The nurse-patient relationship: a consideration of its discursive context

This paper is a theoretical exploration of the discursive context that shapes the nurse-patient relationship. It represents a feminist poststructural consideration of the broader institutional and social context that influences the dynamics of that relationship. The characteristics of that relationship can be regarded as performances of subjectivity shaped by managerial, medical and nursing discourses. Both nurse and patient signify particular discursively constituted meanings to each other which shape the relationship. It is proposed that the discourses which inform how each should respond to the other encourage the utilization of disciplinary tactics by the nurse which relay to the patient what is expected of him/her. An effect of these disciplinary procedures is to rein in the caring potential of nursing practices. However, nursing's relationship with women's work and the social history of caring may provide it with a discursive context that recognizes the social significance of this work.     

Esthetic abilities: a way to describe abilities of expert nurses in palliative home care

Aim. The aim of this paper is to focus on the abilities needed to create the caring relation in palliative home care and to find ways to describe these abilities and skills from an esthetic perspective. Background. Nurses in Palliative home care have to create a functioning relationship between themselves the patient and the patient's next of kin, this puts special demands on the nurse. A number of abilities, such as creativity, intuition, empathy and self‐knowledge are mentioned in literature related to the caring relation. Many nursing theorists have referred to the art and esthetic of nursing when trying to describe these abilities. Methods. Data were collected using semi‐structured interviews with eight expert nurses in palliative home care. The transcribed interviews were analysed using qualitative content analyses. Findings. Three main categories where found: The will to do good, Knowledge and Perceptiveness. Subcategories that can be seen as abilities where found in the main categories knowledge and perceptiveness. Conclusions. The main categories can be seen as expressions for abilities, personal qualities and skills needed to create the caring relation in palliative home care. We found interesting connections between the three main categories and the concepts of esthetics, ethics and science. We also found that nurses develop in a way, i.e. similar to an artist. Relevance to clinical practice. The concepts brought forward in this paper could be used in clinical supervision and education as well as in clinical practice. If nurses think about the three aspects: Knowledge, the will to do good and perceptiveness, the chance for a positive relation between the nurse and the patient, and the patient's next of kin might increase. One could speculate that perceptiveness is a vital ability in order to achieve the expert level of nursing and that this perspective should be taken in consideration when recruiting nurses and in curriculum development.     

Releasing the therapeutic potential of the psychiatric nurse: a human relations perspective of the nurse-patient relationship

In psychiatry mental health nurses form the largest professional discipline providing care on an everyday basis for sustained periods. Mental health nurses therefore are in a pivotal position to establish valued therapeutic alliances. In practice, however, a disproportionate amount of nursing time is taken up by administration, time spent talking to patients is minimal and when interactions do occur they remain notionally therapeutic and often are not theoretically informed. This noted paucity of therapeutic contact is antithetical to the aspirations of service users who increasingly are asking for a more skilled approach to the talking-listening that occurs in the therapeutic encounter. It is hypothesized by the present authors that an object-relations perspective of the nurse-patient relationship could release the largely untapped therapeutic potential of the psychiatric nurse by (1) bridging the gap between theory and practice and (2) providing a professional identity from within which nurses can begin to 'get to know' and understand the predicament of the patient with severe mental illness.     

Nursing contribution to the rehabilitation of older patients: patient and family perspectives

tyrrell e.f., levack w.m., ritchie l.h. & keeling s.m. (2012)?Nursing contribution to the rehabilitation of older patients: patient and family perspectives. Journal of Advanced Nursing68(11), 2466-2476. ABSTRACT: Aims. This article reports a study of the perspective of older patients and their family members on the role of nurses in inpatient rehabilitation. Background. Rehabilitation services are used increasingly by older patients as life expectancy increases. The role of rehabilitation nurses in the multidisciplinary team has, however, yet to be clearly articulated. Previous research has focussed on the views of health professionals about nursing involvement in rehabilitation, but none has sought family members' perspectives. With the expectation of patient-centred care, it is important to consider what older patients and their families expect and require from nurses. Design. Grounded theory was used to collect and analyse data from interviews in an inpatient rehabilitation unit in New Zealand with seven patients, aged 72-89?years, and six family members, during 2009-2010. Findings. A substantive theory was developed which recognizes that the older patient values the relationship they build with nurses more than any specific role nurses perform. Participants acknowledged that rehabilitation nurses' roles included 'looking after', 'stepping in' and 'coaching independence' but 'best fit' nurses were identified by patients based on their 'nature', 'being available' and 'being attuned' to the patient's individual needs. If a 'connection' was formed, then this 'best fit relationship' maximized the older person's motivation to participate in his or her rehabilitation therapy. Conclusion. Patients and family members appreciate 'best fit relationships' where nurses seek to enter into the older person's world of disability to form a partnership which enhances their motivation to achieve independence.     

To surrender in dependence of another: the relationship with the ambulance clinicians as experienced by patients

Historically, the ambulance care has focused on acute transports and medical treatment, although ambulance care has also been reported as complex, encompassing more than just medical treatment and transports. Previous studies, on ambulance clinicians, have pointed out the importance of interpersonal caring activities complementary to the medical treatment. Those activities can be understood as taking part in the relationship between patients and ambulance clinicians, earlier described as essential and a core component of care. The aim of this study was to elucidate the meaning of the relationship with the ambulance clinicians as experienced by patients. Twenty ambulance patients were interviewed in the study. The interviews were transcribed verbatim and analysed with a phenomenological hermeneutical method to grasp meanings in the patients' experiences. The regional ethical committee approved the study. In the result emerged one main theme: To surrender in dependence of another. The main theme includes four themes: Being in the hands of another, Being in a caring temporary presence, Being important while involved and Being powerless while insignificant, and the themes comprise eleven subthemes. The main theme meant to have no other option than to surrender and to put their life into the hand of another. This surrender also meant to adapt to the clinicians' views even if not shared. This is experienced as excessive care. Summarised, the patients' experiences were both positive and negative and the findings provide a complex understanding of the relationship between the patient and the ambulance clinicians. Overall, the relationship embraces the whole person without reducing the patient to be a recipient of an objectified ambulance care.     

The quality of nursing care as perceived by individuals with chronic illnesses: the magical touch of nursing

Providing high quality nursing care is the vision of nursing. The literature has revealed gaps between the perspectives of patients and nurses regarding the quality of nursing care. The purpose of this study was to investigate how individuals with chronic illnesses perceive the quality of nursing care in order to enhance the quality of care. The participants were 11 Icelandic individuals, aged 39-80 years with various chronic illnesses. Phenomenology was the research approach and in-depth dialogues were used. Five themes emerged: nurses who provided high quality nursing care, the effects of high quality nursing care, the lack of good quality nursing care and its effects, ancillary factors, and the art of being a patient. Based on the findings I conclude that professional caring is the most important part of quality of care as perceived by individuals with chronic illnesses.     

The role of reflection in the development of practice theory: a case study

Many authors view practice theory as the strongest form of theory for an applied discipline like nursing. It is based upon the idea that theory emanates from practice, is strengthened and is returned to inform practice. The first part of this paper is concerned with identifying the contribution that practice theory can make to patient care. While there are many positivistic ways of generating practice theory, one method which is getting increasing attention is reflection. In this paper, Boud et al.'s framework for reflection is used to identify phenomena related to the empowerment of patients and staff in psychiatric hospitals (Boud et al. 1985). A real life case study is described and concepts and beginning propositions are uncovered. Conclusions are drawn which from the basis for theory development and testing.     

Nursing leadership from the perspective of clinical group supervision: a paradoxical practice

bondas t. (2010) Journal of Nursing Management 18, 477–486
Nursing leadership from the perspective of clinical group supervision: a paradoxical practice Aim Increase understanding of nursing leadership in group clinical supervision (CS). Background Leadership in CS has received little interest besides the theories in use and administrative CS. Method Hermeneutic interpretation of written narratives of 24 clinical nurse supervisors. Results Continuity in structuring, story and mission and reflection in group and leadership processes and theories of nursing and caring characterize leadership in CS. Leadership by inhibiting and creating fear, inapproachability and indistinctiveness were patterns in content brought to CS. Supervision when leadership was involved illuminated a reflexive change in focus from leadership to nursing care, from particular experiences to nursing and caring science, and from the unfamiliar to the well known and the well known to the unknown. Conclusions Continuity and reflective changes using nursing and caring theories seem to be core ideas of nursing leadership from the perspective of CS. The poles of separation and communion show opposites of nursing leadership as it is illuminated in CS. The findings add knowledge to Bondas’ theory of caritative leadership. Implications for nursing management CS is a reflexive practice of support and guidance that seems to have an impact on the trajectory of nursing care and staff development using nursing and caring theories.     

Interactional nursing – a practice‐theory in the dynamic field between the natural,human and social sciences

Nursing is often described from the point of view of either the natural or the human sciences. In contrast to this, the value foundation in Interactional nursing practice is understood from the point of view of the natural sciences as well as that of the human and social sciences. This article presents many‐faceted practice‐theory of nursing, which is situated in the dynamic field between these three sciences. The focus of the theory is on interaction and practice resulting in a caring practice. Here practice is based on Taylor’s and MacIntyre’s interpretation of this concept. Action in nursing is based on Habermas’ three varied modes of action seen in the light of an understanding of the world as a system world and a life world. Nursing as an interactional practice‐theory is presented with examples of interpretative nursing science, seen in the ethical action‐oriented, socio‐cultural framework of Taylor and Habermas. It is concluded that phenomenologic and socio‐cultural research into caring practice as well as an in‐depth, comprehensive interpretation of nursing practice are both highly suited to forming the fundamental theoretical framework in nursing, here seen as an interpretative nursing science. Finally, a comparison is drawn between Interactional nursing practice and Benner’s theory of nursing practice.     

Iranian nurses’ preparation for loss: finding a balance in end‐of‐life care

Aim. To explore the nurse–patient interaction in terminally ill situations in acute care, focusing on the nurses’ preparation for loss. Background. Caring for dying patients can be a distressing and sometimes even threatening experience for nurses. Despite the vast body of literature on nurse/patient interaction and the quality of end‐of‐life care, few studies focus specifically on nurses’ experience. Design. A grounded theory approach was used to explore nurses’ interaction with dying patients and their families and examine how nurses deal with situations in which the patient’s death is inevitable. Method. Eighteen nurses were interviewed up to three times each at three teaching hospitals in Isfahan, Iran, during autumn 2006. A shortlist of possible participants was obtained by means of theoretical sampling and those who had experienced the death of patients and were able to express their feelings verbally were selected. Results. The results clarified a core consideration: striking a balance between restorative and palliative care, information and hope, expectations and abilities and intimacy and distance. Conclusion. Attaining a balance in caring for dying patients is a major challenge to nurses: it concerns not only their interactions with patients and their families, but also their perceptions of themselves and their actions in end‐of‐life care. Relevance to clinical practice. In end‐of‐life care, it is important for nurses to be able to change the focus of their care when the patient’s condition is diagnosed as irreversible. They also need to be well equipped to maintain a balance, thereby preparing themselves for the patient’s forthcoming death.     

Patients' and nurses' experiences of delirium: a review of qualitative studies

Background: Knowledge of delirium accumulated over the past two decades has focused more on its characteristics, pathophysiology, incidence, aetiology and prognosis as well as interventions for preventing, detecting, evaluating or managing this syndrome and less so on how patients and nurses who care for them experience it. Aims: To present the state of knowledge derived from qualitative studies of the experiences of persons who suffered delirium and of nurses who cared for them to guide critical care practice. Results: Delirious patients experience incomprehension and various feelings of discomfort. Understanding, support, believing what they are experiencing, explanations, the presence of family/friends and the possibility of talking about the lived experience are interventions that might help them get through such episodes more easily. Nurses who tend to delirious patients fail to comprehend the utterances and behaviours of the persons cared for and experience various feelings of discomfort as well. Nevertheless, they intervene following different goals and intervention strategies that seem to vary as a function of their culture and values. Conclusion: Qualitative studies conducted on persons who suffered delirium and on nurses who cared for them have shed light on their lived experience and provide insight on how to improve critical care practice. Relevance to clinical practice: The findings suggest that nurses must acknowledge the lived experience of the persons cared for and they must seek out the meaning that patients ascribe to this experience to understand the situation and thus conduct interventions that meet the needs expressed.     

A dimensional structure of nurse-patient interactions from a caring perspective: refinement of the Caring Nurse-Patient Interaction Scale (CNPI-Short Scale)

AIM: This paper reports the development of a short version of the Caring Nurse-Patient Interaction Scale. BACKGROUND: Since the 1980s several instruments have been developed to assess external aspects of caring. They involve using an inductive process of knowledge development to investigate the underlying structure of caring, and few reflect an explicit underlying caring theory. We developed the Caring Nurse-Patient Interactions Scale (CNPI-Long Scale) based on both inductive and deductive processes to assess attitudes and behaviours associated with Watson's 10 carative factors. Two issues led us to abridge our original 70-item scale into a more concise Short Scale (CNPI-Short Scale). First, many of our subscales were moderately to highly correlated, which is an empirical reflection of the theoretical non-independence of the carative factors. Secondly, a 70-item questionnaire was difficult to be deal with in the clinical research setting with severely ill patients because of its length. METHOD: Items selected were determined by factor analysis, with specific theoretical and empirical requirements. Data were collected in September 2003 from 377 nursing students beginning their first, second or third year of a nursing programme. RESULTS: The Short Scale comprises 23 items, reflecting four caring domains: Humanistic Care (four items), Relational Care (seven), Clinical Care (nine) and Comforting Care (three). All items are related to their theoretical domain alone (i.e. factor loading >or=0.40). Alpha coefficients for the four domains were adequate (0.63-0.74, 0.90-0.92, 0.80-0.94 and 0.61-0.76 respectively). CONCLUSIONS: The CNPI-Short Scale, has potential for use in clinical research settings, particularly when questionnaire length is an issue. It is a useful tool for research aimed at demonstrating that caring is indeed fundamental to nursing.     

The experience of caring for someone over 75 years of age: results from a Scottish General Practice population

Aims and objectives. To understand the unpaid carers’ experiences of looking after someone aged over 75 at all stages of their caring career. Background. The role of, and support for, unpaid carers have become central in the debates surrounding community care in the UK. This paper presents the findings of a study to elicit the complexities of the caring role and inform the Primary Health Care Team to help support carers more effectively. Designs and methods. A quantitative research design was employed. Carers of people over 75 years of age in a General Practice, who had been previously identified from a screening questionnaire, were sent the Carers Assessment of Difficulties Index, the Carers Assessment of Satisfactions Index and Carers Assessment of Managing Index questionnaires which examine the experience of caring. Results. From a sample of 247 carers, a 70% response rate (n = 172) was achieved. Satisfactions lay in the quality of care provided; difficulties reflected the potential and actual family tensions generated; coping strategies included reframing difficulties, using humour and practical problem solving. The data show that caregivers’ reactions, such as feeling angry about the situation, or the consequences of their involvement, such as tensions within the family, cause them more difficulties than the actual care‐giving tasks they perform. Conclusion. This study adds to the understanding of carers’ roles by including carers across a range of situations, including those at an early stage of their caring career. Service providers are better able to support carers if they understand the complex interplay of difficulties, rewards and personal coping strategies associated with the caring role. Relevance to practice. The study helps illuminate the less obvious, but important, emotional aspects of carers’ difficulties and suggests strategies which service providers may find helpful in assessing carers’ needs and determining the appropriate interventions.