Emergency Nurses' Perceptions of Providing End-of-Life Care in a Hong Kong Emergency Department: A Qualitative Study.

INTRODUCTION: Provision of end-of-life (EOL) care in the emergency department has improved globally in recent years and has a different scope of interventions than traditional emergency medicine. In 2010, a regional hospital established the first ED EOL service in Hong Kong. METHODS: The aim of this study was to understand emergency nurses' perceptions regarding the provision of EOL care in the emergency department. A qualitative approach was used with purposive sampling of 16 nurses who had experience in providing EOL care. Semi-structured, face-to-face interviews were conducted from May to October, 2014. All the interviews were transcribed verbatim for content analysis. RESULTS: Four themes were identified: (1) doing good for the dying patients, (2) facilitating family engagement and involvement, (3) enhancing personal growth and professionalism, and (4) expressing ambiguity toward resource deployment. DISCUSSION: Provision of EOL care in the emergency department can enhance patients' last moment of life, facilitate the grief and bereavement process of families, and enhance the professional development of staff in emergency department. It is substantiated that EOL service in the emergency department enriches EOL care in the health care system. Findings from this study integrated the perspectives on ED EOL services from emergency nurses. The integration of EOL service in other emergency departments locally and worldwide is encouraged.

Factors associated with resilience of adult survivors five years after the 2008 Sichuan earthquake in China.

Given the paucity of quantitative empirical research on survivors' resilience and its predictors in the context of long-term recovery after disasters, we examined how resilience predictors differed by gender among adult survivors five years after the Sichuan earthquake. This was a cross-sectional survey study of adult survivors (N = 495; aged 18-60) living in reconstructed communities five years into the recovery process after the Wenchuan earthquake. The instruments we used included assessments of sociodemographic characteristics and earthquake exposure level, the Connor-Davidson Resilience Scale, and the Social Support Rating Scale. Support-seeking behaviors emerged as a significant predictor of male survivors' resilience, while subjective support and marital status were found to be predictors of female survivors' resilience. Annual household income and chronic disease were predictors for both male and female groups. The findings of this study can be used in devising methods to boost survivors' resilience by promoting their satisfaction with social support and their ability to obtain effective support. Additionally, the results suggest how to assist survivors who may have relatively poor resilience.

A field study of the role of nurses in advocating for safe practice in hospitals.

AIM: To explicate nurses' role and the underlying processes involved in advocating for safe practice in hospitals. BACKGROUND: Nurses' role as patient advocates in safeguarding patients' interests and well-being is constantly upheld. As previous studies have fallen short in delineating the processes of how and in what conditions the patient advocate role is operationalized, this study was conducted to fill the evidence gap through examining nurses' advocacy role and practices in real clinical contexts. DESIGN: A field study approach that involved multiple methods of data collection was adopted. METHODS: This study was conducted from February 2010-March 2011 in four medical units in two public hospitals in Hong Kong. Empirical data were generated from weekly field observations, review of relevant documents and individual semi-structured interviews with 28 nurses and were then analysed through a comparative analysis process. RESULTS: Nurses play an integral role in ensuring safe practice in hospitals through mitigating risk arising from sudden changes in patients' health conditions and the hospitalization process and correcting near-misses for co-workers to prevent harm. The modelling of expert nurses and team-based learning emerged as essential factors facilitating the development of nurses' advocacy role and practices. The state of 'limited advocacy', as characterized by the adoption of disempowering and coercive measures to ensure patient safety, clearly indicates a need to re-examine the concept of advocacy in contemporary health care. CONCLUSION: The findings contribute to a more complete understanding of nurses' advocacy role and practices, which have a significant bearing on patient safety.

Living and dying with dignity in Chinese society: perspectives of older palliative care patients in Hong Kong.

BACKGROUND: the empirical Dignity Model has profoundly influenced the provision of palliative care for older terminally ill patients in the West, as it provides practical guidance and intervention strategies for promoting dignity and reducing distress at the end-of-life. OBJECTIVE: to examine the concept of 'living and dying with dignity' in the Chinese context, and explore the generalisability of the Dignity Model to older terminal patients in Hong Kong. METHODS: using qualitative interviews, the concept of dignity was explored among 16 older Chinese palliative care patients with terminal cancer. Framework analysis with both deductive and inductive methods was employed. RESULTS: the three major categories of themes of the Dignity Model were broadly supported. However, the subtheme of death anxiety was not supported, while two subthemes of generativity/legacy and resilience/fighting spirit manifested differently in the Chinese context. Furthermore, four new emergent themes have been identified. They include enduring pain, moral transcendence, spiritual surrender and transgenerational unity. CONCLUSION: these findings highlight both a cultural and a familial dimension in the construct of dignity, underline the paramount importance of cultural awareness and competence for working with ethnically diverse groups, and call for a culturally sensitive and family oriented approach to palliative care interventions with older Chinese terminal patients.

Attributes of nursing work environment as predictors of registered nurses' job satisfaction and intention to leave.

AIM: To examine how front-line registered nurses' perception of their work environment associates with and predicts nurse outcomes in terms of job satisfaction and turnover intention. BACKGROUND: Mounting evidence has pointed to an inseparable link between attributes of the nursing work environment and nurse outcomes. However, there is a paucity of research examining nurses' perception of their work environment beyond the Western context. METHODS: This cross-sectional survey involved 1271 registered nurses working in 135 inpatient units in 10 public hospitals in Hong Kong. The instrument comprised items developed from in-depth interviews with front-line nurses that explored nurses' perception of their work environment. RESULTS: Factor analysis identified five dimensions (professionalism, co-worker relationship, management, staffing and resources, and ward practice) of the nursing work environment. Logistic regression analysis further identified professionalism, management and ward practice as significant factors in predicting nurses' turnover intention, and staffing and resources as an additional factor in predicting their job satisfaction. CONCLUSIONS: Attributes of the nursing work environment have a significant bearing on nurses' job satisfaction and intention to leave. IMPLICATIONS FOR NURSING MANAGEMENT: Managerial effort should focus on improving nurses' work conditions through detailed resource planning, effective management and removal of work constraints that affect nursing practice.

Stabilizing and destabilizing forces in the nursing work environment: a qualitative study on turnover intention.

BACKGROUND: The nursing work environment, which provides the context of care delivery, has been gaining increasing attention in recent years. A growing body of evidence points to an inseparable link between attributes of the nursing work environment and nurse and patient outcomes. While most studies have adopted a survey design to examine the workforce and work environment issues, this study employed a phenomenological approach to provide empirical evidence regarding nurses' perceptions of their work and work environment. AIM: The aim of this study was to advance our understanding of the phenomenon of increasing nurse turnover through exploring frontline registered nurses' lived experiences of working in Hong Kong public hospitals. METHODS AND PARTICIPANTS: A modified version of Van Kaam's controlled explication method was adopted. Individual semi-structured interviews were conducted with 26 frontline nurses recruited from ten acute regional, district and non-acute public hospitals in Hong Kong. Their perspectives in regard to their work and work environment, such as workload, manpower demand and professional values, were extensively examined, and a hypothetical description relating the nursing work environment with nurses' turnover intention was posited. RESULTS: Contemplation of nurses' experiences revealed the vulnerable aspects of nursing work and six essential constituents of the nursing work environment, namely staffing level, work responsibility, management, co-worker relationships, job, and professional incentives. These essential constituents have contributed to two sets of forces, stabilizing and destabilizing forces, which originate from the attributes of the nursing work environment. Nurses viewed harmonious co-worker relationships, recognition and professional development as the crucial retaining factors. However, nurses working in an unfavorable environment were overwhelmed by destabilizing forces; they expressed frustration and demonstrated an intention to leave their work environment. CONCLUSIONS: The nursing work environment is a complex entity comprising multiple constituents; its attributes affect nurses' perceptions of their work and work environment, which warrant special attention in addressing the phenomenon of increasing nurse turnover.

Influenza vaccine preference and uptake among older people in nine countries.

AIM: This paper is a report of a study delineating factors that influence older people's preferences and uptake of the influenza vaccine in nine countries. BACKGROUND: Vaccination uptake for the aging population in many countries still remains below the World Health Organization recommended rate. Older people who perceive higher susceptibility to and severity of influenza, and more benefits from vaccination and action cues prompting vaccination, tend to accept the vaccine, but those with more perceived barriers to vaccination are less likely to accept it. METHOD: A total of 208 older people from China, Indonesia, Turkey, Korea, Greece, Canada, the United Kingdom, Brazil and Nigeria were recruited to 14 vaccinated and 12 unvaccinated focus groups. They shared their experiences of influenza, and influenza vaccination, and promotion of influenza vaccination in focus groups. The data were collected in 2007. FINDINGS: We identified five themes and generated a hypothetical framework for in-depth understanding of vaccination behaviour among older people. Participants' vaccine preferences were determined by their behavioural beliefs in vaccination, which were based on their probability calculation of susceptibility to and severity of influenza and vaccine effectiveness, and their utility calculation of vaccine, healthcare and social costs. Action cues prompting vaccination and vaccine access further affected the vaccine uptake of participants with vaccine preferences. Vaccination coverage was likely to be higher in the countries where normative beliefs in favour of vaccination had formed. CONCLUSION: The hypothetical framework can be used to guide healthcare providers in developing strategies to foster normative beliefs of older people in vaccination, provide effective action cues and promote vaccine access.

The effect of Chinese food therapy on community dwelling Chinese hypertensive patients with Yin-deficiency.

OBJECTIVES: The objectives of this study are to evaluate the effectiveness of Chinese food therapy in correcting the Yin-deficiency and to examine its impact on the patients' quality of life and hypertension control. BACKGROUND: Epidemiological studies have shown 14-50% of people with hypertension have Yin-deficiency. Whether restoring the Yin-Yang balance by means of Chinese food therapy can help to better manage patients with hypertension has yet to be examined. DESIGN: Two groups randomised controlled trial. METHODS: Eighty-five hypertensive patients recruited from two community health service centre were divided into two groups. The intervention group (n = 48) received specific dietary instructions and corresponding management of their antihypertensive medication if indicated and brief health education, whilst the control group (n = 37) received routine support involving only brief health education. Data were collected at baseline, after intervention at four, eight, 12 and 16 weeks follow-up. Comparisons were made to examine the effects of Chinese food therapy on Yin-deficiency symptoms, blood pressure and quality of life of hypertensive patients. RESULTS: The intervention group had reduction in the numbers of antihypertensive medication taken as well as improvement in most of the Yin-deficiency symptoms after 12 weeks of Chinese food therapy and mean scores of several SF-36 dimensions were higher than that of in the control group after 12 and 16 weeks follow-up. Significant difference was found in systolic blood pressure in the intervention group when it was compared from baseline to after four and eight weeks respectively. CONCLUSION: Chinese Food Therapy can restore body constitution with Yin-Yang imbalance and may potentially improve hypertensive patients' quality of life. It is also beneficial in controlling blood pressure in hypertensive patients. RELEVANCE TO CLINICAL PRACTICE: Chinese food therapy may become a complementary therapy in health care and it should be a component of nursing education and health education.

Pressure ulcer development in older residents in nursing homes: influencing factors.

AIM: This paper is a report of a study assessing pressure ulcer incidence and factors affecting pressure ulcer development among older nursing home residents. BACKGROUND: Previous researchers have shown that demographic, clinical, health status, risk and human resources factors affect pressure ulcer development among older people in various healthcare settings, but none has investigated their interactive effects among older nursing home residents. METHOD: This was a prospective cohort study involving 346 residents aged 65 years or over from four private nursing homes in Hong Kong. We collected information on participant demographics and assessed their clinical characteristics, health status and pressure ulcer risk factors. Subsequently, we assessed their skin condition every 2 days for 4 weeks to detect pressure ulcers that developed after the initial assessment. The data were collected between December 2006 and September 2007. RESULTS: The pressure ulcer incidence was 25.16%. The model in which the factors of clinical characteristics, health status, pressure ulcer risk and human resources were controlled was more reliable in predicting pressure ulcer development than the other two models. It showed that bedfast or chairfast residents, especially those with co-morbidities (renal failure and stroke) and living in nursing homes where there were no nurses but more nursing assistants, were at higher risk for pressure ulcer development. CONCLUSION: Evidence-based interventions should be adopted to minimize the possible problems of pressure, malnutrition, friction and shear force, and the decreased pain perception of bedfast or chairfast residents in nursing homes, especially those with renal failure or stroke.

Ethical analysis of non-medical fetal ultrasound.

Obstetric ultrasound is the well-recognized prenatal test used to visualize and determine the condition of a pregnant woman and her fetus. Apart from the clinical application, some businesses have started promoting the use of fetal ultrasound machines for nonmedical reasons. Non-medical fetal ultrasound (also known as 'keepsake' ultrasound) is defined as using ultrasound to view, take a picture, or determine the sex of a fetus without a medical indication. Notwithstanding the guidelines and warnings regarding ultrasound safety issued by governments and professional bodies, the absence of scientifically proven physical harm to fetuses from this procedure seems to provide these businesses with grounds for rapid expansion. However, this argument is too simplistic because current epidemiological evidence is not synchronous with advancing ultrasound technology. As non-medical fetal ultrasound has aroused very significant public attention, a thorough ethical analysis of this topic is essential. Using a multifaceted approach, we analyse the ethical perspective of non-medical fetal ultrasound in terms of the expectant mother, the fetus and health professionals. After applying four major theories of ethics and principles (the precautionary principle; theories of consequentialism and impartiality; duty-based theory; and rights-based theories), we conclude that obstetric ultrasound practice is ethically justifiable only if the indication for its use is based on medical evidence. Non-medical fetal ultrasound can be considered ethically unjustifiable. Nevertheless, the ethical analysis of this issue is time dependent owing to rapid advancements in ultrasound technology and the safety issue. The role of health professionals in ensuring that obstetric ultrasound is an ethically justifiable practice is also discussed.

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting.

AIMS AND OBJECTIVES: To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. BACKGROUND: Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. DESIGN: A prospective cohort study. METHOD: A total of 197 subjects in a 106-bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. RESULTS: Out of 197 subjects, 18 patients (9.1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0.736 and for the Braden scale was 0.648. The modified Braden cut-off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = -1.544, OR=0.214, p = 0.016), body build for height (Beta = -0.755, OR = 0.470, p = 0.030) and skin type (Beta = -1.527, OR = 0.217, p = 0.002) were significantly predictive of pressure ulcer development. CONCLUSION: The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. RELEVANCE TO CLINICAL PRACTICE: The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.

A comparative study of Chinese, American and Japanese nurses' perceptions of ethical role responsibilities.

This article reports a survey of nurses in different cultural settings to reveal their perceptions of ethical role responsibilities relevant to nursing practice. Drawing on the Confucian theory of ethics, the first section attempts to understand nursing ethics in the context of multiple role relationships. The second section reports the administration of the Role Responsibilities Questionnaire (RRQ) to a sample of nurses in China (n = 413), the USA (n = 163), and Japan (n = 667). Multidimensional preference analysis revealed the patterns of rankings given by the nurses to the statements they considered as important ethical responsibilities. The Chinese nurses were more virtue based in their perception of ethical responsibilities, the American nurses were more principle based, and the Japanese nurses were more care based. The findings indicate that the RRQ is a sensitive instrument for outlining the embedded sociocultural factors that influence nurses' perceptions of ethical responsibilities in the realities of nursing practice. This study could be important in the fostering of partnerships in international nursing ethics.

Nonpharmacologic sleep promotion: bright light exposure.

This paper presents findings on utilizing bright light to entrain the sleep-wake cycle in order to improve the perceived quality of sleep.The feasibility of including bright light as one of the nonpharmacologic nursing interventions for sleep promotion is discussed. A decade ago, nurses relied on sleeping pills to solve patients' sleep problems (Halfens et al. 1991). Reported obstacles to the development of sleep management tools included insufficient knowledge of sleep (Edéll-Gustafasson et al. 1994) and unfamiliarity with effective nursing methods for tackling sleep problems (Halfens et al. 1991). Ten years later, nurses took the initiative in sleep promotion activities. In their book, Morgan and Closs (1999) introduced several sleep management methods in nursing practice. Floyd et al. (2000) summarized that 12 nonpharmacologic interventions used by nurses in the past to promote sleep. These 12 interventions are categorized according to their mechanism of action as relaxation, noise management, circadian repatterning and sleep hygiene. Light is thought to regulate the circadian system (Dawson & Van den Heuvel 1998) as a major synchronizer of endogenous circadian cycles (Dijk et al. 1995).