Sunday, 23 April 2017

Caring for a dying child at home

Roger Watson, Editor-in-Chief

There can be few things that have more impact on a family than the death of a child. But the period leading up to death is also hard. Where parents may receive post-bereavement counselling, support is also needed when death is approaching as this study from Switzerland by Eskola et al (2017) titled: 'Maintaining family life balance while facing a child’s imminent death—A mixed methods study' and published in JAN explores.

The aim of the study was to: 'understand parents’ experiences and needs during a child’s end-of-life care at home and to identify systemic factors that influence its provision.' From a nationwide study in Switzrland between 2012-2015, 47 families were studied between 2011-2102 who had a dying child at home. Information from questionnaires and interviews was used.

The physical and emotional toll on some parents is captured in this quote from one father: 'I drove home in the evening, parked in front of the garage. . . Do you think I was able to get out of the car?! I remained seated three quarters of an hour, just sat there and slept. In fact, I was at home, but couldn’t manage to get out of the car. No energy, empty batteries.' Practical help was really appreciated as explained by one mother: 'This daily household crap—getting groceries, cooking, cleaning, paying the bills (. . .) It would have been so nice, if there had been somebody to take over all these tasks and we could have spent the time with our child.' The authors concluded: 'Paediatric end-of-life care at home is only feasible if parents make extraordinary efforts. If family-centred end-of-life home care is provided by a hospital-based paediatric palliative home care team, which includes paid housekeeping help and psychological support, parents needs could be better met.'

You can listen to this as a podcast

Reference

Eskola K, Bergstraesser E, Zimmerman K, Cignacco E (2017) Maintaining family life balance while facing a child’s imminent death—A mixed methods study Journal of Advanced Nursing DOI: 10.1111/jan.13304


Friday, 21 April 2017

Commentary on: Leading change: a concept analysis

Commentary on Nelson-Brantley H.V., and Ford D.J. (2017) Leading change: a concept analysis. Journal of Advanced Nursing 73(4), 834-846.


Dr Mark Hughes
University of Brighton, UK


As a management and organization studies academic with a strong interest in leading change, I read Nelson-Brantley and Ford’s (2017) recent paper with interest and I will certainly be referring to this informative paper in my future work. I share their desire for greater conceptual clarity around change leadership. Ford and Ford (2012) raised similar concerns, although not nursing specific, in their review of the leadership of organizational change literature published in peer-reviewed journals between 1990 and 2010.

As the authors rightly remind us, the focus of their concept analysis potentially has life or death consequences, so I do hope that their paper provokes much-needed debate, as the debate often appears to myself and others to be trapped in the past (see By et al, 2016). I want to fuel this debate through raising four challenges which could be directed at the paper and more generally at leading change theories and their implications for nursing practices.

1. Do aggregate success/failure rates inform or misinform nursing change practices?

A shift away from management towards leadership was prefaced by claims of change failure. In essence, change management failed, with an implication that change leadership was going to succeed. However, the evidence base for these highly publicized aggregate failure rates was non-existent (Hughes, 2011). Intuitively we appreciate that a success/failure rate for transforming a hospital will differ from the rate for improving nursing education given that they are completely different activities and that there will be considerable contextual variations even within nursing.

2. Are the prescriptions of Kotter really applicable to nursing change practices?

Professor John Kotter’s 1996 book features very prominently in the paper, potentially reflecting his contribution to leadership studies. Even assuming that Kotter’s business cases are applicable to healthcare settings, I have generic concerns about this model of leading change (Hughes, 2016). Over the past two decades, we have witnessed academic advances in understanding ethics, power and politics, processes, agency and discourses in relation to organizational change, which appear to be missing from Kotter’s account of leading change. It was disappointing that the conceptual analysis did not reveal ethics as one of the attributes for leading change or make any reference to ethics.

3. Do we need nurses to lead or manage change or both?

The call for nurses to lead change has been echoed in the UK. But as a patient of the UK National Health Service, rather than a practitioner, I fear we may underestimate management in delivering high-quality healthcare. As a patient more mundane aspects such as hospital cleanliness, available appointments, maintaining effective medical records and effective hospital communications with myself really do matter. My fear is that organizations have become seduced by notions of leading change at the expense of other crucial activities. The paper rightly touches upon dualities and paradox, but potentially misses an opportunity to encourage a dualities aware approach.
Effective change leadership means appreciating how dualistic forces can shape and enable change. By adopting a dualities aware perspective, leaders can come to terms with the intuitive desire to resolve contradiction by instead managing the complementarities within contradictory forces. (Sutherland and Smith, 2013: 220)
The implication is that rather than nurses leading or managing and dealing with change or continuity, they will typically be involved in managing and leading changes and continuities. In any effectively run hospital continuities may prove to be as important as changes and we may find managing those continuities is as important as leading changes.

4. Does associating leading with changing really inform nursing change practices?

The authors rightly tend to make associations between leading and changing, rather than asserting that leaders influence organizational change. Whilst institutional rhetoric of nurses leading change may be strong, I have reservations about the empirical reality of leaders influencing organizational change. Parry (2011:57) is cited in the concept analysis, but what I took away from his short review of leadership and organizational change was that ‘there are many more books and articles on practitioner or conceptual scholarship than on theoretical or empirical scholarship. Much of the practitioner work is case study-based, and anecdotal and not rigorous in its conduct.’ This concern could be levelled at some citations in the content analysis. I personally found Ford and Ford’s (2012:22) review of the leadership of organizational change literature persuasive:
There is simply too little empirical research that specifically addresses the leadership of change to warrant a prescription for what works…we find, the available research equivocal and incomplete regarding both what constitutes effective leadership and the impact of change leaders approaches, behaviors, and activities on change outcomes of any type.

I welcome the publication of this concept analysis in clarifying the concept of leading change and situating this analysis in the context of nursing and healthcare. I am personally still not convinced that we have the empirical evidence to satiate the institutional desires for leading change in healthcare or any other sector.


Dr Mark Hughes
Reader in Organizational Change
University of Brighton
Brighton Business School
Brighton, UK
m.a.hughes@brighton.ac.uk



References

By R.T., Hughes M & Ford, J. (2016) Change leadership: Oxymoron and myths. Journal of Change Management 16 (1), 8-17.

Ford, J.D. & Ford L.W. (2012) The leadership of change: A view from recent empirical evidence. In Research in Organization Change and Development (Pasmore W., Woodman, R and Shani, A. eds) 20: (1-36).

Hughes, M. (2011) Do 70 per cent of all organizational change initiatives really fail? Journal of Change Management 11(4), 451-464.

Hughes, M., (2016) Leading changes: Why transformation explanations fail. Leadership 12(4), 449-469.

Nelson-Brantley H.V. & Ford D.J. (2017) Leading change: a concept analysis. Journal of Advanced Nursing 73(4), 834–846. doi: 10.1111/jan.13223

Parry K.W. (2011) Leadership and Organization Theory. In The SAGE Handbook of Leadership (Bryman A., Collinson D., Grint K., Jackson, B. & Uhl-Bien, M. eds), SAGE Publications Ltd., London EC1Y 1SP, pp. 53.70.

Sutherland, F. & Smith, A.C.T. (2013) Leadership for the age of sustainability: A dualities approach to organizational change”. In Organizational Change, Leadership and Ethics: Leading Organizations Towards Sustainability (By R.T. & Burnes B. eds), Routledge, London, pp. 216-239.



Sunday, 16 April 2017

Improving outcomes in gastroesophageal cancer

Roger Watson, Editor-in-Chief*

What influences the time between developing gastroesophageal cancer and a doctor realising a patient has it? This was the subject of the a study titled: 'Which interval is most crucial to presentation and survival in gastroesophageal cancer: A systematic review' by Lee et al (2017) and published in JAN. The aim of the study was to: 'identify the most crucial interval to encourage earlier diagnosis in with gastroesophageal cancer and to identify potential factors effecting this interval' and the study used a systematic review method. Twelve articles published between 2000-2016 were analysed.

Three main themes were used to present the data: total delay; patient interval (ie time between symptoms and seeing a doctor); and treatment interval. In the words of the authors: 'This literature review identifies the patient interval as the most crucial factor for engaging in preventive measures to encourage earlier diagnosis. Most patients present at too late a stage for curation of GOC.' This supports UK government and cancer research charity calls for campaigns to increase earlier diagnosis by increasing awareness of symptoms in the general population. This should encouage people who have symptoms to see their doctor as early as possible, to receive trearment and survive longer. In conlusion, the authors say: 'The incidence of GOC is increasing across the globe, yet survival remains poor. However, there is a significant lack of focus on this cancer in the literature' and 'Potential sufferers of this cancer need to be encouraged to seek medical attention as the patient interval is the most crucial to survival. For this, community level interventions are required to raise awareness of the signs and symptoms of this cancer.'

*Declaration of interests: Roger Watson is a co-author of this article

Listen to this as a podcast

References

Lee A, Khulusi S, Watson R (2007) Which interval is most crucial to presentation and survival in gastroesophageal cancer: A systematic review Nursing Open DOI: 10.1111/jan.13308

Wednesday, 5 April 2017

What tells us that an older person is going to be malnourished in a nursing home?

Roger Watson, Editor-in-Chief

What indicates that an older person in a nursing home will develop malnutrition? That is the subject of a study by Bauer et al (2017) titled: 'Changes in nutritional status in nursing home residents and associated factors in nutritional status decline: a secondary data analysis' and published in JAN which aimed to: 'describe changes in the nutritional status of nursing home residents over a period of 1 year and identify factors associated with a decline in nutritional status'.

Using data from 157 older residents, several factors were related to the development of malnutrition. In the words of the authors: 'care dependency, length of stay, changes in body mass index and malnutrition risk at baseline were significantly associated with a decline in nutritional status.' However, risk of malnutrition at admission to a nursing home is 'the most important risk factor indicating a decline in nutritional status.' The authors conclude: 'Our findings indicate that it is critical for the topic of malnutrition to be emphasized in basic and advanced nursing educational programmes, to train nursing professionals to identify nursing home residents at risk effectively and early on. The identification of residents at risk should be performed during their admission to nursing homes and at regular time intervals using validated nutritional screening tools.'

You can listen to this as a podcast.

Reference

BAUER S., HALFENS R.J.G. & LOHRMANN C. (2017) Changes in nutritional status in nursing home residents and associated factors in nutritional status decline: a secondary data analysis. Journal of Advanced Nursing doi: 10.1111/jan.13297

How effective are physician substitutes?

Roger Watson, Editor-in-Chief

You may not be aware that in the NHS there are people with roles that are like doctors and nurses, but they are neither. Depending on your view these people can be either ‘super nurses’ or ‘sub-doctors’. But do they work?

A recent review of research compared these ‘substitute doctors’ roles with doctors in long-term care of older people. The results show they are better than doctors at improving health of patients, preventing secondary complications and completing care processes. They are equally as good as doctors at preventing deaths, providing medications and completing mandatory physical examinations. They are also cheaper. This is important as more older people spend their final years in long-term care, which is expensive and health service resources are scarce. 

There are two main substitute doctors roles are Nurse Practitioners and Physician Associates. They are different but have very similar roles in assisting or even substituting for doctors. Nurse Practitioners are Registered Nurses with advanced training in diagnosis and treatment. Physician Associates are science graduates with similar advanced training.

Like most of these advanced roles, Nurse Practitioners and Physician Assistants started in the USA. Nurse Practitioners began in the USA in the 1940s and they were trained in areas like midwifery and anaesthetics where they could work independently. Physician Associates started in the USA in the 1960s and their role was designed to assist doctors directly with examining patients and prescribing drugs. The two roles have spread across the world and Nurse Practitioners now exist in over fifty countries and Physician Associates exist in over ten countries.

Nurse Practitioners can perform many of the tasks of doctors and are generally well accepted in advanced roles by doctors. But less is known about the new Physician Associate roles and some doctors are worried. The role is recognised as one that can assist doctors but replacing doctors is another matter. The lack of professional registration, which helps to define a role, is one worry. It leads to a ‘fluid’ role which could be used to undermine the role of the doctor and take away training opportunities for junior doctors. Other than that, Physician Associates lack many of the skills required to work independently or unsupervised.

Nurse Practitioners – who have several titles – have existed for over twenty years in the UK and since this is not a ‘registerable’ profession, the exact numbers are not know but there are many hundreds working in the UK. Physician Associates have only existed here for about ten years and the government wants to increase their numbers. This is also not a registerable qualification and exact numbers are not known. But in 2014 there were around 200 in the UK with plans to increase that and more than double the number of training places from 100 to 225. The recent research showing that they can be successfully used to replace doctors is good news for the UK government and for UK universities.

The future for substitute doctors in the UK looks very good. Funding issues in the NHS probably make them a necessity. The evidence that they are effective in at least one important role and often better and cheaper that doctors will surely encourage more growth in training places and numbers in the NHS.

One issue remains for both Nurse Practitioners and Physician Associates and that is regulation. Being a Nurse Practitioner is what is known as a ‘recordable qualification’ and Nurse Practitioners can choose to do this with the Nursing and Midwifery Council. Of course, all Nurse Practitioners are Registered Nurses and must keep that status to work as Nurse Practitioners. For Physician Associates, there is the Faculty of Physician Associates at the Royal College of Physicians of London. Registering with them is only encouraged but not compulsory.

Proper registration and regulation of substitute physician roles will increase confidence in them and lead to wider acceptance. It is doubtful if people will turn up at doctors’ surgeries and say, ‘can I see the substitute physician?’. But soon it is more likely that this is who they will see.


You can listen to this as a podcast

Reference

Lovink MH, Persoon A, Koopmans RTCM, Van Vught AJAH, Schoonhoven L, Laurant MGH (2017) Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the aging population: a systematic literature review Journal of Advanced Nursing doi: 10.1111/jan.13299



Tuesday, 4 April 2017

Commentary on: Models of partnership within family-centred care in the acute paediatric setting

Commentary on Dennis, C., Baxter, P., Ploeg, J. & Blatz, S. 2017. Models of partnership within family-centred care in the acute paediatric setting: a discussion paper. Journal of Advanced Nursing, 73, 361-374.


Denise A. Sackinger, MN, RN, CPNP-PC, CPN
University of Washington


In the discussion paper “Models of Partnership Within Family-Centred Care in the Acute Pediatric Setting,” Dennis et al. (2017) present a cogent discussion of partnership models within the acute pediatric setting. The authors used a self-developed appraisal tool to evaluate eight partnership models originating from Western and developed countries. The tool evaluated each of the models on defining characteristics or dimensions, major conceptual propositions or relationships and context or role of environment. The category of defining characteristics evaluated the extent to which the major concepts were clearly defined in the model (semantic clarity).

It is discouraging that in six of the eight models reviewed, the concept of “partnership” was not explicitly defined. Family Centered Care is the core of pediatric nursing. Partnership is a foundational concept of Family Centered Care (Institute for Patient- and Family-Centered Care). Practice models are symbolic representations of knowledge (Chinn and Kramer, 2015). For models to be translated into practice, the concepts must be clearly defined (Meleis, 2012). As such, a partnership model which does not plainly explicate the primary concept upon which it is focused lacks semantic clarity. Lack of semantic clarity, thus concept clarity, leaves the model open to individual interpretation rather than being a unifying model of nursing care delivery. As nursing scientists, we must be clear and consistent in our conceptual definitions to provide the building blocks for model development to allow for model testing across various contexts. My hope is that we are training and developing a generation of nursing scholars who strive to understand and clarify the abstract concepts we accept as a normal part of our profession. As abstract concepts are clarified, practice models can be hypothesized and tested in an effort to provide the best care to patients and families.

I commend Dennis et al. (2017) for providing us with a framework to evaluate models of care. This framework is helpful for critically analyzing conceptual models of care. This framework can help us to identify critical aspects of conceptual models that need refinement.



Denise A. Sackinger, MN, RN, CPNP-PC, CPN
Doctoral Student, School of Nursing
University of Washington
Seattle, Washington
esacki@uw.edu


References

CHINN, P. L. & KRAMER, M. K. 2015. Knowledge Development in Nursing:  Theory and Process (9th Ed), St. Louis, MO, Elsevier.
DENNIS, C., BAXTER, P., PLOEG, J. & BLATZ, S. 2017. Models of partnership within family-centred care in the acutepaediatric setting: a discussion paper. Journal of Advanced Nursing, 73, 361-374.
INSTITUTE FOR PATIENT- AND FAMILY-CENTERED CARE. Patient- and Family-Centered Care [Online]. Available: http://www.ipfcc.org/about/pfcc.html [Accessed].

MELEIS, A. I. 2012. Theroretical Nursing:  Development & Progress (5th ed), Philadelphia, PA, Lippincott Williams & Wilkins.