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Hospice, Palliative Care, Gero, dementia

Content by marachne

  1. Hopefully it's not bad form to post here about another forum. The Hartford Institute for Geriatric Nursing has launched a new forum. Some of the top names in the field (Mathy Mezy for example) are running the place, and it is focused on substantive discussions. You may want to check it out: http://forums.hartfordign.org/
  2. I often get the "that must be hard, I could never do it," but don't necessarily see a wince or a shudder, more often appreciation and/or admiration." I usually say how I love it, how it feels like such a prividedge and humbling to be with people at a most vulnerable and intimate time. If they are a nurse or a nursing student, I'll often add something about how that's one of the wonderful things about nursing -- there are so many different things one can do and so many different kinds of people to fill those niches -- I doubt I'd ever be a good ED nurse, and my exposure to ICU made it clear to me that that was not the kind of nursing that I enjoy -- and I'm so grateful that there are others for whom it's a perfect fit.
  3. marachne

    Hospice Opportunities in Arkansas?

    I don't know anything about the Arkansas VAMC, but across the US the VA system is doing a really good job with palliative care. And the VA is a great system to work in.
  4. marachne

    Public health nursing in Oregon

    Glad it worked for you -- really encourage checking out Outside In. They are set up to work w/students and HC professionals.
  5. marachne

    Public health nursing in Oregon

    Two places that come to mind are Outside In, which provides services to homeless youth and has a huge volunteer program specifically for people w/a medical background, http://www.outsidein.org/volunteer.htm and Virginia Garcia Memorial Medical Center -- I don't know about volunteers and you probably need to have pretty good Spanish language skills. Also, Our House of Portland may be able to use you -- they work w/people with HIV/AIDs Finally, I just put into google health care volunteering in Portland and got a listing through Business Week, plus this one via Reed College: http://www.reed.edu/seeds/volunteer/volunteer_health_care.html It's amazing what one can find w/just using a search engine!
  6. marachne

    How do you use the FAST Scale?

    So what, exactly do you think is meant by "CNS aging?" I would also refer back to the article I cited in my earlier post -- the reliability of the FAST has studied and validated with AD, but I'm not so sure about its reliability or validity for other conditions. For example, we know that vascular dementia has a different presentation, and therefore may not progress in the same way. Lewy Body Dementia is even more of a different course, and we're still talking dementias. (the line in the abstract I'm referring to is: "This system has been studied extensively and proven to be reliable and valid for staging dementia in Alzheimer's disease (AD)" I guess the caveat/point I'm trying to make is just because a scale/instrument exists, doesn't mean it's the best thing to use. Now if funding is based on using it, then you're stuck until something changes. But my understanding is that even w/CMS no one expects agencies to use the FAST for anything other than dementia.
  7. marachne

    Hospice question from a new-ish LTC nurse

    My thought is that someone needs to talk to you board of nursing about the behavior of the DON and NM. I would call them and ask about annonymous reporting, explaining, if necessary your concerns about your job/work relationships. Have you spoken to anyone in the hospice agency you worked with? They may be able to do an in-service on symptom management, that includes a discussion of the kinds of uncomfortable side effects that people can experience with opioids (and morphine often has the most uncomfortable effects, whether it is itching, or nausea, or just a feeling of vauge, general, discomfort), as well as a strong emphasis on patient-centered care, and how sometimes when we are medicating for (percieved) discomfort we are medicating the caregivers (paid or unpaid) as much as the patient! Good luck with this. I understand you being in a difficult situation regarding the work relationships, particularly in this economy, but you also need to be comfortable with your co-workers/superiors, and you do have an obligation both to future patients and the profession to report unethical/illegal behavior. One other thought, if going through channels does you no good -- contact a local television station and tell them you might have a story for them. Health care issues are allways good stories, and if you make it clear that you need to protect your annonymity, they will. I'm not saying this should be your first course of action, but if nothing else helps, bad publicity can be a very stong motivator to change bad practices!
  8. marachne

    Questions and a Request

    Hi all, I have an interview a week from Tuesday with Kaiser Hospice, and I have a few questions, and a request. First of all, as those of you who've hung around here know, I have a background in both hospice and palliative care, but it's a bit different from the norm. My hospice (and some of my palliative care) background is in the VA, in patient. So the biggest difference is that I'm not dealing with Medicare at all -- no COPS, no (traditional) certification/recertification, little dealing w/outside primary docs (and they all tend to be w/i the VA system). Our palliative care pts are often folks are sometimes people who need their symptoms controlled, but often they are admitted into the unit b/c they are getting a radiation series, often for head and neck cancer so they need supportive care, either because they are from other parts of the state, or they have no support system while they are going to get debilitiated and likely need support in terms of tube feedings and the like. Sometimes tx doesn't allow for discharge and they just seamlessly move over to hospice care. Also, while we try and limit the time that our hospice patients are with us (after having the first few be with us for over a year) we're not talking GIP where the requirements are very strict. LOS sometimes IS hours (when they get sent over from the hospital at the last minute), but it can be months. The other, large part of my palliative care expierience was in a role that is usually more an NP role where we do hospital consults for symptom management, goals clarification, care planning, etc. What is of course the same is that I've dealt with all the stuff around EOL -- symptom manaagement, dying trajectory, pyschosocial & spiritual issues, family support / conflict resolution, supportive presence, education, etc. The other thing that is different for me is that I was never hired specifically as a hospice nurse. The unit is part of the skilled/LTC facility, and really, my interview was kind of a formality anyway, because my mentor (who worked for quite a while as a CNS in the facility) and is close to the DON basically said "she's a good one, hire her." So: I've never worked community based hospice (although I have some knowledge/experience w/it) I've never interviewed for a hospice position I've never worked community palliative care (and while I know that Kaiser does have community-based palliative care, I'm not sure if the same folks do both). I'm interviewing for two positions really, one is a per diem, one is part time (benefited). I have been told that the job requires working one weekend a month, and being backup on-call once a month. I can't work full-time right now anyway, because I'm still finishing up my PhD dissertation. I have read through some of the prior posts here about interviewing for hospice positions, but I'd appreciate any words of advice and wisdom y'all can give me. The other reality is that I haven't worked outside of the VA, and have only done a few nursing interiviews of any kind before. So, anything about interviewing for a nursing position in general, for a hospice position (not full-time) specifcially, and for the Kaiser system in particular would be appreciated. And the other request? Think good thoughts for me on 7/28! miriam
  9. marachne

    Questions and a Request

    Bumping this up in hopes of a reply.
  10. marachne

    How Much Autonomy Do Hospice Nurses Have?

    I can't speak specifically for in-patient hospice, as you are still going to be w/i whatever is the culture of the institution -- after all, ICU RNs have a lot more autonomy, than the average med/surg RN, but that is going to vary from hospital to hospital, as well as the relationships between physicians/NPs and RNs. If she/he is a good one, having a certified hospice/palliative care physician will make a big difference, because the traning includes an emphasis on working cross- inter- disciplinary, and recognizing that that the folks that are at the bedside have the best picture of the current situation. Ideally, the RNs who are going to be working w/the doc would get to be part of the hiring process, but that's probably asking a bit much.
  11. Without getting into a "AD vs. BS" fight, I would argue that there ARE advantages, in terms of learning things at another level in getting a BS. In addition, even if base pay is the same, somepositions are often only open to those with a BS. Sometimes it is stated with the caveat "or equivalent experience," but that's a very subjective term and you are at the mercy of the person doing the hiring.
  12. marachne

    scheduled meds and PRN dose orders in nursing home

    Abosolutely agree w/what everyone has said, and here's a few other things to think about: besides dose, what is the action (as in time to effect/half-life) of the med? For example, po tab morphine is going to take longer and stay in the system longer than IV morphine, so dosing timing will vary. Also, where is the patient in terms of their needs? If pain/anxiety/SOB, what ever is being tx is labile, you may be using the PRN more frequently. If there is a clear escalation of symptom, or tolerance, you're going to want to do whatever you need to keep on top of it (boney mets?) If we're talking incident pain (pain with movement, like when cleaning up or changing position or dressing change), you want to plan those PRNs to coincide with need. Another thing that hopefully is being looked at is the PRN useage -- if there is a consistent pattern of high PRN useage, it's time to adjust the scheduled dose to more frequent and/or higher dose (or other agent/route!)
  13. marachne

    Capella PhD in nursing education

    As others have noted, many, if not most universities that have PhD programs will have faculty pages that list current, or most salient publications/active funded research. Looking at this information will give you info regarding what their research focus areas are. As was mentioned, it is also good to do a lit search on the research area in CINAHL and see what names come up, and then what unis they are at. One caveat about that -- if you depend on the listing on the article, they may no longer be at the institution listed on the manuscript. If you think you are iterested in a particular institution, I would contact their graduate department, tell them where your interest lies, and ask what faculty are engaged in research in that area. I just went and looked at the Capella site. I would be very cautious about getting an EdD from a generic institution like this. While there is certainly aspects of education that is cross-discipline and profession, there are also aspects of nursing education that are much more specific to the profession. I would wonder about the quality/appropriateness of the education you recieved, as well as your marketability as nursing faculty w/o some connection to nursing education. When I did a search on PhD in nursing education distance programs, I see that Capella came up, but the fact that when you go to their site you don't get any kind of listing of the specific faculty to me is not encouraging. Not saying you shouldn't explore it as an option, but I'd say look at other options that might serve you better. Ask to be able to interview faculty. Ask for names/contact info of graduates from the program who you can talk with. Really do your homework, as it's too much of an investment of time and energy to not get what you want or need.
  14. If you want to go for a PhD, another thing to look for are programs that have recieved GAANN funding, which is often specifically aimed at people who plan to teach. I don't know where you are located, but I googled "Nursing PhD programs with GAANN funding" and found several programs that have recieved these grants. If you get into a school and get a GAANN fellowship, it can be renewable for up to 5 years. It covers tuition and a stipend -- I believe the funding is somewhat based on need. Below is the statement from AACN about GAANN funding for SONs New Funding Opportunity for PhD-Level Nursing Education AACN is pleased to announce that nursing has now been designated by the U.S. Secretary of Education as an "area of national need" under the Graduate Assistance in Areas of National Need (GAANN) program within the Higher Education Act. As a result, new funding is now available to nursing schools offering PhD programs. GAANN provides funding for fellowships to attract students into graduate programs in specific disciplines. Nursing has now been added to the list of national need areas that also includes biology, chemistry, computer and information sciences, engineering, geological sciences, mathematics, and physics. This important addition resulted from a three-year legislative and regulatory lobbying effort led by AACN. AACN is grateful to Representatives Jon Porter (R-NV), Carolyn McCarthy (D-NY), and their colleagues for their ongoing efforts in the House to make this important amendment to the GAANN program. Advocates in the Senate have also addressed this need with their legislative efforts. On August 29, the Office of Post Secondary Education within the U.S. Department of Education issued a call for applications to schools seeking GAANN funding in FY 2006. Schools of nursing are invited to apply for funding to offer fellowships to graduate students with excellent academic records who demonstrate financial need and plan to pursue a PhD program. The Secretary is "particularly interested" in applications from nursing programs that focus on the preparation of nurse scholars at the PhD level for educational leadership roles. Graduates of this type of program will become the teachers preparing students for careers in nursing and will disseminate to the public new knowledge gained from disciplined inquiry related to nursing and nursing education. Fellowship monies will cover the costs of tuition and fees as well as student expenses. The Department of Education estimates awarding to schools of nursing approximately 96 grants averaging $211,000 each.
  15. marachne

    Who is Responsible for Discussing End-of-Life Treatment Options?

    This is why a palliative care team is a team, and the good ones include physicians, rn's APNs, SWs, chaplains (specially trained in EOL), and when they're really lucky, a psych person. It's about exploring values and goals as well as prognosis and options. That said, nurses are the ones who spend the most time with patients, who often are the best known and trusted by pts & families. We are often, in many ways, good generalists, and approach care from a holistic perspective -- mind, body, and spirit. I feel it is a nurse's duty to share her/his knowledge, wisdom, and experience with a pt or family if the physician is doing a disservice to the patient in not sharing full information about what the options are, and what the (likely) consequences/outcomes of certain decision paths. The problem is that the system often leaves nurses feeling intimidated and afraid to speak up.
  16. marachne

    Nonverbal symptoms of pain

    There is a well tested and recognized means of assessing pain in persons with dementia called the PainAD. (It is also appropriate for other non-verbal patients) There is a wonderful website called "How to Try This" that has a number of Assessments and Best Practices in Care of Older Adults. There is both written information and video individuals using the different tools. Pain Assessment in People with Dementia is here: http://tinyurl.com/dhvz8x and the video is here: http://links.lww.com/A251 good luck w/the family and the medical director And yes, grimacing, moaning, guarding are all signs of pain! So are less subtle things, so maybe bringing some information from experts will help your case
  17. marachne

    Medicine disposal

    another way to deal with liquid meds is to use diapers (depending on the quantity you have). I would imagine if you you tabs/capsules and a sharps container, you could use that. Having to grind them up and then mix w/litter or coffee grounds seems like a major problem. Also, they are rare and far between, but I have found some places that will accept unused medications (but that would require an agency-level policy change.
  18. marachne

    How Hard Is It To Get In TO Hospice Nursing?

    I do agree that it is the very rare person who can go directly into hospice nursing as a new grad. I do wish to humbly disagree that the prior experience has to be in acute care nursing. I think, depending on the setting that a lot of the skills you need for hospice can be gained working in LTC. You become used to working with families as well as patients, communication, assessment, coordinating others efforts, making do with what you have, working with a population that often has multiple issues (not just physical either). I have never worked in the acute care setting. I did a final rotation in my accelerated bac program in ICU -- 360 hours in 10 weeks. I think that gave me a boost on some of the skills that are part of nursing, but it is my years in a VA long-term care that gott me comfortable in my "nursing skin."
  19. marachne

    BSN to PhD as a New Grad

    I am currently finishing up (i.e. in the data collection part of my dissertation) a BS to PhD. I went straight from my BSN to my PhD (well, I had 9 months of full-time work between an accelerated bachelor's program and starting my PhD program), BUT, I also was a returning student with a lot of life experience. That said, my program has had everything from people like me, to people who had been working for quite a while, to people who were in their 20's and had little experience. All have had at least some experience in either research or heath care (even if it was in a CNA or volunteer role). What I have observed* is: If you are going directly into a PhD program post receiving your BSN, it is essential that you work at least part-time. You cannot develop the deep thinking about nursing and clinical issues without clinical experience. I see that that is your plan, and that shows good thinking. People with limited experience, tend to have a harder time deciding on a research topic -- not a general area, such as you have expressed, but the specific topic that will become their dissertation. That said, I think it is also important to be open, as you go through the early years of a PhD program to ideas other than the ones you come in with -- your learning and understanding will grow as you progress through the program. As BBFRN stated, you need to look for a program that has faculty doing research in your area of interest. That said, it could be people doing work on MH issues, people doing work on health disparities...possibly even policy-focused research, but that's a bit more vauge. Once you have found institutions with like-minded faculty, interview the school -- talk to potential mentors/advisors, talk to current students, find out how they structure their BS to PhD program, who their students are, how they support them etc. If you are interested in teaching as well as research, I would also take a hard look at the curricurlum -- do they include classes, or access to classes about education? As someone with limited nursing experience, you will have an harder time making the transition to the classroom w/o some education background. One thing I would NOT suggest (and I admit, this is my bias showing) is a distance learning program. I think they are difficult for anyone, because you do not get the socialization or informal time with faculty and colleages, but particularly as a new grad with little experience, I think you need to potentially supportive environment of a campus-based program. One last comment, which is not meant to discourage you: something that has become evident to me as I go through my program and watch others in their process is that a PhD is not for everyone. Be open to finding out what does and doesn't work for you, and do not become so stuck on a particular vision that you loose sight of what is really the best fit for you. Good luck with your decisions! *anecdotal, not empirical evidence
  20. marachne

    Accelerated A/P class at PCC???

    PCC used to offer an intensive A & P series over the summer that covered all three courses: Human Anatomy & Physiology I, II, and III, BI231, 232, 233. It was brutal. Five days a week, a "final" or "midterm" every Friday. It was impossible to actually learn the material unless you had a photographic memory. I had a friend who took one of the series and then decided it was too much stress. I looked at the summer schedule and didn't see anything like that, but if you want to be sure, I'd call the registrars office and ask.
  21. marachne

    Research Ethics Case Study

    And here's another example, from my Research Ethics course in my PhD program. Enjoy! Case Presentation Rebecca Goldman was a registered nurse working on a doctoral research study. Her background was in hospice and pain management. Her dissertation was an exploration of the experience of individuals enrolled in hospice and their primary caregivers in rural areas. The study was longitudinal, involving participant observation and multiple interviews with caregiver-care recipient dyads as well as the hospice professionals providing care. When meeting participants, Rebecca’s introduction included her background as a nurse but clearly emphasized her research role. All participants were promised confidentiality during the informed consent process. Over the course of her interviews, one of her participants expressed two strong sentiments: a desire to die at home and a fear of dying in pain. This participant had previous experience caring for others who suffered painful, hospital deaths involving a high level of medical intervention and social isolation. The research participant had liver cancer, which had metastasized to both bone and brain. There was also confusion related to hepatic encephalopathy. The primary caregiver also expressed the desire for his partner to die at home. Up until the time of the disputed event, the primary caregiver had been able to handle most of the caregiving needs; however, he found witnessing his partner’s pain extremely distressing. Rebecca had been interviewing this couple for several months and had developed a comfortable relationship with them that felt equitable and mutual. The participant dyad expressed their appreciation for her “listening ear” and shared a great deal of very rich data. One day, Rebecca arrived for an interview and found the patient-participant in excruciating pain and acute confusion. The hospice nurse had adjusted his pain medication several times in the prior week, increasing his CADD pump, both basal rate and PCA dose, increasing his oral Roxinal dose, and adding Lidocaine patches to areas where there were suspected pathological fractures. Rebecca found the caregiver at his wits end, because nothing he did seemed to help. The bone metastasis made it almost impossible to move the patient for care; the confusion caused him to try to get out of bed several times increasing the risk of falling. The caregiver had not slept in days, and while hospice offers limited respite, it had not been sufficient to allow the caregiver to catch up on his personal needs. Rebecca concluded that this couple no longer had the resources to continue home care. There is no freestanding hospice in town, but there is a hospital with a respected pain team. With some trepidation, as she felt it was not in her role to make suggestions, she broached the subject of transferring the dying man to the hospital. Upon hearing this suggestion, the caregiver burst into tears and stated that he felt it would be “failing his partner and denying his last wish” to transfer him to the hospital. He also shared that he was never designated as medical power of attorney (POA) and fears that in this conservative, rural area he would be denied access to his partner in his dying days. Rebecca was heartbroken by the situation. She attempted to comfort the caregiver and shared that she understands his concerns because she is a lesbian. She asked if it would be permissible for her to talk to the hospice agency and see what can be arranged. She also indicated that it might be possible that his partner could become lucid enough to grant him POA rights. The caregiver hesitated: among other things, he was concerned about being publicly “out” in this small rural town (although he acknowledged that it is probably one of those open secrets, at least among some of his community) but agreed that it was worth trying. He reiterated, however that he would not agree to have his partner moved unless he felt assured that he would be allowed access. Did Rebecca overstep her role as a researcher by making any suggestions? Was her self-disclosure inappropriate? Is it appropriate for her to approach the hospice agency? Were her comments about POA within her scope of practice? What should she have done differently? What, if anything, does she need to do now? Case Analysis and Recommendations While the main issue here is role conflict, the ethical issues of beneficence and autonomy frame it. While Rebecca’s fidelity to her research role can be interpreted as meaning she must separate herself from her nursing role because it will introduce bias and contaminate her data, others would state that her on-going relationship with these individuals has created a fiduciary relationship and a related “duty to care.” Additionally, even the literature, which cautions nurse researchers to avoid their clinical role, make exceptions for instances when the participant is in a state of anxiety or a life-threatening situation. At this time, it is generally believed that the researcher, as a health care professional must intervene. This description fits this case. In terms of her disclosing personal information, this is in keeping with the relationship established and displays appropriate levels of reciprocity. Regarding her making suggestions regarding POA, this seems outside her scope of practice as either researcher or health care provider. Therefore, the following recommendations are provided: Having gained permission from the caregiver, Rebecca should approach the hospice nurse and share her concerns and the information she has received from the caregiver. Rebecca should explain to the family caregiver her limitation regarding assurance of access to the caregiver if his partner is hospitalized, and the limits of her understanding of the mechanics of creating a proxy. That said, Rebecca is now committed, by her words and actions, to fulfilling her role of advocate and following through to the best of her ability in ensuring appropriate access. Rebecca needs to document this interaction via memos and fields notes, as well as discuss her thought process and decisions with her dissertation committee. She will have to abide by any decisions they make regarding her course of action. Any publications involving this data needs to have an explanation of the situation and outcome. Ethical Essay “The venue of research provides greater access to participants’ otherwise private lives and thereby presents ethical dilemmas and challenges. The researcher must respect the individual’s privacy and yet prevent harm” (Locher, Bronstein, Robinson, Williams, & Ritchie, 2006 p. 401) Role conflict as experienced by nurse researchers appears to be a common phenomenon; however, there appears to be little effort to curtail its occurrence and limited agreement on how to respond to the problem. It is not surprising then, to find researchers in the field confronted with situations that they did not expect and where they are unsure how to act. It appears there is a broad spectrum of beliefs and approaches to this issue. At one end is the pure researcher, whose adherence is to the researcher role, described as investigational and dedicated to increasing knowledge, collecting and analyzing uncontaminated data, and improving practice (2001; Colbourne & Sque, 2004). Those in this camp caution against falling into traditional nursing roles as it can introduce bias (Colbourne & Sque, 2004). The other end of the spectrum finds the nurse researcher who never stops being a nurse, and for whom the nursing role is often the paramount duty. These duties are often described in terms of professional responsibility (Beale & Wilkes, 2001; Ulrich, Wallen, & Grady, 2002), professional socialization (Colbourne & Sque, 2004), and/or professional ethics (Beale & Wilkes, 2001; Colbourne & Sque, 2004; Locher et al., 2006; Martin, 1995). Somewhere in the middle are those who see nurse researchers as primarily researchers who, when the situation warrants it, resume the role of the nurse (Colbourne & Sque, 2004; Proffitt et al., 1993; Wilde, 1992; Wilkes & Beale, 2005). While many nursing roles, including advocate, counselor, therapist, teacher and political activist have been cited as part of the nursing role employed by the nurse researcher, the most common role assumed is advocate (Beale & Wilkes, 2001). Much of the literature discussing role conflict relates to qualitative research. Many authors describe how this combining of roles is a natural outcome of qualitative methodology. They refute the claim of introducing bias. The literature discusses the critical role the interaction between researcher and participant plays (Carolan, 2003; Martin, 1995). This interaction is often described as a reciprocal relationship, generally built on and engendering trust (Borbasi, Jackson, & Wilkes, 2005; Johnson & Clarke, 2003; Proffitt et al., 1993; Sterling & Peterson, 2005), with the interview viewed as a conversation (Borbasi et al., 2005). Personal involvement, self-disclosure, caring, and intimacy are perceived as means by which rich data is acquired, especially when dealing with sensitive subjects (Borbasi et al., 2005; Carolan, 2003; Fitzsimons & McAloon, 2004; Wilde, 1992). In addition to the need to establish trust and relationship, many authors describe the need to include the researcher as subjective self in qualitative research and the incorporation of reflexivity and the “self as instrument” into the process, both of data collection and analysis (Borbasi et al., 2005; Carolan, 2003; Cartwright & Limandri, 1997). Whether seen as a desired approach or not, mixing, melding, and switching roles does create conflict. The conflicts include an inability to reconcile the two roles (Beale & Wilkes, 2001), let go of the nurse role (Colbourne & Sque, 2004), or juggle the two while attempting to maintain the integrity of the research process (Beale & Wilkes, 2001; Borbasi et al., 2005; Wilde, 1992), and their own perceived role as researcher (Carolan, 2003). The issue arises most commonly when the nurse researcher sees the participant’s welfare as threatened, and despite any inclination to remain neutral, feels compelled to intervene (Beale & Wilkes, 2001; Cartwright & Limandri, 1997; Johnson & Clarke, 2003; Locher et al., 2006; Wilde, 1992). As Martin (1995) describes it, in cases where “the participant’s welfare is threatened…the ‘individual as nurse’ feels compelled to act, and the ‘individual as researcher’ feels constrained from acting to avoid damaging the research study” (p. 44). This situation occurs with even greater frequency when interviews are performed in the participant’s home; involve sensitive subjects, and vulnerable individuals (Cartwright & Limandri, 1997). An ethical issue that arises from this conflict is between beneficence and autonomy. Or put another way, between confidentiality and duty of care (Beale & Wilkes, 2001). In the face of perceived need, it appears that the nurse role easily trumps the researcher role. As Proffitt et al. (1993) state “Nurses often found subjects with conditions or circumstances that they thought warranted nursing interventions as a higher priority than data collection” (p. 310). Colbourne and Sque (2004) found it was easy for a researcher to slip into the nurse role when encountering a participant who was distressed or in need of information. Adherence to the research protocol was seen as important, but secondary when concern for a participant’s well-being was an issue (Fitzsimons & McAloon, 2004). Nurses found that sustaining the data-gathering role challenged the very essence of their identity as caring professionals. When the participant did not express a concern for their own welfare, or directly ask for information or assistance, the situation was exacerbated. In these situations, and if the nurse researcher felt there were threats to the participant’s welfare, the nurse researcher often felt anxious breaching a participant’s confidentiality to address the perceived need, particularly if the threats to health were not related to the research itself or when the research was observational (Johnson & Clarke, 2003; Locher et al., 2006). Other role conflict issues relate to the greater ethical issues of confidentiality, autonomy, and beneficence. One often cited is reciprocity and the effect of the relationship between the researcher and the participant on the data gathering process. Because the participants often give a great deal of time and information, and the information shared is often emotionally laden, the researcher may be left with a feeling of indebtedness and a need to compensate for this (Cartwright & Limandri, 1997; Johnson & Clarke, 2003). Another kind of discomfort occurred when the researcher felt they had to limit the aspects of themselves they presented to the participant. This led to a feeling of dishonesty and unnaturalness, which, it was felt, hampered the research relationship (Colbourne & Sque, 2004) The literature supplies a multitude of solutions to the issue of role conflict, many of which contradict each other. There are those who hold that roles should be kept separate and conflict avoided—that one must keep the focus on the research at hand, remain a researcher and investigator and not take on the role of counselor, educator or preacher, as that would introduce bias (Beale & Wilkes, 2001; Colbourne & Sque, 2004; Wilde, 1992). Others do not see the strict separation of roles as essential—or even possible. Rather they believe it possible to see oneself as both research and nurse (Borbasi et al., 2005; Fitzsimons & McAloon, 2004; Wilkes & Beale, 2005). Fitzsimon and McAloon (2004) state that not only are the roles of researcher and clinician not mutually exclusive, but that it may be beneficial, at times, to allow the two to converge—that it is possible to respond both as a nurse who cares about the participants well-being and a researcher who seeks to analyze the experience. Even those who see the roles as being separate concede that if the participant is in a state of anxiety or a life-threatening situation, the researcher, as a health care professional, must intervene (Beale & Wilkes, 2001; Colbourne & Sque, 2004; Martin, 1995; Wilde, 1992; Wilkes & Beale, 2005). The timing of the intervention is also debated—some saying that it should come at the end of the interview (Beale & Wilkes, 2001; Colbourne & Sque, 2004; Wilde, 1992), while others contend that it is a matter of neither degree or timing. These individuals state that advocacy takes precedence over advancing knowledge, and one should actively utilize one’s nursing skills as the occasion warrants, and in a timely manner (Beale & Wilkes, 2001; Colbourne & Sque, 2004 Wilde, 1992; Wilkes & Beale, 2005). Fitzsimons and McAloon (2004) propose assessing the probability of harm occurring and the potential magnitude of harm before acting. As a further safeguard, some authors suggest enlisting the help of others, either specialists or individuals more versed in the particular issue (Fitzsimons & McAloon, 2004; Wilkes & Beale, 2005). Influencing factors can include the study design and paradigm (Cartwright & Limandri, 1997). No matter what course the researcher takes, it is important that actions come from a position of reflexivity and recognition of one’s own personal concepts and prejudices (Colbourne & Sque, 2004), as well as the ethical framework of beneficence, respect for persons, and justice. One way to balance these ethical concerns is to ask the participant for permission to reveal information, or pass information along for further assistance. Issues of confidentiality and consent maintain their validity, whether viewed from a scientific/rigor protocol perspective or from the ethical perspective of respect for persons. (Wilkes & Beale, 2005). How nurse researchers present themselves and interact with participants can have an impact on the data gathering process and the study’s results. Some authors suggest the researcher needs to represent themselves honestly. Subterfuge and modified behavior is often apparent to the participant and off-putting. The researcher’s distancing of their self can lead to the participants distancing themselves. Conversely, reciprocity allows for the development of relationship, which is a vital part of the interviewing process. Self-disclosure by the researcher enhances the information exchange and results in more honest and meaningful sharing by the informant (Carolan, 2003; Wilde, 1992). This point is emphasized in the statement “self-disclosure or intervention did not equate to high treason and that it need not invalidate the study” (Colbourne & Sque, 2004 p. 302). Additionally, the issue of secondary gain for both participants does not appear to negate the value of a study. One author comments that benefits accrued on both sides was beneficial in that it created a more equitable situation, eliminating, or at least reducing, the inherent power imbalance favoring the researcher (Wilde, 1992). Some authors found perceiving the researcher as a nurse enhanced the trust felt by the participants and enriched the sharing of experiences. The relationship can add to the richness and detail of data acquired, as well as deepen the researcher’s understanding of the phenomena (Cartwright & Limandri, 1997). Appropriate interventions by the nurse researcher can have additional positive impacts. Wilde (1992) found that after advice was given, participants would often provide new data and new avenues of inquiry would open up, as well as creating new awareness in the researcher leading to new ways of thinking about a situation. While owning all of one’s roles and providing interventions can have positive effects, there is also potential for deleterious impact. There are a myriad of potential impacts ranging from unintended consequences, to questions about subsequent data and compromised rigor (Cartwright & Limandri, 1997; Fitzsimons & McAloon, 2004), to loss of boundaries and unintended disclosure (Borbasi et al., 2005), to unintended influence on the informants’ answers (Wilde, 1992). One author recommends that information gained from interactions while in the nurse role should not be considered data for the study (Beale & Wilkes, 2001). It appears that role conflict and the attendant dilemmas are highly likely to occur when nurses are engaged in research. The question then becomes what is the correct action to take? Two main themes dominated the readings. One related to self-awareness and reflexivity. Researchers need to account for their positions and behavior, and be attentive to how their actions influence the research, the participants, and the researcher (Borbasi et al., 2005; Carolan, 2003). Ways suggested to track this awareness include field notes, memos, discussions with experienced field researchers, regularly scheduled team meetings, debriefing, and accounting for one’s actions in manuscripts (Cartwright & Limandri, 1997; Locher et al., 2006). The second theme concerns the ethical response to the situation. While historical cautions to remain objective and uninvolved are noted, the majority of authors encouraged action based on general and professional ethical principles. Some spoke from the perspective of the statement from the Declaration of Helsinki ‘The health of my patient will be my first consideration.’ This was interpreted to mean not only protection from harm caused by the research, but also protection of the rights and welfare of participants encountered in the course of the research (Fitzsimons & McAloon, 2004; Locher et al., 2006; Sterling & Peterson, 2005; Ulrich et al., 2002). This beneficence however needs to be tempered with respect for persons and their autonomy. In general, actions to protect and/or ameliorate risks should only be undertaken at the participant’s request. When the participant is incapable of seeking help, either because of fear or because of other limiting circumstances, this stipulation can be modified. In such a case, the individual may be seen as not truly autonomous or competent. At this point, the risks of harm need to be balanced against the possible risks that may result from an intervention (Locher et al., 2006). One way of balancing the concerns of beneficence and autonomy is by sharing concerns with the participant, asking permission to share this information with appropriate care providers, and then sharing the pertinent information (Cartwright & Limandri, 1997). One caution is for the researcher to ask themselves “Is the process by which the decision is made appropriate?” and “Are the reasons for making the decision justifiable?” (Fitzsimons & McAloon, 2004 p. 401). Conclusion. Investigating this question revealed some of the thinking related to the issue of role conflict, particularly among nurse researchers. At the same time, it sheds light on some of the shortcomings in the current ways that research is conducted and that researchers are trained. The literature discussing this issue is limited and contradictory without adequate discussion or debate (Beale & Wilkes, 2001; Cartwright & Limandri, 1997; Colbourne & Sque, 2004). As is noted by Borbasi et al. (2005), “The increasing number of nurses undertaking field research who report pragmatic, ethical, and epistemological difficulties surrounding the multifaceted nature of the role is compelling” (p. 500). Difficulties can be linked to lack of training and preparation (particularly regarding negotiating access, interviewing skills, and role relationship with participants), supervision, support, and guidelines (Cartwright & Limandri, 1997; Johnson & Clarke, 2003). This situation can be at least partially ameliorated by discussion of situation as they arise with colleagues and mentors. Also needed is better reporting in published literature regarding incidents and ethical issues (Beale & Wilkes, 2001; Cartwright & Limandri, 1997; Colbourne & Sque, 2004). Perhaps most importantly, identifying potential ethically challenging situations during the study design, and developing plans to address these issues should be included in study proposals (Fitzsimons & McAloon, 2004) . Annotated Bibliography Beale, B., & Wilkes, L. (2001). Nurse researcher: Always a researcher, sometimes a nurse. Collegian, 8(4), 33-39. This article describes a qualitative study of nurse researchers’ views of their roles as clinician and researcher. Two approaches to research are explicated. The article is useful in that it illustrates the thinking of working nurse researchers, however the findings are limited by the small sample and limited educational level and experience of several of the respondents. Borbasi, S., Jackson, D., & Wilkes, L. (2005). Fieldwork in nursing research: Positionality, practicalities and predicaments. Journal of Advanced Nursing, 51(5), 493-501. This article explores concerns of nurses engaged in fieldwork from a theoretical framework, focusing on ethnographic approaches. The authors do an excellent job of framing the methodological and epistemological context and providing cautions to novice nurse researchers. Carolan, M. (2003). Reflexivity: A personal journey during data collection. Nurse Researcher, 10(3), 7-14. Carolan presents a combination of theoretical exploration and personal musing on the concept of reflexivity and issues facing the nurse researcher studying a field of personal and clinical interest. In the process, she provides a good example of both reflection and reflexivity as well as a good working definition of that oft-used and rarely explained term. Translating her personal journey into larger concepts is sometimes a stretch, leaving the reader with more questions than conclusions. Cartwright, J., & Limandri, B. (1997). The challenge of multiple roles in the qualitative clinician researcher-participant client relationship. Qualitative Health Research, 7(2), 223-235. The authors use a description of a specific study and the issues it raised to discuss the various relationships researchers and participants engage in. They also provide concrete suggestions for methodological ways to deal with issues of role conflict. While an older article, the concepts presented, as well as the issues raised are still salient. Colbourne, L., & Sque, M. (2004). Split personalities: Role conflict between the nurse and the nurse researcher. NT Research, 9(4), 297-304. The lead author of this article describes her personal struggle with reconciling her nurse and nurse researcher roles. The authors offer strong suggestions for how to approach this dilemma. Their model of the differences between the beginning nurse researcher and the experienced nurse researcher is both clear, elegant and sensible. Their arguments are solid, and their definition of reflexivity helpful. The strength of their surety in their suggestions however, leave little room for discussion and debate. Fitzsimons, D., & McAloon, T. (2004). The ethics of non-intervention in a study of patients awaiting coronary artery bypass surgery. Journal of Advanced Nursing, 46(4), 395-402. The authors of this article provide a striking case study wherein the project design clearly created problems. Their honesty in sharing such an experience, and the steps they took to correct the situation is commendable. They also present a nuanced argument regarding the deontological and utilitarian positions surrounding their situation. The greatest shortcoming may be in trying to cover too much ground in one article. Johnson, B., & Clarke, J. M. (2003). Collecting sensitive data: The impact on researchers. Qualitative Health Research, 13(3), 431-434. The authors of this article describe a study investigating the issues that arose for researchers exploring “sensitive” topics. While issues pertinent to role conflict in field research are well described, nothing is clarified regarding the difference between research in these sensitive topic areas and other sorts of field research. The authors do provide a forceful argument for better preparing clinical researchers for the field. Locher, J. L., Bronstein, J., Robinson, C. O., Williams, C., & Ritchie, C. S. (2006). Ethical issues involving research conducted with homebound older adults. Gerontologist, 46(2), 160-164. This article explores a specific research subject population—homebound older adults—and the ethical issues related to their study. It is both more general, as the researchers cross multiple disciplines, and more specific than other articles reviewed, because of its subject population. Published very recently and reflecting the aggregate experience of several experienced researchers, it offers a number of concrete and practical suggestions worth exploring. Martin, P. (1995). Qualitative nursing research: The issues and pitfalls. Nursing Times 1995, 91(12), 44-45. This slight and older article adds very little to the literature, however its discussion of “invisible” problem areas is worth noting. Proffitt, C. J., Byrne, M. E., Namei, S. K., King, M. O., Schmidt, S., & Brott, T. G. (1993). The nurse clinician: Role conflict in research. Clinical Nurse Specialist, 7(6), 309-311. This older article describes the experience and issues that arose when masters-prepared nurses are used as data collectors for a quantitative study. In contrast to most of the other articles reviewed, it illustrates some of the problems that can be experienced in a quantitative context. It can also be seen as a cautionary tale regarding the use of personnel not well trained and versed in research methods and ethics. This article is very adamant about the need for the researcher to maintain distance and neutrality, possibly reflecting the quantitative approach. Sterling, Y. M., & Peterson, J. W. (2005). Clinical methods. Lessons learned from a longitudinal qualitative family systems study. Applied Nursing Research, 18(1), 44-49. This article describes a study of African American families where the researchers had a high level of involvement with the participant. The fieldwork involved repeated visits to participants within fluid family systems. Several research issues are discussed, including that of conflicting roles. Practical, concise recommendations are made with a strong patient advocate bias. Ulrich, C. M., Wallen, G. R., & Grady, C. (2002). Research vulnerability and patient advocacy: Balance-seeking perspectives for the clinical nurse scientist? Nursing Research, 51(2), 71. A very brief editorial, the authors urge nurse scientists to maintain advocacy as a centerpiece to their practice. Their conceptualization of vulnerability doesn’t add anything to their argument. Wilde, V. (1992). Controversial hypotheses on the relationship between researcher and informant in qualitative research. Journal of Advanced Nursing, 17(2), 234-242. An older, reflective piece, the author describes the theories she developed as a result of a qualitative study involving nurses. This article provides an excellent example of the impact personal knowledge, experience, and identification with the research participants can have on the researcher. Many of the points Wilde makes are reflected in later works. Her manner of stating her discoveries as hypothesis is a useful technique. Wilkes, L., & Beale, B. (2005). Role conflict: Appropriateness of a nurse researcher's actions in the clinical field. Nurse Researcher, 12(4), 57-70. This article describes a study performed with nurse researchers to explore their responses to vignettes describing the actions of nurses conducting clinical research. Building on a prior study cited above, the authors avoid one of the limitations of the prior work by purposefully sampling experienced nurse researchers. The vignettes were based on actual scenarios, lending greater credence to the study. Their framework of four decision-making styles makes sense, but the results feel thin and somewhat limited. The four vignettes could be a useful tool in training future nurse researchers.
  22. marachne

    NLN - Transforming Clinical Nursing Education

    I just saw this, I don't know if anyone is working on a PhD in Education, but if you are, it'd be a great opportunity: NLN Education Summit 2009 - Doctoral Students Oh, and I know I've said it several times, but I'm at OHSU, and while my PhD focus is not education, I know my abilities as faculty will be greatly enhanced by the leadership she has provided in our education offerings.
  23. marachne

    Opioids and Hyperalgesia

    I imagine some of you think I'm crazy over the top w/my cautions about hyperalgesia, but I just saw the following: Opioid use associated with increased pain sensitivity Methadone-maintained patients and pain patients treated with methadone and morphine experienced hyperalgesia when exposed to a cold pressor test, placing the nondominant forearm in freezing cold water, but not with electrical stimulation, according to an observational Australian study, involving 40 participants, published in The Journal of Pain . Subjects taking opioids were tested just before a scheduled dose. The investigators did not note allodynia after application of von Frey hairs. The authors concluded that methadone-associated hyperalgesia is not only a phenomenon found with a particular population but reinforces the concept that hyperalgesia, but not allodynia, is associated with the long-term administration of opioids. The authors believe this is the first study to compare pain sensitivity to certain stimuli in chronic pain patients treated with morphine or methadone with methadone-maintained patients or healthy opioid-naïve control subjects. http://www.jpain.org/article/S1526-5900(08)00801-8/abstract Opioid use associated with increased pain sensitivity Hyperalgesia in Opioid-Managed Chronic Pain and Opioid-Dependent Patients Justin L. Hay, Jason M. White, Felix Bochner, Andrew A. Somogyi, Tim J. Semple, Bruce Rounsefell The Journal of Pain - March 2009 (Vol. 10, Issue 3, Pages 316-322, DOI: 10.1016/j.jpain.2008.10.003)
  24. marachne

    FDA Reverses On Roxanol.

    a/k/a it may be but I was able to figure it out
  25. marachne

    FDA Reverses On Roxanol.

    And reading the OP, I realize I've been very neglectful of my pals over at Pallimed. Christian really pointed out the power of social media and the public voice -- and rngolfer53, I think I saw your post over there too -- good work at plugging AN there :) The Role of Social Networks in FDA Morphine Reversal Thanks to all the people who emailed, called, and talked about the FDA's memo on stopping production of highly concentrated liquid morphine and other opioids. The comments came very quickly after the post went up on Pallimed on April 1st. As Drew noted, the FDA reversed the decision. From listening to the teleconference, I thought Dennis Throckmorton and the FDA were immensely conciliatory and apologetic in not discussing the matter with the hospice and palliative medicine community. I imagine there will be many more discussions in the future now that they realize we are here. It was pretty amazing the FDA reversed their decision in only 9 days. Obviously a lot of it has to do with the efforts of the AAHPM, NHPCO, and the HPNA leaders getting together to present a united front. But behind that is another important story. The role of social networking in getting this message out. It was fax, email, Twitter, Facebook, face to face, phone calls, and blogs. So I put together a slide show to review the order of events from my viewpoint; how I came to find out about the memo, how that message was passed on, how we can learn from this event. (best viewed in full screen) Social Media In Health CareView more presentations from ctsinclair. Pallimed readers were an important part of the leverage of the social network. Could this have happened without Pallimed, Twitter or Facebook? Of course. But an argument could be made for developing more robust and dynamic social networks in our field to help spread the messages important to our field. Do you have any stories about how you heard or passed on information from the FDA memo reversal? http://www.pallimed.org/2009/04/role-of-social-networks-in-fda-morphine.html

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