Models, muddles and medicine

A Survey of the Health Experiences of International Business Travelers

Occupational health professionals need to know more about the health, worklife, and family life of international business travelers (IBTs). This descriptive correlational study, in two parts, examines the physiological and psychosocial experiences associated with business travel for a sample of 140 employees from western Canada's oil and gas industry. Results for Part One show that 76% of IBTs report travel related health problems, 74% have jet lag, 45% have travelers' diarrhea and gastrointestinal complaints, 12% to 16% have climate adaptation problems, and 2% report accidents and minor injuries. High risk behaviors include not carrying a first aid travel kit (54%); drinking more alcohol than ordinarily (21%); and neglecting food, water, and antimalarial precautions (6% to 14%). Other risk factors include age, length of stay, destination, pre-travel medical examinations, pre-travel advice, and eating and accommodation facilities. Findings show that IBTs are at risk for travel related physiological health problems. Implications for practitioners call for increased occupational health expertise in pre-travel preparation, follow up post-travel and regular health surveillance for employees who travel on international business.

Practice-based interprofessional education: looking into the black box

This paper reports on part of the evaluation of "The Common Learning Programme in the North East", which offered practice-based interprofessional education (IPE) to pre-qualification students. A realistic evaluation approach was used and data collection methods included interviews and observations in an attempt to look into "the black box" of practice-based IPE. The contexts of the sessions covered a number of clinical settings and involved a range of participants. Mechanisms included the content of the sessions and the procedures involved. Findings illustrate the complex and unpredictable ways in which discussions arise and evolve during IPE sessions and how interplay exists both between the contexts and the mechanisms, and between knowledge types. Issues are raised regarding the facilitation of IPE and the influence of the current evidence-based movement on research types. This study highlights the complexity and unpredictability of practice-based IPE and the usefulness of research approaches that look into the black box of educational practice.

Critical incident: a nurse's personal reflection

This thought-provoking article describes how a perioperative nurse of twenty years' experience reflected on a critical incident that happened in the hospital where she works, and what she gained from the experience. She also provides us with a survey of the literature pertaining to the processes underlying critical analysis.

Comprehensive integrated primary mental health care for South Africa. Pipedream or possibility?

While the vision for restructuring health care in South Africa is based on a comprehensive primary health care system, care at the primary level remains largely biomedical in orientation. Given this, I argue that whilst adding mental health care to primary level care may increase accessibility of psychiatric care. it will not, however, provide for comprehensive integrated primary mental health care as planned. This would require a paradigm shift towards a comprehensive discourse of care which includes mental health care. While efforts towards reorienting health care personnel in South Africa towards the primary health care approach have been initiated, an examination of the primary health care system in one sub-district in South Africa, reveals that the delivery of biomedical care is sustained by a number of factors within the primary health care system as well as within the macro-context. A shift in the paradigm of care provided would therefore require the transformation of the system on many fronts. Of central importance would be the restructuring of the primary health care system to be supportive of emotional labour, health promotion, empowerment of service users and of care which takes the subjectivity of the illness experience for the patient into account.

The lived experience of countertransference in psychiatric/mental health nurses

The purpose of this study was to evolve a structural description of nurses' experience of countertransference. The phenomenological method was chosen for the study. The sample consisted of 5 participants who met selection criteria. The participants gave audiotaped descriptions of their experiences in caring for patients for whom they experienced countertransference. The lived experience of countertransference emerged from the findings of this study as a process of the continuous growth of self-awareness. Initially, the experience entailed the struggle to abandon objectivity, emotional neutrality, and therapeutic omnipotence. It was the abandonment of these principles that enabled the nurse to begin to use the self's experienced emotions therapeutically in interactions with patients. For the participants, the feelings aroused in the self came to be understood as having meaning within the concept of countertransference and thus, came to be understood as normal responses to caregiving. It is the continuing ability of these nurses to transcend this normal, human response, and to use their growing self-awareness to provide an appropriate level of care to the patient, that is the hallmark of the lived experience.

Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.

Learning about reflection

An understanding of the nature and function of reflection in recognizing and developing nursing knowledge is a key concern. This paper describes a longitudinal study investigating the ways in which undergraduate student nurses reflected about practice as they progressed through a 3-year programme in adult nursing. The method was qualitative, with data gained from written critical incidents based on practice experiences and classroom discussions, and analysed using the constant comparative method. Findings revealed the range of issues students perceived as most important, and to some extent, changes in levels of thinking. A strong theme occurring throughout related to the complexity of learning what it means to be a professional and, in consequence, what they learn about themselves. Students' preoccupation with emotional aspects of learning and nursing care was evident. They had difficulty in disentangling 'personal' and 'professional' involvement but later data indicates that they had begun to learn to differentiate between involvement as a general characteristic of nursing practice and a overwhelming personal attachment. They generally use their own and each others' experiences to examine meaning, in preference to formal theoretical explanations although there is evidence students moved from acceptance of information to the questioning and critiquing of arguments and professional assumptions, particularly concerning their relevance and appropriateness for practice.

Countertransference in the nurse-patient relationship: a review of the literature

Countertransference is a psychoanalytical concept which, when applied to nursing, refers to the unconscious response of the nurse to the patient. Psychoanalytical concepts such as the unconscious are infrequently mentioned in the nursing literature and have received little research attention. In this paper the literature about the nurse's countertransference is reviewed. In order that the psychodynamic aspects of this phenomenon are more fully appreciated, both the concepts of the unconscious and transference are first described. The nurse's countertransference has many expressions. The literature under review has highlighted the expression of countertransference through physical symptoms, through the nurse's level of involvement with the patient and through the nurse's positive and negative descriptions of patients. The value of recognizing countertransference is universally acknowledged. It is suggested that countertransference in the nurse-patient relationship should be explored further. The knowledge provided would help provide greater insights into the nurse-patient relationship, and ultimately will be reflected in the quality of care which the patient receives.

The Roy Adaptation Model: a consideration of its properties as a conceptual framework for an intervention study

The underlying premise of this paper is the belief that one of the core values of nursing research is its ability to demonstrate that nursing interventions influence care outcomes. From this perspective the contribution offered by the Roy Adaptation Model for Nursing within an intervention study is evaluated. Although it was believed that the model enriched the study in several ways, its overall contribution was likened to a "conceptual stepping stone', used by the researcher en route back towards its underlying theories and classical intervention design methodologies.

The value of Peplau's theory for mental health nursing

Recent changes in mental health care have necessitated reevaluation of Peplau's nursing theory. There is an expanding body of nursing knowledge and a debate is taking place regarding the difference between models and theories. Peplau's theory considers nursing as an interpersonal process between nurse and patient. The theory lacks empirical investigation and is not yet tested regarding the multidisciplinary team approach, which is largely based on the medical model. For the theory to gain credibility within the dynamics of the multidisciplinary team, it must be tested within a framework of robust research design involving various diagnostic groups and practice settings. Until such time, the theory's utility must seriously be questioned within contemporary mental health practice.

The social body and the biomechanical body: can they coexist in nurse education?

The curricula of tertiary nursing courses usually involve a number of complementary strands. These include biological sciences, social sciences, behavioural sciences, other support subjects and clinical units. These different strands each, to some extent, present the nursing student with a dilemma as they may present entirely different models of the body. Explorations of this dilemma show that students are also being presented with different models of illness and different conceptions of appropriate health care response to illness. The question is then raised as to which of these approaches most accurately reflects the realities of nursing practice.

Nurses, doctors and the body of the patient: medical dominance revisited

Medical dominance is one of the most obvious features of the health care system and is particularly apparent in the relationship between doctors and nurses. Reasons given for the subordination of nurses to doctors have included matters of gender, class and state patronage of medicine. This paper, through an examination of university curricula and journal content, explores the notion that control over the model of the body is a major way in which medicine preserves its dominance over nursing. One reason for medicine maintaining its superior position is that nursing is not challenging this model of the body.

Measuring constructs accurately: a prerequisite to theory testing

Accurate identification and measurement of constructs is particularly relevant to mental health nurses, who often have to work with clients that have intangible needs and problems. In this paper, the measurement of constructs, the relevance of construct validity to nursing research and, in particular, to theory testing will be discussed. Constructs within the health belief model are used to illustrate the discussion and procedure of factor analysis. Analysis of data based on a survey of health beliefs of 276 adults with the chronic condition of insulin-dependent diabetes is presented, interpreted and discussed. Whilst the paper focuses upon specific constructs and study population in order to provide a worked example, the issues raised and principles outlined relate to an analytical model that can be applied to other research problems and settings.

The impact of the medical model on nursing practice and assessment

In its extreme form, the medical model with its concerns of diagnosis, treatment and cure, has been criticized for the narrow and unsatisfactory view it takes of health care. Proponents of nursing theory, in contrast, attempt to develop a conceptual structure which offers a more humanistic approach to patient care, where nurses attempt to move beyond the influences of medical values in the way that they work. This study indicates, however, that the medical model is occasionally compatible with nurses' values, and in certain settings can enhance and support nursing care. In other settings, however, the medical model, although in accord with nursing values, has little to offer practice, and indeed may have a negative effect on the development of alternative approaches to care.

Nursing's syntax revisited: a critique of philosophies said to influence nursing theories

Lodged within the syntax of a discipline are the value systems and research constraints that influence theory development and research strategies. Humanism and postmodern philosophy have challenged natural science philosophical influences on nursing's syntax. This paper examines the construction of nursing's syntax from empiricist, hermeneuticist, feminist, and critical social theory views. In this critique, two requirements are placed on the world views: (1) they must accommodate theoretical (realist) terms important to nursing; and (2) they should provide explanatory power for these terms within nursing's disciplinary substance. Arguments are continued for a "within-the discipline" structure, a substantive and syntactical structure for the discipline of nursing that recognizes the centrality of biobehavioral processes in the practice of nursing [Gortner, IMAGE: J. Nurs. Scholarship 22, 101-105 (1990)].

Nurses' assessment of elderly patients in hospital

Nurses' assessment of patients' mobility in hospital provided the focus for an inductive qualitative study which examined how an everyday aspect of nursing practice was carried out. The study described assessment practices in both long-term care and acute care wards for elderly patients as a situated activity. Interviews with nurses, as well as observation of their activities and records, resulted in explanations of their behaviour as deriving from their conceptions of ward functions. These conceptions arose from their adoption of the values of cure and discharge and so, in the different types of ward, assessment held different meanings and was carried out in different ways. The findings have implications for nursing practice in different settings but also for the care of elderly and chronically ill patients, where cure is an inappropriate end goal of care. This example of developing explanatory theory inductively also has implications for the development of mid-range nursing theory and suggestions are made for its extension.