This is the last editorial for 2002; it is also my final one as Editor-in-Chief of JAN. In January 2003 this responsibility will pass to Professor Alison Tierney, supported by an expanded editorial team. Over the past five and a half years many changes have taken place. To make JAN more relevant and accessible to its readership, developments have included the introduction of nine categories for published articles and since 2001, structured abstracts and twice-monthly publication. To continue to raise the standard of articles published, a global database of subject expert reviewers was created together with statistical review for all appropriate manuscripts. To improve the efficiency of the editorial and publishing processes, most significant from an editor's perspective have been the centralization of editorial and production processes in Oxford, increasing editorial support and the development of electronic communications. The recent introduction of statistical guidelines for authors is a further important innovation and I am including them for information at the end of this editorial.
All of the changes have been introduced with the support and encouragement of Blackwell Publishing's permanent team, led by Griselda Campbell, Publisher. The nursing editors have been enabled to work closely together on editorial decisions, offering support for authors with individual commentary on submitted manuscripts, with finally accepted articles being published within 4 months.
It has been both a privilege and a challenge to be associated with these significant developments in nursing publishing at Blackwells. My editorial role has incorporated a crucial educational element as JAN publishes not only the work of experienced researchers, but also encourages neophyte authors. Accepting the diversity of nursing world-wide and the different stages of its practical and intellectual development have been exciting challenges when editing articles for publication. The breadth of international ideas in articles submitted for consideration has been a fascinating aspect of my involvement with the journal. When writing successive versions of ‘This issue of JAN’ (introduced in 2000) I have been struck not only by the journal's eclecticism, but also by the many connections that can be made between nursing in various settings and the different ideas that are being developed by contributing authors. I see these connections as a crucial route to eventual generalizations in nursing practice and theory. Examples of these connections include the ongoing definition and management of fatigue (for discussion see 32, pp. 1042–1043) and sleep deprivation (34, pp. 149–150), in different nursing situations. It is this aspect of JAN that I shall miss most but, as I move in January 2003 to edit the International Nursing Review, official journal of the International Council of Nurses (another Blackwell Publishing journal), I know that similar opportunities will continue in this new context. Meanwhile, I wish Professor Tierney and her team every success in the continuing development of JAN. Also, I take this opportunity to thank all members of the Editorial Board, reviewers, authors, and editorial colleagues for their contributions to the development of JAN that has brought such satisfaction over the past 5 years. I congratulate Professor Roger Watson (Media Reviews) who in 2003, becomes Editor of Journal of Clinical Nursing, and Hussein Rassool who will continue to edit Current issues and forthcoming events from his position as Professor of Addiction and Mental Health at the University of Sãn Paulo, Ribeirao Preto.
The contents of this issue begin with two review articles. The first from Australia makes a further contribution to the subject of physical restraint of older people, a subject of great concern to many nurses (see Editorial in 38, pp. 541–542 and 40, pp. 405–412). As this article reports, rigorous research into the minimization of restraint in acute settings is extremely limited. More studies were identified from the residential care setting, but with only one randomized control trial (RCT) identified. The author is able nevertheless to make cautious recommendations for nursing practice based on the limited evidence available, at least for residential care. The second review, from the United States of America (USA), concerns sampling and data analysis issues related to gender in the literature. Male caregivers have received scant attention in studies of functionally impaired older people, despite their considerable contribution to the family caring role. This review makes an important contribution to our understanding of the methodological issues involved. Limitations in sampling and convenience samples in particular have been mainly responsible for the bias found in many studies, with the sons of older people frequently being excluded. The recommendations provide useful design guidelines, which should lead to more representative studies in future.
A single article in the category Methodological issues in nursing research concerns the philosophical background to constructivism, the influence of which is seen in many health services research studies undertaken in natural settings. The authors explore five principles underlying the concept and compare it with other research methodologies. They argue that the adoption increasingly in health studies of generic research methods without consideration of their ontological and epistemological origins demands rigorous evaluative frameworks. Further, there is a need to keep the relationship between philosophy, methodology and qualitative research under constant review, if richer and more robust research is to be developed.
A welcome increase in contributions to JAN Forum has been seen recently, with contributors willing to enter into discussion and debate on a range of topics; JAN Forum in this issue contains three contributions on statistical and methodological issues.
A single article under Health and nursing policy issues provides a rare insight into the health needs of vulnerable elder people in rural USA. For most non-American readers, images of the USA are possibly confined to the major, prosperous cities of the Eastern and Western seaboards, with little appreciation of the vast and often remote territories in between. On a memorable AMTRAK train journey in 1997, I travelled from Washington DC in the East to Seattle in Washington State in the north-west of the USA. The Chicago to Los Angeles leg of the journey (a distance shown on the author's map of the area) took 36 hours, during which we passed through vast tracts of largely uninhabited land with occasional ranches, landscapes and settlements that were reminiscent of western films. In this article, the author demonstrates that the problems of inequalities in health in this region are as acute as in many other countries, with declining traditional industries and ageing populations with few resources on which to draw. The soaring costs of prescriptions, ignorance of eligibility for support, poor access to health care, isolation and the fragmentation of formal services were all found to be barriers to care. Yet, New Mexico is a favoured retirement area with its dry, warm climate and the prospect of increasing numbers of older people in the future. Studies such as this are clearly needed for health planning, particularly on the provision of cost-effective community nursing services.
Six articles follow on Issues and innovations in nursing practice. Total hip replacement in one Australian hospital with a study population of 95 was found to contain a larger proportion of younger people (aged 55–64 years) than expected. Generally, the postoperative health-related quality of life in this population was found to be good, and better than that reported in previous studies. The authors conjecture that this may have been because of successful pain relief; participants were also satisfied with services received. It is good to read that adequate discharge planning and successful recovery were identified as positive features in these findings, when many studies have reported otherwise. A qualitative study using focus groups with participants who were also over, and less than, 65 years is reported next from Sweden. Participants all had present or previous diabetic foot lesions and the study explored their beliefs about health and illness. Substantial gender differences were identified in men's reactions to the lesion. As this appears to be the first study of its kind no comparisons could be made with the literature. Clearly, replication is called for as diabetes is such a major health concern world-wide.
Pain management in terminal care is the subject of the next two practice articles. Canadian authors report first on the detailed processes involved in developing and implementing a Pain and Symptom Assessment Record (PSAR) in palliative care. Designed to meet the expressed concerns of health providers in Ottowa, the PSAR includes symptoms as well as pain assessment, sedation, patient satisfaction and action taken. In this exploratory study, the tool was found to be both valid and appropriate, as it did not cause ‘excessive weariness on the part of the patient’. However, the sensitivity of the tool to changes over time requires further testing. This study has value not only in its practical utility but also as an exemplar for students setting out on the labourious process of research instrument development. The second article from Finland reports on part of a larger survey on the views of nursing staff on the needs of patients in the transition to terminal illness in cancer care. A total of 238 nurses working in 32 municipal health centres responded to a structured questionnaire; one third of who reported that patients often had pain that could not be alleviated. Respondents also reported many problems in pain management, including insufficient medication. It appears that the pain management culture in Finland results in less pain medication being used than in other Scandinavian countries. The development needs of staff are obviously not confined to nurses and the authors make recommendations for continuing multiprofessional education and collaboration. The cross cultural testing of the PSAR referred to in the previous article would seem to be ideally suited to this population, and see also the education article on cancer care below.
The last two practice articles report on studies of the work of nurse specialists in Scotland. The first explores the nature of the knowledge required by district nurses to carry out first assessment visits and its relationship to their decision making. Although only 11 nurses were included, the ethnographic study had the virtue of being longitudinal and previous data analysis and field notes informed questions asked one year after the initial interviews. Hence a rich picture emerges of the nurses' cognitive processes and their related practice. Five major categories emerged with 17 subsidiary themes. The author concludes on the basis of this substantial analysis that district nurses' everyday assessment practices lie in the ‘reflexive nature of their actions and context in which visits took place’. The connection between ‘knowing how’ and ‘knowing that’ is crucial to this process. This study provides not only further insights into nurses' decision-making processes, but also powerful refutation of the mistaken idea that district nursing is ‘unfocused and generally of poor quality’. The second article is similar to the one above on PSAR from Ottowa inasmuch that it describes both the development and testing of a tool in practice, in this case one designed to measure the quality of Emergency Nurse Practitioner-led (ENP) care in Accident and Emergency (A & E). Consecutive patients meeting the study criteria were randomized either to an ENP or Senior House Officer (SHO)-led care, with the successful demonstration of the tool and impressive results for ENP-led care. Areas requiring further testing of the tool, and its potential application to other A & E departments, are outlined.
This issue concludes with two articles under the category heading Issues and innovations in nursing education. The United Kingdom (UK) Department of Health has given high priority to the development of effective communication strategies for all professionals working with patients with cancer. The first education article reports therefore on a study of the effects of a communication skills programme delivered to 308 nurses who were studying concurrently on one of five diploma/degree courses offered at regional cancer and palliative care centres in the north-west of England. The procedure involved the assessment of pre-course and 3 months' post-course audiotape-recorded nursing assessments, which involved a substantial amount of data. A statistically significant improvement in mean pre- and post-intervention scores, together with improvements on each of nine individual elements of assessment, supports the effectiveness of the communication skills training programme used. The authors pose three important questions that need to be addressed if this labour-intensive form of training is to be extended more widely. This article has contributed a third perspective on cancer care in this single issue of JAN. Taken together the three articles, involving authors from Canada, Finland and the UK, offer insights that are greater when viewed in total than just individually. They offer a further example of the possible connections between ideas and practice referred to earlier. In considering the relationships between them, nurses have an opportunity to take ideas from articles submitted across international boundaries and to develop and test them in their own local practice situations. The next stage in the loop is that they should then report their findings in published articles.
The final article from an author in Hong Kong is based on narratives that took place originally in Canada, and which explores the conflicting professional identities experienced by nurse teachers as they moved between classrooms and clinical settings. The author contends that health care reform in Canada and a revised nursing curriculum has resulted in uncertainties for faculty staff when crossing the borders between biomedical science and the philosophy of the caring paradigm. The plot line of the story, which centres on a contentious appeal by a student against nursing faculty, will resonate with any educationalist who has been in a similar situation. By a deep analysis of the narratives involved, the author moves to theoretical explanations for the phenomena experienced. As she does so, a paradox emerges; namely the recognition that uncertainty is inherent in nursing and teaching, yet their counterpart is the certainty of evidence –‘college educators like nurses in clinical settings, live simultaneously the known and the unknown’. She and her colleagues came to recognize and develop an understanding of opposites; that their ‘sense of ambiguity was really the knowledge of uncertainty’. This article struck a personal chord, for my personal philosophy on the benefits of higher education for nurses is that it should enable students to understand, and learn to handle, the nature of uncertainty. This seems an entirely appropriate point therefore at which to conclude my very enjoyable editorial relationship with JAN.