The development and implementation of a clinical skills matrix to plan and monitor palliative care nurses' skills

AimTo develop and implement a region wide skills matrix for palliative care and district nurses in rural Victoria in order to identify and address individual learning needs and appropriate professional development strategies based on the Australian National Palliative Care Standards. This study is the first in a series of papers discussing and evaluating the development and implementation of a skills matrix. Future papers will report on participants’ data reporting.MethodsThe development and implementation of a skills matrix for palliative care nurses was based on using several evidence-based strategies involving four main stages. There were: stakeholder consultation, collaboration, consolidation and implementation. The initial stage of development of the matrix involved consultation with regional stakeholders to establish and refine the project objectives. The second stage involved collection of information from regional stakeholders; brainstorming and discussion of the technical skills required for palliative care and the cross over with district nursing. The third stage involved a facilitated process whereby action plans were devised and the final stage involved a plan for the survey dissemination and evaluation of the training needs.Other evidence-based strategies used were Benner’s theoretical model of clinical competence, the Australian National Palliative Care Standards and the triple C model of project implementation.ResultsThis study reported on the development and implementation of a self-assessment of competencies skills matrix for nurses working in palliative care based on the Australian National Standards of palliative care used by services.The matrix included all the aspects covered by the Australian National Palliative Care Standards and mapped them to various competencies using Benner’s model ranging from novice to expert. The availability of a skills matrix tool to self-assess is important to keep track of the clinical competencies gained by palliative care nurses. Targeted educational interventions identified by the skills matrix have the potential to improve quality of care provided in the palliative care setting.ConclusionThe successful development and implementation of the palliative skills matrix across the Gippsland region relied on using several evidence-based strategies to standardise the competencies across the palliative care setting in rural Victoria, Australia. Examples of these strategies included using Benner’s theoretical competency model, the Australian National Palliative Standards and the triple C model, which included stakeholders’ consultation, collaboration and consolidation.     

Asthma and dualism

The rejection of Cartesian dualism can be taken to imply that the mind is implicated in health and illness to a greater degree than conventional medicine would suggest. Surprisingly, however, there appears to be a train of thought in antidualist nursing theory which takes the opposite view. This paper looks closely at an interesting example of antidualist thinking - an article in which Benner and her colleagues comment on the ways in which people with asthma make sense of their condition - and concludes that it places unduly stringent and arbitrary limits on the mind's role. It then asks how antidualism can lead to such a dogmatic rejection of the idea that states of the body are clinically influenced by states of mind. The answer to this question is that Benner assimilates very different philosophical theories into the same 'tradition'. On this occasion, she has combined Descartes, Kant and the Platonist ascetics into a single package, misleadingly labelled 'Cartesianism', and this move accounts for her unexpected views on the relation between mind and body in asthma.     

Expertise or performance? Questioning the rhetoric of contemporary narrative use in nursing

BACKGROUND: In the early 1980s there emerged in nursing a self-conscious and well-articulated concern to articulate nursing's contribution to patient care. This has fostered the production of a large volume of practice narratives that today form the basis of professional self-understanding. First-person practice narratives are now widely used as the evidence base for nursing expertise, not only in their natural home, the world of interpretative research, but also in the bureaucratic-judicial domain of professional regulation, health care organizations, trades unions and professional associations. AIM: The aim of this paper is to question the use of individual narrative accounts of nursing practice as evidence of nursing expertise. METHOD: We examine the model, method, and continuing consequences of these discursive formations of practice. First, we present a methodological discussion of how personal narratives are produced by the interplay between discourse and subjectivity. Second, we explore clinical narratives of expertise in the work of Patricia Benner and others to uncover the common template for contemporary narrative. DISCUSSION: Narrative production in nursing has led to particular constructions, rather than free representations of practice. It is these particular constructions that we call into question. Rather than viewing these narratives as revelatory of nursing practice, we argue that they place a 'spotlight' on the individual actor - the nurse - with an absence of structural practice context. CONCLUSION: We make the case that treatment of these narratives as individual evidence of expertise fundamentally misunderstands their function and purpose, and reduces the constitution of nursing expertise to the performance of a palatable and highly desirable discourse for a nursing audience.     

Explicating Benner's concept of expert practice: intuition in emergency nursing

Title. Explicating Benner’s concept of expert practice: intuition in emergency nursing. Aim. This paper is a report of a study exploring the experience of intuition in emergency nursing in relation to Benner’s fifth stage of practice development, ‘the expert practitioner.’ Background. Expert nurses anecdotally report actions and thoughts that present in their consciousness and have an impact on the care given. Benner used the term ‘intuition’ for the fifth stage of practice development. However, Paley has criticized Benner’s model for its lack of clarity about the nature of an expert practitioner. This criticism is further justified by Benner’s inadequate explanation of expert. Method. A hermeneutic phenomenological study was conducted using van Manen’s approach and a Gadamerian analysis. Fourteen expert emergency nurses in Australia were interviewed between January 2000 and December 2003. Findings. The analysis resulted in the reconstruction of Benner’s expert stage into three distinct phases: cognitive intuition, where assessment is processed subconsciously and can be rationalized in hindsight; transitional intuition, where a physical sensation and other behaviours enter the nurse’s awareness; and embodied intuition, when the nurse trusts the intuitive thoughts. Conclusion. The findings validate the use of intuitive decision‐making as a construct in explaining expert clinical decision‐making practices. The validity of intuitive practice should be recognized. It is essential to recognize the conditions that support practice development, and in the prenovice stage (during their university course) factors such as reflection, research (in its broadest sense) and clinical curiosity should be fostered.     

贝那普利与非洛地平联合治疗高血压合并糖尿病的临床观察

目的观察贝那普利与非洛地平联合治疗高血压合并糖尿病的疗效。方法选择高血压合并糖尿病患者64例,随机分为2组,贝那普利组32例,给予贝那普利10nag,1次／d,联合治疗组32例,在贝那普利组治疗基础上加用非洛地平5mg,1次／d,均治疗4周,治疗前后检测收缩压、舒张压、空腹血糖,并对比分析治疗前后上述指标差异。结果治疗4周后2组血压均下降,组内治疗前后比较均有统计学意义（P〈0．01）,联合治疗组降压幅度高于贝那普利组,与治疗前后比较差异有统计学意义（P〈0．01）。结论贝那普利与非洛地平联合应用降压疗效更好。     

苯磺酸左旋氨氯地平治疗颈动脉硬化的临床研究

目的探讨苯磺酸左旋氨氯地平治疗颈动脉硬化的临床疗效。方法选取我院2010年8月至2012年8月收治的颈动脉硬化患者70例,按照随机数字表法分为观察组和对照组各35例,观察组使用苯磺酸左旋氨氯地平治疗,对照组使用盐酸贝那普利治疗,观察比较两组疗效。结果观察组治疗前后颈内动脉IMT、颈总动脉IMT比较差异有统计学意义（P〈0．05）,对照组治疗前后颈内动脉IMT、颈总动脉IMT比较差异无统计学意义（P〉0．05）,治疗后组间比较差异有统计学意义（P〈0．05）。结论苯磺酸左旋氨氯地平治疗颈动脉硬化临床疗效良好。     

贝那普利联合氨氯地平对高血压的治疗效果

目的：观察贝那普利联合氨氯地平治疗高血压临床效果。方法：抽选我院2011年4月～2014年5月接收的高血压患者100例,按入院编号分成两组（医治组、对照组）,对照组给予贝那普利药物治疗,医治组在上述基础上加用氨氯地平药物,比对两组临床治疗效果。结果：医治组临床治疗好转率（96.0%）、并发症发生率（2.0%）和对照组（80.0%、14.0%）相比,差异显著（P<0.05）;医治组临床血压指标、超声心动图指标和对照组相比,差异显著（P<0.05）。结论：临床治疗高血压期间联合使用贝那普利、氨氯地平药物,安全、可靠,可改善患者血压指标,减少并发症,提高好转率,意义重大,值得使用。