This issue of JAN

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The first two articles in this issue concern organizational issues in health care. From Switzerland an article in the category Health and nursing policy issues examines nurses' knowledge regarding local health care reform in their own Canton Vaud. It is interesting from a United Kingdom (UK) perspective to discover that in a federal system such as Switzerland, health care decision-making for a canton population around the size of an average to large English Health Authority is highly decentralized. It is probably not surprising therefore to discover that Swiss nurses overall, showed a moderate to high level of knowledge of the reforms, or that employment in the community, a managerial position, or possession of a non-nursing degree were all positively correlated with higher levels of knowledge. However, levels of certainty were significantly higher for knowledge of the Federal Health Insurance Law than for the principles of health care reform in Canton Vaud itself. The authors argue that this phenomenon may arise from the structure of the Swiss political system itself rather than from nurses' professional status, and they recommend that crucial knowledge deficits identified in their study should be addressed by the implementation of dedicated educational programmes.

The second article, in the management category, concerns the role of ritual in the British National Health Service (NHS), which has long been known for its manifestations of tribal behaviours between different groups. Here, the authors from two English university schools of business and management challenge the predominantly negative view of ritual held by many nurses. They argue that the judicious elimination, or reinforcement, of traditional ceremonies by managers can help to break down unhelpful barriers between subcultures in the NHS and promote flexible, team-orientated working arrangements. This is a novel argument that supports the practical development of less rigid working practices between different groups. This is a very different view to that traditionally held of ritual where in nursing, at least, it has often been seen to promote routine and uncritical practice. This view was also challenged in an article in issue 38:2 (pp. 144--151), where the author argues that the rituals used by nurses, provide a rich source of insight, meaning and purpose into nursing actions. Perhaps the time has come to reassess the place of ritual in health care. It would also be useful to distinguish between nurses' use of intuition and ritual, for it seems that the two concepts can be confused and that both may have positive and negative connotations, and consequences.

Two integrative literature reviews follow, both from the United States of America (USA). The extensive historical literature is reviewed first to establish a framework for defining quality of nursing care. The authors explain the complex ramifications of ‘quality’ and conclude that nursing has defined high quality nursing care inappropriately in the past as a product defined from the patient's perspective, rather than a service offered by the profession. They indicate that progress will be made when ‘(these) models and theories yield empirical indicators for measuring quality by providing a clear description of what nurses do’. One can only agree wholeheartedly and say ‘Amen’ to that. The second article reviews the literature on cognitive functioning in older adults within the context of what the authors term the 4 D's. They argue that age-related cognitive decline may be characterized by delirium, depression, dementia and/or a combination of these. If remedial action is to be taken nurses need to know the different aetiology of each of these symptoms, and how they are expressed in observable changes. Both of these reviews contain important information for improving the quality of nursing practice, one from a theoretical perspective and one that is highly applied. They both provide information for nurses to influence patient outcomes for the better.

The category Nursing theory and concept development or analysis contains two articles. First from the UK, Foucault's analysis of disciplinary power is applied in a critique of British health visiting. The author identifies from her interviews with both mothers and health visitors their mutual engagement in disciplinary practices. The ambiguity of the British health visitors' universal role with families of young children has been written about now for almost half a century. Celia Davies's (1988) seminal analysis of health visiting between 1900 and 1914 traces some of the forces of class and gender that contributed almost a century ago to the development of health visiting as it is today. That contemporary health visitors simultaneously exert disciplinary power whilst also being a ‘friend of the family’ is not in doubt. What is less certain is how the resultant ethical and moral dilemmas for health visitors should be resolved. On the basis of substantial accumulated evidence, policy action and a systems approach to resolving this health-visiting dilemma is long overdue.

The second theory paper unusually applies a concept analysis technique to defining and measuring nursing productivity. A pilot study was carried out after the concept analysis in three units to test the impact of a differentiated Registered Nurse practice model on productivity. This preliminary study showed that changes could be detected using this approach and the authors discuss its possible future application. Unsurprisingly, their recommendations include meeting the challenges thrown up by this approach, and combining longitudinal productivity measurement with quality patient care indicators. This suggests a need to combine the principles of this approach to productivity with those for determining the quality of nursing care, possibly as discussed in the third article in this issue, also from the USA.

Four practice papers conclude the articles in this issue. The first, from Finland, concerns expert supervisors' views of clinical supervision in a multiprofessional team. Finland has been one of the countries where nurses have carried out research on clinical supervision issues for more than a decade. (The third author's doctoral dissertation on the subject is referenced for 1989.) It is to be expected, therefore, that the Finns would turn their attention to the highly topical subject of multiprofessional teams. In this study, the supervisors' views of this experience were generally positive, although they reported that the work was challenging and demanding. Here again is a link with the second paper in this issue, on influencing multiteam working through the judicious use of ritual. Should lessons be learned and applied for improving multidisciplinary team working from the conclusions of both these articles?

An article follows from Taiwan, on pre-discharge predictors of follow-up care for elderly patients. These were found to be associated with pre-admission institutionalization and caregivers' preferences. In addition, strong predictors of home nursing use included self-care ability, level of consciousness and tubes in situ before discharge. Whilst it could be argued that the findings are intuitively obvious, it is extremely useful to see them identified so systematically. The possibility of a scoring system for predicting possible discharge needs and arrangements seems to be a logical consequence of this work.

A study of the safety and effectiveness of a nurse-led anticoagulant service is reported from the English Midlands. The findings from a retrospective, random sample of 197 patients provided some useful indicators. Anticoagulant nurses were found to be at least as safe as the consultant haematologist in managing outpatient anticoagulant patients over the study period. The authors outline a number of study limitations and this study paves the way for a multicentre prospective RCT on this highly topical subject of labour substitution. The final article, from Norway, reports on a relatively neglected aspect of mental illness – nursing staffs' perceptions of persons suffering from mania in acute psychiatric care. The paradoxical nature of the manic person's suffering is described, and the authors found that nursing staff appeared to understand well the manic patient's intense frustrations and his/her need to be understood and confirmed as a person. This article represents another insightful piece of work from Scandinavia on the experiences of caring for ‘difficult to care for’ patients. The authors are to be commended and we hope that the much-needed patient's perspective will form the basis of further study.

We conclude this issue with two letters in JAN Forum. We always welcome challenging and critical commentary on what we publish in JAN.

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