Search

Purpose To develop and validate an instrument to collect data on symptoms (frequency/intensity) in older palliative cancer patients. Methods A four-phase instrument development and validation study was performed. A preliminary version of the instrument was developed through a literature review. Face- and content validity were assessed in a Delphi-procedure with eleven experts. Cognitive interviewing with 24 older cancer patients was performed to enhance content validity of the instrument. Test–retest was performed to assess the stability. Results An 40-item instrument was developed. The Assessment Symptoms Palliative Elderly (ASPE) collects data on frequency and intensity of 24 physical, 10 psychological, 3 functional, 1 spiritual and 2 social symptoms. Content validity was excellent (I-CVI 81.8%–100.0% and S-CVI 92.9%). Cognitive interviewing allowed to improve the content validity. Test–retest showed substantial to almost perfect agreement for 87.5% of the items. No item had poor or fair agreement. Conclusion This study resulted in the development of the ASPE which reflects good properties for face- and content validity and reliability. Cognitive interviewing has a valuable contribution in the validation process. The instrument can be used to gain insight in symptoms in older palliative cancer patients.

Background: Nonadherence in cancer patients taking oral anticancer drugs is common. Reasons for nonadherence are still not really understood as influencing factors are often complex, dynamic, and interrelated. Objective: A qualitative study was conducted to gain insight into (non-)adherence behavior in patients taking oral tyrosine kinase inhibitors by exploring (1) processes and factors influencing (non-)adherence and (2) their interrelatedness. Methods: Semistructured interviews were held with 30 patients of different ages and with different types of cancer. A grounded theory approach was used. Results: Three foci were found when dealing with oral tyrosine kinase inhibitors: (1) a focus on survival, (2) a focus on quality of life, and (3) a balance between survival and quality of life. The process of adherence was determined by a set of complex and interrelated influencing factors: treatment-related side effects, hope, anxiety, trust, and feedback mechanisms. Conclusions: This qualitative study gives insight into processes and factors influencing (non-)adherence behavior in patients taking oral tyrosine kinase inhibitors. The results of this study can help healthcare professionals understand why patients taking oral tyrosine kinase inhibitors do not always adhere to their therapy. Implications for Practice: Conditions should be created by which patients get maximum opportunity to establish a balance between survival and quality of life. An open climate and a trust-based relationship should be established in which patients feel comfortable to openly discuss their therapy and the difficulties they experience.

Background: The first generation of immigrants to Belgium from Turkey and Northwest Africa are aging and at risk for developing cancer. Family members play an important role in both illness and old age. Objective: The objective of this study was to gain insight into experiences and perceptions of families with Turkish or Northwest African backgrounds who were caring for cancer patients older than 50 years in Flanders, Belgium. Methods: A qualitative research design with elements of constructivist grounded theory was used. Twenty-eight loosely structured interviews were conducted. Three researchers were involved in data analysis (researcher triangulation), and 6 conversations took place with experts. Results: Cancer appeared to be a family matter. Caregiving had a strong moral meaning for all participants, particularly for children providing care to a parent. Caregiving could be described as "guiding": family members led the patient through, or familiarized the patient with, the healthcare system. There were strong differences in the extent to which family members believed they should provide care, as well as the kind of professional care considered desirable. Conclusions: Despite shared values of the importance of family and family caregiving, concrete ideas about caregiving differed considerably. The findings imply that shared cultural or religious normative values do not predict day-to-day care practices. Implications for Practice: This study provides new insights into the moral and practical meaning of caregiving, which will help professionals understand the roles adopted by family members. Furthermore, individualized approaches to care appear to be essential, because concrete ideas about informal caregiving differ strongly despite shared values.

Objectives To investigate what published research reveals about the views and experiences of oncology health workers when caring for ethnic minority patients. Design Systematic review of qualitative and quantitative studies. Data sources The following databases were systematically screened: PubMed, CINAHL, Web of Science, and AnthroSource. Reference lists were checked for additional articles. Review methods Empirical studies or systematic reviews (1/2000 to 12/2013) were included if they concerned the oncology setting and the views or experiences of healthcare workers and care users belonging to an ethnic or cultural minority group. The methodological quality of each individual study was assessed using the Critical Appraisal Skills Programme for Qualitative Studies and the Quality Assessment Tool for Quantitative Studies. Results Eighteen publications met the inclusion criteria. Thirteen articles had a qualitative, four a quantitative, and one a mixed methods design. The results in the individual studies were heterogeneous. Most studies reported challenges or barriers when caring for ethnic minority patients, whereas fewer than half of the articles discussed facilitating factors and opportunities. Oncology health workers participating in the included studies sought to provide professional standards of care and tried to adapt care to the needs of ethnic minority patients. However, they experienced formidable communication barriers and they feared doing things that might be considered culturally insensitive. The organizational aspects of care for the oncology patient appeared to have a significant influence on how healthcare providers view and experience oncology care for ethnic minority patients. Conclusions Views and experiences of participating oncology health workers were characterized by a willingness to provide proper care for ethnic minority patients, but this was hampered by a tangle of interrelated issues such as linguistic barriers, fear and uncertainty, and assumptions about cultural matters. Organizational aspects were shown to be a strong influence on healthcare workers caring for ethnic minority patients. Due to methodological limitations of the included studies, conclusions should be viewed with caution.

It could be challenging for nurses to develop new roles under the umbrella term advanced practice nursing, such as the nurse practitioner (NP) role. Advanced nurses are expected to have more comprehensive insights of the complexity of healthcare situations than nurses working at a lower level, which means they have to redefine themselves in their healthcare contexts (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004). NPs are qualified to diagnose and treat a variety of health problems, activities that are perceived to belong to the doctor's repertoire of skills. Therefore, the professional boundaries of nursing and medicine are challenged, which can be stressful for new NPs. Brown and Olshansky (1997) described the first years of practice of primary care NP graduates as a process, in which a crisis in confidence and competence associated with taking on a new position may lead to anxiety. Kelly and Mathews (2001) and Heitz, Steiner, and Burman (2004) described similar findings for NPs working in hospitals and for family NPs, respectively. Taking on a new role can be seen as a transition with profound changes in role relationships, expectations, and abilities. According to Meleis (2010), a transition like this does not simply equal a change, but is rather a process to incorporate changes in or disruptions of one's life. To do this well, it is important to know what may influence this process and its outcomes.BackgroundIn the Netherlands, the NP role has existed since 2000. Master's in advanced nursing practice programs especially designed for NPs are organized as 2-year work- study programs. The students work as NPs in training for 32 hr per week in their clinical work settings, and attend class 1 day per week. In medical courses they are trained in physical examination, medical diagnosis, and treatment planning. Moreover, courses are offered on leadership, patient education, coordinating clinical pathways, guidance, and coaching. These courses provide the tools to deepen their understanding of clinical, professional, and policy issues, allowing them to move beyond their present bachelor's degree level and to cope with the demands of complex patient care. In research courses they learn how to read and understand scientific research, and to design and conduct practice-oriented research. All programs are concluded with a master's thesis on a clinical topic related to NP practice (Verpleegkundige Beroepenstructuur en OpleidingsContinuum [Structure of the Nursing Profession and Education] 2008). The professional master's degree entitles NPs to use the protected title "nurse specialist." In 2011, they gained direct legal authority to perform medical procedures within their areas of expertise (e.g., emergency care, rheumatology, diabetes care, etc.).As soon as the NP role was initiated in the Netherlands, a fierce debate started on whether deployment of NPs could solve healthcare and workforce problems (Ter Maten-Speksnijder, Grypdonck, Pool, Meurs, & Staa, 2014). In the debate's efficiency discourse, the arguments in favor of a formal transfer of medical tasks to nurses included the expected shortage of physicians, increased healthcare spending, and the need for coordinated care. The debate's professional discourse, however, focused on the desirability of combining comprehensive nursing care with medical care. Although most physicians were found willing to delegate tasks to NPs, and the government urged physicians and NPs to realize the formal transfer of tasks (KNMG Koninklijk Nederlands Medisch Genootschap [Royal Dutch Medical Association], V&VN: Verpleegkundigen & Verzorgenden Nederland [Dutch Nurses' Association], NAPA: Nederlandse Associatie Physician Assistents [the Netherlands Association of Physician Assistants], Dutch Professional Healthcare Organizations, 2012), the physicians wished to retain final responsibility for medical care. Nurse leaders, on the other hand, found it important to strengthen the core values and practices of nursing (i. …

Background Given the worldwide ageing of the population and the changes in the structure of society and family, the likelihood increases that older parents face a serious illness in an adult child and will even outlive their child. Objectives To gain insight into older parents' experiences, concerns, and dilemmas regarding their position and role as a parent of an adult child with cancer. Design Qualitative interview design. Setting A geriatric ward and four oncology wards of a university hospital, several nursing homes, local health service agencies. Participants Twenty-five parents (age range 65–91 years) of 22 adult children with cancer (age range 33–66 years) of differing stages and types (with a preponderance of breast cancer). Methods Using a qualitative research methodology underpinned by grounded theory, we conducted semi-structured interviews with a fairly open framework. Results Suffering in silence emerged as the core category encapsulating three interrelated balancing acts: (1) shielding their child while being shielded by their child, (2) being involved while keeping an adequate distance, and (3) shifting attentional priorities between their child, themselves, and others. The emotional interconnectedness between older parents and their adult child with cancer becomes tangible in the transformational process of their parental role and position described in the three balancing acts. Conclusions Faced with their child's illness and possible death, older parents experience overwhelming feelings often underestimated by their (close) environment. Nurses need to be susceptible for the needs and experiences of these older parents. For care by nurses to make a difference, their attention must be directed to how older parents can be invigorated in their parenthood while respecting the child's autonomy.

Purpose In 2017 almost 25,000 Belgians between 40 and 60 years (38% of new diagnoses) were diagnosed with cancer. With increasing life expectancy the chance augments that these patients still have older parents alive. This implies that oncology care should also take into account the impact cancer may have on (the relationship with) older parents. The purpose of this study was to explore how cancer patients communicate and deal with their older parents during the illness trajectory. Method Semi-structured interviews were conducted with 11 cancer patients. Interview transcripts were analysed using the principles of the constructivist Grounded Theory Approach. Results Depending on the situation, the time frame and the person the patients are talking about, cancer patients oscillate between perspectives (I, They and We). A common denominator in all three perspectives is silence fuelled by different forms of solicitude (self-protection and other-protection). This solicitude underpins the cancer patients' communicative behaviours and ways of relating towards their parents. Conclusions Present findings underline the importance of health care providers considering the often hidden complexity of giving information and talking about feelings. Nurses' strategies must be designed not to harm the existing mechanism of solicitude and the diligent management of the patients' relationship with their parents. Conversations about functionality of avoiding certain topics and the impetus behind certain communicative patterns should be put forward instead of consensually advising open communication.

Zorgverleners zijn geen superhelden, maar onvolmaakte mensen met hun tekortkomingen en kleine ondeugden. Als we die onvolmaaktheid erkennen en accepteren maken we het moeilijke werk in de zorg een stukje makkelijker en uiteindelijk ook de zorg misschien wel beter. Dat is de teneur van Gekkenwerk, het recente boek van Linus Vanlaere en Roger Burggraeve. Mieke Grypdonck gaat de dialoog met hen aan.

Context Symptom control is an essential part of palliative care and important to achieve optimal quality of life. Studies showed that patients with all types of advanced cancer suffer from diverse and often severe symptoms. Research focusing on older persons is scarce because this group is often excluded from studies. Consequently, it is unclear which symptoms older palliative care patients with cancer experience and what is the prevalence of these symptoms. To date, no systematic review has been performed on the prevalence of symptoms in older cancer patients receiving palliative care. Objectives The objective of this systematic review was to search and synthesize the prevalence figures of symptoms in older palliative care patients with cancer. Methods A systematic search through multiple databases and other sources was conducted from 2002 until April 2012. The methodological quality was evaluated. All steps were performed by two independent reviewers. A meta-analysis was performed to pool the prevalence of symptoms. Results Seventeen studies were included in this systematic review. Thirty-two symptoms were identified. The prevalence of these symptoms ranged from 3.5% to 77.8%. The most prevalent symptoms were fatigue, excretory symptoms, urinary incontinence, asthenia, pain, constipation, and anxiety and occurred in at least 50% of patients. Conclusion There is a high degree of uncertainty about the reported symptom prevalence because of small sample sizes, high heterogeneity among studies, and the extent of instrument validation. Research based on rigorous methods is needed to allow more conclusive results.

Aim To explore the debate on the development of the nurse practitioner profession in the Netherlands. Background In the Netherlands, the positives and negatives of nurse practitioners working in the medical domain have been debated since the role was introduced in 1997. The outcome of the debate is crucial for nurse practitioners' professional development and society's justification of their tasks. Method Review of 14 policy documents, 35 opinion papers from nurses, 363 opinion articles from physicians and 24 Dutch research papers concerning nurse practitioners from 1995 to 2012. Results Two discourses were revealed: one related to efficiency and one to the development of the profession. In both, the nurse practitioner role was presented as a solution for healthcare and workforce problems, while arguments differed. The efficiency discourse seemed most influential. Opinions of nurse practitioners were underrepresented; taking up new responsibilities was driven by the wish to improve patient care. While most physicians were willing to delegate tasks to nurse practitioners, they wished to retain final responsibility for medical care. Limitations All available publications were extensively studied, which could not include unpublished policy documents from the government or influential parties. This may have led to some selectivity. Conclusion The case of the Netherlands shows that nurses in developing their advanced role are facing barriers, similar to those in other countries. The dominance of efficiency arguments combined with protection of medical autonomy undermines the development towards nursing care that really benefits patients. Implications for nursing and health policy Nurse practitioners should strive to obtain positions in which they are allowed to make their own decisions and wise use of healthcare resources for the good of patients and society. Nurse practitioners should aim to become members of influential healthcare Boards in their countries, in which they can raise their voices and be involved in policy making.

Objective Advance Care Planning (ACP) – the communication process by which patients establish goals and preferences for future care – is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients. Methods We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis. Results The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control. Conclusions ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patient's power of imagination. This may result in end-of-life decisions not reflecting the patient's true wishes. Practice implications Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.

As life expectancy grows, the death of an adult child becomes a highly prevalent problem for older adults. The present study is based on nine interviews and explores the experience of parents (≥70 years) outliving an adult child. The bereaved parents described some silencing processes constraining their expression of grief. When an adult dies, the social support system nearly automatically directs its care towards the bereaved nuclear family. Parental grief at old age is therefore often not recognized and/or acknowledged. Health care providers should be sensitive to the silent grief of older parents both in geriatric and oncology care settings.

Aims and objectives. The Forensic Early Warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying early warning signs and constructing individual early detection plans (EDP) for the prevention of aggressive incidents. The aims of this research were as follows: First, to study the prevalence of early warning signs of aggression, measured with the FESAI, in a sample of forensic patients, and second, to explore whether there are any types of warning signs typical of diagnostic subgroups or offender subgroups. Background. Reconstructing patients’ changes in behaviour prior to aggressive incidents may contribute to identify early warning signs specific to the individual patient. The EDP comprises an early intervention strategy suggested by the patient and approved by the nurses. Implementation of EDP may enhance efficient risk assessment and management. Design. An explorative design was used to review existing records and to monitor frequencies of early warning signs. Methods. Early detection plans of 171 patients from two forensic hospital wards were examined. Frequency distributions were estimated by recording the early warning signs on the FESAI. Rank order correlation analyses were conducted to compare diagnostic subgroups and offender subgroups concerning types and frequencies of warning signs. Results. The FESAI categories with the highest frequency rank were the following: (1) anger, (2) social withdrawal, (3) superficial contact and (4) non-aggressive antisocial behaviour. There were no significant differences between subgroups of patients concerning the ranks of the four categories of early warning signs. Conclusion. The results suggest that the FESAI covers very well the wide variety of occurred warning signs reported in the EDPs. No group profiles of warning signs were found to be specific to diagnosis or offence type. Relevance to clinical practice. Applying the FESAI to develop individual EDPs appears to be a promising approach to enhance risk assessment and management.

The transition from RN to nurse practitioner presents challenges. Because nurse practitioners require deeper critical decision-making abilities to provide safe and quality health care, the Master in Advanced Nursing Practice curriculum implemented reflective case studies to facilitate active and reflective learning. To identify the learning opportunities, we performed a qualitative interpretative study of 77 reflective case studies written by students enrolled in the program. Analysis revealed two categories of learning opportunities—(a) Direct Care, with subcategories of focusing on patients’ needs, exploring one’s own values, and providing comprehensive care; and (b) Increased Performance Demands, with subcategories of handling independence and dependence, and dealing with emotions. The reflective case study is a powerful educational tool to create and guide a new professional with increased responsibilities for a comprehensive and compassionate response to patients’ needs.

Objective "Early warning signs of aggression" refers to recurring changes in behaviors, thoughts, perceptions, and feelings of the patient that are considered to be precursors of aggressive behavior. The early recognition of these signs offers possibilities for early intervention and prevention of aggressive behaviors in forensic patients. The Forensic Early warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying and monitoring these early warning signs of aggression. Methods The FESAI was developed by means of qualitative and quantitative strategies. One hundred seventy six early detection plans were studied to construct a list of early warning signs of aggression. Inventory drafting was done by merging and categorizing early warning signs. Forensic nursing professionals assessed face validity, and interrater agreement was tested. Results The investigation of early detection plans resulted in the FESAI, which contains 44 early warning signs of aggression subdivided into 15 main categories. The face validity of the form was very good, and the interrater agreement was satisfactory. Conclusions Preliminary findings indicate that the FESAI provides a useful listing of early warning signs of aggression in forensic patients. It may facilitate the construction of early detection plans for the prevention of aggressive behaviors in forensic psychiatry.

Aims and objectives. This literature review aims to delineate the determinants of perceived burden by informal caregivers and provide insight into the interrelatedness between these determinants. Background. Despite the attention given to the various determinants of perceived burden, their interrelatedness has not been unravelled. Insight into this interrelatedness is mandatory for the development of successful, complex, multivariate interventions to reduce perceived burden of informal caregivers. Design. Systematic review. Method. Four electronic databases, CINAHL, Embase psychiatry, Medline, Psychinfo and reference lists of selected articles, were searched. Publications between January 1985–2008 were included if they concerned mental illness, burden and care giving. Articles were selected according to predefined inclusion and exclusion criteria. Results. The results of mostly descriptive, cross-sectional and univariate research and the more process-oriented results coming from qualitative burden research are organised in a process orientated conceptual scheme or model adapted from the stress-theoretical framework by Lazarus and Folkman. The model indicates that perceived burden must be understood through the individual appraisal of stressors and the availability and use of internal and external resources. Perceived burden is the outcome of multiple, clinically overlapping psychiatric problems, problematic behaviour and functional disabilities. Conclusions. So far, intervention programs to reduce perceived burden of informal caregivers have not devoted much attention to the interrelatedness of the origins of burden. The conceptual model provides an overview of the various determinants of perceived burden and a clear picture of the possible interrelatedness appears. This overview of the most important sources of burden helps to develop a complex, multivariate intervention that is comprehensive, long-term, individually tailored and has the flexibility to meet the dynamics of burden over time. Relevance to clinical practice. Use of the conceptual model is crucial to professional nursing and the quality of support of informal caregivers.

OBJECTIVE: Improvement of the interaction between forensic mental health nurses and patients may lead to a reduction of inpatient violence. The concept under study is detached concern, which refers to nurses' skills to neutralize the emotional appeal of patients by a balanced attitude between objectivity and emotional involvement. The Patient Contact Questionnaire (PCQ) aims at measuring the degree of concern of nurses for their patients. METHODS: The PCQ was applied in a pretest-posttest design, evaluating the effects of the Early Recognition Method (ERM). This method aims at the prevention of inpatient violence in forensic psychiatry. Subjects were 116 forensic mental heath nurses working on 16 wards of a large Dutch forensic hospital. First, the baseline scores were compared to scores reported in an earlier study conducted in general psychiatry. Second, pretest-posttest comparisons were carried out for all nurses, and for subgroups of nurses with regard to gender, educational level, years of working experience, and patient population. Third, pretest-posttest comparisons were made on the PCQ item level. RESULTS: The baseline scores of male nurses indicated significantly higher levels of concern than those of female nurses. In addition, more experienced nurses scored significantly higher with regard to concern than less experienced nurses. When comparing the scores before and after applying ERM, no significant differences were found. However, the sores of female nurses showed a tendency toward more concern after implementation of ERM. CONCLUSIONS: Detached concern may be a meaningful concept in forensic mental health nursing in measuring nurses' concern for their patients. Levels of detached concern did not change significantly after application of ERM. However, the application of the PCQ could contribute to a better understanding of the interaction between nurses and their patients. Language: en

Objective: In the Netherlands HIV nursing consultants have participated in HIV-care since 1985: their profession has changed with developments in HIV-treatment over time. The study goal was to gather information about their role in HIV-care and to provide an useful example to other (HIV-)care settings over the world.Methods: Interviews were held with HIV nursing consultants from all AIDS treatment centres. Descriptive analyses and statistical tests to detect differences between centres categorized by care model (parallel/unstructured/alternating), were performed.Results: 58% centres perform substitution of care. HIV nursing consultants see almost all patients at least once a year and see all patients when treatment is started/altered. The frequency of consultations for HIV-patients in stable condition varies, 2-4 times a year. Substitution leads to a slight, non-significant decrease in number of consultations. Adherence support is provided at the start of and during treatment. Regular patient discussions are common. All respondents are acquainted with the guidelines. Detailed knowledge of the adherence issues is limited: 58.3% had read the adherence chapter.Conclusion: Substitution of care model is an appropriate and effective method for the management of HIV-infected patients.Practice implications: Further development of and research into this new role of HIV nurse consultants is appropriate. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Purpose The purpose of this qualitative study was to explore how patients undergoing stem cell transplantation (SCT) keep courage and pull through this demanding therapy. Method A qualitative design using a grounded theory approach was used. Data were collected by participant observation and by conducting 16 semi-structured interviews with patients who had undergone SCT and six interviews with nurses. Results Research findings provide an explanation for the process of keeping courage during SCT. In this publication we focus on the core category in that process: the writing of a positive story. To endure and give meaning to the suffering of the therapy, patients do their best to believe in a happy ending. Patients exert every effort to keep faith: they count their blessings, they protect their positive story from the assaults of negative information and threatening signals through rationalization and they do everything in their power to increase their chances of a happy ending. The positive story is most vulnerable during aplasia, when patients seem to lose both physical and mental strength. Patients feel nurses and doctors help them to muster up courage. Nurses carry patients through the hardest and most despondent moments. Conclusions During stem cell transplantation, patients make many efforts in order to write a positive story and to keep courage. These efforts involve much more active strategies than the rather passive concept of hope suggests.

Objective. The Early Recognition Method aims at improving collaboration between nurses and patients to prevent aggression in forensic psychiatric care. To achieve this goal, Early Recognition Method strongly focuses on early signs of aggression. In the current study, we investigated whether application of Early Recognition Method led to a significant decrease in inpatient incidents. Background. Nurses in forensic settings are often confronted with patients’ aggression. Better collaboration between nursing staff and patients may improve patients’ ability to self manage aggression and contribute to a decrease in inpatient aggression. Design. Naturalistic one-way case-crossover design. Methods. The Early Recognition Method was introduced on 16 wards of a maximum security forensic hospital. Using a oneway case-crossover design, where cases were their own controls, the effects of Early Recognition Method were assessed by comparing the number of incidents of 189 patients during ‘Treatment As Usual’ with the period after Early Recognition Method was implemented. The Early Recognition Method intervention involved weekly evaluations of signs of aggression between staff and patients. The outcome measures were the number of seclusions and the severity of inpatient incidents. Results. A significant decline in the number of seclusions was observed after Early Recognition Method was introduced. Apart from this decrease, the mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia, however, showed modest, yet significant, effect sizes. Conclusions. The results suggest that Early Recognition Method may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders. Relevance to clinical practice. This article aims to contribute to evidence-based risk management for nurses in collaboration with their patients, resulting in a decrease in inpatient aggression.

Aims. The identification and description of the basic psychological process linked with the focus of family members’ functioning during the acute phase of traumatic coma. Background. Earlier research learned that hope is a core category in coping with traumatic coma. Hope seems to be the drive to keep family members going and to enable them to fulfil their main task, namely protecting. In the two articles on the focus of family members functioning, this task is defined and the process linked with it is described. Design. A qualitative approach according to the ‘grounded theory’ method. Method. Twenty-four in-depth interviews with 22 family members of 16 patients with traumatic coma. Results. Family members describe the period after the confrontation with traumatic coma as a battle. During this battle, they feel the urge to protect their relative in coma, other family members and themselves. They go through three phases: protecting life, protecting from suffering, protecting what remains to rebuild life. In this article (Part Two) we describe the phase of protecting from suffering and protecting what remains to rebuild life. Conclusions. All relatives go through the three phases. Family members who have already overcome previous set-backs get through the process slightly more quickly and experience less extreme emotions. Relevance to clinical practice. Understanding the process of protecting in different phases may help health care professionals to do anything in their power to avoid unnecessary suffering, to ease the pain and to support family members in their task of protecting.

This study describes strategies used by Dutch HIV nurse consultants to promote adherence to anti retroviral therapy (ART) and the assumptions on which these strategies were based. The study used a descriptive qualitative design with individual and focus group interviews. Individual semi-structured interviews (n = 23) focusing on adherence-supporting procedures and case-based focus groups (3 groups with 5-7 participants each) focusing on adherence strategies were held with HIV nurse consultants (n = 19). The strategies described were mainly based on experience. Theoretical principles were rarely discussed and participants seldom referred to the literature. Adherence-promoting strategies were identified for two phases: (a) before beginning ART and (b) during follow-up care while on ART Strategies that were not used in one specific phase were categorized under "all phases." Data yielded useful ideas for the care of HIV-infected patients, and findings can be applied to the development and use of adherence-promoting strategies. (Journal of the Association of Nurses in AIDS Care, 21, 489-502) Copyright (C) 2010 Association of Nurses in AIDS Care

PURPOSE. The purpose of this study was to develop and test an evidence-based guideline that would support nursing care for suicidal patients with schizophrenia. DESIGN AND METHODS. Systematic review of the literature and consultation of experts preceded completion of the guideline. Twenty-one nurses from two mental health institutions tested the guideline for feasibility in nursing practice. FINDINGS. The guideline was found to support discussing suicidality with patients and assessing suicide risk. Participants endorsed implementation of the guideline in mental health care. PRACTICE IMPLICATIONS. Nurses who care for patients with schizophrenia are advised to use this guideline as a foundation for their care. Search terms: Guideline, nursing assessment, schizophrenia, suicide

Verpleegkundigen worden in hun werk met patienten met schizofrenie regelmatig geconfronteerd met suicidale gedachten, intenties en gedragingen van deze patienten. Het omgaan hiermee ervaren verpleegkundigen vaak als erg moeilijk. Het stelt hen voor vele vragen en dilemma's. De richtlijn suicidaliteit ondersteunt hen in de effectieve omgang met suicidale patienten met schizofrenie. Dit artikel beschrijft de wijze van ontwikkeling van de richtlijn, de inhoud van de richtlijn en de resultaten van een eerste pilotstudie.

Aim: The aim of the study was to determine the effectiveness of two cushions in the prevention of heel pressure ulcers in a geriatric population. Background: Heel pressure ulcers are a major problem in nursing practice. Several measures for the prevention of heel pressure ulcers are discussed in the literature, but the effectiveness of the different types of cushions in the prevention of heel pressure ulcers is poorly studied. Methods: In this comparative study, two different cushions to prevent heel pressure ulcers were investigated: a wedge-shaped, bedwide, viscoelastic foam cushion and an ordinary pillow. All patients were lying on a viscoelastic foam mattress and were repositioned every 4 hours. Sample: One hundred sixty-two patients over 75 years of age. Results: The incidence of heel pressure ulcers grades 2-4 was 1.9% in the wedge-shaped cushion group and was 10.2% in the pillow group. The patients in the wedge-shaped cushion group developed significantly fewer heel pressure ulcers (p = 0.03). Patients with a wedge-shaped cushion under the lower legs had an 85% less chance in developing a heel pressure ulcer (p = 0.02). The median time to develop a heel pressure ulcer was 4.0 days (IQR = 3.0-5.0) in the wedge-shaped cushion group and 3.5 days (IQR = 1.0-5.8) in the pillow group (p = 0.61). The probability to remain pressure ulcer-free at the heels was significantly higher in the wedge-shaped cushion group (p = 0.008). Conclusion: The study provides evidence that a wedge-shaped, bedwide, viscoelastic foam cushion decreases the risk of developing a heel pressure ulcer compared with the use of a pillow.

Hoe reageren adolescenten op de dementie van hun opa of oma? En hoe zou je hen kunnen steunen? Daarover was tot voor kort nog weinig bekend. De dienst Verplegingswetenschap van de Universiteit Gent heeft nu een tipje van de sluier opgelicht. Veel onzekerheid, schaamte en angst soms ook, maar weinig geneigdheid om erover te praten.

Title. Improving decision-making in caring for people with epilepsy and intellectual disability: an action research project. Aim. This paper is a report of an action research study aimed at improving decision-making concerning risks in people with epilepsy and intellectual disability and the empowerment of participants to sustain this improvement. Background. Residents of long-stay units in specialized epilepsy centres suffer severe epilepsy and are often intellectually disabled. Professional caregivers have to find a balance between risk-taking and protection, as both can have a negative effect on quality of life. Clients, their representatives and caregivers are involved in this decision-making process. Method. A participative action research project was conducted. Data were gathered continuously over a 22-month period in 2004–2006 by interviews, observation, written reports of meetings and personal stories. Findings. The action research resulted in an ongoing process of improvement. Problems in decision-making about risk were clarified. The importance of consensus about risks and commitment to risk management between all involved became apparent. Phases in risk management were discerned and used to adjust caregiving to clients’ needs and capacities Assessment of client risk became more systematic and ‘steps to an individual framework for decision-making’ were developed as a tool for a systematic approach. Conclusion. Using an action research model to improve decision-making provided the preconditions for improving decision-making and risk management and suggesting a way to improve this process in this and other institutions.

Purpose To clarify the concept of early recognition for the field of forensic nursing. The concept is based on the proposition that patient behavior deteriorating toward aggression is idiosyncratic but nevertheless reconstructable like a "signature." Once reconstructed, this signature can be used to detect "early signs" of deterioration and thus prevent violent behavior. Concept Early recognition is approached from the perspective of deteriorating behavior. Special attention is paid to the social and interpersonal factors related to the individual behaving violently. From this perspective, the thoughts, feelings, and behavior of the patient can indicate the onset of aggression, and early recognition of these warning signs can help thwart such deterioration. The aviation metaphor of a "black box" is used to emphasize the importance of attention to early warning signs. Patients in forensic care must draw upon their previous experiences (i.e., their own black boxes) to gain insight into their violent behavior and the warning signals for this. The emphasis is on the cooperation between the patient and the nurse in the application of risk management strategies. The Early Recognition Method provides an approach in which patients and nurses also gradually attune their perspectives on aggressive behavior. Conclusion The concept of early recognition is important because it extends the idea of early intervention to include enabling patients to control their own behavior. Early recognition has strong practical implications for forensic nurses as it allows them to attenuate aggression by assisting patients with the detection of early warning signs.

Aims and objective. To examine the feasibility of the nursing programme ‘Coping with Itch’ and the effect of the programme on the frequency and intensity of itching and scratching, itch-related coping, skin-related psychosocial morbidity and quality of life. Background. Itch is a major symptom of many chronic skin diseases and has a considerable impact on the quality of life. Therefore, the nursing programme ‘Coping with Itch’ has been developed and implemented at the outpatient departments of dermatology of one university and one general hospital in the Netherlands. The programme is intended to reduce itch and to help the patient cope with his or her itch. Design and methods. The feasibility of the programme has been determined by interviewing the nurses who carried out the programme, dermatologists and one medical social worker and by counting the number of visits and specific interventions. The effect of the nursing care programme ‘Coping with Itch’ was evaluated in 32 patients with pruritic skin diseases. Paired t-tests were used to determine its effect after three and nine months. Results. The nursing programme ‘Coping with Itch’ proved to be practically feasible. It leads to a significant reduction of the frequency and intensity of itching and scratching, to a significant reduction of catastrophizing and helpless coping and to a significant reduction of skin-related psychosocial morbidity in the short term. These results stabilized at nine months. No changes were found in the quality of life. Conclusion. The nursing programme ‘Coping with Itch’ is a promising intervention for patients with chronic pruritic skin diseases.

Early postoperative 30? lateral positioning after coronary artery surgery: influence on cardiac output Aims and objectives. We investigated whether: (i) Early postoperative lateral position after coronary artery bypass surgery may have a negative influence on the cardiac output and (ii) Whether turning procedures cause practical problems. Background. Directly following surgery, coronary artery bypass patients are not receiving routine turning every two hours to prevent pressure ulcers, because a negative influence on hemodynamic parameters is assumed. Design. Clinical trial. Methods. Fifty-five coronary artery bypass patients were randomly assigned to four intervention regimens and underwent a two-hour period of 30? lateral position. Fourteen patients in supine position served as a reference group. We hypothesized that 30? lateral position does not cause a relevant change in the cardiac output. Results. Turning the patients did not have any significant influence on the cardiac index, not even in the patients in a poor hemodynamic condition. The cardiac index in 30? lateral position and supine position two to eight hours postoperatively after coronary artery bypass surgery is statistically bioequivalent. No clinically relevant deviations from preset ‘safe’ values for mean arterial pressure, right atrial pressure, pulmonary artery wedge pressure and pulmonary arterial pressure were observed, which would require ending the lateral position. There were no practical problems hindering the turning regimen, not even in the patients with an intra-aortic balloon pump. Conclusions. Early postoperative turning of coronary artery bypass surgery patients in lateral position is an easy and feasible procedure that does not influence the cardiac index not even in patients receiving antihypertensive or inotropic/vasopressor therapy. Further research is needed to find out whether our findings are also valid in other patient groups and other position conditions. Relevance to clinical practice. If there are no strict contra-indications, lateral position has to be considered to prevent complications of continuous supine position within two hours after coronary artery bypass surgery patients have been admitted to the intensive care unit.

Insight into nurse practitioners' (NPs') role transition can help NP students and new graduates in taking on new responsibilities in a changing and demanding healthcare context. The aim of the research was to explore the role transition from nurse to NP using the components of Meleis's Framework of Transitions.A qualitative descriptive design was used. Individual interviews (n = 9) and two focus group discussions (n = 12) were held with NPs. Data were analyzed with the directed content analysis method.The Framework component transitions' nature was characterized by changes in the healthcare system, combined with professional and educational role changes. Transition conditions showed that the respondents felt distressed after they became accountable for a patient's care and well-being. Although the respondents were authorized to do medical procedures, they initially lacked nursing role models and NP protocols. Process indicators showed ongoing transition; the respondents were still developing clinical competencies and confidence in patient care while relying on earlier acquired nursing competencies. Outcome indicators showed that the respondents found themselves successful in the medical extension of two different nursing roles: continuity of medical care for hospitalized patients in acute and intensive care settings, and being responsible for continuity of care for chronic patients in outpatient clinics.Role transition was characterized by coping with feelings of distress at the cost of time and effort. The respondents' strategies to adapt to new expectations, combined with organizational support, determined the outcomes as well as the start of new transitions.NPs' role transition in hospital care implies a dynamic ongoing process that needs to be supported, with the ultimate goal to improve patient outcomes.

Background: Literature has shown the serious impact of severe mental illness on the daily life of caregivers. Westudied reported caregiver support practices by mental health nurses for use in the development of a nursingintervention. We aimed to explore current caregiver support practices by mental health nurses.Methods: Twenty-one participants completed semi-structured interviews, and 17 participants attended two focusgroups. All interviews were audio-taped, transcribed and coded for qualitative analysis.Results: The diversity in caregiver support could best be described by three prototypes: the tolerator, the preventerand the concerner, representing three approaches of involvement with caregivers. At one end of the spectrum aremental health nurses (MHN) who are essentially only concerned with the wellbeing of the care recipient and seethe caregiver as a potential impediment in reaching the client’s goals. We call these the tolerators. At the other endof the spectrum are the MHNs who see the caregiver and the care recipient as inextricably connected with eachother. In these cases the MHN directs her/his intervention towards both the informal caregiver and the carerecipient. We call these the concerners. In the middle position are MHNs who realize that caregivers are importantagents in the achievement of the client’s goals, and therefore consider preventing them from becomingoverburdened as an important goal. We call these the preventers.Conclusions: Based on the extent to which the MHNs believe that the informal caregiver plays a necessary role inthe client’s support system, and the degree to which they feel responsible for the caregiver’s wellbeing, threeMHN prototypes can be distinguished. These prototypes determine how the nurses’ vision directs theirunderstanding of their role and responsibilities and the content of their behaviour. This implies that a change inbehaviour needs to be preceded by a change in vision. Therefore, promoting family support cannot be achievedby one-size-fits-all-programmes.

Objective In pediatric oncology, parents want, and are expected, to act and decide in the best interest of their child. A recent qualitative study (PRESENCE study) indicated that parents had difficulty in doing so. The aim of this subanalysis was to describe and offer an explanation for the parents' actions in expressing and handling of "the voice of the child." Method A multicenter, qualitative research study comprising 37 interviews conducted with 34 parents of 17 children with incurable cancer, cared for at home, during the palliative phase. A thematic analysis was conducted. Results The "voice of the child" becomes manifest in the parents' expressions of the child's needs and perceptions. Parents who actively searched to understand their child's inner perspective used direct and indirect strategies. Parents preferred indirect strategies when their child avoided talking or when they considered the conversation as threatening for the child, or for themselves. Even if the parents show an intense involvement in the care and support of their child; they can still have difficulty acknowledging the child's perspective. An inability to take into account the child's perspective was largely due to the parents' own struggle to cope with loss. Conclusions Whether or not the voice of children approaching the end-of- life is heard, often depends on their parents' ability to give them a voice. Professional caregivers have a difficult task in supporting parents in giving their child his or her voice, while at the same time preserving their, and their parents', ability to cope.

Objective The aim of the present study was to test the potential beneficial effects of an information brochure on undergoing a gastrointestinal endoscopy for the first time. The information provided was based on self-regulation theory, and patients could restrict themselves to reading the summary only. Methods Patients were randomly assigned to an experimental group receiving the brochure at least 1 day before the gastroscopy ( N =47), or to a control group not receiving the brochure ( N =48). Results The results show that all experimental subjects, except one, fully read the brochure. Those receiving the brochure experienced less anxiety before the gastroscopy and, afterwards, they reported greater satisfaction with the preparation for it. With regard to coping style there were some small moderating effects into the direction expected: low blunters (those not seeking distraction under impending threat) as compared to high blunters showed extra reduced anxiety after reading the brochure. They also tended to read the brochure more often. High monitors (those seeking information under impending threat) receiving the brochure showed reduced anxiety during the gastroscopy as compared to low monitors (tendency). Conclusion We conclude that providing patients with the developed brochure constitutes an efficient, beneficial intervention. Practice implications The brochure could easily be implemented in standard practice without the necessity to take the patient's coping style into account.

Aim. This paper presents a literature review whose aim was to provide better understanding of living with early-stage dementia. Background. Even in the early stages, dementia may challenge quality of life. Research on early-stage dementia is mainly in the domain of biomedical aetiology and pathology, providing little understanding of what it means to live with dementia. Knowledge of the lived experience of having dementia is important in order to focus pro-active care towards enhancing quality of life. Qualitative research is fundamentally well suited to obtaining an insider's view of living with early-stage dementia. Method. We performed a meta-synthesis of qualitative research findings. We searched MEDLINE, CINAHL, and PsycINFO and reviewed the papers cited in the references of pertinent articles, the references cited in a recently published book on the subjective experience of dementia, one thesis, and the journal Dementia. Thirty-three pertinent articles were identified, representing 28 separate studies and 21 different research samples. Findings were coded, grouped, compared and integrated. Findings. Living with dementia is described from the stage a person discovers the memory impairment, through the stage of being diagnosed with dementia, to that of the person's attempts to integrate the impairment into everyday life. Memory loss often threatens perceptions of security, autonomy and being a meaningful member of society. At early stages of memory loss, individuals use self-protecting and self-adjusting strategies to deal with perceived changes and threats. However, the memory impairment itself may make it difficult for an individual to deal with these changes, thereby causing frustration, uncertainty and fear. Conclusions. Our analysis supports the integration of proactive care into the diagnostic process, because even early-stage dementia may challenge quality of life. Moreover, this care should actively involve both the individual with dementia and their family so that both parties can adjust positively to living with dementia.

Aim. This paper reports a study of the process of risk-evaluation and subsequent decision-making in the care for people with epilepsy and intellectual disability. Background. People with intellectual disability and severe epilepsy are at risk of suffering accidents during seizure, and often need protection. Whether to implement protective measures or to accept risk is a complex decision, burdened with uncertainty. Taking risks can lead to dangerous, sometimes life-threatening situations, while protective measures are restrictive and may raise ethical concerns. Methods. In 2003 a multiple embedded case study was conducted with 15 clients. In each case, the client, their representative, care-manager and nurse were interviewed. Findings. The decision about whether to accept risks or implement protective measures was always taken in relation to specific events, and varied from medication and supervision to total restriction of the client's mobility. Decision-making was influenced by frequency, type, predictability and consequences of seizures; the effectiveness and practicability of protective measures; additional disabilities; characteristics of the client and their representative; and characteristics of nurses and organization. The predominant factor was the attitude of the representatives. They determined the relative weight of the other factors involved. Conclusion. A systematic approach to risk management could considerably improve the balance between risk and quality of life. Continuous evaluation would make it possible to tune the application of protective measures to the severity of the seizures at any time, and to avoid protective measures being maintained only because care providers have become accustomed to them. A systematic assessment of clients’ capabilities to participate in this complex decision-making process is equally indicated.

Elders represent 6.4% of the world's populations, and 60% of them take medication. In one of six hospital admissions of elders, failures in medication intake are involved. Most of these admissions (88%) could be prevented if elders at risk can be identified (Beijer & Blaey, 2002). This review was conducted to identify and gain insight into which factors influence medication intake in elders. The factors are grouped into six categories: physiological factors, cognitive factors, polypharmacy and medication frequency, patient consent to the treatment and motivation for taking the medication, demographic variables, and family caregivers and social support. In order to identify elders at risk in an early stage, it is recommended that a risk-assessment instrument be developed. Keywords: medication intake; adherence; aged; predisposing factors Elders worldwide have become the fastest growing segment of the population. In developed countries, they represent 12-18% of the population and consume approximately 50% of all prescription medicines (Sabate, 2003). Taking medication is not always as easy and obvious as it seems. A recent study of the World Health Organization on adherence to long-term therapies estimates that 50% of all patients do not adhere to their medication regime (Sabate, 2003). The improper intake of medication does not always lead to serious consequences for the patient. In 60% of the hospital admissions of elders, however, failure of medication intake plays a significant role (Mannesse, Derkx, de Ridder, Man in 't Veld, & van der Cammen, 2000). Eighty-eight percent of these admissions can be avoided by enhancing patient adherence in medication intake. In The Netherlands (with more than 16 million inhabitants), this means that 77,000 elderly people incurring hospital admissions are costing between 200 and 400 million a year that could be prevented (Beijer & Blaey, 2002; Mannesse et al, 2000). Hospital admissions can have serious consequences for elders. From 30% to 60% of elderly people admitted to hospital became less independent after discharge (Fortinsky, Covinsky, Palmer, & Landefeld, 1999). Hospital admission creates much personal suffering and has tremendous economic consequences, and it must be prevented when possible. District nurses and nurse practitioners are in an ideal position to signal patients' failures with medication intake early in the process. Improper intake of medication is often described as nonadherence. Adherence is defined as the extent to which a person's behavior (taking medication, following a diet, or executing lifestyle changes) corresponds with recommendations from a health care provider and agreed to by the patient (Sabate, 2003). In this review, we restrict ourselves to medication nonadherence. We conducted a literature review to gain insight into factors influencing medication nonadherence with focus on community-dwelling elders. The aim of this review is to identify the factors that contribute to medication nonadherence as the first step in the development of a risk-assessment instrument for elders. We have concentrated on elderly patients, because problems related to medication intake and adherence are great in this group (Fulmer, Kirn, Montgomery, & Lyder, 2001 ; Pesznecker, Patsdaughter, Moody, & Albert, 1990; Ryan, 1999; Wade & Bowling, 1986). METHOD IDENTIFICATION OF RELEVANT LITERATURE We searched for studies related to improper intake of medication by elders in which adherence plays an important role. Studies published from 1990 until the present were identified by searching the following databases: Cinahl, PubMed, Invert (Dutch database), E-psyche, and PsycINFO. The full text databases of the Nursing and Allied Health Collection and the Psychology and Behavioral Science Collection were searched from 1995, the date of availability of those databases. Searches were performed using different combinations of the following keywords: "aged," "elderly," "adherence," "compliance," and "medication. …

On the basis of qualitative interviews with relevant patients 2 bipolar items were formulated tapping the experience of undergoing a gastrointestinal endoscopy. In preliminary research the version with fixed answer categories turned out to have better psychometric properties than the version with Likert scales, so we continued our research in a new sample (N=26 ) with the former version, now called the Experience of Gastro-endoscopy scale (EG; in Dutch: BG). Internal consistency was good (Cronbach’s a = .9 ), as was test-retest reliability with an interval of three days (Kendall’s tau = .78). Factor analysis showed one strong factor (5 .7% explained variance). Results with regard to convergent construct validity are satisfactory: significant, moderate correlations with state-anxiety, pain and heart rate. The correlation with the external criterion of ‘gagging’ was r = .45. Correlations with sex, educational level and trait anxiety were low to zero. We conclude that this short questionnaire is a useful instrument for effect research.

Item does not contain fulltext A closer look at the lived illness experiences of medical professionals themselves shows that shared decision making is in need of a logic of care. This paper underlines that medical decision making inevitably takes place in a messy and uncertain context in which sharing responsibilities may impose a considerable burden on patients. A better understanding of patients' lived experiences enables healthcare professionals to attune to what individual patients deem important in their lives.This will contribute to making medical decisions in a good and caring manner, taking into account the lived experience of being ill.

In dieser qualitativen Studie wird die Angehörigenpflege von russlanddeutschen Spätaussiedlern untersucht. Seit Anfang der 1990er Jahre ist es Russlanddeutschen vermehrt möglich, nach Deutschland zurückzukehren. Zum Phänomen der Angehörigenpflege in dieser Gruppe ist bisher allerdings nur wenig bekannt. Was es in dieser spezifischen Gruppe von Immigranten bedeutet, in den Familien zu pflegen, kann jedoch nur dann verstanden werden, wenn betrachtet wird, woher diese Pflege stammt, welcher Art sie ist und wie sie grundsätzlich gestaltet wird. Nach der Methode der Grounded Theory wurden vier Interviewbestände in Russland und Deutschland erhoben, Interviews mit 81 Teilnehmenden wurden analysiert. Angehörigenpflege ist in der Gruppe der russlanddeutschen Spätaussiedler Teil umfassender familialer Hilfen, die dem kollektivistisch orientierten Familienkonzept entspringen. Angehörigenpflege wird dabei als selbstverständlich und als ein Muss erlebt. Aufgrund der lebensgeschichtlichen Erfahrungen und auch der Erfahrungen im Migrationsprozess ist das Versorgungsverhalten der russlanddeutschen Spätaussiedler mit dem, welches in Deutschland vorliegt – und erst recht mit jenem der professionellen Helfer – nicht unbedingt kongruent. Dies hat Auswirkungen auf die Inanspruchnahme professioneller Hilfen. Um hilfreiche Unterstützung leisten zu können, sollten Professionelle das gesamte System der familialen Helfer berücksichtigen und Trennungen der Familien vermeiden.

Aims and objectives. This literature review aims to structure the available information on the psychological reactions of family members confronted with traumatic brain injury. The stress–coping theory and the systems theory provide the theoretical framework for this review. Method. Literature review. Results. The level of stress experienced by the family members of patients who have traumatic brain injury is such that professional intervention is appropriate, even after 10–15 years. Not the severity of the injury but the nature of the injuries determines the level of stress. Partners experience more stress than parents. Children have specific difficulties. Young families with little social support, financial, psychiatric and/or medical problems are the most vulnerable. Coping with traumatic brain injury can be described in phases. The better family members can cope with the situation, the better the patient's recovery. There are functional and non-functional coping mechanisms and coping is influenced by such factors as gender, social and professional support and the possibility to have reciprocal communication or an affective relation with the patient. Relevance to clinical practice. Support from professionals reduces the stress being experienced and encourages people to cope effectively. Conflicts with professional carers should be avoided. Every attempt should be made to develop models of long-term support and care that alleviate sources of burden on relatives. Further research is necessary to develop such models.

Aims and objectives. Insight into the needs and experiences of family members is an initial but necessary step in providing appropriate care for both family members and the patient. This literature review aims to structure the available scientific knowledge on needs and experiences of family members of intensive care unit patients with particular extension to coma patients. Qualitative as well as quantitative studies are discussed. Method. Literature review. Results. Needs are divided into four categories: cognitive, emotional, social and practical needs. The need for accurate and comprehensible information that leaves room for hope is universal. Family members want to speak to a doctor every day about the condition of and the prognosis for the patient, and want a nurse to explain to them about the care, the unit, the equipment and what they can do for the patient during visiting hours. Family members place great importance on being called at home if the condition of the patient changes. Emotional needs as hope, reassurance and being able to remain in the vicinity of the patient are crucial. Family members always give priority to the welfare of their relative. In their confused state, they often do not get around to paying attention to themselves. Caregivers underestimate all of the needs of family members and do not do enough to meet these needs. Relevance to clinical practice. Priority needs should be central in the nurses’ approach of family members. The initiative for meeting the needs must be with the caregivers. Future, focused and well-designed qualitative research over a longer period of time could clarify the process that family members go through and explain the results of quantitative studies.

The effects of the provision of information were tested in a sample of patients who underwent a gastrointestinal endoscopy for the first time (N=260). On the basis of their Threatening Medical Situation Inventory (TMSI)-monitoring score these patients were divided in high monitors versus low monitors. On the basis of the existing literature each group received the type of information that was considered most beneficial with regard to their coping style, and each group was compared with a control group receiving standard care (the usual information plus coaching by a nurse). Dependent variables were anxiety at different points in time, heart rate and skin conductance, pain, experience of the procedure, course of the procedure, duration of gagging, and satisfaction with the information provided. Unexpectedly, it turned out that high monitors did not profit by extensive information when compared with high monitors receiving standard care. Also for low monitors their minimal informational intervention did not exceed the effects of standard care. In the discussion, four factors possibly responsible for these results were elaborated. It is concluded that reservedness is required in providing (too) extensive information to patients who ask for this. Furthermore, considering the rather unpredictable and uncontrollable course of a gastrointestinal endoscopy, coaching by a nurse remains a valuable type of support.

This article describes the results of a survey conducted among nurses who work in psychiatric care. Within the experimental condition of a randomized controlled trial, they executed an intervention protocol to prevent psychotic relapses among patients with schizophrenia. The central objective of this protocol was early recognition of the warning signs of psychosis and timely performance of actions intended to re-establish the equilibrium of the patient. The nurses were asked about the execution of the intervention, their experiences with it, and their evaluation. The nurses actually did execute the protocol in large measure and also made use of opportunities to tailor it to the individual patient. For the most part, the nurses judged that the intervention protocol contributed significantly to the treatment of the patient. The survey also revealed a number of difficulties in the execution of the protocol that deserve attention in the future.

Summary • The original philosophy of palliative care emphasizes the importance of the integration of compassion and medical science. The meaning palliative care nurses assign to their relationships with patients has been described in several studies. • This qualitative research was undertaken in order to elicit the way nurses working on a palliative care ward in an academic hospital perceive their role and gain insight into the problems they encounter. • The findings present two different perceptions held by nurses about the nature of their work. The first, the more prominent, is ‘striving to adopt a well-organized and purposeful approach as a nurse on an academic ward’; the second is ‘striving to enhance the well-being of the patient’. • Nurses should be supported in the development of their palliative care approach and be assisted in reflecting on their practice in terms of a model of ‘reflective practice’ and in the development of ‘moral imagination’.

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses’ perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment.

BACKGROUND: After graduation, nurse practitioner students are expected to be capable of providing complex, evidence-based nursing care independently, combined with standardized medical care. The students who follow work-study programs have to develop their competencies in a healthcare environment dominated by efficiency policies. OBJECTIVE: This study aims to explore nurse practitioner students' perceptions of their professional responsibility for patient care. METHOD: This qualitative interpretative study entails a content analysis of 46 reflective case studies written by nurse practitioner students. FINDINGS: The students felt responsible for the monitoring of patients' health status, attending to psychosocial problems, emphasizing compliance, and optimizing the family's role as informal caregivers. At the same time, students struggled to understand the complexities of their patients' needs, and they had difficulty applying their knowledge and skills to complex medical, psychological, and social problems. CONCLUSION: The students' perceptions of their new responsibility were characterized by a strong focus on curative care, while psychosocial components of health and illness concerns were often overlooked. The students experienced difficulties in meeting the criteria of advanced practice nursing described in the Dutch competency framework.

The effectiveness of a continuing pain education program, directed to surgical cancer nurses, was investigated in a pretest posttest controlled intervention study. ANCOVA for repeated measures revealed that the programme resulted in a lower pain intensity of surgical colon and breast cancer patients (p=0.02). However, no effects were found on pain duration, sleepless hours as a result of pain, state anxiety, mood disturbances, and duration of hospitalization. It is assumed that because the pain CE programme had a moderate impact on pain intensity, this had no consequences for the other outcome variables mentioned. (aut.ref.)

Factors that, according to nurse participants, influenced the application of what was learned in a pain program were explored by means of qualitative interviews. Participants indicated that the correspondence between the program and their personal view on pain management, attitudes toward the program and innovations in general, self-efficacy perceptions, and (un)familiarity and taboos with respect to program items influenced what they put into practice. In addition, participants indicated that interactions with colleagues, nursing managers, patients, and physicians affected their application of the program. Furthermore, organizational factors, such as limited time and lack of formal program implementation, were mentioned as influential.

Surgical nurses from five Dutch general hospitals participated in a continuing education program on pain assessment and management. A pretest-posttest controlled intervention study revealed theat the program led to an increase in the quality of activities relevant to taking pain histories. Although this increase in quality was most apparent 1 month after the program, it was still observable 6 months after the program. There were, however, no effects on the number of activities relevant to taking pain histories, or on the number of nurses who used direct questioning as a method to determine pain. There may be several explanations for these results, including nurses' limited openness to new approaches, a lack of support from physicians and nurse superiors, and that program items were not translated into ward policy.