Sunday, 19 October 2014

Ebola and nursing history

Christine Hallett
Professor and Director of the UK Centre for the History of Nursing and Midwifery and Chair of the UK Association for the History of Nursing


Professor Hallett
On Wednesday 15 October 2014, the Guardian newspaper reported that Will Pooley, the British nurse who had contracted Ebola virus while working in Sierra Leone, was returning to Africa to continue his work. Pooley had been brought back to his home country to be nursed in isolation, and had survived against 70% odds. He said that he could not now ‘sit in the UK and watch the people of Sierra Leone die’. Like any other reader, I was moved by his courage and professional dedication; but as a historian, I was also aware that such astonishing bravery is not a new phenomenon. It is as old as epidemic disease itself, and has most often been shown by nurses.  

During the plagues of Medieval and Early Modern Europe, it was nurses, many of them belonging to religious communities, who put their lives in danger by entering the homes of the sick - places that were shunned and avoided by everyone else.  When bubonic plague – the so-called Black Death – became endemic in the fleas carried on Europe’s black rat population, city-states were subjected to frequent outbreaks. Italy was one of the worst-affected regions. Unhygienic conditions meant that rat populations expanded rapidly and commercial travel ensured that these disease-carrying vectors could move easily from place-to-place. The bacterium, later to be known as Yersinia pestis, mutated – a new, highly virulent airborne strain appeared as pneumonic plague – a form that could be transmitted directly from person to person, with a case-fatality rate of 80%. Populations reacted by isolating sufferers. In cities like Venice and Florence, the sick were moved to isolation hospitals called lazzaretti, where conditions were appalling. ‘Attendants on the sick’ had no professional identity, did not belong to any unions and had no workers’ rights. They were as trapped as their patients. Yet stories of immense courage came out of these places of horror, and some nurses did survive. Like Will Pooley, they used the immunity conferred by such survival to continue their work.  

The Ebola virus
But those who respond with courage and compassion to the plight of populations devastated by epidemic disease are a tiny minority. The response of so-called civilized nations to the Ebola crisis in West Africa has shown that, although technology has advanced, humanity itself has made little progress.  Its ethics remain medieval. Wealthy nations seem to be putting more effort into keeping Ebola beyond their borders than into saving lives in Africa. Like (I suspect) most other British citizens, I must confess to a cowardly relief that my own safety is being given the highest priority. But, as a health professional, I also know that such efforts are misplaced.  Ebola cannot be kept at bay for long unless the epidemic is tackled at its root, in Africa.  If the compassion of Northern nations had been stronger than the false sense of security afforded by their border controls, the epidemic might now be under control and threatening no-one.

And bubonic plague is not the only world pandemic that can provide lessons. At the end of the First World War, the world’s population, weakened by four years of industrial warfare, deprivation and food shortages, experienced one of its worst-ever pandemics: the so-called Spanish influenza. Nurses in military hospitals wrote of how, on Armistice day, 11 November, 1918 - as entire populations were engulfed in the heady atmosphere of victory - they themselves could only watch helplessly as young men who had survived active war-service died horrible deaths, suffocating, their faces turning blue or black, their entire systems shutting-down. The virus killed within days, sometimes within hours, affecting people of all ages and backgrounds – but predominantly young, apparently healthy adults.  Again, it was nurses who were at the forefront of the fight against disease.  Historian, Arlene Keeling has shown how the visiting nurses of cities like New York, Baltimore and Philadelphia went into the homes of the sick and dying, taking canisters of soup to helpless victims and offering the fundamental nursing care that kept bodies alive until immune systems had a chance to react. Many of these nurses, themselves, caught the disease, and some died.

Health workers dressed to handle Ebola victims
For as long as human communities have dominated the earth, they have been at risk of epidemic disease.  However well-prepared we are, pandemics always seem to take us by surprise. Even as we stockpile vaccines against the latest strains of influenza, Ebola is poised to threaten our existence. A mutation of the virus, producing an airborne form like the pneumonic plague or Spanish flu is said by experts to be unlikely, but the longer the organism has to move, uncontrolled, from host to host, the more likely such mutation becomes. Meanwhile, it is nurses such as Will Pooley who will continue to fight a losing battle – one disease-host at a time – because his compassion as a nurse will not allow him to ‘watch the people of Sierra Leone die’.



Friday, 17 October 2014

Genetics in nursing: long overdue for a tipping point

Rita Pickler, Editor

We all know about the tipping point, described by Malcolm Gladwell as that moment when an idea crosses a threshold, tips, and spreads like wildfire (Malcolm Gladwell, The Tipping Point: How Little Things Can Make a Big Difference). The authors of the collected papers in the JAN’s latest virtual issue would argue that nursing is overdue for its tipping point in genetics education, genetic knowledge, genetic research and genetics in practice for the nursing profession. Advances in genetics have brought great benefit to humans, revealing the basis of health and illness, disease risk and treatment response. The progress in genetics and genomics can be applied to the entire spectrum of health care; we can all potentially benefit from what is known now and will be known in the future. And yet, a barrier to those benefits is nursing’s minimal involvement in the genetics knowledge explosion.

Nursing and genetics work share a focus on health promotion and disease prevention. Nursing clearly then has a place in genetics work. But nurses are woefully undereducated about even the most basic of genetics knowledge. Moreover, nursing educational programs have not followed the longstanding recommendations in both the US and Europe regarding essential genetics education and minimal genetics competencies needed in order for nurses to meet the needs of the public they serve. Further, despite a growing body of evidence about the contribution of genetics and genomics to health and illness, the evidence specific to outcomes of nursing practice provided by genetics competent nurses and the impact on the public’s health is very limited.

For people to benefit from the growing arsenal of genetic and genomic discoveries, nurses must be competent in obtaining comprehensive family histories. They need to help identify family members at risk for developing a genetically influenced condition or having a genetically influenced drug reaction. They need to understand the potential benefit or harm that may ensue from participating in genetics and genomic research. The public depends on nurses, the most trusted of health care providers, to help them make informed decisions about and understand the results of their genetic/genomic tests and therapies and to refer them, if they are at-risk to the most appropriate health care professionals and agencies. All of that requires knowledge and competence in using that knowledge.

More than that, qualified nurses need to be engaged in research about genetics and genomics Nurses are well poised to do the work of investigating the behavioral, social, and physiological benefits and risks for individuals and families who are asked to participate in genetics research or to use genetically engineered interventions. Moreover, nurses need to study the epigenetic effects of our own practices in order to understand the potentially long reaching effects of the care we give.

As providers of quality health care services, it is essential that nursing cross the threshold and embrace genetics knowledge, tip the balance from passive bystanders of genomic research to active participants in genetic discoveries and their application, and join other scientists and health care practitioners in ensuring that genetics knowledge is used wisely and well to improve health around the world. Yes, we are overdue for our tipping point. Perhaps the time is now.

The selection of papers in JAN’s Genetics Virtual Issue are available for view now on the JAN website. There readers will find papers about nursing’s current genetics competencies and abilities in applying genetics knowledge to care (Barnoy et al, 2009; Godino et al, 2012; Skirton et al, 2012), interesting efforts and strategies to improve genetics competencies within nursing curricula (Andrews et al, 2013; Kirk et al, 2013) and practice (Andrews et al, 2014), as well as papers that will educate readers about the breadth of genetics knowledge (Bancroft, 2010), newly emerged genomic tests (Prows et al, 2014), and future possibilities for genetics research in nursing science (Munro, 2014). The selection of papers reveals nursing’s gaps and also its potential to reach the genetics tipping point.


Andrews V, Tonkin E, Lancastle D, Kirk M (2013) Using the Diffusion of Innovations theory to understand the uptake of genetics in nursing practice: identifying the characteristics of genetic nurse adopters. Journal of Advanced Nursing DOI: 10.1111/jan.12255

Andrews V, Tonkin E, Lancastle D, Kirk M (2014) Identifying the characteristics of nurse opinion leaders to aid the integration of genetics in nursing practice. Journal of Advanced Nursing DOI: 10.1111/jan.12431

Bancroft EK (2010) Genetic testing for cancer predisposition and implications for nursing practice: narrative review. Journal of Advanced Nursing DOI: 10.1111/j.1365-2648.2010.05286.x

Barnoy S, Levy O, Bar-Tal Y (2010) Nurse or physician: whose recommendation influences the decision to take genetic tests more? Journal of Advanced Nursing DOI: 10.1111/j.1365-2648.2009.05239.x

Godino L, Turchetti D, Skirton H (2013) Knowledge of genetics and the role of the nurse in genetic health care: a survey of Italian nurses. Journal of Advanced Nursing DOI: 10.1111/j.1365-2648.2012.06103.x

Kirk M, Tonkin E, Skirton H (2013) An iterative consensus-building approach to revising a genetics/genomics competency framework for nurse education in the UK. Journal of Advanced Nursing DOI: 10.1111/jan.12207

Munro C (2014) Individual genetic and genomic variation: a new opportunity for personalized nursing interventions. Journal of Advanced Nursing DOI: 10.1111/jan.12552

Prows C, Tran G, Blosser B (2014) Whole exome or genome sequencing: Nurses need to prepare families for the possibilities. Journal of Advanced Nursing DOI: 10.1111/jan.12516

Skirton H, O’Connor A, Humphreys A (2012) Nurses’ competence in genetics: a mixed method systematic review. Journal of Advanced Nursing DOI: 10.1111/j.1365-2648.2012.06034.x





Saturday, 11 October 2014

Will nursing be influenced by genomics?

Roger Watson, Editor-in-Chief

My original training was in biochemistry and I always considered the discovery by Watson & Crick of the double-helical structure of DNA to be one of the most exquisite and important in biology. It was exquisite in the sense that it explained how DNA was able to replicate and yet conserve the genetic code; it also provided a mechanism whereby messenger RNA, the template for building proteins, was coded and it started the search for the genetic code. This one discovery had many 'spin-offs' for the rest of biology and it was important as it also led to an understanding, at the molecular level, of how things go wrong in genetics and – ultimately – what we may be able to do about it. But, apart from in the role of genetic counselling, I did not consider that it may lead to changes in the way we deliver nursing practice...until I read a recent discussion paper by Munro (2014) and published in JAN titled Individual genetic and genomic variation: a new opportunity for personalized nursing interventions.

Pointing out that nursing has not yet embraced the possibilities of exploiting the consequences of genetic variation, Munro says: 'There are potentially many nursing interventions that would be more effective if they were individually tailored to the patient’s genetic/genomic profile.' The potential for this has manifest itself in the new relatively new fields of personalized medicine and pharmacogenomics, but Munro discusses the possibility, based on people's individual genetic make up of moving towards personalized nursing interventions. In the words of the author: 'The use of genetic variation to understand and predict human responses and to tailor nursing interventions is a powerful concept that could inform – and fundamentally change – nursing practice.'


Reference

Munro CL (2014) Individual genetic and genomic variation: a new opportunity for personalized nursing interventions Journal of Advanced Nursing DOI:10 1111/jan.12552


Thursday, 25 September 2014

Shall we speak, or...?

Roger Watson, Editor-in-Chief

The first computer in the hospital where I was a Charge Nurse was the one I took in with me on night duty. I unloaded my excellent (in my view unsurpassed as a dedicated word-processing tool) Amstrad PCW from the car and set it up at the nurses' station where, between my nursing duties, I would write manuscripts and I even developed a program using the programming language Mallard for PCW which calculated cost-effectiveness data in the clinical trial I was running. Well, those were the days! My computer was not linked up to anything or anyone and I was viewed as some kind of technological wizard, mainly eccentric, who was engaged in something that would probably 'never catch on'.

Fast forward approximately 25 years and every clinical area and office in my GP surgery, the local hospitals and anywhere healthcare is delivered is festooned with electronic equipment. A Finnish study entitled The use of electronic devices for communication with colleagues and other health professionals - nursing professionals' perspectives by Koivunen et al. (2014) and published in JAN looks at how nurses experience the use of electronic devices for professional communication. The study involved 123 Finnish nurses and found that a variety of electronic means of communication was used with email being the most popular. Synchronous communication - Skype, FaceTime - was used very little. While the nurses found the use of electronic devices useful and efficient, concerns remained about security of information. However, some were concerned about the lack of social interaction and, I guess, it will be a sad day if electronic communication replaces such interaction in a profession which aims to be person-centred and caring.


Reference