30 year old of – 39 year old
when 30 years old, the breast question many are the benignity (cannot cancer). But the young women will have the breast textile fiber cystic will change generally, take the breast ache, the cyst and the non-cancer tumour as the characteristic. Arizona health sciences center university clinical medicine assistant professor Leon · Dr. Tangni said that “the breast ache possibly is cycle of operations, it may follow the menstrual period to occur, may also be the long-enduring ache”.
Many females often felt that the breast spot has the aching feeling, sometimes light sometimes heavy, intermittent, lets the human ponder over airtight, had many people to carry on the back the something weighing on one’s mind for this reason, was afraid itself to suffer from “breast cancer” ……How to reduce the breast ache? Oregon health sciences university assistant professor concurrently Oregon cancer association breast health education project person in charge Dr. Elizabeth · Stan suggested that the female “is far away from the caffeine”. If is hard to endure in the ache, may excise the breast thready lump through the surgery.
Worries the mastoptosis?
Childbirth period, nursing may prevent the breast cancer. The expert thought that nursing cannot cause the breast organization atrophy. On the contrary, the nursing period breast’s inflation may stretch breast’s skin. But when the breast contracts, the flaccid skin can cause the breast to look like compared to before sags.
In fact, the US Orthopedic surgery Academic society a research which carries on 2007 demonstrated that causes the mastoptosis reason also to have: The being pregnant period use’s bra covers the cup to be oversized, many are pregnant the number of times, smoking and the age grows.
Other reason is in breast’s textile fiber ties a belt, is also called the breast to hang ligament’s stretch to create the mastoptosis. Because the breast does not have the muscle, therefore the mastoptosis is unable to prevent, but some doctors suggested woman when jogging puts on the mode of motion bra to prevent ligament’s stretch.
Cuts the breast cancer disease incidence rate
Breast cancer by no means common disease. The American Country Cancer Research institute pointed out: 30 years old to 39 year old of breast cancer disease incidence rate has 1/229. Only if has the family medical history, 30 years old to 39 year-old woman does not need the breast X picture. In fact, the young woman’s breast cancer is very difficult with the breast X picture to examine. This age section’s woman should report the long-term breast change or the ache to doctor. The young woman’s breast ache is benign, but the breast cancer will also occur on the young woman body.
The regular manual examination must, least by be familiar with own breast menstrual, reported to doctor.
If in the menopause, the examination most ideal time is after the menstrual period starts 5 to 10 days, at this time hormone effectiveness is lowest, the test result is most accurate.
40-49 years old
40th period, the majority woman’s udder shapes can change. Dr. Tangni said that “along with the age growth, change speed quick somewhat, but after the menopause, the breast can change is more plentiful, the glandiform textile fiber can reduce, will thus cause more sagging”.
In this age stage, the cyst is the most common breast tumour, these flowing sac is benign, but also meets the ache, may do its platoon or the surgery detachment.
The non-typical nature drive pipe proliferation will also occur in this age stage, in these laticiferous vessel not the normal cell may increase the breast cancer disease incidence rate.
The data demonstrated that this time breast cancer disease incidence rate will increase. Is in 40 years old to 49 year-old woman, the breast cancer disease incidence rate is 1/68. The American Country Cancer Research institute suggested woman when 40 years old according to the first breast X picture, illuminates one time every two years. If has the breast cancer or the carcinoma of uterus family medical history person may in doctor under the suggestion, in 40 years old before shines the breast X picture.
When the feminine breast has the following symptom, please tell doctor:
- And neighbor have the tumour in the breast or the armpit,
- And neighbor have thick or the hard organization in the breast either the armpit;
- The nipple overflows the fluid or the tenderness;
- The nipple reduces or turns with in;
- The breast itches or the skin color change, like changes red, falls off, turns or the fold;
- Udder size or shape change;
- Brings the wheel rim bra, the use tiperspirant, or will have the flesh wound not to increase the breast cancer disease incidence rate.
Each year, about 24,000 people in the United States learn they have cancer of the stomach. Stomach cancer, also called gastric cancer, is the fourth most common cancer today, although it is not nearly as common in this country as it was 60 years ago. Dietary changes and the greater use of refrigeration for food storage are credited for the lower incidence of stomach cancer.
Scientists don’t know why some people develop stomach cancer and others don’t. But they do know that some people are more likely than others to develop it. For instance, stomach cancer occurs mostly in men over 40, and is more likely to occur in black people than in white people.
There are other factors that can increase the risk of getting stomach cancer:
Helicobacter pylori (H. pylori). Some studies suggest that a type of bacteria, Helicobacter pylori, which lives in the stomach lining, is a major cause of stomach cancer. It is found in 20% of people age 40 and under and 50% of those who are 60 or over. H. pylori bacteria often cause peptic ulcers. However, stomach ulcers do not appear to raise a person’s risk of developing stomach cancer. People with H. pylori infection have three to eight times greater risk of developing gastric cancer than those not infected, although most never develop stomach cancer.
Diet. A diet high in preserved foods – such as those that are smoked, dried, salted or pickled – that contain nitrates and nitrites are linked to stomach cancer. These substances can be converted inside your stomach into compounds that increase your risk of stomach cancer. Researchers have also found that people who have diets rich in meat, cheese, and whole milk may be at increased risk of developing cancer in both the esophagus and stomach.
Previous stomach surgery. Stomach surgery may result in higher levels of nitrite-producing bacteria and bile in your stomach, which increases the risk of stomach cancer.
Stomach polyps. Polyps are small bumps or larger mushroom-like growths of the lining of the stomach. Most types of polyps (such as hyperplastic polyps or inflammatory polyps) do not increase a person’s risk of stomach cancer, but adenomatous, benign polyps sometimes develop into stomach cancers.
Pernicious anemia. Having chronic vitamin-deficiency anemia can put someone at an increased risk of developing stomach cancer. Pernicious anemia occurs in older adults and is characterized by numbness and tingling in the extremities.
Genetics. Stomach cancers are two to four times more common for immediate family members of those who have had the disease. However, more than 90% of people with stomach cancer have no family members with stomach cancer.
Country of origin. Stomach cancer is more common in some parts of the world – such as Japan, Korea, parts of Eastern Europe, and Latin America – than in the United States. Researchers believe that is because people in these areas eat many foods that are preserved by drying, smoking, salting, or pickling.
Smoking and alcohol abuse. Both of these substances can irritate the lining of the stomach, particularly the upper parts, and increase the risk of developing cancer.
Environmental exposure. Certain dusts and fumes in the workplace have been linked to a higher-than-average risk of stomach cancer.
If caught early, stomach cancer is treatable. However, when the cancer has spread, the outlook isn’t as good. The 5-year survival rate for stomach cancer is 90% when the cancer is detected in its earliest stages. The problem is that often there are no symptoms in the early stages of stomach cancer. When symptoms do occur, they are usually vague or mistaken for other less serious health problems such as a stomach virus or an ulcer that the patient may choose to ignore.
Stomach cancer can cause the following symptoms:
- Indigestion or a burning sensation (heartburn)
- Discomfort or pain in the abdomen
- Nausea and vomiting
- Diarrhea or constipation
- Bloated feeling after meals
- Loss of appetite
- Weakness and fatigue
- Bleeding (vomiting blood or having blood in the stool)
- Black, tarry stools
Any of these problems could be caused by less serious health problems as well. Symptoms should prompt the patient to see the doctor, who may then refer that patient to a gastroenterologist, a doctor who specializes in diagnosing and treating digestive problems.
To find the cause of your symptoms, the doctor will ask for a medical history, do a physical exam, and may order laboratory tests. They may include one or all of the following exams:
Fecal occult blood test – a check for hidden (occult) blood in the stood. This test is done by placing a small amount of stool on a plastic slide or on a special paper. It may be tested in the doctor’s office or sent to a laboratory.
This test is done because stomach cancer sometimes causes bleeding that cannot be seen. However, noncancerous conditions may also cause bleeding, so having blood in the stool doesn’t mean that you have cancer.
Upper GI series – x-rays of the “GI tract” – the esophagus (which connects your throat and stomach) and stomach. After fasting the night before, the patient drinks a thick, chalky barium liquid. The barium outlines the stomach on the x-rays, helping the doctor find tumors or other abnormal areas. The problem with the x-ray study is that it rarely reveals small, early tumors. The doctor may pump air into the stomach to make such small tumors easier to see.
Endoscopy – an exam of the esophagus and stomach using a thin, lighted tube called an endoscope (also called a gastroscope). Endoscopy is the best diagnostic procedure because it allows the doctor to see the stomach. A local anesthetic is first sprayed into your throat to reduce discomfort and gagging. You may also receive medication to relax you. Your doctor then inserts a thin, flexible tube (endoscope) equipped with a light through your mouth and into your esophagus, stomach, and small intestine. Your doctor will be able to see the upper part of your digestive tract, and remove a small sample (biopsy) of any tissue that appears abnormal for further assessment. The tissue sample is sent to a pathologist who examines it under a microscope to check for cancer cells. A biopsy is the only sure way to know whether cancer cells are present.
If a diagnosis of stomach cancer is made, your doctor may recommend additional tests to determine the extent of the cancer and the best treatment. These tests may include:
Endoscopic ultrasound. Using an endoscope, the doctor can thread a small ultrasound device into the stomach to get a close-up image of it on a computer screen.
Computerized tomography (CT) scan. To see if the cancer has spread to nearby organs, such as the lymph nodes, pancreas, and liver, the doctor may have you undergo a CT scan, which provides an image of your internal organs.
The four stages of stomach cancer progression are:
Stage 1: Cancer cells are confined to only the inner stomach lining. They are absent from the wall of the stomach or from lymph nodes.
Stages 2: Cancer cells exist in the tissue of the second or third layers of the gastric wall, and may or may not exist in the lymph nodes. Cancer has not spread to other areas.
Stages 3: Cancer cells have spread (metastasized) to other areas adjacent to the stomach.
Stage 4: Cancer cells exist in the lymph nodes and/or distant areas of the body.
Treatment for stomach cancer depends on the size, location, and extent of the tumor; whether the cancer has spread and, if so, what parts of the body are affected; the patient’s general health; and other factors.
Treatment may include surgery, chemotherapy, and/or radiation therapy. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials. A patient may have one form of treatment or a combination of treatments.
Surgery. Surgical removal of the stomach tumor is the most common treatment for stomach cancer. In the operation (called a gastrectomy), the surgeon removes part (subtotal or partial gastrectomy) or all (total gastrectomy) of the stomach, as well as some of the tissue around the stomach. After a subtotal gastrectomy, the surgeon connects the remaining part of the stomach to the esophagus or the small intestine. After a total gastrectomy, he or she connects the esophagus directly to the small intestine. Lymph nodes near the tumor are often removed during surgery so they can be checked for cancer cells. The presence of cancer cells in the lymph nodes tells doctors that the disease may have spread to other parts of the body.
Chemotherapy. In chemotherapy, anticancer drugs are given to kill cancer cells. These drugs work on cancer cells, wherever they are in the body, not just in the stomach. They can be taken orally or are given by injection. Chemotherapy is sometimes used before surgery to shrink the tumor, or after surgery to destroy remaining cancer cells. Doctors are also testing a treatment in which cancer-killing drugs are administered directly into the abdomen.
Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment, and so on.
Radiation therapy. Like surgery, radiation therapy (using x-rays) targets cancer cells in a specific area. Radiation may be used after surgery to destroy remaining cancer cells. The patient usually has radiation treatments 5 days a week for 5 to 6 weeks. Sometimes, this treatment is used in combination with chemotherapy. Researchers are conducting clinical trials to find out whether radiation therapy administered during surgery is helpful.
Biological therapy. This form of therapy, also called immunotherapy, uses the body’s immune system to attack and destroy cancer cells. It may also help a patient recover from some of the side effects of treatment. In clinical trials, doctors are studying biological therapy in combination with other treatments to try to prevent stomach cancer from recurring. In other cases, patients who have low blood cell counts during or after chemotherapy may receive biological therapy (substances made by the body or in a laboratory, such as tumor vaccines) to help restore the blood cell levels.
- Avoid diets that are high in smoked and pickled foods and salted meats and fish.
- Eat a diet high in fresh fruits and vegetables. The American Cancer Society recommends that people choose most of the foods they eat from plant sources. This includes fruits, vegetables, breads, cereals, pasta, rice, and beans.
- Limit or cut out alcohol.
There is also evidence that antibiotics and dietary supplements can thwart precancerous changes that may lead to stomach cancer. Researchers studied 1219 people in the province of Narino, Columbia, in the Andes Mountains, a region with some of the highest stomach cancer rates in the world. Those participating in the study had stomach-lining biopsies that showed precancerous changes. They were given one of the following treatments, or a placebo:
- Antibiotics alone
- Beta carotene alone or along with antibiotics
- Vitamin C alone or along with antibiotics
- Both vitamin C and beta carotene together, with or without antibiotics
Each treatment increased the likelihood about three- to eight-fold that their next stomach lining biopsy, taken 6 years later, would be normal. Researchers at the Louisiana State University Medical Center, who conducted the study, found that combining two treatments was no more effective than one treatment alone. The study was reported in the Journal of the National Cancer Institute (Dec 6, 2000 issue).
National Cancer Institute
The American Cancer Society
US National Library of Medicine
After cancer patient surgery, the suitable whole body activity is necessary, but must take the physical condition permission as the premise, is different from person to person.
(1) after technique, like does not have the contraindication, the patient should 1~7 days later gets out of bed to move, namely the early time gets out of bed to move, may support by the arm by the family member in the hospital ward takes a walk, promotes the bodily each function restoration.
(2) if the surgery wound is heavy, the technique postosome strength is bad, when cannot get out of bed, may make the body movement and the turning over movement on the bed.
(3) if the body restores good, may enlarge the physiological load of exercise gradually, the transformation exercise content, from takes a walk, the qigong, the Taijiquan to do holds and even jogs.
Takes a walk builds up strength beneficially
In the tumor patient’s recovery movement, first is worth recommending is takes a walk. Its physiological load of exercise is not big and is easy to do, not condition limits and so on time, space, besides the patient who is ill abed, all tumor patients may choose this mode of motion.
Takes a walk may not arrest the season, is momentarily feasible. Spring the fragrant grass place, the summer step the riverside, the fall enjoys the lotus to settle, between the winter good pinery, each its interest, takes a walk relaxes.
Takes a walk not the space limitation, regardless of strolls slowly on the village field alley, perhaps leisurely strolls on the urban avenue tours, that broad space, the green environment, the fresh air, will cause the person god fresh air to be crisp, completely relaxed.Takes a walk also has the knowledge, ancient cloud: “the walker, disperses does not arrest so-called, and line and stands, and stands and the line, must hold one kind of leisure from like that condition.”
Below to each position introduced takes a walk main point:
(1) attire must be loose, the shoes and socks must be appropriate, if old impotent, may lean on the stick, but the line, guarantees the security.
(2) takes a walk must be unflustered, contented, abandons all distracting thoughts.
(3) step must be relaxed, has like the idle courtyard to leisurely stroll, causes hundred arteries openings, the inside and outside to be coordinated, reaches the whole body vitality to be gentle.
(4) proceeds in an orderly way, does what one can. The time may long be possible to be short, achieves shape Lao Er to be tireless, do not make to be mad that the deficiency is short of breath.
(5) taking a walk time: First, in the morning takes a walk, places oneself between flowers and plants trees, then may the crisp spiritual adjustable vitality. Second, after the food takes a walk, ancient thought: after “food, food stops the stomach, must go slowly several hundred steps, disperses its gas to lose in the spleen, then easy, but hard putrefication.”Third, before resting takes a walk, may cause the spirit to relax, promotion sleep. Other time, may also take a walk, are valued were insisting that long must obtain benefits.
If cancer patient the long-term bed, the body is at uses the condition waste, will cause the joint to be unbending, ischemic muscular atrophy. The bed time is longer, restores the time which the physical strength needs to be also longer. Under this situation, may let the patient make on the bed to suit methodically in own physical strength and the endurance setting-up exercises. When to improve and may get out of bed the activity, then may carry on the active mass slightly big setting-up exercises exercise. This may cause the muscle not as for the atrophy, the joint not as for stiff. May also reduce the osteolysis, prevents the bedsore and the thrombus formation, and causes the patient to whet the appetite, has the healthy feeling.
The suitable physical training may through following 4 o’clock, play the prevention cancer’s role.
(1) can increase organism the immunologic function;
(2) can promote organism metabolism, delays the cell senescence, reduces the cell cancer opportunity;
(3) can whet the appetite, improvement digestion function;
(4) can cause the human to be open and bright, eliminates the worry and melancholy, promotes the psychologically healthy.
During the colder months of the year, it is not uncommon to experience complications with throat pain. For most children, the complications with throat pain are attributed to a viral or bacterial infection that can be treated with medications, or resolve spontaneously. If you have a child who seems to suffer from recurring throat complications, it may be prudent to ask your physician if the risk is associated with tonsil polyps – a rare form of health risk in children.
These polyps are a common health risk in older adults who have suffered from many years of tonsillitis and throat ailments. In children, however, the onset of polyps is often not common and, in many cases, a pediatrician will overlook this as a potential diagnosis. If your child has had frequent throat infections, and if the tonsils are inflamed, then tonsil polyps and throat polyps could be a health issue worth addressing.
When evaluating your child for tonsil polyps, clinical examination will be done but will not reveal the whole picture. To adequately determine if your child has polyps in the throat or tonsils, endoscopy or MRI study of the head and neck should be performed. While some children develop tonsil stones, these are not the polyps but tonsil stone removal should be considered before further assessing a polyp complication.
Tonsil stone removal is a simple process that can be done in the doctor’s office or, in some cases, your pediatrician may recommend a complete tonsillectomy. The advantage to a tonsillectomy, for many children, lies in the removal of not only the tonsil stones but also the removal of any tonsil polyps. If you opt for this surgical procedure, be sure that you child’s pediatrician has ruled out the presence of throat polyps as this will require another form of aggressive care.
Tonsil and throat infections are a common part of human illness and, in children, can be quite frequent. Not all throat and tonsil infections are related to stones and polyps but, when the condition is recurring, your pediatrician to confirm or rule out the health risk as a possible concern. In treating the polyps’ condition early, your child will have a more health throat and neck outcome in the years thereafter.
Sources: Pathology of the Head and Neck, by Antonio Cardesa and Health Guide HQ – http://www.healthguidehq.com/know-before-removing-tonsil-stones.html and http://www.healthguidehq.com/tonsil-stones-removal.html
DISCLOSURE OF MATERIAL CONNECTION: The Contributor has no connection to nor was paid by the brand or product described in this content.
Blood in stool can be triggered by many conditions in the body. Humans are prone to erroneous eating habits, which incidentally is one of the major if not the main cause of most disease like condition that causes blood in feces. Example: constipation. Constipation is among blood in stool causes. It is triggered by taking in little or no water at all, eating fatty food, dry foods etc. The process of forcing hard feces causes tear in the anus which result to blood in the feces, and it is indicated during clean up with tissue paper, or when seen on the stool. This is just an example of a minor condition triggering blood in stool conditions, other major ones like colon cancer is very upsetting, so your are justified if you freak out after detecting blood in your stool, but should you keep to proper dietary recommendations that will be supplied in this article and by your doctors, you won’t freak out after detecting blood in your stool.
Blood in stool causes
Blood in stool causes are numerous, and it will be discuss with treatment procedures.
1. Blood can be caused by abrasion in the gastro intestinal tract or ulcer. Should you have ulcer in the stomach region, and peptic ulcer the blood from the sore can escape into food particles during the process of digestion. The mixing of blood with food particles under the process of oxidation gives stools the back appearance. Remember that stress is among the major cause of ulcer, so to avoid stress is a number one way of avoiding blood in feces
2. Colon cancer is another major condition of blood in stool causes
3. the swelling in the food pipe (esophagus) is one of the blood in stool causes
4. Over the counter habit of drug consumption habits also causes blood in the feces
5. Smoking. This is a very dangerous practice that destroys vital organs like: lungs, heart, kidney, liver etc. It weakens the muscle causing injuries and bleeding, the blood mixes with food particles during digestion thereby resulting in blood in the feces
6. Diarrhea caused by food poison or amoebic dysentery is among blood in stool causes
7. Colon inflammation or ulcerative colitis can also result in bleeding that mixes with the feces. This condition is often linked with slight pain in the abdominal regions, mild feverish condition, and cramps
8. Worms residing in the intestine can cause bleeding
Blood in feces is just a sign that indicates conditions like the ones mentioned above. Except blood in stool causes is as a result of constipation or hard stool experiences which probably led to tearing in the anus, the attention of a medical personnel may not be required. Simple procedures like: eating regularly on time, drinking at least 6 glasses of water daily, eating fiber rich food like: fruits and vegetable, staying away from smoking, eating oily foods, staying away from excessive coffee intake etc will surely prevent blood in stool causes and conditions.
Many women prefer using home remedies for Bacterial Vaginosis rather than visiting a doctor to take care of their symptoms they experience, so it is good to gain some knowledge about Natural cures for this condition.
Since the symptoms of this condition are so uncomfortable, many people will look for a quick fix solution to gain immediate relief from BV. Included in the condition and the discomfort, is the vaginal discharge which has an odor that smells like fish. Some people even feel uneasy visiting their doctor with this condition when they are seeking treatment, which is why they resort to natural cures for their condition,
A person who has been infected with Bacterial Vaginosis has a much greater chance to encounter the same problem over and over again, especially if they have been taking antibiotics to relieve the condition. It could be a vicious cycle; antibiotics lead to lowered immunity in the vaginal area and so the “good bacteria” is destroyed along with the “bad bacteria”, therefore leading to a new case of BV later on.
The constraints on the doctor are great, let alone the expenses the patient has to pay, going from one doctor to another in order to do clinical tests and diagnosis for the condition. Then there are follow-up visits and consultation fees every time BV comes back, and worst of all, the antibiotic medication is not even effective. It is an embarrassing situation and complete relief is not obtained unless the patient is treated with natural remedies.
Save yourself time and money, as well as embarrassing trips from one doctor to another, by looking into the natural cures. These remedies are accepted and harmless, they will get rid of the painful symptoms and itch immediately, and the patient is cured from all the imbalances in the pH level of the vagina, which lead to Bacterial Vaginosis in the first place.
Use these natural treatment options and put an end to the uncomfortable itching, burning and fish smelling discharge instead of taking antibiotics:
Yogurt is one of the home remedies and it is very effective in clearing up the infection. Plain yogurt should either be consumed or applied directly to the infected vaginal area on a regular basis, and within a short time the symptoms of burning and itching will stop and diminish permanently. Yogurt has live bacteria that when applied to the vaginal wall, will help balance the bacteria in the vagina. Some may think it awkward to apply yogurt inside the Vagina, but it has been tried out before, so it is safe and very effective in curing this condition.
Another natural cure is cider vinegar. Soaking the lower body and the vagina area for a couple of minutes in a mixture of warm water with 2-3 cups of vinegar diluted in the water has been very successful in getting rid of the condition. Garlic is also known to be a natural antibiotic, and so eating cloves of garlic will help relieve and eradicate Bacterial Vaginosis.
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When the NHS first evolved, the prognosis for patients with Cancer was appalling, but over the last 30 years, the revolution in drug therapies has transformed nursing practice. Advancing technology over the last decade in particular, has resulted in major changes in the specialist field of oncology, where medical innovations have had an enormous impact on the role of the nurse working in cancer care. Cancer nurses are now performing tasks that nobody would ever have thought possible, and their contribution to patient care is now being increasingly recognised.
The past few years have seen remarkable advances against cancer, which have led to dramatic improvements in longer-term survival and cure. One prime example, is in the area of childhood cancers, where by the year 2000, it is estimated that 1 in 1000 of our young adult population between the ages of 20-29yrs, will be survivors of childhood cancer (Meadows et al, 1986). Although innovations have resulted in a current 65% overall cure rate in childhood cancer, the associated effects carry the potential of multi-organ system morbidity. As a result, cured and grown survivors have the potential to develop significant problems, which may last a lifetime. In this respect childhood cancers are qualitatively and quantitatively unique. A 5 year old cured of cancer has over 70 years of life expectancy left, thus allowing the emergence of long term effects in the future, which wouldn’t have the same effect in a 70 year old cured of cancer with around 5 years of life expectancy left. This has an enormous impact on the nurse working with children and young people with cancer.
Medical innovations, which have led to increased survival in many types of cancer, in both adults and children, have not been without consequence. For some it has meant the development of intensive treatment protocols, with devastating widespread side effects, which have created a higher dependency of patient, who require intensive nursing care and support. For Example: –
- the development of biological therapies, such as
i) Monoclonal antibodies, which can target specific tumours; i.e. Mibg therapy.
ii) Colony stimulating factors, such as GCSF, that help the patient’s immune system recover more quickly from the effects of cancer drugs, enabling more high dose intensive treatments to be given.
- Peripheral stem cell harvests and transplantation, to support high dose therapies.
For other patients, innovations have improved the quality of life, decreased hospitalisation and facilitated for many, ambulatory care. For example : –
- less radical surgery for breast, and prostate cancers
- limb sparing surgery for many sarcoma patients
- more accurate, less invasive procedures for detection, using fibre-optic technology
- increased precision in treatments such as Radiotherapy, decreasing normal tissue toxicity
- increased ability to individualise treatments because of improved diagnostic tools
- the development of drugs, which have facilitated better control of pain, nausea and vomiting.
The impact, however, is just as great on the patient, but poses different challenges to the nurse. They require as much support as patients receiving intensive in-patient treatments, their diseases and treatments being as much a source of anxiety and stress. In relation to Radiotherapy treatment in particular, the vast majority attend daily, and the location of the treatment centre and frequency of treatments can cause additional significant disruption (Hinds and Moyer, 1997).
The role of the nurse in out-patient care is rapidly changing, and nurses need to be empowered to assume new roles, which can be achieved through the development of nurse-led clinics. This is vital, as the whole thrust of modern care is towards treating as an outpatient whenever possible. The number of outpatient attenders is therefore rising, and the need to rationalise how care is delivered is becoming imperative.
Professional nursing bodies, have, in response to changing needs, encouraged nursing to open the door to further expansion and development, through their work on the Code of Professional Conduct, and the Scope of Professional Practice, both, 1992. These frameworks have assisted nurses in the move further along the road towards professional accountability and autonomy in practice. The Scope of Professional Practice, 1992, in particular, has helped pave the way for nurses to extend their role in the provision of care, in a way which has increased the status and value of nursing, instead of allowing ourselves to remain handmaidens to the medical profession. Nurses now have the opportunity to extend their roles appropriately, absorbing activities into the holistic nature of nursing, informed by nursing values (Denner, 1995).
Medical innovations have therefore, had a major impact on the role of the nurse working in cancer care, presenting a myriad of challenges. The nurses’ role has expanded to incorporate co-ordinator, facilitator, educator , researcher, communicator, innovator and advocate, to name but a few of the competencies required. To meet these goals, the nurse must have the authority and autonomy to manage and control nurses’ practice (Bowman, 1995).
Nursing care of the patient today makes great demands on nurses’ knowledge and skills, especially if the care given is to be competent, efficient and effective. It also raises many ethical issues and dilemmas, and it is imperative that nurses’ familiarise themselves with basic ethical principles. Ethical dilemmas remain an uncomfortable issue for many nurses, who are increasingly faced with decisions that have no clear “right” answers. The role of the nurse in this capacity, is to work in collaboration with other healthcare professionals, to make the best possible decisions that support the underlying ethical principles of highest value (Vestal, 1995).
The possibilities for progressive and innovative practitioners are wide-ranging, but to be effective, must have the support of managers and the organisation as a whole.
Educationally, oncology nurses need to develop a wide knowledge base, in order keep up to date with current practices, and the continually changing wealth of oncology literature. It is imperative for each individual nurse to be familiar with the potential effects on the patients they care for, regarding problems which may arise relating to treatments, and unique aspects of definitive management of those problems. Nurses therefore need to ensure they keep up to date with personal and professional development, and are supported throughout professional life. Indeed, there is
no end point in the need to maintain and develop standards of practice, (UKCC, 1993), particularly in a rapidly changing environment such as oncology nursing.
There are an ever increasing variety of roles for the cancer nurse. Much of the progress made, over the years, has resulted from clinical trials and research. Nurses are currently developing their roles alongside of this, in particular, through specific disease orientated groups, thereby creating specialist roles within a speciality. Nurses are also working more in the promotion of health, in an attempt to utilise prevention strategies.
For patients on intensive treatments, reliable intravascular access for administration of chemotherapy agents, fluids, blood products, antibiotics and nutritional support, has become an essential feature of medical care (Maki, 1991). The increasing use of central venous access devices has greatly facilitated safe and effective administration for patients on intensive protocols, with minimal discomfort. However, there are potentially very dangerous consequences, and they require effective management. Nursing staff, must undertake specific training in order to develop a knowledge, expertise and competence if they wish to care for them, an extended role undertaken by many nurses’ in an attempt to provide holistic and efficient care for the patient. Indeed the creation of specialist nursing roles, are facilitating insertion of the central lines by appropriately trained nurses, with extremely effective outcomes.
In relation to technology, the nurse has to contend with the increasing sophistication of information, and the growth of telecommunications, which continue to speed up the exchange of information, knowledge and ideas. Our specialised body of knowledge is now being challenged. Both the medical and nursing professions no longer have a monopoly over their knowledge bases. Access to information from the media and the Internet, and the increasing emphasis placed on health promotion has resulted in the wider public becoming far more aware of medical innovations taking place all over the world. Families bring this information into our clinical areas when discussing treatment options. In addition, there have been the ever-increasing demands of informed patients on matters relating to their health, care and progress, with rights enshrined in the Patient’s Charter. (DOH, 1991).
It is now, therefore, even more crucial that nursing keep abreast of developments in cancer care. Alongside of this, it has become increasingly important that nurses recognise their own limitations in practice, referring clients to the appropriate personnel as required. In an era of increasing litigation and accountability, the nurse working in cancer care needs to develop a solid understanding of legal issues. With advances in practice through medical innovations, nurses are increasingly confronted with many varied and complex practice situations. It is therefore imperative to produce legible, accurate, effective, contemporaneous nursing records which co-ordinates and communicates patient care activities.
The role of the nurse not only involves planning, implementing and evaluating hospital care effectively, but planning for discharge, must be commenced right from admission, so that effective care can be maintained following discharge of care into the community. This is an essential aspect of the nursing role, as, regardless of whether the patient is being treated with curative or palliative intent, it is important that their individual needs continue to be met by the appropriate personnel at all stages in their illness.
Medical innovations have resulted in the rapid and continuing expansion of specialisation and complexity in the delivery of healthcare. This has led to the development of an array of levels of nursing practice and a multitude of titles, competencies and training programmes (Furlong and Glover, 1998).
The creation of enhanced nursing roles, with titles being inconsistently applied, such as clinical nurse specialist, specialist practitioner, advanced nurse practitioner, nurse specialists and nurse practitioner, suggests that the scope and content of roles vary widely, but even where roles share a common title, there is evidence to suggest that they operate in different ways (Furlong and Glover, 1998). Fellow healthcare professionals, both nursing and medical, and, more importantly, patient’s themselves, are finding it difficult to keep up with the changes, often not clearly understanding an individual’s nursing role. We have been used to sharp boundaries between services, and clearly defined roles for professionals in the past, but these are slowly being eroded by medical innovations with shifting demands, and resulting ethical challenges, which have blurred professional boundaries (DOH, 1994). Therefore, alongside of developing roles, we need to establish a recognised framework that encompasses ethical, educational and legal accountability issues, and clarifies for the post- holder, fellow healthcare professionals and patients, the scope and remit of their role.
Educationally, staff must receive appropriate training and development in order to carry out their roles effectively. Lack of clarity and definition of certain roles has hampered this to some extent, but nurses need to, and must learn to take responsibility for their own personal and professional development, and plan how these needs are going to be met. The opportunities for staff development in cancer care are numerous. There is a multitude of support available, from teaching sessions and relevant study days, through to specialist courses, leading to recognised specialist qualifications. These are, in the main, easily accessible and well supported by management. The Calman-Hine Report re-iterates that if the treatment and care of patients with cancer is to be maintained at a uniformly high standard, the health care professionals involved must receive special training in oncology (DOH, 1995). This has become even more vital, as technology affects where a service is offered and by whom. It has in the past promoted centralisation of services, but now its effect is to facilitate movement the other way (DOH, 1994). Indeed, it is the objective of the Calman-Hine recommendations that commoner cancers are treated in cancer units, with specialist centres caring for the more complex and unusual tumours.
Nurses’ working in cancer care, must therefore seize the initiative, and take responsibility for their own learning needs, if they are to increase their expertise in line with the complexity of modern medicine.
While many innovations have been made, cancer mortality rates remain high in a number of areas, and more work still needs to be done. We do, however, now know much more about the limits, as well as the triumphs, of medical science. As our understanding of what constitutes health care shifts, and we continue to develop partnerships with the patient, patients may not welcome increased medical intervention at the expense of quality of life. This is all about informed choice, and an important aspect of care. One thing for certain, is that the skills involved in caring and communicating with the cancer patient, the traditional domain of the nurse, will continue to become increasingly important to all cancer nurses. (Hancock, 1998). As Christine Hancock recently said, “Perhaps for the patient’s of the next century, the key question will not be: Can you cure me doctor? but: What are my options, nurse?” (Hancock, 1998).
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I feel so liberated and secure now that I am making $60,000 a year. I am filled with so much joy and inner peace when I am surrounded and visited by friends and family, my mom, dad, brother, sister and grandparents. I love my job. I love doing massage. I love helping others to heal. I am at peace with my career and my work atmosphere. I love my current living environment. It feeds me spiritually, physically and emotionally. I love waking up and seeing the beautiful blue hues of the ocean and being surrounded by beautiful mountains and nature. I love watching Lily run and play and be happy. Im excited about all the new and wonderful people and opportunities that come to my life and I am making friends easily. I am surrounded by happiness and I am filled with appreciation. I am deeply in love and I have found my twin soul. Our relationship is loving, supportive and committed. I feel stimulated by my partner and everyday together feels passionate and exciting. I am physically healthy and I am completely in tune with myself and aware of my own inner thoughts and feelings. I am the best “Me” I can possibly be.
I will be grateful for everyday. I will allow myself only to think positive thoughts. I will be more aware of the opportunities that arise around me. I will forgive myself for past mistakes. I will have faith and believe that nothing but good things are coming to my life. I will have an open heart and an open mind.
I recently relocated to the Boca Raton area and I am feeling spiritually empty. I feel restless and I’m having a hard time finding inner peace. I continue to carry on a relationship with a person that is emotionally unavailable to me and I continue to mistake physical connection for real intimacy, I can’t seem to let him go. I feel as though I am ready for a great change, but I feel scared and that something is holding me back. I want to have more faith and be able to be confident about my life. I want to feel good about me.
The assignment focuses on the promotion of oral health in the immunocompromised adolescent receiving chemotherapy. The client groups particular health education/promotion needs will be identified, followed by a detailed action plan, using authoritative literature and a theoretical framework, and discussion and critical evaluation of the strengths and weaknesses of the proposed plan of action.
The aim is to promote good oral health practices and minimise the severity of mucositis post chemotherapy. Corbett, (1991), suggests 90% of children receiving chemotherapy develop oral complications with factors such as dental caries, poor existing oral hygiene, age, inadequate self-care abilities, and nutritional state influencing its severity. Oral health is important, the presence of dental disease and mucositis affecting the most basic of human functions; communication, eating, social interaction, taste and breathing. It can be a dose limiting toxicity of treatment, (Graham et al, 1993, Dodd et al, 1996), and an important source of bacteraemia, which can cause life-threatening infections. (Dando, 1995). Combined with severe pain and distress, the impact is devastating.
Health promotion is based on many different theories about what influences people’s health and what constitutes an effective intervention or strategy to improve health. Nursing knowledge and skills are invaluable in empowering, supporting and teaching adolescents to achieve the potential for health. A theoretical framework facilitates the organisation of an effective plan of action. (Ewles and Simnett,1999).
The Specialist Practitioner role involves examining wider implications of service provision when identifying health promotion strategies for this client group. Advances in the control of nausea and vomiting and the introduction of colony stimulating factors to decrease the severity of aplasia have led to intensifying chemotherapy, increasing the potential for oral cavity breakdown, which still causes significant morbidity. (Berger and Eilers, 1998). Patients are often readmitted with oral problems associated with side effects of chemotherapy, which negatively impacts on quality of life. (Kennedy and Diamond, 1997). A rise in consumerism in health matters (Maben and Macleod Clark, 1995), an increasing number of long-term survivors, (Kissen and Wallace, 1995), and epidemiological shifts in disease patterns from acute to chronic morbidity all demonstrate the need for life-long oral health promotion. The specialist practitioner needs to ensure staff are involved with primary prevention of dental caries, secondary prevention, in promoting early detection and treatment and tertiary prevention in minimising potential complications relating to treatment, to give the best life chance benefits from health care. National objectives are laid out to improve the management of children’s services, through a shared governance approach (DOH, 1998), putting the patient at the centre of the care process.
There are many different models of health promotion (Becker, 1974, Ajzen and Fishbein, 1980, Tones and Tilford, 1993), but Becker’s (1974) Health Belief Model, promotes an individualistic health promotion ideology, highlighting the function of beliefs and attitudes in decision making. This is important in understanding the needs and characteristics of chronically sick adolescents, expected to follow unpleasant and disruptive treatments. Benner and Wrubel, (1989), identify that each kind of illness and disability create different demands for nursing care, but Zelter, (1980), asserts that it is more important to know what type of child has the disease.
The Health Belief Model suggests when people are faced with pressure to change their lifestyles they weigh up the potential costs to themselves with the perceived benefits, and make a decision accordingly, assuming that if the risks are great enough, behaviour will be changed (Purandare, 1997, Obeid, 1996). Buckingham, (1997), proposes this will determine compliance, of which attitudes play a large part. A family’s attitude to health and health beliefs will influence adolescents attitudes towards health care, as will personal attitudes such as self-esteem, self-perception, health locus of control and self-confidence. Purandare, (1997), advocates negative attitudes must be identified and dealt with before effective communication can take place, which can be achieved through an accurate Health needs assessment, which includes physical, psychological, social, educational, religious and cultural needs. The negative aspects of mucositis, such as intense pain and life-threatening bacteraemia, can then be changed into there being a reward for positive health behaviour, such as preventing or minimising complications. The Health Belief Model suggests cues to action may help motivate or maintain behavioural changes. The triggers may come from external sources, like a periodic reminder for a dental appointment or advice from nursing staff, or an internal source, such as prior pain and suffering of severe mucositis, which may improve the likelyhood of taking recommended action.
Rosenbaum and Carty, (1996), confirm the importance of peers, suggesting nursing interaction with young people be guided by issues related to the subculture of adolescence and the understanding that health and care have many meanings to adolescents. Whyte and Smith, (1997), support this view, stating adolescents report a therapeutic value from belonging to a peer group, which becomes increasingly important and influential in adolescence. Critics, however, suggest the Health Belief Model takes little account of the influence on an individual of the environment, family, friends and peer group, viewing health as a personal strength. (Buckingham, 1997). Environment is important, as the socio-economic status of the family appears to have the biggest negative effect on Health Beliefs, posing the greatest barriers to health care. (Buckingham, 1997). Glasper and Campbell, (1995), report a correlation between poverty and prevalence of illness, which makes it increasingly difficult to get patients out of the ill-health role.
Individual characteristics vary enormously, and in formulating an action plan factors need identifying that impact positive and negative patient education systems such as experience, knowledge, culture, language, attitude, literacy, motivation, age, level of ability, psychological mood, receptiveness, symptom distress and locus of control, which influence health promotion strategies. Hinds et al, (1992), indicate adolescents with cancer report higher symptom distress levels than children, possibly due to attaching a more negative meaning to the symptoms and having greater concern over their body image. Indeed, Enskar et al, (1997), identifies the adolescent’s own experience of areas of life situation affected by the disease, highlighting that physical side effects experienced during the treatment period, were seen as the worst aspect of the disease, influencing the ability to live the life they wanted. This relates to the Health Belief Model’s locus of control, the loss of which can lead to non-compliance. Psychological mood can also affect compliance, Borkoswka et al, (1998), suggesting that intermediate levels of anxiety may be optimal in predicting compliance. Low levels may mean the adolescent is not concerned enough to follow advice, whilst high levels indicate they may be unable to correctly interpret advice. The specialist practitioner is in a unique position to foster a supportive environment whereby nurses can provide appropriate counselling and psychological support.
A major goal of education is to gain patient compliance with oral health and self-care measures. Factors affecting compliance include the adolescent’s estimation of the seriousness of the problem, relating to perceived susceptibility. Adolescents who underestimate the seriousness have a greater possibility of non-compliance. (Olson et al, 1986). The main objectives are raising health awareness, improving knowledge, self-empowering, changing attitudes and behaviour and environmental change.
Current health promotion ideology accepts empowerment as enabling and supporting clients to acquire the skills and confidence to take greater control of their own health status (Rodwell, 1996). The specialist practitioner needs to assist the health educator in raising awareness of the wider factors determining health choices, so adolescents feel that significant control resides with themselves. (Downie et al, 1998). Schulmeister, (1991), attributes symptom distress as a potential to affect patients learning abilities. Components of the process of patient teaching therefore include assessing learning needs and readiness to learn, setting learning goals, teaching and evaluating learning.
A Successful plan of action will depend on collating the evidence, effective communication, meeting the information needs of adolescents, education needs of staff, developing a strategy for shared governance, promoting “Partnerships” and effective management of the change process. Identifying what resources are already available is important to determine what additional resources will be required. Examining existing government policies, service provision, facilities, material resources and evidence-based practice will assist this process. A literature search and communication with other oncology centres, alongside identifying current practice throughout the trust, will determine existing service provision and an evidence base. There is undisputed evidence relating to the benefits of oral assessment and dental health promotion. (Kenny, 1990, Beck, 1992, Dose, 1995, Madeya, 1996, Clarkson and Eden,1998), but studies of specific oral care protocols over the last 20 years, have failed to identify a consistent preferred agent to reduce mucositis severity, (Dodd et al, 1996). Government initiatives such as the National Institute of Clinical Excellence will assist in providing guidance and support through clear consistent guidelines about which treatments work best. (DOH,1997). The Young Oncology Unit currently utilises prophylactic Nystatin, which, Buchanan et al, (1985), suggest is of no value. Epstein et al, (1992), supports this claim confirming that compliance with Nystatin is limited by an unpleasant taste, nausea and vomiting, which according to the Health Belief Model would be a perceived barrier in relation to cost-benefit analysis. Nystatin also conflicts with dental health advice as it is sugary and decays teeth. This could be an inhibiting factor in promoting health in relation to perceived benefit, as a sufficiently threatened adolescent may not accept recommended health action unless perceived as effective. (Obeid, 1996, Purandare, 1997).
Evidence suggests normal toothbrushing with a soft brush twice a day, alongside professional dental care promotes good oral hygiene, (Beck, 1992, Gibson et al, 1997, Dose, 1995) which could be a motivating factor in conforming to peer group actions. Prophylactic Chlorhexidine mouthwashes may, in addition, benefit the severely immunocompromised patient, because of its proven prophylactic anti-fungal effect against candida. (Ferretti et al, 1990, De Beule et al, 1991, Dose, 1995).
The literature recommends all cancer patients have oral assessment and treatment of pre-existing disease prior to commencing chemotherapy, indicating the need to integrate medical and dental care.(Dose,1995, Madeya, 1996, Clarkson and Eden, 1998). This is a huge task considering the NorthWest has the worst child dental health record in England (Ashton, 1995), with only 65% of children in England even being registered with a dentist. (The Health Committee, 1996-1997). The Government is however, committed to improving the health of the population and existing policies will be a useful resource. (DOH,1998, NHSE,1998).
It is important to plan evaluation methods as evaluation is an integral part of the overall plan, and ensure effective documentation processes are in place. A detailed action plan can then be initiated which meets the needs and characteristics of the client group using the resources identified, whilst continually reviewing and monitoring the process to achieve the desired objectives.
Successful health promotion requires multi-collaborative working, networking, liaising, managing change and developing effective partnerships. (NHSE, 1998). The Health Committee Report, (1996-1997), repeatedly emphasises the importance of integrating services, whilst Casey et al, (1997), discuss the present fragmentation and lack of communication. The “UK Children’s Charter”, (NHSE, 1996), expressly states that all parents should have appropriate help and support from the community. Adopting a shared governance approach with the Doctors, Nursing staff, Pharmacist, Managers, School teacher, Dentist, Social worker, School nurse and Community team, will assist in integrating services, (DOH, 1998), and improving communication processes. This will help to establish clear lines of accountability and empower staff to take ownership of their own roles.
The specific information needs of adolescents’ need identifying as imparting appropriate, meaningful information may enhance self-care measures, increase self-esteem and decrease anxiety. The locus of control is then more likely to stay with the adolescent, facilitating the development of positive health beliefs, which may improve oral health promotion. In self-regulation theory, people form schemata of impending experiences. When people are faced with cancer, excessive amounts of new information must be incorporated into their schema. (Fieler, 1996). Health promotion and education may be difficult where the desired behaviour is unpleasant or doesn’t fit into their particular schema. Kanneh, (1991), advocates that failure to understand health education literature, or being denied access to it, can disempower young people. The psychological and social impact of cancer also makes information more difficult to absorb. Consideration needs to be given to user-friendly material in a suitable format and language and appropriate teaching strategies for individual needs, which will facilitate participation in the decision-making process. Working with Health Promotion units and Information forums may assist this process.
There is good evidence on which to promote oral health and immense organisation is required in preparing teaching and information packages, an oral assessment criteria and standards. The draft guidelines produced require dissemination to relevant personnel, which can also be fed through to local and national initiatives.
The benefits on a macro level are seen in terms of improved quality of care and patient satisfaction. Cost-benefit advantages may also emerge; a reduction in the incidence of preventable disease or morbidity, a lower re-admission rate, earlier recovery, less absenteeism from school, work or college and the acquisition of positive health related behaviours. (Palmer, 1994). There may also be reduced medication costs, particularly in relation to antibiotics where a decrease in usage is also of major importance in terms of resistance.
There are many strengths and several weaknesses to the proposed plan of action. The specialist practitioner needs to be proactive in facilitating learning of all members of the multi-disciplinary team in current oral health issues, to develop service provision. One strength is a shared governance approach helps staff to learn rather than teaching them, which will unlock their potential to maximise their own performance. The Specialist Practitioner can then act as facilitator and coach, bringing staff together and motivating them to achieve change. The patients needs also drive the system, important in the effective management of change. Multi-collaborative working utilising a shared governance approach will assist in the integration of services, particularly important in the increasing provision of community support, and provide an environment in which nurses feel valued, supported and empowered, which will enable nurses to support and empower their patients.
Becker’s (1974) Model is useful in developing an understanding of individual needs and characteristics, but can be criticised for taking little account of the influence on an individual of the environment, family, friends and peer group. It is an excellent model for addressing compliance issues, and promotes choice and control, an important aspect of our nursing philosophy.
On the macro level, the specialist practitioner needs to ensure nurses are fully aware of their role as health educators. It may be necessary to change the beliefs and attitudes of staff, which hasn’t specifically been addressed within the action plan. This is important as patients and staff don’t always consider the health-within-illness concept, which can provide the opportunity for positive change. (Moch, 1998). Wallace et al, (1997), found staff working in areas where stomatitis was most severe scored low on attitude compared with general medical units, believing they had little impact on the problem. Thoughts and actions of staff have not been well explored by the Health Belief Model, (Obeid, 1996), yet, in order to motivate staff, they too need to believe the patient is susceptible, see the perceived benefits to the patient, have some locus of control and perceive that the process for making the change will work.
Another weakness is that the Health Belief Model assumes all people are able to process information rationally. Some studies appear to support the hypothesis that giving patients more information reduces anxiety levels and promotes recovery. (Hagopian, 1991; Poroch, 1995), but there is evidence of contradictory results. (Miller et al, 1988, Wells et al, 1990, Ohanian, 1990). Indeed, Ohanian (1990) demonstrated that information needs of parents and adolescents are quite different, with parents more concerned with prognostic indicators, whilst adolescents highlighted the need for information relating to personal bodily concerns. Hinds et al, (1995), suggest not everyone desires information. Malin and Teasdale, (1991), advocate this theory would predict a nurse with an ideological commitment to empowerment could make some patient’s unnecessarily anxious if a blanket information giving strategy was employed without regard to individual differences.
Cultural attitudes haven’t been specifically addressed but are important so staff don’t transmit negative non-verbal cues whilst trying to impart positive verbal messages, resulting in mistrust and confusion. (Purandare, 1997). It is sometimes difficult to be non-judgemental and objective in working with families whose behaviours and attitudes differ from or conflict with our own. Whilst empowerment, information and communication is emphasised, in the wider context of other significant factors, the adolescent may induce a compromise in respect of care. What the health care professional may see as irresponsible may be what the adolescent sees as the most responsible action in the circumstances, and this poses ethical dilemmas in allowing the individual to control their own lives and still trying to facilitate what’s best.
Other weaknesses of the action plan are that in taking a behavioural individualistic approach, using the Health Belief Model, it assumes that each individual has the genuine freedom to choose a healthier life-style, but this may be limited by economic and social factors. Indeed, a study of a lower socio-economic status, predominantly black sample of adolescents, found no relationship between variables from the Health Belief Model and dental appointment compliance. (West et al, 1993). The specialist practitioner must therefore assist staff in working within the socio-economic framework of the family. (Glasper and Campbell, 1995). Also, where the proposed behaviour is accepted, it may induce feelings of guilt if the action taken does not work, which, in relation to mucositis cannot be guaranteed.
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The focus of the assignment is to improve the discharge planning process through the development of an integrated care pathway (ICP). The author’s client group relates to care of children and adolescents with cancer, aged 0-21 years, the multidisciplinary team including nurses, doctors, physiotherapist, dietitian, social worker, community liaison nurse, palliative care team, the patient, carer, other specialist nurses and outside agencies including primary care teams. The rationale for development will be highlighted, followed by critical analysis of the implications of implementing the proposed change, which will be addressed from a specialist practitioner perspective. Management and Leadership strategies that would be employed by the Specialist Practitioner will be discussed, followed by critical evaluation of the proposal.
The recommendation chosen from the NHS, Modern, Dependable (DOH, 1997), relates to improving integration and collaboration, proposed as an integral part of future patient care. The reason for choosing the recommendation is the increasing importance for NHS staff to work efficiently and effectively in teams within and across organisational boundaries.
Maloney and Preston (1992) highlight the acute and chronic nature of cancer can profoundly affect quality of life, the period following discharge being one of great vulnerability and anxiety. Planning care, providing adequate information and involving clients can minimise distress and disruption.
In relation to the health needs of the specific client group, children and adolescents with cancer move through many healthcare settings during the course of their illness, encountering numerous healthcare professionals. Maloney and Preston (1992) indicate successful transition through these settings is dependent upon the collaborative efforts of healthcare providers.
Scott and Cowen (1997) assert a collaborative model of care assists in breaking down professional barriers, enhancing communication and increasing awareness of individual roles. This is important, Smith (1996) identifying that interprofessional conflict often results from differing role perceptions.
The proposed change is to improve integration and collaboration of care for the entire client group through the development of an ICP. Lowe (1998) proposes this offers the potential to involve all relevant professionals, care-givers and clients in decision-making and co-ordinating care across the primary/secondary interface. Hotchkiss (1997) believes it offers a system of multidisciplinary care planning based around the principles of clinical audit, providing a system for effective monitoring and evaluation of the discharge process.
The specialist practitioner role involves identification and examination of the wider issues contributing to the problems of current discharge planning to provide a rationale for change. As Maloney and Preston (1992) indicate, historically, care was provided at home until the advent of the NHS in 1948 shifted primary care responsibilities from family to professional care-giver. They believe a cyclic phenomenen has resulted in transition of care back into the community, but with increased responsibilities and changing family structures, requiring effective discharge planning to meet the challenge of increasing and complex needs.
Macmillan (1994) discusses that demographic changes alongside advances in healthcare have resulted in an ageing population, of which Nazarco (1997) highlights, a growing number will develop cancer. Whilst this does not relate specifically to the client group, it is relevant as it has a major impact on the organisation’s resources, the paediatric unit being within an adult cancer centre. Coupled with this, an overall survival rate of 65% in childhood cancer, has shifted the focus from an incurable disease to supporting a child with a chronic illness (Gibson and Evans 1999), another major resource issue.
Macmillan (1994) discusses the shift in focus from hospital to community, which, coupled with increasing pressures on beds and the average length of stay being measured in terms of efficiency, have produced quicker and sicker discharges. She argues that these parameters, whilst taken as indicators of good management, often conflict with the desire to see clients safely returned to the community.
Currently, a lack of integration and collaboration results in poor communication and documentation which leads to duplication or omission of services, fragmentation of care, delays in discharge, increased pressure on beds and NHS resources, complaints and critical incidents. Wilson (1998) identifies that documentation and communication regularly let practitioners down in the discharge process. Wiffin (1995) substantiates this view highlighting that record-keeping studies show nursing records often lack information relating to the individuals home environment and previous level of functioning, whilst King and McMillan (1994) suggest information obtained is often inadequate for making informed discharge decisions. Mantel (1995) concludes documentation is a key issue, the best legal protection resulting from effective record-keeping. The need for comprehensive and co-ordinated discharge planning has therefore never been greater.
Maloney and Preston (1992) propose ongoing communication is the key and foundation upon which successful collaboration is built. Indeed, Smith (1996) identifies interprofessional communication as a significant factor in providing patient-centred care and ensuring a seamless transfer from hospital to community. Victor (1991) supports this viewpoint, highlighting poor communication leads to difficulties co-ordinating members involved in the discharge planning process. Currie (1999) advocates the development of an (ICP) for discharge planning may improve communication and enhance client involvement.
Government initiatives to address discharge problems place increasing emphasis on collaboration and integration of services, and the development of effective Partnerships, resulting in a shifting balance from acute sector to community (DOH, 1990, DOH, 1997, DOH, 1998).
Fletcher and Buka (1999 ) believe the increased focus on primary healthcare and a greater patient-focus gives rise to ethical questions of autonomy on the part of the client and practitioner, with care needing to be negotiated to achieve a successful outcome. They suggest this includes respecting the right of individuals to make decisions for themselves even if those decisions are not congruent with others goals, which may involve conflict, choice, values and conscience.
In implementing the change, the specialist practitioner must state clearly what is to be achieved. The vision is one of integrated, patient-focused care, provided through collaborative working. Nazarko (1998) proposes this requires examination of internal structures and external influences. This relates to the organisation’s structure and culture, access to resources, potential barriers to change and possible facilitators, economic and political factors. Determining the power base is an important element of the specialist practitioner role to recognise who has the influence over the proposed change. The main thrust for improving documentation stems from the management structure, in particular the clinical governance and risk management agenda. However, the corporate position is to strengthen leadership and involve staff in decision-making. Staff would therefore direct the way the proposed change could be achieved. This supports the argument advocated by McCormack et al (1999) that successful change needs to be practitioner owned and organisationally supported. They also propose successful change needs to be undertaken using a systematic approach. Lewin’s (1951) force field analysis provides a framework for problem solving and planning change, through identification of driving and restraining forces.
Force field analysis enables the Specialist Practitioner to make a correct assessment of the forces present important to the change process, understand how they affect one another, determine how goals can be met and shift the balance in the direction of change. This requires identification of appropriate strategies for the client group and relates to the first stage of Lewin’s change theory, known as unfreezing (Lewin,1951), which prepares people for change. Allen (1993) suggests unfreezing occurs by increasing the driving forces whilst decreasing the restraining forces thus reducing resistance to change. The specialist practitioner needs to involve everyone concerned in developing a shared vision and commitment, establish open communication channels at all stages, select optimal change strategies, lead and apply all components of dissemination and implementation strategies.
Broome (1998) proposes creating a culture of change and innovation is relevant to leadership issues. Sofarelli and Brown (1998) advocate transformational leadership, an empowering style that works on ideas and visions, and builds common commitment. Research has reported transformational leadership to be positively tied to job satisfaction and organisational commitment. (Morrison et al, 1997, Stordeur et al, 2000). Sofarelli and Brown (1997) suggest this style is ideally suited to the present climate in actively embracing and encouraging innovation and change. Girvin (1996) however, suggests transformational leadership may not be so effective when used alone and in fact acts as an enhancer of transactional interventions, which concentrates on achieving the task, building and maintaining the team and developing the individual. Adair (1988) argues that leaders are most effective when they address all three functions simultaneously. McCormack and Hopkins (1995) believe these aspirations are best achieved when leaders function in a collaborative and collegial way.
In developing an ICP for discharge, a combination of both styles would be useful. Utilising a transformational style, the specialist practitioner can provide the leadership qualities and motivation for multidisciplinary team members to become innovative in viewing problems and solutions. This is increasingly important as the focus shifts from hospital to community and staff must ensure the client is adequately prepared for discharge. The transactional element will ensure the task as well as the team and individual are considered, important in moving the proposed change forward and achieving the desired objectives within a given timescale.
Stordeur et al (2000) asserts the hospital’s structure and culture are major determinants of leadership styles and the key to successful change is excellence in leadership at both clinical and managerial level. The organisation however, needs to be ready for this commitment as it moves away from the traditionally hierarchical approach inherent within the organisation for many years, the power base still evident within the medical profession. Preparation is therefore a major aspect of the specialist practitioner role. The Trust is developing active strategies and investing in the development of effective leadership and the Specialist practitioner needs to act as role model, developing a positive culture whereby staff are pro-active and interactive.
Rocchiccioli and Tilbury (1998) advocate a collaborative care model maximises staff contribution to patient care. The model reflects a participative management style, linking well with a transformational style of leadership, assisting in integrating services (DOH 1998), improving communication processes, establishing clear lines of accountability and empowering staff to take ownership of their own roles. Clutterbuck (1994) believes shared vision is vital for the learning organisation, helping individuals develop an appetite for beneficial change in terms of behaviour and skills that stick. He suggests empowerment is a tool that can help bring this about. This requires creation of a culture which both encourages people at all levels to feel they can make a difference and help them acquire the confidence and skills to do so.
Doherty and Hope, (2000) advocate the philosophy of shared governance relates to a decentralised style of management that creates an environment of empowerment. Geoghegan and Farrington (1995) discuss the benefits of this approach, recognising that it gives nurses collective responsibility and accountability for practice by moving away from the traditional “management” hierarchical style to one where staff are more involved in decision-making processes and managers have a facilitative rather than controlling role. They assert this will increase morale, motivation and staff contribution, encourage creativity, promote interpersonal relationships, ownership and a sense of value. On a macro level, this could impact on professional development, recruitment and retention.
Involving staff in service development and planning change with open communication and collaboration is a central vision of current UK govt (DOH, 1997 NHSE, 1999). The multidisciplinary team need to work collaboratively to ensure effective utilisation of existing service provision. The Specialist Practitioner can assist in defining individual roles and facilitating ownership to minimise resistance. This supports a normative-re-educative approach to change, which Andrews (1993) suggests is most effective if the change is to be long term and beliefs and attitudes altered. Sullivan and Decker (1997) propose it rests on the assumption that people act in accordance with social norms and values, and in contrast with the empirical-ration approach, information and rational arguments are insufficient strategies to change people’s patterns of actions. The specialist practitioner must therefore focus on behaviour as well, as relationships, attitudes and feelings will influence acceptance of change. As Sullivan and Decker (1997) indicate, in this mode, the power ingredient is not authority or knowledge, but skill in interpersonal relationships. Rocchiccioli and Tilbury (1998) advocate the leadership style for a normative re-educative approach is participation, communication, education and collaboration. This reflects the philosophy of shared governance and links well with a transformational style of leadership. It is therefore a useful strategy, but used alone may be insufficient to sell the change in practice to the multidisciplinary team. An empirical-rational approach during initial stages may assist in persuading the team to accept a rationally justified change that will benefit both themselves and the client (Sullivan and Decker1997), important as these benefits will become the major driving force for accepting change. A mix of strategies would also suit the organisation’s commitment to a bottom up and top down approach, Wright (1996) emphasising an empirical-rational strategy is essentially top down, whilst the normative re-educative strategy supports a bottom up change strategy.
During the moving stage, the specialist practitioner role involves planning and implementing the change, requiring consideration of how the ICP will be formatted, who would be involved and what roles they will perform. Conducting a focus group of relevant personnel will ensure multidisciplinary input into its development. Time must be allowed for support, discussion, evaluation and feedback, with open communication at all stages. The ICP would then be piloted prior to implementation, final adjustments made and a decision taken if it could be used in other areas, which may help sell the change to the multidisciplinary team and management.
Once participants integrate new patterns of behaviour, a refreezing takes place. (Sullivan and Decker, 1997). The specialist practitioner role would be to monitor the effects of the change and prepare to alter or adapt plans as necessary, using ongoing communication, so problems can be identified and addressed as quickly as possible. Otherwise there is a danger that staff will revert to previous practices and the change be less effective. Lewin (1951) identifies this stage as the refreezing process, the final stage of the change process.
Consideration needs to be given to the strengths and weaknesses of implementing and establishing the proposed change in practice. This requires exploration of potential driving and restraining forces that may influence acceptance of the change. Examination prior to introducing change enables the specialist practitioner to minimise potential restraining forces and make effective use of facilitators which may drive the process.
The specialist practitioner must consider economic and political factors. Many changes are resource driven due to the need for cost-effective healthcare and introducing change requires examination of resource issues. One major Political strength is integrated care replacing the internal market with a system of collaborative care delivery, involving teams working more in Partnership (DOH,1997). This is important, the development of an ICP for discharge relying on the collaborative efforts of all healthcare providers to ensure a smooth transition from hospital to community. The literature highlights potential benefits, which on a macro level may be seen in terms of improved quality of care and patient satisfaction (Hotchkiss 1997). Cost-benefit advantages may also emerge; a reduction in the incidence of preventable disease and length of hospital stay (Kitchiner 1996), lower re-admission rate (Lowe 1998), earlier recovery and more efficient use of resources (Currie 1999), all of which fit well with the corporate agenda.
The literature, coupled with the thrust from government initiatives therefore provide clear benefits and opportunities for the development of an ICP for discharge. One weakness identified by Currie (1998) is that, as yet, there is a lack of systematic research into care pathways as to their effect on patient outcomes, but Kitchiner et al (1996) highlight their potential as a powerful audit tool.
Shared governance is an important opportunity as a driving force, Geoghegan and Farrington (1995) highlighting its potential for enhancing staff involvement in decision-making. Government initiatives also provide an important opportunity in strengthening the nursing contribution (DOH,1999). Geoghegan and Farrington (1995) recognise setting up a shared governance system within an organisation is an enormous task. One current strength is the organisation actively embracing the concept of shared governance and investing in the development of effective leadership. The Trust is moving towards a process oriented organisation, described by Scott (1999) as a decentralised system of management where communication is bottom up and top down and the patient at the centre of the care delivery process. This relates well to the chosen strategies that would be employed by the specialist practitioner to implement the ICP for discharge.
An important restraining force to consider is the hierarchical culture still prevailing within the medical profession. A mix of leadership styles would therefore work better because of the culture and personalities still evident within the organisation, which can pose great barriers to change. Doherty and Hope (2000) indicate that to ensure lasting change, a slow evolutionary approach to implementing shared governance is necessary, requiring persistence and determination. The specialist practitioner role would be to examine behaviours and attitudes, identify what influences them and how they may be changed or addressed. Sometimes the barriers come from individual staff who carry out care in a controlling rather than empowering way, perceiving what is in the best interests of the patient rather than identifying individual needs.
Some staff find it difficult to be non-judgemental and objective working with families whose behaviours and attitudes conflict with our own. This can pose ethical dilemmas in allowing the individual to control their own lives whilst still trying to facilitate what they consider to be in the client’s best interest. Healthcare professionals need to develop effective communication networks in which the client is fully involved in decision-making, negotiating care to achieve a successful outcome. Whyte and Smith (1997) highlight that this is of vital importance particularly within the adolescent age group in which locus of control is important in achieving compliance. An ICP for discharge will assist this process. One potential driving force is staff commitment to a patient-focused care model in which choice and control are important considerations.
On a macro level, a potential weakness is patients and staff don’t always consider the health-within-illness concept, which Moch (1998) suggests can provide the opportunity for positive change. The specialist practitioner needs to ensure nurses are fully aware of their role as health educators. This is important as nurses are uniquely positioned to assist clients with a chronic illness such as cancer, in the process of health-within-illness, an important consideration to promote optimum self-care measures. Other challenges must also be confronted such as re-entry into school, and as DuHamel (1999) indicates, resuming normal interaction with peers is an important process in promoting optimal rehabilitation. A chronically ill child with cancer may spend long periods of time in hospital and interaction with peers is often affected. The implementation of an ICP for discharge will facilitate early consideration of important issues and development of effective partnerships with outside agencies who can assist the process as early as possible.
Whilst government initiatives support reducing inequalities in health (DOH,1997), there are still constraints for some families who do not have the genuine freedom to choose a healthier lifestyle. The Specialist Practitioner role is to assist the health educator in raising awareness of the wider factors determining health choices, so the client feels significant control resides with themselves. Also, whilst empowerment is an important consideration, some clients may not want to be empowered, in which case, empowerment can be disempowering. Consideration needs to be given to each individual family incorporating cultural differences, language barriers, and specific individual needs. It is important that individual needs are acknowledged and supported by the multidisciplinary team. An ICP for discharge will assist this process, facilitating a smoother transition from hospital to community.
Clinical Governance is an excellent opportunity as a driving force. It will assist in breaking down barriers within the organisation and social care system so patient’s needs are dealt with holistically, important in ensuring a seamless transition into the community. It demonstrates an open, participative culture, commitment to quality, patient involvement and an ethos of multidisciplinary teamworking at all levels in the organisation, all of which are vital in the development of an ICP for discharge. It reflects the principles of shared governance in that professionals are provided with the responsibility to take on the task, the authority to make changes and establishes leadership and accountability so everyone is aware of their role. It is therefore ideally suited to the chosen strategies that would be employed by the Specialist Practitioner in implementing the change. One potential constraint within the Clinical Governance process is highlighted by Scott (1999), who proposes that it still primarily generates a model of medical governance, which sits well with the power culture still evident within the organisation. The specialist practitioner in adopting appropriate leadership strategies and supporting nurses to acquire the competencies and skills required to enhance their influence and participation, will assist in changing this into a driving force.
Accountability issues could be a potential restraining force with the current diversity of roles causing duplication, omission and fragmentation of care. The commitment to multidisciplinary working is evident and the development of an ICP would assist the integration of documentation which would improve communication processes. The specialist practitioner would need to ensure the ICP clarified the scope and remit of each individual role, established clear lines of accountability and empowered staff to take ownership of their own roles.
Enlisting support of the multidisciplinary team would be vital to ensure effective utilisation of existing service provision and clarification of individual roles. Ashford et al (1999) advocates that utilising existing skills and knowledge of staff enhances role development, an important consideration, as who is involved and what roles they perform can influence the success of implementation strategies. This will also promote interaction of individuals within the multidisciplinary team important if effective collaboration is to take place and the management and leadership strategies identified are to be utilised effectively.
The multidisciplinary team need to be actively involved in the change process, willing to accept new ways of working, and if they are to be motivated, must see the perceived benefits to the patient and believe the process will work. Utilising a mix of change strategies incorporating both an empirical-rational and normative re-educative model may assist this process. This will combine the power ingredient of knowledge and rational thought in persuading staff of the benefits of the proposed change, and skill in interpersonal relationships, which focuses on behaviour, attitudes and feelings to influence the acceptance of change. (Sullivan and Decker, 1997).
The Specialist Practitioner would need to consider training and education issues and develop effective strategies to support understanding, ownership and acceptance of the proposed change. This would require acting as facilitator and coach, bringing staff together and motivating them to achieve change. Whitmore (1996) identifies this would create the right learning environment to unlock individual staff potential, an important element of the empowerment process. It sits comfortably with the strategies identified to take the proposed change forward, reflecting both a participative management style and relating to the qualities identified in transformational leadership. Otherwise, there is a danger staff will revert to previous poor practice and fail to make effective use of the new documentation. This relates to Lewin’s third and final stage of the change process, identified as the refreezing process. (Lewin, 1951). At this stage behaviour moves to a new level at which the opposing forces are brought into a new state of equilibrium and new patterns of behaviour are integrated (Sullivan and Decker, 1997).
In Conclusion, the implementation of an ICP for discharge will assist in establishing a patient-focused collaborative model of care, aid integration of services and help to co-ordinate care more effectively within and across organisational boundaries. Utilisation of effective change management, and management and leadership strategies will assist its development, ensuring the patient is put at the centre of the care process.
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The author works on the Young Oncology Unit (YOU), at Christie Hospital, Manchester, within the area of Paediatric Oncology. The Units client group consists of young people aged 0-21 years. The hospital itself is a regional specialist centre for cancer and radiotherapy treatment, and patients attend as outpatients whenever clinically and demographically possible. Care is provided for inpatients and ambulatory patients by the same nursing staff.
As an enhanced practitioner, it is important to reflect on and critically evaluate care given, in order to identify areas requiring improvements in the provision of care. The assignment will focus on a practice-based problem, relating to a lack of support for patients and families attending for radiotherapy treatment in the paediatric ambulatory care setting. There will be a critical evaluation of the methods currently used, a review and analysis of the literature which exists in relation to the highlighted problem, an exploration of how practice could be enhanced in this area and change effectively implemented within current organisational constraints. The aim is to establish a nurse-led clinic to support children and their families through radiotherapy treatment and its subsequent effects, within the paediatric ambulatory care setting.
The term “ambulatory care” is a popular expression for day care provision,, being defined as :
“Health services provided on an outpatient basis to those who visit hospital or healthcare facilities and depart after treatment on the same day”. (Turner, 1998).
It is a bit of a misnomer in that non-ambulatory patients can receive ambulatory care.
The rational for selection of this topic is that problems have been highlighted in recent months, demonstrating a lack of information and support to patients and families from nursing staff, largely due to:
- chemotherapy treatments and oncological emergencies creating a higher dependency of patient, resulting in inpatients placing greater demands on the nursing staff’s time
- outpatients spending relatively little time on the ward
- staff sometimes perceiving radiotherapy treatment to be an easy option
It is however, vital to meet the needs of each individual patient and family, whether they are in hospital or receiving ambulatory care. Throughout the rest of the assignment the term “patient” will refer to the child and family as a unit.
Childhood cancer exerts an immense practical and psychological burden on the patient over many years. Advances in treatment, along with the continued push from government reports, (Platt report, DOH, 1959, Court report, Fit for the Future, DOH, 1976, The Welfare of Children and Young people in hospital, DOH, 1991, Children First, Audit Commission, 1993) has led to a higher profile for ambulatory care which sits comfortably with the philosophy of nursing children. (YOU, 1998).
When considering the provision of ambulatory care in a paediatric oncology environment, there are a number of specific objectives:
- to provide patients with expert medical and nursing care throughout the course of illness, whether that is as a long term survivor, or to the child’s death
- to have patients experience as little disruption of their lives as possible through treatment (Fieler, et al, 1996)
- to develop effective communication networks to prevent care becoming fragmented
- to manage time effectively for maximum patient benefit
- to provide continuous appropriate information and support, recognising that patients needs continually change as treatment progresses
However, there is little published research within this area (Glasper and Lowson, 1998), and this is disappointing given the large numbers of patients now attending for ambulatory care. Outpatient areas are no longer used as a dumping ground for nurses with difficult personalities and bad backs. (Laurent, 1992). It is now being recognised that it should not be second class, but an area of excellence in practice.
The literature primarily relates to adult oncology, but is still an effective indicator of how both young patients and their family react to radiotherapy treatment. A review of the literature consistently demonstrates only a small percentage of information is retained during a consultation, improvements in patient education vital, further information and support required in order to maintain positive outcomes and facilitate patients to participate in more self-care measures. (Schulmeister, 1991, Poroch, 1995, Hinds and Mood, 1995, Fieler, 1996, Hagopian, 1996, Hinds and Moyer, 1997). Poroch, suggests this is because radiation therapy, in comparison to other cancer treatments, seems to be disproportionately associated with misconceptions, misunderstandings and apprehension. This is undoubtedly true, many families arriving on the YOU with gross preconceived misconceptions relating to treatment. One recent example relates to a 5 year old boy who wouldn’t lie on the table because he was frightened of being sucked into the machine. Another example relates to a 15 year old young lady who commenced radiotherapy to the head and neck, which requires a mask to enable pinpoint accuracy of treatment to vital structures. She freaked as the mask was put on, thinking it would have to get hot in order to give the “radiation”. This was entirely her own misconception of treatment on hearing the word radiate. These two examples demonstrate the extent of support required by all patients not just young children. Although patients do rely on Doctors as a key source of information, nurses are seen as a viable source and are in a key position to provide support (Hinds et al, 1995), radiotherapy being primarily nursing initiatives rather than medical interventions.
There is an increasing government demand for patients, families and carers to receive clear information and assistance in a form they can understand about treatment options and outcomes available to them at all stages of treatment from diagnosis onwards” (DOH, 1995). This is especially important on the YOU, with many issues surrounding the rights of children and consent. Further research needs to be undertaken to determine how younger children may benefit from strategies such as audiotapes, videotapes or storybooks containing information in a form they can understand.
On the YOU, patients see a consultant weekly, but attend the unit daily so nursing staff can monitor the effects of treatment. Systematic assessment varies considerably according to service priorities, staff often being reactive rather than proactive in their approach to care. Schulmeister, 1991, indicates, that with the increasing complexity of outpatient care, and dwindling nursing resources, teaching all patients about all topics of importance is impossible. The enhanced practitioner is in a prime position to examine how innovative practice can be developed to meet individual needs.
The reality of nursing pressures mean we often accept the brave face shown, not having time to look beneath the surface. A review of the literature reveals the “hidden” experiences of adult patients receiving radiotherapy treatment, but is still an effective indicator of how families may react to radiotherapy treatment. Few existing studies have examined what happens when radiotherapy is over, yet this is the time when reactions are at their peak. A qualitative study of patients following completion of radiotherapy treatment, (Wells, 1998), found that despite considerable physical and emotional trauma, patients showed remarkable resilience and a profound reluctance to ask for help. This is often true on the YOU. The findings demand that we re-examine our styles of communication, consider how well we give information and listen to what is really happening. There is a need to provide greater consistency and continuity of care during radiotherapy, recognise the impact of the whole experience and respond to post treatment needs. One comment epitomising the extent to which distress often remains hidden from view came from a patient’s diary, which read:
“Everybody says I look well, but I feel like the placid duck pointing upstream- it looks quiet and serene, but under the water line it’s paddling away like hell”, (Wells, 1998).
Radiotherapy, whilst an effective mode of treatment, is undoubtedly stressful. As the vast majority of treatment is given in the ambulatory care setting, the location and frequency of treatments can significantly disrupt patterns of family life (Hinds and Moyer, 1997). Debilitating acute effects and anxiety surrounding the potential late effects of treatment compounds this. Anxiety is heightened further as radiotherapists need to inform patients of all the potential acute and late effects, prior to achieving informed consent, which can be devastating.
Radiotherapy remains as great a source of anxiety as it was 20 years ago. The literature suggests this is largely due to patients rarely reporting receiving support from professional caregivers, or finding some of the support unhelpful (Galbraith, 1995). Hinds and Moyer, 1997, determined patients experiences of support whilst receiving radiotherapy. A substantive theory of support emerged which showed that support is an interpersonal process embedded in an array of social exchanges which involves encountering support, recognising support and feeling supported. Three main types of support are encountered: being there, giving help and giving information. They concluded that professional support was mainly informational, with family and friends being the principle source of all types of support. Given the characteristics and quality of behaviours patients recognise as supportive, it is easy to understand why the literature consistently reports that health professionals in general are not seen by patients as providing support (Hinds and Moyer, 1997).
Moreover, as patient survival improves, the late effects of treatment emerge more forcefully, creating a major impact on the care and support required to meet the individuals ever growing needs. Radiotherapy can impede any organ in the beam from maturing beyond the stage of development when the organ was treated. In general this is related to the dose of radiation and the potential for further development of the organ. It only affects the area being treated and therefore the consequences will be different for each individual, but nevertheless, will have a great impact on their lives. Many effects will resolve with time, some will be permanent and distressing. Others will emerge many years after completion of therapy.
Late effects of radiotherapy treatment are the most formidable in children. (Kissen and Wallace, 1995). In this respect, childhood cancers are qualitatively and quantitatively unique. A 5 year old cured of cancer has over 70 years of life expectancy left, allowing the emergence of long term effects in the future, which wouldn’t have the same effect in a 70 year old cured of cancer with around 5 years of life expectancy left. This is important as by the year 2,000, it is estimated that 1 in 1,000 of our young adult population, between the ages of 20-29, will be survivors of childhood cancer (Meadows and Hobbie, 1986; Kissen and Wallace, 1995).
The nursing role in chemotherapy is largely well defined, but equal recognition has not been received within radiotherapy. The literature suggests it is difficult for the nurse to provide appropriate nursing interventions because of the vagueness of their role in radiotherapy, (Wengstrom and Haggmark, 1998), which lacks definition, clinical standards and nursing research (Downing, 1998). This is undoubtedly true, reflection on practice on the YOU highlighting that we have no definitive nursing roles in radiotherapy and no clinical standards to support quality care. Much work is needed so care can be properly validated, and the role developed, to ensure consistency of practice amongst staff. The future of ambulatory care is exciting due to the emergence of late effects and the continuing growth of outpatient care as the NHS attempts to deliver more health care within limited resources.
The enhanced practitioner needs to organise care so healthcare professionals are available to recognise the true impact of treatment and respond to it. This means giving information, symptom support and practical advice which is meaningful to each individual patient, whilst acknowledging one’s own limitations in practice. It is often assumed that all patients want and seek information. However, not everyone does. This may be difficult for nurses to accept, but it is equally important that the patient’s right not to receive information is respected if this wish is communicated.
One needs to think creatively and innovatively and find ways of developing and promoting clinical excellence in nursing outpatients (Marsden, 1992), that meet the holistic needs of the patient. A nurse-led clinic could be considered as the logical outcome of the expanded role of the nurse within ambulatory paediatrics. A review of the literature is complicated by the diversity of role titles, but indicates that the concept of the nurse-led clinic although not new, is just beginning its evolution within the hospital setting. (Glasper and Lowson, 1998). There needs to be more thought on how to create autonomous nurse-led practices. With vision and courage, the enhanced practitioner, as a highly skilled, motivated and dynamic practitioner, can create an improved service offering high-quality, responsive and continually developing healthcare, by exploring new horizons for themselves, their patients and the profession. (Lowry, 1996). A nurse-led clinic would create opportunities to assess patient needs prior to, during and following radiotherapy treatment, including long term follow up, changing the environment of care for patients and putting their difficulties and problems far higher on the agenda. (Moore, 1997).
Guerrero, 1994, established a nurse-led clinic for adult patients undergoing cranial irradiation, which appears to be the first example in oncology of transferring medical follow up of patients undergoing irradiation to a nurse based on- treatment clinic.
There are many opportunities and several constraints that would exist in implementing the change, and it is important they are considered to ensure a smooth change in practice. Exploring these areas prior to introducing the change would enable the enhanced practitioner to identify potential problems before they arise, and formulate plans to avoid or minimise them.
One such opportunity has resulted from the Scope of Professional Practice, and the Code of Professional Conduct (UKCC, 1992), which have assisted nurses in the move towards professional accountability and autonomy in practice. Nurses have the opportunity to extend their roles appropriately, absorbing activities into the holistic nature of nursing, informed by nursing values (Denner, 1995). Accountability issues could also be a possible constraining force to implementing change, with the current lack of definition and diversity of roles. Alongside the developing role, the enhanced practitioner would need to establish a recognised framework that encompasses accountability issues, and clarifies for nursing staff, fellow healthcare professionals and patients, the scope and remit of their role.
Educationally, there is a concern cited in the literature regarding the approach to preparation. In an evaluation of nurse-led care in accident and emergency departments, educational preparation ranged from an in-house course of a few days to a two- year nurse practitioner programme. (Dolan et al, 1997). There are many opportunities for personal and professional development, and continued lifelong learning support, which would be essential in the creation of a nurse-led clinic, to ensure staff receive effective training and development to carry out their role effectively. Indeed, it is the aim of the government that training and development plans are in place for the majority of health professional staff by April, 2000, in order to support the delivery of high quality, modern, effective healthcare in a fast changing world. (DOH, 1998).
If enhanced practice is to be nurse-led, the practitioner needs to identify who should carry out the role. Effective follow up of patients both in the long and short term, may cause severe disruption to the entire family. The development of satellite clinics and utilisation of nursing skills within the Community and District General Hospitals may be the most effective way to provide continued support to all patients. It is important for Staff to take ownership of their own roles, but this would require appropriate training and support. This could be achieved through a co-ordinator leading the service with specialist knowledge and skills in radiotherapy, with a specific remit for training and development and audit in order to monitor outcomes. This would facilitate the development of nursing skills not only within the Unit itself, but enable provision of shared governance.
The most important consideration is that the skills and knowledge required to fulfil the role are clearly acknowledged, and the role supported by an educational process set in a framework of clinical supervision. (Briggs, 1997).
A nurse-led clinic must have the support of the managers and organisation, which could be an opportunity as well as a potential constraint. The Trust would be keen to provide as much care as possible on an ambulatory basis, it being more cost-effective than hospitalising the patient. The shift from inpatient to outpatient care has focused attention on providing the highest quality care using the most efficient and productive means available. However, assessing productivity and workload measurement is difficult because of the number of variables that occur, including patient volumes, complexity of needs and the lack of definition of roles. (Medvec, 1994). One opportunity would be to fund the initiative with a review of the establishment, which could be possible as it changes to accommodate 7 day opening. The cost implication may then be minimised, but still not necessarily a cheap option. Patients would need adequate support, requiring more time than would be allocated in a traditional clinic, and staff would need appropriate training. It’s perceived benefits are that it may reduce some of the workload for medical staff, reduce waiting times in clinic, improve continuity of care and prevent admissions for certain preventative problems, but, may not reduce costs enormously as nurses would be identifying patient needs previously unmet, which may also lead to a higher number of referrals to other healthcare professionals.
There is little documented evidence of the benefits in the literature (Briggs, 1997), which provides good accounts of changes to practice, but few structured evaluations to demonstrate the stated benefits in practice. There would need to be a commitment to monitoring outcomes to provide an evidence base to service development, and ensure that limited resources are used appropriately. (Dolan et al, 1997). Griffiths, 1995, in examining the progress in measuring nursing outcomes, concluded there is a clear need for more research aimed at determining the contribution of nursing interventions to patient outcomes, which in the current economic and political climate, demand that nursing prove its value. Clinical Governance is another excellent opportunity, as it will ensure this is addressed.
As an enhanced practitioner, enlisting the support of medical staff is vital, as the success of such a clinic will depend on doctors recognising there are areas of clinical work well suited to the skills of appropriately trained nursing staff. Moss and McNicol 1995, demonstrated the need for consultants to rethink their roles, saying that nursing roles should be acknowledged, explored and developed for the patient’s benefit, and that unless the service faces up to the need to restructure and reorganise, everyone, especially the patients will be losers. The YOU has very supportive medical staff, who value the nurses contribution, and work collaboratively as part of a multi-disciplinary team. However, whilst the nursing role remains ill defined, unstructured and limited, practice cannot be enhanced nor further possible developments explored.
Parental involvement would also help to facilitate the change. They will need a clear understanding of the role, or may think of it as a cheap option or the loss of opportunity to see medical staff. Families themselves, also continually put nurses under pressure because they never want to stay on the unit for very long whilst attending as an outpatient. This would need careful negotiation to avoid frustration.
It is vital that changes are driven by the need to improve patient care and take place with a clear nursing focus, with clear objectives. Careful change management and evaluation must accompany developments, as must full dissemination of results. (Garbett, 1996).
The change, in order to be effective must be planned, not imposed. As a change agent, the enhanced practitioner would, having identified opportunities for change, build a readiness and commitment, create a climate for change and establish an internal capacity to sustain the change effort, evaluate and review it (Broome, 1998). One opportunity is that the unit is undergoing a period of great change. A recent extension has created separate facilities for the children and adolescent patients, through the development of a “Teenage” unit. Alongside this, the unit is moving from 5-7 day opening, with an increase in staffing to facilitate this. Staff are therefore currently motivated to change and the momentum needs to be maintained. The enhanced practitioner needs to make the most of these opportunities, to extend the support required and provide a better service for ambulatory patients. One of the potential constraints would be the possibility of extra workload for staff, but individual job descriptions could be written to clarify each individual’s role.
The enhanced practitioner would need to facilitate staff ownership during the change process in order to identify and break down sources of resistance, which could then be turned into a force for change. Acknowledging their contribution creates a trusting collaborative relationship, important in helping to alleviate any obstacles to proposed change. This discussion form is the first stage of Lewin’s change theory, known as unfreezing (Lewin, 1951), which helps to prepare people for change. Most people are motivated to change if they can see the perceived benefits. Focus can then be on the weakening of the objections and fears of the resisting forces, which could be looked at and addressed (appendix 2).
Effecting change is vital but not always easy to achieve. As an enhanced practitioner it is important to communicate effectively, as most difficulties in its management arise from failure to communicate effectively. A mix of an organic and mechanistic structure is essential to ensure a two-way flow of communication, and involvement from everyone concerned, to enhance commitment and minimise resistance, utilising a mechanistic approach to final decision making, to ensure action is taken to meet the objective within given time constraints. Implementing change can be a lengthy process and it is easy for staff to become disillusioned and de-motivated. One would minimise this with open communication, ensuring all staff were informed at all stages of progress being made.
The success of change, no matter how good the planning, cannot always be guaranteed. The enhanced practitioner would therefore monitor the effects of change, and prepare to alter or adapt plans as necessary, using ongoing communication to ensure the team continues to work towards the same goals. Problems can then be identified and addressed more quickly. Otherwise there is the danger that staff will revert back to previous practices, and the change be less effective. Continued support would be necessary to allow engraftment to take place. Lewin, 1951, identified this stage as the refreezing process, the final stage of the change process.
In conclusion, it can be seen that ambulatory care is developing a high profile in paediatrics, but research is needed so care can be properly validated. It is time for a more structured approach to developing the role of the nurse in radiotherapy, to ensure consistency in practice and high quality care for patients receiving care in the ambulatory setting. This includes detailed assessment of patients’ needs and service requirements, clear outlines of responsibility and scope of accountability, managerial support within an agreed educational programme and a commitment to the continuous evaluation of the role which would inform future development. There is scope for developing specialised areas of care, through innovations such as nurse-led clinics, and enhanced practitioners are ideally placed to be proactive and creative in designing services that best meet the holistic needs of the patient and family.
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Broome A, 1998. Managing Change : Essentials of nursing management.2nd Edition. Macmillan Press Ltd. London.
Denner, S, 1995 : Extending Professional Practice : Benefits and Pitfalls.Nursing Times. Vol. 91, no. 14, 27-29, 1995.
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Mesothelioma is one of the rare forms of cancer which is quite difficult to diagnose the death rate due to this disease is increasing every year and the target of this critical disease are the senior citizens. This dangerous disease is caused due to the exposure to the asbestos. In this disease, the lungs linings get affected first, and then it may target the heart. The entire abdomen system gets affected due to this disease, and the victim has to bear a lot of pain during this disease, and it affects the entire body after that. More than 3,000 patients are registered every year and this is a serious threat. The latency period of this disease is very long, which is the factor that this disease cannot be diagnosed correctly, which lead to the complications in the patients’ body, and it is almost impossible to save the life of a patient due to the timing of this disease. If you cannot afford the treatment of this critical disease, and you are suffering from this critical disease then you should hire a lawyer or a law firm to know about the cancer law mesothelioma which will help you to claim your compensation for the cost that could occur on the treatment. The symptoms of this disease are very light and cannot be noted until you consult a doctor.
There are many ways to consult a lawyer or a law firm that handles such cases. If you wish to win the case then you should hire an experienced law firm which had won other cases of mesothelioma. Inexperienced firm might not have complete information regarding cancer law mesothelioma, which will lead you to lose the case which is much more dangerous if you can not afford the treatment and you also loss the case then you really has a misfortune. There are some tips for you to select the best law firm for your case.
1) You should know the experience of the firm you are willing to deal with in these sort of cases. The number of cases which have won by the attorneys can provide you the idea about its professionalism. The experience is important but if the attorney has an experience of decades but could not win even a single case then what would you do? The winning ratio can tell you about the attorney.
2) The knowledge of the attorney about the cancer law mesothelioma is important as well as the experience. If experience and knowledge is blended perfectly will lead you to the victory, and you will be able to get you compensation. The information about the attorney that you have hired for you will also help you to remain in peace of mind, which is also needed when you are suffering from such diseases.
3) Before giving your case to any attorney you should decide the cost first so that in case of winning, he would not charge you more than the fees, and you can easily pay the cost.
I was born and raised in the city of and suburbs of Philadelphia, Pennsylvania. Once my parents’ moved myself and my brother out to the suburbs, we were still wild children with way too much energy for my tired parents’ who were logging 20 hour days at their clothing store.
But my mother always told me something that still sticks with me to this day, “Never let a boy tell you that you’re not good enough, or that you can’t do something!”
She marched me to the Little League sign-ups for softball, tee-ball, and all types of sports camps. And though money was always tight and she could never come to the games like all the other moms, I knew that she saw herself in me.
Things got tougher financially when I was in middle school and high school, and I threw myself into academics. I wasn’t the smartest in my class, but I tried the hardest. And of course, I tried out for all the sports teams, some I didn’t make it, and most, I was benched in Junior Varsity. But I always loved to run. Sometimes I’d run fast sprints, sometimes I’d run slow jogs. I’d run in rain, snow, cold, hot, outside, or on the local YMCA treadmill.
Perhaps it was an escape, running away from family and money problems, or the fact that I didn’t fit in at my Abercrombie and Fitch school. Slowly but surely, I started to gain confidence from my running ability. I remember a line from one of my favorite movies, “Forrest Gump,” where Jenny calls out to the main character, Forrest, “Run Forrest Run!!.” Forrest didn’t exactly run the fastest, but he just kept going. He didn’t stop until he felt like it was the right time to take off his running shoes.
I, on the other hand, have learned that running won’t make my problems go away. It just gives me a better perspective about life, about working towards a goal, about patience. Most of all, running gave me the ability to look in the mirror and tell myself that I’m okay. Not perfect at all, but I’m cool with being me. Plus the endorphins rock.