This issue of JAN


The Current issues and forthcoming events of Issue 36·3 contained a section on the incidence of Buruli ulcer in sub-Saharan Africa, a condition caused by a Mycobacterium from the same family of bacteria that cause tuberculosis and leprosy. Unlike these two diseases however, Mycobacterium ulcerans appears to be resistant to all known antibiotics, and its increasing prevalence poses an emerging public health threat in the wet areas of many tropical and subtropical countries. Early identification appears to offer the best hope of surgical treatment before major disfigurement from the disease results in severe complications and costly hospitalization. Of personal interest was that the disease was first described in 1897 by Sir Albert Cook, eminent physician in Uganda and founder of Malaga Hospital, now the University Hospital of Makere University, Kampala. The medical and nursing school collections at Makere are housed in the Sir Albert Cook library, named after this pioneering Victorian physician. All of his papers on hospital admissions and treatments are also housed there. It was a great privilege to be shown this archive by Dr Maria Musoke, Senior Librarian, when I visited in January 1997. Regrettably, lack of resources mean that it is not possible to keep the papers in conditions of ideal temperature and humidity and this invaluable resource is suffering from inevitable and serious decay. Yet, the significance of a resource of this kind is demonstrated when contemporary epidemiologists need to trace the natural history of a disease back in time. We never know when the apparently ephemeral phenomena of our daily lives will become a priceless resource.

The articles in this issue begin with two in the category Nursing and healthcare management issues. The first reports on the application to practice of the first results (1998) from an ongoing national study (1999, 2000) of pressure ulcers. The study sought to identify the extent to which knowledge of the 1998 results had influenced institutional policy on pressure ulcer management. The study coordinators in each participating institution were asked to respond to a postal questionnaire framed around an innovation decision-making model. The responses to the questionnaire were promising, although different institutions took initiatives on different categories of activities, and the authors acknowledge that self-report at coordinator level may not necessarily reflect activities actually planned and implemented. Of more general interest was the fact that The Netherlands, where this study is ongoing, appears to be making great strides in establishing research on nursing subjects at a national level. For example, an earlier study that explored the Netherlands nursing minimum data set was reported recently in JAN (Griens et al. 36:1, 89–101). One can appreciate that conditions for national level research are favourable in a country with just 16 million inhabitants, Gross National Product per capita in 1998 of US $24,760 (The World Bank 2000, page 231) and good communication networks. Nevertheless, these initiatives suggest that good research networks are also in place, that supportive attitudes may be found at institutional and government levels and, above all, dedicated funding is available for the research of nursing issues. A paper on the development of the nursing research infrastructure in The Netherlands would therefore be timely and helpful for nurses in other countries who are struggling to find a way forward in national research.

The second management paper might at first sight appear more appropriate for Issues and innovations in nurse education. However, the findings from this study of third year undergraduate nurses’ expectations of their graduate year have more implications for managers’ recruitment and retention strategies than for the development of nurse education. More than 100 Bachelor of Nursing undergraduates from one metropolitan university in Australia were surveyed by questionnaire. The majority of preferred options for the graduate year were to work in a large public hospital that offered wide experience in a learning-centred environment, preferably in critical care, surgery, paediatrics and/or emergency services. Their least popular career choice was care of the elderly. Despite Victoria State government funding to run graduate nurse programmes, usually involving a one-year internship, tensions apparently still exist between the expectations of the graduates themselves, the universities, and staff in the clinical settings. There is much to be learned from this student-centred study, particularly as it comes from a region of the world where considerable thought has already been given to first year graduates’ needs.

Gerotranscendence, and its perception by nursing staff, is the subject of the one paper on nursing theory in this issue. This concept has an intuitive ‘fit’ with older persons’ changing outlook on reality, yet I had not heard of it before. Nurses working, teaching and researching in gerontology should find this paper from Sweden an invaluable addition to other theories of ageing in current use.

Two papers from the United Kingdom (UK) follow in the category Methodological issues in nursing research. Both discuss the ethically sensitive problems of carrying out research with frail or vulnerable subjects. The first concerns the recruitment of frail older people, and the second considers the problems of conducting focus groups with people with enduring mental illness. Both papers will be an important resource for students, and teachers of research methods, and they reinforce the importance of taking ethical issues into account throughout the research process. The first paper contains useful discussion on the nature of informed consent as well as the particular problems of approaching frail elderly persons to take part in a randomized control trial. The second discusses the issue of access to women with serious and enduring health problems, and the role of the researcher in facilitating communication and interaction in focus groups with this clientele.

A second article by a Swedish author on conversations between parents and health professionals in the child health centre heads the papers in the category Issues and innovations in nursing practice. Research on interactions in this setting have been neglected relative to those taking place in a child’s home, and this paper is to be welcomed as a new dimension on nurse–parent/child communication. The dominance found in this study of the nurse’s agenda raises the question of how easy it is to have client-centred interactions in a clinic setting. This issue merits further study as home visits decline as a result of financial pressures, and other demands on child health services. The second article describes nurses’ perceptions of their interactions in the telephone consultations with callers at an NHS Direct site. This is a relatively new service in the UK where clients worried about a health issue can talk directly by telephone to a specially trained nurse. Visualization of the situation takes place by ‘building a picture’ of the patient and their concerns. Various interactional activities help the caller to describe what the nurse cannot see. This timely study of a new service will no doubt prompt further work on the effectiveness of the measures used in telephone consultations.

The relationship between social support and postpartum stress is the subject of the next article, from Taiwan. Taiwanese traditional culture emphasizes the importance of maternal postpartum rest, with many domestic duties carried out by relatives. The author concludes that the persistence of this tradition accounts for low levels of self-reported stress amongst the women sampled. Three factors were important predictors of women’s postpartum health status. Some did show signs of minor psychiatric morbidity, and stress rose at the third and fifth weeks, perhaps as social support was reduced. The author recommends comparative studies between Eastern and Western cultures to test out the findings of this study.

The final article in the practice section, from England, reports on a pre- and post-test survey to evaluate a middle phase of facilitating knowledge and use of research in practice. No significant differences were found before and after the facilitation exercise, and attrition from the study further suggested weak support for the ideas. Nevertheless, qualitative data from those involved in the clinical projects provided useful information on the feasibility of, and constraints on, undertaking research in practice.

One literature review is presented in this issue, for which nine primary research articles published within the last decade on ‘Critical care outreach services and early warning scoring systems’ were reviewed. The important findings on suboptimal care; outreach services, and the use of early warning scoring systems, are analysed mainly in the context of their relationship to recent UK government policy initiatives in intensive and high dependency care. The author points out that in an ideal world critical care outreach teams would not be necessary, as wards would be appropriately staffed with nurses and doctors trained and competent to identify those at risk of developing critical illness. In a less than ideal world however, clinical and educational staff should still be making this competence their aim.

This issue concludes with an article under the heading Experience before and throughout the nursing career on the distribution of nurse endoscopists in the UK, and the range of their diagnostic and therapeutic skills. Postal questionnaires were delivered to every relevant hospital in the UK (292). Sixty per cent of respondents (176) said that nurse endoscopists were employed in their hospital, a figure of 26% of the total surveyed. Forty-four nurse endoscopists were reported to carry out both upper gastrointestinal and flexible sigmoidoscopy. The majority performed diagnostic procedures, with a smaller group performing some therapeutic interventions. This type of information is always useful as a baseline to track future developments, and 45% of those responding who did not currently have nurse endoscopists planned to do so in future. A follow-up survey in perhaps 5 years’ time would help to establish the extent of the consolidation of this development in nurse/physician substitution.