Living with advanced breast cancer: perceptions of Pakistani women on life expectations and fears.

BACKGROUND: Pakistan has the highest rate of breast cancer in Asia. Many women delay seeking heath advice and treatment for breast cancer, and between 50% and 70% of women will present when the disease in is in an advanced, aggressive form, particularly young women. The psychological impact of breast cancer is challenged by the negative public perception of cancer. OBJECTIVES: This qualitative study explored the psychological impact of advanced breast cancer in women receiving follow-up care in an oncology hospital in Pakistan. METHODS: This qualitative study used semistructured interviews to explore women's experiences of living with advanced breast cancer and the impact that this had on their lives as women, mothers, and wives. Twenty-one women were interviewed. Data were analyzed using thematic analysis. RESULTS: The majority of 21 women interviewed were diagnosed between 1 and 11 years, and 15 women had a history of metastases. Four themes emerged from the data. These were reaction to the diagnosis, change in outlook, living life positively, and motivating factors. CONCLUSION: Women acknowledged the significance of their illness on their health and longevity. Their individual cancer journey was multilayered and imbued with the hope of cure, remission, and an emotional catalog of feelings. All married women wished for sufficient time to visualize their children reach adulthood and marry. Single women wished to care for their mothers and families. IMPLICATIONS FOR PRACTICE: Through education and support, nurses can provide women with advanced breast cancer and their families educational, spiritual, and psychological care.

Case studies of patient interactions, care provision and the impact of emotions: a qualitative study.

Caring is a complex phenomenon. Nurses aim to relieve patient suffering, acknowledge subjective experiences, display empathy but also manage emotions related to care provision. This study explored nurses' perceptions, experiences and emotions related to caring for cancer patients. This qualitative study used semi-structured interviews to explore the emotions management of 32 nurses working in a cancer hospital in Pakistan. Data saturation occurred after 20 interviews. Three themes emerged from the data related to caring, acknowledgement of patients' feelings, professional behaviour, patient involvement and emotional control. Some nurses repressed their emotions and feelings over patients who had difficulties sustaining hope. In such cases nurses require supportive networks to assist their emotions management and intra-personal skills. Educational support is needed to help nurses express their views in relation to emotional contagion, significance of repressed emotions and to identify supportive ways to assist nurses to communicate their experiences.

Perceptions of breast health awareness in Black British women.

PURPOSE: Breast cancer is a global concern. Published studies indicate that 43% of Black and ethnic minority women interviewed have reported that they did not practice breast awareness because they did not know the relevant breast changes that occur in breast cancer. Black women are also more likely to receive a diagnosis of breast cancer when it is in an advanced stage. This pilot study aimed to address the views of Black British women on breast health awareness and breast health screening practices. METHODS AND SAMPLE: In this qualitative study I used semi-structured interviews were used to investigate breast health perceptions, practices and education in a pilot sample of ten women. KEY RESULTS: Women held numerous perceptions of breast cancer which ranged from no knowledge to well informed through receiving extensive education. Two out of ten women were relatively uneducated with regard to breast self examination (BSE). The remaining eight women participated in a variety of screening routines which varied from undertaking BSE everyday to once every few months. Women's experience of breast health education was also variable. One woman, younger woman, had not received any health education advice in relation to breast health awareness or BSE. The remaining nine women had received some health advice following visit to their General Practitioners, Medical consultant, media information or as a result of participating in mammographic screening. CONCLUSIONS: Black British women require health education that focuses on breast cancer and its associated risk factors, technique of BSE, and national breast cancer screening recommendations.

Black women and breast health: a review of the literature.

AIM: In the UK, it is known that screening inequalities exist involving ethnic minority groups such as Black women (Patnick, 2009). To date, there is limited UK data on Black British women and breast health awareness. Black British women appear to be an underrepresented group in breast cancer studies (Breast Cancer Care, 2004, 2005). This literature review aimed to explore Black women's perceptions of breast health and factors that influence breast cancer screening practices. METHODS: A literature search for the period 1994 to September 2009 was undertaken using BNI, CINAHL, PubMed, OSH-ROM, PsyInfo, Google scholar, and Scopus databases. Key words used included: breast cancer, breast health, African American women, Black British women, black women, breast cancer screening, qualitative studies. Hand-searching was also done, and reference lists of papers were examined for relevant studies. RESULTS: Black women hold a variety of views and perceptions on the risk that breast cancer poses. These perceptions are strongly related to existing knowledge, related stigmatization, spiritual and religious beliefs, all of which can adversely influence motivation to engage in self-breast examination and breast cancer screening. CONCLUSION: US based studies identified several influential factors: religion, educational awareness of breast cancer screening, breast health awareness. Breast health interventions and research are needed to increase breast health awareness in Black British women.

Cultural interrelationships and the lived experience of Pakistani breast cancer patients.

AIM: There is a paucity of British and international literature on the psychological, sociological and cultural correlates of breast health in ethnic minority women. METHODS: This two centre qualitative study was part of a larger study that aimed to examine the influence of culture on the lived experience of Pakistani Muslim breast cancer patients. Thirty six patients attending hospital out-patient breast cancer clinics in Lahore, Pakistan and London, UK were recruited to the study. Women were predominantly married, 20-76 years of age with an average of three children. Semi-structured interviews were undertaken. Interview data were analysed using thematic analysis. RESULTS: Five themes emerged: Discovery and reaction to the disease; disclosure to family; developing emotions; emerging reality; long term uncertainty. CONCLUSIONS: Data infer that irrespective of city of residence, the cultural attributes of women, breast health awareness and reactions to the diagnosis and treatment are similar. To raise awareness, more focused health education interventions are needed.

The impact of culture and sociological and psychological issues on Muslim patients with breast cancer in Pakistan.

Breast cancer is the most common form of cancer in Muslim women in Pakistan. The impact of the initial diagnosis, culture, religion, and psychosocial and psychological aspects of the disease is not well established. This qualitative study examined the experience and coping strategies used by patients with breast cancer in relation to its impact on their physical, mental health, religious, and family issues. Thirty patients with breast cancer were interviewed. Data were analyzed using thematic analysis. The patient's experience of breast cancer focused on the range of emotions felt throughout the illness trajectory, the importance of religion and family support on coping strategies used to manage the adverse effects of chemotherapy, and also the financial concerns. This is the first study to examine Pakistani Muslim women's views on the lived experience of breast cancer. This article provides clarification of the voiced experiences of women with breast cancer. The data not only highlight the role of religion and family support as essential coping strategies but also emphasize the issues of isolation, aggression, and anger as common responses to chemotherapy. Unique features of this study are women's need to seek spiritual support for their illness and the overriding innate characteristic of maternal responsibility. These cultural features require further analysis and research.

A review of interventions used to improve adherence to medication in older people.

BACKGROUND: Medication mismanagement is a continuous problem particularly in older people. Numerous interventions have been developed and tested in an attempt to improve adherence with medication in this client group. OBJECTIVES: This review aimed to examine the simple to complex interventions that have been used to assess and improve adherence with medication in older people. DESIGN: An extensive review of the literature was performed and 20 relevant research papers and one report were chosen. FINDINGS: Research papers were evaluated according to design, RCTs were analysed using the JADAD scoring system, systematic reviews and reviews of the literature were reviewed using the Critical Appraisal Skills Programme and subjected to a narrative analysis. This process assisted the development to emerging themes. Four themes were developed: patient barriers, health professional involvement, and health related outcomes and formation giving. CONCLUSIONS: The salient findings of the review infer that there is no clear definition of non-adherent behaviour. Quantitative interventions fail to assess patient choice in relation to medication taking. Pharmacist-driven interventions are resource intensive. Health care outcomes and clinical effectiveness are seldom addressed in interventions. Among the many difficulties encountered when attempting to use interventions to promote adherence with medication in older people is their perceptions and beliefs, the appropriateness of the medicines prescribed as well as the impact of lifestyle patterns: smoking, alcohol and diet. Many intervention studies are of poor quality and do not include a theoretical framework to underpin the interventions being used. More focused research is needed to improve understanding of the theoretical knowledge that underpins the complexities of adherence with medication in older people. In-depth qualitative studies can be used to develop such theory. In addition, the quality of intervention research can be improved by the inclusion of a research framework such as the Medical Research Council model.

Evaluating practice-based learning specific to the community matron role.

Since the inception of the community matron role in 2004 there has been much debate about the exact nature of the role in primary and secondary care. How to effectively skill-up and educate a diverse group of clinicians has been a hot topic. This study involved a small focus group of community matrons in training. The qualitative themes extracted from this work are reported on and suggest that practice-based learning is both valuable and efficacious.

Perceptions of breast health practices in Pakistani Muslim women.

OBJECTIVE: Even though breast cancer is the most common form of cancer in females in Pakistan, there is a paucity of evidence on the views of Pakistani Muslim women in relation to breast cancer. This study aimed to investigate the perceptions of Pakistani Muslim women in relation to the aetiology of breast cancer and impressions of breast health. The study took place in Lahore, Pakistan. METHODS: This survey used a questionnaire and focus group interviews to investigate women's perspectives on breast health. Data was collected over a period of six months, quantitative data was analysed using descriptive statistics and qualitative data was analysed using thematic analysis. RESULTS: 105 women participated in the questionnaire and 48 women contributed to 6 focus group interviews. Women generally were aware of the term breast cancer but were unsure of its aetiology. The questionnaire data revealed that women were aware of both mammography (55%) and breast self-examination (BSE) (77%). Fifty five percent of women had been taught the BSE technique. In comparison, the majority of women attending the focus group interviews had limited exposure to BSE or mammography. Although women had heard of mammograms and BSE they were unaware of BSE technique or breast cancer screening procedures. CONCLUSIONS: Even though there is a desire amongst women to engage in BSE by being taught the necessary technique and specific pathological changes to look for, there is a strong cultural opinion that breasts are private organs that should not be discussed publically. In view of this and the frequency of breast cancer in Pakistani Muslim women, it is essential that breast awareness campaigns are implemented by health care professionals such as breast cancer nurses, midwives and medical practitioners to explore the concept of BSE and breast cancer. Selective health education can educate women and lead to changes in health behavior.

Topical diclofenac: clinical effectiveness and current uses in osteoarthritis of the knee and soft tissue injuries.

BACKGROUND: Diclofenac is a commonly used non-steroidal anti-inflammatory drug (NSAID) for symptom control in osteoarthritis (OA) of the knee and soft tissue injuries. Although treatment with oral diclofenac is associated with serious adverse effects involving both the gastrointestinal and renal systems, these adverse effects are thought to be limited with topical diclofenac formulations without loss of efficacy. OBJECTIVE: The aim of this review is to explore the available evidence in relation to the pharmacokinetics, efficacy and reported adverse effects of the topical diclofenac formulations available. RESULTS/CONCLUSIONS: In the majority of studies examined, topical diclofenac formulations with sodium lotion, lecithin or epolamine gel, patch or plaster were either superior or equivalent to oral diclofenac formulations or placebo. Topical diclofenac significantly reduced pain and morning stiffness and improved physical function and patient global assessment without major adverse effects reported in patients with OA of the knee; and provided significant pain relief in patients with sports and soft tissue injuries involving the ankle, knee or shoulder. In the majority of studies, the predominant adverse effect involved pruritus or rash at the site of application, or nausea. The principle outcome of these studies is that topical diclofenac is a safe and practical alternative as a method of treatment in OA of the knee or as an alternative treatment for sports and soft tissue injury.

A hermeneutic phenomenological study of community nurses' CPD.

Continuing professional development (CPD) is a mandatory aspect of nurse registration. In the NHS, more demanding professional roles compel nurses to develop and update their knowledge and skills through CPD. Even though CPD is an essential component of nurse education, research investigating community practitioners' views, experiences and perceptions of the link between reflection and CPD is limited. This phenomenological study explored community health practitioners' experiences of CPD and perceptions of the link between CPD and reflection. Ten community practitioners who specialized in district or school nursing and health visiting were interviewed using an in-depth approach. Data was analysed using thematic networks as a tool (Attride-Stirling, 2001). Findings revealed that community practitioners viewed CPD positively, perceived the benefits as both professional and personal development. Development needs were identified through reflective practice and appraisal. Even though significant barriers were apparent, the organization provided opportunities to access formal and self-directed learning events. There is a need for organizations to invest in CPD of the workforce, consider cheaper alternatives for meeting CPD needs and for further research to assess the impact of CPD on clinical practice.

Older people and adherence with medication: a review of the literature.

BACKGROUND: Older people represent a sizeable population of the UK. Many older people receive drug treatment for long-term conditions. Adherence with medication is therefore an important clinical, financial and resource intensive concern. OBJECTIVES: This review aimed to examine patient's beliefs, perceptions and views in relation to adherence with medication. DESIGN: A comprehensive search of the literature was undertaken using numerous approaches. The search of revealed 30 research papers. FINDINGS: Articles were initially evaluated using Critical Appraisal Skills Programme principles to identify those relevant to the review. Relevant studies were then subjected to a narrative analysis to assist the development of relevant themes. Four themes were identified; experience of adherence; perceptions and attitudes to medication adherence and non-adherence; patients acceptance of their illness and impact on medication taking behaviour and shared decision making. CONCLUSIONS: The findings of this review imply that there is a need for more emphasis on shared decision making between the older patient and the prescriber. Using this approach, adherence with medication may improve. There is also a need to develop a standardized measure of medication adherence.

'Nurse entrepreneurs' a case of government rhetoric?

INTRODUCTION: Nursing has come to play a prominent role in government health policy since 1997. Extending the scope of nursing practice into activities previously carried out by doctors can assist a managerialist and 'modernizing' project of increasing National Health Service (NHS) efficiency by removing demarcations between professional groups. METHODS: Drawing on elements of poststructuralist linguistics, this paper presents an analysis of a key government speech in the context of a discussion of overall policy intentions. RESULTS: The speech can be seen as an example of how government has attempted to use rhetoric to make its goals attractive to nurses. CONCLUSION: Policy-makers have to make their policies acceptable to those whom they expect to implement them. In this case, organizational efficiency, chiefly in terms of broader access to NHS services, as well as role substitution, is aligned with government policy promoting social enterprise and 'sold' to the nursing profession as enhancing its status compared with medicine.

A review of clinical decision making: models and current research.

AIMS AND OBJECTIVES: The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model. BACKGROUND: Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition. DESIGN: Literature review. METHODS: Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005. RESULTS: The characteristics of the three models of decision making were identified and the related research discussed. CONCLUSIONS: Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed. RELEVANCE TO CLINICAL PRACTICE: It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

Clinical reasoning and its application to nursing: concepts and research studies.

Clinical reasoning may be defined as "the process of applying knowledge and expertise to a clinical situation to develop a solution" [Carr, S., 2004. A framework for understanding clinical reasoning in community nursing. J. Clin. Nursing 13 (7), 850-857]. Several forms of reasoning exist each has its own merits and uses. Reasoning involves the processes of cognition or thinking and metacognition. In nursing, clinical reasoning skills are an expected component of expert and competent practise. Nurse research studies have identified concepts, processes and thinking strategies that might underpin the clinical reasoning used by pre-registration nurses and experienced nurses. Much of the available research on reasoning is based on the use of the think aloud approach. Although this is a useful method, it is dependent on ability to describe and verbalise the reasoning process. More nursing research is needed to explore the clinical reasoning process. Investment in teaching and learning methods is needed to enhance clinical reasoning skills in nurses.

The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students.

Even though clinical reasoning is attributed with the expert practitioner, there is limited evidence to support methods of teaching and learning that are used to foster its development in nurses. In nursing, a considerable range of teaching and learning strategies are available that can be used to develop clinical reasoning skills. This includes the think aloud seminar. This process oriented method has been successfully used to develop reasoning skills in nursing students [Lee, J.E.M. and Ryan-Wenger, N. 1997. The "think aloud" seminar for teaching clinical reasoning: A case study of a child with pharyngitis. J. Pediatric Health Care 11(1), 105-110.] and is one that should be adopted by nurse educators as a core teaching and learning strategy when educating pre-registration student nurses.

Advanced breast cancer: aetiology, treatment and psychosocial features.

Breast cancer is a common form of cancer in women of varying age. Due to the relationship between breasts, sexuality and reproduction, this form of cancer has an interconnected psychological and psychosocial influence on the well-being of women. Current understanding of the aetiology and pathogenesis of the disease has evolved as evidence supporting a role for genes such as the HER2 gene has emerged. HER2-positive breast cancer is a particularly progressive form of the disease as a result of its ability to differentiate and spread. Trastuzumab (Herceptin) forms part of the current treatment for this form of breast cancer; albeit costly, it has been shown to improve survival rates in women. For this reason it is now a recommended treatment for early-stage breast cancer. During and after treatment cycles, the breast cancer nurse and medical practitioners should be available to provide emotional support and advice on the manifestations of the disease, coping strategies and how breast cancer patients manage close family relatives.

The use of topical diclofenac for pain in osteoarthritis of the knee: a review.

Osteoarthritis (OA) is a common complaint that affects millions of people worldwide. As there is no cure for OA, drug treatment is the main form of management. This can be achieved through the use of analgesics and anti-inflammatory drugs such as the NSAID diclofenac sodium. The chronic use of diclofenac sodium can lead to adverse gastrointestinal problems. The use of a topical formulation of diclofenac sodium aims to reduce this problem. Evidence from four randomized controlled trails of the efficacy and safety of topical diclofenac sodium as a method of pain relief for the treatment of OA of the knee is presented and discussed. Findings imply that topical diclofenac sodium is an efficacious and safe method of pain control in patients with OA of the knee.