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Issue 119 - 23 Nov 2009

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JOURNAL:  Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
EDITOR'S CHOICE
1. Past research evidence has not been heeded

In this issue of JAN we publish a paper by Pickles et al. (2009, pp. 2262-2273) reporting their thematic review of studies published over the past decade concerning nursing students' knowledge and attitudes towards HIV/AIDS.

REVIEW PAPERS
2. Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review. 
by David Pickles, Lindy King, Ingrid Belan. Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a literature review conducted to examine current research studies into attitudes of nursing students towards caring for people with HIV/AIDS and to identify factors that influenced those attitudes to inform current nursing practice and to develop nursing education regarding care provided to people with HIV/AIDS.
Background. Attitudes of nurses towards people living with HIV/AIDS have long been scrutinized. Studies show that some nurses have negative attitudes and are reluctant to provide care to people with HIV/AIDS, resulting in poorer quality nursing support being provided. Attitudes of nursing students towards caring for people with HIV/AIDS is thus of vital importance since they become the future practising nurses.
Review methods. Criteria used for study selection were: attitudes of nursing students towards caring for people with HIV/AIDS, primary research studies, published in English language in peer reviewed journals from 1996 to June 2008. Sixteen studies were identified for inclusion in this thematic review.
Results. The following themes were identified: education and knowledge of HIV/AIDS; fear of contracting HIV/AIDS; reluctance to care for people with HIV/AIDS; homophobia; and stigma associated with HIV/AIDS.
Conclusion. There is reluctance on the part of some nursing students in specific regions of the world to provide care for people with HIV/AIDS. Educational programmes based on research evidence must play a leading role in developing strategies to help nursing students understand and overcome such attitudes.

3. Psychological adjustments made by postburn injury patients: an integrative literature review
by Kerry Klinge, Diane J. Chamberlain, Maurine Redden & Lindy King. Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a review examining the variables that predispose individuals to significant psychological maladjustment following burn injury.
Background. The psychological sequelae of burn injury are well documented; however, the variables that influence individuals' adjustment following burn injury lack consideration.
Review methods. An integrative review of the studies was conducted over a 6-month time period during 2007–2008.
Results. Burn patients are a heterogeneous group and typically have comorbidities. While preburn personality and coping strategies can influence long-term psychological adjustment, the relationship between postburn adjustment and burn size and severity, and gender are poorly understood. Much of the literature focuses on the prevalence of psychological maladjustment rather than on identifying variables that influence psychological adjustment.
Conclusion. The diversity and complexity that characterize burn patients lead to unique adjustment difficulties. Recognizing these difficulties is the first step to offering appropriate intervention and treatment for this unique patient group.

4. Review Summaries. Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Abstract:
The impact of hospital visiting hours policies on paediatric and adult patients and their visitors; Interventions for preventing falls in older people living in the community; Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnoea; Lack of effectiveness of primary conservative management for infants with brachial plexus birth palsy.

RESEARCH PAPERS - Original Research
5. Variations in nursing care quality across hospitals
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aims.
The aim of the study was to describe Registered Nurses' reports of unmet nursing care needs and examine the variation of nursing care quality across hospitals.
Background. Large proportions of Registered Nurses have reported leaving necessary care activities undone because they lacked the time to complete the activities. Nursing care left undone can be expected to adversely affect the quality of care. However, little is known about the degree of variation in the quality of nursing care across hospitals.
Methods. In 2008, a secondary analysis of a 1999 survey of Registered Nurses (n = 10,184) was conducted using descriptive and comparative statistics. Data were derived from inpatient staff nurses working in acute care hospital settings (n = 168). A hospital-level measure (i.e. unmet nursing care needs) of the quality of nursing care was developed from care needs left undone among all nurses.
Results. Across hospitals there was a wide range in the proportion of Registered Nurses who reported leaving each nursing care need undone. They reported leaving two of seven necessary nursing care activities undone during their last shift. After controlling for nurses' demographic information, we found statistically significant variations in the quality of nursing care across hospitals.
Conclusion. Differences in nursing care quality across hospitals appear to be closely associated with variations in the quality of care environments. Understanding the determinants of unmet nursing care needs can support policy decisions on systems and human resources management to enhance nurses' awareness of their care practices and the care environment.

6. The health of children with cerebral palsy and stress in their parents
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study conducted to describe the health of children with cerebral palsy and investigate predictors of stress in their parents.
Background. Children with severe cerebral palsy tend to have poorer health than their able-bodied peers, and their parents are more likely to be stressed and have poorer health.
Method. A cross-sectional survey with home visits using standard questionnaires was administered to parents in 2004–05. A total of 102/199 (51%) children and parents participated. The children were compared with a normative sample.
Results. Children with cerebral palsy had poorer physical health, and 79% of parents reported that their child had moderate to severe pain. Their poorer health, in comparison with the normal sample and measured by the Child Health Questionnaire, was related to feeding problems and seizures, general health perceptions to intellectual and feeding impairment, and family activities with severe motor, intellectual and feeding impairment. Poorer psychological well-being on the hyperactivity domain of the Strengths & Difficulties Questionnaire was related to feeding difficulties, on the prosocial domain to more severe forms of all child impairments, and on the social impairment scale to intellectual impairment. Children with psychological problems had statistically significantly increased
odds (OR = 7·2, 95% CIs 2·6–20·3) of having parents with high stress.
Conclusion. Children with cerebral palsy and associated impairments are at higher risk of poorer health and family well-being. A family-centred approach to the care of children with cerebral palsy and their families is essential to ensure both receive adequate care and support.

7. Parenting self-efficacy after childbirth. 
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of study of parent, infant and environmental correlates of mothers' and fathers' perceptions of their parenting self-efficacy.
Background. Many parents are not confident in their ability to be good parents. Parenting self-efficacy is important for parents' sense of well-being, is a possible predictor of parenting practices and might be an indicator of risk. However, very little evidence exists on factors that influence fathers' perceptions of parenting, or comparisons between the parents.
Methods. The data were collected by questionnaire in 2006–2007 in two hospitals with a convenience sample of Finnish-speaking parents (N = 1300 families) during the first postpartum week. Multiple-birth and early-discharge parents were excluded. The response rate for mothers was 66% (n = 863) and for fathers 40% (n = 525). Comparisons were made by percentages and means. Statistical significance was determined by Generalized Estimating Equations models and one -way anova. Pearson's and Spearman's correlation coefficients were used to determine correlations, and multiple regression analysis to clarify the effect size.
Results. Mothers scored higher than fathers on parenting self-efficacy. Parity, self-concept, depressive symptoms and state of mind on discharge contributed to parenting self-efficacy. Experiences of childbirth and life change correlated with mothers', but not with fathers', parenting self-efficacy. Perceptions of infant, family functioning, health and advice from personnel were major contributory factors.
Conclusion. Assessments of parenting self-efficacy are recommended to identify at-risk groups and at-risk parents. More research is recommended to look into the effect of rooming-in, feeding practices, fathers' presence and social support from personnel and parenting self-efficacy and to evaluate risk scales for at-risk parents. Parent attributes had a greater effect on mothers' parenting self-efficacy, while environmental attributes had a greater effect on fathers' parenting self-efficacy. At-risk parents can be supported by conducting face-to-face discussions about significant topics.

8. Heteronormative communication with lesbian families in antenatal care, childbirth and postnatal care
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study of lesbian parents' experience of antenatal care, childbirth and postnatal care.
Background. In a strictly heteronormative-based care system, 'parents' naturally implies a man and a woman, and all communication and routines are based on heterosexual couples.
Method. A qualitative interview study was carried out in 2008. Ten mothers, eight of whom were in a relationship with another woman, participated. The participants had experience from several care facilities from three different cities in central Sweden.
Findings. Most participants had positive experiences but also complained that the focus was not always on the pregnancy and that no parenthood education had been offered. Heteronormativity was communicated by midwives and nursing staff throughout the process – from antenatal care to postnatal care, via forms, journals, verbal communication and orientation visits. This was experienced as embarrassing for the participant parents, and they also described encountering what they interpreted as embarrassment on the part of care providers. Participants called for increased knowledge about lesbian parenting, since they believed this would influence and facilitate communication, not least with midwives in antenatal care.
Conclusion. Midwives educated in lesbian issues could ask questions and communicate in a more neutral way at the first meeting, and thereby make prospective parents feel less insecure. Special parenthood education groups for lesbians are recommended so that lesbian couple can meet others with similar experiences and so that the focus will be on prospective parenthood and not on their sexual orientation.

9. Empowering surgical nurses improves compliance rates for antibiotic prophylaxis after caesarean birth
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study of the effect of empowering surgical nurses to ensure that patients receive antibiotic prophylaxis after caesarean birth.
Background. Despite the consensus that single dose antibiotic prophylaxis is beneficial for women have either elective or non-elective caesarean delivery, hospitals need methods to increase compliance rates.
Method. In a study in Israel in 2007 surgical nurses were empowered to ensure that a single dose of cefazolin was given to the mother after cord clamping. A computerized system was used to identify women having caesarean births, cultures sent and culture results. Compliance was determined by chart review. Rates of compliance, suspected wound infections, and confirmed wound infections in 2007 were compared to rates in 2006 before the policy change. Relative risks were calculated dividing 2007 rates by those in 2006, and 95% confidence intervals were calculated using Taylor's series that does not assume a normal distribution. Statistical significance was assessed using the chi-square test.
Findings. The compliance rate was increased from 25% in 2006 to 100% in 2007 (chi-square test, P < 0·001). Suspected wound infection rates decreased from 16·8% (186/1104) to 12·6% (137/1089) after the intervention (relative risk 0·75 - 95% confidence interval, 0·61–0·92).
Conclusion. Surgical nurses can ensure universal compliance for antibiotic prophylaxis in women after caesarean birth, leading to a reduction in wound infections.

10. Women's experiences with vaginal pessary use
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study of the lived experiences of women using vaginal pessaries for the treatment of urinary incontinence (UI) and/or pelvic organ prolapse.
Background. The use of a vaginal pessary offers a non-surgical treatment option to provide physical support to the bladder and internal organs. As the literature asserts, a woman's choice to use a pessary is very individual and involves not only physical, but also psychological and emotional considerations.
Method. Narrative inquiry was used to conduct face-to-face semi-structured interviews in 2007 with 11 postmenopausal women who accessed services from a Urogynecology Clinic in Eastern Canada.
Findings. The women's stories revealed that living with a pessary is a life-changing experience and an ongoing learning process. The women's comfort level and confidence in caring for the device figured prominently in their experiences. Psychosocial support provided by the clinic nurses also played a primary role in the women's experiences.
Conclusion. Women and healthcare professionals need to be aware of the personal isolation and embarrassment, and social and cultural implications that urinary incontinence may cause as well as the subjective experiences of using a pessary. With appropriate support, vaginal pessaries can provide women with the freedom to lead active, engaged and social lives.

11. Coping experiences of adolescents with cancer: a qualitative study
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study of the coping experiences of Taiwanese adolescents with cancer.
Background. Cancer treatments have adverse effects and negatively affect adolescents' lives. Psychological coping strategies are antecedents to adjustment. Little is known about the essential structure of the coping experience in adolescents with cancer.
Method. Ten adolescents aged 12–18 years who were receiving chemotherapy were interviewed in 2007. Open-ended interviews were conducted in a quiet in-hospital setting. Interview data were analysed using Giorgi's four-step procedures.
Findings. The essential structures of the coping experience were losing confidence and rebuilding hope. Losing confidence included sub-themes of physical and psychological suffering; rebuilding hope included sub-themes of thought restructuring, revaluing what I have, and envisioning hopeful images of the future. Interviewees vacillated
between moving on and giving up, depending on the strength of their hope. A focus on rebuilding hope helped the adolescents to move on in the midst of many distressful events.
Conclusion. Understanding adolescents' coping processes relative to cancer can facilitate the establishment of a more supportive milieu. The findings can provide guidance for instrument development on coping for adolescents with cancer and be useful in guiding intervention development to promote positive psychological adjustment.

12. Healthcare routines of university students with Type 1 diabetes
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study examining the benefits that university students with Type 1 diabetes associate with diabetes self-care routines, and the barriers that they experience in enacting self-care routines in the university environment.
Background. Many young adults with Type 1 diabetes attend university, and it is thought that these students might experience difficulties with their self-care routines while they are there.
Method. A qualitative method was chosen to explore students' own perspectives. Seventeen students with diabetes were interviewed twice, and each kept a research diary for a 2-week period. Interviews and diaries were analyzed using standard qualitative techniques. The study was conducted in 2004–2005.
Findings. Routines had a number of identity-producing benefits for students. However, students often experienced difficulties routinizing their self-care practices at university. These difficulties stemmed both from the irregular nature of university life and from students' desires not to let their diabetes interfere with their student lives. Most participants learned to adjust to university and enact self-care routines, although they could still experience routine difficulties during times of transition and stress.
Conclusion. Healthcare professionals need to be aware of the difficulties that university students with Type 1 diabetes experience with their self-care routines. This awareness needs to encompass older students in the second, third and fourth years of their undergraduate degrees and postgraduate students as well as students in their first year at university.

13. Hope, self-efficacy, spiritual well-being and job satisfaction
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study of the relations of spiritual well-being, global job satisfaction, and general self-efficacy to hope in Continuing Care Assistants.
Background. Healthcare providers have described their hope as an important part of their work and a form of work motivation. Hope may be an important factor in preventing burnout and improving job satisfaction.
Methods. A concurrent triangulation mixed method design was used. Sixty-four Continuing Care Assistants (personal care aides) who registered for a 'Living with Hope' Conference completed a demographic form, Herth Hope Index, Global Job Satisfaction Questionnaire, Spiritual Well-Being Scale, General Self-Efficacy Scale, and a hope questionnaire. Data were collected in 2007. The response rate was 58%.
Results. Using linear regression, 29·9% of the variance in Herth Hope Index score was accounted for by scores from the General Self-Efficacy Scale and Spiritual Well-Being Scale. General Self-efficacy scores (positive relationship) and Spiritual Well-Being scores (negative relationship) accounted for a significant part of the variance.
Qualitative data supported all findings, with the exception of the negative relationship between hope and spiritual well-being; participants wrote that faith, relationships, helping others and positive thinking helped them to have hope. They also wrote that hope had a positive influence on their job satisfaction and performance.
Conclusion. Hope is an important concept in the work life of Continuing Care Assistants. Supportive relationships, adequate resources, encouragement by others, and improving perceptions of self-efficacy (ability to achieve goals in their workplace) may foster their hope.

14. Anxiety, depression and perceived control in patients having coronary artery bypass grafts
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study to determine (1) the course of anxiety, depression and perceptions of control and (2) the influence of perceptions of control, in patients undergoing coronary artery bypass grafts before surgery after surgery in hospital and 2 weeks after discharge.
Background. Anxiety and depression are common in patients undergoing coronary artery bypass graft surgery patients and predictive of worse outcomes. Few researchers have examined the influence of perceived control on these emotional states in the acute surgical period.
Methods. A prospective, descriptive design was used with a convenience sample of patients having coronary grafts (n = 155). Anxiety and depression were measured by the Hospital Anxiety and Depression Scale and perceptions of control over their cardiac illness by the Control Attitudes Scale before surgery, after surgery during
hospitalization and 2 weeks after hospital discharge. The data were collected in 2005.
Results. Patients had low levels of anxiety at each timepoint; however, borderline or clinically significant levels were common before surgery (38·7%) and after discharge. (38·6%). Depression levels were low, but increased over time (F = 27·03, P < 0·001). Patients had low to moderate perceptions of control over their illness before surgery, which increased over time (F = 25·51, P < 0·001). Those with stronger perceptions of control were less anxious or depressed at all times and those who were more anxious or depressed before surgery continued to be so afterwards.
Conclusion. Routine assessment of anxiety, depression and perceptions of control are justified to identify patients at risk and to intervene to promote control perceptions.

15. Effects of thermal therapy on uremic pruritus and biochemical parameters in patients having haemodialysis
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a trial to identify the effect of thermal therapy with far-infrared rays in comparison with non-thermal therapy on uremic pruritus and biochemical parameters.
Background. Uremic pruritus remains one of the most frustrating, common, and potentially disabling symptoms in patients undergoing haemodialysis. The mechanism underlying uremic pruritus is poorly understood. Although enough is known to determine a reasonable treatment approach, more research is needed to evaluate more reliable treatments.
Methods. A randomized, double-blind, controlled trial was conducted in 2005 using questionnaires and measurement of blood biochemical parameters. A total of 41 uremic patients on maintenance haemodialysis were randomly assigned either to the thermal therapy group or the control group. The thermal therapy group was treated with 40°C thermal therapy with far-infrared rays at the Sanyinjiao acupoint for 15 minutes once a day on two days a week for a total of 18 sessions. The control group received a plain adhesive patch placed on the same acupoint.
Findings. Both groups showed statistically significant improvements but there were no differences between groups, while a relatively large decrease in pruritus scores was found in the thermal therapy group (P < 0·001) as compared with the non-thermal therapy group. Serum calcium level decreased statistically significantly in the thermal therapy group and was statistically significantly different from that of the control group.
Conclusion. The lack of effect does not necessarily demonstrate that thermal therapy is not effective or has no therapeutic benefits for uremic pruritus in patients having haemodialysis. Further investigation is warranted, with larger samples and longer intervention.

16. Surgical facial cancer treatment: the silencing of disfigurement in nurse–patient interactions
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
The aim of this study was to explore and explain how disfigurement is addressed in interactions between patient and nurse during the period in hospital immediately after undergoing disfiguring facial surgery.
Background. Facial disfigurement as a result of head and neck or eye cancer surgery is associated with psychosocial problems; however no successful intervention program has been developed. Empirically derived knowledge about what goes on in the patient–nurse interaction is missing.
Method. A grounded theory design was used, with data derived from audio-recorded conversations between and individual interviews with 14 patients and their connected nurses, from three participating university hospitals. Data were collected in 2007.
Findings. A substantive model with silencing disfigurement as a core category was developed. The model included three categories; minimizing disfigurement, disfigurement is a luxurious problem and another time, another place. A condition of implicit and unverified professional assumptions about addressing the issue of disfigurement became an underlying character. Without this the core category could not exist.
Conclusion. The model elucidates a silencing process maintained by preconceived assumptions which need to be challenged to help patients adjust to their changed appearance after facial cancer treatment.

17. Fitness support group for organ transplant recipients: self-management, self-efficacy and health status
Journal of Advanced Nursing, Volume 65 Issue 11, November 2009
Aim.
This paper is a report of a study conducted to describe postoperative self-management behaviours, perceived self-efficacy and health outcomes in adult organ transplant recipients who participated in a fitness support group.
Background. Self-management behaviours designed to promote patient autonomy contribute to positive health outcomes after therapeutic interventions. Despite an increase in organ transplantation, little is known about the impact of self-management on health outcomes after adult organ transplantation. Even less has been investigated regarding nursing interventions in the organ transplantation patient demographic to promote positive outcomes.
Method. Using a cross-sectional descriptive design, 20 participants completed a questionnaire that included measures of self-management, self-efficacy and health status during the 2006 training season.
Findings. Participants were, on average, 55 years of age and 6 years since transplantation. Their results were compared to mean values as reported in the literature, and revealed consistently superior scores for the outcome variables. The mean amount of weekly aerobic exercise in the transplant group was 3·2 hours (sd 1·4). Participants
demonstrated impressively high amounts of self-efficacy. Confidence was inversely related to extent of illness interference in activities of daily life (r = -0·772, P = 0·01). Health status scores also exceeded the norms, with all participants reporting at least 'good' health. Seventeen participants reported zero emergency department visits in the last 6 months. Nursing interventions geared toward maximizing patient self-efficacy may improve health outcomes for adults after solid organ transplantation.
Conclusion. Group participation in a fitness programme may support achievement of self-management activities and feelings of self-efficacy in maintaining disease management.

18. Dignity in the life of people with head injuries
Journal of A

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