Parent-child communication and timing of interventions are challenges in the Duchenne muscular dystrophy care.

AIM: Duchenne muscular dystrophy (DMD) is an X-linked myopathy affecting one in 3600-6000 live male births. The aim of this study was to gain further insight into how parents experience caring for boys with DMD. METHODS: Using a qualitative design, parents in 12 families with boys with DMD, whereof two pairs of siblings, were interviewed in 2014 and 2015. Participants were parents of boys followed at Oslo University Hospital or other hospitals in the south-eastern health region of Norway. Mean age of the boys was 13 years, range 7-17. RESULTS: Parents expressed the importance of obtaining good information about the diagnosis, supplied with sensitivity for them as clients, and the parents must be involved in timing of interventions. Meeting with others in the same situation was highly appreciated. Many of the parents expressed their own need for support to cope with the difficult situation. Continuity of support in the boys' transition to adulthood was pointed out as important, as well as the need for professional help to talk to the boys about their diagnosis. CONCLUSION: Our study suggests that professional teams should expand the parental perspective and emphasise a holistic approach in their work with patients with DMD.

Analgesia and sedation of mechanically ventilated patients - a national survey of clinical practice.

BACKGROUND: The importance of balanced sedation and pain treatment in intensive care units (ICUs) is evident, but regimes and use of medication differ widely. Previous surveys have focused on the use of various medications and regimes. What has not been explored is the process by which nurses and physicians assess patients' needs and work together toward a defined level of sedation and pain for the ICU patient. The purpose of the study was to determine the use of protocols and medications for sedation and analgesia in Norwegian ICUs and the degree of cooperation between nurses and physicians in using them. METHODS: A national survey was conducted in autumn 2007, using postal self-administered questionnaires. RESULTS: Written pain treatment and sedation protocols were not routinely used in Norwegian ICUs; however, half of the departments titrated sedation according to a scoring system, most commonly the Motor Activity Assessment Score. The most commonly used sedatives were propofol and midazolam, while fentanyl and morphine were the most used analgesics. The majority of respondents were concerned about the side effects of sedation and analgesics, leading to circulatory instability and delayed awakening. Nurses and physicians agreed upon the main indications for sedation: patient tolerance for ventilation, tolerance for medical and nursing interventions, and patient symptoms. CONCLUSIONS: Potential factors which may improve sedation and pain management of mechanically ventilated patients in Norwegian ICUs are more systematic assessments of pain and sedation, and the use of written protocols. Strategies which reduce side effects should be addressed.

Targeting risk factors for impaired wound healing and wound complications after kidney transplantation.

BACKGROUND: Because of potent immunosuppression, impaired wound healing and complications are frequent features after kidney transplantation (KTx). OBJECTIVE: To investigate the incidence and nature of impaired wound healing and complications at a single transplantation center in Norway. PATIENTS: Of 226 patients who underwent KTx, 199 (87%) were followed up prospectively for 1 year (2005) via close and meticulous wound inspection. RESULTS: The study revealed a high rate of wound complications (200-250/y) in a high-volume center. Fifty-four patients (27%) experienced prolonged wound healing, defined as gaps, secretions, or wound complications, at 3 to 5 weeks posttransplantation, and 41 patients (21%) had impaired wound healing, defined as gaps, secretions, or wound complications after 5 weeks posttransplantation. In total, 50 patients (25%) required surgical or radiologic reintervention. Complications included lymphocele in 29 patients (14.6%), wound dehiscence in 16 (8.0%), bleeding or hematoma in 10 (5.0%), and infection in 9 (4.5%). Risk factors associated with wound complications included recipient older than 60 years, body mass index greater than 30, hemoglobin concentration less than 10 g/dL, albumin concentration less than 36 g/dL, duration of surgery more than 200 minutes, no subcutaneous sutures, and sirolimus or everolimus therapy. At nominal and logistic regression analysis, recipient older than 60 years, body mass index greater than 30, and no subcutaneous sutures were independent risk factors. CONCLUSION: Risk factor analysis and previous documentation suggest that wound complications might be counteracted using the following measures: subcutaneous sutures, predialysis transplantation, sealing or ligation of lymphatic trunks, prophylactic fenestration, reduction of corticosteroid load, and avoiding sirolimus/everolimus therapy.

From simplicity to complexity: developing a model of practical skill performance in nursing.

The purpose of this article is to present and discuss a new model of practical skill performance in nursing. The model is conceptualized as having five components: substance and sequence; accuracy; fluency; integration; and caring conduct. The model challenges the truism of 'simple' nursing procedures. It is argued that performance of practical skills in nursing is characterized by complexity on many levels. Complexity lies within and between the components of the performance model and in the interaction between the nurse and the clinical context where practical nursing actions are performed. These complexities are described. Examples that illustrate the complex and reciprocal nature of these components are drawn from an empirical study of graduate nurses' development of practical skill in surgical hospital units. Implications of the model for education, practice and research are discussed.

Issues in nurses' practical skill development in the clinical setting.

Generally, it is assumed that nurses are reasonably skilled in the performance of practical nursing actions by the end of their first year of practice. This article contests this assumption based on empirical data from a longitudinal study of newly graduated nurses. Three issues are discussed: the notion that experience (per se) can guarantee a positive development in practical skill performance; the failure to relate to inherent complexities in practical skill performance during evaluation of skill; and the significance of acknowledging differences in skill complexity during skill development. A reinstated focus on practical skill in nursing education and collaboration between education and practice is needed to secure quality in a nurse's actual performance.

What constitutes a nursing practical skill?

Practical nursing skills ensure patients' physical comfort, hygiene, and safe medical treatment. The learning, performance, or significance of nursing practical skills are seldom a theme in theoretical and philosophical debate or the topic of research within nursing. This might be due to a long-standing behavioristic tradition in nursing of viewing nursing practical skills in a simplistic way, only as correctly sequenced motor movement. The purpose of this article is to bring forth an argument for a broader understanding of the constitution of nursing practical skills. This argument is substantiated by a review of past and present conceptualizations of nursing practical skills as well as by philosophical reflections on the value of practical skills in the nursing profession. Nursing practical skills embrace dimensions of performance, intention, and nursing "disciplined" understanding.

Practical skill development in new nurses.

This paper reports the results of an empirical study of new nurses' development of practical skill. Actual practice and clinical learning of new nurses has received minor attention in nursing research. This may build on the assumption that practical skill naturally improve as a result of working in the clinical setting. In the present study nurses were videotaped several times as they performed in the clinical setting, and interviewed after each filming. Analysis of skill development was rendered possible by comparing characteristics of performance over time. A model of practical skill performance was developed during the analysis. This model advances a broader understanding of practical skill by incorporating the following constructs: substance and sequence, accuracy, fluency, integration and caring comportment. The nurses' trajectories of practical skill development are presented on the basis of this model. Individual and common trends in practical skill development are discussed, and the idea of development of practical skill as a natural happening in the clinical setting is critiqued.

Changing conceptions of practical skill and skill acquisition in nursing education.

The learning of practical skill in nursing is not a priority of nursing education today. This is a result of a narrow and mechanistic concept of practical skill and its acquisition in nursing education. This paper reviews these conceptions as they have been developed in major textbooks for nurse teachers and in research articles on skill teaching, learning and evaluation over the past 50 years. Nursing research must move out of the laboratory and into the clinical setting in order to incorporate the typical aspects of practical skill learning in nursing. Future challenges in this kind of research are discussed.

Neglected conflicts in the discipline of nursing: perceptions of the importance and value of practical skill.

The patient's body has moved out of focus in nursing. This has led to the diminishing importance of practical skill in the discipline of nursing. Patients, however, consider these skills to be a vital part of good nursing care. How can nursing as a practical discipline live with the long-standing conflicts that these disparate views create? It is time that theoretical discourse within the discipline paid attention to the patient's perception of good nursing care, and that efforts are made to investigate how nurses in the clinical setting develop and consolidate the practical skills needed for the patient's hygiene, comfort and medical treatment. In this paper the conflicts are delineated and conditions relevant to their development are discussed.