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This article explores the spiritual pain that patients may experience, which is often hidden or overlooked in healthcare settings that tend to focus on managing physical manifestations of pain. As part of their role in responding to patients' needs, nurses need to be willing to engage with spirituality, which is an important aspect of many people's lives. This article examines the meaning of spirituality and how spirituality may - or may not - relate to religious beliefs. It describes a whole-person approach to understanding the physical, social, emotional and spiritual dimensions of pain, and how this may assist nurses in recognising and addressing patients' spiritual needs. The article also explores attributes, skills and resources that can support nurses in responding to spiritual pain, including a caring presence, courage, compassion, and respect for other people's beliefs and values., Competing Interests: None declared, (© 2020 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

This article explores the concept of leadership in health and social care. All nurses have an important leadership role, which is reflected in the principles of the NHS Leadership Academy and in the new curriculum for nursing students. By critically applying the 'novice to expert' model of clinical competence to leadership, nurses are encouraged to consider the skills involved in moving from novice to expert alongside identifying the strengths and skills they wish to develop. Nurses are encouraged to reflect on leadership approaches operating in health and social care and to consider the type of leader they want to be. This article examines what expert or exemplary leadership might involve and some of the characteristics that are required. An expert leader can recognise their own values and beliefs, and the values and beliefs of those they lead and serve., Competing Interests: None declared, (© 2020 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

The central purpose of scientific research and emerging dental health technologies is to improve care for patients and achieve health equity. The Impact of Scientific Technologies and Discoveries on Oral Health Globally workshop conducted joint American Dental Education Association (ADEA) and the Association for Dental Education in Europe (ADEE) 2019 conference, Shaping the Future of Dental Education III, highlighted innovative technologies and scientific discoveries to support personalized dental care in an academic and clinical setting. The 2019 workshop built upon the new ideas and way forward identified in the 2017 ADEE-ADEA joint American Dental Education Association (ADEA) and the Association for Dental Education in Europe (ADEE) 2019 conference, Shaping the Future of Dental Education II held in London. During the most recent workshop the approach was to explore the "Teaching Clinic of the Future". Participants applied ideas proposed by keynote speakers, Dr. Walji and Dr. Vervoorn to educational models (Logic Model) in an ideal dental education setting. It is only through this continuous improvement of our use of scientific and technological advances that dental education will be able to convey to students the cognitive skills required to continually adapt to the changes that will affect them and consequently their patients throughout their career. This workshop was a valuable experience for highlighting opportunities and challenges for all stakeholders when aiming to incorporate new technologies to facilitate patient care and students' education., (© 2020 John Wiley & Sons A/S and American Dental Education Association. All rights reserved.)

The aim of this study was to develop and test a scoring system to assess the learning progression of novice dental students using haptic virtual workstations. For the study, 101 first-year dental students at a UK dental school conducted one practice task (task 1) and four simulated cavity removal tasks (tasks 2-5) of increasing difficulty over two laboratory sessions in 2015. Performance data on the students' attempts were recorded as haptic technology-enhanced learning (hapTEL) log-files showing the percentage of caries, healthy tissue, and pulp removed. On-screen results were photographed and submitted by the students to the tutors. A scoring system named the Accuracy of Caries Excavation (ACE) score was devised to score these results and achieve an even distribution of scores and a calculated combined score. A total of 127 individual logged attempts by 80% of the students over sessions 1 and 2 were recorded and submitted to the tutors. The mean ACE scores for both sessions for tasks 2 through 5 were 9.2, 11.6, 6.4, and 4.9, respectively; for Session 2 (tasks 3-5), scores were 12.4, 6.7, and 5.0, respectively (p<0.001). The average performance on task 3, which was attempted in similar numbers during both sessions, improved from the first to the second session (8.14 vs. 12.38; p=0.009). Using the HapTEL system in a first-year BDS curriculum improved the students' performance of simulated cavity preparation after practicing over two sessions. Use of the ACE scoring system enabled tutors to make consistent assessments across a large student cohort and provided an objective method of formative assessment.

This article encourages nurses to explore the concept of leadership in the constantly changing field of health and social care. All nurses have an important role in leadership, and they should consider what type of leader they want to be and what leadership skills they might wish to develop. This article examines what leadership might involve, exploring various leadership styles and characteristics and how these could be applied in nurses' practice. A core component of nursing and nursing leadership is the ability to provide compassionate care. This could correspond with the idea of servant leadership, an approach that moves the leader from a position of power to serving the team and supporting individuals to develop their potential., Competing Interests: None declared, (©2017 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Heart rate variability (HRV) and baroreceptor sensitivity (BRS) quantify autonomic variability in heart pacing and the autonomic response to blood pressure changes respectively. By necessity, the signals used to calculate HRV and BRS (systolic blood pressure (SBP) and RR interval) have one data point every cardiac cycle. Due to inherent variability in heart rate, these are non-uniformly sampled data. A number of calculation methods exist that adjust for non-uniform sampled signals. This study compared frequency domain methods of HRV and BRS calculation to ascertain whether more complex methods resulted in different results to simpler methods. Wistar rats (n=10), and rats with induced diabetes (n=8) were anesthetized and SBP and RR interval measured for a period of approximately 5 minutes. This data were analyzed using the sequence technique (for BRS), fast Fourier transform (FFT), non-uniform discrete Fourier transform (NDFT) and an extended Lomb-Scargle Periodogram (LSP). There were small but significant differences in NDFT from LSP technique for both BRS in the low frequency range (p=0.005) and HRV in the high frequency range (p=0.001). The NDFT technique was also significantly different to FFT technique for BRS in the low frequency range (p=0.023). All other methods were not statistically different. However, all techniques showed the same results comparing diabetic to control rats. This study shows more complex methods that correct for the non-uniformity of the sampling have significant differences but those differences are small to the point of not altering findings associated with HRV or BRS.

Nursing is a wonderful profession filled with opportunity, but one that remains grounded in care and clinical practice.

The aims of excellent end of life care (EOLC) and nursing are at the heart of healthcare. Chelsea and Westminster Hospital NHS Foundation Trust, a multi-site London teaching care provider, recognises and values the importance of good EOLC, and the quality of EOLC is used as one of the key metrics in assessing the quality of patient and family care across the trust. The principles of EOLC, including those enshrined in the Gold Standards Framework (GSF), are closely aligned with the trust's core values. Each member of staff is encouraged and supported, through the GSF process, to recognise and respond as befits their role in implementing the principles of EOLC, agreed by staff, and by patients and their relatives. This article describes the experience of, and collaboration between, trust staff and members of the GSF team, who have worked together for the past 18 months, and how this work has placed EOLC at the heart of patient care and staff recruitment. This collaboration has helped to enrich the culture of compassion and care that the trust aims to deliver, and to focus on providing person-centred care.

Aim To develop, implement and evaluate a collaborative intervention in care homes seeking to increase the confidence and competence of staff in end of life care and enable more people to receive end of life care in their usual place of residence. Method A two-phase exploratory mixed methods design was used, evaluating the effect of an end of life care toolkit and associated training in care homes, facilitated by a specialist palliative care team. Six care homes in England were recruited to the intervention; 24 staff participated in discussion groups; 54 staff attended at least one training session; and pre- and post-intervention questionnaires were completed by 78 and 103 staff respectively. Results Staff confidence in receiving emotional and clinical support and managing end of life care symptoms increased post-intervention, but confidence in discussing death and dying with residents and relatives decreased. Audit data indicate greater reduction in the number of residents from participating care homes dying in hospital than those from comparison homes. Conclusion Collaborative end of life care interventions support care home staff to manage end of life and may enable residents to have choice about their place of death.

Background: Oesophageal strictures can be caused by benign or malignant processes. Up to 10% of patients with a benign stricture are refractory to pneumatic dilatation and may benefit from biodegradable stent (BD) insertion. Biodegradable stents also have a role in malignant oesophageal strictures to facilitate enteral nutrition while staging or neo-adjuvant treatment is completed. The aim of this study was to review the safety and efficacy of BD stents in the management of benign or malignant oesophageal strictures., Methods: A single centre retrospective cohort study was performed. Dysphagia was graded before and after stenting using a validated score. All patients were followed up for at least 30 days and all adverse events were recorded., Results: Twenty eight stents were inserted in 20 patients; 11 for malignant and 17 for benign disease. One further attempted stenting was impossible due to a high benign stricture. There were no perforations and the 30-day mortality rate was zero. Mean dysphagia scores improved from 2.65 to 1.00 (p value <0.001) in benign disease and from 3.27 to 1.36 (p value <0.001) in patients with malignant disease. Surgical resection was not compromised following stent insertion in the malignant group., Conclusions: Biodegradable stent insertion is a safe and efficacious adjunct in the treatment of benign and malignant oesophageal strictures. In malignant disease, BD stent insertion can maintain enteral nutrition while staging or neo-adjuvant therapy is completed without adversely impacting on surgical resection., (Copyright © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

'To find grace, watch a 16-year-old carer feed an 85-year-old woman with severe dementia, but pass by those in the office writing care plans' ( Barritt 2005 ).

Purpose: Hematology-oncology patients undergoing chemotherapy and hematopoietic stem cell transplantation (HSCT) recipients are at risk for oral complications which may cause significant morbidity and a potential risk of mortality. This emphasizes the importance of basic oral care prior to, during and following chemotherapy/HSCT. While scientific evidence is available to support some of the clinical practices used to manage the oral complications, expert opinion is needed to shape the current optimal protocols., Methods: This position paper was developed by members of the Oral Care Study Group, Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT) in attempt to provide guidance to the health care providers managing these patient populations., Results: The protocol on basic oral care outlined in this position paper is presented based on the following principles: prevention of infections, pain control, maintaining oral function, the interplay with managing oral complications of cancer treatment and improving quality of life., Conclusion: Using these fundamental elements, we developed a protocol to assist the health care provider and present a practical approach for basic oral care. Research is warranted to provide robust scientific evidence and to enhance this clinical protocol.

Abstract Spirituality affects us all, although it takes many different forms. The spiritual needs of patients and families may not always be obvious to health professionals and this module will consider the theoretical and practical skills required to address them.

Purpose: The Prospective Oral Mucositis Audit assessed the incidence, duration, and determinants of severe oral mucositis (OM; WHO oral toxicity scale grades 3 to 4) in patients with multiple myeloma (MM) or non-Hodgkin's lymphoma (NHL) receiving high-dose conditioning chemotherapy before autologous stem-cell transplantation., Patients and Methods: Patients with MM (n = 109; mean age, 57 +/- 8 years) or NHL (n = 88; mean age, 50 +/- 13 years) were treated with high-dose melphalan (200 mg/m(2)) or carmustine 300 mg/m(2), etoposide 800 mg/m(2), cytarabine 800 to 1,600 mg/m(2), and melphalan 140 mg/m(2) chemotherapy, respectively, in 25 European centers. OM assessments were made daily until 30 days after transplantation or hospital discharge. High quality of OM assessment was ensured by an intensive training program., Results: Severe OM occurred in 46% (95% CI, 36% to 56%) of patients with MM and 42% (95% CI, 32% to 53%) of patients with NHL, with a mean duration of 5.3 days (95% CI, 4.4 to 6.1 days) and 5.5 days (95% CI, 4.5 to 6.7 days), respectively. Time from start of conditioning to peak OM score was 12.1 +/- 2.6 and 14.6 +/- 2.4 days. Severe OM risk and/or duration was significantly associated with higher chemotherapy dose per kilogram of body weight and poor performance status, but in contrast with some previous reports, this was not related to age., Conclusion: Severe OM is more common in the transplantation setting than previously reported, justifying effective preventative and therapeutic measures.

Oral mucositis (OM) is a serious consequence of some chemotherapy and radiotherapy regimens. A number of reliable instruments are available to assess OM, but none are universally accepted. A unique collaboration of multi-disciplinary experts from Europe was formed to make recommendations on OM assessment, based on a systematic literature review and the experts' experience. The main recommendations are listed. There should be a comprehensive baseline assessment. OM should be frequently assessed using a standardised instrument, or a combination of instruments. Physical, functional and subjective changes should be measured. Subjective measures should be assessed prior to any physical examination. The use of pain scoring, in particular patient self-reporting, should form part of any OM assessment. Any assessment instrument should be validated, easy to use and comfortable for the patient. Training of, and monitoring in, the use of the instrument is vital to successful monitoring of OM.

Oral mucositis (OM), which occurs in many patients with hematologic malignancies treated with high-dose therapy and stem cell transplantation, is associated with substantial clinical, economic, and quality-of-life (QOL) consequences. It has been associated with an increased need for total parenteral nutrition and opioid analgesics, prolonged hospital stays, and increased risk of infection. The research subgroup of the European Group for Blood and Marrow Transplantation Nurses Group surveyed nurses at transplantation centres for their thoughts about the clinical, QOL, and economic consequences of OM; tools for assessing OM; strategies for preventing and treating OM; and the need for the development and implementation of treatment guidelines. The responses from 46 centres, in 16 countries, indicated that most nurses (91%) believe OM has a large effect on patients' QOL. Nurses are not highly satisfied with current treatments for OM, but they believe the discomfort is reduced with oral care protocols and mouthwashes. Oral mucositis is routinely and frequently assessed, however there are inconsistencies in how it is managed. Most centres used unpublished, centre-specific guidelines, and the survey found that most nurses agreed that published national guidelines would be valuable for standardising the assessment and management of OM.

Oral mucositis (OM) has substantial negative clinical, quality-of-life, and economic consequences for patients with haematologic malignancies who require myeloablative chemotherapy or radiotherapy. Uniform training in OM assessment is infrequent in clinical practice, so the true incidence and duration of OM are unknown. Nurses and physicians from the European Group for Blood and Marrow Transplantation recently undertook an audit of 214 patients (197 evaluable patients) treated at 25 centres, the Prospective Oral Mucositis Audit (POMA), to determine the incidence, severity, and duration of OM. To standardise the assessment of OM severity, the World Health Organization (WHO) Oral Toxicity Scale was used across centres. This article focuses on the quality control analyses that were conducted to ensure that OM was accurately assessed across all 25 centres. Twenty-two trainers, who received comprehensive training about POMA study design, pathobiology of OM, and endpoint assessment, educated staff at the 25 transplantation centres about OM assessment. The trained staff collected data by completing daily worksheets for each patient. Three quality control analyses, of 82, 1949, and 4111 worksheets respectively, showed a nurse assessment accuracy rate of 74%, 90%, and 90%. The most common errors were in assigning WHO grade 0 or 1. This analysis shows that training of nursing staff had a positive effect on assessment of OM severity, which should ultimately lead to improvement in the quality of supportive care.

This presentation begins to discuss the findings of an ongoing doctoral study that arose as the result of clinical experience, previous studies and ongoing reflection. Building on the work of Frankl this study explores the search for meaning in the context of living with cancer. In this study people with cancer share their experience of trying to make sense of their disease and the treatments they underwent. Some of the findings that have begun to emerge include: the search for meaning is ongoing, multifaceted and may be lived out in a variety of ways, living with cancer and the treatment it demands brings many changes some of which lead to a sense of loss of control, there are a multitude of relationships involved which may help or cause distress to the person dealing with cancer, the health care team while often supportive sometimes failed to see the needs of those they cared for, while people with cancer value the expertise and knowledge of the health care team they also want the team to demonstrate compassion and sensitivity while delivering care and information, while a few people had found particular meaning to aspects of their experience all recognized that the ongoing process of searching to find meaning continues after treatment finishes. It is hoped that by listening to the experiences of these individual people living with cancer the insights gained will support the health care team in their efforts to help those undergoing treatment for cancer.

This article presents the findings from an interpretive phenomenology study looking at nurses' experiences of supporting cancer patients in their search for meaning. Eleven nurses were interviewed from a Medical Oncology Unit and a Bone Marrow Transplant Unit in a central London teaching hospital. Having analysed the interviews, six major themes were identified: the value of experience, understanding the search for meaning, the value of time, the relationships involved, caring and the skills used by nurses, and the difficulties nurses' experienced and the support they needed to continue this role. Like many aspects of nursing care that are intangible in nature, this aspect of care was seen as important and valuable to the nurses in the clinical environments of cancer care. The findings do not represent a definitive approach to this aspect of care, but offer an insight into nurses' experiences. In order to continue this aspect of cancer care, the findings suggest that nurses need support.

Two studies investigating nurses' involvement in supporting cancer patients with sexuality and fertility concerns were carried out after listening to the experiences of patients living with cancer. Findings from the studies revealed that while nurses recognised their role in supporting patients with sexual and fertility concerns, they avoided the subject, citing reasons such as lack of knowledge, experience and resources. The findings of one of the studies are reported here, together with the subsequent clinical practice developments that were initiated.