Do blood transfusions make a difference when you are dying?

Recent blood transfusion guidelines published by the UK National Institute for Health and Care Excellence (2015) recommend restrictive single unit transfusion practices with a threshold haemoglobin level of 70?g/l. While these guidelines do not specifically relate to palliative care patients, neither do they exclude them. Prompted by these guidelines, and studies questioning the costs and benefits of red cell transfusions, a retrospective review of the electronic patient records was undertaken to explore the use and impact of blood transfusions over a 54-month period on the in-patient unit of a 14-bedded hospice in the UK. The objective was to identify the reasons for transfusion and documented evidence of benefit and outcome. Results showed that transfusions were infrequent, the reason given for transfusion was fatigue in 84% of cases, benefit was reported in 39%, and 50% died within 4 weeks of transfusion. These findings are similar to those of other studies highlighting the low level of benefit and short survival time post-transfusion. Anaemia is common in the palliative population and fatigue is increasingly prevalent in the final weeks of life. It has been postulated that fatigue may provide protection from suffering at this time, suggesting that appropriate selection of patients for transfusion is important to prevent the potential to do harm. The use of validated tools, goal setting conversations, and an algorithm for the management of fatigue have now been implemented to support more rational transfusion decisions in the hospice.     

Community children's nursing services in Wales: will the NSF make a difference?

The 2006 edition of the RCN Community Children's Nursing Directory lists 239 services--16 of which are based in Wales, 12 in Northern Ireland, two in the Channel Islands, one in the Isle of Man, 23 in Scotland and 185 in England. This listing highlights the continued development and expansion of services across the UK, as well as the further developments that are needed to ensure equity of provision in many areas. The lack of UK or national strategies means that services continue to be developed in an ad hoc way. The National Service Framework for Children, Young people and Maternity Services in Wales (NSF) includes the need for community nursing services in every area of Wales in its recommendations (Welsh Assembly Government (WAG) 2005). As with previous policy recommendations dating back almost 50 years, no additional resources have been provided and no funding has been ring fenced to enable trusts to achieve this key action. With services competing for limited resources there is the risk that community children's services will remain under funded and continue to develop in an ad hoc manner.     

Employing children's nurses?

In 1994, the UKCC directed employers 'only to appoint persons into posts for which they have been appropriately by their programme of education and training leading to registration'. As part of a larger study into the expectations that NHS organisations have of newly qualified children's nurses, data were collected on the nursing registrations employers stipulated when wishing to appoint D grade staff to their children's wards. The survey was initially undertaken in 1998 and repeated in 2002. A letter requesting an application pack for 'a position as a D grade staff nurse on your children's ward/s' was sent to English NHS trusts identified as having a children's service. In 1998, 28 out of 47 (56 per cent) of the trusts appeared willing to employ nurses without a children's nursing qualification, indicating that a registered general nurse (RGN) or enrolled nurse qualification (EN) would be acceptable. In 2002, 12 of the trusts had changed their registration requirements for the D grade post since 1998 but four (out of 19 that provided data) were still apparently willing to employ non-children's nurses on children's wards. The size of the sample makes it inappropriate to generalize the results across all acute NHS trusts but there are indications that in spite of government policy and recommendations, some trusts appear willing to consider employing nurses without a children's qualification on children's wards.     

How do children's nurses make clinical decisions? Two preliminary studies

Aims and objectives. To gain an understanding of how children's nurses make clinical decisions. Background. Several studies have explored how nurses make clinical decisions and the factors that may affect the decision‐making strategies used. However, the results of these studies are contradictory. Further, little is known about children's nurses’ decision‐making strategies. Design. The think aloud technique. Methods. Nurses (n = 12) from three surgical wards and nurses (n = 15) from three medical wards in a Scottish children's hospital were presented with clinical scenarios and asked to think aloud. The verbal protocols were analysed to provide an indication of how children's nurses made decisions. Whether there were any differences in decision‐making between experienced and less experienced nurses and between graduates and non‐graduates was also explored. Results. Analysis of verbal protocols obtained using the think aloud technique suggested that all the nurses in the sample used a hypothetico‐deductive (analytical) model of decision‐making. Further, all participants appeared to use backward reasoning strategies regardless of their level of expertise. This is a characteristic of non‐expert decision‐making. Experienced and less experienced nurses collected similar additional information before planning nursing interventions, supporting the conjecture that they were functioning at a non‐expert level in relation to decision‐making. No differences were seen in the information collected by graduate and non‐graduate nurses. Conclusions. The decision‐making strategies of children's nurses need exploring further and further research is needed to identify factors that may affect decision‐making strategies. Several strategies to support nurses’ clinical decision‐making have been proposed but need testing to ascertain their effectiveness. Relevance to clinical practice. In clinical practice nurses make numerous decisions throughout the course of a shift. Sub‐optimal decision‐making strategies may adversely affect the quality of nursing care provided. It is imperative, therefore, to ascertain how nurses make clinical decisions and the factors that may influence the decision‐making strategies used.     

Caring for older people in prehospital emergency care: can nurses make a difference?

Aims and objectives. The aim of this paper is to explore older people's experiences in prehospital emergency care, and identify benefits and difficulties associated with developing a nurse‐led ambulance service. Data were collected at sites in Sweden and Norway. Focus group interviews were conducted to enable the collection of data from paramedics, ambulance nurses and nursing students, while individual interviews were utilized to gather data from older people. Background. There is little research on the quality of care older people over 65 years old receive in prehospital emergency care. Older people often present with multiple pathology and diverse needs that nurses are well equipped to deal with, but presently there is no clearly defined role for nurses in prehospital emergency care in the United Kingdom, although other countries such as Sweden and Norway are developing an ambulance nurse role. Conclusions. If the multiple needs of older people were addressed in the prehospital field, a reduction in readmissions and increased functional ability might be achieved. Comprehensive training is required for ambulance staff to enable them to meet such needs. While nurses have a great foundation for this care, additional specialist ambulance training is required alongside a need for education on older people's needs and attitudes to older people. Relevance to clinical practice. The introduction of ambulance nurses will result in role differentiation between paramedics and ambulance nurses, which has the potential for creating role conflict. To ensure a smooth transition appropriate training and education for nurses and paramedics should be provided. The end result is a potentially greatly enhanced ambulance care provision, enabling high quality care to all patients.     

Does non-medical prescribing make a difference to patients?

This article examines the literature on non-medical prescribing to establish its impact on UK healthcare. It discusses how better access to medication through non-medical prescribing can improve patient safety and patient-centred care, and how nurse prescribing can help ensure quality of care in the NHS during the current financial crisis.     

Do interventions make a difference to bereaved parents? A systematic review of controlled studies

The provision of bereavement support for parents who have lost a child is based on the assumption that it will lead to better subsequent adjustment. To determine the validity of this assumption, a systematic review of studies was undertaken, looking at bereavement support programmes for parental grief between 1990 and 2001. This review focused on controlled studies. The exclusion of non-controlled studies, case studies and those using only participant evaluation as an outcome measure, left only three studies. No overall benefit for the interventions was shown. However, for highly distressed mothers, psychological symptoms and marital dysfunction were significantly reduced. Disparities in the findings, such as the effects of interventions on fathers, may be explained by flawed methodology. Applied to practice, these findings suggest that only some bereaved parents benefit from bereavement support programmes. A targeted approach may therefore be the best use of resources.     

Age of blood: does it make a difference?

During the past 20 years, the perceived value of blood transfusions has changed as it has become appreciated that transfusions are not without risk. Red blood cell transfusion has been associated with disease transmission and immunosuppression for some time. More recently, proinflammatory consequences of red blood cell transfusion have also been documented. Moreover, it has become increasingly evident that stored red blood cells undergo time-dependent metabolic, biochemical, and molecular changes. This 'storage lesion' may be responsible for many of the adverse effects of red blood cell transfusion. Clinically, the age of blood has been associated with multiple organ failure, postoperative pneumonia, and wound infection. The relationship between age of blood and clinical adverse effects needs further study.     

Cutting healthcare costs. Can physicians make a difference?

Information about healthcare "bargains" is easy to obtain. Physicians who take the time to familiarize themselves with costs in their hospitals and clinics can help reduce charges for tests and drugs and can avoid wasteful use of supplies and misuse of staff time that can lead to additional charges. Education is effective in fighting rising healthcare costs, but efforts need to be ongoing if patients and medical institutions are to benefit in the long run.     

Outcome evaluation: does continuing education make a difference?

This article describes how an outcome evaluation model was used for a 1-day continuing education conference focusing on genomics implications for nursing practice. Findings from this evaluation process are described, including results from subjects who participated in surveys prior to the conference (n = 119), immediately after the conference (n = 119), and 3 months after the conference (n = 59). Significant differences in overall genomics knowledge were measured before and immediately after the conference and these gains were maintained 3 months following the conference. There also was evidence that the conference participants used the information gained through continuing education to transform their nursing practice. This model can be used to evaluate continuing education, especially with newer knowledge such as genomics.     

Continuing professional development: does it make a difference?

Continuing professional development (CPD) is costly in terms of both organizational resources and personal time and effort. It forms an important part of the strategy for modernizing the health service and is an expectation of qualified nurses. There is little evidence to demonstrate the impact of CPD in terms of improved patient care and services. A small pilot study was undertaken. A group of intensive therapy unit (ITU) managers developed a goal attainment scale (GAS) to evaluate the impact of an ITU course. Results suggest that the ITU course did make a difference to the development of ITU nurses, but the nurses who did not take the course also developed. This has implications for service providers and educationalists in terms of expectations, timing and content of courses. The GAS was a useful tool as an approach to evaluating the impact of CPD but requires more rigorous testing before it can be described as reliable and valid.