This issue of JAN


The snappy title ‘Foucault could have been an operating room nurse’, conceals a deep analysis by two Australian authors of the nurse's role in this highly specialized area of practice. They demonstrate how the application of Foucault's ideas (a notable theorist on the nature of power) can help to illuminate the complex, hidden aspects of a nursing role. Traditionally seen as task-orientated and medically based, operating room (or theatre) nursing has been questioned for some time as within the province of the nurse at all. Looking specifically at issues of power, disciplinary technologies and knowledge in the domains of space, time and the ethical self, the authors develop an analysis of the underlying forces that shape both others' and the operating room nurses' own perceptions of their role. They argue that by raising nurses' own awareness of the contested structures of the operating room, they can come to ‘understand how they exercise power through their activities and acknowledge that their roles exceed traditional interpretations where they are cast as surgeons’ assistants.' This article surely extends our understanding of nursing in general by subjecting one highly specialized aspect of the role to such critical scrutiny.

The second article in the category Philosophical and ethical issues raises once again the issue of spiritual assessment as a basis for nursing practice. Probably no area of nursing is the subject of such polarized debates. A recent editorial (39:1, pp. 1–2) argued that there is no necessity for nurses to engage in this form of assessment at all. Here, the North American authors accept that such views exist, but discount them in developing an approach to spiritual care that balances control and spirituality within the context of an individual's history, values and needs. A theoretical framework is introduced to act as an organizing structure for nurses in their delivery of spiritual care, and a case study is used to illustrate its application. The authors argue that the openness and trust that the example demonstrates can only develop if nurses are comfortable with their own spirituality. We recognize that for many this will be a useful adjunct to knowledge in the field, whilst at the same time acknowledge that others may be uncomfortable with the ideas advanced. Whatever one's individual philosophy however, we cannot disagree with the principles for sensitive nursing care that are embodied in this article.

The following six articles are concerned with a variety of issues and innovations in nursing practice. First, a study of the attitudes of primary health care nurses to brief alcohol intervention and their practices in this field isreported by researchers from the University of Newcastle in the north-east of England. Interviews were conducted with 24 nurses who had been involved in a prior intervention trial led by general practitioners (GPs). All respondents were involved to an extent in alcohol-related work, but some did little more than record consumption levels in patients' notes. Others offered advice, whilst a further group reported working in a more sophisticated way with excessive drinkers. The general lack of training for primary health care nurses in this area was a notable feature of the findings. Although relatively small in size, this study contains a wealth of information for policy makers, educators and managers in primary health care. As the authors conclude ‘As current health policy is to encourage, sustain and extend health promotion and the public health role of primary care nurses, more attention should be given to…better preparation and support to carry out such work’. Who could disagree with this conclusion?

The next two articles concern the evaluation of different forms of alternative or complementary care. So often these forms of intervention are criticised for a lack of evidence for their effectiveness, and it is good to see the increasing development of rigorous nursing research (see, for example, studies on foot massage and guided relaxation following cardiac surgery, [JAN 37, pp. 199–207]; and the effects of massage on pain and anxiety during labour, [JAN 38, pp. 68–73]. The first study, from Taiwan, reports on a randomized block experimental design to assess the efficacy of acupressure to prevent postoperative nausea and vomiting. Significant differences were found between the acupressure group, an alternative intervention and a control group. All three groups were demographically comparable and the authors believe that the improvement was the result of acupressure. Studies of this kind inevitably carry certain limitations in design and the authors conclude with useful recommendations for further research as well as describing the implications of their findings for practice. The effect of music as a method of inducing relaxation and calm is a subject of increasing interest as the number of surgical interventions carried out using epidural or local anaesthesia increases. A recent systematic review (JAN 37, pp. 8–18) identified a lack of evidence on many specific aspects of music as an intervention, and the authors of the next article from Hong Kong found no previous work on the effects of music intervention on preoperative anxiety in males undergoing transurethral resection of the prostate. In their study they aimed to remedy this omission in the literature. Three groups were again used in its quasi-experimental design and the music intervention significantly reduced all blood pressure levels for the music patients compared to the other two groups. Several methodological issues are raised, including the apparently neutral effect of the presence of a nurse in one of the groups, which merit further investigation. Points that I noted also include the fact that this study related to preoperative anxiety and many surgical units also introduce music during the surgical procedure itself. Also, the music was chosen for the patients and this is a variable that would bear further investigation. For example, an acquaintance told me that only ‘Country and Western’ music was on offer during their conscious surgical intervention and, as a result, the offer was declined!

An action research study of the implementation of audit in palliative care is the subject of the next article. The authors observe that the introduction of quality assurance in palliative care has been fraught with difficulty, partly because of the way that it has developed in a relatively unplanned way and also because of the ethical dilemmas of carrying out random allocation of patients in the final stages of their lives. One could add that palliative care has tended to be viewed as inherently a ‘good thing’ and that audit might seem an unnecessary intrusion on the private aspects of altruistic, compassionate and often voluntary forms of care. This account therefore has both specialist and general points of interest, including the development and modification of an appropriate tool to assess effective teamwork. The next article represents a further in-depth account from Scandinavian authors of phenomenological work with patients with profound mental illness, in this case severe dementia. The authors in this study have clearly followed-up an earlier report published in 1998 on episodes of lucidity in dementia (JAN 28, 1295–1300). In this study, a dementia patient's awareness was actively promoted by supporting them in a number of ways. This painstaking activity with what are often regarded as ‘unrewarding’ patients gives hope not only to patients and their relatives, but also to staff. As the authors conclude, ‘a patient with severe dementia may be much more present as a competent person than we sometimes believe’.

The final article in the practice category concerns the stresses and coping strategies used by mothers who are living with a child with cystic fibrosis, and contributes to a growing literature on parental experiences of having a child with a chronic condition (for recent examples in JAN 38, 449–457 and 38: 598–606). This study, carried out by a medical student with a GP supervisor at the University of Birmingham in the English midlands, reports that life expectancy for cystic fibrosis sufferers now stands at 40 years of age. In 1956, when I nursed at the Birmingham Children's Hospital, their survival could not be assured beyond the age of 4 or 5. This miracle brought about in less than 50 years by improvements in pharmacology and general care has had the unintended consequence of untold associated anxiety and stress for parents, as they manage the genetic implications together with the day-to-day exigencies of this chronic disease in their child. In this study, specialist care was highly valued but that provided in primary care was limited. It is notable that the medical authors see nursing professionals as the holders of hope and bridge builders for families with a cystic fibrosis member.

The article in the category Experience before and throughout the nursing career follows an earlier one by the same authors on ritual in the National Health Service (JAN 38, 341–352). Drawing on data from the same study, they examine the life world of night nursing; seeing it in the context of a temporal landscape with permeable borders between different time contexts. This novel approach brings a different interpretation of familiar territory where managers might talk about the possibility of ‘annualized hours’ whilst nurses think in terms of ‘three shifts’. Shifts themselves are conceptualized in various ways (not least in terms of their fiscal implications) and ‘flexibility’ has many connotations. Once again in JAN, non-nurses look at nursing issues and here challenge us with a temporal ‘map’ to re-think how we view our working environment and our place within it.

The final article in this issue presents a systematic review of the literature on cultural aspects of coronary heart disease (CHD), focusing on the Chinese-Australian population. The authors point out that in Australia's culturally diverse population (24% born overseas) China is proportionately the fastest growing of all cultural groups. Chinese-Australians are not only one of the fastest growing populations; they are also at increased risk of CHD upon settling in Australia. Drawing on 50 relevant articles from searches that resulted in over 1000, the authors review CHD in Australia and various aspects of culturally related behaviour covering adjustment following diagnosis, health seeking, use of health services, and cultural influences on the experience of CHD. They found only limited research on many of the above aspects and a paucity of nursing studies. They now plan a study to evaluate systematically the health seeking behaviours and belief models of Chinese-Australians. Almost invariably research throws up more questions than it answers, and this review is no exception. However, the authors provide a model for acting on their findings and for addressing systematically the many knowledge gaps regarding minority cultures, which they identified. We hope to hear more on the progress of their proposed study and its potentially important findings.