Assisted Dying and Nursing Practice

Nurses' views are often solicited about physician-assisted dying, a concept that incorporates both assisted suicide and active euthanasia. Yet nurses are rarely asked about their own clinical experience of assisted dying. The literature indicates that many nurses experience difficulty distinguishing professionally sanctioned end-of-life interventions from those that are not. In this article the investigator explores the social, legal, and political roots of assistance in dying, and critically examines the profession's position on nurse participation in assisted dying and the research regarding nurse-assisted dying.

Scope:

The bioethics and nursing literature was reviewed from 1990 to 1999. The databases used were the Cumulative Index to Nursing and Allied Health Literature and Medline.

Conclusions:

The complex nature of caring for highly symptomatic dying patients, and the difficulty some nurses experience in distinguishing a moral difference between hastening and assisting death, strongly indicate a need for additional nursing research that does not use a forced answer.     

Influence of Managed Care on Professional Nursing Practice

To explore how nurses in one U.S. state perceived that managed care influenced professional nursing in that state. The nursing community is challenged to move with haste in demonstrating, through research, the clinical and economic value that nurses add to cost-effective outcomes.

Design:

A Delphi survey in 1996 of a convenience sample of 84 clinical nurse specialists (CNSs) and nurse practitioners (NPs) in California.

Methods:

CNSs and NPs contributed to the list of managed care influences on nursing practice. Fifty-seven (68%) completed the third and final round.

Findings:

Panelist agreement was the highest for (a) exploring new approaches to providing quality care more cost-effectively, (b) expanding nurse practitioners' rote in primary care, and (c) more effectively partnering with clients in helping them assume greater self-responsibility for their health. Greatest threats were perceived to be hassles involved in seeking authorization for care and responding to payment denials; the tenuous job market for nurses; and encroachment on nursing practice by others.

Conclusions:

The findings can assist nurses in states with low managed-care concentration to create their preferred future within health care delivery. A more highly educated nurse workforce will be needed for 21st century health systems in which more care is likely to be delivered outside hospitals.     

A Model for Change to Evidence-Based Practice

To describe a model that guides nurses and other healthcare professionals through a systematic process for the change to evidence-based practice. The tremendous increases in clinical research and accessibility to research findings have prepared the way for the paradigm shift from traditional and intuition-driven practice to evidence-based practice. Although several models have emerged to guide practitioners in research utilization, practitioners continue to have difficulty synthesizing empirical and contextual evidence and integrating evidence-based changes into practice.

Organizing Framework:

The model is based on theoretical and research literature related to evidence-based practice, research utilization, standardized language, and change theory. In this model, practitioners are guided through the entire process of developing and integrating an evidence-based practice change. The model supports evidence-based practice changes derived from a combination of quantitative and qualitative data, clinical expertise, and contextual evidence.

Methods:

The model was developed using sources identified on searches of Medline, CINAHL, and systematic reviews available on the Internet. Review topics were focused on evidence-based medicine and nursing, research utilization, and change process. Other sources included clinical expertise and quality-improvement information.

Conclusions:

Practitioners need skills and resources to appraise, synthesize, and diffuse the best evidence into practice. Patient outcomes must reflect discipline-specific and interdisciplinary accountabilities. Collaboration between researchers and practitioners within and among disciplines will enhance the diffusion of evidence-based practice innovations.     

Nebraska School Nurses Identify Emotional Maltreatment of School-Age Children: A Replication of an Ohio Study

P urpose . To determine how often school nurses identify emotional maltreatment using validated vignettes.

DESIGN.

DESIGN. Survey, with 16 behavior vignettes, mailed to 550 Nebraska school nurses. Four forms represented nonwhite and white, male and female children. Demographic questionnaire included.

SETTING.

SETTING. Survey mailed with regular spring school nurses' newsletter.

PARTICIPANTS.

PARTICIPANTS. One hundred twenty-one school nurses completed and returned surveys.

MAIN OUTCOME MEASURES.

MAIN OUTCOME MEASURES. Each vignette was an example of emotional abuse; subjects indicated "refer" or "not refer" decisions about the vignette. All items were positive for emotional abuse.

RESULTS.

RESULTS. Sixty-four of 121 (53%) respondents correctly identified 13 or more vignettes as referable for emotional maltreatment. No influence of child gender and race on reporting decision. No nurse characteristics correlated with referral rates.

CONCLUSIONS.

CONCLUSIONS. None of the variables studied significantly influenced school nurses' identification of emotional abuse. Further research is needed to ascertain correlation between text vignettes and reporting, and to identify interventions to increase the rate of identifying emotional abuse.     

The Effectiveness of a Standardized Educational Program for Children Using Patient-Controlled Analgesia

purpose . To examine the effectiveness of two types of preoperative education (routine education and a standardized educational program) for children undergoing spinal fusion.

design.

design. Two group, phase-lag design.

setting.

setting. Tertiary pediatric hospital.

participants.

participants. Children ages 8-18 years (N = 93)

main outcome measures.

main outcome measures. Adolescent Pediatric Pain Tool, Child Pain Scale, Post-PCA Satisfaction Interview, and PCA infusion pump data.

results.

results. No statistically significant differences between the groups on any of the main outcome variables. Children and parents reported, however, that the SEP provided them with invaluable information regarding the use of PCA and alleviated their concerns about getting "hooked on drugs," overdosing, side effects, and being able to get pain relief when needed.

conclusion.

conclusion. Children having spine fusion surgery experienced severe postoperative pain that was not ameliorated by optimizing use of PCA through standardized education. Further testing of the SEP with other populations is needed in order to more fully realize its potential for influencing pain outcomes.     

A Model of Chronic Dyspnea

To present an overview of dyspnea, differentiate chronic dyspnea from acute dyspnea, critique models of dyspnea found in the nursing literature, and propose a new model of chronic dyspnea to guide the care and evaluation of chronic dyspnea in patients living with chronic obstructive pulmonary disease (COPD). Dyspnea is the major symptom that impairs quality of life for nearly 16 million Americans who have COPD.

Methods and Sources:

Review of scholarly literature on dyspnea by searching CINAHL and MEDLINE (1980-1998) using dyspnea and chronic obstructive lung disease as key words. The search produced studies conducted by a variety of health care professions including those in nursing, medicine, exercise physiology, and respiratory therapy.

Findings:

The existing models fail to differentiate between acute and chronic dyspnea. These models were found to be inadequate for guiding interventions to decrease the long-term adverse consequences of chronic dyspnea.

Conclusions:

A useful model of chronic dyspnea defines chronic dyspnea as distress with varying levels of intensity and long-term physical, psychologic, and sociocultural consequences. The proposed model has implications for both research and clinical practice by identifying the consequences of chronic dyspnea as outcome measures of the effectiveness of treatment.     

Pediatric Nursing Resources in Cyberspace

P urpose . To provide information on pediatric nursing resources on the Internet.

POPULATION.

POPULATION. Pediatric nurses in all settings.

CONCLUSIONS.

CONCLUSIONS. A basic understanding of essentials for "surfing the web" will open the doors to unprecedented opportunities to query, find, and share information with others.

PRACTICE IMPLICATIONS.

PRACTICE IMPLICATIONS. Pediatric nurses in every setting can benefit from access to the Internet and knowledge of what resources are available to enhance their practice and support their clients.     

Parental Consent for Bone Marrow Transplantation in the Case of Genetic Disorders

purpose. To describe the responses of mothers and fathers who were offered bone marrow transplantation (BMT) for their children with genetic disorders

design.

design. Qualitative

setting.

setting. Private hospital rooms/offices

participants.

participants. Six mothers and 4 fathers of children with genetic disorders

results.

results. The basic social-psychological problem confronting the parents was the conflicting alternatives of life versus death for their children. It was certain that these children would die from their genetic disorders but without having to endure the pain and suffering of a BMT. The BMT would be difficult, possibly resulting in death, but with a chance of survival.

conclusions.

conclusions. Parents believed that BMT was the only chance of survival for their children, leaving them no choice except to pursue the BMT treatment     

From Randomized Trial to Community-focused Practice

To describe the use of findings from a randomized trial—a nursing intervention using telephone contacts to reduce the incidence of low-birth-weight and preterm births—in four community settings in North Carolina, to show that implementing research into practice is important. Low-birth-weight and preterm births are the major cause of high infant mortality in the United States. Rates are highest among African-American women. Telephone intervention as a strategy for preventive health care can be cost effective, reduce low-birth-weight and preterm births in African-American women, and provide a means of health consultation for parents of children age five and under.

Organizing Framework:

Four community programs are discussed in relation to five phases of implementing and sustaining research in communities: research, transfer, transition, regeneration, and empowerment. Modification from the original research, bonuses, and barriers are described for each program.

Methods:

The randomized trial was conducted from 1990-1995. Randomized trial data and data for subsequent projects were collected from telephone interviews and health care records from 1994-1998. A successful adaptation was made from the original randomized trial to the four programs by (a) educating the staff for each program about the methods and findings in the original research, and (b) working with program staff to make appropriate modifications for each site.

Conclusions:

Findings from a randomized trial can be used in a variety of settings. By working together, researchers and community-health nurses can integrate research findings into community-health nursing practice.     

Adolescent Resilience

To explore what resilience means to adolescents and whether the Resiliency Scale can accurately measure resilience. Researchers have identified that resilience in children and adolescents may lead to psychosocial maladaption and psychopathology in adulthood. Further research is necessary in order to understand what resilience is in adolescence and to identify those at risk for psychosocial problems.

Design:

A triangulated research design was used to explore the concept of resilience in adolescents. This small pilot study, conducted in 1997, had a purposive sample of 51 10th-grade and 11th-grade volunteers from one inner-city, vocational high school in New England.

Methods:

A researcher-developed demographic tool was used to explore the environment of adversities to which students were exposed. Wagnild and Young's Resiliency Scale was used to measure adolescents' perceptions of their resilience. Focus groups, structured and unstructured interviews, and written stories were used to gather phenomenologic data.

Findings:

Despite the traumatic and violent world in which participants lived, the adolescents ranked themselves as "resilient." These adolescents believed that being resilient was to be (a) disconnected from others because they could not trust, (b) isolated because they had inadequate or no support systems, and (c) insulated because the emotional pain was too much to bear.

Conclusions:

This study of resilience in adolescence shows the need for further research; the investigators question whether resilience is really a healthy state, and wonder if similar interventions are necessary for both "resilient" and "vulnerable" adolescents.     

Depression, Social Support, and Quality of Life in Older Adults With Osteoarthritis

To develop an understanding of the quality of life of older adults with osteoarthritis (OA) with varying levels of depression and social supportas a basis for nursing interventions. Osteoarthritis in the United States is the number one chronic disease in late life and the major cause of disability in older adults. In addition to the functional disability and economic effect of OA, older people with this disease experience suffering, depression, and diminished quality of life.

Design:

For this cross-sectional survey, a convenience sample of 50 older adults with OA was recruited from two U.S. hospital-based arthritis clinics in northern Ohio for 3-months during 1995.

Methods:

During face-to-face interviews, the Arthritis Impact Scales, Center for Epidemiological Studies Depression Scale, Social Support Questionnaire, and Quality of Life Survey, were used to measure osteoarthritis severity, depression, informal social support, and quality of life.

Findings:

Although few formal social support services were used, high levels of satisfaction from the subjects' large informal networks of family and friends were reported. In addition, satisfaction with subjects' quality of life was extremely high despite depression, co-morbid conditions, pain, and functional limitation.

Conclusions:

Social support appeared to play an important role in moderating the effects of pain, functional limitation, and depression on these subjects' quality of life. Nurses who work with older adults are in a unique position to help them adjust to living with osteoarthritis by providing them the support needed to help them manage their disease.     

Language Plus for International Graduate Students in Nursing

To provide information about an English-language support program that focuses on the needs of international graduate nursing students. The growing presence of these students coincides with the increasing numbers of universities committed to world health. Crucial social and language competence affect the success and progress of international students in graduate nursing programs.

Design:

Reviewed literature was 1980 to 1998, in nursing and applied linguistic research including second-language acquisition, phonology, discourse analysis, and language pragmatics to identify social and language phenomena.

Findings:

Investigators suggest essential elements such as conventions of academic writing, reading comprehension, vocabulary, and pronunciation skills be included in the supportive Language Plus program.

Conclusions:

Ongoing development of the Language Plus program can promote collaboration between nurses and linguists and increase the success of international graduate nursing students.     

Learning the Baby: A Maternal Thinking and Problem-Solving Process

purpose. To describe a maternal problem-solving process from new mothers' day-to-day experience of caring for and developing a relationship with their babies

design.

design. Qualitative study using grounded theory approach

setting.

setting. Mothers' homes (n = 23) and workplaces (n = 2)

participants.

participants. 25 mothers of babies from 2 weeks to 7 months

main outcome measures.

main outcome measures. Semi-structured interviews

results.

results. "Learning the Baby" was a major thinking process that emerged. Systematic thinking dominated mothers' problem-solving. Even after the babies were comforted, mothers were not certain their efforts alleviated the babies' problems, because they usually were not certain of the problem.

conclusions.

conclusions. Mothers' thinking directs their caregiving actions. The findings were related to previous problem-solving and women's thinking perspectives. Nurses must use planned and unplanned encounters effectively to collaborate with and teach mothers about baby behavior and health care.     

Ethical and Methodologic Benefits of Using a Reflexive Journal in Hermeneutic-Phenomenologic Research

To illustrate the importance of considering the researcher's written reflections on the qualitative research process as a valuable source of data and as a means of enhancing ethical and methodologic rigour.

Organizing Construct:

Excerpts from the researcher's reflexive journal are presented as evidence of an audit trail. Ethical and methodologic concerns arising during the research process are outlined and the value of reflecting on these issues is addressed.

Methods:

A hermeneutic-phenomenologic study, conducted in Scotland, included in-depth interviews with six problem drinkers to explore the lived experience of their suffering. The researcher was considered to be a primary data-collection tool, whose reflections on the research process added to the contextual richness of the study. For an interpretative approach to data analysis, the researcher found metaphors to convey the participants' stories to a new audience. This intuitive, creative process was analysed and reported in the reflexive journal.

Conclusions:

The researcher's self-awareness, fostered by the use of a reflexive journal, is mirrored by the participants' ability to reflect on the final interpretation of their stories and on the therapeutic benefits of the research process. The researcher's reflexive journal reveals previously hidden contextual information which enhances the prime ethical and methodologic aim of the study—to understand the lived experience of suffering by problem drinkers.     

Varicella Zoster Infection in the Immunocompromised Child

purpose . To describe varicella zoster virus infection in the immunocompromised child and provide guidelines to decrease the risk of infection and complications for these children.

population.

population. Children infected with varicella zoster virus, particularly those with a compromised immune system.

conclusions.

conclusions. Varicella zoster virus infection can have serious consequences for children with malignancies and infection with the human immunodeficiency virus, as well as children on chronic steroid therapy.

practice implications.

practice implications. The advanced practice nurse often is responsible for identifying those children at increased risk for VZV infection and its complications and for planning and implementing interventions to decrease the risks to the immunocompromised child.