Do the potential benefits outweigh the risks? An update on the use of ziconotide in clinical practice

Ziconotide is a selective and potent blocker of N‐type voltage‐gated calcium channels. It was approved by the Food and Drug Administration in 2004 and by the European Medicines Agency in 2005 for the treatment of severe chronic pain in patients needing intrathecal analgesia (ITA). The aim of this paper is to provide a practitioner‐oriented, educational, narrative, up‐to‐date review on the use of ziconotide in clinical pain medicine. Of special concern regarding safety is the partial incongruity between dosing statements in the Summary of Product Characteristics and novel low‐dosage, slow uptitration recommendations. Even though ziconotide has obvious advantages compared to opioids, pain practitioners pondering the use of ziconotide nonetheless have to balance its proved potential analgesic effect against its neurological side effects, with special consideration being given to dosing and neuropsychiatric dangers. Using a seesaw analogy, the paper discusses what factors pain physicians should weigh in when considering ziconotide as ITA drug, the non‐opioid advantages of ziconotide being counterbalanced by its potential psychiatric side effects. Ziconotide is an important part of the armamentarium of modern interventional pain medicine. If ITA is deemed necessary, ziconotide is a rational alternative, at least in chronic (neuropathic) non‐cancer pain. However, in many European countries, ziconotide treatment is only available in a few (if any) centres. The safety profile of ziconotide is not fundamentally more worrying than that of opioids or cannabinoids; it is just different. This paper provides a concise, up‐to‐date and clinically‐oriented summary of the use of ziconotide in clinical practice, not least concerning safety and dosage issues.     

Revisiting the issue of co-dependency in nursing: caring or caretaking?

It is purported in the literature that individuals who demonstrate co-dependent traits (consistently taking responsibility for others to the point of neglecting onself) enter the nursing profession to fulfill pathological needs and that nursing encourages co-dependent behaviour through its focus on "caring." This study was undertaken to determine whether nursing students have higher co-dependency scores than students in other programs. Data were collected through a questionnaire. A continuum-based Co-dependency Index was constructed with a Caring and Caretaking Sub-index to allow for more accurate measurement of co-dependency traits. In contrast to results reported in the literature, one-tailed testing indicated no significant relationship between co-dependency and university program. The results of this study suggest the need for a continuum approach to measuring co-dependency, to ensure that the presence of caring behaviours in measurement tools do not create a bias against nursing, a profession based on caring.     

Better late than never? An evaluation of community nursing services for children in the UK

• ? The development of community nursing services for children in the UK was first suggested by Platt in 1959; until recently, however, such services have been rare and children have spent many unnecessary and potentially traumatic days in hospital.
• ? This paper considers the development of community nursing services for children in the UK.
• ? It identifies factors which have promoted the growth of these schemes, and examines the effectiveness of services from professional, managerial and economic perspectives.
• ? The viewpoint of the consumer – the child and family themselves – is also considered.

     

An evaluation of the seminal work of Patricia Benner: theory or philosophy?

The purpose of this article is to review the seminal work of Patricia Benner, From Novice to Expert, in order to assert it as a philosophy and not a theory. In the literature there is no clear consensus on where this model stands - theory or philosophy. There is no intent to devalue Patricia Benner's work as it is valuable and has become widely used in nursing practice, research, education and administration. However, as a philosophy, Benner's interpretive work is more constructive. Appropriate use of this model requires an understanding of whether it is a theory or a philosophy, its underpinnings and an assessment of its development and testing. This can be accomplished by knowing the differences between a theory and a philosophy and by reviewing the ways of knowing and processes of reasoning which are necessary for skill acquisition. Much of the critique of Benner's work falls into two categories: it is not quantitative research and there are issues with the use of narratives. These will be reviewed. Judgment and understanding of the nature of Benner's model allows for its appropriate use in journal articles, research, or other projects and/or modification as necessary.     

Do caring behaviors in the quality caring model promote the human emotion of feeling cared for in hospitalized stroke patients and their families?

The aim of this study was to explore the discrete behaviors that comprise the human emotion of feeling cared for as described by hospitalized stroke patients and their families. Joanne Duffy's Quality Caring Model© (QCM) describes 8 caring behaviors supporting the experience of caring relationships exhibited during health care encounters. A secondary analysis of data from a guided interview was analyzed by 3 persons independently using general thematic content analysis and predetermined categories from the QCM, with final validation by the theorist. Percent agreement was 74.3% at first analysis, and 100% after secondary analysis. 82 of 100 phrases fit into at least one caring behavior, 17 phrases overlapped, and 18 phrases did not fit. Overlap between the caring behaviors is consistent with published quantitative reports. Patient experiences generating the emotion of “feeling cared for” may be formed from multiple caring behaviors enacted simultaneously by clinicians. Characteristics of clinicians, such as knowledge, may be as important as caring behaviors.     

Does minimal access major surgery in the newborn hurt less? An evaluation of cumulative opioid doses

Background: Minimal access surgery (MAS) in adults is associated with less postoperative pain in comparison to conventional ‘open’ surgery. It is not known whether this holds true for neonates as well. Less pain would imply that opioid consumption can be reduced, which has a beneficial effect on morbidity. Aim: To evaluate potential differences in' opioid consumption between neonates undergoing thoracoscopic minimal access surgery or conventional surgery of esophageal atresia (EA) and congenital diaphragmatic hernia (CDH). Methods: In this retrospective cohort study we included two controls for each MAS patient, matched on diagnosis, sex and age at surgery. Opioid dose titration was based on validated pain scores (VAS and COMFORT behaviour), applied by protocol. Cumulative opioid doses at 12, 24, 48 h and 7 days postoperatively were compared between groups with the Mann—Whitney test. Results: The study group consisted of 24 MAS patients (14 EA; 10 CDH). These were matched to 48 control patients (28 EA; 20 CDH). At none of the time points cumulative opioid (median in mg/kg (IQR)) doses significantly differed between MAS patients and controls, both with CDH and EA. For example at 24 h postoperative for CDH patients cumulative opioid doses were [0.84(0.61–1.83) MAS vs. 1.06(0.60–1.36) p =1.0] controls, For EA patients at 24 h the cumulative opioid doses were [0.48(0.30–0.75) MAS vs. 0.49(0.35–0.79) p =0.83] controls. This held true for the postoperative pain scores as well. Conclusions: Minimal access surgery for the repair of esophageal atresia or congenital diaphragmatic hernia is not associated with less cumulative opioid doses.     

Integration or pragmatic coalition? An evaluation of nursing teams in primary care

Changing structures and organisations in primary care raise questions about the role and fit of traditional nursing disciplines. This paper discusses recent findings from an evaluation of integrated nursing teams. The study design used a mixed method approach measuring workload activity of health visitors, practice nurses and district nurses, through time diaries; and teamwork using the Primary Care Teamwork Questionnaire, in conjunction with semi-structured interviews exploring the views of key stakeholders and the nurses themselves. The main themes arising from the interviews are discussed, taking account of the findings from the assessment of workload and teamwork questionnaire. The key themes addressed are implementation of change, shifting role boundaries, communication and teamwork. The findings indicate that this type of organisational change is concerned predominately with structure, professional and organisational issues rather than patient care. In the teams studied the opportunity of integration led to a pragmatic coalition that encouraged its members to plan, execute and manage change by themselves, according to a vague definition rather than a patient focused agenda. In order to ensure a quality nursing service and avoid old historical rivalries this needs to be addressed as nursing teams are reconfigured in primary care groups.     

Care or custody? An evaluation of palliative care in prisons in North West England

This study aimed to evaluate health professionals' views about palliative care provision in prisons in the counties of Cumbria and Lancashire in the North West of England. Seventeen prison healthcare staff and nine specialist palliative care staff participated in semi-structured interviews and 16 prison healthcare staff completed a questionnaire designed to measure knowledge, skills and confidence in relation to palliative care. The findings highlighted tensions between the philosophies of care and custody, and the many challenges in providing palliative care in a custodial setting. This paper presents two illustrative case study examples, and suggests ways in which some of these challenges can be overcome in practice.     

Blackbirds singing in the dead of night?: Advancing the craft of teaching qualitative research

Qualitative research education, which is overly concerned with teaching content, can reduce knowledge to the technical-rational domain, and in this process, opportunities for students to be inspired and passionately engaged with the art of qualitative research are lost. Although students may acquire the characteristics of qualitative researchers by observing role models, there is much skilled teachers can do to teach students not only how to conduct research, but also how to be committed qualitative researchers. The craft knowledge of skilled teachers in facilitating these understandings, techniques, and attributes in students must be shared and discussed in meaningful ways to advance quality education and, in turn, quality nursing research. If unshared, teachers' knowledge may go unheard, and they may be left isolated, like blackbirds singing in the dead of night. In this article, the skills of "doing and being" in qualitative research are emphasized by sharing strategies the authors have used in research education. The aim is to discuss creative aspects of teaching practice that are helpful in understanding and advancing rigorous qualitative research.