I Hopelessness, loss of meaning, and existential distress are proposed as the core features of the diagnostic category of demoralization syndrome. This syndrome can be differentiated from depression and is recognizable in palliative care settings. It is associated with chronic medical illness, disability, bodily disfigurement, fear of loss of dignity, social isolation, and-where there is a subjective sense of incompetence-feelings of greater dependency on others or the perception of being a burden. Because of the sense of impotence or helplessness, those with the syndrome predictably progress to a desire to die or to commit suicide. A treatment approach is described which has the potential to alleviate the distress caused by this syndrome. Overall, demoralization syndrome has satisfactory face, descriptive, predictive, construct, and divergent validity, suggesting its utility as a diagnostic category in palliative care. Me miserable! Which way shall I fly Infinite wrath, and infinite despair? Which way I fly is hell; myself am hell; So fareWell hope, and with hope farewell fear, Farewell remorse: all good to me is lost; Evil be thou my Good.

Objective: To explore the ways that patients and health professionals communicate about intimate and sexual changes in cancer and palliative care settings. Design: A qualitative study using a three‐stage reflexive‐inquiry approach, with semi‐structured, participant interviews (n = 82); textual analysis of national and international cancer and palliative care clinical practice guidelines (n = 33); and participant feedback at 15 educational forums for cancer patients or health professionals. Setting: A large Australian public teaching hospital between 2002 and 2005. Participants: 50 patients diagnosed with cancer, and 32 health professionals who had worked in cancer and/or palliative care for a minimum of 12 months. Main outcome measures: Communication about intimacy and sexuality: patients’ needs and experiences and health professionals’ attitudes and experiences. Results: There were mismatched expectations between patients and health professionals and unmet patient needs in communication about sexuality and intimacy. Most patients sought information, support and practical strategies about how to live with intimate and sexual changes after treatment for cancer, even if their cancer type did not affect fertility or sexual performance. In contrast, many health professionals assumed that patients shared their professional focus on combating the disease, irrespective of the emotional and physical costs to the patient. Health professionals overwhelmingly limited their understanding of patient sexuality to fertility, contraception, menopausal or erectile status. Many stereotypical assumptions were made about patient sexuality, based on age, sex, diagnosis, culture, and partnership status. There was a relationship between providing patient‐centred communication about intimacy and sexuality and health professionals’ understanding of their own attitudes and beliefs. Conclusion: Resources are needed to help health professionals engage in an exploration of their own definitions of intimacy and sexuality and understand how these affect interactions with patients with cancer.

This paper describes the participation of critical care nurses in ward rounds, and explores the power relations associated with the ways in which nurses interact with doctors during this oral forum of communication. The study comprised a critical ethnographic study of six registered nurses working in a critical care unit. Data collection methods involved professional journalling, participant observation, and individual and focus group interviews with the six participating nurses. Findings demonstrated that doctors used nurses to supplement information and provide extra detail about patient assessment during ward rounds. Nurses experienced enormous barriers to participating in decision-making activities during ward round discussions. By challenging the different points of view that doctors and nurses might hold about the ward round process, the opportunity exists for enhanced participation by nurses.

This pilot study investigated the relationships between stressors, work supports, and burnout among cancer nurses. One hundred and one registered nurses, employed at a major specialist oncology, metropolitan Australian hospital, completed self-report questionnaires measuring these constructs and provided responses to open-ended questions. The 50 listed stressors were experienced as sources of stress by more than 50% of the sample; most work support came from peers, rather than supervisor and organizational supports; and the overall level of burnout for the sample was moderate to low. Significant positive correlations were found between Stressors and the Emotional Exhaustion and Depersonalization subscales of the Maslach Burnout Inventory and a significant weak positive correlation between Peer Support and Personal Accomplishment (intensity). Findings are discussed in relation to developing strategies for reducing stress and burnout among cancer nurses, and directions for further study are suggested.

No abstract

While the body of nursing research in forensic psychiatry is growing rapidly, the therapeutic nurse-patient relationship in secure hospitals needs to be further examined. This paper reports on a research project that found two representations of the nurse-patient relationship in two male acute secure inpatient units. One representation was formed by the data collected from the unit nurses in semistructured interviews. The nurses valued the relationship and described their practice as therapeutic, however, evidence from the interviews would suggest that the nurses operate from a social frame of reference. Examination of the nurses 'entries in patients' case files formed the other representation. Through their documentation practices, nursing was represented as being oriented to custodial care. While neither representation can capture the clinical reality, these findings are relevant to forensic psychiatric nurses as their entries are a historical record through which their practice will become known to others, and in some cases, judged by others.

In order to advance understanding of the complex issue of desire for hastened death in the context of palliative care, research should focus on studies with patients who have actually made a desire to die statement and the development of guidelines to help health professionals respond. Direction for research in this area is described.

Health care professionals use policies and protocols in varying ways to guide their clinical activities and to promote quality patient care. The critical ethnographic case study upon which this paper is based, involved a research group comprising six registered nurses who worked in a critical care setting. Research methods included professional journalling, participant observation, and focus group and individual interviews. This paper examines the power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediating communication. While policies and protocols provided nurses with legitimacy of their knowledge in the clinical arena, doctors tended to rely on their past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through policies and protocols to confirm and support their knowledge. Policies and protocols of critical care activities provided nurses with expected standards of care, which they used to legitimize their knowledge and to communicate with doctors about 'undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurses used these written guidelines to assert power and demonstrate resistance. Policies and protocols do not exist in isolation; they occur within a complex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors establish a fine balance between using policies and protocols to provide directions for practice, and to allow sufficient latitude and flexibility in addressing the complexities of patient care.