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In this essay it shall be discussed whether there are any arguments which work to prove the existence of God. The teleological and cosmological arguments shall be first discussed, criticised by showing their reliance on the ontological argument, which shall then be shown to be an inadequate argument. It will then be concluded that there appear to be no arguments which work to prove the existence of God.

The Teleological Argument

The teleological argument, or the argument from design, puts forward the claim that God’s existence is proven by the evidence that the universe is so well ordered, and its contents complex, to the point that they must have been designed. If this is the case, then there must be a designer of the universe, and this designer can only be God.

The strongest version of this argument is put forward by Paley. He claims that should he find a stone on the ground, he might suppose that it had always been there. However, should he then come across a watch, he could not hold this same supposition. This, he claims, is because the watch’s parts are such that “they are framed and put together for a purpose” (Paley, 1867: 11). The watch must have been designed and must therefore have a designer. Paley makes this same claim of the universe. He argues that:

“Every manifestation of design, which existed in the watch, exists in the works of nature; with the difference, on the side of nature, of being greater and more…” (Paley, 1867: 21).

Therefore, as the universe is of such a complex nature, in which all things are made of parts which allow them to fulfil their purpose in the same way the watch is made of mechanisms which permit its owner to tell the time, the universe must have been designed and must therefore have a designer. This designer, the argument concludes, is God.

However, there are problems with this argument. Firstly, it can be claimed that the world isn’t as perfectly designed as it would have been should God (being omniscient, omnipotent etc.) have created it. For example, there are many degenerative diseases which affect animals as they grow older, and therefore show the parts of their anatomy to be unable to complete their purpose of life.

Secondly, there are other, scientific, arguments which give explanation for things in nature being fit for their purpose such that do not suppose the existence of God. The most prominent of these arguments is evolution, proposed initially by Darwin (Darwin, 1859). Evolution argues that living beings in nature come to fit their purpose by adaptation, and therefore, though appearing to be designed, are not.

The Cosmological Argument

The cosmological argument, or the argument from first cause, claims that everything in the universe must have a cause. Were all the chains of cause and effect to be traced backwards in time, they would lead to the creation of the universe. However, the creation of the universe must also have a cause, since the universe cannot be the cause of itself (as nothing but an ontological being can be). The cause of anything must be either a physical law or a personal being. The first cause must be a personal being, as no physical laws predated the universe, which is God. Therefore, simply in virtue of the fact that the universe itself exists, God must exist. (Reichenbach, 2012).

As a first criticism against the cosmological argument, the argument relies on the existence of a being which can be the cause of itself. This, therefore, necessitates a reliance on the ontological argument which will later be shown to fail.

There are two more direct criticisms of the argument. Firstly, modern science has set forth hypotheses which aim to establish what could have been the cause of the universe other than God. Of these, the most prominent is the Big Bang. According to this theory, the universe literally arose out of nothing, and there is therefore no need to rely on God’s existence to explain the existence of the universe.

A criticism against this may be that the Big Bang itself, since it was an event, must need a cause. However, to claim this is to misunderstand the theory of the Big Bang. The Big Bang did not occur within the space-time continuum; the continuum was created from the Big Bang. It therefore does not need to rely on the regular cause and effect model of the universe.

A second criticism against the cosmological argument directly is that it relies on the claim that the universe itself must have a cause. However, should it able to be shown that the universe has existed for an infinite amount of time, it will need no cause, and therefore there is no reliance on God’s existence.

The argument that the universe cannot be infinite is that, if it were so, it would be impossible to reach the present moment from the beginning. Since we have arrived at the present moment, the universe cannot be infinite. However, Mackie argues that this representation of infinity is misleading. A true representation of infinity would not include a starting point. Whilst this may seem to make the arriving at the present moment more impossible, this isn’t the case. Mackie argues that to truly understand infinity is to know that from any past cause, no matter how far back the cause, there will be a finite number of links in the chain of causality to the present moment. Therefore, even in an infinite chain of causality, it is possible to reach the present moment (Mackie, 1983).

The Ontological Argument

The ontological argument differs from the other arguments for God’s existence because it argues that God must exist simply because of the concept of God, and not because of the existence of the universe, or some fact about it. As has been seen, the teleological argument and the cosmological argument both necessitate the existence of an ontological being. An ontological being is one which cannot but exist. The ontological argument claims that, simply in virtue of the concept of God, God must exist. That is, if we can conceive of the concept of God, without any contradiction, by the fact that it is possible, it must be true.

The classical version of this argument is put forward by Anselm. He claims that the definition of God is “a being than which nothing greater can be conceived” (Anselm, 1077: chapter 2). By this definition, Anselm claims that God now cannot be conceived not to exist (Anselm, 1077: chapter 3). This is because if we conceive of God (with all his qualities, including omniscience, omnipotence, omnipresence), and then believe God not to exist, we are not in fact conceiving of God, as a being greater than this one of which we conceived could be conceived: one which existed. Whichever being is greater of the two, and Anselm claims the one which exists would be greater, must therefore be God (Anselm, 1077: chapter 3).

A similar argument is found in Descartes’ Meditations. He claims that God is a “supremely perfect being” (Descartes, 1641: 45); a being who holds all the perfections. However, included within this, Descartes claims that there is also the perfection of existence (Descartes, 1641: 46). If we conceived God to be without the perfection of existence, we would not actually be conceiving of God. Therefore, to conceive of the perfect being necessitates its existence, and God must exist.

A criticism is put against this by Kant. Kant argues that if we deny something’s existence, we do not contradict a concept, as the ontological argument would claim we do, because he argues that existence does not “add” anything to a concept. That is, he holds that stating that something exists cannot make a concept greater. In order that a concept may be made greater by a predicate (in relation to the concept as a subject), the predicate must be something which, were it to be removed from the subject, would create a contradiction. In the example of God, we cannot claim the concept cannot be omniscient, as this would create a contradiction with the predicate “God is omniscient”. This, Kant claims, is a “determining predicate” (Kant, 1781:A598/B626).

Existence, however, is not a determining predicate. Kant claims, even, that it is not a predicate at all. Instead, to say something exists is “merely the positing of the thing” (Kant, 1781:A598/B626); that is, to say that something exists does not add to the concept, but simply states that there is an actual occurrence of the concept. So when we state “God exists”, we do not state anything extra of the concept as we would in saying “God is omnipotent”; instead, as Kant argues, “we attach no new predicate to the concept of God, but only posit the subject in itself with all its predicates” (Kant, 1781:A599/B627). Therefore, there is no reason to suppose that a being greater than which none can be conceived must necessarily exist. This is because there it is not necessary that there must be an actual occurrence of the greatest being in order that it is the greatest being. Therefore, the classic ontological argument fails.

There have been more recent applications of the ontological argument. Platinga aimed to show that, by the possibility of certain concepts, God must exist. These two concepts are maximal excellence and maximal greatness. Maximal excellence, he argues, “entails omniscience, omnipotence, and moral perfection” (Plantinga, 1974: 108). That is, all the concepts one attributes to God. Secondly, a being has maximal greatness if it has “maximal excellence in every world” (Plantinga, 1974: 108); that is, every possible world. These two concepts, Plantinga claims, are not self-contradictory, and therefore possible. Plantinga then argues that if the concept of maximal excellence is possible, there is a being, in some possible world, which has maximal excellence; this need not necessarily be the actual world. However, if the concept of maximal greatness is also possible, this means that in every possible world there is a being which has maximal excellence, including the actual world. The being who has maximal excellence is God, and therefore God must exist. (Plantinga, 1974: 108).

A criticism to be made of Plantinga is that the concept of maximal greatness, though it is not self-contradictory, may not necessarily be possible. Indeed, consider the case that it is possible that maximal excellence may not exist. Therefore, there is a possible world in which maximal excellence does not exist. However, if maximal greatness was to be possible, there must be a being with maximal excellence in the world in which there is no being with maximal excellence. This, of course, cannot be the case. Plantinga himself admits this. He writes:

“We must ask whether this argument … proves the existence of God. And the answer must be, I think, that it does not. An argument for God’s existence may be sound … without in any useful sense proving God’s existence.” Plantinga, 1974: 112).

The argument only proves God’s existence if the premise that maximal greatness is possible is accepted. However, this premise will only be accepted by people who already believe in God’s existence. Therefore, the argument fails in proving his existence externally of prejudiced beliefs.

In conclusion, the cosmological, teleological, and ontological arguments for God’s existence have been put forward. The criticisms put against them, in that the two former arguments rely on the ontological argument, and the ontological arguments fail to prove God’s existence, seem to indicate that there are no arguments which work to prove the existence of God.

Reference List

Anselm. (1077). Proslogium. Accessed online at: https://legacy.fordham.edu/halsall/basis/anselm-proslogium.asp. Last accessed at 24/09/2015.

Darwin, C. (1859). The Origin of Species. London: Everyman’s Library.

Descartes, R. (1641). Meditations on First Philosophy. Translated and edited by Cottingham, J. (1996). Cambridge: Cambridge University Press.

Kant, I. (1781). Critique of Pure Reason. Translated by Kemp Smith, N. (1933). London: The Macmillan Press ltd.

Mackie, J. L. (1983). The Miracle of Theism. Oxford: Oxford University Press.

Paley, W. (1867). Natural Theology. Ohio: DeWard Publishing Company.

Plantinga, A. (1974). God, Freedom, and Evil. New York: Harper and Row.

Reichenbach, B. (2012). “Cosmological Argument”. Accessed online at: plato.stanford.edu/entries/cosmological-argument/. Last accessed at 23/09/2015.

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The importance of leadership is now widely recognised as a key part of overall effective healthcare, and nursing leadership is a crucial part of this as nurses are now the single largest healthcare discipline (Swearingen, 2009). The findings of the Francis Report (2013) raised major questions into the leadership and organisational culture which allowed hundreds of patients to die or come to harm and further found that the wards in Mid Staffordshire, where the worst failures of care were found were the ones that lacked strong and caring leadership, highlighting the crucial role of nurses in leadership. Research into nursing leadership has shown that a culture of good leadership within healthcare is linked to improved patient outcomes, increased job satisfaction, and lower staff turnover rates (MacPhee, 2012).

Although the NHS currently faces many challenges such as financial constraints and a growing elderly population, leadership cannot be viewed as an optional role. Previous research by Swearingen (2009) has suggested that educational programmes for nurses do not fully prepare them for leadership roles, and this gap between the demands of clinical roles and adequate educational preparation can result in ineffective leadership in nursing (Feather, 2009). It is important to recognise the critical role that nurses and nurse leaders play in establishing leadership for patient care and the overall culture within which they work (Feather, 2009). Themes explored in this essay will include defining leadership, leadership in nursing, factors that contribute to nursing leadership, and leadership preparation as part of nursing education.

What is leadership and culture?

Leadership can mean many different things and has clearly evolved in meaning over time (Brady, 2010). Common qualities associated with leadership are influence, innovation, autocracy, and influence (Brady, 2010, Cummings, 2010). A key factor which has remained part of leadership during its evolution has been the ideas that leadership can involve the influence of behaviours, feelings, and actions of other people (Malloy, 2010). Culture is different, and refers to the implicit assumptions that each member of a group or organisation perceives and reacts to different things (Malloy, 2010). Culture is often regarded as a good reflection of what an organisation values most: if compassion and safety are highly regarded, staff will assimilate this (Hutchinson, 2012). Interactions by leaders at all levels of an organisation have been identified as the most important aspect/component of establishing and maintaining a culture of leadership (Malloy, 2010, Hutchinson, 2012). The most senior level of leadership within NHS trusts often comes from the board of directors, who have overall responsibility for the overall leadership strategy (Brady. 2010).

Nursing leadership

Although there are many research articles and books about leadership and management, there has been relatively little research until recently into what nursing leadership entails. Cummings (2008) found that perceptions of nursing leadership were different from general leadership because it placed a greater emphasis on nurses taking responsibility for and improving and influencing the practice environment. Brady (2010) reported that anytime a nurse had recognised authority, they were providing leadership to others. By this argument, student nurses are leaders to their patients, a staff nurse is a leader to student nurses and patients, and the leader to all team members is seen in the ward manager (Brady 2010, Sanderson, 2011). It is also important to distinguish between a manager and a leader (Brady 2010, Sanderson, 2011). Mangers are seen to be those who administer, maintain, and control, whereas leaders are those who are seen to innovate, develop, and inspire (Sanderson, 2011). Whilst there is obvious need for managers within the health service, it is vital to realise that there is a clear distinction in the roles of managers and leaders (Sanderson, 2011), and that there are areas where these roles may not overlap (Sanderson, 2011). One of the key challenges facing the NHS is to nurture a culture which allows the delivery of high quality healthcare (MacPhee, 2012) and one of the most influential factors which can impact the delivery of quality patient care is leadership: ensuring there is a clear distinction between management and leadership, and that leaders are equipped with the necessary tools to inspire others to follow their example (Jackson, 2009).

Factors which contribute to nursing leadership

The systematic review by Cummings (2008) demonstrated that research into nursing leadership falls into two categories – studies of the practices and actions of nursing leaders including the impact of differing healthcare settings, and the effects of different educational backgrounds of nurse leaders. The conclusion from the systematic review by Cummings (2008) suggests that leadership from nurses can be developed by a stronger emphasis placed on leadership in education, and by modelling leadership styles on those which have been seen to be successful in the workplace. Several studies also highlighted personal characteristics which were deemed to promote leadership qualities, such as openness and the motivation to lead others (Jackson, 2009, Brady 2010, Sanderson, 2011). Marriner (2009) also showed that contrary to popular belief, age, experience, and gender did not seem important factors when considering the effectiveness of leadership, and that interpersonal skills were more important than financial or administrative skills. However this focus on financial and managerial skills seems to suggest an overlap between management and leadership, which has previously been shown to be two different areas (Richardson, 2010, MacPhee, 2012). They also showed that leadership was perceived to be less effective when leaders had less contact with those delivering care, highlighting the importance of nurses on the ward to also be effective leaders (Richardson, 2010, MacPhee, 2012).

The emphasis which has been placed on interpersonal skills and relationships between healthcare workers is strongly suggestive that this is an important leadership skill, and could be a key part of leadership development programmes (Malloy, 2010). A recent review of the role of emotional intelligence and nursing leadership highlights the need for emotional intelligence in effective leaders and has been shown to be highly influential on healthcare cultures (Hutchinson, 2012). Although the impact of these factors can suggest how best to promote leadership in nursing, it is clear that a thorough understanding and overview of their interactions are needed to fully understand their effectiveness. Sorensen (2008) suggested that these effects can also be promoted through educational programmes, particularly at undergraduate level.

Education

It is clear that leadership is considered to be fundamental to nursing, and that nurses are now expected to act as leaders across a wide variety of settings (Richardson, 2010). If nurses are expected to undertake such roles it is important that they are adequately trained and prepared for this (Sanderson, 2011). Studies have found that many undergraduate nursing courses now view organisation and management to be fundamental parts of autonomous nursing practice, and it is widely part of the curriculum (Richardson, 2010, Sanderson, 2011). However it is unclear what is actually taught, and much of the content appears to be focused on the transition period from student to qualified nurse (Sanderson, 2011). However it seems that current expectations of leadership within the NHS are not suitable to be taught as isolated elements within the curriculum, and should instead be embraced throughout training and beyond (Richardson, 2010, Sanderson, 2011). The development of leadership skills should also be continued through a nurse’s career to continually promote the importance of leadership, and to develop newly-qualified nurses into role models for others (Jackson, 2009).

Collective leadership

In collective leadership there are both individual and collective levels of accountability and responsibility (Cummings, 2008). There is a strong emphasis on regular reflective practice which has been shown to improve the standard of care given by nurses, and strives to make continuous improvement a habit of all within the organisation (Cummings, 2008, Cummings, 2010). This is in contrast to a command and control style of leadership, which displaces responsibility onto individuals and leads to a culture of fear of failure rather than a desire to improve (Feather, 2009). Leadership comes from both the leaders themselves and from the relationships among them and with other members of staff. Key to leadership is also the idea of followership – that everyone supports each other to deliver high quality care and that the success of the organisation is the responsibility of all (Hutchinson, 2012). It is important to recognise that good leadership does not happen by chance, and that collective leadership is the result of consciously and purposefully identifying the skills and behaviours needed at an individual and organisational level to create the desired culture (Hutchinson, 2012). This is in contrast to more traditional leadership development work, which has focused on developing individual capacity whilst neglecting the need for developing collective capability (Cummings, 208, Cummings, 2010). This style of leadership has been linked to poorer patient outcomes, decreased levels of job satisfaction, and higher levels of staff turnover (Sorensen, 2008). The challenge of recruiting and retaining leaders at all levels must be recognised, as there is need for clinical leadership at every level (Cummings, 2010).

Research has shown that where leaders and relationships between leaders are well developed, there is an increased quality of care due to all staff working towards the same goals and a well-established culture of caring (Sanderson, 2011). In addition to this, there is also an increasing drive to form leadership partnerships with patients (Sanderson, 2011, Hutchinson, 2012). Collective leadership with those receiving care functions in a similar way to multidisciplinary team working as this style of leadership with patients needs a redeployment of both power and decision making in addition to a change in thinking about who should be included in the collective leadership community (Hutchinson, 2012). Several authors (Cummings, 2008, Jackson, 2009, Malloy, 2010) recommended that NHS leaders should work with those seen as patient leaders to facilitate the changes outlined in the Francis Inquiry report (2013). There have been frequent reports that staff working in healthcare settings are often overwhelmed by the workloads required and are unsure of their priorities, sometimes because there are too many priorities identified by senior managers (Cummings, 2008). This can result in stress and poor quality care for patients (Cummings, 2008, Cummings, 2010). Whilst mission statements about efficient and high quality care can be helpful for staff, they are only helpful when translated into objectives for individuals (Jackson, 2009). Establishing and maintaining cultures of high-quality care relies on continual learning and improvements in patient care from all members of staff, and thus taking responsibility for improving quality (Jackson, 2009, MacPhee, 2010). Where there is a well-established mentality of collective leadership, all staff members are more likely to work together to solve problems, to ensure that the quality of care remains high, and to work towards innovation (MacPhee, 2012).

Conclusion

The importance of effective leadership to the provision of good quality care is firmly established, as is the central role that leadership plays in nursing (Cummings, 2008). It is now also clear that leadership should be found at all levels from board to ward and it seems obvious that the development of leadership skills for nurses should begin when training commences and should be something which is honed and developed throughout a nursing career (Feather, 2009). For health care organisations to provide patients with good quality healthcare there must be a culture that allows sustained high quality care at multiple levels (Francis Report, 2013). These cultures must concentrate on the delivery of high quality, safe health care and enable staff to do their jobs effectively (Jackson, 2009, Francis Report, 2013). Part of this is ensuring that there is a strong connection to the shared purpose regardless of the individual’s role within the system and that collaboration across professional boundaries is easily achieved (Cummings, 2010). Nurses can be a key part of this by using collective leadership to establish a culture where all staff take responsibility for high quality care and all are accountable (Malloy, 2010). This may require a shift in mentality of the way many see leadership – from seeing leadership as a command-and-control approach, to seeing leadership as the responsibility of all and working together as a team to work across organisations and other boundaries in the best interests of the patient (Brady, 2010).

References

Brady, P. (2010). The influence of nursing leadership on nurse performance: a systematic literature review. Journal of Nursing Management, 18(4), pp.425-439.

Cummings, G. (2008). Factors contributing to nursing leadership: a systematic review. Journal of Health Services Research and Policy, 13(4), pp.240-248.

Cummings, G. (2010). The contribution of hospital nursing leadership styles to 30-day patient mortality. Nursing Research, 59(5), pp.331-339.

Feather, R. (2009). Emotional intelligence in relation to nursing leadership: does it matter? Journal of Nursing Management? 17(3), pp.376-382.

Hutchinson, M. (2012). Transformational leadership in nursing: towards a more critical interpretation. Nursing Inquiry, 20(1), pp.11-22.

Jackson, J. (2009). Patterns of knowing: proposing a theory for nursing leadership. Nursing Economics, 27(1), pp.149-159.

MacPhee, M. (2012). An empowerment framework for nursing leadership development: supporting evidence. Journal of Advanced Nursing, 68(1), pp.159-169.

Malloy, T. (2010). Nursing leadership style and psychosocial work environment. Journal of Nursing Management, 18(6), pp.715-725.

Marriner, A. (2009). Nursing leadership and management effects work environments. Journal of Nursing Management, 17(1), pp.15-25.

The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: executive summary. London: Stationery Office (Chair: R Francis).

Richardson, A. (2010). Patient safety: a literature review on the impact of nursing empowerment, leadership, and collaboration. International Nursing Review, 57(1), pp.12-21.

Sandstrom, B. (2011). Promoting the implementation of evidence-based practice: a literature review focusing on the role of nursing leadership. Worldviews on Evidence-Based Nursing, 8(4), pp.212-223.

Sorensen, R. (2008). Beyond profession: nursing leadership in contemporary healthcare. Journal of Nursing Management, 16(5), pp.535-544.

Swearingen, S. (2009). A journey to leadership: dsigning a nursing leadership development program. The Journal of Continuing Education in Nursing, 40(3), pp.113-114.

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Make recommendations on how the impact of moral distress on nursing staff can be limited.

What is moral distress?

Moral distress is the state of psychological discomfort and distress that arises when an individual recognises that they have moral responsibility in a given situation, make a moral judgement regarding the best course of action but for a range of reasons are unable to carry out what they perceive to be the correct course of action.A In reference to nursing, it specifically refers to the psychological conflict that occurs when a nurse has to take actions that conflict with what they believe is right, for example, due to restrictions in practice policies within institutions (Fitzpatrick and Wallace, 2011).A A Studies in this area usually use the original definition by Jameton in 1993 “moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984).A Further work by Wilkinson in 1987, who published an account of moral distress (Wilkinson, 1989) refined this definition to relate it directly to “psychological disequilibrium and negative feeling” (Wilkinson, 1987).A Common causes cited by nurses for not being able to fulfil their moral responsibility include a lack of confidence in the ability of colleagues, negative attitudes of colleagues towards patients and a team decision on care that does not follow the patients expressed wishes, or fear of reprisal resulting from the course of action they feel is best for the patient (Wojtowicz et al., 2014).A

For example, a nurse working in post-operative ward might experience a patient dying as the result of refusing a blood transfusion following surgery due to religious beliefs.A The nurse’s personal judgement may be that the patient should receive the blood transfusion to give them the best chance of surviving the surgery.A However, because the patient did not consent, the nurse could not carry out the action they perceived to be correct.A When the patient died, the nurse may have experienced emotional and psychological distress in the form of guilt and anger that they had not saved a life that may have been possible to save, as well as feelings of helplessness that they could not overrule the patient’s wishes (Stanley and Matchett, 2014).A A

What situations are more likely to cause moral distress?

In 2015, Whitehead et al carried out a large scale questionnaire based study in the USA on moral distress amongst nurses and other healthcare professionals (592 participants, 395 of which were registered nurses).A The most common causes of moral distress in nurses included frustration at a lack of patient care due to inadequate continuity (rated 6.4 by nurses on a Likert scale of 0-16), poor communication (5.8) or inadequate staffing levels (5.7).A Additionally, nurses reported that giving life supportive therapy when not in a patient’s best interest (6.0), or resuscitation only to prolong the process of death (5.8) were also rated highly.A This study also showed that physicians and other healthcare professionals also rated these factors highly, but overall their scores were less than those of nurses.A The authors concluded that nurses are more likely to experience moral distress than other healthcare professionals, possibly due to a discrepancy between levels of responsibility for patient welfare and the required autonomy to make the decisions they believe should be made, as well as feelings of accepting treatment protocols from physicians which they feel are incorrect but unable to challenge or overrule.A Poor team leadership and poor communication was also cited by nurses as a cause of moral distress (Whitehead et al., 2015).A

Moral distress appears to be more likely amongst nursing staff who are involved in patient care protocols that are considered to be aggressive and futile e.g. prolonged end of life care, or care protocols that the nurse does not consider to be in the patient’s best interest.A For these reasons, moral distress is thought to be particularly prevalent amongst nurses treating patients in palliative care (Matzo and Sherman, 2009), paediatrics, intensive care (Whitehead et al., 2015; Wilson et al., 2013; Ulrich et al., 2010) and neonatal environments (Wilkinson, 1989).A Additionally moral distress is also prevalent amongst psychiatric nurses due to increased feelings of responsibility for vulnerable patients, particularly as these patients are at risk of suffering from ethical mistreatments, e.g. misinformation about drug side effects (Wojtowicz et al., 2014).A Other studies have also identified that issues with the institution itself can cause moral distress, such as inadequate staffing, depersonalisation of staff, inadequate supply of resources and overloading of work (Dalmolin et al., 2014).

How does it affect nursing staff?

Moral distress can have psychological consequences that affect the nurse’s performance and wellbeing.A For example, it is thought that nurses experiencing moral distress may self-blame or criticise themselves for an unsatisfactory outcome, and may experience emotions of anger, guilt, sadness or powerlessness (Fitzpatrick and Wallace, 2011; Borhani et al., 2014).A They may shift blame onto others or exhibit avoidance behaviours such as taking time off for illness.A Physical manifestations may also include headaches, diarrhoea, sleep disturbance and palpitations, which may well be interpreted as illness and require time off work, further contributing to low staffing levels, which perpetuates a cycle of understaffing = moral distress / illness = time off = understaffing (Fitzpatrick and Wallace, 2011).A Moral distress is associated with “burnout” (or emotional exhaustion and extreme stress) and with a reduced sense of professional fulfilment (Dalmolin et al., 2014) .A

Moral distress and staff retention

Because experiencing moral distress has been linked to harm and stress to nurses, as well as a reduction in the quality of patient care, many studies have cited it as a reason for nurses to leave the profession, resulting in a reduction in staffing levels and self-perpetuating cycle of staff shortages (Fitzpatrick and Wallace, 2011; Borhani et al., 2014).A Indeed, one study of 102 intensive care nurses in the USA found that as many as 40% had left or had considered leaving a job as the direct result of moral distress (Morgan and Tarbi, 2015),

Together, these issues can significantly compromise the quality of patient care and result in “burnout” of nursing staff, causing more to leave the profession to avoid the feelings of guilt that moral distress can cause, particularly in those specialisms typically associated with moral distress such as oncology or paediatrics.A Moral distress also contributes to job dissatisfaction, typically as the result of a discrepancy between the experience the nurse is expecting to have at an institution, and the actual experience (Borhani et al., 2014) This is particularly true of student nurses, who are more likely to have higher expectations of the profession they have worked hard to join, and will be more familiar with the policies and values by which organisations “should” be run rather than the reality, where it is likely that some practices will be sub-optimal or archaic (Wojtowicz et al., 2014; Stanley and Matchett, 2014).A A

Managing and limiting the impact of moral distress

As previously discussed, moral distress is thought to primarily result from either institutional disorganisation (which can be prevented), or distressing ethical situations such as providing futile life prolonging treatment which are unfortunately inevitable (Whitehead et al., 2015).A However, there are ways in which nurses and their management can prepare themselves to deal with these situations effectively, thus reducing the impact of the moral distress (Deady and McCarthy, 2010).A A Although it is important for nursing staff to be supported by their management, ultimately the nurse should be responsible for themselves and their own psychological wellbeing in order to prevent burnout from moral distress (Severinsson, 2003).A

Several studies have suggested that the best way to reduce the risk of burnout as a result of moral distress is for nurses to share their feelings and seek support from their peers, ideally in an environment where nurses can share their experiences and discuss ethical implications of specific situations.A It is also important that nurses understand what moral distress is, and can identify the source of negative feelings.A Psychologically it is thought to be important that nurses acknowledge and identify these feelings so that they may be processed in a less damaging manner (Matzo and Sherman, 2009; Deady and McCarthy, 2010; Em Pijlaˆ?Zieber et al., 2008).A Nurses should also be encouraged to challenge treatment protocols they feel are inappropriate without fear of reprisal (Deady and McCarthy, 2010).A Some researchers have advocated approaches such as nurses emotionally distancing themselves from distressing situations, or actively striving to desensitise themselves.A However it is controversial whether or not this actually reduces moral distress, and of course raises questions about patient welfare with some suggesting that it is important that the nurse feels ethically responsible (Whitehead et al., 2015; Severinsson, 2003) and has a degree of emotional involvement in the situation in order to provide best possible care (Bryon et al., 2012; Linnard-Palmer and Kools, 2005; Severinsson, 2003).A

The majority of studies in this area recommend that moral distress should be included in the curriculum studied by student nurses, along with practical recommendations regarding measures that can be taken to deal with it as and when it occurs (Wojtowicz et al., 2014; Borhani et al., 2014; Matzo and Sherman, 2009; Stanley and Matchett, 2014; Whitehead et al., 2015), for example in the form of ethical philosophical discussion to facilitate students to explore their individual moral value systems and emotional responses, as well as be more informed regarding the underlying psychological processes involved.A Therefore nurses may better understand the thought processes involved, and be better equipped to identify unhelpful thinking patterns that may result from moral distress, thus limiting stress and avoiding the development of “burnout” (Stanley and Matchett, 2014; Severinsson, 2003).A

It has been shown by several studies that moral distress occurs less in institutions and teams where there is a healthy and positive attitude towards ethics and the discussion of the application of ethics (Whitehead et al., 2015).A Therefore, it is important that institutions encourage the development of an ethically healthy environment at all levels of management (Deady and McCarthy, 2010).A A Additionally, many studies highlight that incompetence in colleagues and subsequent errors in patient care is a primary source of moral distress in nursing staff, and as such institutions should ensure that an adequate quality of care monitoring system is in place, preferably where staff are able to raise concerns without fear of reprisal (Whitehead et al., 2015; Stanley and Matchett, 2014).A A Institutions should also strive to reduce factors such as institutional disorganisation, inadequate resource levels and understaffing (Dalmolin et al., 2014).A Anonymous reviews have also identified extreme examples of patient mistreatment and poor care, and a lack of empowerment of student nurses in particular to report or challenge unacceptable behaviour in colleagues.A Universities and institutions should therefore encourage an environment where this is possible (Rees et al., 2015).A Feelings of powerlessness to contest clinical decisions can also be reduced by encouragingA collaborative decision making within teams (Karanikola et al., 2014; Em Pijlaˆ?Zieber et al., 2008).A

Healthcare institutions should also recognise their responsibilities in reducing moral distress amongst nursing staff in order to support them correctly and also to retain staff and limit absence due to staff sickness.A For example, an institution could appoint a designated ethics consultant who can offer guidance to nurses, and ensure that staff have access to counselling if required to address any psychological distress.A The institution could also support the setting up of an ethics discussion forum where staff could discuss troubling situations (Matzo and Sherman, 2009), for example using an online forum which would also provide anonymity to facilitate open discussion.A It has been recommended that such groups be cross-disciplinary, as this would allow for potentially valuable differing viewpoints to facilitate discussion and potentially offer different solutions or approaches to those traditionally used by a team (Matzo and Sherman, 2009).A

Nursing management staff are thought to experience less moral distress than nurses themselves, presumably as the result of the “distance” perceived between themselves and the questionable moral decision (Ganz et al., 2015).A As a result it may also be beneficial for management staff to receive specific training about moral distress so that they can understand the situation better and provide more effective support to their teams.A

Conclusion

Moral distress is a significant factor for nurses leaving the profession.A Combatting moral distress is important, not only for the welfare of nursing staff but also the patients themselves.A Healthcare institutions have a responsibility to minimise moral distress as much as possible by improving administrative issues such as staffing levels, team organisation and job satisfaction.A However nurses still have a responsibility to themselves and their patients to reduce moral distress and thus negate its impact on patient care (as well as their own health and wellbeing) by actively partaking in activities such as ethical discussion groups and peer support networks.A Together nurses, healthcare institutions and universities can reduce the impact of moral distress by cultivating an environment where nursing staff can participate in controversial care plan discussions.A

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It is estimated that approximately 60% of the nursing workforce consists of newly qualified nurses: consequently there is much literature that examines the transitions that individuals experience as they progress from the student nurse to the newly qualified nurse (Whitehead, 2001; 2011). The recruitment and retention of nurses globally is a major issue, and hence healthcare systems need to address how best to ensure smooth transition into the professional nurse role to ensure newly qualified nurses successfully adjust into their new roles (Duchscher, 2008). In facilitating such transitions, great emphasis has been placed upon providing effective work environments in which newly qualified nurses can be best supported through the use of supervisors and preceptorship, and in having their views acknowledged and valued (Department of Health, DoH, 2008; Nursing and Midwifery Council, 2006). Indeed the policy paper, ‘A High Quality Workforce’ (DoH, 2008) specifically acknowledged the role that the National Health System must adopt in improving not simply the quality of care but also the quality of support offered to NHS staff. Key DoH (2008) recommendations were placed on establishing more effective nursing training to ensure newly qualified nurses were better prepared for the realities of nursing practice, and providing avenues for appropriate continued professional development. However, studies still highlight that in reality, newly qualified nurses’ experiences are not aligned with these recommendations and nurses are still experiencing great challenges and difficulties in adjusting to the newly qualified nurse role (Mooney, 2007; Nash et al. 2009). The aim of this essay therefore is to examine the challenges that newly qualified nurses’ experience as they make their transitions into professional nursing practice, and to explore particular evidence based strategies to facilitate effective adjustment to their new role.

Nursing role transitions

The difficulties that student nurses experience in making the transition to newly qualified nurse has been highlighted by both the Department of Health (DoH, 2007) and the Nursing and Midwifery Council (NMC, 2006) who raise concerns around whether such nurses are being appropriately prepared to feel confident and competent in their new nursing positions. As the NHS ethos of the 6 Cs of care demonstrates, competence, and the courage to act with confidence, alongside communication, collaboration and continuity, are essential aspects of the nurses’ role in order to practice effectively (NHS, 2013). The literature indicates however that student nurses are simply not being effectively supported by both the NHS health care system and pre-registration training, which is leading to ineffective training which results in poorly prepared student nurses with expectations that do not translate into their actual new ‘professional’ nursing roles (Mooney, 2007; O’Shea and Kelly 2007). As Clark and Holmes (2007, p.1211) state, nursing education does not offer students “the knowledge, skills or confidence necessary for independent practice”. As O’Shea and Kelly (2007) also highlight, newly qualified nurses’ transitions are further challenged by little knowledge of the diverse roles qualified nurses engage within, such as managerial, leadership, decision-making and clinical duties. Studies however reveal that amongst newly qualified nurses there are similar, shared personal values based on altruistic values of desiring to help, care and support patients’, which promotes the person-centred model of care (DoH, 2000). However studies highlight that in practice, organisational constraints (Lack of time and staffing problems) combined with managers’ high expectations create challenges for new nurses in implementing theoretical knowledge and personal values into practice (Mackintosh, 2006). Therefore there is much need to determine key strategies that can promote effective transitions for nurses to help them to negotiate new positions as newly qualified nurses that prevent disillusionment, frustration, stress and potential burnout (Mackintosh, 2006).

The shock of transition

Duchscher (2008) identifies two key processes, those of socialisation and professionalisation, that occur as student nurses adjust to becoming a newly qualified nurse, Duchscher states that in order for nurses to effectively adjust to the transition they must modify their professional and personal values so that they are more aligned with the actual role. Duchscher (2008) argues that these changes result in nurses experiencing a process of intellectual, emotive personal, professional, role, skill and relationship transitions, which lead to new understandings, expectations and, subsequently, experiences. Studies corroborate this by highlighting that the first three months of becoming a newly qualified nurse have been reported by such nurses to be a sharp shock, as prior expectations of theory-based nursing are challenged by having such ideals of person-centred care made often impossible through different care practices expected within NHS settings being reinforced within health care teams (Kelly and Ahern, 2009; Hollywood, 2011). As multi-disciplinary teamwork in NHS care systems is a key aspect of NHS policy (DoH, 2010; NHS, 2013), newly qualified nurses can feel coerced into adopting different care practices that challenge their theoretical understanding of best practice, which can lead to tensions and, as studies reveal, could lead to distrust and poor staff morale (McDonald, Jayasuriya, and Harris, 2012). The literature evidences that newly qualified nurses who feel pressured to follow the practices of other staff can become desensitised to the use of poor practice through rationalising the need for such practice as a result of environmental pressures, such as time or staffing issues, which can lead to the nurse also adopting them (Mackintosh, 2006). Mackintosh (2006) highlights how this can lead to newly qualified nurses re-negotiating new nursing roles where personal values are re-assessed to enable adoption of similar practices, which serves to further reinforce the use of poor care within NHS settings.

Consequently as Kelly and Ahern (2009) identified, it is no wonder that newly qualified nurses report finding the transitional process overwhelming and stressful, confirming Mooney’s (2007) findings that nurses are unprepared and experiencing unexpected difficulties. Whitehead (2011) and Scully (2011) argue that such difficulties are a result of a theory-practice gap, which leads to nurses experiencing a conflict amongst theoretical, personal and professional values (Maben, Latter and Clark, 2006). Mooney (2007) confirms this in research conducted with newly qualified nurses that reported that pre-registration training did not prepare them for the realities of actual practice. Mooney (2007) also demonstrated how the high expectations of staff-leaders and patients furthered nurses’ feeling of lacking skills and knowledge, as no accommodation was made for their newly qualified status and lack of experience, which led to stress and disillusionment (Hollywood, 2011). As Maben et al. (2006) state, such treatment and lack of support places newly qualified nurses in vulnerable situations: they are at great disadvantage due to lack of experience and appropriate support strategies (Hollywood, 2011).

Addressing stress and expectations

Whilst studies highlight the difficulties that nurses experience in adjusting to the newly qualified nurse role (Whitehead, 2001; 2011), Edwards et al.(2011) reveal that appropriate support can minimise student nurses’ anxiety and help to build confidence through enhancing greater understanding of their role and staff demonstrating acceptance within nursing teams. However, Edwards et al. (2011) identify that staffing issues, staff attitudes and time constraints often lead to such nurses being unsupported, and can foster inequalities across NHS settings in the level of support provided. Scully (2011) emphasises that in order to provide appropriate support to newly qualified nurses, the political, social, and cultural barriers inherent in such a context must be addressed to help such nurses to overcome the theory-practice gap. As Fenwick et al. (2012) recommend, staff support needs to support a re-negotiation of newly qualified nurses’ expectations – resulting from theoretical training – to offer contexts in which discussions can be promoted that can address unrealistic expectations of the newly qualified nurse’s role so that what Kramer (1974) terms as reality shock is prevented. Theory-practice gaps, if strategies are not developed, can lead to segregation across newly qualified nurses and experienced staff, as when high expectations are placed upon newly qualified staff, they are unable to re-negotiate their new roles as they have no understanding of how their role can be limited by the particular socio-political and organisational constraints that can impede their practice (Maben et al. 2006).

Supportive work environments

Consequently the actual NHS environment and organisational culture in which newly qualified nurses find themselves can elicit a major impact upon how such nurses manage their transitions and forge a new self-identity and come to make sense of the role of the newly qualified nurse (Mooney, 2007; Whitehead, 2001). A key strategy promoted by the Nursing and Midwifery Council (NMC) (2006) is the employment of preceptors and supervisors to facilitate newly qualified nurses’ adjustment to their new practice settings (NMC 2006). Preceptorship within a nurse’s first year of professional practice can be utilised to highlight newly qualified nurses’ existing strengths and weaknesses, so that areas of development can be highlighted and addressed. However, it can also provide a valuable context in which fears, emotions and challenges can be discussed (NMC, 2006). Despite NMC (2006) recommendations however, the utilisation of preceptorship support strategies in practice is limited, with its use across the NHS being fragmented and inconsistent. However the literature does demonstrate that preceptorship strategies can be very effective in supporting newly qualified nurses in successfully managing such transitions, with student nurses reporting that preceptorship facilitated easier transitions into clinical practice and helped them to negotiate better understandings of their new roles (Mooney, 2007). Whitehead’s (2001; 2011) studies’ findings led to the recommendations that newly qualified nurses must have access to preceptorship, clinical supervision and some form of full time support so that difficulties can be addressed swiftly and reduce the number of newly qualified nurses living too hastily without appropriate discussion the nursing profession. As Whitehead (2011) states, social support and peer interaction can help to address and alleviate fears and stress through nurses being able to access appropriate emotional support and guidance at any time (Mooney 2007).

A qualitative study by Jonsen et al. (2012) examined the impact that providing preceptorship support elicited upon nurses’ successful transition into new practice, Jonsen et al. (2012) identified three key aspects, these being: preceptors; theory and practice; and reflection. Jonsen et al’s (2012) findings revealed that student nurses found the availability of support through preceptorship facilitated positive working environments which promoted feelings of security and yet fostered enhanced confidence and greater clinical effectiveness. As Jonsen et al. (2012) state, preceptorship provides contexts in which nurses are able to reflect upon their clinical practice experiences, which provides an environment in which students are able to balance theory with practice and personal with professional values, which facilitates better practice and confidence.

Conclusion

In summary, this essay demonstrates that to ensure student nurses adapt and make effective transitions to the role of newly qualified nurse, vital support is needed to offer appropriate supportive working environments, which can help nurses to re-negotiate the theory-practice gap. NHS settings need to acknowledge, accept and address the unique and individual needs of newly qualified nurses so that strategies can be employed that can facilitate continued professional development and encourage nurses to discuss their actual fears, issues and needs. The provision of preceptors and supervisors is essential to enable newly qualified nurses to have access to contexts in which personal and professional values can also be discussed so that they are able to not simply assimilate dominant practices inherent in the NHS setting but to also question them. Such strategies can thus offer newly qualified nurses context in which to reflect upon such practice experiences so that they can make sense of their new roles and re-negotiate new identities. It is therefore recommended that nurse training must address the potential transitionary difficulties that newly qualified nurses can experience to better prepare individuals for the realities of professional practice. NHS health care contexts must also promote greater access to preceptorship for newly qualified nurses to cater to the specific needs of newly qualified nurses. It is anticipated that through this development and a universal shift to enabling newly qualified nurses access to support such as preceptorship, newly qualified nurses can act with greater confidence and feel more supported in their clinical practice.

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Introduction

All nurses have a duty of care to their patients (Brooker and Waugh, 2013). Nurses are expected to play a safeguarding role, recognising vulnerable patients and protecting them from harm, abuse and neglect. Elderly patients are at especial risk due to their poor health, disabilities and increased frailty (de Chesnay and Anderson, 2008). Of concern here, is the higher than average incidence of abuse in elderly people with dementia (Cooper et al., 2008). Nurses play an important role in recognising signs of abuse and acting as advocates for their dementia patients. Here, the principles of safeguarding and how they are applied in dementia nursing are presented.

Dementia: Cause of Vulnerability

Dementia is a group of symptoms that are associated with declining functionality and physical health of the brain (NHS Choices, 2015). This decline in mental function makes a person increasingly vulnerable (de Chesnay and Anderson, 2008). Dementia is typically seen in elderly people with one in every three people over 65 having dementia, and two-thirds of these will be women (Alzheimer’s Society, 2014). The signs and symptoms of dementia demonstrate how this condition makes someone vulnerable to harm, abuse or neglect (Hudson, 2003) as they include: memory loss, reduced thinking speed, reduced mental agility, language difficulties, lower levels of understanding and reduced judgement. Furthermore, as dementia develops people become more apathetic and isolated as they lose interest in socialising, putting them at increased risk.

Dementia can alter a person’s personality (Hudson, 2003). They may find it difficult to control their emotions and hard to empathise. They may appear more self-centred, suffer from hallucinations and even make false claims or statements. All of these factors make it difficult for relatives and carers to interact with the dementia patient especially when offering very personal care (Adams and Manthorpe, 2003). Dementia reduces a person’s ability to live independently and, as the condition progresses, they will increasingly need support and assistance. Their lack of mental capacity makes dementia patients vulnerable to the actions of others (Hudson, 2003). They will require assistance with decisions and gradually lose their autonomy as the dementia progresses, eventually relying on others for even the most simplistic decisions. Depending upon the stage and severity of their dementia, they may be living at home with support from relatives, or they may be in residential care.

Safeguarding: Duties and Expectations

Safeguarding adult patients means to protect those at risk of harm from suffering any abuse or neglect (Tidy, 2013). The CQC (2015) defines safeguarding people as “protecting people’s health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect”. Safeguarding is seen as an essential component of high quality health and social care. The healthcare provider is expected to minimise the risk of any abuse or neglect befalling a patient, identifying any potential causes and taking steps to mitigate them. A patient’s right to live safely and free from abuse or neglect must be protected, and their wellbeing promoted with ample consideration for their own views and beliefs.

The overall responsibility for safeguarding vulnerable adults lies with Adult Social Care (Dementia Partnerships, 2015). They receive and process and safeguarding issues from their partner agencies. However, each partner agency is expected to have its own procedures and practices to recognise and respond to any safeguarding alerts. This means that all staff employed by a health or social care provider has a duty to identify and report any safeguarding issues. Nurses caring for patients with dementia therefore have a duty to identify and report any signs of abuse or neglect (Hudson, 2003). Furthermore, they must have the knowledge and skills necessary to provide quality care to these patients with reduced mental capacity.

Abuse of a vulnerable adult can occur anywhere: at their home, in a hospital or a residential care setting (Tidy, 2013). Abuse can include physical actions, sexual abuse, mental or emotional abuse, neglect and also financial abuse. Often, the abuser is well known to the victim (de Chesnay and Anderson, 2008). They could be a neighbour, relative or friend, carer, nurse or social worker, a fellow resident or service user. The adults most at risk of abuse are the frail elderly people who either live alone, or live in residential care, but without any family support (Mandelstam, 2008). In terms of suffering physical harm, the most at risk are those adults with mental or physical disabilities.

Dementia Specific Issues

Dementia patients are vulnerable adults, their degree of vulnerability dependant on the stage and severity of their condition (Tidy, 2013). The Department of Health describes vulnerable adults as those who are unable to take care of themselves, or who are unable to protect themselves from harm (DH, 2000). People with care and support needs require help and assistance from both the nursing and social care disciplines. Part of the nurse’s duty is to safeguard their vulnerable patient from abuse and neglect (SCIE, 2015). The Care Act (HM Government, 2014) requires local authorities to perform safeguarding duties. This stipulates a multiagency approach where any safeguarding concerns are recognised, acknowledged and addressed. Dementia patients are especially vulnerable as they increasingly lack the mental capacity to participate in the decision-making process that will ultimately protect and promote their own interests (BMA, 2011). This means that any decisions made regarding their care or treatment are made on their behalf. This loss of autonomy disempowers them and makes them subject to others’ will. Coupled with the ageing process, declining physical health and increased frailty, this puts dementia patients in a highly vulnerable position.

Steps a Nurse Can Take: Identification

Safeguarding adults with dementia is a difficult task. It is widely acknowledged that it is difficult for the nurse to spot signs of abuse in dementia patients due to similarities between signs of abuse and symptoms of their underlying condition. General signs of abuse can include frequent arguments between the caregiver and the patient, and changes in the dementia patient’s personality or behaviour (Tidy, 2013). Yet, as noted above, these are also signs and symptoms of the progressive disease. Furthermore, spotting such trends requires the nurse to have good knowledge of both patient and carer. Recognised signs of emotional abuse such as rocking, sucking and/or mumbling to themselves are also dementia-like (Tidy, 2013). Often professionals can only detect the signs of physical abuse and neglect by way of a detailed physical examination. The nurse should look for signs of physical and sexual abuse such as physical injury, bruising and bleeding. These may seem more easily detectable, but can be concealed or explained away as accidents. Signs of neglect, including weight loss, dirty living conditions, poor personal hygiene and untreated physical problems, should be identified by the nurse. Again, factors associated with dementia such as increasing apathy, reduced taste / appetite may be the underlying cause and will need to be explored.

Effective safeguarding requires the nurse needs to get to know their patient, discussing all aspects of their well being with them and/or their carer. People with dementia are especially vulnerable to abuse being less able to remember or describe what has occurred (Alzheimer’s Society, 2014). Victims, whether they have dementia or not, find it difficult to tell anyone what has happened. Added to this general reluctance, are issues specific to dementia: patients may feel that they will not be believed, have difficulties recalling and communicating events. The distress caused by the abuse may exacerbate these difficulties. Dementia patient are often not believed, being discredited and thought of as confused and unreliable. Therefore, to protect their patients and best represent their interests it is essential that the nurse understands them and establishes a good trusting relationship.

Dementia patients are also at increased risk of financial abuse. This can include sales-people taking advantage of them, relatives or carers accessing their bank details or causing them to alter their will and/or gain power of attorney (Adams and Manthorpe, 2003). Yet, the nurse should remember that some of these actions may be necessary steps so as to provide care to elderly dementia sufferers. For example, a carer may need to pay for some goods or services for the patient, and, in cases of significant reductions in mental capacity, power of attorney has to be awarded to ensure that all aspects of the dementia patient’s life are managed. Nurses should be aware of the Mental Capacity Act (HM Government, 2005). This was introduced to help protect the rights and wellbeing of those who lack capacity. It governs the responsibilities and jurisdiction of those making decisions on another’s behalf. It aims to ensure that people’s autonomy is protected, but where they cannot make a decision, they are not ignored and any actions are in their best interest (Adams and Manthorpe, 2003).

The demanding care needs of dementia patients can result in high levels of ‘carer stress’ to be experienced by relatives and friends. This may cause that individual to do abusive things and behave out-of-character. Nurses should recognise that carers of dementia patients experience greater strain and distress compared to carers of other elderly people (Alzheimer’s Society, 2014). The enforced change of lifestyle resulting from caring full time can manifest as resentment and dislike. External pressures and stress can make people abuse others, as can a history of being abused themselves, previous violent or antisocial behaviour. Nurses should endeavour to develop a good relationship with both patient and carer(s). They should seek to establish trust and empathy and learn about the people behind the condition. This will enable the nurse to offer high quality care as described in the next section.

Steps a Nurse Can Take: Prevention

Nurses should recognise that abuse can take place in all settings and be performed by all people (Tidy, 2013). Abuse of dementia patients in formal residential or hospital care settings is usually a sign of an overall poor quality of care. It signifies that staff are not appropriately trained and skilled in dementia care. They do not understand the complex needs of these patients and therefore cannot adequately address them. Thus, where a nurse identifies abuse at an organisational level, the situation should be reported so the necessary systems and training can be put in place. Remedial action on this scale is outside the scope of this essay, but where a colleague or individual carer acts inappropriately, the nurse can intervene to educate and train them.

The communication difficulties posed by dementia patients does mean that it is more difficult to offer person-centred care. This results in an individual’s needs not being met. This is further exacerbated where the dementia patient exhibits behavioural and psychological symptoms such as restlessness, shouting and aggression. These can result in the patient being restrained or medicated inappropriately. Therefore, nurses should ensure that they have the knowledge and skill to work with dementia patients so as to act in their best interests. On occasion, the requirements of the Mental Capacity Act are not followed appropriately: Staff assume that all dementia patients lack capacity and therefore don’t involve them in decisions. Nurses should be aware of, and understand, the Act. They should know how to implement it and where to gain advice if necessary. Ideally, there should be continuity of care. The same nurse should work with the patient and their carer(s) throughout the progression of the condition. By knowing the patient well, they will be better able to facilitate person-centred care, upholding the patient’s interests and best representing their views.

The nurse also has safeguarding duties with regards to home-based care. Improving the emotional and practical support given to family carers of dementia patients is recognised as key to safeguarding patients. These carers have little or no training and often do not feel adequately prepared (Alzheimer’s Society, 2014). They often find the situation stressful and demanding: circumstances that could lead to abuse or neglect. The nurse should therefore ensure that they are approachable and inspire confidence in the patient and carer. They should provide education and advice to carers and ensure that back-up support and resources are available to those who need it at all times. Developing a good relationship between all parties is essential in preventing abuse from occurring, ensuring the patient’s needs are met and their interests respected.

Conclusion

Nurses play a key role in protecting dementia patients from abuse. In order to effectively safeguard their patients, it is essential for nurses to understand the types of abuse, how and why it may occur. Dementia patients are at especial risk due to their declining mental capacity and reliance on others. Nurses are well placed to identify and prevent abuse through establishing close, open and trusting relationships with both patient and carer. Nurses can act as advocates for their patients, representing their best interests and facilitating person-centred care. Through providing education and support for carers, nurses can ensure that all the dementia patient’s needs are met.

References

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Alzheimer’s Society, (2014). Dementia 2014 Infographic [on-line]. London, Alzheimer’s Society via: http://www.alzheimers.org.uk/infographic

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Tidy, C., (2013). Safeguarding Adults. Leeds, Emergency Medical Information Service

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Terms of Reference

Accountability: Means that healthcare professionals are accountable to their selves and to others on the care received by the patients.

Adverse event: Refers to an incident that occurred in the hospital or any other clinical setting that resulted to harm or could have resulted to the patient’s harm.

Colleagues: Other healthcare professionals, co-workers, midwifery and nursing students.

Patient-centred care: A consideration of patient preferences, engagement and needs when making healthcare decisions.

Patient satisfaction: The perceived level of satisfaction on the quality of care they receive from their nurses.

Introduction

This report aims to discuss the role and career opportunities for a nurse. This report will include the qualification, skills and experience that are required to be a nurse in Ireland. A discussion on the daily work of a nurse with reference to health and safety issues will also be presented. Possible job opportunities for nurses in the Irish healthcare system will also be discussed. A conclusion will summarise the key points raised in this report.

Qualification, Skills and Experience Required to be a Nurse

The Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives (Nursing and Midwifery Board of Ireland, 2014) lays out the skills and professional requirements necessary for registered nurses in Ireland. These skills include the ability to provide safe and quality care for different groups of patients, respecting the dignity of each patient, professional accountability and responsibility, quality care, collaboration and trust and confidentiality. Since nurses continue to professionally develop from newly registered to specialist nurses, it is expected that professional characteristics and skills would be honed as nurses begin their practice. One of the important skills required for quality patient-centred care is the ability to communicate effectively with patients and colleagues. Communication is defined as a two-directional process that could involve transmission and receiving of verbal and non-verbal messages (Kourkouta and Papathanasiou, 2014). Nurses have a crucial role in promoting the health and welfare of patients. Establishing a relationship of trust in the beginning of care is crucial in promoting effective communication (Houghton and Allen, 2005). The first meeting between a nurse and a patient is important since this could either reassure patients or convey fear and indifference (O’Daniel and Rosenstein, 2008). However, communicating with patients who suffer from cognitive impairment or are unable to communicate because of confusion and hypoxia is often difficult and challenging (O’Daniel and Rosenstein, 2008). In patients unable to verbally express themselves, nurses have to recognise non-verbal messages in order to determine the healthcare needs of the patients (Watson, 2008). For instance, facial expressions, body gestures and posture (Houghton and Allen, 2005) could help identity the patient’s feelings and needs. Effective communication is important in patient care since this will help facilitate timely and early intervention for the needs of the patients (Watson, 2008). Kourkouta and Papthanasiou (2014) argue that physical space, social and cultural values and psychological conditions have an impact on the communication between the nurse and patient and vice versa. Hence, it is crucial for nurses to identify the factors that promote effective communication and those that deter patients from communicating their needs with the nurses. For instance, a language barrier might lead to miscommunication or misinformation, which in turn, affects the quality of communication of the nurses and patients.

Apart from communication skills, healthcare professionals are also bound to provide safe and effective care as stressed in the Code of Conduct for nurses in Ireland (Nursing and Midwifery Board of Ireland, 2014). Avoidance of medication errors does not only promote safe and effective care but also prevents adverse events and death of the patients. Acquiring numeracy skills is a prerequisite in the preparation and safe administration of medications. However, Eastwood et al. (2011) suggest that a number of nursing students have poor numeracy skills. While applicability of the findings of these studies to a larger and more heterogeneous population is limited due to the small sample sizes, findings could show a trend on the numeracy skills of nursing students. These suggest the need to enhance nursing curriculum to ensure that students have sufficient numeracy skills to prepare and administer medications before they become registered nurses. It is noteworthy that these findings are not only seen in nursing students but also in registered nurses (Warburton, 2010). This indicates that there is a continuing need to train nurses on how to safely administer or prepare medications in order to prevent medication errors.

Another nursing quality that is associated with quality care is the ability to show empathy to patients. Empathy is described as the ability to share and understand the feelings of other people (Kinnell and Hughes, 2010). Developing this characteristic could calm down patients and let them feel that nurses are willing to listen to their concerns and are available to help them with their needs. Rana and Upton (2009) suggest that patients are satisfied with the care they receive if they perceive nurses to be empathic to their needs, feelings and concerns. Increasing levels of patient satisfaction is important since high levels are associated with better quality care (Rana and Upton, 2009).

The Code of Professional Conduct and Ethics (Nursing and Midwifery Board of Ireland, 2014) should also develop skills on how to collaborate effectively with others. This means that individuals also have to learn effective leadership skills in order to lead health care teams, introduce innovations and work in partnership with other agencies in order to improve care. It has been shown that the transformational leadership style is consistent with effective leadership (Bach and Ellis, 2011). This type of leadership requires leaders to develop empathy with their colleagues and patients. These leaders also tend to have high emotional intelligence (Bach and Ellis, 2011). Hence, developing the skills needed to become a transformational leader would be essential as a nurse. Further, collaborating with others requires skills on how to resolve conflicts.

Health and Safety Issues

Nurses working on clinical and primary care settings have some health and safety issues to consider. For example, nurses assigned to patients who are immobile often have to handle these patients manually. Failure to properly handle patients could lead to health issues such as musculoskeletal injuries (Cornish and Jones, 2007; Powell-Cope et al., 2014). The rising incidence of musculoskeletal injuries (Powell-Cope et al., 2014) is a cause of concern since guidelines are available for nurses and students on how to properly handle patients manually. Yet, it has been shown that adherence to these guidelines is not optimal for both students and registered nurses (Powell-Cope et al., 2014). This suggests that translating evidence and uptake of guidelines in actual practice still remains to be low despite aggressive implementation of these guidelines in clinical practice. Health and safety issues are often influenced by the culture present in the clinical setting (Powell-Cope et al., 2014). For instance, student nurses who observe registered nurses not following policies or guidelines might assimilate this bad practice once they become registered nurses (Cornish and Jones, 2007).

Apart from developing musculoskeletal injuries, nurses who work long hours are also at risk of nursing burnout. It has been shown that nursing burnout is associated with lower job satisfaction (Mrayyan, 2006). This in turn affects the psychological health of the nurses, their interaction with patients and reduces the quality of care they provide to their patients (Mrayyan, 2006). Hence, it is essential to consider the number of nursing staff and whether this could support the current needs of patients in healthcare settings. Further, nursing burnout also indirectly affects nursing-patient ratio since nurses who report burnout are more likely to leave their jobs (Mrayyan, 2006; Wong et al., 2013). This could lead to a high turnover of nursing, which in turn, affects the quality of care received by the patients.

Another important health and safety issue in healthcare setting includes percutaneous and needle-stick and sharp injuries. This health issue is related to poor compliance to universal precaution (Jacob et al., 2010). This is challenging since studies (Gershon et al., 2009; Jacob et al., 2010) have shown that nurses tend to report high knowledge and awareness on universal precaution. The risk associated with failure to observe universal precaution when handling sharp objects in clinical settings include increased risk of acquiring HIV infection, Hepatitis B and C (Mark et al., 2007; Elder and Paterson, 2007). Reporting of injuries is also crucial in maintaining the safety of nurses in clinical settings. However, current data on this type of injuries might not truly reflect actual practice since underreporting is often noted in published studies (Gershon et al., 2009). For instance, Gershon et al. (2009) report that 45% of percutaneous injuries were not reported. The incidence of percutaneous injuries highlights the need for consistent training of the nurses.

Job Opportunities

Nurses in Ireland have many job opportunities as demand of healthcare increases. Incidence of long-term conditions such as obesity, diabetes and heart diseases have increased in the last few decades (DHSSPS, 2012). This requires specialist care from nurses. Further, the ageing population also means that individuals are living longer and hence, might require additional care to ensure longevity or address chronic conditions that affect older persons (DHSSPS, 2012). Newly registered nurses could acquire experience and develop to become specialists in their respective fields. For example, there is a need for specialist nurses such as diabetes nurses to manage patients suffering from type 1 and type 2 diabetes. On the other hand, mental health nurses are required in community and clinical settings to manage patients suffering from schizophrenia, depression, postpartum psychosis, depression and other mental health conditions. Learning disability nurses provide support and care management to patients and their families suffering from learning disabilities. Meanwhile, paediatric nurses provide care to paediatric patients.

Nurses could also choose to specialise to become part of surgical theatre teams. Others could also opt to become mentors, cardiology nurses or respiratory specialists. Nurses who are now specialists could also choose to further hone their skills and qualify as a nurse prescriber. These nurses could prescribe medications from their own field of specialty only (Nursing and Midwifery Board of Ireland, 2015). It has been shown that inclusion of nurse prescribers allow continuity of care and higher patient satisfaction (Nursing and Midwifery Board of Ireland, 2015). Patients report that they are also satisfied with the type of care they receive from nurse prescribers and view them as showing more empathy and sensitivity to their situations. However, it should be noted that nurses who choose to become specialists or nurse prescribers have to engage in continuing professional development, earn a Master’s degree in nursing or continue to train in their respective fields. Hence, learning is seen as continuous when an individual engages in the nursing profession. Since this is a caring profession, nurses are also expected to show empathy and compassion to their patients. These characteristics are often honed as nurses become highly specialised in their chosen fields.

Conclusion

Nursing is a caring profession that aims to provide quality, patient-centred care to the patients. Preparing to become a registered nurse in Ireland requires earning a nursing degree. The path to becoming an effective nurse begins in the nursing student years. Developing attitudes such as empathy, compassion, responsibility and accountability and practical skills such as numeracy skills could all promote quality care. As patients perceive their nurses to reflect these attitudes and skill, they would be reassured that their nurses truly care and are willing to manage their health condition. This essay also argues the importance of developing communication skills in order to identify the needs of the patient and introduce early interventions. However, becoming a nurse is also challenging because of health and safety issues. These include the risk of musculoskeletal, percutaneous and needle-stick injuries. Some nurses, due to a low nurse-patient ratio, may also suffer from nursing burnout. Once this occurs, this might lead to poor job satisfaction and high nursing turnover. Quality of patient care is affected when there are fewer and dissatisfied nurses. Finally, this essay shows that there are many job opportunities for nurses in Ireland.

References

Bach, S. & Ellis, P. (2011) Leadership, Management and Team Working in Nursing. Exeter: Learning Matters.

Cornish, J. & Jones, A. (2007) ‘Evaluation of moving and handling training for pre-registration nurses and its application to practice’, Nurse Education in Practice, 7(3), pp. 128-134.

Department of Health, Social Services and Public Safety (2012) Living with long term conditions: A policy framework. Dublin, Ireland: Department of Health, Social Services and Public Safety.

Eastwood, KJ, Boyle, MJ, Williams, B, & Fairhall, R (2011) ‘Numeracy skills of nursing students. Nurse Education Today. 31(8) November. pp. 815-818.

Elder, A. & Paterson, C. (2006) ‘Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices’, Occupational Medicine, 56 (8), pp. 566-574.

Gershon, R., Pearson, J., Sherman, M., Samar, S., Canton, A. & Stone, P. (2009) ‘The prevalence and risk factors for percutaneous injuries in registered nurses in the home health care sector’, American Journal of Infection Control, 37(7), pp. 525-533.

Houghton, A. & Allen, J. (2005) ‘Doctor-patient communication’, British Medical Journal Career Focus, 330, pp. 36-37.

Jacob, A., Newson-Smith, M., Murphy, E., Steiner, M. & Dick, F. (2010) ‘Sharps injuries among health care workers in the United Arab Emirates’, Occupational Medicine, 6(5), pp. 395-397.

Kinnell, D. & Hughes, P. (2010) Mentoring Nursing and Healthcare Students. London: SAGE.

Kourkouta, L. & Papathanasiou, I. (2014) ‘Communication in nursing practice’, Materia Socio Medica, 26(1), pp. 65-67.

Mark, B., Hughes, L., Belyea, M., Chang, Y., Hofmann, D., Jones, C. & Bacon, C. (2007) ‘Does safety climate moderate the influence of staffing adequacy and work conditions on nurse injuries?’, Journal of Safety Research, 38(4), pp. 431-446.

Mrayyan, M. (2006) ‘Jordanian nurses’ job satisfaction, patients’ satisfaction and quality of nursing care’, International Nurse Review, 53(3), pp. 224-230.

Nursing and Midwifery Board of Ireland (2014) The Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives. Ireland: Nursing and Midwifery Board of Ireland [Online]. Available from: http://www.nursingboard.ie/en/code/new-code.aspx (Accessed: 15 June, 2015).

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Introduction

This essay will discuss how play therapy improves the cognitive and social functions of young children. A brief review of child development theories and how these underpin play therapy will be done. A critical analysis of published literature on play therapy and its impact on child development will then be presented. Finally, a conclusion summarising the key points raised in this essay will be presented.

Child Development Theories and Play Therapy

Piaget’s theory proposes that cognitive development of children occurs in four stages: sensorimotor, preoperational, concrete operational and formal operational stages (Nevid, 2008). Piaget observes that very young children engage in general patterns of behaviour once they are at play. These include being fascinated with objects, covering objects, filling or emptying containers, transporting objects and connecting them together. Crowley (2014) explains that these behaviours are known as schemas. As children assimilate new experiences and accommodate learning, these schemas will help them to make sense of the world around them (Crowley, 2014). Hence, allowing children to play and explore will help them develop a schema of their environment (Keenan and Evans, 2009). Piaget’s theory helps to underpin play therapy since it acknowledges that play will help children to construct knowledge and develop cognitive abilities. For instance, in the sensorimotor stage, providing children with a treasure basket will expose very young children to a wealth of sensory stimuli (Shaffer and Kipp, 2009). In turn, this will promote cognitive development as children become acquainted with different sounds, shape, colour, taste and texture of toys. Children, according to Piaget, develop through assimilation or through using an existing schema to make sense of a new situation or object (Shaffer and Kipp, 209). This is then followed by accommodation when existing schema has to be changed in order to deal with a new situation. As children continue to develop, new information is quickly assimilated based on existing schema. Piaget explained that equilibrium is reached when children learn to deal with new information through assimilation. Meanwhile, Vygotsky’s theory proposes that social interaction is crucial in the cognitive development of children (Shaffer and Kipp, 2009). He suggests that social, linguistic and interpersonal factors all play a role in the mental development of children. In this theory, social interaction during play is critical in developing cognitive learning. It has been shown that during play, social skills are developed along with skills on problem solving (Keenan and Evans, 2009).

Critical Review of Play Therapy

Play has long been recognised as crucial in the healthy development of children (Ray, 2011). However, it was only in the 1900s when therapeutic settings began using play as a means for young children to express their emotions and feelings. Early proponents of play therapy include Melanie Klein and Anna Freud (Ray, 2011). They used play to help analyse childrens’ behaviour, feelings and responses to events or situations. Both early scholars used play to help children communicate non-verbally. Today, child-centred play therapy is widely accepted as a means of helping children resolve or prevent psychological and social difficulties and in helping them to achieve optimal development (Keenan and Evans, 2009). A meta-analysis (Bratton et al., 2005) on the efficacy of play therapy reviewed and pooled data from 94 studies that investigated play therapy outcomes. Forty-two of these studies were published in peer-reviewed journals while 50 were unpublished dissertations. Two of the articles were from the Education Resources Information Center (ERIC) database. Studies included in the meta-analysis utilised the comparison or control-group design or pre and post-treatment measures. Treatment effect was calculated after pooling data from these studies.

Findings of the study reveal that the effect of play therapy on different treatment outcomes ranges from 0.66 to 0.84. According to Cohen’s guideline for interpretation of treatment effect, a value of 0.80 suggests a large treatment effect (Ellis, 2010). This suggests that play therapy is effective in managing behavioural and emotional difficulties in children. Although duration of treatment varies, findings suggest that 35-40 sessions of play therapy significantly improved treatment outcomes. Findings also appear to suggest that positive outcomes declined with prolonged sessions. For instance, findings suggest that positive outcomes declined after multiple sessions (40 sessions). This suggests that findings should be taken with caution in determining whether long-term play therapy is effective. In contrast, children ending play therapy prematurely or engaging in less than 14 sessions of therapy did not show positive treatment outcomes compared to children who completed 35-40 play therapy sessions. Meanwhile, investigators of the study failed to mention the average number of hours for each session. This could have provided important information on how long each session should last. Findings also show that gender and age were not significant predictors of the treatment outcomes, suggesting that this type of therapy is equally effective for boys and girls and across all ages of the children. Although the study shows equal effectiveness of play therapy for different age groups, this intervention might be more successful in younger children. Since play therapy is considered as sensitive to the development stage of the children (Nevid, 2008), it is reasonable to apply this form of therapy to younger children while older children might benefit more from traditional talk therapies (Bratton et al., 2005). The study also suggests that when parents are trained to partner with healthcare professionals in conducting play therapy, the treatment effect of play therapy significantly increased when compared to therapy conducted by professionals alone. Hence, when supervised by healthcare professionals and therapists, the involvement of parents would result in the greatest benefit.

A meta-analysis allows pooling of data from studies with small sample sizes and hence, insufficiently powered (Polit et al., 2013). It should be noted that small studies are often rejected for publication due to sample size or once published, have limited applicability due to insufficient treatment effect (Polit et al., 2013). Hence, a meta-analysis would be able to address this issue since findings are pooled (Ellis, 2010). A review of the study of Bratton et al. (2005) reveals that all resources for both published and unpublished studies were exhausted to avoid publication bias (Burns and Grove, 2013). Further, investigators only included studies that reported statistics and have sound methodological procedures. Further, the study was able to establish that play therapy could be an agent in changing children’s behaviour, help them adjust socially and adapt to a group in order to fit in. Likewise, play therapy also appears to be uniquely responsive to the children’s developmental needs. However, play therapy was compared only to no intervention, making it difficult to establish if play therapy is the most effective intervention for children’s behavioural, social and cognitive difficulties. Comparing play therapy with other form of interventions might help to provide more information on its effectiveness in improving the behaviour of children.

Apart from promoting positive treatment outcomes, play therapy also facilitates social competence and problem solving skills in preschool children (Stone and Stark, 2013; Chinekesh et al., 2014). Stone and Stark (2013) reveal that short-term therapy groups were shown to facilitate development amongst 3-5 year old preschool children. Findings are noteworthy since it has been suggested that very young children are not yet developmentally prepared to engage in a group process (Stone and Stark, 2013). However, findings of the study suggest that very young children are able to participate in structured play therapy. Further, they benefit from these structured plays as evidenced in improvements in their social skills. Meanwhile, Chinekesh et al. (2014) investigated the effects of play therapy on children’s emotional and rational skills. A total of 372 pre-school children were recruited in the study and randomly assigned to the group play therapy and control group. Pre and post-tests were done to compare the children’s self-regulation, self-awareness, empathy, social interaction and adaptability before and after the intervention. Findings between case and control groups were also compared. Results of the study suggest that play significantly improved the children’s social and emotional skills (p0.001). Further, Chinekesh et al. (2014) observe that play therapy could help improve the children’s ability to learn problem-solving skills and communicate with other children. Providing an environment where children are engaged in unstructured play would help them develop their social skills as they learn to interact with other children (Chinekesh et al., 2014).

Play therapy has also been shown to improve outcomes among children with disabilities. For instance, the studies of Abdollahian et al. (2013); Kasari et al. (2012); Wilkes-Gillan et al. (2014); Cantrill et al. (2015) have similar findings and suggest that play therapy is effective in improving social play skills of children with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). For instance, Kasari et al. (2012) suggest that play therapy could help improve the language skills and communication of children with ASD. This was a longitudinal study and followed preschool children who received early play therapy intervention. During the 5-year follow-up, children who received play therapy were more likely to have better language skills. The strength of a longitudinal outcome is its ability to show patterns regarding how play therapy improves the social and cognitive skills of children over time (Ellis, 2010). However, panel attrition might affect the findings of a longitudinal study (Gray, 2009). Panel attrition could occur if several members of a cohort decide to drop out or are unable to participate during the last stages of the study. In addition, play therapy (Abdollahian et al., 2013) has been shown to be effective in reducing symptoms associated with ADHD. Abdollahian et al. (2013) emphasise that play therapy would be effective in managing symptoms associated with ADHD. Meanwhile, Cantrill et al. (2015) point out that children’s social play skills are further enhanced when parents are involved in the delivery of the therapy. A third study (Wilkes-Gillan et al., 2014) suggests that social play outcomes of children with ADHD significantly improved following play therapy. Although this study has a small sample size (n=5 children with ADHD), it was able to demonstrate preliminary efficacy.

In summary, recent literature has shown that play therapy consistently promotes positive outcomes for children with or without disabilities. Specifically, it promotes social and cognitive skills in very young children and could be used as a method to prepare these children for transition from kindergarten to infant school. The effectiveness of play therapy is also not influenced by gender and age, suggesting its effectiveness for both boys and girls and those in the younger or older age group. However, the impact of play therapy appears to be greatest amongst younger age children. This form of therapy could also be used to improve language skills in children suffering from autism (Kasari et al., 2012). Literature also demonstrates that the participation of parents significantly enhances the effectiveness of play therapy. This suggests that parents should be involved to facilitate sustained positive outcomes in children.

Conclusion

Play therapy could help to improve both social and cognitive functions of children with or without disabilities. Hence, there is a need to provide children with a safe environment that would allow them to play and interact with other children. While most studies reviewed in the present essay used play therapy as treatment for behavioural and social difficulties, play therapy could also be used for children without disabilities. Specifically, it can be used for preschoolers to help them develop their social and cognitive skills. As Vygotsky’s theory suggests, social development would help children develop mentally. Hence, promoting play therapy amongst young children with no disabilities would not only help to develop their social skills but also their cognitive skills. Finally, play therapy could also promote social and cognitive skills in children with disabilities such as ADHD and ASD. It is recommended that play therapy should be introduced into preschool settings for better outcomes for children. It is also recommended that parents should be involved in order to enhance the impact of play therapy. Hence, there is a need to train parents on how to deliver this type of therapy on their children.

References:

Abdollahian, E., Mohkber, N., Balaghi, A. & Moharrari, F. (2013) ‘The effectiveness of cognitive-behavioural play therapy on the symptoms of attention-deficit/hyperactivity disorder in children aged 7-9 years’, Attention Deficit and Hyperactivity Disorders, 5(1), pp. 41-46.

Bratton, S., Ray, D. & Rhine, T. (2005) ‘The efficacy of play therapy with children: A meta-analytic review of treatment outcomes’, Professional Psychology: Research and Practice, 36(4), pp. 376-390.

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Wilkes-Gillan, S., Bundy, A., Cordier, R. & Lincoln, M. (2014) ‘Eighteen-month follow-up of a play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder’, Australian Occupational Therapy, 6(15), pp. 299-307.

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Australia has a large and expanding population of people from a refugee background – referred to as ‘refugees’. Refugees in general, and refugee women in particular, have distinctive and diverse health needs which require complex and conscientious responses from nurses and health systems. In the context of nursing refugee women in Australia, this paper will explore the need for cultural safety in nursing. It will then analyse the negative impacts of culturally unsafe nursing practices and health systems in Australia on refugees and refugee women. Finally, it will discuss how culturally safe nursing practice can (and should) be achieved in Australia to improve the health outcomes of refugee women and others of diverse backgrounds.

The Nursing Council of New Zealand (2002: p. 7), which developed the concept of cultural safety, defines it as “the effective nursing … [care] of a person or family from another culture, [as] determined by that person or family”. Fundamentally, culturally safe nursing practice focuses on supporting diverse people to effectively access and engage with mainstream ‘biomedical’ health systems, and so reducing the high rates of poor physical and psychological mental health outcomes in these populations (Johnstone & Kanitsaki, 2007). Culturally safe nursing practice achieves this by attempting to deconstruct the inequitable power relationships between patients and health providers and systems, which are a significant barrier to health access and engagement for socio-culturally vulnerably groups (Anderson et al., 2003; Woods, 2010). This is achieved through a focus on culture. However, culturally safe practice does not involve nurses learning others’ cultures; indeed, diversity both between and among cultures is too significant to allow a nurse to do this meaningfully (Woods, 2010). Instead, culturally safe nursing involves a nurse reflecting on their own culture and on the legitimacy of others’ cultures in the context of the nursing care they provide (Mortensen, 2010). Belfrage (2007) notes that ‘cultural safety’ underpins the provision of the most effective health practice and systems for diverse groups in Australia. This is particularly true in the context of refugee health.

The United Nations’ 1951 Refugee Convention, Article 1(A)2, defines a refugee as any person residing outside their country of nationality or residence due to fear of persecution (UNHCR, 2015). As a signatory to this Convention Australia has an obligation to assist with the resettlement of refugees, including a special category of refugees referred to ‘women at risk’ (Australian Law Reform Commission, 2015; Parliament of Australia, 2015b). In 2013-14, Australia resettled a total of 6500 refugees, approximately 3.2% of its total migrant intake (Parliament of Australia, 2015b). The majority of these refugees were from Afghanistan (39%), with significant numbers also from Myanmar (18%) and Iraq (13%) (Parliament of Australia, 2015b). In response to the Syrian refugee crisis, in 2015-16 Australia will significantly increase its intake of refugees within existing humanitarian quotas (Parliament of Australia, 2015a). Under the Migration Regulation 1994 Australia allocates 12% of its humanitarian quota to ‘women at risk’, and in 2013-14 granted over 1000 visas to women at risk (Parliament of Australia, 2015b). This program highlights the fact that refugee women are particularly vulnerable to the effects of conflict and persecution (Federal Minister for Women, 2014).

Refugees in general, and refugee women in particular, have “unique and diverse health profiles” (Hadgkiss & Renzaho, 2014: p. 157). Though refugees make up a very small part of the overall Australian population, it is essential that nurses are aware of refugees’ health needs and their complex sociocultural determinants if culturally safe health care is to be provided. In a seminal work on refugee health in Australia (examining the health of refugee children specifically), Davidson et al. (2004) report that a significant number of refugees arrive in Australia with complex health needs. The psychological issues experienced by refugees are well-recognised. Exposure to trauma leaves many refugees – up to 60% in one Australian study – with complex psychological sequelae, including impairments to memory function and debilitating dissociative reactions (Alvin Tay et al., 2013). Nickerson et al. (2014) reports that up to 25% of refugees receive a psychological diagnosis of Post-Traumatic Stress Disorder (PTSD), and 16% of these people also have disorders related to grief. Costa (2007) highlights that refugee women in particular face an increased risk of psychological morbidity related to trauma underpinned by conflict, persecution and forced resettlement. For example, one study found that the gender discrimination experienced by a large number of refugee women is positively correlated with increased incidence of traumatic disorders (including PTSD) and increased risk of suicidality (Kira et al., 2010). It is important to note that issues related to gender, including roles and access, may also limit a refugee woman’s health-seeking behaviours related to mental illness (O’Mahony & Donnelly, 2013).

In addition to mental illness, a large number of refugees – up to 77% in some reports – also experience physical illness; indeed, Hadgkiss and Renzaho (2014) note that poor mental health is strongly correlated with poor physical health in refugee populations. Physical illnesses which are particularly prevalent in refugee populations include dental disease, non-specific migraine, musculoskeletal pain and disorders of the integumentary, respiratory and gastrointestinal systems (Hadgkiss & Renzaho, 2014). There is also a high prevalence of infectious disease in refugee populations, including human immunodeficiency virus (HIV), active tuberculosis, Hepatitis B and C and chronic gastrointestinal infections (Hadgkiss & Renzaho, 2014). Costa (2007) notes that refugee women are disproportionately affected by nutritional deficiencies and anaemia, and a sequelae of physical and psychological issues related to gender-based violence. Refugee women experience higher rates of complex gynaecological and obstetric conditions, are more likely to have been sexually assaulted and are more likely to have had an unwanted pregnancy and / or abortion than other women in host countries (Goosen et al., 2009; Kurth et al., 2010).

The myriad of complex health issues faced by refugees highlights the importance of host countries’ health systems being responsive to refugees’ health needs through the provision of culturally safe care and services. However, there is evidence to suggest this is not being achieved in the Australian context; indeed, Johnstone and Kanitsaki (2007) conclude that cultural safety is both poorly understood and lacks currency in Australia’s mainstream health contexts (Johnstone & Kanitsaki, 2007). This leads to culturally unsafe nursing practices. The Nursing Council of New Zealand (2002: p. 7) define this as “compris[ing] any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual”, either overtly and intentionally or otherwise.

There are many examples of culturally unsafe practice relating to refugees in the Australian context. For example, many refugees, both in Australia and elsewhere, perceive themselves to be discriminated against by health staff in their host countries – a key aspect of culturally unsafe practice. Multiple studies report on such issues – including refugees’ perceptions of denial or provision of poorer-quality care on the basis of race and / or immigration status (Bhatia & Wallace, 2007; O’Donnell et al., 2007; O’Donnell et al., 2008; Wahoush, 2009; Bernardes et al., 2010; Kokanovich & Stone, 2010; Asgary & Segar, 2011). This is particularly problematic in terms of the provision of mental health services for refugees in Australia; indeed, Newman et al. (2008) highlight that Australian health workers frequently devalue and deligitimise refugees’ experiences of mental illness – for example, by dismissing the self-harm behaviours of refugees in immigration detention as being politically-motivated. Hadgkiss and Renzaho (2014) report a high level of ‘medical mistrust’ among refugee populations, underpinned by issues such as a fear of financial exploitation and that health information will be used to inform decisions about asylum status (Kokanovic & Stone, 2010; Asgary & Segar, 2011). Covert institutional racism is recognised to be a significant problem in Australian health settings, and this is underpinned by the prejudicial and discriminative attitudes towards refugees which are pervasive in wider Australian society (Henry et al., 2004; Davidson et al., 2008; Johnstone & Kanitsaki, 2008). This ‘systemic trauma’ compounds the health issues of refugees settled in Australia, and is a particular problem for women. Indeed, one Australian study found that women with vulnerabilities related to social adversity were substantially more likely to experience inequalities in health access (in this study, in the context of perinatal care specifically) (Yelland et al., 2012).

In addition to culturally unsafe nursing practices, the provision of culturally unsafe health services is a particular problem for refugees in Australia. As noted by Renzaho et al. (2013) the health systems in host countries are often poorly-equipped to manage the complex health, linguistic and cultural needs of refugee populations (Renzaho et al., 2013). It is well-recognised that Australia’s mainstream biomedical health system is highly Eurocentric, disempowering because of its exclusivity and repressive of the fundamental social dimensions of health (Willis & Elmer, 2007). Additionally, the biomedical model of health may be incompatible with refugees’ diverse perceptions of health, focusing instead on a limited ‘pathological’ definition of disease and a reductionist distinction between physical and mental health (Willis & Elmer 2007). Again, this is particularly problematic in terms of the provision of refugee mental health services; for example, Savy & Sawyer (2008) present evidence for the considerably limited culturally safe treatment options in Australia for refugees suffering acute mental illness. These issues may result in refugees’ exclusion from or disengagement with health services (Correa-Velez et al., 2013). Indeed, there is evidence to suggest that refugees’ engagement with health services is poor; in a European study, Bischoff et al. (2009) found that refugees attend far fewer than the average number of consultations, and that their cost to the health system of their host country was just half that of others in host countries. There is minimal current data available on the engagement of refugee women specifically with health services; however, one study suggests that refugee women are 40% less likely than other women in host countries to attend health screening (in this case for Papanicolaou testing, a common screen for cervical cancer) (Rogstad & Dale, 2004). Refugees’ exclusion from and disengagement with health services feeds into the cycle of poor physical and mental health outcomes in this population.

Woods (2010) notes that nurses have a critical role to play in deconstructing the power imbalances which exist between patients and health providers, and which often result in the provision of culturally unsafe care – thereby promoting refugees’ access to and engagement with health services in a culturally safe way. The Nursing Council of New Zealand (2002: p. 7) highlights that culturally safe nursing practice is underpinned by nurses “hav[ing] undertaken a process of reflection on [their] cultural identity and … recognis[ing] the impact that [their] personal culture has on [their] professional practice”. Here, the notion of ‘culture’ extends beyond the traditional definition of the term as a system of worldviews, value systems and lifestyles based on shared race or ethnicity, and instead ‘culture’ is considered as a complex, changing concept underpinned by factors such as individual experiences, gender and social position, etc. (Woods, 2010). It is important to note that achieving culturally safe nursing is an ongoing process of continuous reflection (Ogunsiji et al. 2007). Given the covert but pervasive negative views of refugees in Australian health systems and wider society (Henry et al., 2004; Davidson et al., 2008; Johnstone & Kanitsaki, 2008), reflecting on one’s own culture in this way is a particularly important aspect of providing culturally safe health care to refugees.

In addition to reflecting on their own culture, a nurse must also reflect on the cultures of others – but should do so in the context of cultural relativism. Cultural relativism is a sociological theory which posits that all cultures are, and therefore must be recognised as, equally valid and legitimate forms of human expression (Kottak, 2004). Cultural relativism is particularly important when caring for refugees, including refugee women, who engage in unfamiliar and challenging health practices, one example of which is ritualised genital cutting (also referred to as ‘female genital mutilation’). Many refugee women from parts of Africa and the Middle East perceive genital cutting to be an important cultural practice and fundamental to their identity, role and beliefs, however the mainstream biomedical health system in Australia denounces and reproves the practice (Ogunsiji et al. 2007). If such issues are not dealt with sensitively and approaches – from both nurses and the health system – balanced through the application of principles of cultural relativism, refugee women may disengage from health services (Ogunsiji et al. 2007). As noted, disengagement drives the cycle of poor physical and mental health outcomes for refugees in Australia.

Australia has a large refugee population which is predicted to increase significantly in the coming years. Refugees in general, and refugee women in particular, have distinctive and diverse health needs which require complex and conscientious responses from nurses and health systems. In the context of nursing refugee women in Australia, this paper has explored the need for cultural safety in nursing. It has also analysed the negative impacts of culturally unsafe nursing practices and health systems in Australia on refugees, with a focus on refugee women. Finally, it was discussed how culturally safe nursing practice can (and should) be achieved in Australia to improve the health outcomes of refugee women and others of diverse backgrounds.

References

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Johnstone, MJ & Kanitsaki, O 2007, ‘An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context’, Journal of Transcultural Nursing, vol. 18, no. 3, pp 247-256.

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This work was produced by one of our professional writers as a learning aid to help you with your studies

The National Health Service is the universal medical care provider for residents of the UK. The principles it was originally developed upon ensured the service was provided free to meet everyone’s clinical need (NHS, 2013). This ethos is still at the core of its delivery, but additional principles have been added to its constitution to improve quality standards and to provide the public with rights as an NHS patient (Department of Health, 2012). Thus, for health professionals and the wider NHS workforce to achieve these principles, the patient needs to be central to the delivery of their healthcare. Therefore, the focus of this essay will be to explore the relationship between a positive NHS culture and increased quality of patient care. In this essay the phrase ‘positive NHS culture’ has two definitions: 1) its internal organisational structure and the working environments of staff 2) the public and patients’ perception and experiences of the NHS as service users. Due to the limited word count of this essay, the following factors will only be discussed: multi-disciplinary working, patient engagement and the role of the media.

Within an organisation, a positive work culture is the key to successful delivery to its customers, clients, service users or patients. An inclusive workplace is constantly promoted by governing bodies, trade unions and human resource professionals because it allows for greater happiness to be achieved at work through the creation of a positive working environment (Equality and Human Rights Commission, 2010). This is because when professionals are respected and their skills are valued, they feel a sense of autonomy and purpose (West et al, 2011). Furthermore, this supportive environment can create trusting relationships amongst colleagues, which can result in a positive internal work culture. Oppositely, within an organisation where there is a lack of respect and trust, the service of the quality being delivered can become compromised. For example, cases have been identified where clinicians did not trust the medical judgments of fellow clinicians and this resulted in clinical assessments being repeated on patients (NHS Institute for Innovation and Improvement, 2010). This mistrust can result in creating more worry for the patient, a negative relationship between clinicians, an increased waiting time for the result of the assessment and possibly delaying NHS services to another patient and wasting NHS money.

It can be argued that this critical approach by one clinician can ensure the diagnosis of a patient is correct; however as the UK has a high standard in its medical education progammes, the knowledge of another clinician should be respected. Also, there are other processes to ensure the diagnosis and treatment/care of the patient is suitable and of a high quality through regular discussions with allied health professionals who have been trained in a varied way to meet specific service areas. This allows alternative methods and treatments to be discussed and leads to better quality decisions on patient care (Borrill et al, 2002).

Multi-disciplinary working is essential for a large organisation like the NHS, who aim to provide healthcare for everyone regardless of what health and well-being support or treatment is needed by the patient (NHS Institute for Innovation and Improvement, 2010). It allows professionals to efficiently manage their times and reduce patient waiting times, and more importantly it ensures the patient is receiving care from the relevant expert. Multi-disciplinary working could in the future challenge the entrenched feature of ‘waiting times’ in the NHS healthcare system. It is often accepted by NHS professionals that it is normal for a patient to wait to be seen: this indirectly disrespects the status and clinical need of the patient, suggesting that their time is less valuable than the healthcare professional’s time (Leape et al, 2012).

Over time, a blame culture has developed within the NHS when poor quality of care has been delivered, or more extremely when a number of fatal cases have been reported within one trust. Multi-disciplinary working is used to promote a team effort in high quality care and it is also used to challenge and prevent poor quality care (Berwick and Department of Health, 2013). To ensure poor standards are not accepted, patient partnerships need to be created to allow patients to participate in planning future NHS care improvements. Furthermore, if healthcare professionals communicate with patients in a method which allows them to understand jargon and medical information related to their health condition, this can then empower them to make suitable decisions in regards to their healthcare (Leape et al, 2012). Furthermore, the patient may become confident enough to comment on their healthcare and also feel respected and comfortable in the medical environment which they are being treated within, hence positively influencing their perception of the NHS.

To further support the comfort patients’ feel when using the NHS services, practitioners need to have a level of emotional intelligence as well as the intellectual ability to provide high quality care. This is because ‘good health’ is a combination of mental, physical and social well-being (WHO, 1946). Intellectual ability is usually identified and revisited often in a practitioner’s healthcare training because it is thoroughly assessed. However, emotional intelligence differs within training depending on the role of the practitioner. Also, trainers of technical skills would argue it is not easy to teach emotional intelligence because it is often connected to an individual’s personality/character and the events they have experienced throughout their own personal life (Tapia and Hyter, 2015). Nursing staff initially deal with difficult patient situations where emotional intelligence is essential to solve or ease the patient’s situation. Therefore, showing care and compassion towards the patient often shows the patient they are being supported, hence improving the patient’s satisfaction towards the support offered by the nurse (Ruddick, 2015).

Media are used globally to reach a mass audience. Therefore, the NHS uses the mass media to reach a national audience for their health campaigns. Cutting down the number of smokers in the country is still a high priority to improve public health (NICE, 2015). The NHS using media campaigns for smoking cessation services, and the advice these provide has resulted in an overall positive effect for the incentive, due to the campaign reaching a mass audience (NHS Institute for Innovation and Improvement, 2013). This has been due to the development of diverse and creative advertisements being produced and made available freely to healthcare professionals, organisations and the public (NHS, 2015). These advertisements are not for online or television use only: they are often displayed or given in physical environments where patients and practitioners are present, hence making the delivery of patient care more interesting and more effective in tackling negative habits such as smoking. The extent of influence that the media has on its audience, and their thoughts and beliefs on specific topics, depend on a variety of factors; hence one single theory cannot sum up the impact of media.

Using the media to acknowledge successful NHS services is important because often the media report investigations or organisational changes. For example, the BBC reported that over 40% of NHS investigations are not carried out adequately (BBC, 2015). This suggests that the culture of the NHS is one that fails to handle a large number of patient complaints appropriately; the complaint of a patient often suggests that there was a negative event when receiving healthcare within the NHS such as medical negligence. Therefore, failing to acknowledge this can further deteriorate the perception of the NHS to the patient. Furthermore, due to the NHS being a healthcare provider it is expected by society to have a high standard service, yet the demands on the staff to provide this service is often forgotten (Griffin, 2014).

The NHS Practitioner Health Programme Team received the ‘Innovation in Mental Health in Primary Care’ award in 2014; this recognition of high quality practice was reported by various forms of media (NHS, 2014). The public were shown that these practitioners were successful and passionate individuals who were working to improve the Mental Health service within the NHS. Despite this not having a direct impact on the quality of patient care, it positively promoted the NHS and it also recognised that the mental health service in primary care was being recognised as innovative. Healthcare professionals can further promote the NHS culture as positive by using social media to engage with a larger public audience and also to connect with other healthcare professionals by increasing their participation in discussions on healthcare knowledge and alternative techniques (Cooper and Craig, 2013). This engagement can promote self-help techniques to patients and support them to manage their conditions. Self-help and self-care of conditions can reduce hospital admissions, hence directly impacting the number of patients waiting in Accident and Emergency departments, which can then allow clinicians to have more time with patients (The King’s Fund, 2010).

To summarise, patient experience is central to the quality of patient care. It seems a positive NHS culture is at the core of positive patient experience because it supports the development of relationships between the patient and the healthcare professional: this then can allow the patient to express their thoughts on the healthcare being delivered to them. In addition to this, trusting and respectful relationships can be created between professionals, who can then apply successful multi-disciplinary working to make the quality of care sufficient to meet service demands yet of a high personalised standard for each patient. Sadly, there are constraints in creating a highly positive NHS culture due to the demands put on the NHS service, diverse training of staff and the influence of the media.

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Since the pioneering experiments of allograft heart transplantation by Christiaan Barnard in 1967, there have been significant advances in the development of human organ transplantation. Indeed, over 35,000 patients in both the US and Europe benefit annually from organ transplantation (Hampton, 2005). Through the transplantation and engraftment of these organs, not only can biological function of organs be restored, but also the quality of life of recipients can be greatly increased. As a result the number of transplantation operations carried out each year has increase exponentially over the past decades. Despite improvements in surgical techniques, the hurdle of immunological rejection by the host of transplanted organs still remains a current obstacle. This represents a challenge both scientifically and clinically and, as a result, is a focus of both the medical and scientific communities.

Over the past 60 years, there has been an exponential increase in the development of immunosuppressive drugs in order to treat organ rejection, as well as autoimmune diseases (Gummert et al. 1999). These drugs seek to suppress various components of the immune system in order to prevent rejection in the context of organ transplantation. This essay seeks to examine the broad immunology of transplantation as well as the different classes of immunosuppressive drugs and their associated benefits and side effects.

Transplantation is broadly defined as the act of transferring cells, tissues, or organs from one site to another. In the context of organ transplantation, this is generally from one person to another, with transplantation classed as either from a living donor or cadaveric. Although less common, there has been some attempt to transplant organs from other animals, known as xenografts. This was initially attempted given the lack of availability of human donor organs. However, as transplantation occurs between two immunologically distinct persons, a degree of immunological mismatch occurs. Due to this mismatch, the host immune system recognises the donor organ as ‘foreign’ and, as a result, activates various arms of the immune system.

Several types of immune rejection can occur in individuals undergoing organ transplantation. Hyperacute rejection occurs when pre-existing antibodies within the host against donor antigens attack the graft and result in rapid rejection of the graft, typically within a few hours (Murphy et al. 2010). This results in rapid declining function of the graft and is often non-reversible, thereby causing the recipient to lose the graft. In contrast, acute rejection occurs within six months following transplantation and is the result of activated T cells against donor antigens (Murphy et al. 2010). The third type of rejection is known as chronic rejection and, as the name suggests, occurs years after transplantation and is mediated by both antibodies and T cells. In order to encourage graft survival, and prevent the aforementioned from occurring, effective regimes in order to suppress these immune responses have been developed, although as outlined, they often come with significant side effects.

Glucocorticoids, such as prednisone, are commonly used in immunosuppressive regimes. These drugs seek to prevent rejection by suppressing various arms of the immune system including T cells, B cells, macrophages, granulocytes and monocytes (Steiner and Awdishu, 2011). These drugs are, therefore considered to be relatively non-specific and highly potent leading to a range of side effects. Glucocorticoids exert their effects by regulating the activity and expression of various cytokines through inhibition of intracellular signalling pathways such as NF-kB. Through modulation of this complex signalling pathway, the production of pro-inflammatory cytokines such as IL-1, IL-6 and TNF-alpha are greatly reduced (Schacke et al. 2002). Although these drugs feature heavily in clinical practice, they are associated with a significant number of side effects. Prolonged glucocorticoid use can lead to Cushing’s syndrome: a constellation of symptoms characterised by increased central adiposity, ‘buffalo hump’, osteoporosis and a round face (Schacke et al. 2002). These symptoms are due to excess exogenous cortisol within the body and therefore have multiple endocrinological effects on various physiological processes. The concentration of such drugs are therefore closely monitored and patients are encouraged to monitor for symptoms suggestive of Cushing’s syndrome.

As well as glucocorticoids, drugs known as antimetabolites are frequently used in immunosuppressive regimes. These drugs, such as azathioprine and mercaptopurine, amongst others, were originally developed in the 1950s, but remain used to this day. Azathioprine is commonly used for liver and kidney transplantation (Germani et al. 2009), as well as for the treatment of autoimmune conditions such as rheumatoid arthritis (Whisnant and Pelkey, 1982). Antimetabolites exert their immunosuppressive effects by blocking the synthesis of purine within cells (Murphy et al. 2010). Through the blockage of purine synthesis, DNA replication is unable to take place, thereby preventing expansion of rapidly dividing cells within the immune system. Through the blockade of T and B cell expansion, the level of rejection against organ transplants can be controlled.

One considerable side effect associated with the use of azathioprine is the increased risk of skin cancer. A relatively recent review by Ulrich and Stockfleth (2006) has shown that sunlight exposure, pre and post transplantation in patients using azathioprine, correlates with an increased incidence of skin cancer. As exposure to UVA light damages skin cells: these cells are unable to undergo repair following damage, due to inhibition of DNA replication from azathioprine. In the long term, this accumulation of damage results in the increased propensity for patients to develop skin cancer. Current clinical guidelines suggest that clinicians discourage patients in spending prolonged periods of time in the sun following transplantation (Perrett et al. 2008).

Along with these classes, of drugs, another category of immunosuppressive medications, known as calcineurin inhibitors, also work efficaciously in organ transplantation. These drugs, which include tacrolimus and cyclosporine, act by inhibiting the protein calcineurin. Calcineurin in activated following the presentation of an antigen by an antigen presenting cell, such as a dendritic cell or macrophage, to a T cell, resulting from an increase in the concentration of intracellular calcium (Reynolds and Al-Daraji, 2002). Following the activation of calcineurin, there is an increase in the production of interleukin 2 (IL-2), which causes the activation of T cells. As a result, this further propagates an immune response. Calcineurin inhibitors are, therefore, useful in dampening an immune response, preventing the activation of T cells against a transplanted organ. Calcineurin inhibitors are popular drugs used in renal transplantation. However, evidence over the past decade has suggested that drugs such as tacrolimus may induce renal failure in some patients (Ponticelli, 2000). Obviously this a key consideration when considering patients who already have poor renal function to being with. As a result, these drugs are often combined with other immunosuppressive agents and tailored to the lowest dosage possible.

The understanding into the way in which the immune system functions has been exploited over the past thirty years with the development of monoclonal antibodies. Monoclonal antibodies were first developed in the 1970s through the fusion of rapidly proliferative myeloma cells with B cells to produce hybridomas (Liu, 2014). Antibodies are protein molecules that have a specific antigen-binding region enabling them to have a high degree of specificity. Antibodies have, therefore, been exploited therapeutically in order to target pathogenic molecules within the body.

Recently, monoclonal antibodies have been developed to target various components of the immune responses in order to modulate organ rejection seen in patients. In particular, monoclonal antibodies have been developed to target T and B cells. Some examples of these therapeutics are discussed below.

Muromonab is a monoclonal antibody, which is specific for cluster of differentiation 3 (CD3), a molecule found primarily on T cells (Murphy et al. 2010). By targeting T cells and preventing their activation against the transplanted organ, there is considerable evidence to show that this can significantly prolong the survival of the organ following transplantation, compared to glucocorticoid steroids (Authors not listed, 1985). However, despite the success of anti-CD3 therapy, there are substantial side effects associated with clinical use. Use of anti-CD3 has been associated with severe fever in patients, as well as the unwanted release of pro-inflammatory cytokines (Norman et al. 2000). As a result the use of anti-CD3 has declined in clinical practice and is reserved for treatment resistant cases of organ rejection.

As well as muromonab, another mainstay treatment for organ rejection are antibodies directed against cluster of differentiation number 25 (CD25). Organ rejection is heavily mediated by T cells, in combination with other arms of the immune system (Ingulli, 2010). When activated, T cells produce large amounts of IL-2, a cytokine that acts in an autocrine fashion to further expand T cells via the IL-2 receptor CD25. Therefore, blockade of CD25 with a monoclonal antibody was hypothesised to offer a novel target in treating immunological rejection by T cells. As a result, daclizumab was developed and was shown by Vincenti et al. in 1998 to be a successful tool in treating renal transplantation compared to using a combination therapy of cyclosporine, azathioprine and corticosteroids. Furthermore, more long term studies have examined the function of renal transplants and concluded that patients on daclizumab showed improved renal function, as established by estimated glomerular filtration rate (GFR) (Ferran et al. 1990). However, like other pharmacological treatments, daclizumab has also been shown to cause a significant number of side effects such as hypertension and insomnia (EPAR for Zenapax).

More recently, the scientific community has sought to develop more refined immunological tools in order to modulate rejection. Through the development of monoclonal antibodies targeting cluster of differentiation 52 (CD52), clinicians are able to target lymphocytes for destruction, sparing the destruction of resident haematopoetic stem cell populations (Flynn and Byrd, 2000). Anti-CD52 drugs were originally developed for multiple sclerosis (Coles et al. 2008) and trials are currently being undertaken to establish their efficacy in organ transplantation.

The overarching side effect with immunosuppressive regimes is the relatively blanket level of immunosuppression which they cause. Although immunosuppression is required to maintain organ survival, immunosuppression also results in a reduced ability to fight infections. In particular, pulmonary infections are common in organ transplant patients, with Hoyo et al. (2012) detailing that around 1 in 5 patients in their study developed pulmonary infections. It is clear that clinicians dealing with organ transplantation patients must remain vigilant for infections. It is similarly clear, therefore, that a fine balance of the level of immunosuppression should be reached: a heavily weighted level will pre-dispose to opportunistic infections, and, conversely, a lightly weighted level will result in organ rejection.

With respect to future outlooks in transplantation immunology, the development of pluripotent stem cells has been hypothesised to overcome immunological issues associated with organ transplantation. Through the use of induced pluripotent stem cells (iPS cells) developed by Takahashi et al. (2006) it has been shown that it is possible to differentiate nearly all existing cell types. As these cells are derived from the patient, they are immunologically matched to the individual and, as a result, patients would not require harsh immunosuppressive regimes. Although this technology has not been tested clinically in patients extensively yet, it is hoped that within the next twenty years this method will provide an unlimited source of organ replacement for patients. Use of such cells is currently being explored for regeneration of certain organs such as the heart (Masumoto, 2014). Use of these cells will require a significant amount of clinical testing to determine their immunological properties, as well as their propensity to develop into tumours. It is likely, therefore, that the clinical applications of stem cells are still many years away.

In conclusion, despite significant improvements in targeted immunosuppressive regimes, significant side effects are associated with current pharmacological treatments. Clearly, as patients treated with these agents are often susceptible to opportunistic infections, their progress must be monitored closely by a clinician who is familiar with such patients, and the complications they can present with. Through our increased understanding of the immune system, alongside new technologies such as stem cell replacement therapy, it is hoped that the immunological issues associated with organ transplantation will in the near future be overcome.

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