Patients' perceptions of hospice day care: a phenomenological study.

This study explored the perceptions of 12 patients attending a day care unit in June/July 1996, with the purpose of finding out what was important to these people about their day care experiences. It used a phenomenological methodology derived from Paterson and Zderad's Humanistic Nursing Theory. The patients described numerous aspects of the day care service that were important to them. All 12 people interviewed considered the service satisfactory, and a number considered it to be more than anyone could or should expect. Day care was found to help them feel comfortable, to feel of value and to feel less isolated. In addition, the participants were found to be living with cancer in two different ways. All 12 knew they had cancer and might be terminally ill. Yet some seemed to "tolerate" their life with cancer, whereas others saw it as requiring "adaptation". The day care service was supporting both these styles of managing life with cancer. The interpretation of the findings suggests that the reason patients expressed such satisfaction with the service offered was because the care was humanistic. It responded to individual opinions, feelings and understandings of health and well-being, by giving people time and responding to their individual concerns. In this way, it was flexible enough to support people in managing their illness using their own preferred style.

Infection control in wound care: a study of fatalism in community nursing.

As part of a study of community nurses' perceptions of quality in nursing care, the author conducted in-depth qualitative interviews with seven community-based nurses. As part of the study, nurses were asked to describe episodes of wound care and to discuss the factors which could affect the quality of such care. One of the most interesting themes to emerge from the data was the apparent ambivalence of the nurses' attitudes towards infection control in wound care. Nurses discussed the concept of 'aseptic technique' in fatalistic terms and seemed uncertain about what could be achieved in terms of infection control. Although their policy guidelines referred to 'aseptic technique', their educational experience appeared to have made them feel uncertain about the implementation of the measures involved. With the proviso that this was a small scale qualitative study, the author concludes by suggesting that there is a need for greater clarity, both in what is taught and in what is included in practice policy with regard to infection control in wound care.

Community nurses' perceptions of patient 'compliance' in wound care: a discourse analysis.

As part of an interview study of community nurses' perceptions of their work, 62 staff working within the district nursing service in one English National Health Service Trust (grades B-H) were asked to recount occasions when they had been involved in wound care and to discuss the ways in which working with patients who required such care could be either enhanced or made difficult. A large number of respondents expressed the view that non-compliance could pose serious problems for the management of wounds. Data relating to compliance are presented here and are interpreted in the light of discourse analysis, an approach which permits the researcher to focus on the meanings underlying the communications of research participants and to interpret those meanings in the light of social and cultural mores and influences. The authors found that non-compliance could be explained by nurses in a number of different ways. These ranged from passive resistance, which could be due to ignorance or lack of motivation, through overt refusal, to deliberate interference in order to prolong treatment. It also seeks to outline some of the factors that appear to motivate the nurses' desire to achieve compliance.

Wound care in the community setting: clinical decision making in context.

Sixty-two community nurses in northern England of grades B and D to H were interviewed by a team of four researchers. The interviews were semi-structured, and were tape-recorded, fully transcribed and content analysed. They were conducted as part of a larger study, the aim of which was to examine community nurses' perceptions of quality in nursing care. One of the main themes the work focused on was decision-making as an element of quality. Data relating to wound care were considered from the perspective of the insights they offered into clinical decision-making. Data were interpreted in the light of a literature review in which a distinction had been made between theories which represented clinical decision-making as a linear or staged process and those which represented it as intuitive. Within the former category, three sub-categories were suggested: theorists could be divided into 'pragmatists', 'systematisers' and those who advocated 'diagnostic reasoning'. The interpretation of the data suggested that the clinical decisions made by community nurses in the area of wound care appeared largely intuitive, yet were also closely related to 'diagnostic reasoning'. They were furthermore based on a range of sources of information and justified by a number of different types of rationale.

The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care.

This paper reports findings from a study conducted in one community health care trust where 62 members of the district nursing team (grades B-H) were interviewed. An adaptation of the critical incident technique was used to determine factors which contributed or detracted from high quality care for a number of key areas including palliative care. The centrality of knowing the patient and his/her family emerged as an essential antecedent to the provision of high quality palliative care. Factors enabling the formation of positive relationships were given prominence in descriptions of ideal care. Strategies used to achieve this included establishing early contact with the patient and family, ensuring continuity of care, spending time with the patient and providing more than the physical aspects of care. The characteristics described by the community nurses are similar to those advocated in 'new nursing' which identifies the uniqueness of patient needs, and where the nurse-patient relationship is objectified as the vehicle through which therapeutic nursing can be delivered. The link with 'new nursing' emerges at an interesting time for community nurses. The past decade has seen many changes in the way that community nursing services are configured. The work of the district nursing service has been redefined, making the ideals of new nursing, for example holism, less achievable than they were a decade ago. This study reiterates the view that palliative care is one aspect of district nursing work that is universally valued as it lends itself to being an exemplar of excellence in terms of the potential for realizing the ideals of nursing practice. This is of increasing importance in the context of changes that militate against this ideal.

Managing change in nurse education: the introduction of Project 2000 in the community.

The United Kingdom Central Council's proposals for nurse education (Project 2000: A New Preparation for Practice) were implemented in 13 demonstration districts in England in 1989. In 1991, as part of an English National Board-funded research study, the author conducted 15 interviews with first line managers from three of these demonstration districts. The data were reinterpreted in 1995; the experience of implementing educational change in the community setting was discovered to be a complex and difficult process for the managers involved. They found themselves confronted with sometimes conflicting responsibilities; their perception of their role encompassed the meeting of a range of needs, which are presented in this paper within three categories. Firstly, the managers felt they had an obligation to meet the needs of students and of education in general in order both to provide an adequate experience for each individual student and to safeguard standards in community nursing in the long-term. Secondly, they were confronted with the need to mitigate the pressures of Project 2000 placed on 'their' staff. The new educational programme meant that community nurses spent much more time with students than formerly, and the difficulties they encountered were exacerbated by uncertainty about their role with these elements. Finally, and most importantly, managers were responsible for ensuring that clients' needs were met. In particular, they saw it as their role to ensure that the presence of large numbers of students in the community for long periods of time did not compromise standards in the delivery of community nursing services.

Learning through reflection in the community: the relevance of Schon's theories of coaching to nursing education.

In 1992, as part of a study funded by the English National Board for Nursing, Midwifery and Health Visiting, the author conducted 26 interviews, 12 with students on the newly-introduced Diploma in Higher Education for Nurses, and 14 with District Nursing Sisters who supervised them during their community placements. The approach to the work was interpretive and was guided by phenomenology. It was discovered that one of the most valuable contributions of their 'community experience' was the opportunities it gave the students to 'think through' and develop their own ideas about their practice. The author's interpretation of these findings was influenced by Donald Schon's ideas about reflective practice and coaching. His theory that professional practice is based on 'knowing-in-action' and 'theories-in-use' which are formulated and modified through a process of 'reflection-in-action' seemed to have direct relevance for the learning acquired by students. The help and guidance given to students by their supervisors bore some resemblance to the types of coaching advocated by Schon, to which he gave the names 'Joint Experimentation', 'Follow Me' and 'Hall of Mirrors'. The interpretation placed on the data discussed here also, however, differs from Schon's theories in advocating that more attention should be given to the academic theory referred to by him as 'technical rationality'.

The helping relationship in the community setting: the relevance of Rogerian theory to the supervision of Project 2000 students.

A series of twenty-six interviews, fourteen with district nursing sisters and twelve with students they supervised, was conducted in 1992 in one Project 2000 demonstration district in England. The data were collected as part of an English National Board funded research study; data were reinterpreted in 1994 and formed one element in the author's PhD thesis. Participants described the ways in which a supervisor might enable a student to learn during a community placement. One of the most important means by which supervisors could provide assistance was by creating an environment in which the students felt supported. Students described how supervisors demonstrated concern, acceptance and understanding, attributes which bore striking resemblance to the qualities of congruence, unconditional positive regard and empathic understanding identified by Carl Rogers as enabling learning.

The learning career in the community setting: a phenomenological study of a Project 2000 placement.

The findings of one element of an English National Board-funded research study conducted in two phases between 1989 and 1992 are discussed. The study examined one aspect of the new Project 2000 courses introduced in 13 'demonstration districts' in England in the autumn of 1989. During Phase 2 of the study (1991-1992). 14 district nursing sisters and 12 of the students they supervised were interviewed. Data were re-transcribed and interpreted in 1993; the interpretation was based on a phenomenological paradigm which focused on the subjective perceptions of students and supervisors. Participants identified 'learning', as it took place in the community setting, as a sequential process, which is referred to here as the 'learning career'. Using terminology adopted by participants themselves; the authors identify the stages of the 'learning career' as:'encountering reality'; 'having a go' 'gaining confidence'; 'thinking through and understanding'; 'developing ideas'; 'being independent'; and 'being assessed'. Supervisors could ease their students' passage through this complex and anxiety-provoking sequence of events in a number of ways. They could demonstrate their practice and provide opportunities for students to gain experience for themselves; they could teach their students about nursing, and enable them to reflect on their own practice; and they could also monitor and assess their students' work.

The time commitment of the community nursing services to Project 2000.

As part of an English National Board funded research study, the authors sent questionnaires to 2500 individuals with community nursing qualifications. The survey was complemented by a series of interviews with community nurse managers. Data indicated that community nurses were spending very considerable amounts of time with students. The number of placements provided per year varied considerably from one respondent to another, as did the average duration of a placement. Community nurses were providing community experience for a variety of types of nursing students, as well as students of other professions, and the time commitment involved placed them under considerable strain. The authors conclude that there is a need to recognise the time given by community nurses to work with students, and the resource implications of this commitment.

The implementation of Project 2000 in the community: a new perspective on the community nurse's role.

This paper considers some of the initiatives taken by community nurses in England in implementing Project 2000 placements. The data were obtained during an English National Board funded study in two phases. The first phase involved a series of exploratory interviews, a postal questionnaire survey, and semi-structured interviews with 15 managers. In phase two, one Project 2000 demonstration district was studied in depth by means of interviews complemented by small-scale questionnaire studies. Community nurses had confronted a number of difficulties in implementing Project 2000. Among the most serious of these were shortage of time, poor communication with the colleges of nursing and lack of preparation. As a consequence, community nurses took what they saw as independent approaches to students' placements. Many set their own aims and objectives for placements and produced written guidelines and teaching plans for students. Many also asserted the importance of their role in the assessment of students' practical work.