Response
Debate on articles in Contemporary Nurse
Susan Tregoning
School of Nursing and Midwifery, University of South Australia, SA
PP: 102 - 104
Article Text
I would like to make a comment in relation to the Soapbox by Judith Wilcox, Nursing Assessment: more than merely 'doing the obs' in Volume 3(1). Whilst agreeing in principle with the content, it is the last sentence that causes my concern... 'The importance of a sound (and relevant) scientific knowledge base to understand skilled nursing assessment must not be forgotten in...continuing education programs for all acute care nurses'.
I believe that it reflects an attitude of many nurses who work in the acute area that skilled assessment is not as relevant or as necessary in other areas of nursing. This shows a lack of knowledge, understanding and dare I say, bias, which is frequently perceived by nurses who choose to work in non-acute areas of nursing.
As one of those nurses, I work in the geriatric field where most of our clients have a multiplicity of medical diagnoses, polypharmacy and psychosocial problems and we need to have assessment skills which are perceptive and on-going with a basis in sound scientific knowledge. Areas such as drug interaction, malnutrition, dehydration and depression can exacerbate, alter or mask classic signs and symptoms of underlying medical problems in geriatric clients. Assessment skills are also very relevant in palliative care, community and psychiatric nursing.
It is my philosophy that geriatric nursing is a specialty requiring expert nurses equal in relevant knowledge and skills as any of the other recognised specialities such as paediatrics, medical/surgical, accident and emergency etc. To therefore identify that it is only significant for acute care nurses to have continuing education programs in assessment skills devalues the clients, their care and the nurses in non-acute areas.
Lorna Williamson RN DipNsgSt(Gerontology) BAdmin Nsg
Deputy Executive Director of Nursing, The Mount Eliza Centre
As discussed in the research by Rod Sloman, 'The use of relaxation for the promotion of comfort and pain relief in persons with advanced cancer' in Volume 3(1) there is indeed a need for investigation into the physiological and psychological experience of pain. In particular, employing alternative methods to relieve pain. In using relaxation, the awareness is placed on the physical body, and for meditation, the awareness is centred on the mental/ mind.
Harnessing the power of the mind to heal the body is not a new concept. The integration of both body and mind is inherent to most eastern philosophies and incorporating this into the modern setting was the aim of the author.
To achieve this the author used Orem's self-care theory as the foundation for the nursing/patient interventions. Indeed, fundamental to the success of Orem's theory is patient activated and patient centred interventions linking the mind/body connection.
The results of the research project indicated there was a significant reduction in sensation, intensity and severity of the pain experience as well as a reduction in non-opiate analgesia. However, the reluctance to decrease the use of opiate analgesia by both nurses and patients, suggests there was not a complete belief in the relaxation interventions. The fear of the pain experience could well be the basis of this reluctance as born out by the findings of no significant decrease in the 'pain effect', or 'emotional meaning' of pain.
Fundamental to all relaxation therapies is the participant's belief in the therapy and being comfortable with the therapist and the setting.
Therefore, questions need to be asked about the practical application of these therapies. How many participants would choose the hospital setting? What past experiences have they had there? What past experience have they had with their nurse/therapist? The time frame offered to effectively learn and incorporate the relaxation therapy was brief, and so the assessment was perhaps premature.
The belief system, time frame, the setting and therapist would all impact on the success of the relaxation experience. Perhaps further investigation into the continuation of relaxation therapy outside the hospital setting is indicated.
The research appears thorough, although I am not completely convinced that the Hawthorne effect did not have an impact on the results.
There is no doubt deep breathing, progressive muscle relaxation and mental imagery induce a relaxation response and this in turn interrupts the anxiety cycle. The anxiety cycle can be best described as a feedback mechanism where a symptom eg, pain initiates the anxiety response causing increased sympathetic nervous system activity which leads to the worsening of the initiating symptom. The result is an escalation of the anxiety response. Inducing a relaxation response when the symptom presents interrupts the anxiety cycle and lessens the distressing effect of the presenting symptom. If this were the case we could indeed modulate the pain experience and conclude that relaxation therapy could be a very useful adjunct to conventional pain therapy by the very preclusion of anxiety escalation from the pain experience.
Based on the preliminary finding of this research it would be useful to undertake further investigations into the efficacy of a relaxation technique as a nursing intervention for the management of anxiety induced escalation of the pain experience in cancer patients.
Overall a thought provoking and interesting research project thoroughly researched and well presented.
Kathleen Blair RN ONC BN
Clinical Nursing Consultant
Oncology Unit, Royal Adelaide Hospital
I refer to the article 'Health assessment and the nursing process: A means to an end?' in Volume 3(1). The authors, Marie Casey and Joyce Hendricks-Thomas, are correct when they state that 'adoption of the nursing process and physical assessment is a means to an end and not an end in itself.' The ultimate aim of any nursing activity is quality care for clients and this process can certainly assist in achieving this aim. The phases of the nursing process do fit into the medical or scientific model, yet are not focused purely on 'cure' but on the client/family.
The authors also assert that the nursing process is reductionist in nature and 'nurses are asked to assist their clients on a needs basis' when using this process. They give an example of nutritional assessment where the client's needs are assessed and found to be well satisfied. They feel, however, that because the client eats alone, this could be problematic and be missed by using the nursing process. I have never encountered this narrow perspective when working with nurses who are truly skilled in the use of the nursing process. This process, which is circular, is a very effective and appropriate scientific method when used correctly.
Health assessment is a vital component of the nursing process and nursing practice. Health assessment of clients is shared by a variety of health professionals, but each professional has a different objective when performing it. The medical profession's focus of care is primarily on the internal functioning of the human body at the cellular and genetic level and has a disease orientation. Frequently this orientation separates body and mind, seeing little, if any, relationship between the two. Conversely, nurses are taught to consider the total person, and the orientation of care is directed towards current health status and maintenance of the individual's well being.
Therefore, the nursing approach to assessment involves the integration of the client interview, the physical assessment and biomedical data, together with the individual's ability to perform activities of daily living and developmental tasks. If all of these areas are not addressed by nurses then the profession is returning to the trial and error methods used for so long before the introduction of the nursing process that entails comprehensive health assessment as its pivotal phase.
Linda L Reaby, Senior Lecturer
School of Nursing, University of Canberra
Concerning the article, 'Childhood Immunization, Homoeopathy and Community Nurses' in Volume 3(1), a common misconception needs redressing regarding homoeopathic prophylaxis. Both medical and homoeopathic schools agree on three points: certain diseases need to be prevented; the best method is specific disease prevention; and the homoeopathic method is safe and non-toxic. However, both schools disagree on the question of efficacy of homoeopathic prophylaxis. The common argument from the orthodox medical school is that there is no conclusive proof that homoeopathic prophylaxis works. But then, all evidence to prove the success of the medical methods have been demographically based and there is no conclusive evidence that medical vaccination on it's own is successful. To my knowledge there have been no human double blind studies to justify medical vaccination even though it is a widely accepted practice.
It is fully possible an explanation will be found that will provide a scientifically acceptable hypothesis for homoeopathy's efficacy. However, because a therapy has not been scientifically proven does not mean it doesn't work; it may mean science has yet to determine why it does work. Dismissing homoeopathic prophylaxis as quackery is a simple subjective judgement levelled at a method of treatment that is in clear defiance of medical paradigms. Homoeopathic prophylaxis can only be disregarded if it is clearly found wanting through concise scientific trials. The experiment raised by the author reported by Davenas et al was doomed from the start. Examination of the protocols and methodology was made by a team of biased observers led by the editor of 'Nature' who made his views perfectly clear in an interview with the 'Washington Post' (30 June 1988) where he stated, 'The results of the experiments are particularly objectionable because they tend symbolically to support homoepathy.' This was even before he examined the experiment itself.
Because of it's nature, it is very difficult to construct a trial based on homoeopathic rules that will also satisfy scientific protocol. The requirement of individual prescribing means a remedy which can treat a particular condition in one patient may be inappropriate for treating the same condition in another patient.
With the heightened interest in things alternative and the further interest towards homoeopathic prophylaxis, rather than dismiss the treatment out of hand, empirical evidence should compel research into this treatment's efficacy. By some as yet undefined scientific principle, homoeopathy works. It is inappropriate to presume it does not just because the current understanding of science denies that it can. Science will in time vindicate homoeopathy as a viable source of therapy for all disease.
To dismiss homoeopathic techniques could very well deny the public access to a system which, by its very nature, would revolutionize medicine.
Spero Tsindos ND Dip Hons
Concaster Naturopathic Clinic
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