This issue of JAN


Policy issues feature strongly in the first two articles in this issue, both relate to subjects of great importance to nursing although their style and content could not be more different. Under the heading Nursing theory and concept development or analysis, two English authors explore the theory of ‘creative altruism’ that for many years has been highly influential in the philosophy of left-of-centre policy theorists. The subject of their inquiry, Titmuss' (1970) The Gift Relationship: From Human Blood to Social Policy, was one of the first books that I read when studying for an MA by research at the University of Keele in 1977. I remember ‘happening’ upon it when browsing the library shelves and, being enrolled in an academic department that included social policy within its remit, was enthralled by the book's comparisons of United States of America (USA) and United Kingdom (UK) social policy. In the USA, the donation of blood was based on market principles; in the UK, Titmuss claimed, that donation was seen as a ‘gift’. To see the issue re-visited here in a critical account both of the book's original methods, and the relevance of its arguments on altruistic behaviour to contemporary social policy debates, is encouraging indeed for the future of nursing research. Certainly the inconsistencies in the original survey design, which the current authors have identified, were far more common in social policy research of the 1970s than we would be prepared to countenance today. Further, it appears that the book's influential argument on altruism was based on fairly shaky empirical research. All of these ‘difficulties’ exemplify something that after 5 years as Editor with JAN, I feel nurse researchers still need to reflect upon and to learn from such erudite articles as this. Too often, in nursing articles there is insufficient historical research into the origins of the policy ideas presented. Of course, the literature needs to be presented judiciously, but this first article demonstrates the rigorous study of historical origins that all nurse researchers should aim to emulate when writing on nursing and health policy.

The second article, under Health and nursing policy issues, confronts the issue of agency nursing in one city in Australia but its ramifications have global significance. Agency nursing is a widely recognized phenomenon in most western countries and is, in part, a consequence of the deliberate casualization of labour that health care reform has frequently engineered. In part, it is also a necessary response to the highly mobile labour force that is itself a consequence of these casualization policies, and which is now a permanent feature of contemporary society. Yet agency nursing is poorly researched. This article begins to make good that omission. The findings confirm much that we know from anecdote, but puts the information on a firm basis, at least for a small sample of hospitals. The study found, for example, high use of agency nurses in acute hospitals, with limited continuing education for them, their qualifications were frequently not matched to the hospital specialities where agency staff were deployed, and permanent staff were leaving the hospital environment (perhaps to become agency nurses themselves). Unfortunately because no ‘before and after’ research has been commissioned, we know little of the consequences of all this for patient care. Anecdote would suggest again that casual staffing arrangements are unlikely to be more beneficial than the use of permanent staff, but we cannot be certain. The authors of the article conclude that an overriding priority must be the regulation of the agency-nursing workforce. We agree, but also conclude that there are many unanswered questions that demand large scale, possibly international, research.

Seven articles on a range of clinical topics follow in the category Issues and innovations in nursing practice. The first, from Scotland, continues the JAN tradition of publishing articles on women's experience of living with chronic disease (for some recent articles see 39, 87–95; 137–145; 146–154 and 441–449). The current paper reports on part of a study on how women with Parkinson's disease experience and cope with menstruation and associated gynaecological problems. The findings on the difficulties experienced by the women extend our knowledge for nursing practice and are of importance to a range of nursing staff working in both community and institutional settings. The second Australian article in this issue explores nurses' knowledge and assessment skills related to the management of epidural infusions in both obstetric and surgical patients. The findings, which the authors emphasize cannot be generalized beyond their own study population, suggest that the nurses scored highly on general and pain assessment, but that their theoretical knowledge outweighed their clinical skills and decision-making. These are unusual findings as they tend to differ from received wisdom on the subject, and suggest that the research should be repeated using larger, representative populations, for the management of epidurals is an area of increasing nursing and midwifery responsibility.

The next three articles concern nursing in primary care, but in very different geographical locations and clinical settings. The first paper compares decision-making between a group of English general practitioners and nurse practitioners, using information processing theory and ‘think aloud’ techniques to understand the cognitive processes involved. This study involved a complex methodology, which included scenarios based on actual clinical cases. The detailed findings are therefore of considerable importance, especially as there were many similarities in the decision-making processes of the two groups, and the differences identified were supported not only by previous research but also by rational explanation in the current study. The second article concerns primary care nursing in a northern remote community in Canada. Institutional ethnography specifically guided the methods used. Potential difficulties for practice are suggested by the differences identified between the nurses' and First Nations people's perceptions. The nurses needed the knowledge and skills to carry on their ‘outpost nursing work’beyond treatment. Members of the indigenous community however, held the view that the nursing station is ‘primarily a place for treatment’ and the nurse is seen as an ‘other’. The authors explicate the significance of these differences for the building of trust, and the importance of relationships in order to provide care that is ‘community-centred as opposed to programme-focused’. The third primary care article reports on a study of NHS Direct. The study investigated the knowledge, confidence and attitudes towards mental health of the staff in this nurse-led telephone service, and the effects of training (for an earlier article following the introduction of this service see 36, 668–675). The findings are enlightening, as they may be indicative of attitudes to mental health among a wider population of Registered Nurses. For example, despite a general confidence in dealing with mental health-related calls, before training there was a tendency to believe in the biochemical basis of depression to the exclusion of socio-economic factors. Training was therefore seen to be an important factor in the potential success of this service, with calls for monitoring its long-term effects.

The last two practice articles both concern very different aspects of the consequences of high technology use in modern health care. From Taiwan, an account of exercise following heart transplant in eight patients is reported. In the decade ending April 1997 almost 200 patients had received a heart transplant in Taiwan, showing how ubiquitous this surgical procedure has become. Cultural attitudes to exercise feature prominently in the findings and once again, we are grateful to authors from Asia for reminding us that the awareness of local cultural beliefs plays such an important part in the effective delivery of nursing care. Authors from Northern Ireland present the second article although their study, which was funded by the European Union, involved five partner countries. The aim was to test the usability of a multimedia software application designed to provide family carers with information, advice and psychological support. The results showed ‘that the majority of users found the programme to be informative and pitched at the right level’. The authors point out the difficulties in conducting a study on this international scale, particularly in the need for staff training and availability. Nevertheless, it appears that with further refinement this application has the potential for helping many family carers across a range of international settings.

Two articles feature in the category Methodological issues in nursing research. The first reports the development and testing of a scale to identify the relevant dimensions of Emergency Nurses' attitudes to clients who present in Accident and Emergency (A & E) with self-inflicted injury. This scale is undoubtedly a much-needed innovation for the ambivalence of A & E nurses to self-harm patients is well known (see JAN 25, 1283–1291). After piloting, the tool was tested by survey with more than a 1000 nurses who were working in just under 40 A & E departments in Queensland, Australia. Unfortunately the response rate was low (35%) but generally attitudes to self-harm were negative. The results identify four dimensions that help to explain variations in the nurses' attitudes and these indicate the need for practical knowledge and support to help them when confronted with such situations. Undoubtedly this study would bear replication elsewhere. The next methods article, from England delineates the political and ethical dimensions of Action Research (AR). These arguments, although not original, appear to need re-visiting for each new generation of researchers. Articles such as this provide an important source of information for beginning researchers. The authors point out, ‘AR is growing in popularity in health care and nursing’ and potential action researchers and participants need to be aware of possible pitfalls before they embark upon their research ‘journeys’.

This issue concludes with an article from the USA under Philosophical and ethical issues. The author begins by citing the statistic ‘54 million people in the USA having a disabling condition that interferes with major life activities’ (this figure is just 4 million short of the 2001 census total population of the UK). In her study she explored the meaning of this impersonal statistic for a group of 30 Americans living in a south-western metropolitan area of the USA and either disabled themselves, or caring for a disabled family member. The research recruitment strategy emphasized that persons with a Christian background would be welcome to participate, for the author wished to explore participants' perceptions of spiritual experiences associated with living with disability. In reporting the detailed findings, it was found that ‘participants’ spiritual beliefs provided assistance with coping and multiple benefits'. The author points to the many practical applications of her study for both helping professionals and for religious leaders. Articles involving spirituality in JAN tend to provoke bi-polar reactions. Yet here is an immensely practical study that once again emphasizes the huge significance of understanding cultural beliefs for the effective delivery of nursing care.