Achieving therapeutic clarity in assisted personal body care: professional challenges in interactions with severely ill COPD patients

Aim and objectives. This paper aims to present a theoretical account of professional nursing challenges involved in providing care to patients suffering from chronic obstructive pulmonary disease. The study objectives are patients’ and nurses’ expectations, goals and approaches to assisted personal body care. Background. The provision of help with body care may have therapeutic qualities but there is only limited knowledge about the particularities and variations in specific groups of patients and the nurse–patient interactions required to facilitate patient functioning and well‐being. For patients with severe chronic obstructive pulmonary disease, breathlessness represents a particular challenge in the performance of body care sessions. Design. We investigated nurse–patient interactions during assisted personal body care, using grounded theory with a symbolic interaction perspective and a constant comparative method. Methods. Twelve cases of nurse–patient interactions were analysed. Data were based on participant observation, individual interviews with patients and nurses and a standardized questionnaire on patients’ breathlessness. Findings. Nurses and patients seemed to put effort into the interaction and wanted to find an appropriate way of conducting the body care session according to the patients’ specific needs. Achieving therapeutic clarity in nurse–patient interactions appeared to be an important concern, mainly depending on interactions characterized by: (i) reaching a common understanding of the patient's current conditions and stage of illness trajectory, (ii) negotiating a common scope and structuring body care sessions and (iii) clarifying roles. Conclusion. It cannot be taken for granted that therapeutic qualities are achieved when nurses provide assistance with body care. If body care should have healing strength, the actual body care activities and the achievement of therapeutic clarity in nurses’ interaction with patients’ appear to be crucial. Relevance to clinical practice. The paper proposes that patients’ integrity and comfort in the body care session should be given first priority and raises attention to details that nurses should take into account when assisting severely ill patients.     

Patient participation in nursing care: towards a concept clarification from a nurse perspective

Aim. The aim of this study was to investigate the meanings of the concept of patient participation in nursing care from a nurse perspective. Background. Participation is essential and increases patients’ motivation and satisfaction with received care. Studies of patient participation in nursing care are not congruent regarding definition, elements and processes. This lack of clarity is amplified by several terms used; patient/client/consumer involvement or collaboration, partnership and influence. Despite the fact that several nursing theories have emphasized the importance of patient participation, an empirically grounded theory has yet to be published. Methods. Seven focus group interviews were held with nurses providing inpatient physical care at five hospitals in West Sweden. The focus groups consisted of Registered Swedish nurses (n = 31) who described the meaning and implementation of patient participation in nursing care. A Grounded Theory approach has been applied to tape‐recorded data. Constant comparative analysis was used and saturation was achieved. Results. Mutuality in negotiation emerged as the core category for explaining nurses’ perspectives on patient participation in nursing care. It is characterized by four interrelated sub‐core categories: interpersonal procedure, therapeutic approach, focus on resources and opportunities for influence. Mutuality in negotiation constitutes the dynamic nurse–patient interaction process. Conclusions. The study clarifies that patient participation can be explained as an interactional process identified as mutuality in negotiation based on four components. Relevance to clinical practice. The results are important and can be used in nursing practice and education. Application in a clinical context means nursing care organized to include all the components presented. The results can also be used in quality assurance to improve and evaluate patient participation.     

Patient participation in clinical decision-making in nursing: A comparative study of nurses' and patients' perceptions

Aims and objectives. The aim of this study was to compare the degree of concordance between patients and Registered Nurses’ perceptions of the patients’ preferences for participation in clinical decision‐making in nursing care. A further aim was to compare patients’ experienced participation with their preferred participatory role. Background. Patient participation in clinical decision‐making is valuable and has an effect on quality of care. However, there is limited knowledge about patient preferences for participation and how nurses perceive their patients’ preferences. Methods. A comparative design was adopted with a convenient sample of 80 nurse–patient dyads. A modified version of the Control Preference Scale was used in conjunction with a questionnaire developed to elicit the experienced participation of the patient. Results. A majority of the Registered Nurses perceived that their patients preferred a higher degree of participation in decision‐making than did the patients. Differences in patient preferences were found in relation to age and social status but not to gender. Patients often experienced having a different role than what was initially preferred, e.g. a more passive role concerning needs related to communication, breathing and pain and a more active role related to activity and emotions/roles. Conclusions. Registered Nurses are not always aware of their patients’ perspective and tend to overestimate patients’ willingness to assume an active role. Registered Nurses do not successfully involve patients in clinical decision‐making in nursing care according to their own perceptions and not even to the patients’ more moderate preferences of participation. Relevance to clinical practice. A thorough assessment of the individual's preferences for participation in decision‐making seems to be the most appropriate approach to ascertain patient's involvement to the preferred level of participation. The categorization of patients as preferring a passive role, collaborative role or active role is seen as valuable information for Registered Nurses to tailor nursing care.     

Towards a comprehensive theory of nurse/patient empowerment: applying Kanter's empowerment theory to patient care

spence laschinger h.k., gilbert s., smith l.m. & leslie k. (2010) Journal of Nursing Management 18, 4–13
Towards a comprehensive theory of nurse/patient empowerment: applying Kanter's empowerment theory to patient care
Aim  The purpose of this theoretical paper is to propose an integrated model of nurse/patient empowerment that could be used as a guide for creating high-quality nursing practice work environments that ensure positive outcomes for both nurses and their patients.
Background  There are few integrated theoretical approaches to nurse and patient empowerment in the literature, although nurse empowerment is assumed to positively affect patient outcomes.
Evaluation  The constructs described in Kanter's (1993) work empowerment theory are conceptually consistent with the nursing care process and can be logically extended to nurses' interactions with their patients and the outcomes of nursing care.
Key issues  We propose a model of nurse/patient empowerment derived from Kanter's theory that suggests that empowering working conditions increase feelings of psychological empowerment in nurses, resulting in greater use of patient empowerment strategies by nurses, and, ultimately, greater patient empowerment and better health outcomes.
Conclusions  Empirical testing of the model is recommended prior to use of the model in clinical practice.
Implications for Nursing Management  We argue that empowered nurses are more likely to empower their patients, which results in better patient and system outcomes. Strategies for managers to empower nurses and for nurses to empower patients are suggested.     

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.     

Self‐transcendence and nurse–patient interaction in cognitively intact nursing home patients

Aims and objectives. The aim of this study was to test whether nurse–patient interaction affects cognitively intact nursing home patients’ interpersonal and intrapersonal self‐transcendence, as well as testing the psychometric properties of the Nurse–Patient Interaction Scale (NPIS). Background. Self‐transcendence is considered a spiritual developmental process of maturity in adulthood, and a vital resource of well‐being at the end of life. The concept of self‐transcendence has previously been explored in various populations, yet the nurse–patient interactions’ potential influence on self‐transcendence in nursing home patients has not been published previously. Design and methods. A cross‐sectional design employing the Self‐Transcendence Scale and the NPIS was adopted. A sample of 202 cognitively well‐functioning nursing home patients in Norway was selected. The statistical analyses were carried out using lisrel 8.8 and structural equation modelling. Results. Structural equation modelling‐analysis indicates statistical significant effect of nurse–patient interaction on the patients’ self‐transcendence. Direct influence on the intrapersonal and indirect influence on the interpersonal self‐transcendence aspects was disclosed. Conclusion. Nurse–patient interaction significantly affected both interpersonal and intrapersonal self‐transcendence among cognitively intact nursing home patients. Hence, facilitating caring interventions can be significantly beneficial to older patients’ self‐transcendence and thereby well‐being, both emotional and physical. Relevance to clinical practice. Caring behaviour signifies the vital and ultimate qualitative nursing behaviour, which promotes self‐transcendence and thereby well‐being. These findings are important for clinical nursing that intends to increase patients’ well‐being.     

Focus on communication: increasing the opportunity for successful staff-patient interactions

mcgilton k., sorin‐peters r., sidani s., rochon e., boscart v. & fox m. (2010) Focus on communication: increasing the opportunity for successful staff–patient interactions. International Journal of Older People Nursing 6 , 13–24
doi: 10.1111/j.1748‐3743.2010.00210.x Objectives. This study reports on a pilot study examining the feasibility of a Patient‐Centred Communication Intervention. Aims of this study include: assessing the implementation of the communication care plans; identifying staff perceptions of the intervention; exploring changes in patients’ perceptions of care and psychosocial functioning; and exploring changes in nurses’ knowledge of and attitude towards communication with patients. Background. More than 50% of stroke survivors have speech and language impairments. Many nurses lack the specialized skills to effectively communicate with patients and therefore have difficulties understanding the patients’ needs. Design. A one‐group pre‐ post‐test design supplemented with a focus group session with nursing staff was used. The intervention consisted of developing individualized communication plans; attending at a workshop; and implementing a system to support nurses when using the plans. The plans were used over a 2‐month period. Focus groups were held with seven nurses. Results. The pilot study demonstrated feasibility. There was an excellent response rate and nurses adhered to the intervention. Conclusion. The Patient‐Centred Communication Intervention is feasible and has demonstrated potential for a larger‐scale study. Relevance to clinical practice. Providing tailored approaches to communication‐enhancement education may be necessary for changes in practice to occur.     

Being asked not to tell: nurses' experiences of caring for cancer patients not told their diagnosis

Aims and objectives. The aim of the primary research was to investigate the impact of the nurse–patient relationship on clinical learning and subsequently clinical practice. Coincidently, 32 participants, all Registered Nurses in Hong Kong, provided details of nurse–patient encounters involving withholding of a cancer diagnosis. Background. The changing face of clinical practice and cancer care has fuelled discussion and debate around disclosure or non‐disclosure of the diagnosis of cancer, global consensus on this issue still does not exist. In different countries there is marked variation in how and what a patient may be told about their diagnosis and prognosis. There is considerable variability in the reported rate of cancer diagnosis disclosure across studies and countries. Being asked not to tell a patient their diagnosis of cancer presents many problems for nurses caring for those patients. The issue of non‐disclosure directly affects nurses and their clinical practice. Methods. This paper reports one of the findings of a large international qualitative study informed by phenomenology into the perceptions of nurses about caring for a patient with a diagnosis of cancer. Results. Responses from participants revealed considerable difficulties for nurses when caring for patients who were not informed of their diagnosis. They recounted having learned from the encounters but remarked on the negativity of the experience. They discussed their inability to act decisively in the past situations but expressed hope that they had found a resolve to act in future. Relevance to clinical practice. Although, overwhelmingly, participants doubted they would actually be able to change the reality of practice. The identified care episode and the nurse–patient relationship, according to participants, did change their clinical practice but often not for the better.     

Surgical nurses' different understandings of their interactions with patients: a phenomenographic study

The aim of this study was to identify and describe different ways surgical nurses understand their roles and interactions with patients and their families in a surgical care setting. The surgical nurse has an important role in supporting and encouraging the patient during the hospital stay. It can be a challenge for the nurse to quickly establish a trustful relationship with the patient. The assumption is that nurses' interactions with patients are affected by their understanding and expectations of the roles in the nurse-patient relationship. A qualitative interview approach was used and the interviews were analysed using the phenomenographic method. A strategic sample of 17 registered nurses in two hospitals in Sweden was interviewed. In the analysis four ways of understanding the nurse's role in interactions with the patient were identified: (A) Focusing on medical treatment, following prescribed instructions, and maintaining routines; (B) Providing information, giving service, and coordinating care and treatment; (C) Seeing patients as vulnerable people and helping and supporting them as individuals; and (D) Inviting patients to participate in the caring process and encouraging them to take responsibility in their own care. Seeing each patient as a person with individual needs and personal resources. The first way of understanding, A, focuses on the work task; the other three understandings focus on the patients, but differ in how the nurses see them as people. Understanding A represents a restricted and task-oriented approach, whereas the others are more patient-focused, but also more complex. To realise patient-centred care, nurses should pay attention to all aspects of the interaction. Nurses need to have time at ward meetings or in supervision to discuss and become aware of different ways of understanding their interactions and relationships with patients. In this way new areas of professional development may be opened up.     

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.     

Being authentic and being a chameleon: nurse-patient interaction revisited

This paper explores contradictory understandings of nurse-patient interaction arising through an exploration of 'being authentic' and 'being a chameleon'. The concepts arose during a critical praxis research study exploring nurse-patient relationships in the context of life-threatening or terminal illness. Being authentic can be understood as a dominant view in the nursing literature of the nurse-patient relationship, incorporating the value of being genuine. However, we argue that this concept offers only a partial and inadequate framework from which to understand nurse-patient interaction. The paper argues that nurse-patient relationships develop intersubjectively, with both the nurse and the patient choosing to reveal or conceal aspects of themselves in response to their interactions. Intersubjectivity as a concept provided the nurses in this study with a means for understanding how the nurse and the patient each contribute to interactions; nurse-patient relationships being understood as mutually constructed. These ideas are explored in this paper using examples from the nurses' stories, along with the implications raised for nursing practice.     

Re-establishing dignity: nurses' experiences of caring for older hospital patients

In western countries, the older population is increasing and with age follows a risk of un-health. Every fifth hospital patient is above 65 years of age. As a consequence, nursing care to older patients is a significant but tacit nursing issue. The aim of this study was to explore Danish clinical nurses' experiences of caring for older hospital patients. The study was based on Benner and Wrubel's phenomenological notion that caring as a special kind of involvement, a grasp of a situation in terms of its meaning, is primary in nursing. A qualitative secondary analysis of data from an interview study with 29 nurses and nurse assistants was performed following Van Manen's hermeneutic phenomenology. Findings show that caring mainly concerns 're-establishing dignity' especially through 'seeing the patient as a unique person', 'assisting in getting rid of the bed' and 'supporting patient appearance'. The study documents that caring for older people is about creating small everyday circumstances in which patient dignity can flourish. Shortcomings of a secondary analysis are discussed and suggestions for future research, such as how older hospital patients experience caring and dignity in relation to nursing care received, are suggested.     

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.     

A theoretical model of ageing hospital nurses' well-being at work

utriainen k., kyngäs h. & nikkilä. j. (2011) Journal of Nursing Management 19, 1037–1046
A theoretical model of ageing hospital nurses’ well-being at work Aim To describe the development process of a theoretical model of ageing hospital nurses’ well-being at work and the subsequent testing of the model itself. Background Factors evoking well-being at work need to be identified to promote nurses’ well-being. Method Qualitative data (n = 21) from ageing hospital nurses, consisting of interviews, diaries and open data collection forms were collected and analysed using grounded theory method. Based on the finding, a survey was developed. Quantitative data (n = 328) were collected from hospital nurses born between the years 1948–1962. Explorative factor analysis was used to create the theoretical model. Results The main concepts of the model were nurse–nurse interaction, nurse–patient interaction and patient-care centeredness. Conclusion According to the theoretical model, well-being at work can be described as nurses’ experience of collaboration, cooperation and togetherness with other nurses in a supporting and caring work environment. The aim and possibility of high-quality patient care, in a spirit where nurses and nursing are appreciated, were also revealed. Implications for nursing management The importance of nurse–nurse interaction and nurse–patient interaction as well as ageing nurses’ patient-care centeredness needs to be taken into account in nursing management and leadership.     

Using holistic interpretive synthesis to create practice‐relevant guidance for person‐centred fundamental care delivered by nurses

Nursing policy and healthcare reform are focusing on two, interconnected areas: person‐centred care and fundamental care. Each initiative emphasises a positive nurse–patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse–patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice‐relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse–patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse–patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person‐centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.     

Factors influencing nurse–patient interaction in the acute psychiatric setting: An exploratory investigation

Nurse–patient interaction in acute psychiatric in-patient facilities has been the subject of much discussion in the literature and remains a contentious issue. How and why nurses interact with patients in the acute care setting requires definition within the current dynamic environment of mental health service provision. Factors which impact on the manner in which nurses care for patients also require investigation. This article presents the findings of a collaborative research study that investigates factors that influence nurse–patient interaction in the acute psychiatric setting. Ten nurses on the study ward were given opportunity, through semi-structured interviews, to outline and describe the factors perceived to influence nurse–patient interaction. Factors identified as influencing interaction included the ward environment, something always comes up, nurses’ attributes, patient factors, instrumental support and focus of nursing. Issues which emerged from the study provide managers and clinical nurses with an opportunity for generating new possibilities for nurse–patient interaction. However, these issues must be addressed in a sensitive way that takes into account the complex and dynamic nature of acute care settings.     

Reflections on intuition and expertise

Reflective practice now appears firmly established in the English speaking world of professional nursing practice and development. Outside this linguistic context, however, the concept seems less well-known. This paper describes an experience drawn from clinical practice and education in French-speaking Switzerland followed by explicit reflection grounded in questions generated by Johns' model for structured reflection. Thus, a concept well-described in the English-language literature underpins an innovative approach to a French-language clinical teaching situation. The professional implications of this situation are explored through meaningful reflection providing new insight into familiar circumstances as they relate to the nurse tutor's role. This exploration is followed by a critical approach to the experience and the subsequent structured reflection in order to address relationships between intuition and expertise and self-awareness through reflection. A hermeneutic perspective provides additional insight into the nurse-patient relationship where both come to the situation with their own 'pre-understandings'. Individual horizons thus endorse a new understanding going beyond taken-for-granted meanings.