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.     

A Model for Cognitive-Behavioral Interventions in Cancer Pain Management

To propose a model for predicting success with cognitive-behavioral interventions in cancer pain management. Practice guidelines are useful, however nurses currently have little theoretic or empiric basis for choosing one particular strategy over another. Moreover, nurses have no way of knowing if a particular intervention is likely to work.

Organizing construct:

The model indicates characteristics of a person in relation to interventions including skill and ability, outcome expectancies, perceived credibility, history of use, preferred coping style, and pain outcomes.

Sources:

The model was developed using sources identified through a literature search of relevant topics in MEDLINE, CINAHL, and Psychlit (1996-1997), as well as through clinical experience.

Conclusions:

Continued empiric testing of the model is necessary to confirm proposed relationships and to assess accuracy of the model's predictions with various cognitive-behavioral interventions. With this testing, the model can help nurses select appropriate interventions for individual patients.     

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.     

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.     

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.     

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.     

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.     

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.     

Ethical and Policy Considerations for Centenarians—The Oldest Old

To illustrate the incongruence of ethical standards and fiscal and policy constraints on quality care for the oldest old. As the fastest growing demographic segment in the United States, care needs of the oldest old are a special challenge to the health care system.

Design:

Narrative analysis of interviews with centenarians who used nursing home services. The sample was three participants of the Georgia Centenarian Study who had been community dwelling and cognitively intact at the onset of participation (between 1988 and 1997). Interviews were conducted in nursing homes or after discharge.

Methods:

Case histories were constructed from interviews in 1997 to improve understanding of quality of care.

Findings:

Less-than-optimal care was provided for these elders, and little consideration was given to their input to care decisions and prospects for medical improvement. Appropriate consideration was not given to providing least-restrictive environments, appropriate restraint use, and options for community care.

Conclusions:

Six policy reforms are suggested for meeting the needs of the oldest-old before and after institutionalization. These include: integration of resident involvement in care decisions; development of alternate models of care; greater input from nurses concerning nursing care of special populations; more effective family and community involvement in the caring of elderly populations; increased research to promote function and independence; and increased education of personnel and nursing students to allow for more accurate assessment of cognitive and physical status.     

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.     

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.     

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.     

A Randomized Trial of Heparin and Saline for Maintaining Intravenous Locks in Neonates

purpose . To determine, the effects of saline, heparin 2 units (U) per ml saline, and heparin 10 U/ml saline flush solutions on the duration of intravenous (IV) locks and the incidence of IV infiltration in neonates.

design.

design. Randomized double-blind experiment.

setting.

setting. Tertiary-care nursery.

participants.

participants. Neonates (N = 90) hospitalized at birth in the intensive, intermediate care, or newborn units.

main outcome measures.

main outcome measures. Total hours from the time the IV was inserted to the time the IV was removed; hours from the time the IV was first flushed to the time the IV was removed; number of IVs removed because of infiltration.

results.

results. No statistical or clinical differences between the three groups for duration of IV nor for incidence of complications.

conclusions.

conclusions. The use of heparin in IV lock flush solution did not affect the duration of IV locks nor the incidence of infiltration in neonates.     

Persistence of Self in Advanced Alzheimer's Disease

To determine if evidence of the persistence of a sense of self or personal identity could be found in people in the middle and late stages of Alzheimer's disease. The theme of diminishing self pervades both the popular and professional literature on Alzheimer's disease.

Design:

Qualitative using conversational analysis. The purposive sample was 23 residents of two urban nursing homes in the southeastern United States who were in the middle and late stages of Alzheimer's disease. Their mean Mini-Mental State examination score was 10.65. Nineteen subjects were women, four were men in this 1993-1997 study.

Methods:

Analysis of 45 conversations lasting 30 minutes with nursing home residents with a diagnosis of probable Alzheimer's disease. Use of the first person indexical and other evidence, such as awareness and reactions to the changes that had taken place, in support of and counter to the notion of persistence of self, were sought in conversational analysis.

Findings:

Respondents used the first person indexical frequently, freely, and coherently. Evidence was also present that participants were aware of their cognitive changes. Many struggled to provide an explanation, but none mentioned Alzheimer's disease.

Conclusions:

Evidence suggests the persistence of awareness of self into the middle and late stages of Alzheimer's disease. Failure to recognize the continuing awareness of self and the human experience of the person in the middle and late stages can lead to task-oriented care and low expectations for therapeutic interventions. The bafflement noted in respondents suggests that people should be told their diagnosis and offered an explanation of what this diagnosis means.     

Parents'' Reports of "Tricks of the Trade" for Managing Childhood Chronic Illness

purpose . To examine how parents respond to and manage the challenges of childhood chronic illness.

design.

design. Qualitative, comparative, secondary analysis.

participants.

participants. Fifty-eight families (55 mothers, 44 fathers) with a school-age child (6-15 years old) with a chronic illness.

results.

results. Three approaches to illness management were identified: strict adherence, flexible adherence, and selective adherence. These approaches varied in the extent to which parents developed and relied on target management behaviors that concurred with or deviated from the treatment plan prescribed by healthcare providers.

conclusions .

conclusions . The three management approaches contribute to understanding the processes associated with differing interactions between healthcare professionals and parents when a child has a chronic illness.