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What is the evidence on evidence-based nursing? An epistemological concern Aim. This paper adopts an epistemological perspective in order to support the assertion that there is very little evidence to support the existence of evidence-based nursing as a distinct construct or process. Rationale. This analysis of concept meaning is based on the theory of symbolic interactionism. By adopting this theory the commonalities and inconsistencies in the use of evidence-based symbolism by nurses and other health care professionals can be used to evaluate the perceived meaning of the term. Methods. A frequency analysis of relevant key words in one publications data-base demonstrates the increasing use of evidence-based terminology and its euphemistic status visa vi research. An epistemological analysis is conducted on a sample of concept clarification statements taken from the popular literature, defining the nature of `evidence' and `evidence-based practice'. Findings. The results of the frequency analysis show that the keywords `evidence-based medicine' revealed 5612 papers, evidence-based practice (EBP) 432 papers, evidence-based nursing 47 papers, evidence-based health care 60 papers, and evidence-based decision making 43. Almost all of these papers have been published since 1995 and the earliest use of the symbol `evidence-based' is 1992. There is also an increase in papers adopting `evidence-based' symbolism along with a commensurate decrease in the use of the term `research' in the nursing context. Conclusion. `Evidence-based practice' is commonly a euphemism for information management, clinical judgement, professional practice development or managed care. There is insufficient evidence to demonstrate that evidence-based nursing is a single construct or process that can be distinguished from its concomitants. The term adds little more to the existing long standing traditions of quality assurance and research-based practice. Nurses must avoid the inefficiency brought about by the `intense enthusiasm followed by sad disenchantment' that has been associated with other attempts to introduce innovation in health care delivery (Fienstein & Horowitz 1997). [ABSTRACT FROM AUTHOR]

BACKGROUND: This paper's starting point is the recognition (descriptive not normative) that, for the vast majority of day-to-day clinical decision-making situations, the 'evidence' for decision-making is experiential knowledge. Moreover, reliance on this knowledge base means that nurses must use cognitive shortcuts or heuristics for handling information when making decisions. These heuristics encourage systematic biases in decision-makers and deviations from the normative rules of 'good' decision-making. AIMS: The aim of the paper is to explore three common heuristics and the biases that arise when handling complex information in clinical decision-making (overconfidence, hindsight and base rate neglect) and, in response to these biases, to illustrate some simple techniques for reducing the negative influence of heuristics. DISCUSSION: Nurses face a limited range of types of uncertainty in their clinical decisions and draw primarily on experiential knowledge to handle these uncertainties. This paper argues that experiential knowledge is a necessary but not sufficient basis for clinical decision-making. It illustrates how overconfidence in one's knowledge base, being correct 'after the event' or with the benefit of hindsight, and ignoring the base rates associated with events, conditions or health states, can impact on professional judgements and decisions. The paper illustrates some simple strategies for minimizing the impact of heuristics on the real-life clinical decisions of nurses. CONCLUSION: The paper concludes that more research knowledge of the impact of heuristics and techniques to combat them in nursing decisions is needed. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a review of nurses' roles and their perceptions of these roles in decision-making processes surrounding artificial food and fluid administration in adult patients. Background. Of all caregivers, nurses have the closest and most trusting relationship with severely ill patients and their families during the entire end-of-life care process. As a result, nurses become closely involved in complex ethical decision-making processes concerning artificial administration of food or fluids for these patients. Data sources. We searched seven electronic databases (1990-2007) and examined the reference lists of relevant papers. Review methods. This mixed methods review was conducted with guidance of the United Kingdom Centre for Reviews and Dissemination guidelines on systematic reviews. Results. Although their direct impact is limited, nurses play a significant indirect role during decision-making processes. Because of their unique position, they often initiate decision-making processes, function as patient advocates and provide guidance, information and support to patients and families. Although nurses considered their role to be very valuable, they felt that their role was not always defined clearly or appreciated. Whether nurses experience decision-making processes positively depended on several contextual factors. Conclusion. Given their knowledge and practice skills, nurses are in a prime position to contribute valuably to decision-making processes. Nevertheless, they remain sidelined. For nurses to receive sufficient recognition, their decision-making tasks and responsibilities need to be clarified and made manifest to other participants. [ABSTRACT FROM AUTHOR]

Aim. This paper describes the evolution of Australian practice nursing and documents seminal events in crystallizing the importance of the nursing role in general practice. Background. Internationally, the potential for nurses to improve health in primary care settings is acknowledged. The general practice setting is a focal point for primary care in many health systems. Despite the important role played in the delivery of primary health care by nurses working in general practice in the United Kingdom and New Zealand, the role of nurses in Australian general practice is much less clearly defined, as reflected by the paucity of research and scholarship in this area. Fuelled by the increasing challenges of workforce shortages and the increasing need for multidisciplinary care, interest in the developing role of the Australian practice nurse among clinicians, researchers and policy makers is increasing. Discussion. Australian practice nursing has reached a critical point in its evolution. It is imperative for the promotion of nursing in general practice that knowledge from descriptive, exploratory research be used to inform strategic decision-making in terms of professional development issues, policy, research and scholarship. These data also need to inform systematic outcome studies. To date, the embryonic nature of practice nursing as a discrete professional entity in Australia has inhibited its representation in nursing curricula and professional bodies. Conclusion. In order to advance the Australian practice nurse movement and demonstrate its important contribution to primary health care, nurses need to take the lead in strategic planning of this emerging specialty. As well as leadership from an academic, research and policy perspective, clinical leaders need to be fostered among the ranks of practice nurse clinicians to drive clinical practice development and the delivery of evidence-based primary care. [ABSTRACT FROM AUTHOR]

AIM OF PAPER: This paper is a response to Thompson's paper 'A conceptual treadmill: the need for a middle ground in clinical decision making theory' published in the Journal of Advanced Nursing in 1999. SUMMARY OF CONTENT: This author agrees with his main recommendations, which are to seek a middle ground in the current polarized debate over clinical decision making in nursing, and to draw upon Hammond's Cognitive Continuum theory to do so. The theoretical background is sketched out, and the implications of these recommendations are analysed against this. It is argued that nurses now need to move the academic debate forward in such a way as to make serious impact on developing and improving practice. Cognitive continuum theory, in the way in which it focuses on practice, holds considerable potential to assist this move. CONCLUSION: Drawing on cognitive continuum theory necessarily leads to consequences which are not addressed in Thompson's paper: namely a need to consider the quality of nursing decisions, and a willingness to consider approaches to decision making which have been neglected or criticised by nurses. These consequences are explored here, and the implications of adopting this approach for nurses are outlined. [ABSTRACT FROM AUTHOR]

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism. [ABSTRACT FROM AUTHOR]

Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis This is the second of two linked papers exploring decision making in nursing. The first paper, ‘Classifying clinical decision making: a unifying approach’ investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses’ professional status. This is particularly important as nurses’ roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses’ decisions as classification behaviour will also enhance clinical effectiveness, and assist in... [ABSTRACT FROM AUTHOR]

This paper considers the nature of decisions made in the context of community nursing practice, in the light of the stages of decision making distilled by Carroll & Johnson from the work of various theorists, and explores the relevance of each stage to community nurses' decision making. Illustrative examples of specific theoretical perspectives are included throughout the paper. The discussion forms part of the literature review for research currently being undertaken by the authors into patient assessment by community nurses. As decision making is a key element of community nurses' assessment practice, the paper argues that decision making theory forms a useful conceptual framework for investigating this aspect of community nursing. [ABSTRACT FROM AUTHOR]

The section comments on the article "Protective Steering: A Grounded Theory Study of the Processes by Which Midwives Facilitate Informed Choices During Pregnancy," by V. Levy, which appeared in the 1999 issue of the "Journal of Advanced Nursing." It discusses the focus of the paper, which is on the relationship between the childbearing woman and the midwife. It characterizes the midwives in Levy's sample in terms of making decisions about their maternity care.

Title. Creating case scenarios or vignettes using factorial study design methods.Aim. This paper is a report of a study conducted to develop clinical case vignettes using an adaptation of an incomplete factorial study design methodology.Background. In health care, vignettes or cases scenarios are core to problem-based learning, common in practice guideline development processes, and increasingly being used in patient or care-giver studies of chronic or life-threatening illnesses. A large number of behavioural, psycho-social and clinical factors can be relevant in such decision problems. Unbiased methods for choosing what factors to include are needed, when it is not possible to include all relevant combinations of factors in the vignettes.Method. The factors to be considered, number of levels or categories for each factor, and desired number of scenarios were decided in advance. An algorithm was used first to create the full factorial data set, and then a random subset of combinations was generated, according to predefined criteria, based on maximizing determinants. The subset of combinations was incorporated into written vignettes. The study was conducted in 2004-2005.Findings. Application of the method yielded diverse and balanced scenarios that covered the full range of factors to be considered for a project to elicit health providers' processes in diet counselling for dyslipidemia.Conclusion. The approach is flexible, decreases possible researcher bias in the creation of vignettes, and can improve statistical power in survey research. This novel application of study design methodology merits consideration when vignettes are being developed to elicit opinions or decisions in studies of complex health issues. [ABSTRACT FROM AUTHOR]

AIM: This paper is a report of a mixed-method systematic review to identify barriers to, and facilitators of, contraceptive needs and choices of women over 40 years old. BACKGROUND: Women over 40 years of age who do not want to conceive have specific needs for contraception to prevent unwanted, unplanned and unintended pregnancies prior to menopause. DATA SOURCES: Six databases were searched for published and grey literature from September 1997 to September 2007, along with the Cochrane Central Register of Controlled Trials. The Internet, professional networks and hand searching were also used. REVIEW METHODS: Mixed-method synthesis using Evidence for Policy and Practice Information and Co-ordinating Centre phased design. FINDINGS: Guidelines to inform clinical decision-making were located but did not take account of age-related social factors affecting women's choices or local service availability. Women's access to services and contraceptive choices were influenced by educational level, general awareness of available methods, fear of side effects, women's social standing, religious and cultural beliefs, personal control, and confidentiality. The main factors influencing compliance and continuation rates were knowledge, positive experience and confidence, unacceptable side effects and safety concerns, information, support and advice, and ongoing husband/partner influences. CONCLUSION: The utility of clinical guidelines could be improved by incorporating socio-cultural factors and women's views. Novel approaches to evidence translation and facilitation are required. Focusing on user-led, age-appropriate services rather than a 'one size fits all' approach could improve the contraceptive choices and outcomes for women over 40 years old. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to describe nurses' perceptions of decision-making and the evidence base for the initiation of insulin therapy. Background. Several theoretical perspectives and professional's attributes underpin decision-making to commence insulin therapy. The management of type 2 diabetes is moving from secondary to primary care and this affects how clinical decisions are made, by whom and the evidence base for these decisions. Method. A postal survey was conducted with a stratified sample of 3478 Diabetes Specialist Nurses and Practice Nurses with a special interest in diabetes across the four countries of the United Kingdom. A total of 1310 valid responses were returned, giving a response rate of 37·7%. The questionnaire was designed for the study and pilot-tested before use. Responses were given using Likert-type scales. Data were collected during 2005 and 2006, and one reminder was sent. Results. People with diabetes are seen as having little influence in decision-making. Consultant physicians appear to be influential in most decisions, and the nursing groups held varying perceptions of who made clinical decisions. Nurses' identified different responsibilities for those working solely in secondary care from those working in both community and secondary care. Practice nurses were not as involved as anticipated. Conclusion. Nurses working with people with diabetes need to encourage them to become more active partners in care. Clinical guidelines can assist in decision-making where nurses are least experienced in initiating insulin therapy. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study examining the barriers associated with research knowledge transfer amongst primary care nurses in the context of clinical decision-making. Background. The research literature on barriers to nurses’ use of research knowledge is characterized by studies that rely primarily on self-report data, making them prone to reporting biases. Studies of the barriers to evidence-based practice often fail to examine information use and behaviour in the context of clinical decision-making. Methods. A multi-site, mixed method, case study was carried out in 2001. Data were collected in three primary care organizations by means of interviews with 82 primary care nurses, 270 hours of non-participant observation and 122 Q-sorts. Nurses were selected using a published theoretical sampling frame. Between-methods triangulation was employed and data analysed according to the principles of constant comparison. Multiple linear regression was used to explore relationships between a number of independent demographic variables (such as length of clinical experience) and the dependent variable of nurses’ perspectives on the barriers to their use of research knowledge. Results. Three perspectives on barriers to research information use emerged: the need to bridge the skills and knowledge gap for successful knowledge transfer; information formats need to maximize limited opportunities for consumption; and limited access in the context of limited time for decision-making and information consumption. Demographic variables largely failed to predict allegiance to any of the perspectives identified. Conclusions. Researchers should consider using decision-making as a contextual backdrop for exploring information use and behaviour, avoid relying solely on self-reported behaviour as data, and use a variety of research methods to provide a richer picture of information-related behaviour. Practice developers need to recognize that understanding the decisions to which research knowledge is to be applied should be a characteristic of any strategy to increase research uptake by nurses. [ABSTRACT FROM AUTHOR]

Aims. The purpose of this paper is to report the findings of an exploratory study designed to test a portion of the Theory of Collaborative Decision-Making in Nursing Practice for Triads by examining the relation between types of decisions and formation of coalitions during triadic interactions among older home healthcare clients, their caregivers and home healthcare nurses during seven admission visits for home health care. Background. Although home healthcare nurses include clients and family members in decision-making about care, few publications address the nature of interactions among triads of clients, caregivers and nurses in home health care and the association between decision-making and those interactions. Method. The data presented in this paper are a secondary analysis of data originally collected in 1994. The sample included 157 decision-making situations identified from interactions of seven triads of older home healthcare clients, their caregivers and nurses. Qualitative data were collected by participant observation and audio-recording of admission visit interactions among clients, caregivers and nurses. Content analysis, augmented by Ethnograph software, was used to analyse the data. Findings. Coalitions were evident in just eight of the 157 decision-making situations. All of the theoretically possible types of nursing care decisions (programme, operational control, agenda) were observed. Each coalition involved one nursing care decision; two coalitions formed in one triad. Seven coalitions formed between nurse and caregiver against client during two programme and five operational control decisions. One coalition formed between client and caregiver against nurse during an agenda decision. No coalitions formed between client and nurse against caregiver. Conclusions. Although the study sample was small, the findings expand understanding of the relation between types of decisions and formation of coalitions during triadic interactions in home health care, and provided empirical support for a portion of the Theory of Collaborative Decision-Making in Nursing Practice for Triads. [ABSTRACT FROM AUTHOR]

Aim. This paper aims to explore the influences on employment related decision making in respect of nurses over 50 in the United Kingdom. It investigates the retirement and labour market relationship through the diverse experiences of older nurses and stakeholders in nursing. Background. The ageing of the United Kingdom nursing workforce constitutes a potential challenge for the National Health Services. There is evidence of increasing efforts to address this issue by encouraging older nurses to remain in the profession, dissuading early retirement and attracting nurses who have retired to return to nursing. However, decision-making by older nurses is influenced by a wide spectrum of factors and perceived employment options. Background. The paper is based on research commissioned by the Joseph Rowntree Foundation as part of its Transitions Over 50 programme. It derives from concern about inadequate knowledge of, and under-developed policy responses to, the ageing United Kingdom workforce and the specific implications of this age shift for the nursing labour market. The research consisted of interviews with nurses over 50 and key stakeholders in nursing in the United Kingdom. Stakeholders included employers, advisers and policy makers in nursing. Method. Interviews with older nurses and stakeholders in nursing were conducted over a period of 12 months. They included face-to-face and telephone semi-structured interviews with 84 nurses over 50 and 18 key stakeholders in nursing in the United Kingdom. Stakeholders included employers, advisers and policy-makers. Findings. Employers, policy makers and advisers and older nurses all identified a range of influences on nurses' employment decisions including a lack of flexible hours, the stress of work, pension-related expectations and the pace of change. Some of these related to negative aspects of work that led nurses to leave ('push' factors), and others to the presence of positive factors in nursing or in pension options ('pull' factors). Conclusion. The study highlighted the need for increased implementation of more flexible hours of work and greater availability of part-time hours for older nurses. It revealed the salience of improved pay, adequate and flexible pensions provision, and opportunities for continued professional development to the recruitment and retention of older nurses. [ABSTRACT FROM AUTHOR]

BACKGROUND: Time is a valuable resource. When nurses experience demands on their services which exceed their available time, then 'rationing' must occur. In clinical practice such rationing requires practitioners to set priorities for care. AIMS: The aim of this paper is establish what is currently known about priority setting in nursing, including how nurses set priorities and what factors influence this. METHOD: CINAHL, Medline, ASSIA, and PsychLit databases for the years 1982-2002 were searched, using the terms (clinical decision-making or problem-solving or planning) and (setting priorities or prioriti*). The publications found were used in a selective, descriptive review. FINDINGS: Priority setting is an important skill in nursing, and a skill deficit can have serious consequences for patients. Recent studies have suggested that it is a difficult skill for newly qualified nurses to acquire and may not be given sufficient attention in nurse education. Priority setting can be defined as the ordering of nursing problems using notions of urgency and/or importance, in order to establish a preferential order for nursing actions. A number of factors that may impact on priority setting have been identified in the literature. These include: the expertise of the nurse; the patient's condition; the availability of resources; ward organization; philosophies and models of care; the nurse-patient relationship; and the cognitive strategy used by the nurse to set priorities. However, very little empirical work has been conducted in this area. CONCLUSIONS: Further study of priority setting in a range of clinical practice settings is necessary. This could inform both practice and education, promote better use of limited resources and maximize patient outcomes. [ABSTRACT FROM AUTHOR]

AIM: The aim of this paper is to explore the literature relating to critical care outreach services and the use of early warning scoring systems to detect developing critical illness. BACKGROUND: Several studies have identified how suboptimal care may contribute to physiological deterioration of patients with major consequences on morbidity, mortality and requirement for intensive care. In a review of adult critical care services, the Department of Health (DOH) (England) recommended in 2000 that outreach services be established to avert admissions to Intensive Care, to enable discharges and to share critical care skills. METHODS: A literature search was carried out of the BIOMED and NESLI databases using the key words 'outreach', 'early warning signs/systems' and 'suboptimal care'. The literature review was limited to the past 10 years, and primary research articles of particular relevance were included in the review. The literature is examined within the context of recent findings relating to the provision of suboptimal care within general wards prior to cardiac arrest and/or admission to Intensive Care Units (ICU), and subsequent government initiatives. Discussion. The discussion explores the potential contribution of critical care outreach services and early warning scoring systems to the care of patients in acute general wards, including the role that education can have in developing the knowledge base and assessment skills of ward nurses. CONCLUSION: The paper concludes that further study is required to evaluate the effectiveness of critical care outreach services and early warning scoring systems, and that ward staff need to be educated to identify those patients at risk of developing critical illness. Finally, it is suggested that nurses' decision-making in relation to calling the outreach team requires further investigation. [ABSTRACT FROM AUTHOR]

AIMS OF THE PAPER: The purpose of the paper is to (1) identify prevalent assumptions that underlie the traditional conceptualization of everyday self-care decision making and (2) contrast these with the findings of relevant research. BACKGROUND/RATIONALE: Current understandings of self-care decision making in chronic illness tend to be extrapolated from knowledge gained in relation to one-time decisions, or decision making in contexts that are only superficially related to the complexity and pervasiveness of living with a chronic disease. FINDINGS: The authors challenge the assumptions with which current understandings represent self-care decision making in chronic illness, using evidence from their research on what it is like to live with and manage the implications of having a chronic disease on an everyday basis. CONCLUSIONS: The paper concludes with a call for a new conceptualization of self-care decision making in chronic illness which sufficiently addresses the unique and complex nature of such decisions. [ABSTRACT FROM AUTHOR]

Treatment decision making by women with breast cancer has been recognized to be an inherently stressful process. However, past decisional theory and research has failed to fully elucidate the personal, transactional, and relational nature of choice behaviour. The purpose of this paper is to explore an embedded decisional model of stress and coping that locates key assumptions of Janis & Mann's (1977) conflict-theory model of decision making within Lazarus & Folkman's (1984) transactional framework. Through combining decisional and stress and coping theories, a model is developed that addresses the theoretical limitations of the conflict-theory model and provides greater specificity within decision-making research. The paper examines the complexity of treatment decision making within the context of the constructs of causal antecedents, primary appraisal, secondary appraisal, coping, and adaptational outcomes. Examples specific to women with breast cancer are provided to illustrate the potential application of the embedded model. The implications of this inclusive and comprehensive decisional theory for future knowledge development and research in the area of treatment decision making are also discussed. [ABSTRACT FROM AUTHOR]

This paper explores the two predominant theoretical approaches to the process of nurse decision making prevalent within the nursing research literature: systematic-positivistic approaches as exemplified by information processing theory, and the intuitive-humanistic approach of Patricia Benner. The two approaches' strengths and weaknesses are explored and as a result a third theoretical stance is proffered: the idea of a cognitive continuum. According to this approach the systematic and intuitive theoretical camps occupy polar positions at either end of a continuum as opposed to separate theoretical planes. The methodological and professional benefits of adopting such a stance are also briefly outlined. [ABSTRACT FROM AUTHOR]

It is generally accepted in many areas of research, including nursing research, that decisions about research methods should be informed by the nature of the research question; that the research question will indicate what approach and methods should be used. However, it is arguable that this over-simplifies the process of decision-making. It is suggested that the axiom that question determines approach and method overlooks the influence of the researcher's personal worldview in such decisions. This paper seeks to examine some of the elements of the process of moving from underlying philosophy to research design and strategies, by exploring the concept of paradigm, features of this researcher's worldview, and the principles and processes which influence decisions about the research. The process is illustrated by reference to features of a study into the work of community psychiatric nurses in relation to the quality of life and social networks of their clients with enduring mental health problems. [ABSTRACT FROM AUTHOR]

This paper was written to assist health professionals who are or who are planning to undertake health education activities with people of a different culture. The focus is on the educative function of health promotion. A short summary of relevant learning theory is presented. Some obstacles (pitfalls) encountered in cross-cultural transfer of information, knowledge and skills are presented and the effects of this learning process on the learner and teacher are explored. Examples of possible conflict situations drawn from the author's experiences and research are presented. Variables which influence planning and implementation of health education in cross-cultural settings are examined. A cyclical model which identifies critical questions to be asked and decisions to be made in a four-phased process of assessment, planning, implementation and evaluation is described for the use of health educators in transcultural settings. The need for systematic cultural assessment prior to planning is stressed to ensure relevancy, acceptance and positive outcome of programmes. Cooperative efforts of health educators with existing systems and traditional teachers and involvement of clients during all phases of the decision making process are suggested. [ABSTRACT FROM AUTHOR]

This paper argues that the rhetoric of multidisciplinary teamwork is central to the provision of health care generally and geriatric care in particular. Yet the notion of teamwork is poorly defined, and the supposed benefits for patients are not always readily apparent. Looking at teamwork in practice, examples from research are used to illustrate how multidisciplinary decision making and work with patients can, under particular circumstances, take on the appearance of collaboration amongst a team of expert colleagues, which co-opts patients and relatives to the status of team members. But very often, multidisciphnary work with patients is coordinated not by mutual collaboration amongst a team of equals, but by means of established work routines which are broadly applied to whole categories of patients, and by the operation of the traditional hierarchy of social relations in health care. For long stay patients, the pervasiveness of the teamwork mythology and the frequent concurrent withdrawal of other professionals can, at worst, leave the nurses in the invidious position of having responsibility, but no formal or legal authority for caring for their patients: work which no other professional is anxious to do. This leads to negative outcomes for patients as well as for nurses. Finally, it is stressed that analysis of multidisciplinary teamwork both in theory and in practice is vital if we are to understand the conditions under which multidisciplinary teamwork both flourishes, and can be demonstrated to be a necessary condition for the creation of positive care outcomes for geriatric patients in hospital. This paper seeks to raise some of the issues which must be confronted in this endeavour. [ABSTRACT FROM AUTHOR]

Title. Parent’s involvement in decisions when their child is admitted to hospital with suspected shunt malfunction: study protocol. Aim. This paper outlines the protocol for a study aimed at exploring parent’s involvement during professional–parent interactions and decisions about their child’s care in the context of suspected shunt malfunction. Background. Hydrocephalus is a long-term condition treated primarily by the insertion of a shunt that diverts fluid from the brain to another body compartment. Shunts frequently malfunction, and parents of children with shunted hydrocephalus are responsible for recognizing and responding to shunt complications. Parents feel that interactions with professionals when they seek healthcare advice for their child do always not encourage active participation in care decisions. Methods. The study design is based on qualitative methodologies: a combination of conversation analysis applied to consultation recordings of professional–parent interactions when a child is admitted to hospital with suspected shunt malfunction, and semi-structured follow-up interviews with the same participants within 2 weeks of the consultation. Participants. This is a prospective study and participants will be purposefully selected. Parents of children who have been admitted to hospital with suspected shunt malfunction and healthcare professionals responsible for the initial assessment of the child will be invited to participate. Discussion. The study will identify how decisions about a child’s care are negotiated between parents and healthcare professionals at key stages of the care pathway. In addition, examining interactions between healthcare professionals and parents may identify approaches that support or hinder parents in contributing to the decision-making processes when they seek advice from healthcare professionals. [ABSTRACT FROM AUTHOR]

Title. Judging nursing information on the WWW: a theoretical understanding.Aim. This paper is a report of a study of the judgement processes nurses use when evaluating World Wide Web information related to nursing practice.Background. The World Wide Web has increased the global accessibility of online health information. However, the variable nature of the quality of World Wide Web information and its perceived level of reliability may lead to misinformation. This makes demands on healthcare professionals, and on nurses in particular, to ensure that health information of reliable quality is selected for use in practice.Method. A grounded theory approach was adopted. Semi-structured interviews and focus groups were used to collect data, between 2004 and 2005, from 20 nurses undertaking a postqualification graduate course at a university and 13 nurses from a local hospital in the United Kingdom.Findings. A theoretical framework emerged that gave insight into the judgement process nurses use when evaluating World Wide Web information. Participants broke the judgement process down into specific tasks. In addition, they used tacit, process and propositional knowledge and intuition, quasi-rational cognition and analysis to undertake these tasks. World Wide Web information cues, time available and nurses' critical skills were influencing factors in their judgement process.Conclusion. Addressing the issue of quality and reliability associated with World Wide Web information is a global challenge. This theoretical framework could contribute towards meeting this challenge. [ABSTRACT FROM AUTHOR]

Title. Nurse prescriber–patient consultations: a case study in dermatology. Aim. This paper is a report of a study exploring the content and processes in consultations between nurse prescribers and patients with dermatological conditions. Background. Communication skills, consultation time, information and follow-up are central to the treatment and management of patients with dermatological conditions. The contribution nurses make to the care of these patients has great potential. Method. A multiple case study was conducted with 10 practice settings across England in which nurses prescribed medicines for patients with dermatological conditions. Data were collected between June 2006 and September 2007 using semi-structured interviews ( n = 40), patient questionnaires ( n = 165/200) and videotaped observations of nurse consultations ( n = 40). Data analysis included thematic analysis, descriptive statistics, chi-square and non-parametric tests. Findings. Nurses believed that their holistic approach to assessment, combined with their prescribing knowledge, improved prescribing decisions. Listening and explanation of treatments were aspects of nurse communication that were rated highly by patients. Listening and dealing sensitively with emotions were also aspects of the videotaped consultations that were rated highly by assessors. Nurses were less consistent in providing information about medicines. Conclusion. Triangulated data from this study suggest that nurse prescribing enhances the care of patients with dermatological conditions through improved prescribing decisions. If patients are to be more involved in this decision-making, nurses must give them more information about their medicines. The benefits of prescribing were most evident in the practices of dermatology specialist nurses. Further evidence is required to identify whether prescribing by specialist nurses offers similar benefits in other therapeutic areas. [ABSTRACT FROM AUTHOR]

Title. Midlife African-American women’s protective and risky practices related to HIV. Aim. This paper is a report of a study exploring the relationships between social, cultural and individual factors and midlife African-American women’s risk taking and protective practices related to HIV/AIDS. Background. The extent of the HIV epidemic among women of African descent around the world is difficult to discern, but women of color are disproportionately affected. While the risk factors for HIV infection are clearly defined, the context for sexual risk-taking and protective practices is poorly understood for midlife African-American women. Method. The study was guided by grounded theory methods. The Afrocentric Paradigm, Theory of Gender and Power, and Social Cognitive Theory formed the basis for developing semi-structured interview and focus group schedules. Theoretical sampling and principles of emergent design were used to guide data collection and analysis. Interview and focus group data were collected between 2003 and 2006. Transcripts were analyzed using constant comparison to develop descriptive themes, and member checking was used to verify findings. Findings. African-American women ( n = 36) who were between the ages of 40 and 64 years and HIV negative volunteered for the study. Participants characterized their sexual decision-making as two conflicting processes –‘Taking Responsibility’ and ‘Getting Caught Up’– related to being accountable for sexual decision-making and having strong sexual desires. Conclusion. Stereotypical views of midlife African-American women must be overcome to ensure that they are treated appropriately in the clinical setting. Increasing emphasis on developing woman-controlled HIV prevention approaches holds the greatest hope for controlling the epidemic among women. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to generate a model of nursing behaviours and social processes inherent in decision-making for acutely ill nursing home residents. Background. Most research concerning clinical decision-making in nursing homes focuses on the perspectives of doctors. Much less is known about the perspectives and actions of nurses with regard to decision-making, despite the centrality of their roles in nursing homes. Method. Grounded theory was used. Data were collected in 2004 in four nursing homes in the United States of America using in-depth, semi-structured interviews, 74 hours of non-participant observation and informal conversational interviews with key nursing staff involved in decision-making. Findings. Nurses strive to create a plan of care acceptable to family members and doctors, consistent with wishes of residents and most comfortable for residents. A unifying theme of satisfying all sides emerged as representative of the negotiation strategies used by nurses to address these competing points of view. Four phases in this negotiation occurred: weighing the significance; notifying the family; feeling it out; and playing the middleman. The outcome was either a decision for life-prolongation or for palliative care. Conclusion. Decisions for nursing home residents are complex and involve weighing and balancing the interests and preferences of many concerned participants, including residents, families and doctors. This process requires skill in clinical judgment, communication and collaboration. [ABSTRACT FROM AUTHOR]

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

Aim. This paper is a report of a study to explore women's perceptions of and experiences with breast cancer treatment decision-making in managed care organizations (MCOs). Background. Managed care organizations are the predominant form of employer-sponsored healthcare insurance in the United States of America. These healthcare financing entities minimize cost by streamlining healthcare delivery and may impose choice restrictions. The extent of these restrictions has not previously been studied from an in-depth patient perspective. Method. A qualitative descriptive approach was adopted using interviews with a purposive sample of 14 managed care enrollees diagnosed with breast cancer at all stages. The data were collected between 2003 and 2005. Data analysis involved a reflexive process of transcript reading, categorization, data reduction and interpretation. Findings. The findings are presented as a single theme: 'decisional conflict in managed care', with two distinct categories: decisions regarding (1) the MCOs and (2) treatment. MCO selection was perceived to be limited by employer constraints, cost issues or healthcare plan providers. For study participants, selecting a MCO was less difficult than issues surrounding treatment decision-making. Women reported that their most important treatment-related decisions surrounded diagnosis and involved selecting a treatment facility and provider. Once a satisfactory facility and provider were selected, these women preferred to defer treatment decisions to their healthcare providers. Conclusion. Decision interventions should be focused on assisting women with provider and treatment facility selection early in diagnosis. Our findings might also serve as a basis for policy/practice changes to address healthcare financing limitations and to expand cancer treatment-related choices while providing desired treatment decision-making support. [ABSTRACT FROM AUTHOR]

Title. Clinical judgement and decision-making in nursing – nine modes of practice in a revised cognitive continuum Aim. This paper is a report of an evaluation of cognitive continuum theory and identification of revisions required for application to clinical judgement and decision-making in nursing. Background. The importance of nurses’ developing and applying sound clinical judgement is reflected in an international classification of nursing practice. Cognitive continuum theory synthesizes rival and complementary approaches to decision theory in an accessible format, which has been applied in medicine, and various nursing scholars have advocated its use to enhance the effectiveness of nurses’ clinical judgement and decision-making. Method. Parse’s structure and process criteria are applied in critiquing the relevance of cognitive continuum theory to nursing. Findings. Cognitive continuum theory illustrates how different judgement tasks are suited to different thought processes and how matching the two can optimize decision-making. However, existing modes of inquiry applied to medicine emphasize experimental research, ignoring many alternative approaches used in nursing. A revised version of the cognitive continuum is developed, incorporating examples of nursing judgements and decisions, a broader evidence base, an ethical dimension, and evaluative competence criteria. Conclusion. The revised cognitive continuum promotes awareness of the nature and the variety of patient-centred judgement tasks and decisions in nursing, how to select the most suitable intervention tactic from available options, and the fallibility of all forms of human judgement from intuitive/experiential to analytic/rational. Hence, it is recommended for use as an educational tool and practice guide to facilitate theory development and the practice of judgement and decision-making in nursing. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to examine how decisions about managing pain were made between patients with chronic kidney disease and nurses, what affected the decision style and the types of analgesics and adjuvant therapies given for pain relief in relation to a particular decision style. Background. While pain often accompanies chronic kidney disease, little is known of how decisions are made about managing pain in clinical practice. Lack of patient involvement in decision-making may lead to inadequate care provision. In some care situations, nurses have been more concerned with medication side effects than giving effective pain relief. Method. An exploratory study was conducted, using observations and interviews with a purposive sample of 14 nurses and 53 patients in five adult renal units in Australia. The data were collected during 2004. Findings. Of the 103 pain activities observed, 78 involved a passive decision style between the nurse and patient, 19 involved a collaborative decision style, and six used an active decision style. The majority of routine analgesic and adjuvant medications administered involved a passive decision style. Most importantly, 25.6% of passive style decisions observed resulted in no administration of an analgesic or adjuvant medication; however, all collaborative and active style decisions observed resulted in administration of an analgesic or adjuvant medication. Conclusion. Nurses need actively to encourage patient involvement in treatment decisions because this promotes effective pain control. More research is needed into how specific detailed information about pain treatments could improve patient participation in decision-making. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to describe and compare thinking strategies and cognitive processing in the emergency department triage process by Registered Nurses with high and low triage accuracy. Background. Sound clinical reasoning and accurate decision-making are integral parts of modern nursing practice and are of vital importance during triage in emergency departments. Although studies have shown that individual and contextual factors influence the decisions of Registered Nurses in the triage process, others have failed to explain the relationship between triage accuracy and clinical experience. Furthermore, no study has shown the relationship between Registered Nurses' thinking strategies and their triage accuracy. Method. Using the 'think aloud' method, data were collected in 2004-2005 from 16 RNs working in Swedish emergency departments who had previously participated in a study examining triage accuracy. Content analysis of the data was performed. Findings. The Registered Nurses used a variety of thinking strategies, ranging from searching for information, generating hypotheses to stating propositions. They structured the triage process in several ways, beginning by gathering data, generating hypotheses or allocating acuity ratings. Comparison of participants' use of thinking strategies and the structure of the triage process based on their previous triage accuracy revealed only slight differences. Conclusion. The wide range of thinking strategies used by Registered Nurses when performing triage indicates that triage decision-making is complex. Further research is needed to ascertain which skills are most important in triage decision-making. [ABSTRACT FROM AUTHOR]

Title. New midwifery? A qualitative analysis of midwives’ decision-making strategies Aim. This paper is a report of a study to explore the reasons why midwives decided to adopt observed decision-making strategies relating to the use of technology. Background. Literature on the development of midwifery and nursing has suggested that they are developing more egalitarian relationships with clients in decision-making processes. Methods. A qualitative approach was adopted, using participant observation with a convenience sample of midwives ( n = 16), and a focus group of midwives ( n = 8). Data collection took place over 9 months in 2004. Findings. The dominant mode of decision-making was bureaucratic decision-making, which involved adherence to written policies and procedures. The least frequently used was ‘new professional’ decision-making, which involved collaboration with clients. The reasons for midwives’ approaches could be categorized under three main headings: first, context, including possible litigation, management strategies, workload pressures, and medical dominance; second, midwives’ characteristics, including both lack of experience and the reliance on tradition of some experienced midwives; and third, women’s perceived characteristics, some of whom were seen by midwives as either unwilling or unable to participate in decision-making. There was also implicit evidence that some midwives were uncomfortable with the new professional rebalancing of power relations between professionals and the laity. Conclusion. Managers need to question whether the strategies they adopt hinder or support clinicians in their efforts to involve women in decisions. Clinicians need to consider whether they wish to be selective or universal in their use of new professional strategies. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to examine how nurse practitioners combine information when estimating patient risk of coronary heart disease. Background. In the United States of America and other countries, nurse practitioners are increasingly working alongside physicians in primary healthcare settings. Given this role, nurse practitioners represent an important resource in early detection of numerous diseases. Understanding how nurse practitioners use patient characteristics (cues) to form estimates of patient risk for disease may improve general disease prevention efforts. Method. Social judgment theory and its lens model analysis are concerned with the correspondence between a person's judgments and the environment. This approach was applied to examine how 15 nurse practitioners weighted eight risk factors for coronary heart disease, how accurate practitioners were in assessing patient risk for coronary heart disease, and how much self-insight practitioners had into their own risk estimation processes. The data were collected in 2006. Results. Nurse practitioners showed moderate to high accuracy and evinced a variety of cue-weighting strategies. Insight into their own judgment policies was modest. The lens model analysis revealed that most practitioners had lower values on knowledge of the ecology than they did on cognitive control. Conclusion. Educational efforts aimed at improving detection of patients at risk for diseases might do better to target increasing clinicians' understanding of cue-criteria relationships, than to stress themes of consistency in evaluating patients. [ABSTRACT FROM AUTHOR]

Title. Clinical decision-making skills on the developmental journey from student to Registered Nurse: a longitudinal inquiry Aim. This paper is a report of a study to explore, from the perspective of nursing students, how they acquire clinical decision-making skills and how well-prepared they feel in this respect regarding their responsibilities as Registered Nurses. Background. Previous research has focused mainly on exploring experienced nurses’ judgement and decision-making. Some studies have elicited senior nursing students’ understanding of the process, but none has explored the development of clinical decision-making skills throughout the educational programme and in the first year as a Registered Nurse. Method. A volunteer sample of 20 respondents, broadly representative of the student cohort regarding qualifications, age, gender and nursing specialty, was recruited. A longitudinal hermeneutic phenomenological study was carried out from 2000 to 2004, using interviews, reflective journals, care studies, critical incident analyses and document analysis. Findings. Ten conceptions of nursing and 10 perceptions of clinical decision-making were identified and a growing pattern of inter-relationships between them became apparent. A ‘matrix model’ was developed by cross-referencing the two thematic categories within the timeline of respondents’ developmental journey through significant milestones and changing contexts. As Registered Nurses they found having to ‘think on your feet’ without the ‘comfort blanket’ of student status both a stressful and formative learning experience. Conclusion. Further collaboration between education and health service partners is recommended to integrate clinical decision-making throughout the nursing curriculum, enhance the development of such vital skills, and facilitate the transition from student to Registered Nurse. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to encourage participants to work together to identify strategies for increasing user participation in clinical decisions and to evaluate the value of co-operative inquiry as a vehicle for supporting learning in practice. Background. Service user participation in the clinical practice decisions of mental health nurses is considered essential for good practice. Methods need to be found which enable opportunities for shared learning, facilitate practice development and empower service users. Method. A co-operative inquiry design engaged all participants (n = 17) as co-researchers and involved repeated cycles of action and reflection, using multiple data collection methods. The research was conducted over a two year period in 2004-2005, with mental health nursing students collaborating with service users. Findings. Factors inhibiting participation included stigmatizing and paternalistic approaches, where clinical judgments were made solely on the basis of diagnosis. Enhancing factors were a respectful culture which recognized users' 'expertise' and communicated belief in individual potential. Inquiry benefits included insight into service users' perspectives, enhanced confidence in decision-making, appreciation of power issues in helping relationships and deconstruction of decision-making within a safe learning environment. Conclusion. Learning from novel approaches which enable nursing students to develop their reflective and reflexive ability is essential to avoid practice which disempowers and potentially harms service users' recovery. Co-operative inquiry is a valuable vehicle for developing professional practice in higher education and practice environments. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of a study to compare the perceptions of adult patients, family carers, nurses and dietitians regarding home percutaneous endoscopic gastrostomy feeding. Background. Healthcare professionals have a major role in patient selection for gastrostomy placement and the provision of aftercare but it is not clear if patients, their carers and healthcare professionals have similar perceptions of the initiation and delivery of feeding and of the care in general. Method. A cross-sectional mixed-method study using purposive sampling, semi-structured interviews and questionnaires was performed. Interviews were undertaken during 2005 with adult patients and carers of adults receiving home feeding. A questionnaire containing comparable questions was distributed to the lead district nurse and dietitian providing the individual patient's care. Binomial regression was used to analyse any differences in perceptions across the groups of respondents. Results. Nurses and dietitians had similar perceptions of gastrostomy feeding in adults. Family carers' perceptions matched those of professionals more closely than did those of patients. The greatest difference in perceptions was between patients and their family carers. Respondents' views about success of feeding and the appropriateness of the feeding regimen were similar, but greater differences existed regarding quality of life, withdrawal of feeding and choice in decisionmaking about tube placement. Conclusion. There is a need for increased patient and carer involvement in decision-making and for sufficient, appropriate information to facilitate informed decision-making. Practitioners who involve carers in decision-making, where patients lack capacity, need to be aware that carers may not represent the views of patients. [ABSTRACT FROM AUTHOR]

Aim. This paper is a report of the findings of a study into the role of district nurses in euthanasia and physician-assisted suicide in homecare organizations, conducted as part of a study into the role of nurses in medical end-of-life decisions. Background. Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study into the role of nurses in medical end-of-life decisions in hospitals, nursing homes and homecare organizations. This is the first quantitative study from the perspective of nurses. Previous quantitative studies were conducted under physicians and information on the role of nurses was obtained indirectly. Method. A questionnaire was sent in 2003 to 500 district nurses employed in 55 homecare organizations. The absolute response rate was 86.0% and 81.6% (408) could be used for analysis. Results. In 22.3% of 278 cases, the district nurse was the first with whom patients discussed their request for euthanasia or physician-assisted suicide. In about half (49.8%) of 267 cases nurses were not involved in the general practitioner's decisionmaking process, and in only 13.3% of 264 cases, did they attend the administration of the lethal drugs. District nurses had provided some degree of aftercare to the surviving relatives in 80.3% of 264 cases. Conclusion. Collaboration between general practitioners and district nurses needs improvement, particularly in relation to decision-making. Our Dutch data could help nurses in other countries to define their (future) role in euthanasia and physician- assisted suicide. [ABSTRACT FROM AUTHOR]

Title. Nurses’ involvement in ‘do not resuscitate’ decisions on acute elder care wards Aim. This paper reports the involvement of nurses in ‘do not resuscitate’ decision-making on acute elder care wards and their adherence to such decisions in the case of an actual cardiopulmonary arrest. Background. Previous literature showed that nurses are involved in half or less than half of ‘do not resuscitate’ decisions in hospitals, but their involvement in this decision-making on acute elder care wards in particular has not been investigated. Method. A questionnaire was sent in 2002 to the head nurses of all acute elder care wards in Flanders, Belgium ( n = 94). They were asked whether nurses had been involved in the last ‘do not resuscitate’ decision-making process on their ward and whether nurses ‘never’, ‘rarely’, ‘sometimes’, ‘often’ or ‘always’ started resuscitation in case of cardiopulmonary arrest of patients with ‘do not resuscitate’ status and of those without. Results. The response rate was 86·2% ( n = 81). In 74·7% of the last ‘do not resuscitate’ decisions on acute elder care wards in Flanders, a nurse was involved in the decision-making process. For patients with ‘do not resuscitate’ status, 54·3% of respondents reported that cardiopulmonary resuscitation was ‘never’ started on their ward, ‘rarely’ on 39·5% and ‘sometimes’ on 6·2%. For patients without ‘do not resuscitate’ status, nurses started cardiopulmonary resuscitation ‘rarely’ or ‘sometimes’ on 22·2% of all wards, and ‘often’ or ‘always’ on 77·8%. Conclusion. To make appropriate ‘do not resuscitate’ decisions and to avoid rash decision-making in cases of actual cardiopulmonary arrest, nurses should be involved early in ‘do not resuscitate’ decision-making. If institutional ‘do not resuscitate’ guidelines were to stress more clearly the important role of nurses in all kinds of end-of-life decisions, this might improve the ‘do not resuscitate’ decision-making process. [ABSTRACT FROM AUTHOR]

AIM: This paper reports an assessment of the effects of a breastfeeding journal on breastfeeding prevalence and perceptions of conflicting advice, self-management and self-efficacy. BACKGROUND: Breastfeeding prevalence rates in most developed countries are not meeting recommendations. Women's concerns about inconsistent advice, limited involvement in decision-making, accessibility of information and inappropriate follow-up have been recognized. Research on evaluation of interventions addressing these concerns and including antenatal and early postnatal periods is required. Method. An intervention study was conducted from July 2003 to April 2004, with control and intervention groups recruited sequentially. The intervention group received a breastfeeding journal at 36 weeks antenatally in breastfeeding classes that were attended at different times by intervention and control group members. The intervention and control groups were compared during postpartum hospitalization and 12 weeks for breastfeeding prevalence and perceptions of self-efficacy, conflicting advice and self-management. FINDINGS: No statistically significant differences were noted between the intervention and control groups in breastfeeding prevalence at 12 weeks or self-efficacy during hospitalization. There was a statistically significant difference between groups in conflicting advice at both times. Although conflicting advice continues to present a dilemma for women, levels of conflicting advice did not explain breastfeeding self-efficacy. Breastfeeding self-management was a statistically significant contributor to breastfeeding prevalence prior to the addition of breastfeeding self-efficacy. CONCLUSIONS: Women's perceptions of their ability to manage and be actively involved in decision-making explained breastfeeding prevalence at 12-week postpartum. Efforts to encourage women's involvement in decision-making about breastfeeding are a useful strategy to promote breastfeeding. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study to identify the extent to which community nurses incorporate patient involvement in decision-making into their everyday clinical practice. Background. The complexity underlying the concept of patient participation is not always recognized. It links the notions of ‘passive patient’ and ‘active participant’, hence its usage along with those of similar terms such as ‘partnership’, ‘involvement’ and ‘collaboration’ is often ambiguous. The literature on this subject is fairly extensive and often contradictory; it encompasses the participation of potential as well as actual patients. Hierarchical structures have been proposed to offer an understanding of the current nature of patient participation, and these have sometimes linked the level of participation to the quality of the nurse–patient relationship. Much work has been done in the area of cancer care, where it has been noted that the role of ‘passive patient’ may in itself be a deliberate choice. Methods. The approach was ethnographic and data were collected during 2000 and 2001 by participant observations with 22 nurses and 107 patients; 137 interactions were observed in all. Detailed field notes were kept and then carefully interpreted. The approach to rigour was primarily concerned with ensuring credibility. Findings. The extent to which nurses involved patients in making decisions about their care, and the manner in which this was achieved, varied considerably. Collectively, the behaviour of participants is presented as the ‘involving–non-involving continuum’, with five typologies of behaviour: ‘completely involving’; ‘partially involving’; ‘forced involving’; ‘covert non-involving’ and ‘overt non-involving’. The findings highlight that caring for people in their own home does not necessarily mean that patients are involved in care and treatment decisions. Conclusion. This observation study of the extent to which community nurses involved patients in decision-making in nursing care offers some useful insights into one aspect of nursing work. The implications of the study are far-reaching. The findings suggest that it could be important for nurses and their managers to devote more time to relationship-building in nursing practice. They also offer a perspective – the involving–non-involving continuum – that could usefully be incorporated into nurse education at both pre- and postregistration levels. [ABSTRACT FROM AUTHOR]

Aim. The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation. Background. Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process. Method. In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations. Discussion. Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level. Conclusion. Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study examining midwives’ perceptions of the way in which they diagnose labour. Background. Diagnosis of active labour is often problematic. A midwifery workforce planning tool identified that up to 30% of women admitted to United Kingdom labour wards subsequently turned out not to have been in labour. There is evidence that if a woman is admitted to a labour ward in early labour, she is more likely to have some form of medical intervention. However, despite the impact of misdiagnosis, there is little research on the process of decision-making by midwives in relation to diagnosis of labour. Methods. This was a qualitative study, employing focus group methods. Participants were a convenience sample of midwives working in a maternity unit in the North of England during 2002. They were asked to discuss their experience of admission of women in labour. Data were analysed using latent content analysis. Findings. Thirteen midwives participated in one of two groups. They described using information cues, which could be separated into two categories: those arising from the woman ( Physical signs, Distress and coping, Woman's expectations and Social factors) and those from the institution ( Midwifery care, Organizational factors and Justifying actions). Midwives’ decision-making process could be divided into two stages. The diagnostic judgement was based on the physical signs of labour: the management decision would then be made by considering the diagnostic judgement as well as cues such as how the woman was coping, her expectations and those of her family and the requirements of the institution. Conclusions. Midwives may experience more difficulty with the management decision than with the initial diagnosis. It may be that the number of inappropriate admissions to labour wards could be reduced by supporting midwives to negotiate the complex management hurdles, which accompany diagnosis of labour. [ABSTRACT FROM AUTHOR]

This paper reports on a study carried out to establish a decision tree model to describe how women in Taiwan make the decision whether or not to have a hysterectomy. In addition, we examined the predictability of the decision-tree model. Hysterectomy is the second most common surgical procedure performed worldwide. Medical professionals believe that the operation can relieve pain and prevent cervical cancer, thus improving a woman's quality of life. While most physicians advise hysterectomy even for benign uterine conditions, feminists decry the belief that the uterus has no purpose, believing that it is an important symbol of womanhood. The study was conducted in two phases. Phase I, the model development phase, was carried out to generalize data from a qualitative study of 14 women and to establish a tree model outlining their decision to proceed with hysterectomy. The second phase was the model prediction phase that applied inductive and deductive methods to data analysis and development of the decision-tree model. The model tree was then tested with 18 women who were deciding whether or not to undergo hysterectomy. Using the decision-making tree, we studied the women's thought processes and analysed their primary concerns. The study was carried out in 1999â2001. The study determined 13 criteria that Taiwanese women use when deciding about having a hysterectomy. Developed in accordance with Gladwin's methodology, the model tree successfully predicted 90% of decisions whether or not to have a hysterectomy. Nurses working in gynaecological services should understand how women decide to undergo hysterectomy so that the proper counselling and follow-up can be provided. With further testing, our decision tree may help in this process. [ABSTRACT FROM AUTHOR]

florin j., ehrenberg a. & ehnfors m. (2005) Journal of Advanced Nursing 51(2), 140–149 Patients’ and nurses’ perceptions of nursing problems in an acute care setting This paper reports a study to determine the degree of agreement or disagreement between nurses and patients in their perceptions of the presence, severity, and importance of nursing problems. Patient experiences, values and preferences are increasingly acknowledged as important factors underpinning healthcare decision-making. The ability to identify patient problems accurately is an important prerequisite for planning and implementing individualized high quality care. A convenience sample of patients ( n = 80) and Registered Nurses ( n = 30) in an acute care setting responded to a 43-item questionnaire. Nurses identified patients’ problems with a sensitivity of 0·53 and a positive predictive value of 0·50. Patients identified several severe problems that were not identified by nurses, particularly problems with nutrition, sleep, pain, and emotions/spirituality. Nurses underestimated the severity in 47% of mutually-identified problems. An overall level of agreement of 44% was found on the importance of patient problems. Low levels of agreement on severity and importance were related more to individual differences than to systematic differences. Nurses need to be more aware that patients and nurses often hold disparate views of the priorities in nursing care. To plan individualized nursing care effectively, nurses need to elicit and use individual patients’ preferences more systematically in care planning. [ABSTRACT FROM AUTHOR]

AIMS: This paper reports a study investigating new mothers' subjective norms in relation to both breast- and bottle-feeding. The influence of norms on women's infant feeding decisions and the relative influence of social referents at varying degrees of social distance were assessed. BACKGROUND: Increasing breastfeeding initiation and continuation rates is a key challenge for health educators. The perceived influence of other people's views (subjective norms), including the views of women's partners and health care professionals, is an important predictor of infant feeding behaviour. METHODS: Semi-structured questionnaires were administered to 203 new mothers in central and northern Scotland and followed-up by postal questionnaire at 6 weeks. Infant feeding intentions, feeding behaviour at birth and follow-up, behavioural beliefs and subjective norms for both breastfeeding and bottle-feeding were assessed. The data were collected in 1998-1999. RESULTS: Subjective norms were important determinants of initiation and continuation of breastfeeding for breast- and bottlefeeders. Breastfeeders rated close social referents as more in favour of bottle-feeding and more against breastfeeding at follow-up, whereas bottlefeeders' ratings did not change. Partner's and nurses'/midwives' views were an important influence at baseline and follow-up. Breastfeeding 'continuers' perceived their partners as more pro-breastfeeding at 6 weeks. Discontinuers perceived more overall social pressure to bottle-feed. However, sampling limitations may have led to over-representation of the views of breastfeeders at baseline and follow-up. CONCLUSIONS: Nurses and midwives have a crucial role in communicating positive views on breastfeeding to new mothers at different time points. Future interventions to promote breastfeeding could adopt a broad social approach, encouraging positive norms for existing and potential mothers and fathers, families and people in general. [ABSTRACT FROM AUTHOR]

AIM: This paper reports a study identifying the criteria chosen by nurses to evaluate whether to use research in practice. This work is part of a larger project on the process of research use by nurses. BACKGROUND: Prescriptive models of research utilization direct practitioners to evaluate a range of criteria to assess the fit of the research to current practice. Criteria relating to the research, task and nursing context are specified, but it is not known whether nurses use these criteria in practice. METHOD: Three different groups of nurse specialists from a number of health care providers in the North West of England were studied. The specialists were involved in a series of meetings at a local university to construct evidence-based policy recommendations for practice. The discussion was analysed to identify the evaluation criteria they used to assess what should be done in the practical setting. FINDINGS: Three sets of evaluative criteria were identified relating to the research, the task and the fit of the task with the nursing context, and included relevance and quality of the research, effectiveness, practicality, effort and the impact of the task on client and staff, feasibility and fit with the status quo, and the availability of nursing control and feedback from practice. Criteria were domain-, task- and context-specific. CONCLUSIONS: Three frames of reference for decisions relating to the use of research are identified: the debate between efficiency and effectiveness in health care, the difficulties of risk management and the responsibility for risk, and research use as a strategy for control in contested arenas. These frames of reference reflect how nurses are judged in a political and organizational context. Attempts to influence research uptake need to take into account how research is perceived and evaluated by practitioners and how it serves their purposes. [ABSTRACT FROM AUTHOR]

AIM: This paper reviews the key research literature regarding men's health-related help seeking behaviour. BACKGROUND: There is a growing body of research in the United States to suggest that men are less likely than women to seek help from health professionals for problems as diverse as depression, substance abuse, physical disabilities and stressful life events. Previous research has revealed that the principle health related issue facing men in the UK is their reluctance to seek access to health services. METHOD: The investigation of men's health-related help seeking behaviour has great potential for improving both men and women's lives and reducing national health costs through the development of responsive and effective interventions. A search of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsychINFO and the Cochrane Library databases. RESULTS: Studies comparing men and women are inadequate in explaining the processes involved in men's help seeking behaviour. However, the growing body of gender-specific studies highlights a trend of delayed help seeking when they become ill. A prominent theme among white middle class men implicates 'traditional masculine behaviour' as an explanation for delays in seeking help among men who experience illness. The reasons and processes behind this issue, however, have received limited attention. CONCLUSIONS: Principally, the role of masculine beliefs and the similarities and differences between men of differing background requires further attention, particularly given the health inequalities that exist between men of differing socio-economic status and ethnicity. Further research using heterogeneous samples is required in order to gain a greater understanding of the triggers and barriers associated with the decision making process of help seeking behaviour in men who experience illness. [ABSTRACT FROM AUTHOR]