Do referrals work? Responses of childbearing newcomers to referrals for care.

BACKGROUND: Health care post-birth may include referrals for additional care. Migrant (i.e., refugee, asylum-seeker, and immigrant) women frequently do not follow-up referrals for care and could be at increased health risk as a consequence. We sought to explore the inhibitors and facilitators of migrant women for following through with referrals for care. METHODS: Twenty-five women living in Montreal who had received a referral completed semi-structured interviews. RESULTS: Inhibitors included language barriers, transportation problems, scheduling appointments, absence of husband, absence of childcare, cold weather, perceived inappropriate referrals, and cultural practice differences. Facilitators included choice of follow-up facilitator, appropriate services, empathetic professionals, and early receipt of information. DISCUSSION: Results indicate that migrant women may not be receiving the care they and their newborns need once a concern is identified. This suggests conceiving of a different approach to the care of this population post-birth, which could include partnering with social or religious networks.

Medical and nursing clinical decision making: a comparative epistemological analysis.

The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skillful conduct of clinical decision making.

Toward a cultural conception of the self.

The dominant mental health models rely excessively on a modern Western ideal of the self. Health services in a pluralistic society require interventional approaches that recognize the significance of culture in shaping a person's conception of self as well as mental health and illness.

Striving to recapture our previous life: the experience of families with critically ill children.

The aim of this practice-based phenomenological study was to examine the experience of families with a critically ill child. Ten families were studied for a minimum of four months and a maximum of five years following the onset of a child's critical illness. 'Striving to recapture our previous life' was the central (systemic) phenomenon that characterized the overall struggles of these families. A number of specific phenomena were identified that related to the particular experiences of parents, siblings, and critically ill children. The findings of this study raise significant implications for the development of support strategies for these families.

The utility of futility: the construction of bioethical problems.

The aim of this article is to analyse the contemporary 'futility discourse' from a constructivist perspective. I will argue that bioethics discourse typically disregards the context from which controversies emerge and the processes that inform and constrain such discourse. Constructivists have argued that scientific knowledge is expressive of the dominant paradigm within which a scientific community is working. I will outline an analysis of 'medical futility' as a construction of biomedical and bioethical communities (and their respective paradigms). I will trace the emergence and utilization of futility in the literature. My analysis of the context (i.e. the historical circumstances, the particular actors involved) within which the futility discourse emerged suggests that medical futility was constructed, in part, as a means of enhancing physician domination of a context wherein medical authority was threatened. The actors in this debate express widely divergent frameworks of 'the good', arguing from distinctive representations of moral agency. At times, this controversy has been argued from incommensurate moral horizons wherein the discussants debate incomparable problems. This discussion is related to a study of the 'practice' of futility in the clinical context. Further studies on the construction of bioethical problems are a necessary condition for supporting the truth claims of bioethical arguments.

Adverse reactions to the withdrawal of opioids and benzodiazepines in paediatric intensive care.

The aim of this study was to examine adverse reactions to the withdrawal of opioids and benzodiazepines among critically ill children. Although withdrawal reactions have been well documented in relation to substance abusers and their newborn infants, there has been little study of this phenomenon as an iatrogenic problem. We developed a graphical case study method for examining patterns over time, and applied this to five cases referred to us by the nursing staff of a 10-bed paediatric intensive care unit. A striking pattern of behavioural distress was clearly associated with the diminution of opioids and benzodiazepines. These adverse reactions were characterized by various combinations of inconsolable crying, tremors, jitteriness, irritability, gagging, vomiting, and feeding problems. These signs appeared as early as 1 h and as late as 24 h following a significant reduction in opioid and benzodiazepine infusion rates, sometimes following very short-term therapy. We elaborate an interpretation of this distress, in light of the multiple disruptions undergone by critically ill children, and conclude by outlining our recommendations for preventing/minimizing these adverse reactions.

The experience of critically ill children: narratives of unmaking.

The purpose of this phenomenological study was to describe the experience of critically ill children. Seventeen children were followed through the course of their trajectory for a minimum of 3 months and a maximum of 5 years. This experience was characterised as a process of unmaking and remaking of the children. This process typically involved a transformation (a reconstitution) of the child. These phenomena were shaped within the child's relationships with significant others. This raises important implications for fostering 'relational' critical care for children.

Engagement and suffering in responsible caregiving: on overcoming maleficience in health care.

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as 'clinical phronesis,' i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of 'virtue ethics,' yet one that is informed by the exigencies of moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy--except, of course, when these notions are taken in their "disengaged" form (reflecting the malaise of "modern medicine"). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving--that ruse Katz has described as the 'silent world of doctor and patient'--provides may deny or refuse any 'given' connection with the patient especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of 'calculative reasoning' only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well--in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can 'save the life of medical ethics'--only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can 'prevent the death of medical ethics.'

Can critical care be delivered humanely?

Technological advances have tremendously altered the nature of health care delivered to the critically ill. High-technology care should be balanced with a humanistic approach to meet the needs of the "whole person". Humanistic care can be fostered by cultivating open dialogue among patients, families, physicians, nurses, and other involved staff.

A description of stressors and coping strategies among parents of critically ill children--a preliminary study.

The purpose of this preliminary study was to describe (1) perceived stressors and (2) coping strategies among parents of critically ill children. Stress and coping within this population has been subjected to little research. The research that has been reported is predominantly quantitative. The validity of this research is unclear. Five parents of children in a pediatric intensive care unit (PICU) setting were interviewed. They were asked to describe the principal sources of stress (stressors) they encountered and how they dealt with these (coping strategies). The interviews were content analysed. Five categories of stressors were identified. These included parental role conflict, concern for child, environment, friends, and child's siblings. Five categories of coping strategies were identified. These included things you think about, actions directed toward other people, drawing on support from others, things you do, and things you draw on from the environment. The findings of this study have highlighted deficiencies within the existing literature on stress and coping within this population. There is a need for further qualitative research in this area. This will foster the development of a better understanding of the experience of parents for caregivers and provide a foundation for further research.