"Nothing's changed, baby": How the mental health narratives of people with multiple and complex needs disrupt the recovery framework.

The dominant narrative in mental health policy and practice has shifted in the 21st century from one of chronic ill health to a 'recovery' orientation. Knowledge of recovery is based on narratives of people with lived experience of mental distress. However the narratives of people experiencing structural inequalities are under-represented in recovery research. Meanwhile, uses of recovery narratives have been critiqued by survivor-researchers as a co-option of lived experience to serve neoliberal agendas. To address these twin concerns, we undertook a performative narrative analysis of two 'recovery narratives' of people with multiple and complex needs, analysing their co-construction at immediate/micro and structural/macro levels. We found two contrasting responses to the invitation to tell a recovery story: a narrative of personal lack and a narrative of resistance. We demonstrate through reflexive worked examples how the genre of recovery narrative, focused on personal transformation, may function to occlude structural causes of mental distress and reinforce personal responsibility in the face of unchanging living conditions. We conclude that unacknowledged epistemological assumptions may contribute to co-constructing individualist accounts of recovery. A critical, reflexive approach, together with transparent researcher positionality, is imperative to avoid the epistemic injustice of a decontextualised form of recovery narrative.

'Maybe I Shouldn't Talk': The Role of Power in the Telling of Mental Health Recovery Stories.

Mental health 'recovery narratives' are increasingly used within teaching, learning and practice environments. The mainstreaming of their use has been critiqued by scholars and activists as a co-option of lived experience for organisational purposes. But how people report their experiences of telling their stories has not been investigated at scale. We present accounts from 71 people with lived experience of multiple inequalities of telling their stories in formal and informal settings. A reflexive thematic analysis was conducted within a critical constructivist approach. Our overarching finding was that questions of power were central to all accounts. Four themes were identified: (1) Challenging the status quo; (2) Risky consequences; (3) Producing 'acceptable' stories; (4) Untellable stories. We discuss how the concept of narrative power foregrounds inequalities in settings within which recovery stories are invited and co-constructed, and conclude that power imbalances complicate the seemingly benign act of telling stories of lived experience.

'You're on show all the time': Moderating emotional labour through space in the emergency department.

AIMS: This is the second of two papers conceptualizing emotional labour in the emergency department (ED). This paper aims to understand the environmental 'moderators' of ED nurses' emotional labour. DESIGN: Ethnography, through an interpretivist philosophy, enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nurses. METHODS: Observation and semi-structured interviews over a 6-month period. Two hospital sites (one district general and one major trauma centre based in the United Kingdom. RESULTS: Over 200 h of observation plus 18 formal/semi-structured interviews were completed. Environmental, institutional and organizational dynamics of the emergency department instrumented the emotional labour undertaken by the nursing team. Time and space were found to be 'moderators' of ED nurses' emotional labour. This paper focusses on the relevance of space and in particular, 'excessive visibility' with little respite for the nurses from their intense emotional performance. CONCLUSION: Emotional labour is critical to staff well-being and the way in which healthcare spaces are designed has an impact on emotional labour. Understanding how emotional labour is moderated in different clinical settings can inform organizational, environmental and workforce-related decision-making.

"I Cry. I Simply Cry." An Ethnography of a Lymphedema Summer Camp.

Background: The aim of this study was to explore how self-management is taught, learnt, and experienced during a 3-day educational Lymphedema Camp for parents of children with lymphedema. Methods: Participants (professionals, parents, and children) were observed during camp activities and interviewed informally and formally in focus groups. The embodied nature of the experience expressed by professionals, parents, and researchers became the analytical focus for understanding the felt tensions in the teaching and learning of self-management to families. Findings: The affective sensibilities associated with the uncertainties involved in teaching and learning self-management skills were palpable given that: young people are now expected to take up strict time-consuming self-management regimens (often via the support of a parent) where "evidence-based" outcomes are uncertain or may not match the outcomes wanted by a young person (varying in age and therefore ability or willingness to engage); or where there are tensions within the family; and the variety of different professionals involved means that techniques varied but where these professionals also lacked the necessary skills training to guide them in how to teach self-management. An analytical focus on the distress, doubt, fear, loneliness, guilt, and moralism felt by professionals, parents, and the researchers supports us to identify the character of the problems associated with performing best practice care guidance where there is a lack of practical support or resources for how self-management in this population should be achieved. Conclusion: To avoid these issues more training and research are needed on "how" to self-manage and stop victim-blaming that generates tensions and drives a wedge between the carer and the cared-for. When systemic problems get located with individuals (professionals, parents, or children), this directs our attention and understanding away from systems of care that lack coordination, may be under-resourced, and where effective training is absent.

"I don't have any emotions": An ethnography of emotional labour and feeling rules in the emergency department.

AIMS: This study aims to apply Hochschild's theory of emotional labour to emergency care, and uncover the 'specialty-specific' feeling rules driving this labour. Despite the importance of positive nurse well-being, the emotional labour of nursing (a great influencer in wellbeing) remains neglected. DESIGN AND METHODS: Ethnography enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nursing team. We undertook first-hand observations at one major trauma centre ED and one district general ED including semi-structured interviews (18). A reflexive and interpretive approach towards thematic analysis was used. RESULTS: We unearthed and conceptualized four feeling rules born from this context and offer extensive insights into the emotional labour of emergency nurses. CONCLUSION: Understanding the emotional labour and feeling rules of various nursing specialties offers critical insight into the challenges facing staff - fundamental for nursing well-being and associated retention programs. IMPACT: What problem did the study address? What were the main findings? Where and on whom will the research have impact? Academically, this research expands our understanding - we know little of nurses' feeling rules and how specialties influence them. Clinically, (including service managers and policy makers) there are practical implications for nurse well-being.

Insights into nurses' precarious emotional labour in the emergency department.

BACKGROUND: Nurses in the emergency department (ED) work in emotionally charged situations and undertake extensive emotional labour. However, that labour is not visible to others, often overlooked and therefore undervalued. Furthermore, there is a lack of literature on the topic. AIM: To explore ED nurses' experiences of emotional labour. METHODS: In-depth semi-structured interviews were conducted with two staff nurses working in the ED of a large UK teaching hospital. Rigorous methods of data collection and analysis, including a strong reflexive stance, were adopted. FINDINGS: Among three overarching themes that emerged from the data, two related more specifically to the ED: 'precarious emotional labour' and 'grieving etiquette'. Participants were found to perform sophisticated forms of emotional labour to manage the precariousness of their role, and to conceal or suppress their own feelings in order to maintain the grieving etiquette. CONCLUSION: The ED is an environment that requires sophisticated but precarious forms of emotional labour. Recognising, valuing and supporting the emotional aspect of an ED nurse's role is essential if emergency services are to remain functional, efficient and humane.

Capitalising on the transformational opportunities of early clinical academic career training for nurses, midwives and allied health professionals.

BACKGROUND: A highly skilled workforce is required to deliver high quality evidence-based care. Clinical academic career training programmes have been developed to build capacity and capabilities of nurses, midwives and allied health professionals (NMAHPs) but it remains unclear how these skills and roles are operationalised in the healthcare context. The aim of this study was to explore the experiences of early career clinical academic NMAHPs who have undertaken, or are undertaking, clinical academic master's and doctoral studies in the United Kingdom. METHODS: We conducted 17 in-depth semi-structured interviews with early career clinical academics which included; nurses, midwives and allied health professionals. The data were analysed using thematic analysis. RESULTS: Two themes emerged from the data; identity transformation and operationalising transformation. Both these highlighted the challenges and opportunities that early clinical academic training provided to the individual and organisation in which they practiced. This required the reconceptualization of this training from the pure acquisition of skills to one of personal and professional transformation. The findings suggest that individuals, funders, and organisations may need to relinquish the notion that training is purely or largely a transactional exchange in order to establish collaborative initiatives. CONCLUSION: Stakeholders need to recognise that a cultural shift about the purposes of research training from a transactional to transformative approaches is required to facilitate the development of NMAHPS clinical academics, to enable them to contribute to innovative health and patient care.

Perils and pitfalls for clinicians embarking on qualitative research in physiotherapy.

AIM: To consider the pros and cons of focus groups versus interviews for studies interested in examining patient experiences of clinical interventions. The paper looks at the hazards of being a clinician when collecting qualitative data and shares these experiences to provide useful learning for other clinicians embarking on qualitative approaches. BACKGROUND: Sub-acromial decompression surgery (SAD) is the accepted, surgical intervention for shoulder impingement syndrome. Evidence suggests that outcomes from SAD are no more superior to conservative management. This raises questions as to whether alternative explanations such as patient experience are at play when considering patient outcomes. DATA SOURCES: A study looking at patients' experiences of subacromial decompression surgery six months after the operation. REVIEW METHODS: One small focus group and one individual interview took place to explore patient experience following sub-acromial decompression shoulder surgery. DISCUSSION: Focus groups risk producing competitive and comparative discussions, and clinical researchers require sufficient training and mentoring to recognise and assist group dynamics. The study exposed ways in which clinicians involved in collecting data may be injured to aspects of patients' experiences, and accordingly may not explore in depth aspects important to patients. CONCLUSION: This paper highlights the importance of novice researchers thinking carefully about the capacity for 'practitioner eyes' to influence analytical decisions about study design and the direction of data collection. Focus group interactions are complex and risk being underestimated by inexperienced clinical researchers. IMPLICATIONS FOR RESEARCH/PRACTICE: Novice researchers are advised to be open to the possibility that unpredictable situations are likely to occur and expose assumptions about the study design. Preparation and guidance is required to avoid some of the challenges and manage group dynamics effectively in the first instance.

MRSA care in the community: why patient education matters.

In primary care, patients are prescribed decolonisation treatment to eradicate meticillin-resistant Staphylococcus aureus (MRSA). This complex treatment process requires the patient to apply a topical antimicrobial treatment as well as adhering to rigorous cleaning regimens to ensure the environment is effectively managed. A pilot study was carried out that involved developing an enhanced, nurse-delivered education tool, training a community nurse to use it, then testing its use with a patient. Three interviews were carried out: one with a patient who received usual care, one with a patient who received the enhanced education and one with the community nurse who delivered the enhanced education tool. The patient who received the enhanced education reported better knowledge and understanding of the application of treatment than the patient who did not. These results are interesting and point the way forward for larger research studies to build on the learning from this limited exploration and develop more effective management of MRSA in primary care.

Investigating the safety of medication administration in adult critical care settings.

BACKGROUND: Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings. PURPOSE: This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant. CONCLUSION: The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.

The attitudes of neonatal nurses towards extremely preterm infants.

AIM: The paper is a report of a study of the attitudes of neonatal nurses towards extremely preterm infants. BACKGROUND: Alongside advancing survival at extremely preterm gestational ages, ethical debates concerning the provision of invasive care have proliferated in light of the high morbidity. Despite nurses being the healthcare professionals who work closest with the infant and their family, their potential influence is usually ignored when determining how parents come to decisions about future care for their extremely premature infant. METHODS: A Q methodology was employed to explore the attitudes of neonatal nurses towards caring for extremely preterm infants. Data were collected between 2007 and 2008 and analysed using PQMethod and Card Content Analysis. RESULTS: Thirty-six nurses from six neonatal units in the United Kingdom participated. Although there was consensus around the professional role of the nurse, when faced with the complexities of neonatal nursing three distinguishing factors emerged: the importance of parental choice in decision-making, the belief that technology should be used to assess response to treatment, and the belief that healthcare professionals should undertake difficult decisions. CONCLUSION: Neonatal nurses report unexpected difficulties in upholding their professionally defined role through highly complex and ever varied decision-making processes. Recognition of individual attitudes to the care of extremely preterm infants and the role of the family in the face of difficult decisions should facilitate more open communication between the nurse and the parents and improve the experience of both the nurse and the family during these emotional situations.

Measuring quality of life in thai women with breast cancer.

Breast cancer has become a commonly diagnosed disease among Thai women in the last decade, despite the fact that Thai women generally have a lower rates than their Western counterparts. With the rising incidence and survival rates, it is crucial for nurses to look at the long term quality of life of these patients. A broad range of instruments have been used in clinical trials among breast cancer patients in oncology, like the EORTC questionnaire including the general quality of life questions (QLQ-C30) and the breast cancer module (QLQ-BR23), and the FACT-B questionnaire consisting of both a generic part (FACT-G) and a breast cancer specific module. They have been shown to have good validity and reliability properties both for the English original and translations into various languages including Thai. A few studies on quality of life in Thai context exist, covering quality of life in women with breast cancer. Therefore, the purpose of this study was to find which standard measure of common Western quality of life scales is appropriate to assess quality of life in Thai women with breast cancer. Results revealed the Thai version of EORTC QLQ-C30 and FACT-G questionnaires to be reliable and valid to assess quality of life in general. The best fit for measuring quality of life in Thai women with breast cancer during adjuvant treatment should be the EORTC QLQ-C30/-BR23.

The concept of 'nursing' in the abortion services.

AIM: This paper is a report of a study of the perceptions of nurses who work in abortion services. BACKGROUND: International debate surrounds abortion. In England and Wales the Abortion Act which was introduced in 1967 recently came under public review in relation to its legal limit of 24 weeks gestation. The review did not extend to those working within abortion services, and these nurses' views remained unknown. Investigating the perceptions of nurses who work in abortion services adds a dimension to the debate from a professional perspective which has hitherto been absent. METHODS: Qualitative semi-structured interviews were conducted in 2007 with nine nurses working in three different abortion clinics in the United Kingdom. NVivo was used to manage the interview data and thematic analysis identified patterns of nursing concepts and attitudes. FINDINGS: Two global themes of 'Attitudes Towards' and 'Coping With' abortion were identified. Six organizational themes detailed these: 'society', 'nurses' and 'reasoning' in 'Attitudes Towards' and 'role', 'clients' and 'late gestation abortion' in 'Coping With'. Eleven basic themes further described the organizational themes. Kim's theory of Human Living was used to clarify and provide a rationale for the nursing approach to care in this setting. CONCLUSION: The ability of participants to care for their clients as individuals illustrates the nature of empowerment of the nurses to attain the goals of the client. Making this support explicit through defined roles for nurses would potentially enable nurses in abortion services to perform their role more effectively at all gestation times.

Desperately seeking sociology: nursing student perceptions of sociology on nursing courses.

This paper will present the findings of a qualitative study exploring the perceptions of students confronted by a requirement to learn sociology within a nursing curriculum. Those teaching sociology have a variety of explanations (more or less desperate), seeking to justify its place on the nursing curriculum. While there may be no resolution to the debate, the dispute thus far, has largely been between sociology and nursing academics. Absent from this debate are the voices of students 'required' to learn both nursing and sociology. What do students make of this contested territory? When students are trying to learn their trade, and know how to practice safely and efficaciously what do they make of the sociological imagination? How realistic is it to expect students to grasp both the concrete and practical with the imaginative and critical? Findings from this qualitative, focus group study suggest that students do indeed find learning sociology within a nursing curriculum "unsettling". It would seem that students cope in a number of ways. They fragment and compartmentalise knowledge(s); they privilege the interception of experiential learning on the path between theory and practice; and yet they appear to employ sociological understanding to account for nursing's gendered and developing professional status.

The perceptions of statutory service providers of a local Sure Start programme: a shared agenda?

Sure Start is the UK government's flagship scheme for providing services to children and their families in deprived areas. This study aimed to examine the perceptions of statutory service providers about their experience of working with Sure Start professionals in one Nottinghamshire (UK) Sure Start programme, and to explore the extent to which there was a shared agenda and successful collaboration. A purposive sample of 18 statutory providers working within existing mainstream health, education and social care services were interviewed, between January and March 2005. Data were analysed through thematic content analysis. We found that although interviewees welcomed the additional input provided by Sure Start for the most vulnerable families, a number of tensions arose over key divergences between the philosophical positions of statutory providers and Sure Start. The most important tension was over Sure Start's philosophy of targeting resources on an entire geographical area. This was seen as antithetical to statutory providers' case-by-case approach, and raised questions about access and equity for families living outside Sure Start's boundaries. Sure Start's concentration on young children, and the time-limited nature of their services and activities, frustrated statutory providers who had a broader family focus, and a longer term perspective. The perceived under-resourcing of statutory services in comparison to Sure Start, and statutory providers' responsibility for 'selling' Sure Start services, strained a sense of equality between agencies and professionals, and undermined a sense of a shared agenda. We conclude that successful collaboration and a shared agenda depends upon a mutual understanding of the basic philosophy of service provision. The government's commitment to developing interprofessional collaboration will be furthered significantly by placing Sure Start services under the umbrella of statutory provision, and ensuring that the differing service philosophies are reconciled.