Spiritual caring: end of life in a nursing home

The purpose of this qualitative study was to explore spiritual care for dying nursing home residents from the perspectives of registered nurses, practical nurses, certified nursing assistants, advanced practice nurses, and physicians. Five major themes emerged: honoring the person's dignity, intimate knowing in the nursing home environment, wishing we could do more, personal knowing of self as caregiver, and struggling with end-of-life treatment decisions. Spiritual caring was described within the context of deep personal relationships, holistic care, and support for residents. Spiritual care responses and similarities and differences in the experiences of participants are presented. Education and research about how to assist residents and families as they struggle with difficult end-of-life decisions, adequate time and staff to provide the kind of care they "wished they could," and development of models that honor the close connection and attachment of staff to residents could enhance end-of-life care in this setting.     

Did We Interpret the Same Thing?

PURPOSE: Motivated by the potential application of "similarity theory" in nursing communication, the primary objectives of this paper are (a) to seek an in‐depth understanding of how nurses identify like concepts when comparing two similar but different images, and (b) to pinpoint the thinking process nurses use to determine "similarity" as a pretest of a framework that is meant to improve nursing communication for better patients' care. METHODS: A think‐aloud approach is used to elicit both written and verbal responses from six participants, who are medical‐surgical registered nurses with an associate degree, by comparing two specifically designed images for similarity determination. Data collected from participants include responses about four levels of similarities, a similarity rating using a 1–10 Likert‐type scale, and a most meaningful concept shared by the image pair. FINDINGS: Collected data indicate noticeable variability in the level and quality of details, which in turn demonstrates inconsistencies. The findings from analyzing the collected think‐aloud responses indicate that the proposed framework of thinking process was undertaken by at least three participants (i.e., 50%) before they reached the similarity rating and a meaningful concept. This study shows how misunderstandings in interpretation can occur simply because nurses used different similarity approaches. Anomalies are also found in the collected data (i.e., think‐aloud responses). Possible causes and explanations are given, along with suggestions for further investigation and validation of the proposed framework. CONCLUSIONS: In this study, a communication framework based on similarity theory was proposed to highlight the thinking process of nursing concept development. A think‐aloud pilot study was conducted. Results suggest that similarity theory and the proposed framework can be used to explain how nurses classify and determine similarities, though an in‐depth validation is needed. This framework may guide nurse educators to promote higher levels of thinking when educating students and nurses in the process of extracting quality information during patient care. The limitations of current research have been addressed. Additional research issues and extensions to this study are also provided in order to further improve nursing communication education.     

Ethical practice in nursing: working the in-betweens

BACKGROUND: While contemporary ethical theory is of tremendous value to nursing, the extent to which such theory has been informed by the concerns and practices of nurses has been limited. PURPOSE: With a view to complementing extant ethical theory, a study was undertaken to explore, from the perspective of nurses, the meaning of ethics and the enactment of ethical practice in nursing. DESIGN AND METHODS: Located in the interpretive/constructivist paradigm, using an emergent design, this inquiry employed focus groups to collect the data. Eighty-seven nurses from a wide range of practice settings were interviewed in 19 focus groups of three to nine nurses each. FINDINGS: The nurses described ethics in their practice as both a way of being and a process of enactment. They described drawing on a wide range of sources of moral knowledge in a dynamic process of developing awareness of themselves as moral agents. Enacting moral agency involved working in a shifting moral context, and working in-between their own values and those of the organizations in which they worked, in-between their own values and those of others, and in-between competing values and interests. CONCLUSIONS: Analysis of the experiences and concerns of the nurses offered new understanding of ethics in nursing and direction for the development of ethical theory pertinent to nursing practice.     

Shifting supervision: implications for safe administration of medication by nursing students

Background. Medication errors made unintentionally by nurses continue to be a major concern in hospitals, medical centres and aged care facilities throughout Australia. While there is a plethora of literature available, which has identified factors that contribute to nurses making errors, few studies have reported on factors that may contribute to errors made by nursing students. Design. A grounded theory approach. Methods. In‐depth interviews with final‐year undergraduate nursing students (n = 28) to explore their experiences of administering medication. Constant comparative analysis was used to identify categories from the data. Results. The central category was identified as ‘shifting levels of supervision’. This describes the process of supervision students received when administering medication. Four levels were identified: ‘being with’, ‘being over’, ‘being near’ and ‘being absent’. The findings suggest that nursing students do not always receive the level of supervision that is legally required. Less than satisfactory levels of supervision were identified by participants as leading to medication errors or near misses. Conclusion. Apart from ‘Being with’, the levels of supervision described by participants have major implications for the safe administration of medication by nursing students and represent the actual or potential cause of error. Relevance to clinical practice. The potential for medication errors pose a major safety issue. Healthcare services have a responsibility to protect patient safety. Appropriate supervision of nursing students when administering education therefore requires urgent attention to ensure best practice is executed.     

Nurses' responses to ethical dilemmas in nursing practice: meta-analysis

Title. Nurses’ responses to ethical dilemmas in nursing practice: meta‐analysis. Aim. This paper is a report of a study to explore nurses’ responses to ethical dilemmas in daily nursing practice. Background. Concern about nurses’ ethical competence is growing. Most nurses perceived that there were barriers in their work environment to ethical practice, compromising their ability to perform ethically. Since most research focuses on contextual barriers to nurses’ ethical practice, little is known about how nurses involve themselves in ethical decision‐making and action in daily care. Method. A meta‐analysis of nurses’ ethical behaviour was conducted using data from nine studies in four countries (n = 1592 registered nurses). In all studies, the Ethical Behaviour Test was used to measure nurses’ ethical responses, based on an adapted version of Kohlberg’s theory of moral development. Data were analysed using random‐intercept regression analysis. Findings. All groups, except the expert group, displayed a uniform pattern of conventional ethical reasoning and practice. When nurses were faced with ethical dilemmas, they tended to use conventions as their predominant decision‐guiding criteria rather than patients’ personal needs and well‐being. Conclusion. Conformist practice (following conventions rather than pursuing good for the patient) constitutes a major barrier for nurses to take the appropriate ethical actions, as creativity and critical reflection are absent. There is an urgent need to find ways to promote nurses’ ethical development from conventional to postconventional ethical practice. More research is needed to strengthen existing empirical evidence.     

Elder RNs: learning from their experiences

A grounded theory study of elderly registered nurses was conducted to explore perceptions about the nursing profession in light of the nursing shortage. The participants ranged in age from 65 to 90 and came from a variety of educational and nursing backgrounds. As they spoke of their perceptions, participants shared their personal stories regarding the reasons they went to nursing school, ways they feel they made a difference in others' lives because they were nurses, and their views as elderly patients of nursing today. Their narratives describe barriers to nursing education and nurses and patients in the 1920s through 1960s and the changes that have occurred in nursing and medicine.     

A qualitative case study review of role transition in community nursing

PURPOSE: This paper aims to describe existing community nursing practices and to explore factors that are associated with the transition of clinical practice from acute care settings to community care settings. METHOD: This qualitative case study assessment described existing community nurse practices and explored factors that were associated with the transition to community practice from acute care settings. The 48 participants in this case study were registered nurses who were working in community care nursing during the interview process. CONCLUSIONS: The results of this investigation revealed themes derived from data collection, including autonomy, client and family, education, and community as nursing work. This study indicated that making the transition to community-based nursing includes conceptual as well as emotional adjustments. Community nursing practice was seen by the participants as nursing that captures a holistic approach incorporating multiple dimensions from psychological, sociological, economic, and physical to spiritual aspects that provides services in interaction between the community nurse, the client, and the family. The findings indicate a need for additional supportive preparation strategies incorporated into nursing orientation and continuing education programs. Future research investigating agency culture and socialization would provide a more definitive survey of perceptions and competencies needed for role.     

Jordanian perspectives on advanced nursing practice: an ethnography

Zahran Z., Curtis P., Lloyd‐Jones M. & Blackett T. (2012) Jordanian perspectives on advanced nursing practice: an ethnography. International Nursing Review 59 , 222–229 Aim: This study aimed to explore how different groups of participants perceived the concept of advanced nursing practice in Jordan. Background: In Jordan, there are postgraduate educational programmes offering a Master's degree in clinical nursing for registered nurses. Intended to prepare nurses to practise at an advanced level as potential clinical nurse specialists in critical care, community health nursing and maternal newborn nursing, little was known prior to this study about the development of advanced nursing roles for nurses in Jordan and the drivers behind their establishment. Methods: Using ethnographic design, narratives from semi‐structured interviews and non‐participant observation with participants from five Jordanian hospitals and two public universities were collected and analysed according to thematic analysis. Findings and discussion: Four themes emerged from the data: core competencies, specific practice area vs. generic practice, beneficiaries of advanced nursing practice and drivers for educational change. The findings are similar to those found in other countries and highlight the need for a consensual understanding between nurse educationalists, professional bodies and employers about what advanced nursing practice in Jordan should be, so that a common framework can be identified. Conclusion: Paralleling the lack of consistency in understanding of advanced nursing practice in the broader literature, participants described a number of different elements of advanced practice that are relevant to the specific context of contemporary Jordanian nursing.     

Factors facilitating and inhibiting evidence-based nursing in Iran

AIM: This paper is a presentation of a study to clarify the concept of evidence-based nursing and to explore the factors that influence evidence-based nursing by Iranian nurses. BACKGROUND: Evidence-based practice was introduced as an approach to high-quality care intended to improve results for patients. Several nurse researchers have studied factors affecting implementation of evidence-based nursing in western countries. However, there is little or no research on the perceptions of evidence-based nursing and its barriers in eastern countries, especially Iran. METHODOLOGY: Grounded theory method was used. Interviews with 21 participants and 30 hours of observation were conducted in hospitals in Iran during 2005. Constant comparative analysis was used to analyse the data. FINDINGS: Two main categories, 'the meaning of evidence-based nursing', and 'factors affecting it', emerged from the data. From participants' perspectives, evidence-based nursing was defined as 'caring for patients based on the nurse's professional knowledge in meeting patients' needs'. The second category, factors affecting evidence-based care, had six subcategories: possessing professional knowledge and experience; having time and opportunity; becoming accustomed; self-confidence; the process of nursing education; and the work environment and its expectations. CONCLUSION: Managers and educators need to be committed to the principles of EBP, provide resources and create a supportive environment for its implementation. Individual nurses also have a responsibility to carry out evidence-based nursing, and researchers should work with practitioners to generate high quality evidence to support nursing practice.     

Rigour and grounded theory research

BACKGROUND: Grounded theory methodology is a suitable qualitative research approach for clinical inquiry into nursing practice, leading to theory development in nursing. Given the variations in, and subjectivity attached to, the manner in which qualitative research is carried out, it is important for researchers to explain the process of how a theory about a nursing phenomenon was generated. Similarly, when grounded theory research reports are reviewed for clinical use, nurses need to look for researchers' explanations of their inquiry process. AIM: The focus of this article is to discuss the practical application of grounded theory procedures as they relate to rigour. METHOD: Reflecting on examples from a grounded theory research study, we suggest eight methods of research practice to delineate further Beck's schema for ensuring, credibility, auditability and fittingness, which are all components of rigour. FINDINGS: The eight methods of research practice used to enhance rigour in the course of conducting a grounded theory research study were: (1) let participants guide the inquiry process; (2) check the theoretical construction generated against participants' meanings of the phenomenon; (3) use participants' actual words in the theory; (4) articulate the researcher's personal views and insights about the phenomenon explored; (5) specify the criteria built into the researcher's thinking; (6) specify how and why participants in the study were selected; (7) delineate the scope of the research; and (8) describe how the literature relates to each category which emerged in the theory. CONCLUSIONS: The eight methods of research practice should be of use to those in nursing research, management, practice and education in enhancing rigour during the research process and for critiquing published grounded theory research reports.     

以提升叙事护理能力为主导的临床护士人文关怀培训模式的构建与应用效果

目的:构建以提升叙事护理能力为主导的临床护士人文关怀培训模式,并探讨其在临床培训中的应用效果。方法:选择62名叙事护理执行水平相近的临床科室护士作为研究对象,采用基础理论课程与叙事故事共情理论教学相结合,结合嵌入临床实践体验、总结反思写作以及参与人文素材开发创作的沉浸体验式培训方式。比较培训前后护士在叙事能力、共情能力、人文关怀能力等方面的表现。结果:培训后护士的叙事能力明显提高(P＜0.05);共情能力量表总分及各维度均显著提升(P＜0.05),护士的人文关怀能力也明显增强(P＜0.05)。有95.1%的学员认为培训方案科学合理、易于接受,并具有实用性。结论:以提升叙事护理能力为主导的人文关怀培训模式能有效提高临床护士的叙事护理能力,提升其人文关怀素养。     

Good nursing from the perspective of nurses

This qualitative study used an in-depth interview method to explore nurses' perspectives on good nursing practices. A balanced stratified sampling approach was employed to recruit 83 nurses from 18 hospitals that were relatively evenly distributed around Taiwan. Fifteen nurses educated to the masters' level and well trained in the in-depth interview approach collected research data from January through May 2002. Interviews were audiotaped and transcribed in verbatim narratives. Content analysis was used to identify good nursing practices common across narratives. Four good nursing practice categories emerged inductively. These included (1) good decision making and execution, (2) dexterous professional skills, (3) good patient-nurse relationships, and (4) a mature self. Findings present quality nursing care as a relationship that combines professionalism and humanism. In order to provide better care, a nurse must incorporate knowledge from empirical research into his or her practice and internalize his or her value as a nurse. A discussion of the process of self-maturation acquisition and reflective learning offers new insights to guide the construction of nursing education curricula and activities for clinical nursing practice. Further research in good nursing is suggested.     

A comparative study of organisational characteristics, work characteristics and nurses' psychological work reactions in a hospital and nursing home setting

OBJECTIVES: The aim of the current study was twofold. First, we explored whether there were any differences concerning organisational characteristics, work characteristics and psychological work reactions in two types of health care setting, hospitals and nursing homes. Second, it was investigated and validated whether relationships between organisational characteristics, work characteristics and psychological work reactions found in research on hospital nursing are also present in nursing homes. METHODS: The variables were assessed by questionnaires that were distributed among nurses and caregivers in 15 randomly selected general hospitals and 14 nursing homes in the Netherlands. Manova and hierarchical regression analyses were carried out to explore differences in the variables and in relationships between the variables. RESULTS AND CONCLUSION: Results show that the major difference in hospital-based and nursing home practice is in the work organisation as assessed by the organisational characteristics "environmental uncertainty" and "decision authority". Relations found between variables are in majority in line with the JDC-model and confirm the applicability of this theory in different types of health care settings.     

Models of care delivery in mental health nursing practice: a mixed method study

The aim of this study was to identify the conceptual models that underpin mental health nursing care in clinical settings. This study is a modification of a previous study which evaluated the influence of implicit models of mental disorder on processes of decision making within community-based teams. Participants completed questionnaires in response to a scenario. A range of explanatory conceptual models were identified in respect to aetiology, treatment and recovery. In a forced choice the participants ranked a medical model of care above other models as underpinning care delivery. The content analysis found that the participants used a psychodynamic framework for understanding the causes of mental distress but described the nursing interventions in terms of supporting a medical model of care. Nursing care is dominated by a medical model which constrains mental health nursing. This potentially creates tension between what nurses believe to be the problem and the responses available for nurses in their clinical setting. A range of psychosocial approaches to mental health care delivery have been developed, but there seems to be problems with their implementation in practice. Further research is required to explore how broader therapeutic interventions can be implemented by nurses within multidisciplinary systems of mental health care delivery.     

The knowledgeable practice of critical care nurses: a poststructural inquiry

BACKGROUND: Contemporary nursing literature emphasises the desirability of clinical nurses being "knowledgeable". However, the need for nurses constantly to acquire more knowledge is reiterated. Lack of knowledge is seen to underlie an array of professional problems. Little is known of how nurses themselves understand what it means to practise knowledgeably. OBJECTIVE: To explore critical care nurses' understandings of knowledgeable practice and its relationship to being a "good nurse". METHODOLOGY: A poststructuralist framework informed the study. The study participants were 12 critical care nurses. Data were generated through three individual focused interviews with each participant. Data analysis involved deconstruction of the interview texts to reveal participants' discourses of knowledgeable practice and the implications of these discourses for their subjectivity and for their work. FINDINGS: A discourse of knowledgeable practice was revealed as central to participants' sense of identity as "good nurses". Participants believed their knowledge resided in their heads ("knowing why") and in their hands ("knowing how"). Fluency of action, which was achieved and maintained by frequent repetition of activities, contributed to their sense of being knowledgeable. Participants described being excluded from knowledge in some instances. In general, however, "actual" knowledge was of less importance than was being positioned, by themselves and others, as knowledgeable. This positioning was frequently undermined by other staff, both medical and nursing. Analysis revealed that the discourse of knowledgeable practice was underpinned by a dichotomy of ignorant/knowledgeable, in which "ignorant" was the dominant category; hence, nurses were assumed to be ignorant until they could "prove" otherwise. CONCLUSIONS: The findings contest the notion, espoused in nursing literature, that acquisition of knowledge can "empower" nurses, thus providing the solution to problems they may experience. Rather, strategies are required that challenge and disrupt relations of power that construct nurses as "ignorant".     

高职护理专业学生实习前心理状态调查及对策

目的了解护生实习前的心理状态，分析影响护生实习前心理状态的因素，探讨相应的对策。方法对122名高职护理专业学生在将实习前进行不记名的问卷调查，内容包括是否对实习有充分的心理准备，实习前最担心的问题，护生希望学校所做的工作等。问卷当场发放当场收回并进行统计分析。结果只有32．8％的护生对于实习已有技能上和思想上的准备。实习前最担心的问题排名前6位的是：担心不能适应医院环境；担心操作技能欠缺；担心与病人难以沟通；担心难以和医护人员相处；担心实习工作中出差错事故；担心实习医院条件差。护生们普遍希望学校能采取一些适当的措施改善目前的状态，其中排名前5位的有：有针对性地进行临床实习前技能培训；有针对性地进行心理辅导；开展关于医疗护理安全的法律法规讲座；邀请有经验的临床护士介绍经验；进行沟通技巧方面的讲座。结论大部分护生对于即将到来的实习缺乏必要的心理准备，尽管担心的内容不同，但均以主观因素为主。在实习前进行心理教育、技术练兵、联谊会及座谈会有助于护生改善对实习的恐惧感，使她们能尽快适应环境，圆满完成实习任务。