Tuesday, 23 December 2014

‘We DECide – Discussing End-of-life Choices’: how to realize advance care planning for nursing home residents with dementia?

Sophie Ampe
KU Leuven, LUCAS, Centre for care research and consultancy

Advance care planning (ACP) is the communication process of preparing care choices for when persons no longer have decision-making capacity. In this respect, it is of utmost importance for nursing home residents with dementia. However, ACP is mostly not realized for this group. Advance care planning consists of discussing care choices and making decisions, and corresponds to shared decision making: the involvement of persons and their families in care and treatment decisions.

Our paper describes the implementation and evaluation of ‘we DECIDE’, an educational intervention for nursing home staff on shared decision making in the context of advance care planning for residents with dementia. ‘We DECide’ is expected to result in a higher realization of shared decision making in individual conversations on advance care planning. A better implementation of advance care planning will lead to a higher quality of end-of-life care and more person-centred care. The study findings will support policy makers, on the one hand, to implement advance care planning in practice and professional caregivers, on the other hand, to conduct conversations about advance care planning.

‘We DECide’ could eventually be integrated in continuing education programs to teach shared decision making skills in the context of advance care planning.


Sophie Ampe, MSc, PhD candidate
KU Leuven, LUCAS, Centre for care research and consultancy
E-mail: sophie.ampe@med.kuleuven.be


Reference

Ampe S., Sevenants A., Coppens E., Spruytte N., Smets T., Declercq A. & van Audenhove C. (2014) Study protocol for ‘we DECide’: implementation of advance care planning for nursing home residents with dementia. Journal of Advanced Nursing. doi: 10.1111/jan.12601


Perceptions, experiences and needs of patients with idiopathic pulmonary fibrosis (IPF)

Annette Duck, MRes BSc RGN, Interstitial Lung Disease Specialist Nurse1
L G Spencer, MB ChB, Chest Consultant2
Simon Bailey, MD, Chest Consultant3
Colm Leonard, M.D, Consultant4
Jennifer Ormes, BSc, Lung Physiologist4
Ann-Louise Caress, PhD RGN RHV, Professor of Nursing4,5

1University Hospital of South Manchester, NHS Foundation Trust, Manchester, UK
2Aintree University Hospital, NHS Foundation Trust, Liverpool, UK
3Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
4University Hospital of South Manchester, NHS Foundation Trust, Manchester, UK
5University of Manchester, UK


Idiopathic Pulmonary Fibrosis (IPF), previously known as cryptogenic fibrosing alveolitis (CFA) is a chronic, rapidly progressive, incurable, lung disease that currently has a mean life-expectancy of 2-4 years from diagnosis. The 5 year survival rate is estimated to be between 20-40% which is worse than most cancers. Despite this, patients with IPF have many unmet diagnostic and support needs as this research illustrates. If this was a cancer, patients could expect an urgent referral pathway to specialists who are familiar with their condition, be offered the latest treatment and given priority in the form of NHS available support.

The UK NHS is in the process of developing regional Interstitial Lung Disease (ILD) networks which will aim to deliver specified services that should improve the national delivery of ILD care. Until regional ILD networks have been fully developed patients may continue to experience the problems outlined in this research with inaccurate diagnosis and ad hoc manner of treatment and support depending upon local service provision.

This research tells in patients' own words what it is like to be diagnosed and live with IPF, illustrating that there is a general lack of knowledge amongst healthcare practitioners, trivialisation of symptoms and adds to the growing body of evidence of inadequate service provision in the UK for patients with IPF.


Reference

Duck A, Spencer LG, Bailey S, Leonard C, Ormes J, Caress A-L (2014) Perceptions, experiences and needs of patients with idiopathic pulmonary fibrosis (IPF). Journal of Advanced Nursing. DOI:10.1111/jan.12587
OnlineOpen article free to view

Tuesday, 16 December 2014

Obesity – the epidemic that can be stopped if we address it as a societal as well as individual issue

Lin Perry, PhD RN RNT
Faculty of Health, University of Technology, Sydney and South Eastern Sydney Local Health District


Response to Lee, G. (2014), Obesity, the epidemic that CAN be stopped? Journal of Advanced Nursing. doi: 10.1111/jan.12584

Health services around the world are all now very familiar with the impending ‘pandemic’ of obesity. Until recently I resisted use of the term ‘pandemic’, in recognition of the primarily psycho-social origins of the problem. However, with the American Medical Association's determination of obesity’s disease status, it would seem that ‘pandemic’ it is.

Lee (2014) provides a very neat synopsis of this obesity ‘pandemic’: its precursors and consequences, its place in history and its dominance of the future. Simple advice – ‘eat less and exercise more’ – is cited as the 1816 solution, and for Lee, the ‘humble healthcare practitioner’ and ‘healthcare changes led by a nurse or similar practitioner’ remain the mainstay, albeit with ‘a need to acknowledge the local environments and the issue of socio-economic deprivation’.

I don’t disagree with these statements but I do think the emphasis is not quite right.

I do believe that nurses have a pivotal role to play in health promotion and the World Health Organisation has emphasised the need to strengthen the capacity of this workforce to meet the demands it is facing (World Health Organisation 2006). Nurses deliver the bulk of health education and health promotion initiatives world-wide. Nurses are visible and accessible as health behavioural role models. Nurses have the socio-economic benefits of above-average education, high health literacy and, generally, the social advantages of being employed. Yet our and others’ work shows that nurses are not just equally but even more affected by this ‘pandemic’ than the populations they serve (Bogossian et al 2012; Perry et al 2014). Our 2014 findings from 5,000 New South Wales nurses are beginning to tease out the implications of this for nursing as a profession and a workforce.

What is very clear, both from what Lee et al (2014) discuss and what we are finding, is that we must address this ‘pandemic’ from within as well as without, taking policy and practice steps to address obesity within the nursing workforce in order to enable nurses to play their pivotal role in addressing this within the world’s populations. Many common characteristics of the nursing workplace can be labelled as ‘obesogenic’. These include, for example, lack of facilities for healthy eating (Wong et al 2010), working practices that exhaust without opportunity for exercise, lack of change facilities to support cycling or running to work, etc. Many could be relatively easily addressed.

It is not a case of ‘physician (or nurse) – heal thyself’; it is not just a case of individual responsibility to ‘eat less and exercise more’. The power-brokers and policy-makers in nursing and healthcare as well as the wider world need to play their parts in making the environmental and socio-economic changes required to halt this pandemic. Halting it in nursing would be a good start.


Lin Perry
Faculty of Health, University of Technology, Sydney and South Eastern Sydney Local Health District
Editor, Journal of Advanced Nursing


References

Bogossian FE, Hepworth J, Leong GM, Flaws DF, Gibbons KS, Benefer CA, Turner CT. A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United KingdomInternational Journal of Nursing Studies 49 (2012) 727–738

Lee G. Obesity, the epidemic that CAN be stopped? Journal of Advanced Nursing 2014 DOI: 10.1111/jan.12584
Perry L, Gallagher R, Hoban K, Shea A. The health of nurses: health risk factor profiles of Australian metropolitan nurses. Wellbeing at Work Third International Conference, Copenhagen 2014 

WHO (2006). Resolution WHA59.27. Strengthening nursing and midwifery. Geneva, World Health Organization.
Wong, H., Wong, M., Wong, S., Lee, A., 2010. The association between shift duty and abnormal eating behaviour among nurses working in a major hospital: a cross sectional study. International Journal of Nursing Studies 47, 1021–1027

Military nurses returning from war

Roger Watson, Editor-in-Chief

Then involvement of western countries in war has been a constant feature of life since 1990 and the First Gulf War which, in addition to the mobilisation of fighting troops and their support, saw one of the largest mobilisations of military medical services since the Second World War.  Nurses play a significant role in military medicine and these are constituted of both regular military and reservists.  Either way, large numbers continue to be mobilised, most recently to Afghanistan, and when they return to their countries they return to 'normal' life working in military and civilian hospitals.  But coming back is never normal and military service changes nurses' perspectives, provides stress and feelings that they no longer fit in on return.

Some of the conflicts, dilemmas and stresses are explored in a recent article from the USA published in JAN by Elliott (2014) titled Military nurses' experiences returning from war.  Elliott interviewed 10 military nurses returning from conflict and developed nine themes including 'Facing the reality of multiple loss', 'Serving a greater purpose', and 'Looking at life through a new lens'.  Clearly there were positive and negative experiences and, in the words of the author: 'Through this research, nurses and healthcare providers will be better prepared to interact and support returning veteran nurses'.


Reference

Elliott B (2014) Military nurses' experiences returning from war Journal of Advanced Nursing DOI: 10.1111/jan.12588

Saturday, 13 December 2014

Education, certification and employment of assistants in nursing

Roger Watson, Editor-in-Chief

'Assistants in nursing' encompasses a wide range of titles ascribed to an occupational group that works alongside registered nurses to perform a range of duties normally associated with the 'basic' aspects of care. Examples of these aspects of care include washing and feeding patients and performing routine tasks such as bed-making. That is the traditional picture; in fact, assistants in nursing  variously called 'nursing assistants', 'nursing auxiliaries', 'auxiliary nurses', 'nurse aides' and, in the UK, 'healthcare assistants' (HCAs)  often do much more. Assistants in nursing in the UK take vital signs and elsewhere have been reported to take electrocardiograms and to initiate intravenous infusions (Duffield 2014).

It is easy for registered nurses to take exception to various aspects of their traditional domain being encroached on while, at the same time, encroaching on various aspects of medicine and surgery. I doubt those for whom we purport to care  our patients and the general public  care about who does what in clinical practice; often they are not clear who is who in any case. The registered nursing scope of practice is, according to the International Council of Nurses, 'dynamic' but, whatever their scope of practice, registered nurses are registered; their names appear on a register which testifies to their preparation and good standing. Frequently, and in most of the UK, assistants in nursing do not appear on any kind of register. The question arises: does it matter?

It clearly does matter. Following the scandals at the Mid-Staffordshire NHS Foundation Trust in England, the Francis Inquiry specified several points which were relevant to assistants in nursing. Specifically, Francis called for standardised preparation, a code of practice and some form of registration. Specifically, the British government have refused to implement these steps, notwithstanding that a form of education and training for HCAs exists in Scotland and, 'in the wake of the Francis Inquiry' the first recommendations of the The Cavendish Review in England referred to the need for education and certification of healthcare assistants.

The risks and advantages around regulation of assistants in nursing can be weighed as follows:
  • Risks: without regulation an assistant in nursing can be dismissed from one hospital for providing poor care or worse and, provided they have not committed a criminal offence, they can take up employment elsewhere with impunity.
  •  Advantages: the above risk is obviated; preparation can be specified and standardised; and an expected standard of practice can be expected. As some may say: 'what's not to like?'
Naturally, regulation costs money and the issue of who regulates assistants in nursing could occupy our politicians and civil servants for months. Nevertheless, the end in this case must justify whatever means evolve. The issue of payment is surely straightforward; those who are regulated and seek to be recognised as such must pay. Currently the Nursing and Midwifery Council is struggling to regulate the nursing register but, surely, they are the obvious choice and if 'pump-priming' funding is required from central government resources, then surely this would be money well spent. After all, we are dealing with people's lives, safety and physical and psychological comfort. If we really think this is too expensive then we may, consequently, get the kind of healthcare we do not deserve.


References
Duffield C (2014) How long in forever? 2014 Australian Capital Region Nursing and Midwifery Research Conference Canberra, Australia