This issue of JAN

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Three papers in the category Methodological issues in nursing research begin this issue. Two are concerned with instrument development. The first, from the United States of America (USA), reports on a study to develop a measure of ‘post-code’ stress amongst critical care nurses, the stress that arises from participation in resuscitation attempts. The second paper, from Taiwan, is concerned with the psychometrics of a Chinese translation of the swallowing questionnaire, tested on populations of patients with Parkinson’s disease and a history of stroke. Highly technical in content, these two papers serve to emphasize the important methodological development work in which nurses are engaged around the world. The third paper reports on the crucial part played by pilot studies in research. Using the Scottish Births Survey as an example, the authors highlight the fundamental issues that the pilot study raised. Yet they point out that pilot studies are frequently only reported in a study as a means of justifying the methods used. Researchers might consider changing their practice in this respect after reading the paper.

The section on Issues and innovations in nursing practice begins with a report on the educational needs of Chinese patients with schizophrenia in Hong Kong, identified from a survey of 192 patients. Length of duration of illness correlated negatively with patients’ identification of need, an indication of the adverse effects of the condition. Gaining information about mental illness, improving social relationships, and how to solve daily problems were given high importance by those who identified their predominant needs. The second paper, from Sweden, also concerns chronic illness. Twenty-five women diagnosed either with chronic fatigue syndrome or fibromyalgia were interviewed in order to illustrate the biographical work done by these individuals in response to the reality of living with a chronic condition. The author found that profound disruption to the women’s identity in relation to work and social life was a consequence of the illnesses. However, these disruptions were partial and different degrees of identity transformation took place, including the experience of illness gains.

The next two articles concern carers. The first reports on a study of 51 adults who, as children, had provided care for adults with chronic physical illnesses. Both positive and negative experiences were reported. As a child, delivering personal care was reported to be the most difficult, and doing household tasks the most time-consuming. The loss of childhood is the most controversial aspect of children providing care, and this is a subject that has also received attention in the United Kingdom. Yet involvement in war, and in natural disasters also disrupts children’s lives in deeply traumatic ways. We cannot write a universal prescription for our stereotypical image of children’s ideal existences. Too often, the reality is very different. We must intervene where possible, balancing the rights of the child with its need to be a participating member of the family group, and recognizing that separation frequently results in even greater emotional damage. Involvement of the child in decision-making is a crucial factor when considering the options in these difficult situations.

The involvement of carers in general is the subject of the second paper. United Kingdom government policy urges service providers to involve service users and their carers in the decision-making process. In this study reported from Scotland, 20 informal carers and 29 members of the multidisciplinary team in a ward in a psychiatric hospital specializing in the care of older people, were interviewed on the subject of carer involvement. Structural and interpersonal difficulties were identified. When the carers felt that their involvement was respected and taken note, it was found that there was usually an intermediary involved in negotiating the community–hospital interface on their behalf. When they felt uninvolved, it was often their reluctance to interrupt apparently busy staff in order to ask questions, or the mechanisms of multidisciplinary meetings where the carer was the only person not represented, that formed the major barriers. These are not dramatic or new findings. They do identify however, where less than good practice is the result of thoughtlessness on the part of staff, and where reflection (that over-discussed but under-used activity) might just make all the difference to involving carers.

The next article in the practice section comes from Catalonia, Spain, where nurses’ attitudes to the terminally ill were studied using a free word-association test. Slightly negative attitudes were identified, although older caregivers and women were more positive. The authors believe that these findings should influence the development of training programmes for staff, when the modification of negative attitudes and the promotion of a professional approach to care could be attempted.

A Norwegian researcher carried out the studies in both Norway and Scotland for the final paper in this section, comparing changes in health visiting in the two countries, respectively. Similarities and differences in the changing roles were found; perhaps unsurprisingly considerable organizational and structural change was identified in both countries. British readers will not be surprised to learn that in the Scottish city, home visiting was decreasing as the role expanded and more tasks were taken on. The next paper also concerns health visiting, although within the category Nursing theory and concept development or analysis. Health visitors in Hayward’s Heath, Southern England, introduced corporate working as a means of dealing with increased demand and large caseloads. This paper analyses the concept of corporate working and compares it with traditional, individualized health visiting. The author concludes that there are many benefits to this method of health visiting, including improved service delivery and enhanced professional growth.

Authors in Australia and the USA write the second paper in this category, on technology and humane nursing care. Both are well known for earlier work on technology, and their current paper addresses the need to reconcile the presumed tensions between technology and person focused care. They argue that the dehumanization of care does not arise from technology per se, but rather from how the technologies are used and operated. Like the involvement of carers referred to above, the need for reflection on how care is delivered seems to be a lesson that should be passed to successive generations of nurses dealing with developments in technology and health care practice.

The third paper on theory and concept analysis, also from Australia, considers subject position theory as a method of explaining interactions between nurses and physicians in terms of power dynamics. I am sure that many nurses could identify with the vignette offered by the author as a means of demonstrating the application of this theory, if not with the clinical situation in neonatal care, then with the interaction between physician and nurse. She comes to the rather depressing conclusion that the political and cultural structure of the health care system does not support the subject position of the nurse advocate. Yet, her reasoning is completely logical and she offers suggestions as to how this situation might be resolved.

The final category in this issue concerns Experience before and throughout the nursing career. Three papers feature, two reporting studies on stress in mental health nursing, one from Wales and one from Scotland. The findings from these two papers provide an example of the importance of studying carefully the characteristics of two apparently similar studies, before drawing general conclusions. Although both studies included the Maslach Burnout Inventory (MBI) in a postal survey, there were more differences than similarities between them. For example, the two populations studied were different. The Welsh paper reports on a postal survey of the total number of Forensic Community Health Nurses (104) attached to all Medium Secure Units in England and Wales (response rate 77%). The Scottish paper, on the other hand, surveyed 1045 nurses who constituted a stratified random sample drawn from nurses employed in a Scottish National Health Service Trust, which provides both acute and continuing care psychiatric services in a range of hospital and community bases (response rate 48·8%). The two studies were based also on differing theoretical rationales and, apart from the MBI, used different measures. Differences in the results of the two studies should not therefore be surprising. In relation to the subscales of the MBI in the Welsh study, 44·3% of respondents were rated as experiencing high levels of emotional exhaustion compared with 21·6% in the Scottish study. High levels of depersonalization, and low levels of personal accomplishment, were experienced by 26·6% of respondents in the Welsh study, compared with 7·1% and 33·1% for each measure, respectively, in the Scottish respondents. Both studies did however, identify a positive relationship between support and lower levels of burnout.

More detailed findings follow in both articles and because of the different measures used these cannot be compared directly. However, the differences are sufficient to raise some interesting questions about these two populations of psychiatric nurses in the UK. For example, are Forensic Community Health Nurses very different to nurses drawn from an NHS Psychiatric Care Trust in their responses to stress? Alternatively, are the workloads so very different that the Forensic nurses become more stressed? If this is so, then why did more NHS Trust nurses experience feelings of lower personal accomplishment? These questions are impossible to answer from the articles presented here, but they could generate interesting hypotheses for further study. This might be particularly useful when considering recruitment and retention amongst the two groups.

The issue concludes with an article on the experiences of leaders of nine Clinical Development Units in Western Sydney. This is a useful, longitudinal study of a developing concept in Australia. The findings reinforce earlier work from the UK in several respects. The nursing leaders felt excited and challenged, but at the same time apprehensive that they might not live up to their own expectations for themselves. Some of the most difficult issues were concerned with sheer survival and, above all, they wanted leadership for themselves. How many times we learn of this last finding. Across a range of nursing research studies the importance of leadership support for nurses working in vastly different situations, stands out.

Leadership not only gives nurses more self-confidence, supported nurses provide better patient care. The difficulties of comparing even two studies on apparently similar populations have been stressed. Yet, literature reviews and meta-analyses of studies involving a range of important concepts for nursing care, including leadership, must be initiated and publicized. Only by providing this evidence will governments begin to listen, and provide nursing with the necessary resources.

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