Helen T. Allan

Using participant observation to immerse oneself in the field The relevance and importance of ethnography for illuminating the role of emotions in nursing practice

In this paper I draw on the findings of an ethnographic study of fertility nursing in a British fertility unit to explore the relevance and importance of ethnography for illuminating the role of emotions in nursing practice. One of the main findings to emerge from the original study was that infertility was an emotional experience for both staff and patients, and that the organisation of the unit ensured that the potentially disruptive emotions of staff and patients were controlled and remained private. These findings have been reported elsewhere (Allan, 2001, 2002). Drawing on these findings, I discuss the role of ethnography in illuminating the role of emotions in the clinic in two ways. First, I will discuss the nature of the data in ethnography and the relationship between participant observation and interviews. Second, I will discuss the experience of researcher reflexivity and ethnographic authority in ethnography.

Reflexivity: A comment on feminist ethnography

This paper comments on feminist research and in particular the use of reflexivity in feminist ethnography. Reflexivity in ethnography is the use of self as an instrument of the data collection and the researchers own awareness of reactions to the research data. Ethnography requires that the researchers immerse themselves in the field and act reflexively while collecting data. I will discuss how using myself reflexively as a researcher during data collection in an assisted-conception unit led me to reconsider an assumption about the methodology underpinning feminist research approaches. It has been argued that feminist research approaches are women-centred and that debates on reproductive technologies are based on the premise that males control assisted conception. My experience of undertaking a feminist ethnography has challenged these two assumptions. Reflection during and after the data collection has led me to question the aims of women-centred research in a field in which men are participants as doctors and patients. By discussing data from field work, I argue that including men in feminist research offers the potential for the emergence of a new type of research.

Cervical screening and the aftermath of childhood sexual abuse: are clinical staff trained to recognise and manage the effect this has on their patients?

AIMS AND OBJECTIVES To evaluate the training needs and awareness of childhood sexual abuse amongst clinical staff taking cervical screening samples in one inner city primary care trust. BACKGROUND Studies exploring sexual abuse and nonparticipation in cervical screening have demonstrated that women can experience re-traumatisation if care during examinations is insensitive to their particular needs. DESIGN This was a mixed methods, service evaluation in three phases. METHODS A literature review, a questionnaire to cervical screening staff in an inner city primary care trust and a focus group of four staff drawn from questionnaire respondents to explore themes raised in the questionnaire data. RESULTS Data analysis of both quantitative and qualitative data showed that clinical staff underestimated the frequency of childhood sexual abuse although they were aware of the difficulties and reluctance some women experience undergoing gynaecological examinations. When women did disclose childhood sexual abuse or when staff suspected a history of childhood sexual abuse, staff reported feeling unsure of how they should proceed. There was no support or clinical supervision, and unmet training needs were identified. CONCLUSIONS Nurses expressed anxiety around the potential of the screening test to cause more harm than good and at their inability to provide more help than listening. Staff wanted support and further training after completing their cervical screening training course to assist in their provision of sensitive care to patients who have experienced childhood sexual abuse. RELEVANCE TO CLINICAL PRACTICE Whilst our results cannot be generalised to a wider population, they may be meaningful for the community of cervical screening takers. We argue that screening staff require further training and professional support (clinical supervision) to increase their confidence when providing safe and sensitive practice for childhood sexual abuse survivors. If staff feel more confident and competent when responding to disclosure of childhood sexual abuse in screening situations, women who have experienced childhood sexual abuse might participate in the screening programme more readily.

Supporting staff to respond effectively to informal complaints: findings from an action research study

AIM AND OBJECTIVE To understand how nurses and midwives manage informal complaints at ward level. BACKGROUND The provision of high quality, compassionate clinical nursing and midwifery is a global priority. Complaints management systems have been established within the National Health Service in the UK to improve patient experience yet little is known about effective responses to informal complaints in clinical practice by nurses and midwives. DESIGN Collaborative action research. METHODS Four phases of data collection and analysis relating to primarily one National Health Service trust during 2011-2014 including: scoping of complaints data, interviews with five service users and six key stakeholders and eight reflective discussion groups with six midwives over a period of nine months, two sessions of communications training with separate groups of midwives and one focus group with four nurses in the collaborating trust. RESULTS Three key themes emerged from these data: multiple and domino complaints; ward staff need support; and unclear complaints systems. CONCLUSIONS Current research does not capture the complexities of complaints and the nursing and midwifery response to informal complaints. RELEVANCE TO CLINICAL PRACTICE Robust systems are required to support clinical staff to improve their response to informal complaints and thereby improve the patient experience.

Exercise: A Path to Wellness during Adjuvant Chemotherapy for Breast Cancer?

Background: Breast cancer treatment can represent a threat to a patient’s wellness. The role of exercise in perceived wellness in women with breast cancer merits further study. Objective: The objective of this study was to describe how exercise is perceived by women to influence their physical and psychosocial wellness at the time they were receiving chemotherapy. Methods: Five focus group interviews with a total of 27 women with early-stage breast cancer were conducted. Prior to the focus groups, the women had participated in an exercise intervention during chemotherapy treatment. Results: Three themes emerged from the analysis: exercise shapes feelings of psychological wellness; exercise stimulates feelings of physical wellness; and exercise influences social wellness. The women reported feeling stronger in a psychological sense after exercising, that the strength exercise improved their upper-limb functioning, and that engaging in exercise triggered social support and interactions. Conclusions: Exercise during breast cancer treatment is perceived to enhance the patients’ wellness on several dimensions and in particular psychological wellness. Exercise might support the patients’ efforts to restore their sense of wellness and enhance their level of daily life functioning. Implications for Practice: Cancer nurses should promote exercise as a wellness-fostering intervention during chemotherapy treatment. Focusing on how exercise can contribute to feelings of wellness may help women with breast cancer choose exercise as a health-promoting activity that contributes to their recovery.

Governing body nurses’ experiences of clinical commissioning groups: an observational study of two clinical commissioning groups in England

Clinical commissioning groups were set up under the Health & Social Care Act (2012) in England to commission healthcare services for local communities. Governing body nurses provide nursing leadership to commissioning services on clinical commissioning groups. Little is known about how nurses function on clinical commissioning groups. We conducted observations of seven formal meetings, three informal observation sessions and seven interviews from January 2015 to July 2015 in two clinical commissioning groups in the South of England. Implicit in the governing body nurse role is the enduring and contested assumption that nurses embody the values of caring, perception and compassion. This assumption undermines the authority of nurses in multidisciplinary teams where authority is traditionally clinically based. Emerging roles within clinical commissioning groups are not based on clinical expertise, but on well-established new public management concepts which promote governance over clinically-based authority. While governing body nurses claim an authority located in clinical and managerial expertise, this is contested by members of the clinical commissioning group and external stakeholders irrespective of whether it is aligned with clinical knowledge and practice or with new forms of management, as both disregard the type of expertise nurses in commissioning embody.

A qualitative study of Advanced Nurse Practitioners' use of physical assessment skills in the community: shifting skills across professional boundaries.

AIMS AND OBJECTIVES To explore multiple perspectives on the use of physical assessment skills by advanced nurse practitioners in the UK. BACKGROUND Physical assessment skills practices are embedded in advanced nursing practice roles in the UK. There is little evidence on how these skills are used by advanced nurse practitioners in the community. DESIGN Case study. METHODS A qualitative interpretative single-embedded case study of 22 participants from South of England. A framework method analysed interview data collected by the researcher between March-August 2013. Participants included nurses, doctors, nurse educators and managers. FINDINGS Physical assessment skills education at universities is part of a policy shift to develop a flexible workforce in the UK. Shared physical assessment practices are less to do with role substitution and more about preparing practitioners with skills that are fit for purpose. Competence, capability and performance with physical assessment skills are an expectation of advanced nursing practice. CONCLUSIONS These skills are used successfully by community advanced nurse practitioners to deliver a wide range of services in response to changing patient need. The introduction of physical assessment skills education to undergraduate professional preparation would create a firm foundation to develop these skills in postgraduate education. RELEVANCE TO CLINICAL PRACTICE Physical assessment education prepares nurses with the clinical competencies to carry out healthcare reforms in the UK. Shared sets of clinical assessment competencies between disciplines have better outcomes for patients. Levels of assessment competence can depend on the professional attributes of individual practitioners. Unsupportive learning cultures can hinder professional development of advanced nursing practice.

The effect of applying pressure to the LIV3 and LI4 on the symptoms of premenstrual syndrome: A randomized clinical trial

OBJECTIVE To evaluate the effect of simple acupressure protocol in LIV3, LI4 and placebo points on the quality of life (QOL) in women with premenstrual syndrome (PMS). METHOD This paper reports a randomized, single blinded clinical trial. 97 participants (students in of Hormozgan University of Medical Sciences, Iran) with PMS were allocated to three groups to receive 20min acupressure on different acupoints for 14days before menstruation for three consecutive menstrual cycles (training and then two cycles self applied acupressure). The acupoints were LIV3 and LI4; one group received acupressure at a placebo point. Each participant completed the PSST scale (to determine PMS severity), HADS scale (for depression and anxiety), and quality of life SF12. RESULTS The number of people with moderate/severe PMS decreased in LIV3 and LI4 acupressure groups by the second and third cycles compared with the placebo group (p<0.04). Moreover, depression and anxiety scores significantly decreased in the LIV3 and LI4 groups by the second and third cycles compared with the placebo group (p<0.05).Analyzing the score of SF12 fields in the second and third cycles showed a significant difference in all dimensions between the intervention and placebo groups. There was no significant difference between LIV3 and LI4 acupressure groups in decrease of PMS symptoms, anxiety and depression and improving SF12scores (p<0.05). CONCLUSION Performing the simple acupressure protocol at LIV3 and LI4 is an effective method to decrease the severity of PMS symptoms, anxiety and depression, and to improve the QOL. Pressure at LIV3 and LI4 appears to be equally effective.

Gatekeeping access to the midwifery unit: Managing complaints by bending the rules

While poor communication between service users and front-line staff causes many service user complaints in the British National Health Service, staff rarely reflect on the causes of these complaints. We discuss findings from an action research project with midwives which suggest that the midwives struggled to fully understand complaints from women, their partners and families particularly about restricted visiting and the locked door to the midwifery unit. They responded to individual requests to visit out of hours while maintaining the general policy of restricted visiting. In this way, the door was a gatekeeping device which allowed access to the unit within certain rules. The locked door remained a barrier to women and their families and as a result was a common source of informal complaints. We argue that the locked door and restricted visiting to the midwifery unit were forms of gatekeeping and boundary making by midwives which reveals a tension between their espoused woman-centred care and contemporary midwifery practice which is increasingly constrained by institutional values.

The health environment: A definition and conceptual framework for research and practice

This paper explores the history of the concept of health environment in nursing discourse. The prompt to investigating the subject followed the national research and development (R&D) initiative set up through the Royal College of Nursing and the Centre for Policy in Nursing Research. Subsequent developments in national healthcare policy, particularly in relation to primary care-based commissioning and public health highlight the timeliness of such a debate. A conceptual framework for the health environment is suggested which is dynamic and practice-oriented. It is hoped that this will appeal both to academics and practitioners in order to build a base of research and practice around the health environment within and beyond the nursing professions.