Dependency in autonomous caring – night nurses’ working conditions for caring in nursing

Scand J Caring Sci; 2010; 24; 312–320
Dependency in autonomous caring – night nurses’ working conditions for caring in nursing Few research studies have focused on nurses’ working conditions for caring provided at night, and these studies have mainly described nurses’ work in hospital settings, not in a municipal, social‐care context. In Swedish municipal care, nurses have responsibility for hundreds of older people in need of care. This working condition compromises caring encounters; instead the nurses’ caring is mainly mediated through care staff (or relatives). In considering that caring based on caring encounters is fundamental to ethical nursing practice questions leads to the aim: to explore Swedish municipal night nurses’ experiences of their working conditions for caring in nursing. All municipal night‐duty nurses (n = 7) in a medium‐sized community in Sweden participated in interviews, while six of them also wrote diaries. Thematic content analysis has been used in analysing the data. The findings revealed that the nurses experienced their working conditions for caring in nursing in the themes of Dependency in the Organisation and Other Staff, Vocational Responsibility, Deficiency in Conditions for Caring and Autonomous Caring. The findings illustrate privileged, as well as, poor working conditions for caring in nursing. The nurses’ role as consultants emerge as their main function. The consultant function implies that nurses do not participate in ordinary bed‐side caring, which makes it easier for them to find time for caring in situations that arise when nurses’ skills, expertise and authority are called upon. Conversely the consultancy function entails short‐term solution of complex caring problems, which can signify deficient caring due to prevailing working conditions. The findings also point to nurses’ possible problems in fulfilling their own and vocational demands for ethics in the practice of caring in nursing related to existing working conditions.     

Attitudes to spiritual care among nursing staff in a Swedish oncology clinic

Aims and objectives. To identify factors which may influence attitudes to spiritual care, test the relevance of these identified influencing factors in a Swedish nursing context, and replicate a part of a previous study by Strang et al. (Journal of Clinical Nursing 2002; 11:48–57) dealing with attitudes to spiritual care in a holistic perspective. A questionnaire was handed out to all nursing staff at a Swedish oncology clinic (n = 93) excluding the radiation therapy ward. Data were obtained from 68 nurses or nursing auxiliaries. Design and methods. (i) Literature review of international research reports concerning spiritual care in a nursing context. (ii) Construction of a questionnaire comprising 17 questions with given alternatives based on the previous literature study. (iii) Operationalization of the concept ‘attitudes to spiritual care’ into some more easily measurable questions through identification in earlier research reports of conceivable indicators of attitudes to spiritual care. (iv) Construction of a suggestion for a definition of the concept ‘spiritual care’ from the results of Strang et al. (2002) to be used in the questionnaire. (v) Statistical analysis of the data from the questionnaire and a comparison with previous studies. Results and conclusions. The replicating part of the study are mainly in accordance with Strang et al. (2002) and lead to the conclusions that holistic care (i) is desirable, (ii) should include spiritual needs of the patients and (iii) is not yet realized in Swedish health care. The identified influencing factors are relevant in a Swedish nursing context. The factors influencing the largest number of indicators of attitudes to spiritual care are ‘non‐organized religiousness’ and ‘degree of comfort while providing spiritual care’. Other influencing factors are: ‘belief in God’, ‘belief in life after death’, ‘organized religiousness’, ‘profession’, and ‘the perceived degree of education in spiritual care’. Relevance to clinical practice. Knowledge of attitudes towards spiritual care among nursing staff and factors influencing these attitudes will improve the possibilities of meeting the spiritual needs of patients.     

Patient participation in hospital care: Nursing staffs' point of view

The aim was to investigate nursing staff's perceptions related to patient participation and the parameters affecting it during nursing care. A cross‐sectional study with both a quantitative and qualitative orientation was conducted. The sample consisted of all nursing staff working in medical and surgical wards in three Greek hospitals. A questionnaire was developed and the data were analysed with exploratory factor analysis, whereas content analysis was used for qualitative data. Nursing staff perceived participation as the process of information giving to patients, communication of symptoms by patients and compliance with the staff's orders. ‘Information providing’ and ‘ability to influence and responsibility’ were significant aspects of the content of participation, whereas the parameters affecting participation were related to patients, nursing staff and the care context. These results support patient engagement in dialogue and shared decision‐making, while highlighting the need to implement participation systematically and stimulate changes in nursing care organization.     

An advanced nurse practitioner-led service - consequences of service redesign for managers and organizational infrastructure

barton d . & mashlan w. (2011) Journal of Nursing Management 19, 943–949 An advanced nurse practitioner-led service – consequences of service redesign for managers and organizational infrastructure Aim A service review of a secondary care advanced nurse practitioner-led service. Background An acute hospital-based elderly care rehabilitation service evolved over a 9-year period from a traditional consultant/junior doctor configuration to a consultant/advanced nurse practitioner configuration. The review evaluated the advanced nurse practitioner team’s role in the clinical setting, and the constraints experienced as a result of the traditions of the hospital organization. Evaluation The review drew its conclusions from opinion data collected from 38 professionals and non-professionals within the rehabilitation service. Key issues The organizational infrastructure and traditions that had an impact on service delivery by the advanced nurse practitioner team. There is a demand for senior management to act on developmental constraints. Conclusions The advanced nurse practitioner-led rehabilitation service was fit for purpose and an emerging model of a non-medical led care. However, important organizational constraints were identified. Implications for nursing management An advanced nurse practitioner team, working in collaboration with medical consultants, was a model for future service redesign in the acute hospital setting. Nevertheless, it presented challenges to senior health-care managers on current organizational infrastructures.     

Evaluation of documented nursing care plans by the use of nursing‐sensitive outcome indicators

Rationale and aim There is a lack of evidence that nursing care plans affect patient outcomes. The aim of the present study was to evaluate whether documented nursing care plans affect patient outcomes by the use of nursing‐sensitive outcome indicators. Method A retrospective, cross‐sectional design with patients surveyed at time of discharge from two hospital units for patients with stroke and after 2–3 weeks at home. The control unit (A) did not employ care plans. The intervention unit (B) used care plans on a daily basis. Outcome was measured by ‘the National Stroke Register’ and the two questionnaires: ‘Quality of patients' perspective’ and ‘Euroquol five dimensions’. Data were collected over a 5‐month period (October 2007–February 2008). Results In total, 87 patients were included in the study. Patient characteristics in the two groups at admission and the health‐related quality of life 2 to 3 weeks after discharge were similar. The patients from unit B were more satisfied with individual care (P = 0.03) and participation (P = 0.007). Unit B also had a shorter length of stay (P = 0.004). Conclusions The effects of documented care plans are difficult to evaluate from a patient perspective, as many factors can improve the outcome. However, documentation of care plans is a prerequisite for measuring the quality and outcome of the care provided. This small study indicates that documented care plans may affect patient satisfaction regarding individual care, participation and length of hospital stay.     

‘It should be an ordinary thing’– a qualitative study about young people’s experiences of taking the HIV‐test and receiving the test result

Scand J Caring Sci; 2010; 24; 678–683
‘It should be an ordinary thing’– a qualitative study about young people’s experiences of taking the HIV‐test and receiving the test result Aim: Increased HIV‐testing has public health benefits, but for youth there is a multitude of barriers against the test. The aim of this study is to explore how young women and men in Sweden experience HIV‐testing within primary healthcare. Method: Six focus‐group interviews were tape recorded, transcribed verbatim and analysed according to qualitative content analysis. Results: Three themes emerged, describing how the informants were met before, during and after testing; ‘Obstacles accessing the clinic’– describes their perceptions on how to overcome different barriers and enter into primary health care. ‘Quick and easy testing’– describes perceptions of the testing procedure and ‘Conflicting and unclear information about test results’– describes inconsistencies concerning communication of the test result and a concern about ‘what would happen’ in the event of an HIV‐positive finding. Most of these youth preferred the HIV‐test ‘quick and easy’ and preferred a telephone referral of the test result. A minority of them worried about HIV, and they thought that the staff seemed to be unprepared for an HIV‐positive test result. Conclusion: According to these youth, a quick and easy testing procedure together with a short pretest discussion may be sufficient and may also help normalising the testing practice. In a Swedish context, it may be common to see heterosexual youth as a risk‐free population, and this perception may act as a barrier for HIV‐testing and increase missed opportunities for early diagnose of HIV within primary care.     

Women at risk of coronary heart disease experience barriers to diagnosis and treatment: A qualitative interview study

Objective To describe the types of patients admitted to the first Dutch general practitioner (GP) hospital, their health-related quality of life and its substitute function.

Design A prospective observational study.

Setting The remaining 20-bed ward of a former district general hospital west of Amsterdam; a region with 62?000 inhabitants and 26 GPs.

Subjects All patients admitted during the 12 months between 1 June 1999 and 1 June 2000.

Main outcome measures Patients’ health-related quality of life (Medical Outcome Study 36-item Short Form Health Survey, Groningen Activities Restriction Scale), GPs assessments of severity of illness (DUSOI/WONCA Severity of Illness Checklist) and alternative modes of care.

Results In total, 218 admissions were recorded divided into 3 bed categories: GP beds (n=131), rehabilitation beds (n=62) and nursing home beds (n=25). The mean age of all patients was 76 years. Main reasons for admission were immobilization due to trauma at home (GP beds), rehabilitation from surgery (rehabilitation beds) and stroke (nursing home beds). Overall, patients showed a poor health-related quality of life on admission. If the GP beds had not been available, the GPs estimated that the admissions would have been almost equally divided among home care, nursing home and hospital care. The severity of the diagnosis on admission of the ‘hospital-care group’ appeared to be significantly higher than the other care groups.

Conclusion The GP hospital appears to provide a valuable alternative to home care, nursing home care and hospital care, especially for elderly patients with a poor health-related quality of life who are in need of short medical and nursing care.     

Pressure ulcer risk screening in hospitals and nursing homes with a general nursing assessment tool: evaluation of the care dependency scale

Rationale In view of an increasing necessity for systematic assessments, nursing practice would benefit from a simplification of assessment procedures. These assessments should be scientifically based. Aims To evaluate the possibility of assessing pressure ulcer risk as well as care dependency simultaneously with a standardized instrument for nursing homes and hospitals. Methods Care dependency was measured with the Care Dependency Scale (CDS). The quantitative analyses were accomplished with data from a cross‐sectional study that was performed in 2005 in 39 German nursing homes and 37 hospitals with a total of more than 10 000 participants. The scale's construct validity was calculated with Pearson's r, and predictive validity was evaluated by computing sensitivity and specificity values and the area under the curve (AUC). Item‐level analyses included calculations of odds ratios, relative risks and logistic regression analyses. Results Construct validity of the CDS was r = 0.79 (P < 0.01) in nursing homes and r = 0.89 (P < 0.01) in hospitals. AUC was 0.80 in hospitals and 0.65 in nursing homes. Analyses on item level identified ‘mobility’ as a key item in both settings and additional differing key items for nursing homes and hospitals. Conclusions The CDS is a well‐functioning tool for pressure ulcer risk detection in hospitals. For this purpose, the most appropriate cut‐off point is 69 while special regard is given to the items ‘continence’, ‘mobility’ and ‘hygiene’. In nursing homes the usefulness of the CDS for pressure ulcer risk detection is limited. Here, the most appropriate cut‐off point is 41 and attention is given to the items ‘mobility’, ‘getting (un)dressed’, ‘hygiene’ and ‘avoidance of danger’.     

Of vigilance and invisibility--being a patient in technologically intense environments

Equipment and procedures developed during the past several decades have made the modern intensive care unit (ICU) the hospital’s most technologically advanced environment. In terms of patient care, are these advances unmitigated gains? This study aimed to develop a knowledge base of what it means to be critically ill or injured and cared for in technologically intense environments. A lifeworld perspective guided the investigation. Nine unstructured interviews with intensive care patients comprise its data. The qualitative picture uncovered by a phenomenological analysis shows that contradiction and ambivalence characterized the entire care episode. The threat of death overshadows everything and perforates the patient’s existence. Four inter‐related constituents further elucidated the patients’ experiences: the confrontation with death, the encounter with forced dependency, an incomprehensible environment and the ambiguity of being an object of clinical vigilance but invisible at the personal level. Neglect of these issues lead to alienating ‘moments’ that compromised care. Fixed at the end of a one‐eyed clinical gaze, patients described feeling marginalized, subjected to rituals of power, a stranger cared for by a stranger. The roar of technology silences the shifting needs of ill people, muffles the whispers of death and compromises the competence of the caregivers. This study challenges today’s caregiving system to develop double vision that would balance clinical competence with a holistic, integrated and comprehensive approach to care. Under such vision, subjectivity and objectivity would be equally honoured, and the broken bonds re‐forged between techne, ‘the act of nursing’, and poesis, ‘the art of nursing’.     

Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence

Scand J Caring Sci; 2013; 27; 253–259 Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence Background: Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs). Methods: Patients’ satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self‐completed questionnaire. GPs’ views on the involvement of nurse specialists were measured in a structured telephone interview. Results: The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1–10), vs. 6.7 for care‐as‐usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2. Conclusions: Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI‐specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.     

Clarifying self‐harm through evolutionary concept analysis

Scand J Caring Sci; 2010; 24; 610–619
Clarifying self‐harm through evolutionary concept analysis Clarification of the concept self‐harm is needed in order to enable research and theory development and facilitate the development and evaluation of medical interventions and nursing care for individuals who self‐harm. This study presents such a conceptual analysis. Articles from 1997 to 2007 were sought from the Medline, PubMed, Cinahl, and PsychINFO search engines by entering the search words ‘self‐harm’, ‘self‐harming’, and ‘psychiatric care’. 25 medicine and 23 nursing science articles were chosen for inclusion and analysed. Rodgers’ evolutionary concept analysis process was used to delineate and clarify the concept’s context, surrogate terms, antecedents, attributes, and consequences, as well as to determine implications for further research. Attributes of self‐harm may include repetitive injury of mouth or exterior body, that is to say the infliction of physical pain to alleviate mental pain, and time spent self‐harming. Antecedents may be gender, mental pain, substance abuse and relational problems. Consequences often include the need for medication and help with altering coping behaviour. Some self‐harm patients met with negative attitudes from nurses. Individualized care and treatment is recommended. Accordingly, inter‐professional collaboration and postgraduate education is needed in order to provide better care and treatment for self‐harm patients. Furthermore, better understanding is needed to help enable health care personnel understand why individuals self‐harm. The conceptual analysis presented in this study may be helpful as regards theory development within this still rather unexplored field.     

The Tri‐focal model of care: Advancing the teaching‐nursing home concept

Providing residential aged care is challenging because of the complexity of residents’ health status, difficulties recruiting and retaining skilled staff, and financial and regulatory constraints. This paper discusses some of these challenges and describes an innovative model of care, termed ‘The Tri‐focal model of care’. This model was developed based on the concepts of ‘partnership‐centred care’, ‘positive work environment’ and the need for evidence‐based practice to underpin all aspects of care. It is envisaged that the implementation of this model will provide a rich learning environment that advances the teaching‐nursing home concept and the quality of residential aged care.     

General practitioners’ reasoning about using mobile distance‐spanning technology in home care and in nursing home care

Scand J Caring Sci; 2011; 25; 117–125
General practitioners’ reasoning about using mobile distance‐spanning technology in home care and in nursing home care The trend for health care and nursing care turns from hospital to health care and nursing care at home. Studies have shown that health care professionals have no access to patient records in home and nursing home settings. Technological development creates opportunities for a host of mobile technology solutions. The aim of this study was to describe the reasoning among general practitioners (GPs) about the use of mobile distance‐spanning technology (MDST) in care at home and in nursing homes. Seventeen GPs were divided in five groups for a group interview. The interviews were tape‐recorded and transcribed verbatim. The qualitative content analysis resulted in four areas about the MDST, MDST has an impact on GPs’ work, the nurses’ profession, and the patient and the family, with nine adherent categories. The findings were interpreted and formulated in the theme: MDST should be used with caution. The results show quite a few expressions about the MDST as useful and valuable in health care at home and in nursing home settings; however, in every category, there were text that we interpreted as caution when using the MDST. The MDST cannot be used in all situations and cannot replace human meetings in health care and nursing care at home and in nursing homes. The MDST should primarily be a tool for the profession, and understanding the professions’ reasoning about technology use in health care at home and in nursing home settings must be the base for implementing MDST.     

Clinical tools for the assessment of pain in sedated critically ill adults

Aim: This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice. Background: Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently. Search strategy: In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: ‘pain assessment’ and ‘sedated’ or ‘unconscious’ or ‘critically ill’ or ‘critical illness’ or ‘critical care’. Conclusions: The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical‐Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non‐verbal Pain Scale (NVPS). Implications for practice: The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.     

A critical analysis of health promotion and ‘empowerment’ in the context of palliative family care‐giving

STAJDUHAR K, FUNK L, JAKOBSSON E and ÖHLÉN J. Nursing Inquiry 2010; 17 : 221–230
A critical analysis of health promotion and ‘empowerment’ in the context of palliative family care‐giving Traditionally viewed as in opposition to palliative care, newer ideas about ‘health‐promoting palliative care’ increasingly infuse the practices and philosophies of healthcare professionals, often invoking ideals of empowerment and participation in care and decision‐making. The general tendency is to assume that empowerment, participation, and self‐care are universally beneficial for and welcomed by all individuals. But does this assumption hold for everyone, and do we fully understand the implications of health‐promoting palliative care for family caregivers in particular? In this study, we draw on existing literature to highlight potential challenges arising from the application of ‘family empowerment’ strategies in palliative home‐care nursing practice. In particular, there is a risk that empowerment may be operationalized as transferring technical and medical‐care tasks to family caregivers at home. Yet, for some family caregivers, a sense of security and support, as well as trust in professionals, may be equally if not more important than empowerment. Relational and role concerns may also at times take precedence over a desire for empowerment. The potential implications of ‘family empowerment’ are explored in this regard. ‘Family empowerment’ approaches need to be accompanied by a strong understanding of how to best support individual palliative family caregivers.     

Improving the quality of life for multiple sclerosis patients using the nurse-based home visiting model

Scand J Caring Sci; 2012; 26; 295–303 Improving the quality of life for multiple sclerosis patients using the nurse‐based home visiting model Purpose: Multiple sclerosis (MS) sufferers have a high prevalence of co‐morbidity associated with poor quality of life, high health care costs and increased risk for adverse outcomes. These patients are often lacking in optimal home care, which may result in subsequent hospital readmissions. However, a specific nurse‐based home visiting model for patients with MS is not yet available in Turkey. The aim of this study was to determine the effects of nursing interventions according to The North American Nursing Diagnosis Association (NANDA). Using the NANDA guidelines, the aim of this study was to determine the effect of home visit nursing interventions on the many challenges and quality‐of‐life (QOL) issues faced by patients with MS. Methods: This study used a pretest–posttest experimental group design. The study sample of 45 patients with MS, who had previously registered with the MS Society, had 21 participants in the intervention group and 24 in the control group. Data were collected with the ‘General Questionnaire Form’ and ‘Symptom Evaluation Form’ and ‘Multiple Sclerosis Quality‐of‐Life Scale’ (MSQOL‐54). The NANDA classification system of care plans for conducting eight home visits with the intervention group was also used. Our intervention would identify symptoms, give training, consulting and care services and be able to recognize when referrals to other medical professionals might be necessary. The control group would receive the usual care with just two visits. Results: There was a statistically significant difference between the intervention and control groups regarding the MSQOL‐54P score change (p = 0.02), but a nonsignificant difference for the MSQOL‐54M. Conclusion: This model helped to achieve an improvement trend in the QOL scores of the MS patient intervention group. This home visit model can also be used to increase the quality of care and quality of life for patients with MS.