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PubMed2004

Medical hegemony in decision-making--a barrier to interdisciplinary working in intensive care?

BACKGROUND: Health care policy in the United Kingdom identifies the need for health professionals to find new ways of working to deliver patient-focussed and economic care. Much debate has followed on the nature of working relationships within the health care team. AIM: This paper reports on an ethnographic study that examined the nursing role in clinical decision-making in intensive care units. This was chosen as a case for analysis due to the close doctor-nurse relationships that are essential in this acute and complex care setting. METHODS: Data were collected during two-stages of fieldwork using participant observation, in-depth ethnographic interviews and documentation across three clinical sites. FINDINGS: The findings revealed the different types of knowledge used for, divergence of roles involved in and degree of authority in clinical decision-making. Furthermore, conflict arose between doctors and nurses due to these differences and in particular because medicine dominated the decision-making process. CONCLUSIONS: The nursing role, whilst pivotal to implementing clinical decisions, remained unacknowledged and devalued. Medical hegemony continues to render nurses unable to influence substantially the decision-making process. This has fundamental ramifications for the quality of team decision-making and the effectiveness of new ways of inter-professional working in intensive care.

Decision Making↗
PubMed2005

The Nurse Educator's clinical role.

AIM: This paper reports a two-phase descriptive study exploring the clinical role of the nurse educator in Malta. BACKGROUND: Previous studies indicate a number of similarities and differences in the clinical role of nurse educators by country of practice. These include importance assigned to the role, factors inhibiting/facilitating the role, means to eliminate barriers to the role, and perceptions of the ideal role. DESIGN AND METHODS: Data were collected using both quantitative and qualitative strategies. The quantitative phase involved asking all educators to fill in a time log of their academic and clinical activities for a 2-week period. In the qualitative phase, the first author interviewed five educators, five nurses and five students about their perceptions of factors which impact the nurse educator's clinical role, as well as what the ideal clinical role of the nurse educator should be. FINDINGS: Maltese nurse educators allot minimal time to their clinical role. Main reasons cited included workload, perceived lack of control over the clinical area, and diminished clinical competence. Nurse educators who frequented the clinical settings (who were either university or joint university and health service employees) where the study took place perceived that employment inequities among the various categories of nurse educators played an important role in the amount of time dedicated by each group to their clinical roles, and the importance individuals in these groups assigned to that role. The majority of interviewees saw the current role of nurse educators in Malta as preparing students for successful completion of the didactic sections of their programme, rather than preparing them with all the knowledge and clinical skills necessary to be competent practitioners. Participants considered that, when in clinical areas, nurse educators did focus on their students, as they should. However, they also thought that they often did not take the opportunity to forge links with professional staff. CONCLUSION: The clinical role of the Maltese nurse educator needs to be more multifaceted in approach.

Health Educators↗
PubMed2005

Exploration of the decision-making process for inpatient hospice admissions.

AIM: This paper discusses some of the findings of a qualitative study which described the decision-making processes that occurred during multidisciplinary meetings when prioritizing hospice inpatient admissions. BACKGROUND: Healthcare rationing and resource allocation have been identified as important but under-represented issues in the British nursing literature generally, and specifically within the field of palliative care. Little evidence currently exists about the rationing decisions made at a clinical level in hospices or palliative care units. METHOD: Adopting an ethnographic approach, data were collected at three hospice sites from three meetings at each site by observation, tape recording and transcribing of the meeting dialogue and examination of the available documentation from admissions meetings. The data were collected in 2002. RESULTS: Factors identified as potentially influential in these decisions included patient diagnosis, symptoms, current location and the stated reason for admission. The person who had assessed the patient's need for admission and whether or not a patient was personally known to a clinician present at the meeting also appeared important. The process seemed complex and incorporated different decision-making methods. Analysis of the group interactions suggested that these meetings were predominantly medically-led. CONCLUSION: Palliative care nurses need to examine their beliefs and practices in relation to how hospice inpatient care is prioritized, and develop sound evidence-based arguments in order to strengthen their role and influence in these important decisions for the benefit of patients. Further research is needed to achieve a greater understanding of these types of decision-making processes.

Decision Making↗
PubMed2006

Identity and resistance: why spiritual care needs 'enemies'.

AIMS: This paper explores certain key critiques of spirituality-in-nursing as they have been offered by people outside of the discipline. It argues that nurses have not taken seriously enough the recent criticism of the nature and role of spirituality in nursing. Not to listen to the 'enemies' of spirituality-in-nursing is to risk stagnation and a drift into obscurity. BACKGROUND: The area of spirituality has become a growing field of interest for nurses and has produced a burgeoning body of research literature. Yet, whilst much has been written about the positive aspects of spirituality, nurses have offered almost no critique of the ways in which spirituality and spiritual care are understood, despite the fact that there are clearly certain key issues that require robust critique and thoughtful reflection. Almost all of the major criticisms of spirituality-in-nursing have come from people outside of the discipline of nursing. The paper argues that nurses need to listen carefully to the criticisms of spirituality and spiritual care offered by the 'enemies' of spiritual care in nursing. When listened to constructively, they highlight issues that are vital for the development and forward movement of this important area of nursing practice. METHODS: Literature review and critical reflection on current critiques of spirituality in nursing practice. CONCLUSIONS: The paper concludes that nurses need to begin to develop spirituality as a specific field of enquiry with its own bodies of knowledge, methodologies, assumptions and core disciplines. RELEVANCE TO CLINICAL PRACTICE: In listening to and taking seriously its 'enemies', nursing has the opportunity to establish spirituality as an important, creative and vibrant aspect of nursing practice that has the capacity to grow and respond constructively to its 'enemies', in ways that make whole-person-care a real possibility.

Attitude of Health Personnel↗
PubMed2006

Every person matters: enabling spirituality education for nurses.

AIMS AND OBJECTIVES: This paper aims to identify how the statutory requirements relating to spirituality in nurse education can be supported in preservice and in-service education, in the context of inter-professional working implied by every child matters (Department for Education and Skills (DfES) Every Child Matters: Change for Children. DfES, Nottingham DfES 2004a; Every Child Matters: Change for Children in Health Services. Department of Health, London 2004). BACKGROUND: The basis for this paper is an exploration of the current requirements relating to spirituality in nursing and the consequent requirements for training and education clarified in part through a consideration of parallel policies on spirituality in school education. Inter-professional work, for example, across health, social care and education professions, has a long history in nursing and the changes brought about by the every child matters policy initiative have given such inter-professional work a considerable boost. That policy change has encouraged consideration, in this article, of some common issues arising in nursing and school education professions. METHOD: This paper consists of a critical review of current and in-coming statutory requirements related to spirituality, nursing and nurse education, and a synthetic review of definitions of and approaches to meeting spiritual needs. CONCLUSION: The emergent relational framework for considering spirituality in nurse education acknowledges the ambiguity of spirituality and treats that ambiguity as in some ways enabling rather than constraining. RELEVANCE TO CLINICAL PRACTICE: It is not simply that nurse practice will be likely to change with respect to children. Every person will, in the terminology of the policy, 'matter': there is significant urgency to consideration of effective education and training provision.

Child↗
PubMed2006

The management of ectodermal dysplasia and severe hypodontia. International conference statements.

An international conference on ectodermal dysplasias and hypodontia, held in London in 2004, featured a session devoted to the management of the ectodermal dysplasias and severe hypodontia. This paper presents a set of statements prepared by an international specialist panel, including representatives of patient support groups, who presented and subsequently debated a series of papers on this subject. The following topics were explored: potential roles of patient support groups; core care standards, including the roles and composition of medical and dental multidisciplinary teams for treating these conditions; the format of a baseline data set for patients with an ED; and priorities for research in ectodermal dysplasias, with particular regard to laboratory and clinical studies, and research methodology. The statements are intended to form an international framework for developing patient care pathways, and collaborative research in this field.

Anodontia↗
PubMed2004

A model for setting up interdisciplinary collaborative working in groups: lessons from an experience of action learning.

There is a current policy emphasis within health services on collaborative interdisciplinary groupworking between professionals, exemplified by the increasing use of action learning sets in a health context. Most of the evaluative research into this type of group collaboration has concentrated on evaluating outcomes, whereas this project aimed to evaluate qualitatively the experiences of the professional group members. The research uses a grounded theory methodology to investigate their perceptions and to analyse the data collected through interview methods. The research addresses an emergent theoretical model that could be of use when planning multidisciplinary task groups. It aims to enhance the success of these groups using a theory based on the concept of project momentum.

Cooperative Behavior↗
PubMed2005

Interprofessional supervision from the perspectives of both mental health nurses and other professionals in the field of cognitive behavioural psychotherapy.

This study reports on an open-ended qualitative survey to describe interprofessional supervision within a sample of 170 randomly recruited accredited cognitive behavioural psychotherapists, the majority of whom are mental health nurses. Interdisciplinary supervision was found to be very common and creating some rich opportunities for learning and practice development. A number of interprofessional difficulties were also found to be occurring for a variety of reasons, which are described. Recommendations are made as to how these problems can be overcome.

Attitude of Health Personnel↗
PubMed1990

Teaching of medical ethics.

Teaching medical ethics in Manchester within the introductory course of obstetrics and gynaecology is a joint activity with the Centre for Social Ethics and Policy. This interdisciplinary teaching has evolved through lecture sessions with small-group discussions dealing with topics of interest in human reproduction. The small-group discussion have been replaced by an open debate conducted by the students. Their own involvement and participation and an exposure to the disciplines of the humanities has broadened their approach to different ways of problem-solving of these real issues.

Bioethical Issues↗
PubMed2004

Expert and trainee determinations of rhetorical relevance in referral and consultation letters.

BACKGROUND: Referral and consultation letters ferry patients among providers, negotiating co-operative care. Our study examined how "relevance" is signalled and decoded in these letters, from the perspective of both experts and trainees in three clinical specialties. METHODS: 104 letters were collected from 16 physicians representing family medicine, psychiatry and surgery. Interviews were conducted with 14 of these physicians and 13 residents from the three specialties. All documents and transcripts were analysed for emergent themes. RESULTS: Six rhetorical factors influenced expert physicians' decisions about what material is relevant: educational, professional, audience, system-institutional, medical-legal, and evaluative. Each specialty placed different emphasis on these factors. Trainees reported having no instruction regarding how to construct rhetorically relevant letters, and they demonstrated awareness of only three of the factors identified by experts--professional, audience and evaluative. Experts and trainees differed in their understanding and application of these three factors. CONCLUSIONS: This research demonstrates that six rhetorical factors influence relevance decisions in letter writing, and that experts address these factors in tacit, dynamic and discipline-specific ways. Trainees share with experts an appreciation of the rhetorical functions of referral and consultation letters, but lack a comprehensive understanding of the influential factors and do not receive instruction in them. These findings provide a framework for instruction in this domain to equip novices to meet the expectations of their professional audiences successfully.

Continuity of Patient Care↗
PubMed2004

A community-based approach to the medical humanities.

BACKGROUND: This paper discusses the rationale behind, and an approach to, the development of a graduate level interdisciplinary curriculum in literature and health care that incorporates community-based learning. Such an innovative approach emerges from the recognition that professional training in both health care and humanities programmes often does not model the kinds of collaborative relationships and professional values desired by contemporary health care students, providers and patients. METHOD: Recent trends in literary study and the medical humanities are described, along with the function (and benefits to students) of interdisciplinary classrooms and the role of community-based learning in higher education. The authors discuss their experiences teaching, and offer students' responses to medical humanities courses from which the concept for such a curriculum evolved. The paper offers advice on developing, evaluating and disseminating such a model curriculum for medical, nursing and graduate literature students. PROPOSAL: By linking health care with graduate English literature students, such a course would promote dialogue and understanding among health professionals, enhance student awareness of the effects of illness on patients, their caregivers and families, and encourage student activism and community service. A common set of literary works would provide a shared vocabulary and opportunities for ethical, critical and personal response. Working together in a community-based project, students from different programmes would learn to appreciate alternative professional and lay perspectives on common experiences.

Community Health Services↗
PubMed2005

Origin and development of a scientific collaboration and a long-lasting friendship.

The aim of this contribution is twofold: to honour Ivan Lefkovits with a short recollection of our scientific collaboration in the years 1972-1985 and a summary of our joint contribution to studies of the mechanisms and functions of the immune system and to acknowledge our long-lasting friendship. Ivan's limiting dilution microculture method was adapted to rabbit peripheral blood lymphocytes (PBL). The antibody produced in the responding cultures was shown to be electrophoretically homogeneous and, in rabbits heterozygous at the b locus, to express either one or the other allele. Thus, the antibody released in single microcultures was indeed the product of single B-cell clones and allelic exclusion, once achieved, was maintained throughout clonal proliferation. In the response to streptococcal polysaccharides, analysis of the clonotypes triggered in vitro provided information on mechanisms of clonal dominance. A two-stage culture system was established, where rabbit PBL were precultured at low cell density with antigen before being partitioned in limiting dilution cultures. This method provided a new tool for studies of various cellular aspects of the immune response. Moreover, it allowed the application of the limiting dilution analysis to PBL from unprimed animals. Later, the method was extended with success to human PBL, leading to studies of regulatory aspects of immunity in this species.

Animals↗
PubMed2006

School re-entry of the pediatric heart transplant recipient.

Pediatric cardiac transplant has become increasingly frequent in the last decade and survival rates have improved remarkably. Outcome research on this population suggests that the majority of children have the capacity for healthy adaptation although 25-40% have been shown to have some type of psychiatric difficulties. As school plays a major role in these children's lives, early intervention and close liaison with schools is indicated to reduce psychological morbidity, enhance adaptation within the school environment and enhance overall adjustment. This paper proposes a model for a school re-entry program for this population. The school re-entry program is aimed at children who are undergoing cardiac transplant and will be entering or re-entering the school system. They may range in academic age from preschool to college level and have been attending private or public schools with placements in regular education programs, regular education programs with resource support, special education programs, and alternative school programs. Others may not have been attending school because of the severity of their medical condition and have been receiving in-home tutoring. Each child is offered school re-entry assistance by a multi-disciplinary team composed of members from the Cardiology Transplant Service. The re-entry program includes cognitive and psychosocial assessment, liaison with the child's school pre- and post-transplant, academic planning and provision of academic, emotional, and behavioral support before, during, and immediately after transplant, a school re-entry visit, and an ongoing school consultation. The goal is to address issues necessary for a successful school re-entry including appropriate academic placement and support, psychosocial adjustment, education of school personnel and ongoing health needs of the student. The next step is to formally evaluate the efficacy of this program in successful school re-entry.

Adaptation, Psychological↗
PubMed2004

Multicentre analysis of treatment planning information: technical requirements, possible applications and a proposal.

Digital data from 3-D treatment planning computers is generally used for patient planning and then never considered again. However, such data contains enormous quantities of information regarding patient geometries, tissue outlining, treatment approaches and dose distributions. Were such data accessible from planning systems from multiple manufacturers, there would be substantial opportunities for undertaking quality assurance of radiotherapy clinical trials, prospective assessment of trial outcomes and basic treatment planning research and development. The technicalities of data exchange between planning systems are outlined, and previous attempts at producing systems capable of viewing and/or manipulating imaging and radiotherapy digital data reviewed. Development of a software system for enhancing the quality of Australasian clinical trials is proposed.

Clinical Trials as Topic↗
PubMed2005

Mediating the meaning of evidence through epistemological diversity.

Nursing's disciplinary recognition of 'multiple ways of knowing' reflects an epistemological diversity that supports nursing praxis. Nursing as praxis offers a conceptual way to explore what it is about the interface of practice, knowledge and evidence in nursing that distinguishes us as a discipline. I suggest that the relationship between evidence and knowledge is defined and mediated by the same epistemological diversity that supports nursing as praxis. Just as the meaning and truth-value of evidence is evaluated from within the body of existing disciplinary knowledge, new evidence may prompt an evaluation of the meaning and truth-value of extant nursing knowledge. Nursing practice that relies on scientific evidence as a singular basis of practice knowledge is susceptible to exploitation by the diverse agendas operating within an ideology of evidence-based practice and the healthcare system. Mediating the meaning of evidence for nursing practice through acknowledgement of the diverse epistemologies that underpin nursing knowledge will contribute to a disciplinary-specific definition of what constitutes evidence for nursing, and will better direct how evidence is integrated into a disciplinary body of knowledge.

Benchmarking↗
PubMed2006

An integrative science approach: value added in stress research.

Integrative approaches to understanding complex health issues can transcend disciplinary and knowledge boundaries and provide opportunities to view phenomena from diverse perspectives. These broad approaches to understanding phenomena of interest to nursing might provide new directions for nursing research and be a requisite for delivering safe, responsible, and holistic nursing care. The relationship between stress and illness is a strong example of a field of study that can be understood more fully from an integrative perspective. The potential of an integrative approach to contribute to improvements in human health and well-being outweigh historical biases that have been associated with an integrative science approach.

Cognitive Science↗