Duncan Randall

Editorial: Failure to care: nursing in a state of liquid modernity?

There has been significant public interest recently concerning perceived inadequacies in the quality of nursing care. Across a number of settings, there has been a litany of neglect and abuse leading to both accusations of a compassion deficit and counterclaims from nurses and nursing scholars. While some of what we are seeing in the media are moral panic and reporting exceptional cases, there has been an increase in complaints made about nurses in several countries (e.g. UK Government 2013). The number of media stories on the systematic failure of nurses to provide care would seem to indicate at least some level of a problem over and above media hyperattention. We know what makes good nursing and good nurses: nursing is perhaps one of the most highly regulated professions with national and internationally stated criteria for practice and education. Even children know what makes a good nurse (Randall & Hill 2012). We have had countless leadership programmes and health improvement programmes, and yet, we see now the failure of nurses, their leaders and of organizations to put in place safeguards that provide patients and nurses with cultures that consistently deliver safe human care. Why? What we want to argue is that this failure of caring systems is directly related to the liquidification of nursing. Bauman (2000) describes a state of liquid modernity, a phase in the development of capitalism where uncertainty reigns and stability are forever undermined. Without wishing to idealise a supposed ‘golden age’, arguably, in the 1950’s nursing was more ‘solid’. The matron ruled, nurses were educated in hospitals to which they were expected to owe a debt of gratitude and to work in the same hospital upon qualification. There was a sense that one worked one’s way up through a perhaps rigid somewhat militaristic structure of staff nurse, junior sister, sister, senior sister, matron. This solid system had certainty about it, but also nurses were encouraged and rewarded for staying in one place, working for the hospital in which they had trained. Patients too were expected to be in hospital for longer periods. Bauman argues that this solidity and sense of location allows systems to be human. It is worth investing in relationships if you can anticipate a certain longevity within which social ties may strengthen and deepen or if you think you are going to be around if people come back to complain! For nurses, it is worth investing time and effort in getting to know patients and their families as people if you are going to be working in a community over time. Compare this with the more recent liquidification, routinisation and mechanising of nursing. Now, nurses are educated by universities in various hospitals, they are encouraged to seek employment on the ‘open market’. Despite attempts to structure nursing careers (Department of Health 2006), it remains unclear what is required of nurses to progress to clinical nurse specialist or nurse consultant levels. Patterns of promotion, even at the initial clinical levels, vary between employers. There is a much faster turnover of staff and of patients too. Many of the important functions of the nurse are being mechanised often in a bid for alleged quality improvement. The nurses’ role is atomised and restructured as a set of competencies or colour-coded tick-box forms which arguably could be completed by any suitably trained person. Thus, the liquid state is one of fast-moving uncertainty and ambivalence, where it is difficult to establish and maintain relationships. Fear stalks the workforce, the liquid-state fear of being replaced, moved or removed. In the UK, it is claimed that the NHS lost over 6000 nursing posts between 2010–2012 (Campbell 2012). Although the actual number of nurses who are reorganised or made redundant may be relatively small, that is not the point; it is the fear of being reorganised or replaced which dominates and pervades nurses’ thinking. This leads nurses to disinvestment in caring for people as fellow human beings. For Bauman, contemporary society finds itself in a perpetual condition of uncertainty. Attempts to design order into systems, such as healthcare systems, are actually doomed to precipitate unanticipated obstacles and problems, ultimately leading to disorder. In some sense, Bauman is concerned with the potential for realising forms of human autonomy and solidarity, but sees this frustrated by the advancement of a consumerist culture as a characteristic of late capitalism. As such, there is a degree of resonance with earlier writing which explored the alienating effects of workplace technologies or the emotional labour of public service jobs (Hochschild 1983), and these ideas have been applied to better understand nursing roles and experiences (Theodosius 2008). Alienation in nursing work is both similar to that experienced by other workers, stemming from lack of control over ones work and how it is organised, but may also involve some factors fairly unique to nursing, such as dealing intimately with the body in illness which may be beyond the control of the nurse or health care more

Be my guest! Challenges and practical solutions of undertaking interviews with children in the home setting

This article aims to share critical debate on undertaking interviews with children in the home setting and draws on the authors’ extensive research fieldwork. The article focuses on three key processes: planning entry to the child’s home, conducting the interviews and exiting the field. In planning entry, we include children’s engagement and issues of researcher gender. In conducting the interviews, we consider issues such as the balance of power, the importance of building a rapport, the voluntary nature of consent and the need for a flexible interview structure. Finally, we address exiting from the child’s home with sensitivity at the end of the interview and/or research study. Undertaking research in the child’s home provides a known and familiar territory for the child, but it means that the researcher faces a number of challenges that require solutions whilst they are a guest in a child’s home.

'Making the bad things seem better': coping in children receiving healthcare.

The focus of children’s healthcare literature has been the delivery of services to children and their parents, little attention has been paid to how children cope with receiving such care. In this paper we use a literature scoping method to bring together the literature on how medical talk can engage or isolate children, consider the environmental factors which can help children to be engaged and discuss an ethical symmetry approach. We propose that an ethical symmetry approach would provide a framework for healthcare teams to explore how to optimize children’s engagement with their healthcare.

Protecting children in research: Safer ways to research with children who may be experiencing violence or abuse

Children participating in research, like other children, may be being maltreated. There is also potential for exposure to abuse during research. Research training, practices and protocols to respond to disclosure and discovery of abuse to protect both researchers and children may not be sufficiently robust. Our aim was to compare and contrast research practices reported in the literature related to protecting children and to recommend safer ways to conduct research. The simultaneous increase in research with children, along with an increased willingness to listen to child victims of abuse, means that researchers must consider the protection of children in the research setting. Twenty-three papers were identified in a literature review. These studies reported a wide variation of ethical considerations, methods, methodology and came from different disciplines. From the 23 papers, two overarching themes were identified: social justice and research and safer research. To make research safer teams should consider training, safety protocols and support for child protection, which includes support to report safeguarding concerns to social care. Further work is required to ensure that training, protocols and support are effective in facilitating researchers to identify and make appropriate child abuse referrals. Ethics practices in abuse research need further debate.

The Spectrum of Children's Palliative Care Needs: a classification framework for children with life-limiting or life-threatening conditions

Objectives This paper examined the potential of a new classification framework, The Spectrum of Childrens Palliative Care Needs, to facilitate identification of children with palliative care needs for the purposes of minimum data set collection and population needs assessment. Methods Health and social care professionals (n=50) in a range of paediatric palliative care settings applied The Spectrum to (i) clinical vignettes and (ii) consecutive children on their caseloads. They also provided confidence ratings and written comments about their experiences. Inter-rater reliability, conceptual validity, acceptability, feasibility and sustainability were examined. A subset of professionals (n=9) also participated in semistructured telephone interviews to provide further insight. Results Inter-rater reliability for the vignettes (κ=0.255) was fair. However, professionals were more confident applying The Spectrum to their caseloads, which included children (n=74) with a range of life-limiting/life-threatening conditions. The Spectrum made conceptual sense in relation to these children and was considered to offer a meaningful way to define the eligible population in service mapping. Benefits for clinical work (eg, facilitating patient review, workload management, clinical audit) and research were also identified. However, important threats to reliability were highlighted. Conclusions Preliminary assessment of The Spectrum confirms its potential to promote consistent data set collection in childrens palliative care. The results have been used to produce a revised version and user guidelines to address issues raised by participants. However, further research is required to further validate the framework and establish its relevance to families’ self-defined needs.

THE BENEFITS FOR CHILDREN'S NURSES OF OVERSEAS PLACEMENTS: WHERE IS THE EVIDENCE?

Overseas placements are presumed to provide students with experiences to enhance their cultural competence and to give them insights into other healthcare systems. However, the literature has not focused on what students of children’s nursing might gain from an overseas placement. This paper is a report of a literature review (2003–2011) and our own student evaluation, both aimed at shedding new light on this important opportunity for learning for children’s nurses. The literature review indicates that current research does not address the learning from overseas placements for children’s nurses. Our student evaluation suggests children’s nursing students are able to explore the position of children in the host culture and to place this in a healthcare context. Students also reported that they adhered to UK scope of student practice when delivering care to children on overseas placement. These placements provide a valuable learning experience for children’s nurses. However, consideration in the shorter term is required to address issues of equity. Looking forward, further large scale studies are required to determine the long term effects of such experience on the health outcomes for children, and development of children’s nurses and children’s nursing globally.

Children’s regard for nurses and nursing: A mosaic of children’s views on community nursing

In the past decade there has been both an increase in the number of children who receive nursing care in their communities rather than in hospitals, and an increasing willingness to listen to children. This qualitative study used Clark’s Mosaic approach to elicit children’s views of community children’s nursing. Twenty-one children took part in total, with seven children making up a core group who participated in a number of activities for over a year. A non-core group of 14 children were observed receiving care from six community children’s nurses. The children had diverse medical conditions, were aged from 11 months to 17 years old and came from diverse social, ethnic and cultural backgrounds. Some children expressed a positive regard for nurses and nursing. Some children a negative regard, others were ambiguous. From these data it is proposed that there is a continuum of regard for nurses. How children regarded nurses did not seem to be related to the nurse’s actions, but to the child’s understanding of their illness and their involvement in care. Further study is required to clarify the concept and should focus on what effect children’s regard for nurses and nursing has on health outcomes.

Solid and liquid modernity: A comparison of the social geography of places to die in the UK and Australia

ABSTRACT Preferred place of care and death is a widely used quality measure for palliative and end of life care services. In this article we explore the use of Zygmunt Bauman’s ideas on solid and liquid modernity to understand the complexity of the social geographical contexts of delivering and receiving care. Although solid ways of dying offer certainty and standardized care, more liquid ways allow for individualized care connected to family and communities. Understanding the complex tensions between solid and liquid aspects of palliative care may allow practitioners to help dying people to die in the ways and places they prefer.

Two Futures: Financial and Practical Realities for Parents of Living With a Life Limited Child

ABSTRACT Today more and more children are living with complex health care needs, many of these children are living with life limiting and/or threatening conditions, some are medically fragile. To live a childhood these children must live in communities and with their families. In most cases this means the child’s carers, their parents, most often their mothers, are required to undertake a great deal of the child’s care. During a project on parental coping I became aware of the ways in which parents were restructuring their working lives in order to meet the demands of the nursing and medical care needs of their children. In this paper I relate the stories we discovered in this qualitative study and discuss the tensions between parental and state’s responsibility for children, carers and the political and cultural rights and responsibilities pertaining to children’s care. I use Margret Urban Walker’s ideas of expressive collaborative morality to argue that the care of life limited and life threatened children should be framed in a negotiation between the state and the carers, both informal and professional. That such an agreement should include a covenant to assist parents and siblings when a child dies to recover and adjust to their loss, in recognition of the work they have performed in caring for the child during their child’s life and their death.

Perceptions of Children's Participation in Their Healthcare: A Critical Review.

Key policies at national and international levels have called for the increased involvement of children in their healthcare. This reflects a growing recognition of the sociology of childhood and of children as social agents. However, it seems that the involvement agenda has met with mixed results, with children often being left marginalized as a result of professional, parental, and other factors. A need for further research into children and health professional’s attitude towards child involvement has been identified by research in this area. In this article we review the current literature on children’s involvement in care, noting the differences between professional views and those of children themselves. To do this we used a literature review, incorporating electronic database searching and snowballing techniques. We found that children and health professionals are in general agreement that children should be involved in their healthcare; however there is some disagreement over the extent of involvement. Many children experienced exclusion due to many factors including parental role, in that there may be a belief among adults that children cannot act in their own best interest. The involvement of children in their healthcare may be considered transitory and dependent upon competing factors. It may be helpful to view child involvement in healthcare in the context of children’s status in their society. Health professionals should aim to empower children with appropriate information about their healthcare.