Search

In vivo delivery of small molecule therapeutics to cancer cells, assessment of the selectivity of administration, and measuring the efficacity of the drug in question at the molecule level, are important ongoing challenges in developing new classes of cancer chemotherapeutics. One approach that has the potential to provide targeted delivery, tracking of biodistribution and readout of efficacy, is to use multimodal theragnostic nanoparticles to deliver the small molecule therapeutic. In this paper, we report the development of targeted theragnostic lipid/peptide/DNA lipopolyplexes. These simultaneously deliver an inhibitor of the EGFR tyrosine kinase, and plasmid DNA coding for a Crk-based biosensor, Picchu-X, which when expressed in the target cells can be used to quantify the inhibition of EGFR in vivo in a mouse colorectal cancer xenograft model. Reversible bioconjugation of a known analogue of the tyrosine kinase inhibitor Mo-IPQA to a cationic peptide, and co-formulation with peptides containing both EGFR-binding and cationic sequences, allowed for good levels of inhibitor encapsulation with targeted delivery to LIM1215 colon cancer cells. Furthermore, high levels of expression of the Picchu-X biosensor in the LIM1215 cells in vivo allowed us to demonstrate, using fluorescence lifetime microscopy (FLIM)-based biosensing, that EGFR activity can be successfully suppressed by the tyrosine kinase inhibitor, released from the lipopolyplexes. Finally, we measured the biodistribution of lipopolyplexes containing 125I-labelled inhibitors and were able to demonstrate that the lipopolyplexes gave significantly higher drug delivery to the tumors compared with free drug.

Illustration of adipose-derived stem cells with tri-modal imaging capabilities for evaluating the efficiency of cell delivery to tumours., Stem cells have been utilised as anti-cancer agents due to their ability to home to and integrate within tumours. Methods to augment stem cell homing to tumours are being investigated with the goal of enhancing treatment efficacy. However, it is currently not possible to evaluate both cell localisation and cell viability after engraftment, hindering optimisation of therapy. In this study, luciferase-expressing human adipocyte-derived stem cells (ADSCs) were incubated with Indium-111 radiolabelled iron oxide nanoparticles to produce cells with tri-modal imaging capabilities. ADSCs were administered intravenously (IV) or intracardially (IC) to mice bearing orthotopic breast tumours. Cell fate was monitored using bioluminescence imaging (BLI) as a measure of cell viability, magnetic resonance imaging (MRI) for cell localisation and single photon emission computer tomography (SPECT) for cell quantification. Serial monitoring with multi-modal imaging showed the presence of viable ADSCs within tumours as early as 1-hour post IC injection and the percentage of ADSCs within tumours to be 2-fold higher after IC than IV. Finally, histological analysis was used to validate engraftment of ADSC within tumour tissue. These findings demonstrate that multi-modal imaging can be used to evaluate the efficiency of stem cell delivery to tumours and that IC cell administration is more effective for tumour targeting.

Stem cells have been utilized as anti-cancer agents due to their ability to home to and integrate within tumors. Methods to augment stem cell homing to tumors are being investigated with the goal of enhancing treatment efficacy. However, it is currently not possible to evaluate both cell localization and cell viability after engraftment, hindering optimization of therapy. In this study, luciferase expressing human adipocyte derived stem cells (ADSCs) were labelled with superparamagnetic iron oxide nanoparticles (SPIONs) conjugated to Indium-111 to produce cells with tri-modal imaging capabilities. ADSCs were administered intravenously (IV) or intracardially (IC) to mice bearing 4T1 orthotopic breast tumors. Cell fate was monitored serially using bioluminescence imaging (BLI) as a measure of cell viability, magnetic resonance imaging (MRI) for cell localization and single photon emission computer tomography (SPECT) for cell quantification. BLI/MRI/SPECT imaging revealed differences in whole body cell distribution between injection routes. BLI showed the presence of viable ADSCs within tumors as early as 1-hour post IC injection compared to 3 days post IV injection. SPECT data showed the percentage of ADSCs within tumors to be 2-fold higher after IC than IV at 5-hour post injection. Whereas, MRI confirmed the localization of SPION labelled cells in tumors after IC injection but not IV. Finally, histological analysis was used to validate engraftment of ADSC within tumor tissue. These findings demonstrate that multi-modal imaging can be used to evaluate the efficiency of stem cell delivery to tumors and that IC cell administration is more effective for tumor targeting.

Coenzyme A (CoA) is a highly selective inhibitor of the mitotic regulatory enzyme Aurora A kinase, with a novel mode of action. Herein we report the design and synthesis of analogues of CoA as inhibitors of Aurora A kinase. We have designed and synthesised modified CoA structures as potential inhibitors, combining dicarbonyl mimics of the pyrophosphate group with a conserved adenosine headgroup and different length pantetheine-based tail groups. An analogue with a -SH group at the end of the pantotheinate tail showed the best IC50, probably due to the formation of a covalent bond with Aurora A kinase Cys290.

This paper presents selective findings from a larger grounded theory study of midwifery and continuing professional development. A grounded theory approach was used to analyse data concerning what motivates midwives to undertake the examination of the newborn post-registration midwifery course and then to utilise their skills or not. Key issues identified in the study related to the midwives'views and perceptions. They found that practice is changing and they are moving away from the holistic perspective of examination of the newborn baby to opportunistic examinations. The midwives' perceptions are that there is a difference in the knowledge and training for midwives compared to paediatricians and although the National Screening Committee has set standards and competencies adhered to by Universities across the UK, from the data in this study midwives do not observe paediatricians using them in practice. The study findings suggest a change of culture and practice may be required by all practitioners who carry out the examination of the newborn.

Aims and objectives To explore how peacetime employment of military nurses in the UK National Health Service Medical Defence Hospital Units prepares them to be competent to practise in their role on deployment. Background Military secondary care nurses are employed within UK National Health Service Trusts to gain clinical experience that will be relevant to their military nursing role. Design A two-stage grounded theory study using mixed methods: postal questionnaire survey and in-depth interviews. Methods In stage one a postal questionnaire was distributed to all serving military nurses. Stage two involved 12 semi-structured interviews. The data from both parts of the study were analysed using grounded theory. Results Four categories and one core category were identified, which suggested that participants did not feel fully prepared for deployment. Their feelings of preparedness increased with deployment experience and decreased when the nature of injuries seen on deployment changed. Respondents argued that even when unprepared, they did not feel incompetent. The findings suggest that the peacetime clinical experience gained in the National Health Service did not always develop the necessary competencies to carry out roles as military nurses on deployment. This study highlights the unique role of military nurses. We discuss these findings in the light of the literature on competency and expertise. Conclusion The military nurses in this study did not feel fully prepared for deployed operations. We propose a new model for how military nurses could gain relevant experience from their National Health Service placements. Relevance to clinical practice National Health Service clinical placements need to be reassessed regularly to ensure that they are meeting military nurses' clinical requirements. Experiences of nurses returning from deployment could be shared and used as a basis for reflection and learning within National Health Service Trusts and also inform decisions regarding the appropriateness of clinical placements for qualified military nurses.

Background: Oncology follow-up has traditionally prioritised disease surveillance and the assessment and management of symptoms associated with cancer and its treatment. Over the past decade, the focus on late effects of treatment has increased, particularly those that have an adverse effect on long-term function and quality of life. The aim of this research was to explore factors that influence the identification of treatment-induced female sexual difficulties in routine oncology follow-up after radical pelvic radiotherapy. Methods: A structured observation schedule was used to systematically record topics discussed in 69 radiotherapy follow-up consultations observed over a 5-month period. Results: Analysis suggests that physical toxicity assessment focused on bowel (81%) and bladder (70%) symptoms. Vaginal toxicity was discussed less frequently (42%) and sexual issues were explored in only 25% of consultations. Formal recording of radiation toxicity through assessment questionnaires was limited to patients participating in clinical trials. Surveillance activity and the management of active physical symptoms predominated and psychosocial issues were addressed in only 42% of consultations. Interpretation: Female sexual morbidity after pelvic radiotherapy remains a neglected aspect of routine follow-up and cancer survivorship. Developments in both individual practice and service provision are necessary if the identification and management of treatment-induced female sexual difficulties is to be improved.

This paper illustrates the role of psychodynamic small group work in integrating theory and practice for nursing students. Psychodynamic work with individual patients and small staff groups is established in some areas of medical and nursing practice although not widely used in general nursing. Clinical material which was brought to two group supervision sessions by student nurses on clinical placement is presented in this paper and discussed using a psychodynamic perspective. A critical review of psychodynamic small group work and a position paper is presented in this paper to argue that using a psychodynamic approach in nurse education may address the theory–practice gap for student nurses by allowing them to reflect on the emotional issues arising in clinical placements. The paper illustrates how supervision can assist students to integrate theory and practice. It is suggested that reflecting on feelings in small group work with student nurses with a tutor or supervisor who works psychodynamically may help students integrate their theoretical and practical learning. Understanding the theory–practice gap from a psychodynamic perspective may help nurse tutors in their personal tutor work to integrate theoretical and practical learning for students and thereby support students in providing good quality care for their patients.

This paper aims to increase our understanding about how student nurses' experiences of supernumerary status are embedded in the hidden curriculum in clinical practice and contribute to the theory-practice gap in nursing.

This paper is a report of a study of women's perspectives on the experience of laparoscopic surgery for endometrial cancer.

This paper considers two questions: what pedagogies for teaching nursing are used in nurse education research? Are these pedagogies transferred to learning in the workplace? We argue that there are underpinning pedagogies identified in nurse education research in the area of workplace and work based learning which are broadly qualitative, action orientated and focused on knowledge generation. Such pedagogies are rooted in a philosophy of teaching and learning where learning is seen as active, reflective and socially constructed. We consider possible answers to these questions through an exploration of empirical work by Evans et al. (2009) which has focused on knowledge transfer in the workplace. Their work offers insights into how pedagogies can be applied to nurse education research which in turn may be transferred into the workplace. In particular, they argue that the concept of knowledge transfer is outdated and we should focus instead on how knowledge learnt in one context (the academy) is re-contextualised in another (the workplace). We also draw on Aranda and Law's (2007) paper on the debates concerning the use of sociology in nurse education to explore competing narratives. We conclude that the pedagogies identified in educational research are not transferred to nurse education and practice yet offer an alternative view of knowledge transfer as illustrated by Evans et al.'s work which explores how learning in the workplace may be facilitated more effectively. We conclude that the lack of transfer of nurse education research pedagogies to practice learning undermines the position of nurse teachers within the academy as nurse education becomes a practice or professional discipline without a discrete disciplinary base.

In a classic paper, Menzies (1960) argued that nurses distanced themselves from patients in order to avoid direct engagement with them and as a means of managing their anxiety. Reflecting on the work 40years later Fabricius argued that in the move from hospital-based nurse education to universities, nurse educators had further entrenched this defence. It is from both these perspectives that we locate this paper to explore the position of nurse teachers today drawing on empirical data from a study set up to investigate who currently leads student nurse learning in the clinical areas and as a follow up to original research on the emotional labour of nursing (Smith, 1992). This paper presents findings from interviews with nurse teachers which are complemented by student nurse responses to a ward learning environment questionnaire, interviews with ward based nurses and documentary analysis. A major theme to emerge from the study was that there has been an uncoupling of education and practice as a consequence of the changes taking place in nurse education over the last two decades. This paper describes the range of emotions expressed as a consequence of this uncoupling such as increasing feelings of uncertainty over the nurse teacher's role in clinical practice and anxiety generated from working in a university system which appeared to devalue caring. The apparent impact of these feelings on nurse teachers was to reinforce the education/practice split and the projection of their anxiety onto students and practitioners. We suggest that nurse teachers and in particular the system in which they work need to recognise both split and projection so that they are able to bear their anxiety and manage it in their teaching.

Summary The study on which this paper reports examined how the widespread changes in the NHS workforce and in higher education which have transformed nurse education in recent decades have impacted on responsibility for the leadership of student nurse learning in clinical practice. Findings from this mixed methods case study carried out at four English higher education institutions between 2006 and 2007 suggest that link lecturers' presence in clinical areas is diminishing, and that practice nurses' involvement with pre-registration students' learning may be limited. Ward managers lead learning at ward level but changes to their role limit their presence on the wards, so that mentors lead student learning on a day to day basis, which they must balance with caring for patients. Changes to the nurse's role mean that modelling bedside care often falls to health care assistants. This deficit of leadership for learning may be understood as a manifestation of the ‘uncoupling' of education and practice following the move of nurse education into higher education and subsequent changes to nursing roles. Strengthening leadership for learning is likely to be associated with recoupling practice and education and indicators to assess the quality of leadership for learning in clinical practice are suggested.

Aim We present three case studies of discrimination to illustrate how racist bullying as discriminatory practices operates in the workplace. Background Workplace bullying in the British health care sector is reported along with evidence of discrimination towards overseas-trained nurses recruited to work in the United Kingdom (UK). Methods The three interviews, which form the basis of the discussion in this paper, were selected purposively from a national study of overseas nurses because they present strong examples of the phenomenon of workplace bullying. The data on which this paper draws were collected through semi-structured, audio-recorded interviews and thematically re-analysed using nvivo V2. Results The national study showed how racism is entrenched in health workplaces. Our findings in this paper suggest that racism can be understood by the concept of racist bullying. There are four key findings which illustrate racist bullying in the workplace: abusive power relationships, communication difficulties, emotional reactions to racist bullying and responses to bullying. Conclusions We argue that the literature on workplace bullying adds a layer of analysis of discrimination at the individual and organizational levels which enables us to further delineate racist bullying. We conclude that racist bullying can be specifically identified as a form of bullying. Implications for nursing managers Our data may assist managers to challenge current workplace working practices and support bullied employees. The three interviews show different responses to racist bullying which allow us to explore some implications for management practice.

In this paper we comment on the changes in the provision of fertility care in Australia, New Zealand and the UK to illustrate how different funding arrangements of assisted reproductive technologies (ART) shape the delivery of patient care and the position of fertility nursing. We suggest that the routinisation of in vitro fertilisation technology has introduced a new way of managing the fertility patient at a distance, the distal fertility patient. This has resulted in new forms of organisational routines in ART which challenge both traditional forms of nursing and advanced nursing roles. We discuss the consequences of this increasingly globalised approach to infertility through the lens of three national contexts, Australia, New Zealand and the UK to unpack the position of nursing within the new forms of organisational routines.

How nursing as a profession is valued may be changing and needs to be explored and understood in a global context. We draw on data from two empirical studies to illustrate our argument. The first study explored the value of nursing globally, the second investigated the experiences of overseas trained nurses recruited to work in a migrant capacity in the UK health care workforce. The indications are that nurses perceive themselves as devalued socially, and that other health care professionals do not give nursing the same status as other, socially more prestigious professions, such as medicine. Organizational and management structures within the NHS and the independent care home sector devalue overseas nurses and the contribution they make to health care. Our conclusions lead us to question the accepted sociocultural value of the global nursing workforce and its perceived contribution to global health care, and to consider two ethical frameworks from which these issues could be discussed further.

To report a literature study of leadership for learning in clinical practice in the United Kingdom. Background Previous research in the United Kingdom showed that the ward sister was central to creating a positive learning environment for student nurses. Since the 1990s, the ward mentor has emerged as the key to student nurses' learning in the United Kingdom.A literature study of new leadership roles and their influence on student nurse learning (restricted to the United Kingdom) which includes an analysis of ten qualitative interviews with stakeholders in higher education in the United Kingdom undertaken as part of the literature study.Learning in clinical placements is led by practice teaching roles such as mentors, clinical practice facilitators and practice educators rather than new leadership roles. However, workforce changes in clinical placements has restricted the opportunities for trained nurses to role model caring activities for student nurses and university based lecturers are increasingly distant from clinical practice.Leadership for learning in clinical practice poses three unresolved questions for nurse managers, practitioners and educators - what is nursing, what should student nurses learn and from whom?Leadership for student nurse learning has passed to new learning and teaching roles with Trusts and away from nursing managers. This has implications for workforce planning and role modelling within the profession.

AIMS AND OBJECTIVES: I will argue that overseas nurse recruitment is the consequence of a care gap, which arose from several policy shifts in the 1990s and in part from the rhetoric of a normative moral discourse in the UK which claims that caring is the moral essence of nursing. I will suggest that this discourse has masked the uncoupling of caring from nursing practice and that this uncoupling places the overseas nurses in a contradictory position. BACKGROUND: In an increasingly competitive global labour market, the UK is faced with a nursing shortage and has been recruiting trained nurses from abroad (NMC 1993-2002). DESIGN AND METHODS: This paper is based on two related, qualitative studies using semi-structured focus groups and individual interviews. The first explored the experiences of overseas nurses in the UK and the second investigated the equal opportunities and career progression of overseas nurses in the UK. RESULTS: The data from these studies challenge the normative UK value that caring is at the heart of nursing. These data are the lens through which we see this contradiction explicitly played out. Overseas nurses observe that caring (as undertaken by health care assistants in care homes) is not nursing yet caring is being passed down the line as a process that marginalizes the overseas nurses and at the same time devalues their skills. I do not argue that overseas nurses care at a higher standard (although this may be the case) just that they care differently, that they expected UK nurses to deliver basic care and, instead, experience UK nursing practice as less autonomous and of a lower standard than they expected. CONCLUSIONS: I argue that the overseas nurses' views help us understand the processes by which the uncoupling of caring from nursing has come about. RELEVANCE TO CLINICAL PRACTICE: This paper discusses a workforce issue which is directly relevant to clinical practice because it focuses on the meaning of care; what is caring, what are caring activities and how are these represented in the discourse on caring in the literature? This paper also reveals significant worries among nursing managers about how to staff the nursing workforce and what nurses should be doing in the clinical areas.

This paper explores the experiences of infertile women who occupy a liminal space in society, and argues that the fertility clinic served as a space to tolerate women's experiences of liminality. It provided not only rituals aimed at transition to pregnancy, but also a space where women's liminal experiences, which are caused by the existential chaos of infertility, could be tolerated. The British experience seemed to differ from the American one identified in the literature, where self-management and peer group support are described as strategies used by infertile women to manage infertility. The British women in this study did not appear to draw so much on self-management or peer group support to deal with their experiences of infertility. They appeared to be isolated in their experience. The clinic thus provided a space in which recognition was given to their intensely private experiences of difference from those in the outside fertile world and allowed them to manage these socially unacceptable, culturally taboo and invisible experiences. However, because of its very limited success rate in enabling women to become pregnant, rather than facilitating the transition of status from infertile to fertile woman, the clinic also served to reinforce the liminal experiences of those women who remained infertile. Inadvertently, the clinic offered a way of being in limbo while at the same time reinforcing the liminal experiences of women.

Aim To evaluate the experiences of health-care professionals, service users and carers of service users from a UK hospice in relation to dependency assessment. Design Qualitative evaluation. Sample Purposive, convenience sample of hospice staff, patients receiving hospice services and carers of patients receiving hospice services. Methods Focus group interviews with hospice staff and carers of hospice service users. Individual interviews with patients. Results Staff felt the tool used produced inaccurate results, in part because of omissions in content. They did not perceive the data produced affected working practice, e.g. staffing levels. Patients described unobtrusive assessment and stated their needs were met. Carers reported feelings of isolation. They also described differing information and support needs from the patients. Conclusion Further research is required to improve the validity of dependency data collection. Further investigation of carer assessment is also justified.

The study reported in this paper explores how infertile women cope with infertility using their religious and spiritual beliefs. In total, 30 infertile women affiliated to different denominations of Christianity and Islam were interviewed in the UK and Iranian fertility clinics using grounded theory. The categories which emerged included governing ones’ ‘Self’ through gaining control of emotions, adopting religious coping strategies, and handling the burden of infertility peacefully, which all related to the core category of ‘relying on a higher being’. We argue that infertile women employ a variety of religious and spiritual coping strategies which are associated with adaptive health outcomes. Further scientific inquiry is required to investigate how religion and spirituality promote adaptation to infertility.

A ‘good enough’ nurse: supporting patients in a fertility unit In this paper, I discuss the findings of an ethnographic study of a fertility unit. I suggest that caring as ‘emotional awareness’ and ‘non-caring’ as ‘emotional distance’ may be forms of nursing akin to Fabricius’s (1991) arguments around the ‘good enough’ nurse. This paper critiques caring theories and contributes to the debates over the nature of caring in nursing. I discuss the implications raised for nurses if patients want a practical approach to caring and do not expect an emotionally intimate relationship from nurses.

This paper presents the findings from an ethnographic study of a fertility unit. Data were collected using participant observation and semi-structured interviews over a period of 2 years. Fifteen patients and 23 members of staff were interviewed. Data analysis was completed using a modified thematic analysis. The findings indicated that the emotions evoked by infertility and medical treatments were powerful and frightening. Patients managed their emotions privately although they were conscious of an emotional awareness by nurses, which they described as 'caring'. Nurses were associated strongly with caring and their role was primarily to manage emotions; however, to do this, nurses used non-caring (emotional distance) rather than caring. Nurses were responsible for managing emotions in the public spaces of the clinics and moved between emotional distance and awareness according to the needs of the clinic. In this article, it is argued that non-caring was a defence against anxiety about coping with painful feelings and that the nursing role was to 'nurse the clinic and the doctor' rather than the patient.

This paper explores the history of the concept of health environment in nursing discourse. The prompt to investigating the subject followed the national research and development (R&D) initiative set up through the Royal College of Nursing and the Centre for Policy in Nursing Research. Subsequent developments in national healthcare policy, particularly in relation to primary care-based commissioning and public health highlight the timeliness of such a debate. A conceptual framework for the health environment is suggested which is dynamic and practice-oriented. It is hoped that this will appeal both to academics and practitioners in order to build a base of research and practice around the health environment within and beyond the nursing professions.

ObjectivesTo explore the experiences of governance and incentives during organizational change for managers and clinical staff.Study SettingThree primary care settings in England in 2006–2008.Study DesignData collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation.Principal FindingsIntegrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty.ConclusionsEliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.

This paper discusses the effects of anxiety and depression on infertile people as they undergo infertility investigations and treatments, and explores what nurses may do to assist them to cope with this anxiety. There is an extensive literature on the psychosocial effects of infertility on couples, women and men separately and their children, but the nursing and midwifery literature lacks an in-depth exploration of the psychological and emotional consequences of infertility for infertile people. The paper concludes by arguing that nurses and midwives need to undertake research into their practice in fertility care, that is, caring for infertile people as they undergo assisted reproductive technologies and, to this end, suggests sources of research funding.

BACKGROUND Chemotherapy toxicity hinders cancer treatment outcomes. Healthcare professionals educated in biomedical-oriented systems tend to label patients who refuse or discontinue chemotherapy as "noncompliant." How diverse discourses in public texts related to chemotherapy toxicity, which may significantly shape patients' actions, has not been formally explored. OBJECTIVE The aims of this study were to explore the 2 dominant discourses in Taiwan related to chemotherapy toxicity within their sociocultural context and to ascertain how chemotherapy toxicity is constructed in the texts of journals and newspapers. METHODS Public, medical, and nursing texts about chemotherapy from 1950 to 2010 were collected and analyzed using Foucaultian discourse analytical techniques; juxtaposing dominant and marginalized discourses, we identified cultural themes. RESULTS In traditional Chinese medicine, toxic chemotherapy drugs are believed to interfere with circulation of energy flow and blood and to disturb the harmony of yin/yang in the body. Findings indicate that biomedical and traditional Chinese medical doctors do not agree about the best management of chemotherapy toxicity. Moreover, lay knowledge and patient voices regarding chemotherapy toxicity are often ignored in medical discourses. CONCLUSIONS Cultural beliefs and covert power relations between diverse medical traditions shape patients' experiences of chemotherapy toxicity. The preferential use by patients of traditional Chinese medicine over biomedicine to manage chemotherapy toxicity sustains its pivotal role. IMPLICATIONS FOR PRACTICE The disparity of perceptions between healthcare professionals and patients regarding chemotherapy toxicity needs to be thoroughly assessed. Thus, culturally specific nursing care models may be developed.

Objectives This paper examines how the interaction between financial and clinical risk at two critical phases of health care reform in England has been experienced by frontline staff caring for vulnerable patients with long term conditions. Methods The paper draws on contracting theory and two interdisciplinary and in-depth qualitative research studies undertaken in 1995 and 2007. Methods common to both studies included documentary analysis and interviews with managers and front line professionals. The 1995 study employed action-based research and included observation of community care; the 2007 study used realistic evaluation and included engagement with service user groups. Results In both reform processes, financial risk was increasingly devolved to frontline practitioners and smaller organizational units such as GP commissioning groups, with payment by unit of activity, aimed at changing professionals' behaviour. This financing increased perceived clinical risk and fragmented the delivery of health and social care services requiring staff efforts to improve collaboration and integration, and created some perverse incentives and staff demoralisation. Conclusions Health services reform should only shift financial risk to frontline professionals to the extent that it can be efficiently borne. Where team work is required, contracts should reward collaborative multi-professional activity.

Pelvic radiotherapy creates physical effects and psychological responses that negatively affect the sexual health of women and couples, yet these sexual consequences are not frequently researched or clinically assessed. This focused ethnographic study explored factors that influence the clinical assessment of treatment-induced female sexual difficulties after pelvic radiotherapy within routine medical follow-up. Participant observation of follow-up clinics (n = 69) and in-depth interviews with 24 women, 5 partners and 20 health professionals were undertaken at two cancer centres in the South East of England from 2005 to 2006. Thematic analysis of interview transcripts resulted in five emergent themes, two of which are explored in detail within this paper. A social constructionist approach to human sexuality was used to explore representations of female sexuality in oncology follow-up constructed by clinicians, women and their partners. Yet neither social constructionist nor biomedical (the predominant model in medical follow-up) perspectives on human sexuality provided an adequate interpretation of these study findings. This paper argues that the comprehensive study and practice of sexual rehabilitation in oncology requires a synthesis of both biomedical and social constructionist perspectives in order to capture the complex, subjective and embodied nature of the female sexual response in both health and illness.

Summary Background The expansion of the higher educational sector in the United Kingdom over the last two decades to meet political aspirations of the successive governments and popular demand for participation in the sector (the Widening Participation Agenda) has overlapped with the introduction of e-learning. Objectives This paper describes teachers' views of using e-learning for non-traditional students in higher education across three disciplines [nursing, chemistry and management] at a time of massification and increased diversity in higher education. Design A three phase, mixed methods study; this paper reports findings from phase two of the study. Settings One university in England. Participants Higher education teachers teaching on the nursing, chemistry and management programmes. Methods Focus groups with these teachers. Findings Findings from these data show that teachers across the programmes have limited knowledge of whether students are non-traditional or what category of non-traditional status they might be in. Such knowledge as they have does not seem to influence the tailoring of teaching and learning for non-traditional students. Teachers in chemistry and nursing want more support from the university to improve their use of e-learning, as did teachers in management but to a lesser extent. Conclusions Our conclusions confirm other studies in the field outside nursing which suggest that non-traditional students' learning needs have not been considered meaningfully in the development of e-learning strategies in universities. We suggest that this may be because teachers have been required to develop e-learning at the same time as they cope with the massification of, and widening participation in, higher education. The findings are of particular importance to nurse educators given the high number of non-traditional students on nursing programmes.

In this article it is argued that there are barriers to effective and non-discriminatory practice when mentoring overseas nurses within the National Health Service (NHS) and the care home sector. These include a lack of awareness about how cultural differences affect mentoring and learning for overseas nurses during their period of supervised practice prior to registration with the UK Nursing and Midwifery Council. These barriers may demonstrate a lack of effective teaching of ethical practice in the context of cultural diversity in health care. This argument is supported by empirical data from a national study. Interviews were undertaken with 93 overseas nurses and 24 national and 13 local managers and mentors from six research sites involving UK health care employers in the NHS and independent sectors in different regions of the UK. The data collected showed that overseas nurses are discriminated against in their learning by poor mentoring practices; equally, from these data, it appears that mentors are ill-equipped by existing mentor preparation programmes to mentor overseas-trained nurses from culturally diverse backgrounds. Recommendations are made for improving mentoring programmes to address mentors’ ability to facilitate learning in a culturally diverse workplace and thereby improve overseas nurses’ experiences of their supervised practice.

This study seeks to explore the cultural practises, which shape the culture of transfusion, and to identify the key elements, which influence clinical decision making in blood transfusion in haemato-oncology and lung cancer patients.The assessment and decision making processes for blood transfusion were explored using fieldwork observation, six patient and nine clinician interviews based on ethnographic methodology. Data were analysed using thematic analysis.First, the findings suggested that despite anaemia and transfusion being ubiquitous in this cancer setting, it sits low in the hierarchy of clinical concerns (The unimportance of anaemia). Second, there is a great deal of uncertainty surrounding the diagnosis and management of this clinical problem; but this uncertainty was acknowledged by both patients and clinicians (Acknowledging uncertainty). Third, clinicians and to some extent patients, are socialised into the practise of the sub-discipline (Socialisation in practise). Fourth, the haemoglobin level was used as a distinct fragment of information on which to assess for the presence of anaemia and base the decision to treat with blood transfusion (Disaggregation of the body).The management of anaemia is not a priority in this setting; however, by understanding the complexity of factors for variation in practise in the clinical context, new models for learning transfusion skills can be developed. Furthermore, different collaborative groups could be organised to develop optimal transfusion practises, for example to include nurse-prescribing of blood components or by developing patient-centred decision making systems.

This book is a thoughtful and useful addition to my reading list as a teacher of nursing, health care and research. It provides researchers and health-care practitioners with a strong foundation upon which to begin to think about race, ethnicity, multiculturalism and health care. This will be a useful textbook for health-care and research students at the postgraduate level; although undergraduates would find it a useful starting point to exploring the topic in greater depth. The intended audience for this book is wide, however: medical scientists, social scientists, health-care practitioners and researchers. The scholarly, but at the same time personal and inviting, style in which the book is written immediately engages the reader and encourages active and consolidated learning. Each chapter has a clearly stated objective, summary and conclusion, which provide the reader with a readily assimilable overview of the material being presented. Raj Bhopal, a well known researcher in the area of race, ethnicity and health care, has a great deal to say about how health-care providers must begin to start thinking about research on, and the provision of, health care in a multicultural society. He acknowledges that multiculturalism and multicultural living are challenges for health-care providers but insists that they need to be addressed if we are to “meet social, ethical, legal and policy obligations to deliver evidence-based health care.” For it is our failure to attend to multiculturalism in a balanced way that has led to unfair and inequitable health-care provision. There is a need for this book because there is poor understanding of how ethnicity and race influence health care in a multicultural society and hence little is being done to address the problem at the practical level. As Bhopal says, the “quality of the research leaves much to be desired” and the service fails to adapt to meet the needs of ethnic minority users. In this book, the author provides readers with the knowledge and skills to deconstruct ethnicity, race and multiculturalism in health care, i.e., he provides historical and sociological explanation of these concepts, which unpick layers of historical and social and cultural meanings. He explores the context in which they emerged and how this context influences their accepted dominant meanings in today’s health-care practice. Much of this may be uncomfortable reading for those of us who are white and have failed to see how such meaning has often shaped poor delivery of health care and poor research. It is through this process of deconstruction that readers are encouraged to reflect on taken-for-granted assumptions and hence to begin the process of thinking about and hopefully changing their practice as researchers or health-care practitioners. The book’s clear presentation of methods of enquiry grounded in examples of health-care policy and planning is designed to encourage changes in actual practice. As Bhopal states “it is the intention that the reader will acquire the depth of knowledge to use the concepts and not merely be aware of them.” ■

In spite of the growing body of literature that has focused on medical, psychological, social, and cultural consequences of infertility, issues such as religious and spiritual dimensions of infertility have received little attention. Considering that infertility is a multifaceted problem and results in multiple losses, we argue that health professionals need to consider all aspects of holistic care when caring for women with fertility problems. Holistic care considers not only the psychological, social and cultural needs of individuals, but also their religious and spiritual needs. Women may use their religious/spiritual beliefs to cope with crisis, and to find meaning and hope in their suffering. This article reviews the literature on religion/spirituality and infertility using Medline, CINAHL, PBSC, IBSS and ISI Web of Knowledge from 1985 to the present. It focuses on religious and spiritual care as one aspect of holistic care of women with fertility problems, and draws attention to the religious perspectives of infertility and reproductive technologies. It highlights the spiritual dimension of the infertility experience in previous research, and concludes with a discussion on the gaps in the literature and the implications of including religious and spiritual issues in infertile women's care.

The aim of this paper is to highlight the gap between existing research evidence and nursing and midwifery practices in caring for women following successful in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), and to suggest directions for research within these disciplines. We argue that although the number of couples in the UK experiencing fertility problems has risen, 1.4% of all births in the UK are as the result of infertility treatments (HFEA, 2005/2006); yet there is little research into the experiences of motherhood for women who successfully achieve pregnancy following IVF or GIFT. Consequently, there is negligible research evidence for nurses and midwives practicing in this area, and British healthcare staff appear to be unaware of the specific needs of infertile women during pregnancy, birth and early motherhood. In this paper we review the existing literature on this group of women, which falls into three areas: studies into the psychosocial development of the child conceived via IVF/GIFT/donor insemination; comparative studies into experiences of women following successful infertility treatment and women who conceive naturally; and studies into the experiences of women following successful IVF treatment. We review this literature to argue for research into the needs of infertile women following successful IVF/GIFT, to inform evidence for practice.

The lack of dialogue between nurses and feminists around fertility and infertility treatments detracts from the development of assisted conception nursing. In this article, the author examines the existing literature and argues for a stronger nursing contribution to this controversial subject.

This paper discusses the concept of interprofessional learning based on empirical data from an evaluation of an interprofessional learning project that was set in a British primary health care centre. A process evaluation methodology was chosen to collect the data using semi-structured interviews and focus groups with stakeholders and staff to gather their experiences and views of the project and documentary data from records written over the lifetime of the project. The paper argues that an interprofessional learning culture requires time to become embedded in everyday practice and to achieve such a culture, shared values, aims and clear communication are essential. The data suggest that there is a need to recognize responsibility for one's own learning as individuals as well as learning as teams of work colleagues if interprofessional learning is to be successful. However, even when these pre-requisites of interprofessional learning are agreed and acknowledged openly in the workplace, participants in the development of a learning culture need to recognize that there are structural controls which influence and constrain such developments which are external to participants and beyond their immediate control.

This paper develops previous work on theories of embodiment by drawing on empirical data from a study into the experiences of infertile women in the UK. I suggest experiences of embodiment shape the preferences of infertile women for a female nurse as chaperone during intimate medical procedures. I explore the impact of this role on the understandings and meanings of nursing in a highly gendered field of practice. I present data from an ethnographic study of infertile women who chose to attend a British infertility clinic for investigation and fertility treatment cycles. Data were collected over 2 years using participant observation and semistructured interviews with 15 women and 20 members of staff in a British fertility unit. Data analysis was completed using a modified thematic analysis following Boyle and McEvoy. I discuss women's experiences of intimacy and bodily care and how these experiences might be understood by exploring the phenomenological concept of embodiment. I argue that women benefit from having a female nurse as chaperone because of their expectations of gender, nursing and caring. Women's expectations reinforce both notions of gendered caring and the gendered role of nursing. These data challenge notions of patriarchal professionalism prevalent in nursing, which seek to move away from the gendered role of the nurse (which traditionally included a chaperone role) towards a model of professional development based on a mind-body split. I suggest that these data offer a way of understanding the female embodied subject in the field of gendered caring, which is potentially transgressive because they suggest ways in which both mind and body can be integrated through the role of the female chaperone.

This paper discusses data from a case study of fertility nursing practice. An ethnographic case study approach using participant observation and nine semi-structured interviews with staff and patients was undertaken. The data were analysed thematically and these themes are discussed in this paper. We present the meaning a small group of nurses working in a fertility unit in the UK attach to new roles and the ways in which changes in practice may be influenced. The nurses in this study believed that nature of the task demanded changes to practice and they identified personal, interpersonal and socio-cultural factors which influenced these changes. These new roles facilitated greater continuity of care for patients. This paper discusses the effects of these new roles on knowing and intimacy in nurse - patient relationships. The data suggests that new nursing roles, which are based on "traditional" nursing and "new" technical skills, are fragile and may not be shared across a professional community.

Nursing the clinic, being there and hovering: ways of caring in a British fertility unit Aim. To explore the meaning of caring in a fertility unit and to present the findings and discuss their implications for practice. Background. Little research has been published internationally on the nature of nursing care in the fertility field. This study was intended to stimulate debate over the nature of care in fertility work. Methodology. An ethnographic approach, which included part-time participant observation and in-depth focused interviews with staff and patients. Data were also collected using a field and a research diary. Data were analysed using a modified thematic analysis. Findings. The data suggest that caring is strongly linked with nurses and that patients' expectations of nurses may be more practically than emotionally focused. I argue that the organization of nursing work, which I call `nursing the clinic and the doctor', facilitated this practical approach to caring. I discuss two features of nursing the clinic and the doctor: hovering and being there. Conclusions. While there may be other factors that influence the practice of this form of non-intimate caring, nursing in this way may be what patients desire and may be congruent with managing emotions. The findings have implications for the discourse on intimacy and caring within fertility nursing as well as in different outpatient settings.