carers, frequently as team co-ordinators; good working relationships with district nurses but less satisfactory relationships with hospitals and social workers; that patient and family were both recipients of care; and honesty in communication with dying people, albeit tempered. Three issues of contemporary relevance were: tensions over the role of hospice and specialist terminal care services; care of people with chronic terminal illnesses other than cancer; and the role of GPs in the social construction of bereavement.     

A comparative study of death anxiety in hospice and emergency nurses

This paper describes a preliminary cross-sectional study which aimed to compare levels of death anxiety and coping responses in palliative care and accident and emergency (A & E) nurses. Forty-three nurses (23 from palliative care and 20 from A & E) were recruited from a district general hospital and nearby hospice. Both sites had the same mean annual death rate of 150 patients. Death anxiety was measured by the Death Attitude Profile-Revised Questionnaire and coping responses were elicited by a semi-structured interview. As hypothesized, hospice nurses had lower death anxiety and they were more likely to recall both good and difficult experiences related to patient care. Unlike the hospice nurses, a subgroup (20%) of A & E nurses reported that they were unable to discuss problems with colleagues. The study has implications for the development of institutional support for staff to enable nurses to provide good quality care for dying patients and bereaved people.     

An exploration of the value of specialist neurosurgical nurses

The differences in the knowledge and skills of 75 nurses working in a variety of practice settings were examined using a case study vignette of a neurosurgical patient developed by researchers. The case study tested nursing care throughout a patient's hospital experience, including admission, presurgery, postsurgery and discharge preparation. The findings showed that nurses who had specialised in neurosurgery scored markedly higher, in all aspects of practice knowledge, than expert nurses in other specialties and general nurses. Patients undergoing neurosurgery are safer if they have nurses who are experienced, skilled and knowledgeable to care for them.     

Struggling for control: the care experiences of 'difficult' patients in mental health services

Although there is increasing recognition of the existence of 'difficult' patients who present particular challenges to mental health nurses, no research has been conducted into their perceptions of services and their experiences of care. This study identifies mental health service users who are defined by nurses as 'difficult' and explores their perceptions of their care experience. The results support earlier studies which suggested that 'difficult' patients challenge nurses' competence and control: despite their different roles both nurses and 'difficult' patients were aware of the struggle to gain or retain a notion of control. Respondents were able to identify the qualities of nurses and nursing interventions which had a positive effect on their care experience. Where nurses were perceived to demonstrate respect, time, skilled care and a willingness to give patients some control and choice in their own care, feelings of anger were reduced. These findings are discussed within the conceptual framework of 'power over' and 'power to' and implications for practice and research are considered.     

Validation of a model of psychosocial determinants of occupational health of geriatric nurses

The purpose of this study was to verify a model of relationships between psychosocial factors and health for 8066 francophone nurses working in geriatric care in Québec. A random sample of 1990 subjects was drawn and a participation rate of 77.9% and 55% was obtained for the two-time study taken twelve months apart. Based on the theory of Maddi and Kobasa (1984), the model was reproduced for the two-time periods with the aid of structural equations. The analyses showed that three variables exert a direct influence on psychological distress: professional burnout, occupational stressors and hardiness. Also, variables have a direct effect on burnout: listed in order of importance, these are hardiness, occupational stressors, work support, active strategies of coping and employment status. In dealing with the work stressors, the nurses who are hardy make use of active strategies of coping and look for support form their colleagues. The results of the study help to better understand the psychological and social resources that best favor adaptation of working women in highly demanding work environments. The fallout of the study converges towards the quality of life of helping professionals and towards the cost and quality of health and social services.     

Surgical removal of subretinal neovascular membranes

Although families can provide important support for individuals with life-threatening illnesses or injuries, the highly technological nature of critical care often limits opportunities for family involvement. While critical care nurses are seldom family specialists, they frequently provide support and assistance to patients' families. This paper describes four types of questions drawn from the family therapy literature that can be used by nurses who are not mental health specialists to support families and mobilize their problem solving skills. A case model of a head-injured child demonstrates the use of these questions with a family. These questions should be useful for the brief, problem-focused, family encounters which characterize critical care settings.     

Generic nursing outcome objectives for use in long-term care facilities

Twenty-two registered nurses employed in four long-term care facilities generated data for a study about nursing diagnoses in long-term care (N = 360). Generic outcome objectives were developed as an integral part of the project. The research team also specified exceptions to the outcomes: instances where meeting outcome objectives might not be possible. The outcome objectives and exceptions for the sample's 20 most frequently occurring nursing diagnoses are presented as working statements. The authors expect that these outcome objectives and exceptions will be revised by nurses who use them in practice, basic and continuing education, and research.     

Staff nurses' ability to assess community patients: a study

This article describes a project to evaluate the effectiveness of staff nurses undertaking patients' first assessment, within the community setting. District nurses selected appropriate groups of patients to delegate to the staff nurses and remained accountable for care throughout the project. Patient documentation, patient satisfaction, and GP, district nurse and staff nurse satisfaction were all audited at the end of the study period. The authors found that while the district nurses remained essential to the management of care, some work could be delegated appropriately to selected staff nurses. The standard of care was not adversely affected by the alteration in working practice.     

Diabetic ulcers of the lower extremity: a review of comprehensive management

The management of lower extremity diabetic ulceration exacts enormous emotional and economic costs from patients, their family members and caregivers, and society. A team approach to wound healing has proved effective, but efforts at prevention have been less successful. The etiology of lower extremity diabetic ulcers includes injury complicated by underlying neuropathy, ischemia, or both. Prevention of primary and recurrent ulcers can be increased through programs to educate patients and caregivers. Proper management begins with thorough assessment and continues with various forms of medical and surgical therapy, and timely referral to specialists when appropriate. The use of recombinant growth factors is becoming more widespread as more is learned about their essential role in wound healing. Monitoring the wound while it is being treated is as important as initial assessment. Across the United States and Canada, wound care clinics are being established to provide intensive care directed by specially trained multidisciplinary care teams. Less populated areas must rely on proper education of ET nurses, home care nurses, visiting nurses, podiatrists/chiropodists, and allied healthcare professionals. Challenges for the future include the development of protocols for comprehensive assessment and care, better methods of prevention, a greater understanding of the role of growth factors in wound healing, and optimizing wound care.     

Advance directives and advocacy in end-of-life decisions

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.     

Clinical oncology nurses' perceptions of research

Within the realm of oncology nursing, research has been an integral part in its development as a specialty practice. Yet despite the growing volume of published nursing research studies, little is known about how nurses working in oncology care settings perceive research. Therefore, the purposes of this study were to examine clinical oncology nurses' perceptions of research and to determine factors influencing their perceptions. Two hundred and eighty-three registered nurses providing cancer care to patients in 40 health care agencies across northern Ontario participated in the survey. Data were collected using a questionnaire developed by Alcock and colleagues (1990) which addressed nurses' perceived value of research, their role, interest and experience in research as well as the research climate of the agency. The findings showed that respondents valued nursing research and perceived a research role for staff nurses. However, the respondents did not perceive strong administrative or collegial support for nurses' involvement in research activities. In addition, the study results indicated that the clinical oncology nurses' perceptions of research were influenced by educational preparation.     

Retention of advanced cardiopulmonary resuscitation knowledge by intensive care trained nurses

The teaching and reinforcing of advanced cardiopulmonary resuscitation (ACPR) is an important part of the role of an intensive care nurse manager. This study highlights the need for a structured training programme, as well as regular updates in ACPR. Current research shows poor retention of CPR skills amongst nursing staff. A small study was undertaken amongst intensive care trained nurses at The Middlesex Hospital intensive care unit (ICU). 18 nurses took part in the study, and were each interviewed with regard to their knowledge of ACPR in December 1990. The period of time since last trained in ACPR ranged from 2 months-4 years. Those who had been recently updated in ACPR (up to 4 months prior to interview) scored higher than those who were updated more than 2 years ago. The results showed that most nurses interviewed were only able to answer correctly half the questions asked. These results indicate that the nurses in the study generally demonstrated a severe lack of knowledge of ACPR. This indicates the need for a structured training package in ACPR, followed by frequent reinforcement of ACPR knowledge and skills for nurses practising in an ICU environment.     

Sources of stress and psychological well-being in high-dependency nursing

The present study examined occupational stress in four areas of high-dependency nursing: theatres, liver/renal, haematology/oncology and elective surgery. A total of 60 nurses from one large NHS hospital completed questionnaires on sources and levels of stress, psychological well-being and ways of coping; interviews with a small sub-sample were carried out. The results indicated that the amount of stress experienced was similar across all four departments, but its sources varied. Theatre nurses experienced less stress through patients' death and dying. Other factors which influenced both the level and sources of stress included post-qualification training, number of children and partnership-status. Nurses with post-qualification training perceived higher levels of stress. Social support was found to influence psychological well-being. Nurses who were living with a partner or were married experienced fewer stress symptoms than those with no partner, and nurses with two children experienced significantly less stress through dealing with patients and relatives. Reactions to stress elicited a range of adaptive and maladaptive coping styles. Nurses sampled indicated universal support for the introduction of 'nurse-for-a-day' and management 'swap-overs' as practised in Boston, USA. This study recommends sending nurses on management and administration courses and stress-management programmes.     

Experimental teleradiology. Novel telematics services using image processing, hypermedia and remote cooperation to improve image-based medical decision making

Various reports draw attention to the deficiency of services available for critically ill children. In December 1993 the British Paediatric Association published a report by a multidisciplinary working party on intensive care. The Minister of Health has apparently promised to act on the recommendations the working party made. In fact, purchasers are being encouraged to act and ask questions about the provision of paediatric intensive care--but no extra funding is available to provide it. However, this will all take time and until more resources are available children are still being cared for on adult intensive care units by nurses who may not be experienced in caring for sick children. One of the main areas of concern nurses have when caring for children is the physiological differences between an adult and a child. This paper is designed to assist in identifying the differences and consequent nursing implications. In an attempt to prioritize the nursing care a systems/modified model has been used over 2 papers. The review of the systems demonstrates the differences between adults and children and, where possible, highlights the nursing care and medical treatment a child requires. All aspects of care have been included as well as the psychological problems (see Part 2 which will be published in the next issue) encountered by the family of a critically ill child. Where possible easy reference tables have been included and the author hopes to introduce the package into the existing orientation programme for established staff and staff new to the unit in the hopes of decreasing the stress when a child is admitted. Paediatric resuscitation has not been covered intentionally, as the information on the physiological differences seemed to grow like 'Jack's beanstalk'. Therefore, a flow chart for basic and advanced life support is included as an appendix in Part I. It is hoped this will stimulate readers' interest for more in-depth study.     

Issues of death and dying: the perspective of critical care nurses

A major shift in the care of terminally ill people, due to advances in technology, and the development of legislation regarding patient self-determination and autonomy, has occurred over recent years. Critical care nurses (CCNs) are involved daily in issues of death and dying and are very aware of the needs, fears and psychosocial issues of patients and their families. Professional associations see a legitimate role for nurses in assisting the dying to achieve a dignified death. For legislation, policies and guidelines surrounding end-of-life issues to be effective, and to assist nursing staff with these sensitive, often difficult concerns, it is important that data on the opinions and perspectives of CCNs be objectively obtained. In a study by the Department of Social and Preventive Medicine at the University of Queensland, questionnaires were sent to 1100 randomly sampled community members and almost 1200 health professionals (nurses, general practitioners and specialists), including 299 CCNs. The response rate of CCNs to a 30-page postal questionnaire was 79 per cent (n = 231), indicating those nurses' high levels of interest in and/or concern regarding this area. CCNs supported the use of advance directives, the appointment of proxies and the need for doctors and nurses to give sufficient medication to relieve pain, even if this hastened the death of the patient. In addition, CCNs, more than any other professional group, supported the right of the terminally ill patient to physician-assisted suicide or euthanasia, their responses being very similar to those of community members. CCNs clearly face issues which, from legal, medical and ethical viewpoints, cause them concern. In sharing their personal experiences, CCNs stressed the need for more communication between doctors and patients, as well as between doctors and nurses. In addition, CCNs saw a clear role for themselves as advocates for patients/families in the decision-making process.     

Evaluation of an interdisciplinary training program in palliative care: addressing the needs of rural and northern communities

Our study was a pilot test of an interdisciplinary training program in palliative care to improve the quality of care to terminally ill cancer and AIDS patients in rural and northern communities in Manitoba. The program involved two weeks of intense palliative care training for nurses, social workers, physicians, and volunteers. Four teams were trained during a six-month period. A repeated measures design was used to assess the effectiveness of the program. Results indicated that health professionals' knowledge about care of the dying, care of individuals with HIV/AIDS, and attitudes toward care of the dying improved upon completion of the training program and remained improved three months following the program. Improvements in use of medications, increased attention to family care, increased discussion of DNR orders, and increased consultation related to symptom management were evident following the training program. The parallel training program for volunteers was also judged to be effective.     

Palliative medicine: a new specialty changes an old debate

The specialty of palliative care, of which palliative medicine is part, has developed from hospice care for the dying and aims to meet the various needs of those suffering from advanced incurable progressive disease. Specialist palliative care is not expensive and can be made available to all those who need it, at home, in hospital or in a hospice. Arguments in favour of permitting euthanasia for those dying as a result of a chronic disease are usually based on compassion respect for autonomy or perceived hypocrisy in existing medical practice. Each of these arguments is examined and found wanting.     

Work-family conflict and psychosocial work environment stressors as predictors of job stress in a cross-cultural study.

The purpose of this cross-cultural study was to investigate the relationship between work-family conflict (WFC), family-work conflict (FWC), job demands, job control, social support, flexibility in working hours, and job stress. The sample consisted of 27 doctors and 328 nurses from Norway, as well as 111 doctors and 136 nurses from India. The results indicate that predictors of job stress in India are different from Norway and different from doctors to nurses. For Norwegian doctors, none of the study variables were predictors of job stress. For Norwegian nurses WFC, high job demands, and low flexibility in working hours were predictors of job stress. For Indian doctors low job control and for Indian nurses high FWC and low social support were predictors of job stress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family physicians' involvement with dying patients and their families. Attitudes, difficulties, and strategies

OBJECTIVE: To determine family physicians' perceptions of the difficulty in caring for dying patients and how prepared they are to provide such care relative to strategies used with difficulties encountered, personal need for support and development, and cooperation with other caregivers. DESIGN: Exploratory. SETTING: Physicians' offices. SUBJECTS: Thirty-five randomly selected family physicians (doctors of medicine and doctors of osteopathy) representative of family physicians practicing in Franklin County, Ohio. INTERVENTIONS: None. MAJOR OUTCOME MEASURES: A semistructured interview guide corresponding to a three-dimensional theoretical model developed prior to the study was used to determine family physicians' perceptions regarding care of dying patients and their families. The three dimensions include family physicians' involvement with dying patients and their families, their personal needs and development, and their cooperation with other caregivers. RESULTS: Participants agreed that the care of dying patients and their families is an important and special component of practicing family medicine. Generally seeing themselves as adequately prepared, they still found such care difficult and desired more education and training to increase comfort of their patients and of themselves. Their perceptions regarding the care of dying patients and their families could be categorized in terms of communication as part of the care process, family issues, legal and ethical issues, coordination of care, physicians' feelings, and physicians' influence and support. CONCLUSIONS: Family physicians require formal training in death issues and need to find a way to maximize learning through personal experiences. Discussion of cases in a support group may be beneficial.