Understanding nurses' communication with patients in accident & emergency departments using a symbolic interactionist perspective

Barriers encountered by nurses in the care of walk-in international patients in an emergency department in Japan

BACKGROUND

An increasing number of international patients continue to visit emergency departments (EDs) in Japanese hospitals. However, nurses in Japan perceive challenges when caring for patients from other countries. This study explored ED nurses' perceptions of barriers when caring for walk-in international patients.

METHODS

Five semi-structured online focus group interviews involving 15 registered nurses with experience in caring for patients in an ED at a university referral hospital located in the center of Tokyo were conducted. Thematic analysis was used to identify patterns from the interviews.

RESULTS

The themes that emerged were as follows: (1) hesitation to engage with patients due to ambiguity, (2) loss of harmony in the ED, (3) difficulty with mutual goal settings, and (4) decreased professional self-efficacy.

CONCLUSION

The findings provide an understanding of the challenges faced when caring for walk-in international patients. Educational interventions for ED nurses and other strategies, such as the use of interpreters, can enhance nurses' abilities to improve patient safety and maintain equality.

Emergency Room Nurses’ Experiences in Person-Centred Care

Implementing person-centred care is often considered difficult in congested emergency rooms. The purpose of this study was to understand person-centred care experienced by emergency room nurses in depth and examine the essence of emergency room nurses’ lived experience of the person- centred care. Eight nurses working in the emergency room of a large hospital in South Korea and who had over six months of experience were surveyed via semi-structured interviews in February 2019. The data were transcribed and analysed using Colaizzi’s framework. The major findings related to person-centred care experiences among emergency room nurses were: (1) feeling distanced from patients; (2) guilt and frustration; (3) accepting patients’ symptoms and emotions as they are; (4) person-centred care as a domain of nursing that cannot be replaced by machines; and (5) nursing as an art wherein the minutest details make a difference. Providing person-centred practice in the emergency room is difficult, but it will not only improve the quality of patient care but also increase the job satisfaction of nurses. Based on an in-depth understanding of person-centred care experienced by emergency nurses, it will contribute to enhancing the quality of nursing care in the emergency room.

Humanitarian nursing with Médecins Sans Frontières: Foregrounding the listening guide as a method for analysing oral history data

AIMS

To demonstrate how the listening guide contributed to oral history data analysis. To better understand the continuing inclination of nurses to engage in humanitarian work, foregrounding the nurses' lives.

BACKGROUND

The voice-centred relational method or listening guide is a method of qualitative data analysis used to analyse oral history data.

DESIGN

A conventional approach to oral history interviews was adopted; intervention into the "flow" of participants' narrative was kept to a minimum. A small number of prompts, how they came into nursing, recruitment to, life with and since Médecins Sans Frontières, were used.

METHODS

Oral history interviews were conducted with seven nurses who had worked for Médecins Sans Frontières. Interviews were digitally recorded. This paper will demonstrate the application of the listening guide to historical data analysis and critique its applicability and value. The listening guide advocates four readings (listenings) of the text. Firstly, locating the plot in the narrative; secondly, actively listening for the use of "I?" ("we", or "you"), the "self" in context of the story being told and "I poem" development; thirdly, listening for relationships and finally, locating accounts in relation to wider social, political and societal contexts.

RESULTS

Analysis revealed: "becoming", "being" and "leaving" Médecins Sans Frontières as chronological thematic areas. At one extreme creating "I poems" foregrounded individual voices while cross-referencing to contemporaneous records of world events locates this in an International context.

CONCLUSION

It is argued that subjecting historical data to the listening guide can enable legitimate, creative exploration and analysis of data.

Nurses' Attitude toward Alcoholic Patients in Accident and Emergency Department in Hong Kong

Few studies on the attitude of nurses toward alcoholic patients have been conducted in Hong Kong. The aim of this study was to understand the attitude of nurses toward alcoholic patients in local Accident and Emergency Departments (AEDs). Alcoholism is a stigmatized ‘disease’. Some studies revealed that nurses tended to have negative attitudes toward people with alcoholic problems. This can influence the quality of healthcare provided to this group of patients. As a result, alcoholic patients may not be properly treated. The researchers of this study employed a cross-sectional survey to gather data from the targeted sample. The Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) was used to evaluate the attitudes of nurses toward alcoholic patients. In addition, relationships between therapeutic attitude toward alcoholic patients and various independent variables (including experience in specialty, education related to alcohol and alcoholic problems, the degree of support received from co-workers, and self-esteem of individuals) were analyzed. Six hundred nursing staff, including registered nurses, enrolled nurses and nursing officers working in AED, were invited to participate in the study. One hundred and ninety (31.6%) of them responded. The findings showed that nurses working in AEDs tended to have negative attitudes toward alcoholic patients. Most of those surveyed got low scores in role security, which indicated they perceived themselves inadequate in both skills and knowledge relating to problem drinkers. The findings also reflected that the degree of support received and self-esteem correlated with the overall attitude toward alcoholic patients. To conclude, providing more support and training opportunities to nursing staff are conducive to more positive attitude of nurses toward alcoholic patients.

Hospital staff experiences of their relationships with adults who self-harm: A meta-synthesis

PURPOSE

This review aimed to synthesize qualitative literature exploring inpatient hospital staff experiences of their relationships with people who self-harm.

METHODS

Nine studies were identified from a systematic search of five research databases. Papers included the experiences of physical health and mental health staff working in inpatient settings. The studies employed various qualitative research methods and were appraised using an adapted quality assessment tool (Tong, Sainsbury, & Craig, 2007). A meta-synthesis was conducted using traditional qualitative analysis methods including coding and categorizing data into themes.

RESULTS

Three main themes derived from the data. 'The impact of the system' influenced the extent to which staff were 'Fearing the harm from self-harm', or were 'Working alongside the whole person'. A fear-based relationship occurred across mental health and physical health settings despite differences in training; however, 'Working alongside the whole person' primarily emerged from mental health staff experiences. Systemic factors provided either an inhibitory or facilitative influence on the relational process.

CONCLUSIONS

Staff experiences of their relationship with people who self-harm were highlighted to have an important impact on the delivery and outcome of care. Increasing support for staff with a focus on distress tolerance, managing relational issues, and developing self-awareness within the relationship may lead to a more mutually beneficial experience of care. Equally, structure, clarity, and support within inpatient systems may empower staff to feel more confident in utilizing their existing skills.

PRACTITIONER POINTS

Working with people who self-harm can be emotionally challenging and how staff cope with this can significantly impact on the engagement of staff and patients. Increasing the skills of staff in managing relational issues and tolerating distress, as well as providing support and reflective practice groups may be useful in managing emotional responses to working with people who self-harm. Refining the supportive, procedural, and environmental structures surrounding the caregiving relationship may help enable better integration of physical and mental health care.

Exploring Nurse's Communicative Role in Nurse-Patient Relations: A Qualitative Study

Introduction: Recognition the nurses’ communicative roles can influence quality of patient’s care. Therefore, this study was aimed to explore nurse’s role in nurse-patient relations.

Methods: This study was a qualitative research in which collected data was analyzed by content analysis method. The participants were 23 nurses, patients and their families in medical and surgical wards of a referral hospital in Tehran, Iran. Data were collected by semi-structured interview and observation.

Results: Data analysis was led to the emergence of a main conceptual category: The patient's need-based communication. This category was derived from two categories: 1) Identifying the patient’s needs; and 2) Communicative behavior in the face of the patient’s needs. "Identifying the patient’s needs" was related to "type of the patient’s problem", "patients’ inquiring about their health status" and "monitoring the patient’s health status". "Communicative behavior in the face of the patient’s needs" was composed of four subcategories: "caring attention", "informal education of the patient", "inducing calmness to the patient", and "obtaining the trust of the patient".

Conclusion: The nurse’s role in relationship with patients is designed according to patients’ needs. Therefore, if the patients’ needs in clinical settings are defined and clarified appropriately, the nurse-patient relations will be enhanced and thereby the quality of care will be improved.

"Let's Sit Forward": Investigating Interprofessional Communication, Collaboration, Professional Roles, and Physical Space at EmergiCare

Communication is key to hospital emergency department (ED) caregiving. Interventions in ED processes (and health care organizing in general) have struggled when they have ignored the professional role expectations that enable and constrain providers with patients and each other. Informed by a communication as design (CAD) approach, this study explored the intersections of professional roles, physical space, and communication at EmergiCare-an academic medical center and level-1 trauma center hospital. Based on an ethnographic analysis of field notes from 70 hours of shadowing at the EmergiCare ED, this study identified two specific communication patterns, "case talk" and "comfort talk," that reflect different logics for communication in health care organizing. The findings indicate (a) that case and comfort talk have different status and therefore different influence in EmergiCare ED interprofessional communication and (b) that the arrangement of physical space at EmergiCare ED reflects the requirements of case talk more so than comfort talk. These findings have important implications for theory and practice, including the importance of considering the macro-discursive construction of professional roles reified in the arrangement of work space.

Factors Involved in Iranian Women Heads of Household's Health Promotion Activities: A Grounded Theory Study

We aimed to explore and describe the factors involved in Iranian women heads of household’s health promotion activities. Grounded theory was used as the method. Sixteen women heads of household were recruited. Data were generated by semi structured interviews. Our findings indicated that remainder of resources (money, time and energy) alongside perceived severity of health risk were two main factors whereas women’s personal and socio-economic characteristics were two contextual factors involved in these women's health promotion activities. To help these women improve their health status, we recommended that the government, non-governmental organizations and health care professionals provide them with required resources and increase their knowledge by holding training sessions.

Survivors' experiences of media coverage after traumatic injury events

Survivors' experiences of media at traumatic events, is still a limited research area. The aim of this study is to explore survivors' experiences of interacting with journalists and media coverage, including their experiences of being portrayed in the media, following two Swedish train crashes. Qualitative interviews were conducted with passengers from two train crashes in Sweden. A qualitative content analysis generated meaning units, subcategories, and categories. Survivors experienced interacting with journalists mainly in three ways: harmful, inconsequential, and helpful. Media content and personal media exposure was experienced in a similar way: uncomfortable, insignificant, and useful. Journalists and media coverage have a large impact on survivors' experiences following a traumatic event. It is important that emergency responders, such as ambulance nurses, are aware of how victims are affected by journalists' presence and the media coverage that follows so that negative outcomes can be reduced and the positive can be enhanced. The present study also shows that media coverage in the long term can become important pieces of information for the victim in order to understand and process the traumatic event.

Precepting and symbolic interactionism--a theoretical look at preceptorship during clinical practice

AIM

To present a discussion of precepting through the use of symbolic interactionism as exemplified by findings from an ethnographic study.

BACKGROUND

It is a well-known fact that clinical practice, where students are supervised by precepting nurses, is an important part of nursing education. Several previous studies have stressed the vital role preceptors have for the development of student nurses' clinical competence. Despite this, few of these findings are discussed from a theoretical standpoint to further explain and illustrate the complexity of preceptorship.

DATA SOURCES

This article builds on findings from an ethnographic study undertaken between November 2006-May 2007 and again between March-September 2009. Full details of the empirical findings have been reported elsewhere.

DISCUSSION

Precepting can be understood as a trusting relationship between preceptor and student interacting and sharing nursing activities. The participants' actions will influence and shape the meaning and understanding of these activities.

IMPLICATIONS FOR NURSING

Precepting is a complex and advanced role for nurses that they need to be properly prepared for. Thus, preceptor preparation needs to be organized in collaboration between healthcare organizations and universities. It is suggested that preceptor preparation programmes should focus on reflection, critical thinking and communication skills.

CONCLUSION

Symbolic interactionism can serve as a potential theory that will expand the understanding of and give new perspectives of nursing practice. It would therefore be encouraging to see further testing of suitable theories to interpret empirical findings and create opportunities for practice improvement.

Experience of being a low priority patient during waiting time at an emergency department

BACKGROUND

Work in the emergency department is characterized by fast and efficient medical efforts to save lives, but can also involve a long waiting time for patients. Patients are given a priority rating upon their arrival in the clinic based on the seriousness of their problem, and nursing care for lower priority patients is given a lower prioritization. Regardless of their medical prioritization, all patients have a right to expect good nursing care while they are waiting. The purpose of this study was to illustrate the experience of the low prioritized patient during their waiting time in the emergency department.

METHODS

A phenomenological hermeneutic research method was used to analyze an interview transcript. Data collection consisted of narrative interviews. The interviewees were 14 patients who had waited more than three hours for surgical, orthopedic, or other medical care.

RESULTS

The findings resulted in four different themes, ie, being dependent on care, being exposed, being vulnerable, and being secure. Lower priority patients are not paid as much attention by nursing staff. Patients reported feeling powerless, insulted, and humiliated when their care was delayed without their understanding what was happening to them. Not understanding results in exposure that violates self-esteem.

CONCLUSION

The goal of the health care provider must be to minimize and prevent suffering, prevent feelings of vulnerability, and to create conditions for optimal patient well being.

Blending practice development methods with social science research: an example of pushing new practice research boundaries

Innovating research methods to better suit clinical contexts and practice puzzles is key to the advancement of practice. To illustrate a mechanism by which this development can be achieved the authors offer a research narrative which is revealing of their thinking, methodological positioning and research activities as they sought to innovate a research design to suit the clinical issues, puzzle and research context. The trigger for this innovative research design was the opportunity provided by a short timeframe and small amount of research funding to work with a health board clinical puzzle to explore presentations of older people to emergency departments in relation to those could be avoided, and by implication consider how better ways of caring for older people could be devised. In the example provided, the authors reveal how they blended practice development methods with collaborative action research to develop a reconnaissance study. The findings and outcomes of the study are affirming of the approach, methodological strategy and use of practice development methods to support engagement and puzzling as methods which support reconnaissance in relation to a complex clinical scenario such as ‘avoidable’/‘inappropriate’ presentation of older persons in the emergency department.

Care planning in the emergency department

There are many demands placed on staff working in emergency departments such as the currently witnessed overcrowding, bed shortages and long waiting times for patients. Despite these demands nursing care needs to be carefully assessed, planned and documented. This study aimed to examine attitudes of staff towards the use of a nursing care plan in the emergency department. The sample comprised the total population (n=38) of all nursing staff working in an emergency department at one regional general hospital in the Republic of Ireland. The method adopted was a survey approach which employed the use of standardised questionnaires comprising both open and closed questioning styles. Raw statistical data were analysed using SPSS for Windows while the qualitative data arising from the open-ended questions were manually analysed for themes. The data obtained in this study identified that care plans were valued by respondents, stating that they contribute to holism, increased nurse/patient contact time and better communication. The findings also identified that there is a need for continuing education, further research and a need to address issues in relation to specific patient groups, including paediatrics, minor injuries, mental health and the elderly attending the emergency department.

Analysis of accident and emergency doctors' responses to treating people who self-harm

Self-harm is a prevalent phenomenon regularly faced by doctors and nurses working in accident and emergency (A&E) departments. We argue that the treatment decisions A&E doctors make are fundamental to decreasing the high risk of suicide among this group. In this article we present a qualitative study exploring how doctors working in A&E respond to treating people who self-harm. In total, five A&E doctors were interviewed and the data were analyzed using interpretative phenomenological analysis. Three main themes were extracted: treating the body, silencing the self, and mirroring cultural and societal responses to self-harm. Within these themes, we identified both facilitative and unhelpful aspects of the relationships between people who self-harm and A&E doctors. We consider the clinical implications of these findings within the context of A&E doctors having limited opportunities to address the relational nature of the care they offer to this group.

Generic qualitative research: a design for qualitative research in emergency care?

The frequency of qualitative studies in the Emergency Medicine Journal, while still low, has increased over the last few years. All take a generic approach and rarely conform to established qualitative approaches such as phenomenology, ethnography and grounded theory. This generic approach is no doubt selected for pragmatic reasons but can be weakened by a lack of rigor and understanding of qualitative research. This paper explores qualitative approaches and then focuses on "best practice" for generic qualitative research.

Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma

STUDY OBJECTIVE

We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change.

METHODS

This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes.

RESULTS

At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED.

CONCLUSION

Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.

The challenges for nurses communicating with and gaining valid consent from adults with intellectual disabilities within the accident and emergency care service

AIM

This paper reports the challenges experienced by nurses within accident and emergency departments in communicating with and gaining valid consent from adults with intellectual disabilities.

BACKGROUND

Consent is both a legal requirement and an ethical principle required to be obtained by health-care professionals, prior to the start of any examination, treatment and/or care. Central to the process of seeking consent is effective communication. However, evidence shows that people with intellectual disabilities are not viewed by professionals within acute general hospitals as a vital source of information, neither are they often communicated with directly, nor involved in discussions or decisions about their health care and are frequently not directly asked for their consent.

METHOD

A purposive sample of nurses working within the accident and emergency departments of five general hospitals was recruited to participate in this qualitative study. Data were collected from five focus groups.

FINDINGS

Effective communication was identified as the most challenging aspect in caring for adults with intellectual disabilities within this environment, having an impact on the assessment of needs, informing patients of their health status and seeking valid consent.

CONCLUSIONS

Fundamental to the provision of quality care are the concepts communication, choice and control. However, these issues are perceived to be more challenging in the provision of health care to people with intellectual disabilities. Communication and consent, therefore, require further consideration within the educational and clinical areas to strengthen nurses' competence in caring for people with intellectual disabilities, with an emphasis and understanding that choice and control are key principles for all people, being central aspects to the provision of an inclusive service for people with intellectual disabilities.

RELEVANCE TO CLINICAL PRACTICE

All nurses need to have a greater awareness of learning disability, how to increase opportunities for effective communication and be very familiar with the issue and guidelines relating to consent, to ensure that people with learning disabilities have choice, control and are more active in decision making regarding their health.

Characteristics and trends of self-harming behaviour in young people

Deliberate self-harm is recognized as a serious public health issue in young people. There is evidence that young people who self-harm are more likely to repeat self-harm, and this in turn increases their risk of completed suicide. Prevalence studies have identified that the rate of self-harm among young people is on the increase, information largely based on data arising from review and analysis of hospital attendances. However, community-based studies indicate that the prevalence is much higher, with those seen in emergency departments representing the 'tip of the iceberg' (Hawton and Rodham, 2006). Young people's motives for self-harm are discussed, as are research findings which indicate that nurses can have negative attitudes towards patients who self-harm. The article considers the implications of this for young people and identifies areas for future research.

Midwives in the UK: an exploratory study of providing newborn feeding support for postpartum mothers in the hospital

Our objective was to explore English midwives' views and experiences of supporting mothers with feeding their newborn baby. Grounded theory methodology was used. Data were collected using in-depth interviews from 30 midwives in the North of England. Data were analyzed using constant comparison techniques. Midwives were theoretically sampled for interview from a pool of volunteers recruited from a poster promoting the study in the clinical areas. Overall, hospital midwives felt that they did not have enough time to support mothers with feeding their neonate. To cope with these time constraints, midwives developed practices of rationing the time that they spent with mothers, and the rationing of resources available to mothers, to help them process mothers through the hospital services. These practices have important implications for the success of breastfeeding in hospitals as the practices by providers who are assigned to help breastfeeding initiation described here may inhibit the breastfeeding process.

Caring for adults with intellectual disabilities: perceived challenges for nurses in accident and emergency units

AIM

This paper reports a study exploring the experiences of nurses in accident and emergency units caring for people with intellectual disabilities.

BACKGROUND

People with intellectual disabilities are increasingly in contact with healthcare professionals in accident and emergency units. Often this contact occurs within the accident and emergency service, an area in which staff care for a diverse range of people. The experiences of people with intellectual disabilities within acute general hospitals in the United Kingdom and internationally has largely been reported as quite negative. Conversely, little is known about the experiences of nurses working in acute general hospitals, nor the exact nature of any challenges they encounter, in providing care to people with intellectual disabilities. This lack of understanding weakens opportunities for nurses to reduce barriers to providing an equitable service for people with intellectual disabilities.

METHOD

Five focus groups were conducted with 27 accident and emergency nurses from five hospitals in Northern Ireland in the spring of 2004. The data were then coded and recurring themes identified.

FINDINGS

This paper focuses on two themes: lack of knowledge of the nature of intellectual disability and dependence on carers. Whilst these themes have been acknowledged in the existing literature, they have received limited attention and exploration. The experience of fear and vulnerability was considered by participants to be a consequence of their lack of knowledge. The experience of these emotions is viewed as a key factor in nurses' over-dependence on patients' informal carers.

CONCLUSION

Increased awareness is needed among professionals in accident and emergency units of the abilities and needs of people with intellectual disabilities.

Emotional comfort: The patient's perspective of a therapeutic context

BACKGROUND

Comfort is a word that is frequently used to describe both physical and emotional aspects of the hospital experience. A number of definitions exist in the literature and there is a lack of clarity in understanding this concept.

OBJECTIVES

This paper describes the therapeutic context of emotional comfort that was identified in a qualitative study that sought to explain the perceived therapeutic effect of interpersonal interactions that were experienced by patients during hospitalisation.

DESIGN

Grounded theory.

SETTINGS

Public and private hospitals situated in Perth, Western Australia.

PARTICIPANTS

40 patient participants from a variety of settings, and 32 nurse participants. All participants were over the age of 18 and spoke English.

METHODS

Formal and informal interviews, field observations.

RESULTS

Patients interpreted the interpersonal interactions that they experienced during hospitalisation in terms of their experience of emotional comfort or discomfort. A central feature of emotional comfort was the patient's perception of personal control.

CONCLUSIONS

This study provides a greater understanding of the concept of comfort from the perspective of hospitalised patients. It highlights that patients approach their illnesses or injuries perceiving that a connection exists between the mind and the body.

An exploration of nurse–patient relationships in accident and emergency

This paper explores the nature of nurse-patient relationships in accident and emergency (A&E) drawing from nursing theory and research, and with reflection on three episodes of practice from the author's experience. First the case for nurse-patient relationships is presented with reference to nursing theory, statutory and professional literature. The benefits of positive nurse-patient relationships in A&E are then explored, followed by a discussion of the barriers to nurse-patient relationships forming in A&E. How relationships are formed is then considered, highlighting the short space of time available, and the importance of first impressions. The first practice episode analysed is a situation where the author felt she had not formed a relationship with the patient at all. In the second, the author questions whether the relationship had been over-involved and this is discussed in relation to the nature of involvement and what constitutes over-involvement. In the final practice episode the author felt that a positive relationship was formed with benefits to the patient concerned. The paper concludes by highlighting the importance of nurse-patient relationships in A&E, and how they can be formed in light of the barriers discussed previously.

Therapeutic communication part 1: general approaches that enhance the quality of the consultation

Consultations that place the patient at the centre of the interaction and actively explore their ideas, concerns, fears, cares and expectations strongly correlate with increased satisfaction, concordance, feelings of enablement and symptom resolution. Primary Care clinicians have developed these therapeutic consultation styles as a result of utilising the extensive research that has been undertaken in General Practice. In contrast, consultations in Accident and Emergency (A&E) have received little investigation and communication has a predominant bio-medical focus. This is the first of two papers which presents the results of a substantive review of the literature which explores therapeutic communication strategies appropriate to Emergency Care. This paper sets the scene by describing the current status of the Emergency Care consultation and reviews the proposed benefits of a consultation centred around the patient. The development of "Patient-Centred Communication" and its philosophical underpinnings are also discussed in order to provide further background. Finally, the general characteristics of therapeutic consultations identified in the substantive review of the literature review are analysed. The second paper describes five key communication strategies which when employed in clinical consultations in Emergency Care, could significantly enhance the therapeutic nature of the clinician-patient interaction.

Therapeutic communication part 2: strategies that can enhance the quality of the emergency care consultation

Therapeutic, patient-centred communication as well as being desirable in its own right may also have the potential to improve satisfaction, health outcomes and change health behaviours in Emergency Care. This paper, the second of two, identifies from a substantive literature review five specific communication strategies that, when employed in an Emergency Care consultation, could significantly enhance its therapeutic potential. The five strategies: questioning, listening and noticing, communicating empathy, establishing and incorporating the patient's cares and concerns and concluding the consultation have been derived from the purposeful selection and analysis of communication research between 1990 and 2002.

Interpreting trauma radiographs

BACKGROUND

Many accident and emergency clinicians regard the radiographic image as an extension of the clinical examination, as a provisional diagnosis, based on clinical signs and symptoms, can be confirmed or refuted by inspection of X-rays. However, the value of radiography in this context is not determined by the actual presence of trauma or pathology on the radiograph, but is dependent on the ability of a clinician to identify any trauma or pathology present. Traditionally, the responsibility for interpreting radiographic images within the accident and emergency environment in the United Kingdom (UK) has been with medical clinicians. However, expansion of the nursing role has begun to change the boundaries of professional practice and now many nurses are both requesting and interpreting trauma radiographs.

AIM

To ascertain the ability of accident and emergency doctors and nurses to interpret trauma radiographs, and identify whether there is a consistent standard of interpretive accuracy that could be used as a measure of competence.

METHODS

A literature review was conducted using the Cochrane Library, Medline and CINAHL databases and the keywords radiographic interpretation, radiographic reporting, accident and emergency and emergency/nurse practitioner.

FINDINGS

The ability of accident and nursing doctors and nurses to interpret trauma radiographs accurately varies markedly, and no identified published study has established an appropriate level of accuracy that should be achieved in order to demonstrate satisfactory competence in the interpretation of radiographic images.

CONCLUSIONS

Determining a measure of interpretive accuracy that can be used to assess ability to interpret radiographic trauma images is fraught with difficulties. Consequently, nurses may attempt to prove their skills by directly comparing their abilities to those of their medical colleagues. However, as a result of marked variation in the ability of senior house officers to interpret trauma radiographs, a similar ability does not automatically imply that a satisfactory level of ability has been achieved.

The view of the child health nurse among mothers

The aim of this exploratory study was to investigate mothers' experiences of their encounters with the child health (CH) nurse. A cross-sectional design was used for the study, based on data from 140 mothers gathered by the critical incident technique. The analysis was accomplished by a thematic content analysis, using inductive reasoning in three steps. Symbolic interactionism was used as a frame of reference. The results suggest that the central factor in the encounter between mother and nurse is that they are able to share the realm of motherhood, meaning that the nurse is open and willing to share all types of emotions, experiences and attitudes related to being a mother. Given this basis, other important factors are the supply of sound advice and practical interventions, and that the nurse is reassuring and accessible. The majority of the participating mothers had experienced CH nurses who had provided them with valuable support during troublesome incidents. However, there were also several dissatisfied mothers who had expected support but thought they received insulting treatment instead. The mothers and the nurses have varying experiences and background and therefore different perspectives, which may lead to difficulties in understanding each other. Knowledge about the important factors, that affect the mother-nurse encounter, can be used to strengthen the nurses' positive behaviours and facilitate understanding of how disappointed mothers have experienced their health care encounters.

Reconstructing a meaning of pain: older Korean American women's experiences with the pain of osteoarthritis

The purpose of this grounded theory study was to gain a deeper understanding of older Korean American women's experiences of chronic osteoarthritic pain. The data included a set of 3 interviews with 7 women over age 60, field notes, observations, memos, and the literature about the chronic pain of osteoarthritis. Through constant comparative analysis and coding typical of grounded theory, a five-stage process emerged inductively from the data. The core variable, Reconstructing a Meaning of Pain, included the concepts of the process in the grounded theory through which the women learned to manage and tolerate the pain. During this process, the women came to perceive their pain as a component of aging rather than as a symptom of disease.

Adolescents accessing emergency contraception in the A&E department - a feminist analysis of the nursing experience

This paper outlines the findings and discussion of a qualitative research study that focused on the experiences of seven qualified nurses working in three Accident and Emergency (A&E) departments in the North West of England. It was exploratory in nature, aiming to describe and explain the nurses' encounters with adolescents accessing emergency contraception (EC) in A&E. The study was carried out using a feminist methodology and a grounded theory method. The findings indicated that accident and emergency is a contradictory location for access to EC for adolescents, where the 'promise' of easy, confidential access contrasts sharply with the nurse's description of reality. The nurse's role is similarly contrasting, where their ideal is counter balanced by organisational limits, and is further shaped by both personal and professional guiding philosophies. The nurse's perceptions of the adolescents revealed the contradiction of both sympathetic and judgmental attitudes towards them, including an 'interpretation' of the reasons the adolescents gave for their attendance. These encounters led to a series of health, legal, and moral dilemmas for the nurses, and a strategy of referral of the adolescents to other agencies was used by them whenever possible.

The holistic nursing care of patients with minor injuries attending the A&E department

Philosophy, theoretical frameworks, and concepts of nursing are applied to the particular context of accident and emergency nursing. From this the research question evolves; the researcher seeks to explore the accident and emergency nurses' perceptions of the concept of holistic nursing care, a concept that is included within their department's philosophy for nursing. An ethnographic approach is applied to the research to gather rich descriptive data through exploratory interviews. The data were collected and analysed simultaneously, categories of data were developed, and these are presented here in the findings. The categories were scrutinised for patterns, similarities, and dissimilarities between the data; recurrent themes emerge. These themes shed light upon the meanings of holism in care to the respondents and offer an understanding of their cultural systems that affect the provision of holistic nursing care, these are discussed and analysed within the contexts of the existing knowledge base. The study identifies issues that adversely affect the provision of holistic nursing care, notably fragmentation of care, dissemination of nursing information, and privacy. The implications for practice are discussed, and recommendations include action research for practical issues and further research into the provision of holistic nursing care incorporating the perceptions of patients who receive care in this setting.

Adolescent access to emergency contraception in A and E departments: reviewing the literature from a feminist perspective

Recent moves in parts of UK to provide opportunities for 'over the counter' purchasing at pharmacies, has meant that access to emergency oral hormonal contraception for adolescents is undergoing something of a revolution. The provision of emergency contraception (EC) to adolescents in Accident and Emergency (A and E) departments, however, is nothing new and is now an established component of the current government objective to reduce teenage pregnancy rates in this country. The tensions apparent in A and E departments related to the provision of EC, particularly to adolescents, have recently been recognized, but little attention has been paid to analysing the reasons why such tensions might exist. This article is based on a literature review carried out as part of a study of nurses' encounters with adolescents accessing EC in A and E departments in the North-west of England. It is a reappraisal of the salient issues in this arena from a feminist perspective, aiming to provide an alternative with which to view the encounter between adolescents and service providers in A and E.

Communication skills training in healthcare: a review of the literature

This article is based on a literature review carried out as part of a study of communication skills teaching in pre-registration nurse education in England in 2000. The rationale for the study was two-fold: the history of patient dissatisfaction with communications and information-giving in the National Health Service and concern about skills deficits in alumnae of recent educational programmes. A lack of research evaluating communications skills training was found in relation to both pre- and post-registration nursing education, and in other healthcare disciplines. Furthermore, the research that has been done is limited by methodological deficiencies in many cases. Recommendations are made concerning improved methods for future research evaluating communication skills training.

Nurses' experiences of abusive/non-abusive caring for demented patients in acute care settings

Nurses caring for patients with dementia in acute care settings often lack specialized education in geriatric nursing. The acute care settings do not have an environment made for dementia care. The staff often had a high workload, which makes the situation stressful and the nurses who take care of these patients might end up in difficult situations. The aim of this study was to describe nurses' experiences of difficulties related to caring for patients with dementia in acute care settings. Interviews were performed with 12 nurses. Qualitative thematic content analyses were carried out in several steps. The results show that the nurses experienced various difficulties in meeting patients with dementia in acute care settings. This gave rise to for example frustration. Most commonly reported was lack of time to treat these patients satisfactorily. The difficulties were mostly related to the often disorderly conduct of these patients, the ethical problems that appeared in the care of these patients, and the medical care organization. The problematic situations described sometimes led to abuse and neglect of these patients.

Baccalaureate Nursing Students' Communication Process in the Clinical Setting

The purpose of this study was to describe and generate theory about how baccalaureate nursing students communicate with patients in the clinical setting using the qualitative method of grounded theory. Third-year and fourth-year generic baccalaureate nursing students were the primary participants in this study. Data were gathered during two academic semesters from formal and informal interviews and observations in hospital and home care settings. Transcribed audiotapes and field memos constituted the data generated in the study and were subjected to generating categories through open coding of data, applying theoretical codes to the data, collapsing and expanding categories reflective of the data, and memoing and uncovering the core category of the data. The core category then became the grounded theory. Analysis of the data revealed that students encountered a basic social psychological problem of "saying the right things to patients" in the clinical setting, which was preceded by the antecedent problem of "fear of saying the wrong things to patients." Students solved the problem, in part, by employing communication strategies and patterns. Eight communication strategies and five communication patterns incorporating communication strategies were identified. In addition, students went through a four-stage basic social psychological process. The process of learning a personal communication repertoire was uncovered as the substantive grounded theory. The repertoire was learned by students in the dynamic environment of the clinical setting in which RNs served as role models and communicating with difficult patients was the crucial step in the process of communication development.

Communication skills: some problems in nursing education and practice

This article is based on a literature review carried out as part of a study of communication skills training in pre-registration nursing education in England in 2000. A systematic literature search was conducted and 200 articles were found that were relevant to the study. Definitional problems were found, with terms such as communication skills and interpersonal skills being used interchangeably. The term communications strategies is suggested to overcome these problems, as it reflects the logical organization of a number of different communication skills within a theoretical or empirical framework. Problems in current communication skills teaching and social barriers to using communication skills in practice are discussed. It is concluded that problems continue to exist in these areas and that an emphasis on both aspects is needed if patient and staff satisfaction is to be improved.

Factors affecting nurses' attitudes towards the screening and care of battered women in Dublin A&E departments: a literature review

The concept of one human being inflicting unnecessary pain and suffering upon another, on a daily basis, is a disturbing and incredulous thought at the very least. This concept also known as domestic violence is all too real for the many victims presently suffering at the hands of their abusive partners. In Ireland, almost one in five women have experienced some form of domestic violence. This phenomenon can also be identified and further clarified as 'woman battering' Due to the confidential and accessible service offered to the client the Accident and Emergency department is a vital source of assistance to women who have been beaten by their partners. Battered women frequently present with injuries both visible and non-visible. More often than not however, many women are treated solely for their injuries and pass through the healthcare system unnoticed. Lydon (1996) estimates that of all presenting cases of domestic violence in the A&E department, only 5% are actually detected. Some literature estimates 3% detection rates (Thompson et al. 1998, Hadley, 1992). The following literature review explores the history behind the phenomenon of violence against women and its extent in Ireland. The literature affirming the important role of the nurse in A&E is reviewed and several themes are explored that affect nurses' attitudes in the screening and care of battered women.

Model of the dentist-patient consultation in a clinic specializing in the treatment of dental phobic patients: a qualitative study

Thirty semi-structured interviews were conducted with 5 dentists (3 male and 2 female) after first and second consultations with 15 newly enrolled dental phobic patients (2 male and 13 female) in a clinic specializing in the treatment of odontophobia. Analysis of the transcribed interviews was influenced by the principles of grounded theory. Five concepts/higher-order categories were grounded in the data: 1 core category: 'Relatedness, based on affective resonance and concordant roles' and 4 additional higher-order categories: 'the dental phobic patient's emotions'; 'the patient's verbal and non-verbal cues'; 'the dentist's role as a clinician: professional interpersonal skills'; and 'the dentist's role as a fellow-being: general interpersonal skills'. The model developed describes the dynamics of the dentist patient interaction and has a theoretical application.

The role of the dental nurse in general practice

Dental nurses have reported dissatisfaction with their work which is associated with feelings of lack of control and being undervalued. This paper examines some of the possible reasons behind job dissatisfaction with illustrations from a pilot study conducted in general dental practice.

Female survivors of abuse attending A & E with self-injury

Accident and Emergency departments are concerned with trauma whatever the source or client age. This mixed trauma culture can be a distressing place, not least for women whose self-injury is 'self-inflicted' rather than accidental in nature. The women, who might be survivors of childhood sexual abuse, are sometimes viewed as service abusers, on occasions subjected to misinterpretation, labelled as 'time-wasters' and consequently stigmatized. The misunderstanding based on misinterpretation of language and theory is explored briefly, as is some appropriate literature on self-injury and abuse. The definitions of self-injury and some of the myths associated with self-injuring women are developed. The relationship of self-injury with suicide is briefly explored, as are issues related to distress and self-injury. The demand on nurses and the case for the development of an appropriate non-medical theory is explored. Areas of positive practice, some of which were visited while the author was on a Nightingale Scholarship, are noted as is the need for nurses to learn from voluntary and survivor groups who work with and for self-injuring women. Client needs and staff awareness is examined in brief. Literature from the survivor perspective is utilized and the conclusion is drawn largely from the recommendations made by this literature.